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APP| Published By AEIRC| https://doi.org/10.29052/2412-3188.v9.i1.2022.39-50 

 

 
Systematic Review                                                                                  

Approaches used for the Quantification of 
Pain in Physical Therapy Practices-A 
Systematic Review 
Shahrukh Abbasi1 , Shahzaib Naseer2  & Sumaira Imran Farooqui1  
1Ziauddin College of Rehabilitation Sciences, Ziauddin University, Karachi-Pakistan 
2Sindh Institute of Urology and Transplantation (SIUT), Karachi-Pakistan 

 

Abstract 
Background: This study aimed to determine the most common pain intensity 
assessment tool that has been used in different physical therapy management-
based studies as a primary outcome measure for the quantification of pain. 
Methodology: The electronic databases including PubMed, Google Scholar, 
PEDro, and Cochrane Library were searched to identify relevant studies from 
January 2015 to September 2021 by using keywords like 'pain,' 'pain intensity,' 
'Visual Analogue Scale,' and 'Numeric Pain Rating Scale.' Randomized controlled 
trials or quasi-experimental studies in which pain management is considered an 
outcome measure published in the English language were included. In contrast, 
Non-RCTs were excluded that were based on pain management strategies other 
than physical therapy or conducted in inpatient department or based on 
approaches of telerehab. 
Results: The findings revealed that n=1,292 participants were given different 
physical therapy interventions in which n=792 (61.3%) were evaluated for their 
pain on VAS, followed by n=453 (35%) on NPRS and n=169 (13%) on PPT of the 
total population. 
Conclusion: VAS was the most frequently used tool to determine the patient's 
perception of pain, followed by NPRS and McGill Pain Questionnaire. 
 

Keywords 
Physical Therapy, Pain Management, Activities of Daily Living, Neck Pain, 

Quality of Life. 

 

 

 

 

 

 

 

Citation: Abbasi S, Naseer S, Farooqui SI. 
Approaches used for the Quantification 
of Pain in Physical Therapy Practices-A 
Systematic Review. APP. 2022; 9(1): 39-50 
 
Corresponding Author Email: 
shahrukh.abbasi@zu.edu.pk 
 
DOI: 10.29052/2412-3188.v9.i1.2022.39-50 
 
Received 18/04/2022 
 
Accepted 06/05/2022 
 
Published 01/06/2022 
 
Copyright © The Author(s). 2022 This  
 is an open access article distributed 
under the terms of the Creative 
Commons Attribution 4.0 International 
License, which permits unrestricted use, 
distribution, and reproduction in any 
medium, provided the original author 
and source are credited.  
 

 

Funding: The author(s) received no 
specific funding for this work. 

Conflicts of Interests: The authors have 
declared that no competing interests 
exist. 
 

https://doi.org/10.29052/2412-3188.v9.i1.2022.
https://orcid.org/0000-0001-5017-7603
https://orcid.org/0000-0002-9540-4280
https://orcid.org/0000-0001-9263-8033
http://creativecommons.org/licenses/by/4.0/)
http://creativecommons.org/licenses/by/4.0/)
http://creativecommons.org/licenses/by/4.0/)


 
 
 

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Introduction  
Pain is considered a fifth vital sign, and 
hence its precise assessment is important for 
its management1. Pain is examined using 
both subjective and objective methods since 
a patient's sense of pain fluctuates based on 
their physiological or psychological status 
at the time, and they may not perceive a 
reduction in symptoms while being treated 
by a physiotherapist2. The patient reports 
his or her pain, which is subsequently 
documented in a subjective technique, 
whereas pain is measured indirectly in 
objective approaches. Physiotherapists, 
however, do not commonly evaluate and 
quantify pain, even though it is becoming a 
trend in their field. Although several scales 
have been established for the subjective 
assessment of pain that clinicians use to 
construct suitable management strategies, 
most approaches are subjective. They rely 
heavily on the patient's self-reported 
strategy for correct assessment2.  
 
For assessing the pain, it is of utmost 
importance for the physical therapist to 
identify its component and which are type, 
duration, intensity, and location of the pain. 
Besides that, another important factor is 
used to define pain, which is its aggravating 
and alleviating factor3. Literature has 
provided evidence that is typically defining 
pain in terms of its type studies have agreed 
upon the concept that patient feelings about 
pain reveal the type of pain from which the 
patient is going through4. Researchers have 
agreed that while defining the type of pain, 
the most widely used types are neuropathic, 
somatic, and visceral, which have further 
classified into deep, viscerosomatic, and 
referred5. Further, while evaluating the 
location of pain, the physical therapist must 
identify the exact location on the patient's 
body where the pain is being perceived 

either due to direct contact or in the form of 
referred pain6.  
 
