39 Ann. psychophysiol. ISSN 2412-3188 (Online) | 2410-1354 (Print) 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/) 40 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 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. 41 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 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. 42 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 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 43 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 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 44 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 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. 45 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 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. 46 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 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, 47 ISSN 2412-3188 (Online) | 2410-1354 (Print) APP| Published By AEIRC| Volume 9 Issue 1 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. 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