Recognising pain sensitivity in the clinic
In the second instalment of our series on pain sensitivity, Darren Beales FACP and Tim Mitchell FACP explain what to look out for when conducting assessments.
In Part 1 of this series we agreed that pain sensitivity is an important consideration for all physiotherapists in clinical practice.
Pain sensitivity may alter a person’s response to treatment, can help patients make sense of their own conditions, could be used for subgrouping people and might provide insight into a patient’s prognosis.
So how do we recognise pain sensitivity in the clinic?
There are many aspects to interviewing people with pain. Ultimately, we need to engage in a person-centred approach that respects the lived experience of the person.
A simple interviewing model to help facilitate a person-centred approach is listen, observe, reflect, act.
The interview is not just the subjective assessment.
It is the entire interaction with the person in front of you, from when they enter to when they leave.
Maybe interview is the wrong word. Nevertheless, here we will focus on the subjective portion of the assessment, which is where clues to the presence of pain sensitivity may emerge.
Less or more likely?
Through a pain sensitivity lens, we should be able to determine from the subjective interview whether pain sensitivity is less or more of a priority when it comes time to perform a physical assessment (and in terms of the contribution of pain sensitivity to the overall presentation).
Deconstruction of different elements of the subjective interview may help physiotherapists answer this question as they move through the examination. Here we go.
Less likely—pain sensitivity is less likely to be a significant contributing factor.
More likely—pain sensitivity is more likely to be a significant contributing factor and may be a priority for the physical examination.
Area of pain
Less likely—pain is likely to be localised in this case. There may be somatic referral of symptoms.
More likely—pain can be localised but is often more widespread or spreading in unexpected ways (that are less anatomically plausible). Think about the person who has pain in the low back and a whole leg.
Constancy of pain
Less likely—pain is more likely to be intermittent (except when inflammation is dominant).
More likely—pain frequently is constant or unrelenting. Think about the person with constant neck, thoracic and low back pain that is at best 7/10.
Spontaneous pain is sharp bursts of pain when a person is truly at rest. It does not relate to bursts of pain associated with movement.
This may be considered a hallmark of neuropathic pain.
Less likely—rarely would this be an issue. If present, it is very infrequent and certainly not daily.
More likely—if this is present, and certainly if it is frequent, pain sensitivity should be more of a consideration.
Think about the person who at night experiences jolts of pain from their elbow into their fingers every five minutes.
Here we refer to pins and needles and numbness, but this may include peculiar feelings other than pain.
Less likely—unlikely to be nerve symptoms.
More likely—the presence of nerve symptoms may be indicative of pain sensitivity.
This may occur in non-dermatomal patterns.
Think about the person with low back pain who reports that they can’t feel their whole leg and that they also have pins and needles in the entirety of both hands.
Think about the person who has a cold arm with a sensation of ants running up and down it.
Report of sensitivity
Less likely—the person is unlikely to report specific symptoms of sensitivity.
More likely—the primary example here is an intolerance of tactile stimuli.
People don’t like being touched in the painful or sensitive area.
Clothes may be irritating. Think about a person who cannot tolerate bedsheets on their foot due to sensitivity.
Think about a person who reports that a breeze blowing on their sensitive forearm feels like being ‘cut by a knife’.
There might be intolerance to temperature.
We once came across a person who had to have a hot shower for the upper body but then change the temperature to cold for the lower body.
There might also be sensitivity to light, sound, smell, simple movement or even stress.
Aggravating and easing factors Less likely—there are clear aggravating activities or postures and very effective easing strategies (mechanical pain).
More likely—often (but not always) everything is aggravating and nothing is truly easing.
Additionally, there may be a ‘disproportionate’ response to activity (non- mechanical pain).
Think about the person with a sore back who, after sweeping one room in their house, is unable to do anything else for the next two days.
Less likely—there are not likely to be other pain-related conditions present.
More likely—there may be additional pain disorders present with a potential underlying basis in nervous system sensitivity.
Think of the person with widespread spinal pain, migraines, unexplained stomach pains and menstrual pain.
Perhaps they have restless leg symptoms as well.
Think more broadly
When pain sensitivity is more likely to be an issue, the odds are increased that the afflicted person might be doing worse generally.
Non-restorative sleep and poor mood might be common issues. Fatigue and cognitive dysfunction can occur.
There may be body perception changes. Think about the person with complex regional pain syndrome who does not recognise their hand.
Understanding patient beliefs is a central component of person-centred care.
If a person’s pain beliefs are orientated towards the biomedical, this may be quite at odds with the mechanisms underlying pain sensitivity.
Pathology can provoke sensitivity but more often pathology does not explain the symptoms of pain sensitivity and a broader perspective is required.
Many times, people with dominant pain sensitivity in their presentation will not understand what is going on.
Think about the person with chronic pain who has seen seven healthcare practitioners and has no plausible understanding of what is going on to cause or contribute to their ongoing pain.
When their pain makes less sense (and red flag and specific pathologies have been ruled out), then the presence of pain sensitivity may make more sense.
If pain sensitivity is more likely, you must act on this.
We understand that in a limited consultation time, the average physiotherapist will not be able to assess every potential aspect of a person’s presentation.
Nor should they have to.
To help guide physiotherapists, we have suggested a system of priorities for the physical examination of people with musculoskeletal pain (see breakout box below).
A key consideration here is that when pain sensitivity is suspected, the clinician must also consider red flag and specific disorders that may present with similar symptoms.
This priority schedule has been designed for musculoskeletal pain presentations and may need to be adapted for other areas of practice.
Darren Beales FACP
Priorities for the physical examination of people with musculoskeletal pain
Red flag disorders first.
Then, based on the subjective finding:
• if there is an indication of a specific neurological disorder (eg, radiculopathy), then triage of neurological function is a reasonable place to start the physical examination
• if there is mechanical symptom presentation but the source of the symptoms is unclear, a pertinent place to start might be a tissue-orientated examination to identify (as much as possible) the source of symptoms (eg, muscle, bone or tendon)
• if there is mechanical symptom presentation and the source of the symptoms is clear and/or not a priority, then functional testing can be a useful place to start.
Focusing on pain sensitivity should not be the initial priority in these cases.
If the subjective assessment suggests a situation where pain sensitivity is more of a feature as a potential contributing factor and/or there is a dominantly non-mechanical presentation, focusing on pain sensitivity at the outset of the physical examination would be a useful strategy.
This is often necessary to help interpret other aspects of the physical examination.
Tim Mitchell FACP
Like to hear Tim and Darren casually chat about the subjective assessment of pain sensitivity? Watch a video here.
Like to read about our take in a scientific journal? Beales et al. ‘Masterclass: A pragmatic approach to pain sensitivity in people with musculoskeletal disorders and implications for clinical management for musculoskeletal clinicians.’ Musculoskeletal Science and Practice, 2021. Read here.
Listening to pain stories might be helpful? Click here.
Want the bigger picture? Click here.
Like something short and fun? (Yes, it’s Tim and Darren again.) Watch here.
>>Darren Beales FACP is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2008) and a director at Pain Options in Perth, WA. As a senior research fellow at Curtin University, Darren is undertaking broad research into clinical pain, from the mechanistic understanding of clinical pain to efforts to enhance the management of persistent pain and implementation of knowledge into practice.
>> Tim Mitchell FACP is a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists in 2007) and a director of Pain Options. Tim has completed a PhD in the area of low back pain and has a special interest in the translation of logical reasoning into clinical practice. He holds positions with the Australian Physiotherapy Council and the Australian College of Physiotherapists.
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