Besides that, determining the intensity of 
pain is one of the essential factors and, 
indeed, a tool for devising a physical 
therapy management strategy for relief for 
the patient. Studies have come across 
multiple subjective assessment tools that the 
physical therapist is extensively using to 
determine the intensity of pain among 
patients and out of all the available pain 
intensity assessment tool setups for 
quantifying pain7. Duration of pain is yet 
another important component that indeed 
provides information regarding the severity 
of pain and combined with execrating and 
relieving factors; this information is vital for 
the physical therapist to identify the 
patient's accurate source of pain and devise 
its management strategies accordingly8.  
 
Literature has provided evidence that most 
patients referred to Physical therapy 
outpatient departments (OPDs) either self-
referral or via physician and surgeons, the 
most common problem they revealed is 
pain9. It is also evident from the data that 
most of the physical therapy-based studies 
available on the database like Google 
Scholar, Cochrane, and other; include pain 
assessment tool. It is consider the most 
common outcome measure that has been 
used as a primary source of assessment to 
identify the efficacy and efficiency of any 
treatment protocol used in the clinical 
setups. Hence it is for this purpose that the 
current study is aimed to determine the 
most common pain intensity assessment 
tool that has been used in different physical 
therapy management-based studies as a 
primary outcome measure for 
quantification of pain. 
 
 



 
 
 

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Methodology 
Study Protocol 
All of the findings were based on 
previously published studies. As a result, 
no ethical approval or patient consent was 
required. The review was carried out 
according to the Preferred Reporting Items 
for Systematic Reviews and Meta-Analyses 
(PRISMA) statement. 
 
Sources of Information and Search 
Strategy 
From January 2015 to September 2021, the 
electronic databases PubMed, Google 
Scholar, PEDro, and the Cochrane Library 
were searched for relevant studies using 
keywords such as 'pain,' 'pain intensity,' 
'Visual Analogue Scale (VAS),' and 
'Numeric Pain Rating Scale (NPRS). 
Additional papers were found by manually 
searching relevant journals, conference 
papers, and reference lists.  
 
Criteria for Eligibility 
Experimental research, including 
Randomized Controlled Trials (RCTs) or 
quasi-experimental designs conducted in 
physical therapy settings between 2015 and 
2021 with pain management as an outcome 
measure published in English, was 
included. Non-RCT or non-clinical trials 
based on pain treatment techniques other 
than physical therapy, trials done in an 
inpatient setting, trials that incorporated 
domiciliary physical therapy services, and 
trials based on telerehab approaches were 
eliminated. Abstracts that did not have a 
complete matching article published in a 

peer-reviewed publication or that did not 
include particular data were also removed. 
 
Outcome Measures 
The primary outcome measures were Visual 
Analog Scale (VAS), Numerical Pain Rating 
Scale (NPRS), Nottingham Health Profile 
(NHP), Northwick Park Neck Pain 
Questionnaire (NPNPQ) score, Pressure 
Pain Threshold (PPT), McGill Pain 
Questionnaire, and Pain Catastrophizing 
Scale. If multiple scales were used to 
evaluate the same outcome index in 
research, the primary outcome scale or the 
most representative scale was chosen for 
analysis. 

 
Search Methods for Identification of 
Studies 
Two authors independently assessed the 
search results to choose potentially relevant 
papers and screened the titles, abstracts, 
and full texts of discovered references. 
 
Extraction of information 
Basic study details, total sample size, and 
results were among the data retrieved. 
 
Evaluation of the Quality Level 
The PEDro scale was used to measure the 
quality of the studies. To authenticate their 
PEDro scale score, all included trial reports 
were reviewed in the PEDro database. 
Trials with a score of 6 points were deemed 
"good," while those with a score of 5 were 
deemed "bad." The analysis was omitted 
because of the low quality of the research.

 
 



 
 
 

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Figure 1: Flowchart of the study procedure 

 

Articles that were included according to inclusion and exclusion criteria have been represented 

in Table 1 as follows: 

 

S# Study Year 
Sample 

Size 
Outcome Measure 

Pedro 
Quality Assessment 

1 The effect of mulligan mobilization 
on pain and life quality of patients 
with rotator cuff syndrome10 

2019 30 VAS Good 

2 Short-term effects of mulligan 
mobilization with movement on 
pain, disability, and kinematic 
spinal movements in patients with 
non-specific low back pain11 

2015 32 VAS Good 

3 The effects of the number of 
physical therapy sessions on pain, 
disability, and quality of life in 
patients with chronic low back 
pain12 

2017 60 VAS & Nottingham 
Health Profile 

Moderate 

4 Effect of isometric back endurance 
exercises on patients with non-
specific chronic low back pain13 

2021 60 VAS Good 



 
 
