Pain is a complex phenomenon that is difficult to evaluate and quantify because it is subjective and is influenced by attitudes and beliefs of the athletic
trigger point Localized deep tenderness in a palpable firm band of muscle. When stretched, a palpating finger can snap the band like a taut string, which produces local pain, a local twitch of that portion of the muscle, and a jump by the patient. Sustained pressure on a trigger point re-produces the pattern of referred pain for that site.
sclerotome A segment of bone innervated by a spinal segment.
trainer and the patient. Quantification is hindered by the fact that pain is a very difficult concept to put into words. 1
Obtaining an accurate and standardized assess-ment of pain is problematic. Several tools have been developed. These pain profiles identify the type of pain, quantify the intensity of pain, evaluate the effect of the pain experience on the patient’s level of func-tion, and/or assess the psychosocial impact of pain.
The pain profiles are useful because they com-pel the patient to verbalize the pain and thereby pro-vide an outlet for the patient and also propro-vide the athletic trainer with a better understanding of the pain experience. They assess the psychosocial response to pain and injury. The pain profile can as-sist with the evaluation process by improving com-munication and directing the athletic trainer toward appropriate diagnostic tests. These assessments also assist the athletic trainer in identifying which thera-peutic agents may be effective and when they should be applied. Finally, these profiles provide a standard measure to monitor treatment progress. 18
Pain Assessment Scales
The following profiles are used in the evaluation of acute and chronic pain associated with illnesses and injuries.
Visual Analogue Scales. Visual analogue scales are quick and simple tests to be completed by the patient ( Figure 3–1 ). These scales consist of a line, usually 10 cm in length, the extremes of which are taken to represent the limits of the pain experi-ence. 25 One end is defined as “No Pain” and the
CHAPTER 3 Managing Pain with Therapeutic Modalities 35 other as “Severe Pain.” The patient is asked to mark the line at a point corresponding to the severity of the pain. The distance between “No Pain” and the mark represents pain severity. A similar scale can be used to assess treatment effectiveness by placing
“No Pain Relief” at one end of the scale and “Com-plete Pain Relief” at the other. These scales can be completed daily or more often as pre- and post-treatment assessments. 21
Pain Charts. Pain charts can be used to estab-lish spatial properties of pain. These two-dimensional graphic portrayals are completed by the patient to assess the location of pain and a number of subjec-tive components. Simple line drawings of the body in several postural positions are presented to the patient ( Figure 3–2 ). On these drawings, the patient draws or colors in areas that correspond to his or her pain experience. Different colors are used for dif-ferent sensations—for example, blue for aching pain, yellow for numbness or tingling, red for burn-ing pain, and green for crampburn-ing pain. Descriptions can be added to the form to enhance the communi-cation value. The form could be completed daily. 24
McGill Pain Questionnaire. The McGill Pain Questionnaire (MPQ) is a tool with 78 words that describe pain ( Figure 3– 3 ). These words are grouped into 20 sets that are divided into four categories rep-resenting dimensions of the pain experience. While completion of the MPQ may take only 20 minutes, it is often frustrating for patients who do not speak English well. The MPQ is commonly administered to athletes with low back pain. When administered every 2 to 4 weeks, it demonstrates changes in sta-tus very clearly. 28
Activity Pattern Indicators Pain Profile.
The Activity Pattern Indicators Pain Profile measures athlete activity. It is a 64-question, self-report tool that may be used to assess functional impairment associated with pain. The instrument measures the frequency of certain behaviors such as housework, recreation, and social activities. 18
Numeric Pain Scale. The most common acute pain profile is a numeric pain scale . The patient is asked to rate his or her pain on a scale from 1 to 10, with 10 representing the worst pain he or she
No pain relief
Complete pain relief
None Severe
Figure 3–1 Visual analogue scales.
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has experienced or could imagine. The question is asked before and after treatment. When treatments provide pain relief, patients are asked about the extent and duration of the relief. In addition, patients may be asked to estimate the portion of the day that they experience pain and about specific activities that increase or decrease their pain.
When pain affects sleep, patients may be asked to estimate the amount of sleep they got in the previ-ous 24 hours. In addition, the amount of medication required for pain can be noted. This information helps the athletic trainer assess changes in pain,
select appropriate treatments, and communicate more clearly with the patient about the course of recovery from injury or surgery.
All of these scales help patients communicate the severity and duration of their pain and appreci-ate changes that occur. Often in a long recovery, athletes lose sight of how much progress has been made in terms of the pain experience and return to functional activities. A review of these pain scales often can serve to reassure the athlete; foster a brighter, more positive outlook; and reinforce the commitment to the plan of treatment.
Documentation. The efficacy of many of the treatments used by athletic trainers has not been fully substantiated. These scales are one source of data that can help athletic trainers identify the most effec-tive approaches to managing common injuries. These assessment tools can also be useful when reviewing a patient’s progress with physicians, and third-party payers. Thus, pain assessments should be routinely included as documentation in the patient’s note.
Left Left Left
Left Left
Left
Left
Left
Left Right
Right Right
Right
Right
Right Right
Right
Figure 3–2 The pain chart. Use the following instructions: “Please use all of the figures to show me exactly where all your pains are, and where they radiate to. Shade or draw with blue marker. Only the athlete is to fill out this sheet. Please be as precise and detailed as possible. Use yellow marker for numbness and tingling. Use red marker for burning or hot areas, and green marker for cramping. Please remember: blue = pain, yellow = numbness and tingling, red = burning or hot areas, green = cramping.”
Used with permission from Melzack, R: Pain measurement and assessment, New York, 1983, Raven Press.
Pain assessment techniques
• Visual analogue scales
• Pain charts
• McGill Pain Questionnaire
• Activity Pattern Indicators Pain Profile
• Numeric pain scales
CHAPTER 3 Managing Pain with Therapeutic Modalities 37
Figure 3–3 McGill Pain Questionnaire. The descriptors fall into four major groups: Sensory, 1 to 10; affective, 11 to 15;
evaluative, 16; and miscellaneous, 17 to 20. The rank value for each descriptor is based on its position in the word set.
The sum of the rank values is the pain rating index (PRI). The present pain intensity (PPI) is based on a scale of 0 to 5.
McGill Pain Questionnaire Patient's Name
PRI S A E
Flickering Quivering Pulsing Throbbing Beating Pounding 1
Jumping Flashing Shooting 2
Pricking Boring Drilling Stabbing Lancinating 3
Sharp Cutting Lacerating 4
Pinching Pressing Gnawing Cramping Crushing 5
Tugging Pulling Wrenching 6
Hot Burning Scalding Searing 7
Tingling Itchy Smarting Stinging 8
Dull Sore Hurting Aching Heavy 9
Tender Taut Rasping Splitting 10
Nagging Nauseating Agonizing Dreadful Torturing 20
No pain Mild
Discomforting Distressing Horrible Excruciating 0
1 2 3 4 5
Cool Cold Freezing 19
Tight Numb Drawing Squeezing Tearing 18
Spreading Radiating Penetrating Piercing 17
Annoying Troublesome Miserable Intense Unbearable 16
Wretched Blinding 15
Punishing Gruelling Cruel Vicious Killing 14
Fearful Frightful Terrifying 13
Sickening Suffocating 12
Tiring Exhausting
Brief Momentary Transient
Rhythmic Periodic Intermittent
Continuous Steady Constant 11
M PRI (T) PPI
Date
(1 –20) (17–20)
(16) (11–15)
(1–10)
Time am/pm
PPI
COMMENTS
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