original article Wien Med Wochenschr (2016) 166:5–8 DOI 10.1007/s10354-015-0411-4
Practical assessment in patients suffering from musculoskeletal disorders Mohammad Keilani · Andrew J. Haig · Richard Crevenna
Received: 24 October 2015 / Accepted: 24 November 2015 / Published online: 9 December 2015 © Springer-Verlag Wien 2015
Summary Short review of exemplary clinical assessment methods to describe clinical evidence-based assessment for patients suffering from symptoms of musculoskeletal pain. History and physical examination are the primary evidence-based assessment instruments for pain patients. Pain scales and questionnaire might allow assessment of different aspects of pain in order to perform an individualized therapy for pain patients. Keywords Pain · Assessment · Clinical examination · Scales · Questionnaires
Praktisches Assessment bei Patienten mit dem Symptom muskuloskelettaler Schmerz Zusammenfassung Kurz-Übersicht zum klinischen Untersuchungsgang und Assessment bei Patienten mit dem Symptom muskuloskelettaler Schmerz unter Berücksichtigung evidenzbasierter Gütekriterien. Evidenzbasierte Assessmentmethoden stellen primär die Anamnese und körperliche Untersuchung dar. Diese können durch Anwendung von Skalen und Fragebögen zwecks genauerer Evaluierung mit dem Ziel der Erstellung eines individuell angepassten Therapieplans gut ergänzt werden.
Dr. M. Keilani, MSc () · R. Crevenna Department of Physical Medicine and Rehabilitation, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria e-mail:
[email protected] Schlüsselwörter Schmerz · Assessment · Klinische Untersuchung · Skalen · Fragebogeninstrumente
Introduction Musculoskeletal pain and pain-associated impairment/ disability have negative influence on health-related quality of life (HRQOL) of patients. Evidence-based pain assessment is an essential step in the treatment and rehabilitation of patients suffering from musculoskeletal pain. The aim of the present short review was to describe clinical evidence-based assessment for patients suffering with the symptom musculoskeletal pain. This review was performed to give specialists in the field of Physical Medicine and Rehabilitation (PM&R) a short overview about clinical examination, scores, and questionnaires which are used in the assessment of patients suffering from musculoskeletal disorders. Furthermore, it could be a practical guide to how to assess such patients in daily routine.
Materials and methods A description of clinical assessment methods of musculoskeletal pain was performed by using the databases PubMed and Embase. Original articles, reviews, and supplements were included in the present short review. The search terms were selected in accordance with Viennese specialists of PM&R to evaluate history taking, clinical examination, scores, and questionnaires for daily routine [1].
A. J. Haig Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI, USA
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Practical assessment in patients suffering from musculoskeletal disorders
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original article Results The symptom of pain can be assessed by using instruments which seem to have sufficient reliability, validity, responsiveness, and objectivity [2].
Clinical examination Clinical examination begins with history taking (including pain history). Pain history can be taken by using the SOCRATES mnemonic [3]. The SOCRATES mnemonic is a pain assessment algorithm that is commonly used by physicians to help them to remember to ask about key questions concerning a patient’s pain [3]. The elements of this framework are site, onset, character, radiation, associated factors, timing, exacerbating and relieving factors, and severity of pain [3]. In the assessment of back pain red flags are examined in order to identify serious pathologies as early as possible [4], [table 1]. A systematic review of red flags to screen for malignancy and fracture in patients with low back pain revealed that older age, prolonged use of corticosteroids, severe trauma, and presence of a contusion or abrasion were the factors with the highest probability for detection of vertebral fracture (95 % CI 0.654–1.014) [5]. Furthermore, probability of spinal fracture was higher when multiple red flags were present [5]. Yellow flags are risk factors of developing chronic disability [6, 7]. Yellow flags consist of psychological risk factors, social, and environmental variables which have different risk intensity of pain chronicity [6, 7]. Table 2 shows different evidence levels of yellow flags. In the optimized management of back pain yellow flags should be recognized. They can be assessed by history taking and using questionnaires. The next step of clinical musculoskeletal pain assessment is the physical examination of the vertebral column and the peripheral joints. Basics of physical examination of vertebral column (including the sacroiliac joint) Table 1 “Red Flags” Age 50 years Failure to improve with therapy; pain persists for more than 4–6 weeks Bad general condition Fever, infections Unintentional weight loss Cancer Chest pain Severe trauma, presence of a contusion or abrasion Intravenous drug abuse Advanced HIV infection, immunosuppression Prolonged corticosteroid use Osteoporosis Progressive neurologic deficit Rheumatic diseases
