Ergonomics 4310

1. Ergonomics 4310 Pain Evaluations for Chronic Pain Clients Will Inkley, Corrin Porter, Ben MacPherson, and Kevin McCrae

2. What is Chronic Pain? • Pain that lasts longer than 3 months • Differs from acute pain in that it is not easy to pinpoint the exact cause • Diagnosis can reveal no injury to the body at all, however the patient may be experiencing very debilitating pain

3. Evaluating Chronic Pain • Keep an open mind when evaluating patients • Don’t fall into the trap of “catching malingerers” for doctor’s and insurance • Look for symptoms consistent with the diagnosis throughout evaluation • Wandering pain may be indicative of Chronic Pain Syndrome

4. Evaluating Chronic Pain • Be very observant and look for inconsistencies • Observed in the workplace .vs. at home • Report what you see and do not be judgmental • Report changes in worker when being unknowingly watched .vs. controlled environments

5. Normal Pain Behaviours • Guarding • Bracing • Antalgic gait patterns • Painful posturing • Grimacing • Rubbing or massaging affected area • Sighing or groaning

6. Evaluation of the Chronic Pain Client Five tests to be administered • Pain Drawings • The McGill Pain Questionnaire • The Visual Analog Scale • Numeric Pain Rating Scale • The Oswestry Low Back Disability Questionnaire

7. Test 1: Pain Drawings Purpose • Allows client to explain to evaluator where he or she feels chronic symptoms • Can be administered informally (through conversation) or formally (using the Ransford Pain Drawing)

8. Administration of Pain Drawing • Ransford Pain Drawing is done on specific body chart with four symptoms: • Stabbing /// • Burning XXX • Pins and needles 000 • Numbness = = = • Instructions state: • “Indicate where your pain is located and what type of pain you feel at the present time. Use the symbols below to describe your pain. Do not indicate areas of pain which are not related to your present condition.”

9. Scoring the Ransford Pain Drawing • Unreal Drawing • poor anatomical localization • Drawing showing expansion or magnification of pain • “I particularly hurt here” indicators • “Look how bad I am” indicators Scores for each section worth 0 (no pain), 1 or 2 (most painful)

10. Interpretation of Scores • A score of 3 or above indicates poor psychodynamics • Test is also useful as a distraction test to observe patient behaviour whilst sitting or standing • Depending on what position he/she is in when doing the drawing • Test takes approximately 5-8minutes to administer and approximately 5minutes to score

11. Evaluation Tool

12. Clinical Applications • Chiropractic offices • Physiotherapy offices • Outpatient clinics

13. Test 2: The McGill Pain Questionnaire (MPQ) Purpose • Provides a valid, reliable, rapid, and consistent way of determining a client’s subjective pain experience

14. Administration of MPQ • Patient is provided with a form comprising instructions in 20 word groups • Patient is instructed to read each group and decide whether a word in the group which describes a symptom he or she is experiencing, at that time • Patient circles word in group which best describes their symptom • If no word in a given group explains their pain, they are to move on to the next group until all 20 word groups have been completed

15. Administration of MPQ • Groups 1-10: • Words used to describe sensory experience • Groups 11-15: • Are effective words • Group 16: • Evaluative • Groups 17-20: • Miscellaneous groups • Words provide the key to diagnosis and may even suggest the course of therapy

16. Scoring the MPQ • Each word in the group has a rank value as follows:

17. Scoring of MPQ • Score each word group according to the word the patient circles and write the score alongside the group number • Add scores for groups 1-10 and record this next to sensory • Add scores for groups 11-15 and record this next to effective • Write score for group 16 next to evaluative • Add scores for groups 17-20 and record this next to miscellaneous • Add all four categories and write score next to Total

18. Interpretation of MPQ • A score of 30 or greater indicates poor psychodynamics • Test may also be used as an evaluative tool to assess pain before and after treatment techniques or medical procedures • Test takes approximately 5-10minutes to complete and roughly 3minutes to score

19. Evaluation Tool

20. Test Results

21. Score • Sensory Score = 18 (sum Groups 1 to 10) • Effective Score = 2 (sum Groups 11 to 15) • Evaluative Score = 5 (score Group 16) • Miscellaneous Score = 6 (sum Groups 17 to 20) • Total Score = 31 • Client results indicate poor psychodynamics

22. Test 3: Visual Analog Scale (VAS) Purpose • Determines patient pain level • Huskisson (1974) claims the scale is the most sensitive way to assess pain • Easy to explain and for the patient to understand

23. Administration of VAS • Provide patient with VAS on a form with instructions to indicate how severe the pain is • Extreme ends on pain scale have “no pain at all” at the bottom of the line to “pain as bad as it could be” at the top of the line • Can be administered before or after treatment to determine whether pain increases or decreases

