Ergonomics 4310

Ergonomics 4310Ergonomics 4310

Pain Evaluations for Chronic Pain ClientsPain Evaluations for Chronic Pain Clients

Will Inkley, Corrin Porter, Ben MacPherson, and Kevin McCrae

What is Chronic Pain?What is Chronic Pain?

Pain that lasts longer than 3 monthsPain that lasts longer than 3 months Differs from acute pain in that it is not easy to Differs from acute pain in that it is not easy to

pinpoint the exact causepinpoint the exact cause Diagnosis can reveal no injury to the body at Diagnosis can reveal no injury to the body at

all, however the patient may be experiencing all, however the patient may be experiencing very debilitating painvery debilitating pain

Evaluating Chronic PainEvaluating Chronic Pain

Keep an open mind when evaluating patients Keep an open mind when evaluating patients Don’t fall into the trap of “catching Don’t fall into the trap of “catching

malingerers” for doctor’s and insurance malingerers” for doctor’s and insurance Look for symptoms consistent with the Look for symptoms consistent with the

diagnosis throughout evaluationdiagnosis throughout evaluation Wandering pain may be indicative of Chronic Wandering pain may be indicative of Chronic

Pain SyndromePain Syndrome

Evaluating Chronic PainEvaluating Chronic Pain

Be very observant and look for inconsistencies Be very observant and look for inconsistencies Observed in the workplace .vs. at homeObserved in the workplace .vs. at home Report what you see and do not be judgmentalReport what you see and do not be judgmental Report changes in worker when being Report changes in worker when being

unknowingly watched .vs. controlled unknowingly watched .vs. controlled environmentsenvironments

Normal Pain BehavioursNormal Pain Behaviours

GuardingGuarding BracingBracing Antalgic gait patternsAntalgic gait patterns Painful posturingPainful posturing GrimacingGrimacing Rubbing or massaging affected areaRubbing or massaging affected area Sighing or groaningSighing or groaning

Evaluation of the Chronic Pain ClientEvaluation of the Chronic Pain Client

Five tests to be administeredFive tests to be administered

1.1. Pain DrawingsPain Drawings

2.2. The McGill Pain Questionnaire The McGill Pain Questionnaire

3.3. The Visual Analog ScaleThe Visual Analog Scale

4.4. Numeric Pain Rating ScaleNumeric Pain Rating Scale

5.5. The Oswestry Low Back Disability The Oswestry Low Back Disability QuestionnaireQuestionnaire

Test 1: Pain DrawingsTest 1: Pain Drawings

PurposePurpose Allows client to explain to evaluator where he Allows client to explain to evaluator where he

or she feels chronic symptomsor she feels chronic symptoms Can be administered informally (through Can be administered informally (through

conversation) or formally (using the Ransford conversation) or formally (using the Ransford Pain Drawing)Pain Drawing)

Administration of Pain DrawingAdministration of Pain Drawing Ransford Pain Drawing is done on specific body chart Ransford Pain Drawing is done on specific body chart

with four symptoms: with four symptoms: Stabbing ///Stabbing /// Burning XXXBurning XXX Pins and needles 000Pins and needles 000 Numbness = = =Numbness = = =

Instructions state: Instructions state: ““Indicate where your pain is located and what type of pain Indicate where your pain is located and what type of pain

you feel at the present time. Use the symbols below to you feel at the present time. Use the symbols below to describe your pain. Do not indicate areas of pain which are describe your pain. Do not indicate areas of pain which are not related to your present condition.” not related to your present condition.”

Scoring the Ransford Pain DrawingScoring the Ransford Pain Drawing

1.1. Unreal DrawingUnreal Drawing poor anatomical localizationpoor anatomical localization

2.2. Drawing showing expansion or magnification of Drawing showing expansion or magnification of painpain

3.3. ““I particularly hurt here” indicatorsI particularly hurt here” indicators

4.4. ““Look how bad I am” indicatorsLook how bad I am” indicators

Scores for each section worth 0 (no pain), 1 or 2 Scores for each section worth 0 (no pain), 1 or 2 (most painful)(most painful)

Interpretation of ScoresInterpretation of Scores

A score of 3 or above indicates poor psychodynamics A score of 3 or above indicates poor psychodynamics Test is also useful as a distraction test to observe Test is also useful as a distraction test to observe

patient behaviour whilst sitting or standingpatient behaviour whilst sitting or standing Depending on what position he/she is in when doing the Depending on what position he/she is in when doing the

drawingdrawing Test takes approximately 5-8minutes to administer Test takes approximately 5-8minutes to administer

and approximately 5minutes to scoreand approximately 5minutes to score

Evaluation ToolEvaluation Tool

Clinical ApplicationsClinical Applications

Chiropractic officesChiropractic offices Physiotherapy officesPhysiotherapy offices Outpatient clinicsOutpatient clinics

