M ARCH 1980 P H Y S I O T H E R A P Y 13 T H E SU B JECT IVE ASSESSMENT O F PAIN DURING T H E TR EA T M EN T O F ORTHOPAEDIC J O I N T PROBLEMS J. E D E L IN G , B.Sc. Physiotherapy (Rand)* SU M M A R Y A system is proposed w hereby the pain syn d ro m e m ay be num erically expressed. T h e system was developed fo r the assessm ent o f conditions w here pain was the dom inant clinical feature an d objective fin d in g s were m in im a l e.g. headaches derived fro m the cervical spine. A com prehensive subjective account o f pain is recorded an d three o f the variables are num erically graded to reflect the severity o f the total syndrom e. A n exam ple is given in order to dem onstrate the clinical use o f the system . 5 In the exam ination of any physical disorder the p ra c ­ titioner tries to reconcile subjective inform ation w ith objective findings. If the condition involves the loco­ m otive parts, the physiotherapist will try to define the problem in term s of jo in t or m uscle dysfunction. O ften the exact n atu re of the pathology has not been defined, and then trial treatm en t will be d irected at effecting an im provem ent in signs and sym ptom s (M aitland, 1977). M ore w eight is usually afforded to th e signs, or objective findings, because they are m ore readily m easurable and therefore of m ore scientific value. In cases w here the subjective an d the objective exam ination are not equally inform ative the physiothera­ pist is obliged to depend largely, and at tim es totally, on the one or the other. In such cases it will be clear th a t m ore tim e and atten tio n m ust be given to ex trica­ ting every possible bit of inform ation from the sources available. P hysiotherapists are often confronted w ith this situ a­ tion in cases w here the overriding com plaint is th a t of pain. T he underlying pathology m ay be o f a degenera­ tive nature, such as osteoarthritis and so we do not aim to arrest or cure it but direct our efforts to relieving the aspect of the pathology th at bothers the p atien t and th at is usually pain. In such conditions pain is usually accom panied by stiffness or lim itation of physiological m ovem ent (that V hich a p atient can perform actively) a n d /o r accessory m ovem ent (that m ovem ent which can n o t be perform ed actively). W hen this is so, m easurem ent of th e restriction form s an im p o rtan t p art of the objective exam ination and the m easured im provem ent in m ovem ent is used to evaluate the effectiveness o f the trial treatm en t (M aitland, 1977). N o t infrequently there are patients w ho com plain of severe pain, yet there is no m easurable lim itation of physiological m ovem ent. T here is, in these cases, painful lim itation o f a p articu lar accessory m ovem ent. T his accessory m ovem ent might possibly be used as a tre a t­ m ent technique, but in the a u th o r’s experience it is not a very useful objective finding for the purposes o f reassessm ent. If, therefore, physiotherapists are to have any chance of therapeutically relieving the pain in such cases they must m ake full use o f all the available inform ation (M aitland, 1978), including the p a tie n t’s subjective account o f pain. M any p ractitioners do not consider a subjective report of pain of m uch scientific value b e ­ cause it is not considered to be m easurable. But when it becom es the only indicator, ways m ust be found to * Private p ractitioner, Johannesburg. Received 19 A pril 1979. OPSOM M ING ’n Stelsel waarvolgens ’n pynsindroom num eries uit- gedruk kan word, w ord voorgestel. D ie stelsel is ont- w ik k e l om toestande waar pyn die oorheersende kliniese teken en objektiew e bevindings m inim aal was, byvoor- beeld h o o fp yn e a fko m stig van die servikale gebied, te evalueer. ’n O m vattende subjektiew e verslag van p yn w ord opgeteken en drie variante w ord num eries gegra- deer om die felh eid van die gehele sindroom te weer- spieel. ’n V oorbeeld w ord gegee om die kliniese aan- wending van die stelsel te dem onstreer. use it. Review of the literature pertaining to the field of pain and inform ation o b tain ed on