 

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5 Swiss ball exercises as an 
alternative to McKenzie exercises 
in treating chronic low back pain 
among poultry workers14 

2020 60 NPRS Moderate 

6 Effect of lumbar stabilization 
versus McKenzie exercises on pain 
and functional disability in 
patients with the post-
laminectomy syndrome15 

2019 45 VAS Good 

7 Effectiveness of mulligans 
mobilizations with upper limb 
movement and McKenzie exercises 
with neural mobilizations in 
patients with cervical spondylitis16 

2018 60 VAS score and 
Northwick Park 

Neck Pain 
Questionnaire 

Good 

8 Kinesio taping reduces pain and 
improves disability in low back 
pain patients17 

2019 108 NPRS Moderate 

9 Comparison of dry needling and 
Kinesio taping methods in the 
treatment of myofascial pain 
syndrome18 

2021 88 Pressure Pain 
Threshold & VAS 

Low 

10 Comparison of different 
electrotherapy methods and 
exercise therapy in shoulder 
impingement syndrome19 

2018 83 VAS Good 

11 Effectiveness of dry needling 
versus a classical physiotherapy 
program in patients with chronic 
low-back pain: a single-blind, 
randomized, controlled trial20 

2017 34 VAS & 
McGill Pain 

Questionnaire score 

Good 

12 A comparison of physical therapy 
modalities versus acupuncture in 
the treatment of fibromyalgia 
syndrome21 

2018 44 McGill Pain 
Questionnaire score 

Moderate 

13 Pain management using a 
multimodal physiotherapy 
program including a biobehavioral 
approach for chronic non-specific 
neck pain: a randomized 
controlled trial22 

2018 47 Pain 
Catastrophizing 

Scale & VAS 

Moderate 



 
 
 

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14 Effectiveness of standard cervical 
physiotherapy plus diaphragm 
manual therapy on pain in patients 
with chronic neck pain23 

2021 40 NPRS & PPT Good 

15 The effect of mulligan mobilization 
technique in older adults with 
neck pain24 

2018 42 VAS Moderate 

16 Effectiveness of physiotherapy for 
seniors with recurrent headaches 
associated with neck pain and 
dysfunction25 

2017 65 VAS Good 

17 Is a combined program of manual 
therapy and exercise more 
effective than usual care in 
patients with non-specific chronic 
neck pain?26 

2019 64 NPRS Low 

18 Manual therapy compared with 
physical therapy in patients with 
non-specific neck pain27 

2017 181 NPRS Low 

19 Effects of myofascial release on 
pressure pain thresholds in 
patients with neck pain28 

2018 41 VAS & PPT Moderate 

20 Effectiveness of core stabilization 
exercises and routine exercise 
therapy in the management of pain 
in chronic non-specific low back 
pain29 

2017 108 VAS Good 

 

Results 
Study Selection 
Literature research of 40 studies was 
conducted on several databases to 
investigate pain assessment techniques, of 
which 30 papers were initially selected and 

included in this study. The publications 
were accepted based on inclusion/exclusion 
criteria that were created specifically for this 
study. Figure 1 depicts a flow chart of the 
schematic portrayal of the full research 
search based on our study's criteria.

  
 
 
 



 
 
 

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Methodological Quality 
The PEDro ratings were used to assess the methodological quality of the selected studies. After 
deliberation and consensus among the reviewers, all disparities in the PEDro scales were 
addressed. Table 1 shows the results of the quality scores, which varied from 3 to 8 on a scale of 
10 points. Ten studies were of high quality, six were of moderate quality, and four were of low 
quality.   
 
Synthesized Findings 
Our data indicated that VAS is the most prevalent outcome measure widely used to quantify 
pain. Aside from VAS, the Numeric Pain Rating Scale, Pressure Pain Threshold Scale, and 
McGill Pain Questionnaire score were some of the most frequently employed outcome 
measures in clinical settings by physical therapists. However, the Nottingham Health Profile 
(NHP), Pain Catastrophizing Scale, and Northwick Park Neck Pain Questionnaire (NPNPQ) 
score were the least commonly used instruments in the study that quantified pain in response to 
physical therapy. Figure 2 shows a diagrammatic depiction of the research findings. 
 

 
Figure 2: Frequency of different Pain Scale commonly used by PTs 

 

The result of our study had revealed that of the total number of literature that we reviewed, a 

total number of n=1,292 participants were given different physical therapy interventions. In the 

litarature reviewed n=792 participants were evaluated for their pain on VAS outcome measure 

that, make a total percentage of 61.3% of the total population of this study. NPRS was used to 

analyze n=453 participants, which comprised 35% of the participants, followed by n=169 who 

were evaluated through PPT, which comprises 13% of the total population. McGill Pain 

Questionnaire score was used for 78 participants making a 6% of the total population. 