Test 2: The McGill Pain Questionnaire Test 2: The McGill Pain Questionnaire (MPQ)(MPQ)

PurposePurpose Provides a valid, reliable, rapid, and consistent Provides a valid, reliable, rapid, and consistent

way of determining a client’s subjective pain way of determining a client’s subjective pain experienceexperience

Administration of MPQAdministration of MPQ Patient is provided with a form comprising Patient is provided with a form comprising

instructions in 20 word groupsinstructions in 20 word groups Patient is instructed to read each group and decide Patient is instructed to read each group and decide

whether a word in the group which describes a whether a word in the group which describes a symptom he or she is experiencing, at that timesymptom he or she is experiencing, at that time

Patient circles word in group which best describes Patient circles word in group which best describes their symptomtheir symptom

If no word in a given group explains their pain, they If no word in a given group explains their pain, they are to move on to the next group until all 20 word are to move on to the next group until all 20 word groups have been completedgroups have been completed

Administration of MPQAdministration of MPQ

Groups 1-10: Groups 1-10: Words used to describe sensory experienceWords used to describe sensory experience

Groups 11-15:Groups 11-15: Are effective wordsAre effective words

Group 16:Group 16: EvaluativeEvaluative

Groups 17-20:Groups 17-20: Miscellaneous groupsMiscellaneous groups

Words provide the key to diagnosis and may even Words provide the key to diagnosis and may even suggest the course of therapysuggest the course of therapy

Scoring the MPQScoring the MPQ

Each word in the group has a rank value as follows:Each word in the group has a rank value as follows:

Word Word RankRank WordWord RankRank

Word #1Word #1 11 Word #4Word #4 44



Scoring of MPQScoring of MPQ

Score each word group according to the word the Score each word group according to the word the patient circles and write the score alongside the group patient circles and write the score alongside the group numbernumber

Add scores for groups 1-10 and record this next to Add scores for groups 1-10 and record this next to sensorysensory

Add scores for groups 11-15 and record this next to Add scores for groups 11-15 and record this next to effectiveeffective

Write score for group 16 next to evaluativeWrite score for group 16 next to evaluative Add scores for groups 17-20 and record this next to Add scores for groups 17-20 and record this next to

miscellaneousmiscellaneous Add all four categories and write score next to TotalAdd all four categories and write score next to Total

Interpretation of MPQInterpretation of MPQ

A score of 30 or greater indicates poor A score of 30 or greater indicates poor psychodynamicspsychodynamics

Test may also be used as an evaluative tool to Test may also be used as an evaluative tool to assess pain before and after treatment assess pain before and after treatment techniques or medical procedurestechniques or medical procedures

Test takes approximately 5-10minutes to Test takes approximately 5-10minutes to complete and roughly 3minutes to scorecomplete and roughly 3minutes to score

Test ResultsTest ResultsGroup

#Score Group

#Score Group

# Score Group

# Score

1 4 6 NA 11 NA 16 5

2 3 7 2 12 NA 17 2

3 4 8 NA 13 NA 18 1

4 1 9 4 14 2 19 NA

5 NA 10 NA 15 NA 20 3

ScoreScore Sensory Score = 18 (sum Groups 1 to 10)Sensory Score = 18 (sum Groups 1 to 10) Effective Score = 2 (sum Groups 11 to 15)Effective Score = 2 (sum Groups 11 to 15) Evaluative Score = 5 (score Group 16)Evaluative Score = 5 (score Group 16) Miscellaneous Score = 6 (sum Groups 17 to 20)Miscellaneous Score = 6 (sum Groups 17 to 20)

Total Score = 31Total Score = 31 Client results indicate poor psychodynamicsClient results indicate poor psychodynamics

Test 3: Visual Analog Scale Test 3: Visual Analog Scale (VAS)(VAS)

PurposePurpose Determines patient pain levelDetermines patient pain level Huskisson (1974) claims the scale is the most Huskisson (1974) claims the scale is the most

sensitive way to assess painsensitive way to assess pain Easy to explain and for the patient to Easy to explain and for the patient to

understandunderstand

Administration of VASAdministration of VAS

Provide patient with VAS on a form with Provide patient with VAS on a form with instructions to indicate how severe the pain isinstructions to indicate how severe the pain is

Extreme ends on pain scale have “no pain at Extreme ends on pain scale have “no pain at all” at the bottom of the line to “pain as bad as all” at the bottom of the line to “pain as bad as it could be” at the top of the lineit could be” at the top of the line

Can be administered before or after treatment Can be administered before or after treatment to determine whether pain increases or to determine whether pain increases or decreasesdecreases