this score fro m treating over a th ousand patients w ith headaches has led th e au th o r to establish a system for the subjective assessm ent of pain w hereby com parable param eters are recorded. T his system has proved to be helpful and dependable. Tt is necessary to elicit and record a total pain pattern (T.P.P.) a t first interview w hich includes a retrospective p attern starting, perhaps, years before and leading up to the p a tte rn currently present. T h e T .P .P . is un iq u e to each patient. G U ID IN G PRINCIPLES 1. T h e recording o f the T .P .P . will n o t necessarily lead to a diagnosis, although som e o f the clinical featu res m ight suggest specific pathology. In such cases it m ay be desirable to retu rn the p atien t to the referring doctor for possible fu rth er investigation. 2. T he purpose of recording a T .P.P. is to have a stan d ard fo r com parison after treatm ent. In this w ay it will be possible to d etect early m arginal changes and so be able to evaluate the effectiveness o f trial tr e a t­ ment. 3. T h ere is adm ittedly no reliable way of com paring the subjective intensity of one p erso n ’s pain w ith th a t of another. A p atien t is, however, well able to com pare the intensity o f her* own p ain a t different times. The p a tie n t’s report o f the varying intensities and th e p re ­ sence and absence of her own p ain are recorded for later com parison. E very o ther clinical fe a tu re th a t can be ex tracted is also recorded. M an y o f these clinical features can be used as additional or altern ate reassess­ m ent points. 4. T h e T .P .P ., if adequately taken, will p o rtray the increasing severity o f the p ain syndrom e up to p resen ­ tation, the initial response to tre a tm e n t and th e steady decrease until discharge. I t will also enable th e physio­ th erap ist to judge to w hat ex ten t the im provem ent is m aintained at subsequent follow -up assessm ent. 5. If th e record is incom plete, attem pts at reassess­ m ent are likely to be confusing and m isleading. TOTAL P A IN PA T T ER N (T.P.P.) Distribution T he p atien t should be asked to indicate, using a * T he p a tie n t will be referred to as she, h e r etc. fo r convenience. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 14 F I S I O T E R A P I E MAART 1980 finger, the area o f the worst pain, the ex ten t and m an ­ ner of radiation and any other related or unrelated areas o f pain; also w here th e pain usually begins. T he p atien t m ight say th a t under certain circum stances it is in one area and under others, elsewhere. T hese areas should be carefully draw n in on a chart w ith suitable .annotations and, before going further, the p atien t should be shown the c h a rt and requested to confirm th e pain distribution recorded and to check notes fo r accuracy (see diagram 1). C hanges in the pain distribution pattern could m ean th a t treatm en t is having an effect on the pain. Nature of Pain A clear distinction m ust be m ade between the nature (or quality) o f pain and the intensity o f pain. I f the question is put as fo llo w s:— “ W hat does th e pain feel lik e ? " the p atien t will often tell how severe it is. I t is better to ask “ W h at does your pain feel lik e ? ” and add “ 1 d o n 't m ean how bad it is but what sort o f pain is i t ? ” If a spontaneous reply is not forthcom ing, she should be helped by saying: “D oes it throb, or is th ere a feeling of pressure or burning w ith it ? ” and she will then tinderstand' and respond by saying: “O h no it never throbs Or burns — it’s just a gnaw ing p ain ” or whatever the case may be. Som e patients do not know th a t there are various qualities to pain. T hey think w hat they feel is pain and th at all pain feels th e way th e ir’s does. Periodicity (P) W hen there is an established periodicity p attern to the occurrence o f p ain this form s th e m ost useful featu re fo r m easuring im provem ent. M ostly it is a very simple m atter. I f a p a tie n t has h ad a continuous pain fo r a long p erio d an d during the course o f treatm en t the p ain becom es in term itten t an d finally