24. Scoring of VAS • Ensure that the vertical line is 10cm and measure the distance from “no pain at all” • Correlating this value with the scoring system for the Numerical Pain Rating scale is useful for determining whether a medical procedure or treatment was beneficial in reducing pain • Test takes approximately 1minute to complete and 1minute to score

25. Evaluation Tool

26. Interpretation of Results • Pain Today is around 7.5 out of 10 rating • In the past 30 days: • Pain on the Worst day was about 9.5 out of 10 • Pain on the Best day was about 3 out of 10

27. Test 4: Pain Rating Scale Purpose • Most clients can easily express pain level with a 0 to 10 rating system • 0 = no pain at all, 10 = maximal / emergency pain • Quick and easy method that can assess the result a treatment or assessment technique has had

28. Administration • Provide client with a copy of the Numeric Pain Rating Scale • Have the client rate intensity of his/her pain and the major area of pain • Client can also use decimal points as well • Scale may also be used during or following an evaluation • Ex: Work Capacity Evaluation (WCE) • Determine clients subjective ratings of pain in response to testing or work activities

29. Key Factors to Observe • Are the client’s pain ratings consistent with the client’s: • Affect or mood • Speed of movement • Symmetry or movement • Rhythm of movement • ROM • Body mechanics • Muscle recruitment • Movement by distraction

30. Scoring of Pain Rating Scale Pain Ratings • Less than or equal to 2 • Movement patterns, speed of movement, rhythm and symmetry of movement are normal or near normal • Between 3 and 5 • Movement patterns are slowed; external indicators of pain are usually observable Ex: Grimacing • Pain ratings in this level following physical activity are not usually symptom magnifiers • Between 6 and 10 • Significantly impaired in their function and movement patterns • Demonstrate considerable pain behaviour, likely to be using analgesics • These ratings of pain are usually indicative of symptom magnification syndrome

31. Evaluation Tool

32. Evaluation Tool (Function – Based)

33. Test Results • Pain Rating Now = 6 • Indicates: • Significantly impaired in their function and movement patterns • Demonstrate considerable pain behaviour, likely to be using analgesics • These ratings of pain are usually indicative of symptom magnification syndrome

34. Clinical Applications • Simple test to administer and evaluate • Used in almost all medical and health related clinics • Ex: chiropractic offices, doctor’s office, hospital triage, physiotherapy clinics, etc….

35. Test 5: Oswestry Low Back Disability Questionnaire Purpose • 10 item, self report checklist • has been shown to be valid in assessing perceived disability • Easy to complete for the client and easy for evaluator to score

36. Administration • Provide client with standard 10-item checklist • Instruct client to read each of the six statements in each scoring section and decide which statement best relates them • Can only choose one statement in each section • Author suggests using Pink paper since it is reported that patients find evaluation forms on coloured paper more acceptable (Eastwood, 1940)

37. Scoring of Low Back Disability Questionnaire • Each section is scored from 0 to 5 points depending on which statement they check • If a section is not checked, potential score is dropped by 5 • First statement in each section score 0 • Second scores 1, third scores 2, etc. • Scores for all answered sections are added together and divided by the total potential score, then multiplied by 100 to obtain a percentage

38. Interpretation of Disability Scores • Minimal Disability (0-20%) • Group can cope with most living activities • Usually no treatment is indicated a part from lifting, sitting posture, physical fitness, and diet • Some patients have particular difficulty sitting and this may be important if their new occupation is sedentary • Ex: a typist or lorry driver

39. Interpretation of Disability Scores • Moderate Disability (20-40%) • Group experiences more pain and problems with sitting, lifting, and standing • Travel and social life are more difficult and they may be well off work • Personal care, sexual activity, and sleeping are not grossly affected and the back condition can usually be managed by conservative means

40. Interpretation of Disability Scores • Severe Disability (40-60%) • Pain remains main problem • Travel, personal care, social life, sexual activity and sleep are also affected • Patients clients require detailed investigation

41. Interpretation of Disability Scores • Crippled (60-80%) • Back pain impinges on all aspects of these patient’s lives both at home and at work • Positive intervention is required • 80-100% • Unspecified in the manual

42. Evaluation Tool

43. Evaluation Tool

44. Test Results

45. Interpretation of Client’s Results • Disability Score = (Sum of sections ÷ Total possible score) x 100% • 9 ÷ 50 = 0.18 x 100% = 18% • Higher range of Minimal Disability • Possibility if no intervention / modifications are made to reach Moderate Disability stage

46. Clinical Applications • Workplace Safety and Insurance Board (WSIB) • Ergonomics assessment for insurance companies

47. Limitations to Pain Evaluations • Vocabulary used in pain evaluation forms may be too complex • Many labour workers, foreign labour workers may not be able to comprehend the dialog used • Tests can not be standardized • For one person, they may have a higher pain tolerance, they may score lower then someone with lower tolerance to pain • Easy for people to abuse the system • Can say they have extreme pain, but no physical tests are administered with these evaluations