Scoring of VASScoring of VAS

Ensure that the vertical line is 10cm and Ensure that the vertical line is 10cm and measure the distance from “no pain at all” measure the distance from “no pain at all”

Correlating this value with the scoring system Correlating this value with the scoring system for the Numerical Pain Rating scale is useful for the Numerical Pain Rating scale is useful for determining whether a medical procedure for determining whether a medical procedure or treatment was beneficial in reducing painor treatment was beneficial in reducing pain

Test takes approximately 1minute to complete Test takes approximately 1minute to complete and 1minute to scoreand 1minute to score

Interpretation of ResultsInterpretation of Results

Pain Today is around 7.5 out of 10 ratingPain Today is around 7.5 out of 10 rating In the past 30 days:In the past 30 days:

Pain on the Worst day was about 9.5 out of 10Pain on the Worst day was about 9.5 out of 10 Pain on the Best day was about 3 out of 10Pain on the Best day was about 3 out of 10

Test 4: Pain Rating ScaleTest 4: Pain Rating Scale

PurposePurpose Most clients can easily express pain level with Most clients can easily express pain level with

a 0 to 10 rating systema 0 to 10 rating system 0 = no pain at all, 10 = maximal / emergency 0 = no pain at all, 10 = maximal / emergency

painpain Quick and easy method that can assess the Quick and easy method that can assess the

result a treatment or assessment technique has result a treatment or assessment technique has hadhad

AdministrationAdministration

Provide client with a copy of the Numeric Pain Provide client with a copy of the Numeric Pain Rating Scale Rating Scale

Have the client rate intensity of his/her pain Have the client rate intensity of his/her pain and the major area of painand the major area of pain

Client can also use decimal points as wellClient can also use decimal points as well Scale may also be used during or following an Scale may also be used during or following an

evaluationevaluation Ex: Work Capacity Evaluation (WCE)Ex: Work Capacity Evaluation (WCE)

Determine clients subjective ratings of pain in Determine clients subjective ratings of pain in response to testing or work activitiesresponse to testing or work activities

Key Factors to ObserveKey Factors to Observe Are the client’s pain ratings consistent with the Are the client’s pain ratings consistent with the

client’s:client’s: Affect or moodAffect or mood Speed of movementSpeed of movement Symmetry or movementSymmetry or movement Rhythm of movementRhythm of movement ROMROM Body mechanicsBody mechanics Muscle recruitmentMuscle recruitment Movement by distractionMovement by distraction

Scoring of Pain Rating ScaleScoring of Pain Rating ScalePain Ratings Pain Ratings Less than or equal to 2Less than or equal to 2

Movement patterns, speed of movement, rhythm and symmetry Movement patterns, speed of movement, rhythm and symmetry of movement are normal or near normalof movement are normal or near normal

Between 3 and 5Between 3 and 5 Movement patterns are slowed; external indicators of pain are Movement patterns are slowed; external indicators of pain are

usually observable Ex: Grimacing usually observable Ex: Grimacing Pain ratings in this level following physical activity are not Pain ratings in this level following physical activity are not

usually symptom magnifiersusually symptom magnifiers Between 6 and 10Between 6 and 10

Significantly impaired in their function and movement patternsSignificantly impaired in their function and movement patterns Demonstrate considerable pain behaviour, likely to be using Demonstrate considerable pain behaviour, likely to be using

analgesicsanalgesics These ratings of pain are usually indicative of symptom These ratings of pain are usually indicative of symptom

magnification syndromemagnification syndrome

Evaluation Tool (Function – Evaluation Tool (Function – Based) Based)

Test ResultsTest Results Pain Rating Now = 6Pain Rating Now = 6 Indicates:Indicates:

Significantly impaired in their function and Significantly impaired in their function and movement patternsmovement patterns

Demonstrate considerable pain behaviour, Demonstrate considerable pain behaviour, likely to be using analgesicslikely to be using analgesics

These ratings of pain are usually indicative of These ratings of pain are usually indicative of symptom magnification syndromesymptom magnification syndrome


Simple test to administer and evaluateSimple test to administer and evaluate Used in almost all medical and health related Used in almost all medical and health related

clinics clinics Ex: chiropractic offices, doctor’s office, Ex: chiropractic offices, doctor’s office,

hospital triage, physiotherapy clinics, etc….hospital triage, physiotherapy clinics, etc….

Test 5: Oswestry Low Back Disability Test 5: Oswestry Low Back Disability QuestionnaireQuestionnaire

PurposePurpose 10 item, self report checklist 10 item, self report checklist has been shown to be valid in assessing has been shown to be valid in assessing

perceived disabilityperceived disability Easy to complete for the client and easy for Easy to complete for the client and easy for

evaluator to scoreevaluator to score

AdministrationAdministration Provide client with standard 10-item checklistProvide client with standard 10-item checklist Instruct client to read each of the six Instruct client to read each of the six

statements in each scoring section and decide statements in each scoring section and decide which statement best relates themwhich statement best relates them

Can only choose one statement in each sectionCan only choose one statement in each section Author suggests using Author suggests using PinkPink paper since it is paper since it is

reported that patients find evaluation forms on reported that patients find evaluation forms on coloured paper more acceptable (Eastwood, coloured paper more acceptable (Eastwood, 1940)1940)

Scoring of Low Back Disability Scoring of Low Back Disability QuestionnaireQuestionnaire

Each section is scored from 0 to 5 points depending Each section is scored from 0 to 5 points depending on which statement they checkon which statement they check

If a section is not checked, potential score is dropped If a section is not checked, potential score is dropped by 5by 5

First statement in each section score 0First statement in each section score 0 Second scores 1, third scores 2, etc.Second scores 1, third scores 2, etc. Scores for all answered sections are added together Scores for all answered sections are added together

and divided by the total potential score, then and divided by the total potential score, then multiplied by 100 to obtain a percentagemultiplied by 100 to obtain a percentage

Interpretation of Disability ScoresInterpretation of Disability Scores

Minimal Disability (0-20%)Minimal Disability (0-20%) Group can cope with most living activitiesGroup can cope with most living activities Usually no treatment is indicated a part from Usually no treatment is indicated a part from

lifting, sitting posture, physical fitness, and dietlifting, sitting posture, physical fitness, and diet Some patients have particular difficulty sitting and Some patients have particular difficulty sitting and

this may be important if their new occupation is this may be important if their new occupation is sedentarysedentary

Ex: a typist or lorry driverEx: a typist or lorry driver


Moderate Disability (20-40%)Moderate Disability (20-40%) Group experiences more pain and problems with Group experiences more pain and problems with

sitting, lifting, and standingsitting, lifting, and standing Travel and social life are more difficult and they Travel and social life are more difficult and they

may be well off workmay be well off work Personal care, sexual activity, and sleeping are not Personal care, sexual activity, and sleeping are not

grossly affected and the back condition can usually grossly affected and the back condition can usually be managed by conservative meansbe managed by conservative means


Severe Disability (40-60%)Severe Disability (40-60%) Pain remains main problem Pain remains main problem Travel, personal care, social life, sexual activity Travel, personal care, social life, sexual activity

and sleep are also affectedand sleep are also affected Patients clients require detailed investigationPatients clients require detailed investigation


Crippled (60-80%)Crippled (60-80%) Back pain impinges on all aspects of these Back pain impinges on all aspects of these

patient’s lives both at home and at workpatient’s lives both at home and at work Positive intervention is requiredPositive intervention is required

80-100%80-100% Unspecified in the manualUnspecified in the manual

Test ResultsTest ResultsSectioSectio

nnStatemeStateme

nt #nt #ScorScor

eeSectioSectio

nnStatemeStateme

nt #nt #ScorScor

ee

OneOne 44 33 SixSix 11 00

Two Two 22 11 SevenSeven 22 11

ThreeThree 22 11 EightEight 11 00

FourFour 11 00 NineNine 11 00

FiveFive 33 22 TenTen 22 11

Interpretation of Client’s ResultsInterpretation of Client’s Results Disability Score = Disability Score =

(Sum of sections (Sum of sections ÷÷ Total possible score) x 100% Total possible score) x 100%

9 9 ÷÷ 50 = 0.18 x 100% = 18% 50 = 0.18 x 100% = 18%

Higher range of Minimal DisabilityHigher range of Minimal Disability Possibility if no intervention / modifications are Possibility if no intervention / modifications are

made to reach Moderate Disability stagemade to reach Moderate Disability stage


Workplace Safety and Insurance Board Workplace Safety and Insurance Board (WSIB)(WSIB)

Ergonomics assessment for insurance Ergonomics assessment for insurance companiescompanies

Limitations to Pain EvaluationsLimitations to Pain Evaluations Vocabulary used in pain evaluation forms may Vocabulary used in pain evaluation forms may

be too complex be too complex Many labour workers, foreign labour workers may Many labour workers, foreign labour workers may

not be able to comprehend the dialog usednot be able to comprehend the dialog used Tests can not be standardizedTests can not be standardized

For one person, they may have a higher pain For one person, they may have a higher pain tolerance, they may score lower then someone with tolerance, they may score lower then someone with lower tolerance to pain lower tolerance to pain

Easy for people to abuse the systemEasy for people to abuse the system Can say they have extreme pain, but no physical Can say they have extreme pain, but no physical

tests are administered with these evaluationstests are administered with these evaluations

Ergonomics 4310

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