abates, one need n o t p erfo rm m ental gymnastics in o rd er to assess im ­ provem ent. All too often th ere are, how ever, confusing factors th at bedevil assessm ent. T h is m ay cause one to a b a n ­ don th e only effective treatm ent because one h ad no t been aw are o f th e in itial m arginal im provem ent in the periodicity pattern. It is useful to grade th e p erio d icity fro m P 1 - P 5 : G ra d e P I = P a in on one day a m onth o r less. P2 = P a in on two o r m ore days p e r m onth. P3 = P a in on one o r m o re days a week. P4 = In term itten t b u t daily pain. P5 = C ontinuous pain. R eassessm ent If a P5 pain abates alto g eth er fo r even a very sh o rt w hile a fte r treatm ent, it is no longer a P5 b u t a P4. If a P4 pain skips a day, this is an im provem ent, etc/- W here p ain p erio d icity p attern s do n o t read ily con-, fo rm to this system because they are erratic, one is still able to use them b u t it requires m uch m o re skill. Intensity (I) G ra d e th e subjective intensity o f pain also fro m 1 - 5: G ra d e U = M ild pain. 12 = M ore th a n m ild pain b u t tolerable. 13 = M oderately severe. 14 = Severe. 15 = Intolerable, suicidal pain. Patients are often quick to m atch th e ir p a in intensity to one o f the above grades. If they are not. they should P A IN D IS T R IB U T IO N F eeling o f pressure here at times Starts here behind rig h t eye moves up and backw ards V ery seldom o n left sam e d istrib u tio n never as severe Diagram 1. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) MARCH 1980 P H Y S I O T H E R A P Y 15 be asked w hat they feel like an d how it affects them when the pain is a t its w orst. T his usually unleashes a vivid d escription o f the im pact o f the p ain on the in d i­ vidual. T h e p h y sio th erap ist m ust then in te rp re t this im pact: II . D oes the p atien t consider it to be “n o rm a l” pain? T h is is a p ain th a t is acceptable to a person and th at has no em otional overlay. 13. Is the p ain affecting th e p a tie n t’s life? Does it in te rru p t life style, w ork, dom estic o r social life? 15. Is the p a in com pletely in to lerab le and disruptive? Is life totally engulfed in unrelieved, severe pain? A re there hints o f suicide? C ould you, the th erap ist, live w ith such pain? Assess accordingly. D o you consider this p ain to be G ra d e II , 13 o r 15 o r in betw een 12 o r 14? T his is the p h y sio th erap ist’s “m easure” o f th e intensity o f pain. Response to Analgesics S elf-adm inistered o r prescribed). I t seems th a t th e response o f p ain to analgesia often depends on the stage o f the pathology w hich is p ro ­ ducing the pain. It also depends on the severity o f the pain. If one considers th e kind o f p a in w hich arises fro m p ain fu l jo in t restriction, it w ill be fo u n d th a t as the jo in t condition deteriorates, analgesics becom e p ro ­ gressively less effective. L ater, if th e physiotherapy treatm ent is im proving the co n d itio n o f the joint, analgesics seem to becom e m ore effective. A s this fact em erged repeatedly in p a tie n ts’ reports, it was included in the system as an o th e r param eter fo r “m easu rin g ” the im provem ent o f p ainful conditions. V ery often assess­ m ent o f the response to analgesics is helpful when re ­ assessm ent of o th e r factors is inconclusive. F o r exam ple, if in itially a p atien t reports th at no a m o u n t of analgesics totally relieves h er p ain but 2 S topain will lessen it fo r an h o u r o r so and afte r a couple of trial treatm ents she tells you th a t h e r pain w ent aw ay com pletely fo r several h o u rs w ith the sam e dose, this indicates an im provem ent. R esponse to an al­ gesics m ay also be graded, R1 - R5: G ra d e R1 = P a in abates readily w ith sm all dose of m ild analgesic. R2 = P a in is lessened but does n o t ab ate w ith m ild analgesic. R 3 = P a in is totally relieved by strong an al­ gesic. R4 = P a in is lessened but does n o t abate w ith large dose o f strong analgesic. R5 = N o dose o f an y analgesic even lessens th e pain. Precipitating and