Nottingham Health Profile (NHP) and Northwick Park Neck Pain Questionnaire (NPNPQ) 

score were used in n=60 participants making a total population of 4.6%. Pain Catastrophizing 

Scale was used in n=47 participants, making it the least used scale by physical therapists 3.6% 

for quantifying pain in the clinical setups. The population-wise frequently used pain assessment 

tool, according to our findings, has been demonstrated in Figure 3. 



 
 
 

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Figure 3: Pain Assessment tool commonly used by PTs in the population 

 

Discussion  
The findings of our study have revealed 
that VAS is the most frequently used tool to 
quantify pain along with NPRS. This may 
be since both these assessment tools are 
user-friendly perception-based tools to 
determine pain severity among patients in 
physical therapy clinic setups. According to 
Lazaridou et al., VAS has been considered a 
measure of choice for pain assessment as 
the assessment tool has good validity and is 
also sensitive to treatment effect. In another 
study, the researcher considered VAS an 
important tool to track pain progression 
among patients and compare the pain of 
patients diagnosed with similar 
conditions30. The numeric pain rating scale 
was the second most common tool as per 
our finding the physical therapists were 
using that in the clinical setups. Literature 
from the previous studies has revealed that 
NPRS, like VAS, had been based on patient 
perception of pain, but unlike VAS, the tool 
has a different format of pain intensity30. 
NPRS has three different scales, 0 to 10, 0 to 
20, and 0 to 100 making this scale slightly 
more complex than VAS as it turns the 
researcher into a perplexed state that out of 
three different scales, which scale is to be 

used31. The pressure pain threshold scale 
was yet another pain assessment scale we, 
during our search, had come across in 
several studies. This scale had five gradings 
where 0 suggested no sign of pain, and IV 
was considered as a noxious intolerable 
pain32. 
 
Although the scale was considered valid 
and reliable, it was observed that the scale 
was not found to be sensitive enough. 
Hence, the scale gets obsoleted from clinical 
and research perspectives32. McGill pain 
questionnaire was another frequently used 
tool for pain assessment, and it comprised 
three different components that were 
sensory, affective, and cognitive. Each 
component had various descriptors ordered 
from no pain to severe33. The complex 
arrangement of the questionnaire made the 
researchers shift towards a short form of the 
questionnaire that too comprises 15 
descriptors ordered from 0 to 3, where 0 
represents no pain, and 3 indicates severe 
pain33. Moving further into the list, we have 
come across two other questionnaire-based 
pain assessment tools: NHP and NPNPQ. 
NHP was a comprehensive questionnaire 
intended to determine the overall condition 
of patient health based on emotional, social, 



 
 
 

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and physical health problems. The 
questionnaire was based on six sub-areas: 
energy level, pain, emotional reaction, 
sleep, social isolation, and physical abilities. 
The questionnaire was related to the overall 
health-related condition of the patient, and 
the pain was only a single component of the 
questionnaire. Hence it was limited to 
studies in which the patient's overall health-
related problems were in question, and also 
the questionnaire did not contain 
parameters to determine the intensity of 
pain hence that was the reason why the 
questionnaire was not widely used in 
research to determine the intensity of the 
pain34. NPNPQ was designed to quantify 
neck pain while performing the activity of 
daily living (ADLs) as the question within 
the tools were mostly related to neck-
related pain; hence not been used widely for 
pain intensity quantification purposes35.  
 
The Pain Catastrophizing scale was the 
most frequently used tool we found during 
a literature search. The scale comprises 13 
questions ranging from 0 to 4, where 0 
indicates not at all, and 4 represents all the 
time. Further, the entire scale had three 
categories for assessing the patient 
situation: rumination, magnification, and 
helplessness36. Though simple in approach, 
the pain catastrophizing scale was not 
widely found among studies which may be 
due to its subscale classification that did not 
reflects patients' pain intensity perception; 
rather, it was more towards patient fear of 
pain. 
 

Conclusion  
The findings of our study revealed that of 
all the pain assessment tools, VAS was the 
most frequently used tool to determine the 
patient perception of pain, followed by 
NPRS and McGill pain Questionnaire. The 
rest of the three assessment tools that 
included NHP, NPNPQ, and Pain 

Catastrophizing scale were not frequently 
found in the studies, which may be because 
NPNPQ was more towards neck-related 
pain problems. NHP was based on the 
overall well-being of the patient, and the 
pain was only one of the subclass of the 
questionnaire. The Pain Catastrophizing 
scale was more towards the patient's 
perception of pain-related fear rather than 
pain intensity quantification. 
 

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