Table 2 Evidence of “Yellow Flags” Strong evidence Depression, distress (negative stress, negative perceptions about the relationship between work and health) Pain-related cognitions: for example, catastrophizing, helplessness/hopelessness, fear avoidance beliefs (e.g., fears about the potential for physical activities to produce pain and further harm to the spine) Passive pain behaviour (e.g., avoidance of activities due to expectations of pain) Moderate evidence Pain-related cognitions: thought suppression Hyperactive pain behaviour (task persistence) Disposition for somatization Limited evidence Personality disorders
in patients with “nonspecific” neck pain, back pain, low back pain are inspection (posture, pelvic obliquity, leglength difference, deformities, trauma signs), palpation of spinous processes and facet joint (pain provocation tests), and testing of general and segmental range of motion (ROM) (motion studies). Furthermore, the basic physical examination is amplified by testing of Lasègue sign, muscular strength, sensibility, and muscle stretch reflexes. In a systematic review by Seffinger et al. a higher percentage (64 %) of spinal pain provocations studies showed acceptable reliability, followed by motion studies (58 %) [8]. The following spinal palpatory diagnostic procedures seem to have acceptable reliability: interrater examination of regional ROM of the cervical spine; intra-rater reliability of thoracic and lumbar segmental vertebral motion tests; inter-examiner testing of pain provocation at L4–L5 and L5–S1, lumbar paraspinal myofascial trigger points, the cervical spine, and the sternocleidomastoid [8]. In another study, standardized clinical tests of the cervical spine (cervical ROM, extension-rotation test, manual spinal examination, and palpation for paraspinal tenderness from C2 through C7) exhibited moderate to substantial reliability in patients with axial neck pain referred for diagnostic facet joint blocks [9]. Therefore, the authors concluded that the incorporation of these tests into a clinical prediction model to screen patients before referral for diagnostic facet blocks [9]. Testing of the lumbar flexion ROM can be assessed by testing the fingertip-to-floor distance and the modified Schober test [10]. It had been shown by Robinson et al. that the fingertip-to-floor distance and the Schober test seem to have excellent inter-tester reliability but with a relatively large smallest detectable change. Nevertheless, the medium negative correlation between these two tests for measurement lumbar flexion ROM indicated that they do not fully assess the same phenomenon and hence should be used in combination when examining patients [10].
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Principles or physical examination of peripheral joints are inspection—palpation—measurements of ROM— pain provocations tests.
Assessment instruments: scales, questionnaires Different unidimensional pain scales such as the Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), Faces Pain Scale-Revised (FPS-R), or Visual Analogue Scale (VAS) are commonly used for assessment of pain intensity (PI) [10]. Overall, the VAS is by far the most frequently used scale [10]. Evidence supports their validity as measures of PI [10]. The order of responsivity seems to be as follows: NRS, VAS, VRS, and FPS-R. Nevertheless, there were relatively small differences in the responsivity between scales [11]. Pain is multidimensional. It has different characteristics (e.g., burning, stabbing), different emotional content (e.g., unbearable, annoying), and different impacts on people (e.g., fear of pain, sleep deprivation, work disability). Thus, a multidimensional pain assessment should be performed. The comprehensive model of the International Classification of Functioning, Disability and Health is an important framework that places the impact of pain, the person, and their environment into context. By using multidimensional pain questionnaires with good psychometric properties, different aspects of pain and localizations of pain can be assessed [12]. For example, low back pain and actual pain-associated physical disability in the activities of daily living (ADL) can be assessed by using Roland Morris Disability Questionnaire [12]. It was designed for use as an outcome measure for clinical trials but has also been found useful for monitoring patients in clinical practice [13]. The Oswestry Disability Index assesses especially the context between chronic low back pain and disability in ADL of patients [14]. It contains topics concerning intensity of pain, lifting, ability to care for oneself, ability to walk, ability to sit, sexual function, ability to stand, social life, sleep quality, and ability to travel [14]. Neck pain and related disability due to neck pain can be assessed by using the Neck Pain Disability Index. It covers PI, lifting, reading, sleeping, and concentration [15]. The Hannover Functional Ability Questionnaire is an assessment instrument for measuring back pain-related disability (FFbH-R). The FFbH-R belongs to a series of short self-administered questionnaires for the assessment of functional limitations in ADL among patients with musculoskeletal pain. In addition to the FFbH-R, a specific version is available for patients with polyarticular diseases (the FFbH-P), as well as with knee and hip osteoarthritis (OA) [16]. A further instrument for assessment of pain in peripheral joints is the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The WOMAC is a questionnaire to assess pain (during walking, using stairs, in bed, sitting or lying, and standing), stiffness (after first
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waking and later in the day), and physical function (stair use, rising from sitting, standing, bending, walking, getting in/out of a car, shopping, putting on/taking off socks, rising from bed, lying in bed, getting in/out of bath, sitting, getting on/off toilet, heavy household duties, light household duties) [17]. The Harris Hip Score was developed for the assessment of the results of hip prosthesis, namely pain, function, absence of deformity, and ROM of the hip [18]. The Disabilities of Arm, Shoulder and Hand (DASH) Questionnaire is used to measure pain and disability associated with any condition of the upper limb. The DASH consists of two components: function/symptom/ social role component [19]. The Constant Murley Score has both performancebased components and self-report. Self-reported items assess the domains of pain and ADL. ROM and shoulder strength are measured from patient performance [20]. The Health Assessment Questionnaire assesses the effect of generalized OA on disability-determining difficulties with the performance of 20 ADL and classified into eight categories: dressing and grooming, arising, eating, walking, personal hygiene, reaching, gripping, and usual activities [21]. Different assessment tools exist to assess contextual factors: The Hospital Anxiety and Depression Scale (HADS-D) was established for assessment of depression and anxiety in patients with somatic disorders. It has two subscales (depression and anxiety) both with seven items [22]. The Fear Avoidance Beliefs Questionnaire (FABQ) focuses on patients’ beliefs about how physical activity and work affect low back pain. It consists of two subscales [23]. The first subscale is the Physical Activity Subscale and the second subscale (items 6–16) is the Work Subscale. The FABQ can help predict those that have a high pain avoidance behaviour [23]. The Mainz Pain Staging Study (MPSS, Gerbershagen) classifies pain patients in three chronicity stages that respectively require more extensive management [24]. The MPSS grades chronic pain in four pain-related axes: persistence, spreading, medication, and healthcare utilization. Pain is classified at three chronicity stages (mild, moderate, and severe). These pain stages represent different phases in the process of becoming chronic: the higher the stage, the more extensive management interventions seem to be necessary, and the less likely a full loss of pain can be achieved [24].
Discussion Clinical examination and scales/questionnaires are important, cost efficient, and simple instruments to assess pain, disability, and quality of life on patients with musculoskeletal disorders. The basis of pain assessment is the clinical examination. Pain scales are suitable for assessment of one dimension of pain, namely PI. They are time saving and easy to use. Nevertheless, multidi-
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mensional assessment instruments like self-administered questionnaires allow assessment of quality of life, disability of pain patients, different important context factors, and pain assessment in different locations of musculoskeletal pain. Choice of an assessment instrument in the daily clinical practice depends on goals of assessment for treatment of patients suffering from musculoskeletal pain. In conclusion, history and physical examination are the primary evidence-based assessment instruments for pain patients. Pain scales and questionnaires might allow assessment of different aspects of pain in order to perform an individualized therapy for pain patients. Conflict of interest M. Keilani, A. J. Haig, and R. Crevenna declare that there are no actual or potential conflicts of interest in relation to this article.
References 1. Keilani M, Heredy U, Hartl F, et al. Assessment in der Physikalischen Medizin und Rehabilitation. Phys Med Rehab Kuror. 2014;24:266–80. 2. Mokkink LB, Terwee CB, Patrick DL, et al. International consensus on taxonomy, terminology, and definitions of measurement properties for health-related patientreported ouctomes: results of the COSMIN study. J Clin Epidemiol. 2010;63:737–45.http://www.cosmin.nl/. 3. Manna A, Sarkar SK, Khanra LK. PA1 An internal audit into the adequacy of pain assessment in a hospice setting. BMJ Support Palliat Care. 2015;5(Suppl 1):A19–20. 4. van Tulder M, Becker A, Bekkering T, et al. Chap. 3. European guidelines for the management of acute non specific low back pain in primary care. Eur Spine J. 2006;15(Suppl 2):S169–91. 5. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain. Br J Sports Med. 2014;48:1518. 6. van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine. 1997;22:2128–56. 7. Nicholas MK, Linton SJ, Watson PJ, et al. Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Phys Ther. 2011;91:737–53. 8. Seffinger MA, Najm WI, Mishra SI, et al. Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine (Phila Pa 1976). 2004;29:E413–25.
9. Schneider GM, Jull G, Thomas K, et al. Intrarater and interrater reliability of select clinical tests in patients referred for diagnostic facet joint blocks in the cervical spine. Arch Phys Med Rehabil. 2013;94:1628–34. 10. Robinson HS, Mengshoel AM. Assessments of lumbar flexion range of motion: intertester reliability and concurrent validity of 2 commonly used clinical tests. Spine (Phila Pa 1976). 2014;39(4):E270–5. 11. Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP, et al. Validity of four pain intensity rating scales. Pain. 2011;152:2399–404. 12. http://www.who.int/classifications/icf/en. 13. Wiesinger GF, Nuhr M, Quittan M, et al. Cross-cultural adaptation of the Roland-Morris questionnaire for German-speaking patients with low back pain. Spine (Phila Pa 1976). 1999;24:1099–103. 14. Osthus H, Cziske R, Jacobi E. Cross-cultural adaptation of a German version of the Oswestry Disability Index and evaluation of its measurement properties. Spine (Phila Pa 1976). 2006;31:E448–53. 15. Cramer H, Lauche R, Langhorst J, et al. Validation of the German version of the Neck Disability Index (NDI). BMC Musculoskelet Disord. 2014;15:91. 16. Kohlmann T, Raspe H. Hannover Functional Questionnaire in ambulatory diagnosis of functional disability caused by backache. Rehabilitation (Stuttg). 1996;35:1–8. 17. Stucki G, Meier D, Stucki S, et al. Evaluation of a German version of WOMAC (Western Ontario and McMasters Universities) Arthrosis Index. Z Rheumatol. 1996;55:40–9. 18. Hinman RS, Dobson F, Takla A, et al. Which is the most useful patient-reported outcome in femoroacetabular impingement? Test-retest reliability of six questionnaires. Br J Sports Med. 2014;48:458–63. 19. Offenbacher M, Ewert T, Sangha O, et al. Validation of a German version of the ‘Disabilities of Arm, Shoulder and Hand’ questionnaire (DASH-G). Z Rheumatol. 2003;62:168–277. 20. Rocourt MH, Radlinger L, Kalberer F, et al. Evaluation of intratester and intertester reliability of the ConstantMurley shoulder assessment. J Shoulder Elbow Surg. 2008;17:364–9. 21. Cuperus N, Mahler EA, Vliet Vlieland TP, et al. Measurement properties of the Health Assessment Questionnaire Disability Index for generalized osteoarthritis. Rheumatology (Oxford). 2015;54:821–6. 22. Herrmann-Lingen C, Buss U, Snaith RP. Hospital anxiety and depression scale—Deutsche Version (HADS-D), 3. aktualisierte und neu normierte Aufl., Manual. Bern: Huber; 2011. 23. Pfingsten M, Kröner-Herwig B, Leibing E, et al. Validation of the German version of the Fear-Avoidance Beliefs Questionnaire (FABQ). Eur J Pain. 2000;4:259–66. 24. Frettlöh J, Maier C, Gockel H, et al. Validität des Mainzer Stadienmodells der Schmerzchronifizierung bei unterschiedlichen Schmerzdiagnosen. Schmerz. 2003;17:240–51.
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