Aggravating Factors In this instance the p hysiotherapist wishes to know from the p atien t w h at brings on a p ain o r m akes a continuous p a in worse. W hen th ere is a spontaneous reply it should be recorded v erb atim and earm ark ed fo r later com parison. If one o r m ore o f these factors becom e im p o ten t after treatm ent, this signifies im provem ent in o r cure o f the pain-producing condition. It will be fo u n d th a t the p a tie n t w ith a long esta­ blished pattern o f pain will readily supply these factors. T hose w ith patterns o f m ore recent onset w ill be less able to do so. If a patient says she doesn’t know th a t brings on her pain, she should be gently probed and given examples o f the factors th a t m any o th er patients report. T his will m ake her think ab o u t it and she m ay be able to supply such in fo rm atio n at her next visit. Sometim es, however, th ere is no discernable trigger factor. Associated or Concomitant Symptoms T h e p atien t should be asked: “A p art fro m the pain, do you have any o th er sensations th a t seem to be related to the p a in ? ” T hese m ust be recorded verbatim . If she says she hears a sound in h e r left ear like a cricket, o r bubbles, these should not be transcribed as “tin n itu s”. R ecord as said by th e patient. A ssociated sym ptom s are less useful as a yardstick fo r im provem ent b u t the T .P.P. is incom plete if you do not know all a b o u t them. I t is here th at w arnings o f pathology w hich may lie beyond the scope o f physiotherapy m ay be recog­ nised. T hese replies should be recorded w ith the neces­ sary attention. Som etim es these factors decrease before th e p a in does in w hich case they m ay be 'n d ic a tiv e of im provem ent. History T o com plete the T .P.P ., take a retrospective history w hich should cover aspects such as the follow ing: 1. In itia l onset o f this p a in pattern. 2. P rogression over years/m onths/days. 3. A etiology — w hether trau m a, disease, strain, surgery, pregnancy, occupational posture etc. 4. P revious treatm ent and response to it. 5. F a m ilia l factors. QU ESTION IN G TECHNIQUE 1. A llow plenty o f tim e fo r th e first interview , ab o u t 45 m inutes. 2. U se record sheets w ith stan d ard headings to achieve an ordered p attern , but do not be rigid if the p a tie n t offers info rm atio n th a t doesn’t seem to fit the form . R ecord it un d er a heading called “m iscel­ lan eo u s” o r “points o f in terest”. 3. D o not restrict th e p atien t to b rie f answers. E n ­ courage her, a t som e stage, to just “tell m e a b o u t y o u r p a in ”. T his elicits a useful im pression o f just how m uch the p ain intrudes u p o n h e r life. I f she ram bles on too m uch, she should be guided back to answ ering m ore direct questions. 4. O ften patients a re em barrassed a b o u t describing b izarre sym ptom s. T hey are afraid th a t the in te r­ view er will th in k th a t they are im agining things or exaggerating. T h e p h y sio th erap ist should seem in te r­ ested b u t u n alarm ed when they confide these “ dark secrets” and reassure w here necessary. 5. T h e p hysiotherapist should n o t seem to be cen­ sorious w hen asking a b o u t analgesics o r o th er drugs. T h e p a tie n t w ill th in k th a t th e phy sio ­ th e ra p ist is going to restrict h e r drug taking and will give evasive answers. She is alread y w orried a b o u t side-effects b u t cannot face th e p a in w ith o u t analgesics. She m ust be given to u n derstand that all th a t is required is in fo rm atio n fo r later com ­ parison. If, later, she needs less by w ay o f p ain killers, h er pain producing co n d itio n is im proving. A lso, if th e sam e analgesic w hich previously gave no o r little relief later gives som e o r total relief, th e condition is im proving. 6. W hen asking a b o u t aggravating o r precip itatin g factors a n d /o r associated sym ptom s th e phy sio ­ th e ra p ist m ust be m a tte r o f fact. P atien ts w ith a chronic headache, fo r instance, freq u en tly have concom itant sym ptom s th a t te rrify them . “Strange noises in m y ears” (tinnitus) o r a constrictive o r o bstructive feeling in th e th ro a t (globulus h y steri­ cus), dysphasia and visual disturbances a re b u t a few of these sym ptom s. T hese sym ptom s should be asked fo r in an o rd in ary so rt o f way, recorded, and th e p atien t should be reassured if she seems R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 16 F I S I O T E R A P I E MAART 1980 anxious. If th e p atient says “you p ro b a b ly w o n ’t believe me b u t m y pain is w orst when m y m other- in-law v isits”, believe h e r and record this fact. If la te r in the course o f treatm en t she rep o rts a visit fro m m other-in-law w ith no ensuing headache, the p h y sio th erap ist m ay assum e th a t it is the condi­ tio n th a t has im proved, n o t the m other-in-law ! If you are alerted by a report, do n o t alarm th e patien t b u t m ake a note to check the follow ing: # Is this a fa m ilia r rep o rt in the clinical situation o r the lite ra tu re ? I f so, was it indicative o f som ething th a t lies w ithin the scope o f physio­ therapy? # H as the p atien t told h e r d o c to r ab o u t it? W h eth er she has o r not, it m ig h t be wise fo r the p h y sio th erap ist to discuss it w ith the doctor before proceeding w ith fu rth e r treatm ent. # H as th e p a tie n t been seen by an a p p ro p ria te specialist a n d have the necessary objective diag­ nostic procedures been executed? If so, th ere is seldom cause fo r alarm . 7. I t is often h elpful to record, verbatim , descriptive w ords o r phrases used by th e patient. T hese should n o t be transcribed. W hen reassessing a t a later date use the w ord o r p h rase w hich was recorded a t the first visit. T h is enables the p a tie n t to identify the sensation w hich she orig in ally described. She will a t once be ab le to com pare h e r present sensations o r pain reliab ly and to say, quite definitely, “I no longer have th a t dreadful scalding p ain , it’s just a dull ache n o w ” etc. 8. If the p a tie n t finds a question difficult to answer, do n o t press her. H elp h e r by: # R e-phrasing th e question. # T elling h e r w hat you, as therapist, a re seeking to establish. # Saying it n eed n ’t be exact b u t approxim ate. # Passing on to the next question, saying it is not im portant. 9. If th e p atien t, at the first visit, is in severe pain do no t subject h e r to prolonged questioning. E n d eav o u r to o b tain sufficient in fo rm atio n to sug­ gest a fo rm o f p alliativ e treatm en t an d leave the T .P.P. till th e severe attack has passed. 10. W hen questioning fo r response to treatm en t never seem to b e d isappointed o r sceptical w hen a patient rep o rts a negative response. She should be questioned fu rth e r to ensure th a t th e re was no m arginal im provem ent w hich the p atien t m ight have thought irrelevant. If there was none, do n o t dis­ credit the p a tie n t’s report, b u t try altern ativ e tech­ niques until there is a positive response. T he p a tie n t m ust understand th a t w hat the th erap ist is seeking is n o t gratification b u t th e tru th . A SSESSM E N T B A SED O N T .P .P . W hen attem p tin g to get a num erical estim ate o f a p ain syndrom e o n e m ust consider m ore than one param eter. P erio d icity (P), intensity (I) and response to analgesics (R) are used according to the grading shown u n d er the relevant headings. P ain should be th o u g h t o f in term s o f “ q u an tity o f p a in ”, i.e. how m uch pain is there fo r w hat proportion o f the day, w eek, m onth, year? T h e q u an tity of pain is th e sum o f P an d I and the indices fo r each o f these are added together. It is not enough to estim ate the severity o f the syndrom e in term s of intensity alone. If one adds th e (R) index the num erical estim ate has a n o th e r dim ension. T h e T .P.P. is the sum o f the three indices, and an increase o r decrease in any one of th em will be reflected in a num erical reduction in T .P.P. E xam ple A typical b u t uncom plicated p a tte rn is depicted as fo llo w s:— A w om an, aged 53 com plains o f daily headache. She wakes w ith o u t it b u t it comes on m id-m orning and builds up. By m idday it is so severe th a t she is unable to concentrate on her w ork as a typist.She is obliged to take two strong pain killers, w hich do n o t totally relieve h er pain b u t reduce it to a level w hich allows h e r to continue h e r w ork through th e afternoon. E stim ate o f her T.P.P. at this stage: P = 4, I = 3, R = 4, T .P.P. = 11. She says th a t she has suffered headaches fo r very m any years, possibly since p u b erty , b u t th a t they have only been as bad as they are now fo r th e p ast fo u r years. D u rin g her high school years she rem em bers having headaches at exam ination tim es b u t they w ere m ild e r com pared w ith h e r present headaches and w ere to ta lity > relieved by an aspirin. Estim ate o f her T.P.P. at that stage P = 1, I = 1, R = 1, T .P.P. = 3. A fter th e b irth o f her second child (at age 23) the headaches becam e worse. She rem em bers when the children w ere sm all th a t she often had headaches w hich w ere no longer m ild and asp irin had less and less effect. E stim ate o f T.P.P. over intervening years: P «= 2 . . . 3, I = 2, R = 2 . . . 3, T .P.P. = 6 . . . 8 F o u r years ago, a fte r a m in o r w hiplash in ju ry the headache w orsened to its present level w hich has been established as p = 4 , I = 3, R = 4. T .P.P. = 11 A fter som e in itial treatm en t she rep o rts th a t her headache cam e on as usual b u t w ent aw ay fo r several hours afte r taking h e r usual tablets. N o w P. = 4, I = 3, R = 3. T .P.P. = 10 T h e th e ra p ist continues w ith the sam e treatm en t and th e p a tie n t subsequently reports th a t her headache skipped a day, b u t when the p ain cam e th e fo llo w in g , day it w as o f the sam e intensity, b u t was again to tally ^/ relieved by the tablets. N o w P = 3, I = 3, R = 3. T .P.P. = 9 Subsequent reports should reveal dim inishing P, I and R indices. W hen the p a tie n t has h ad no p ain fo r a m onth. P = ? O o r I, I = O, R = O, ie T .P.P. = ? 0 o r I T his pattern m ay be graphically represented as shown in D iag ram 2. I t is o f critical im portance to judge th e initial m arginal response to treatm ent. If this is n o t perceived o r correctly in terpreted th e p a rtic u la r technique w hich produced this m arg in al im provem ent m ig h t n o t be pursued. F u rth e rm o re , afte r th e in itial fav o u rab le response to treatm ent, th ere usually is an overall decline in the T .P.P. (and th erefo re o f the syndrom e) b u t it m ay not always be a lin ear decline. T h e im provem ent could be interspersed w ith peaks o f seem ing recurrences. If the th erap ist has an accurate record it will be clear to her, and to th e patient, th at these are peaks in a rapidly declining lin ear relatio n sh ip (see D iag ram 3). R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) MARCH 1980 13 X, T .P.P. H IS T O R Y P H Y S I O T H E R A P Y 17 23 traatment Instigated 33 i»3 Patient'a age in years 53 Diagram 2 C O N C L U SIO N T his system has served its p urpose in over 700 cases of chronic headache assessed and treated over a period o f eight years. A lthough devised specifically fo r cervical headache m ost o f it can be applied to o th e r o rth o p aed ic joint dysfunction an d som e o f it possibly to o th e r pain fu l conditions w hich lie outside the a u th o r’s experience. References 1. G. D. M aitlan d (1977) V erteb ral M a n ip u latio n , 4th Ed., L ondon — B oston, B utterw orths. 2. G. D. M aitlan d (1977) P erip h eral M a n ip u latio n , 2nd E d., L ondon — Boston, B utterw orths. 3. M itchell, D. (1979) L ecture notes on Pain. B ibliography D e C aire, E. (1970) N europhysiology fo r M edical G raduates, Johannesburg, W itw atersrand U niversity R uch, T. C., P atton, H . D ., W oodbury, J. W ., Towe, A. L. (1965) N europhysiology, 2nd Ed., P h ilad elp h ia and L ondon, W. B. Saunders C om pany. K oele, K. D ., Sm ith, R. (1966): D iscussion on research into pain. Section o f G eneral P ractice of the R oyal Society o f M edicine. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )