Appendix

APPENDIX OUTLINE

Appendix Pain and Functional Limitation

 Appendix

PAIN AND FUNCTIONAL LIMITATION

Pain has been viewed by physiologists as a distinct sensation from temperature and other cutaneous senses.
It is defined as an unpleasant sensation and emotional response associated with actual or potential tissue
damage. It is a complex phenomenon encompassing sensory, emotional, motor, and cultural components.
Pain is the signal that is recognized by the brain which can be given due regard immediately by withdrawing the
part of the body to protect it. Pain is sometimes neglected by individuals if its intensity is mild. The potential
damage to the tissues sometimes does not produce pain till a significant disability or movement disorder is
produced. Such pain arriving late in the course of a disease, or produced by dysfunction or rewiring of the
nervous system, has no survival value and can even have adverse health effects and lead to disability. Hence
pain is a significant signal or indication which must be respected by withdrawing the body part from the
stimuli to protect the body and seek medical attention for determination of its source, type and management.

SOURCE OF PAIN
Pain is a complex phenomenon hence; it is not always possible to determine its source reliably as it is originated
from one or several structures or systems of the body. The subjective pain is not associated with the objective
findings. It is, therefore, necessary, for the clinician to have a very clear concept of possible source of pain,
diligently elicit an accurate and lucid history to determine the source of pain. Pain may either be localized,
referred, or radicular. These three patterns of pain are mostly found in the spine. The localized and referred
pain is also produced by the viscera. The localized pain is experienced by the patient directly over the lesion.
The referred and radicular pain is experienced, distal to the lesion. The radicular pain which is originated
from the nerve roots or nerves has distinct features such as parasthesia, numbness, tingling and weakness.
These symptoms are provoked by the specific nerve root or nerve stretching.

Somatic Pain
The somatic pain may either be mediated through the faster conducting A-delta afferent neurons or the
slower C fibers. The somatic pain may either be superficial or deep. The superficial pain originates from the
skin and it is localized. A tender point can easily be elicited. The pain from the muscles, ligaments, tendons,
joints fascia and periosteum is deeply situated and tends to be more diffuse. It may also be localized. The
somatic pain is associated with the protective muscle guarding, and may be aggravated with the movements
at end ranges. The deep pain is thought to be mediated through C fibers, although there is probably overlap
between deep and superficial receptor systems.
 Electrotherapy: Principles and Practice

Visceral Pain
Viscerogenic pain is originated from viscera such as kidneys, the pelvic viscera, lesions of the lesser sac, lungs,
heart and retroperitoneal tumors. Pain originated from the viscera is often poorly localized and is characterized
as an aching or gripping sensation associated with sympathetic effects, such as the pain associated with angina
pectoris. The pelvic and abdominal viscera may refer the pain to the low back area, whereas pain from the
heart may be perceived in the left shoulder and arm. The movements of the spine and extremities do not
aggravate or relieve the viscerogenic pain. To get rid of pain, patients often walk around. The parietal pain
associated with the peritoneum, pleura, and pericardium is innervated by the A-delta fibers are accompanied
by superficial tenderness and reflex rigidity, as seen in the abdominal rigidity of acute appendicitis.

Vascular Pain
Pathological changes in the vessels and arteries may produce similar symptoms as of musculoskeletal tissues,
however, they are differentiated for their distinct feature such as boring, throbbing and heaviness situated
deeply. Pain from intermittent claudication is perceived in the calf, which is aggravated by walking and relived
with standstill. Similarly pain from the superior gluteal artery insufficiency and abdominal aortic aneurysm is
perceived in the lower extremity. The pain is aggravated by walking and is relieved with rest.

Psychogenic Pain
Although patients with pure psychogenic type of pain are rarely seen in clinical practice but failure to
consider may lead to serious errors in diagnosis and management. The patients with psychogenic pain are
very anxious, tend to overexpose their problem. They are usually demonstrative, use their hands to point out
various painful areas. Fear, anxiety, and depression is capable of amplifying pain and environmental stress
can give rise to or amplify pain.7 Anxiety, depression, anger and aggressive behavior may provoke substantial
autonomic, visceral and skeletal activity, which can enhance pain sensations.

RECEPTORS
There are many pain carrying neurons which receive noxious stimuli from the skin, joints, and muscles and
carry them to the higher centers for interpretation.

Skin
Several small free nerve ending receptors situated in the skin which are able to respond to the mechanical,
thermal, and chemical stimuli. There are three types of receptors in skin which carry pain to the higher centers.
High threshold mechanoreceptors –These receptors receive strong mechanical stimuli but do not respond
in normal skin to heat, irritant chemicals, or extreme cold. Polymodal Nociceptors – these receptors receive
strong mechanical stimuli, and also noxious heat and irritant chemical. Cold Nociceptors –Cold receptors
receive extreme cold stimuli but do not respond to the strong mechanical, heat and chemical stimuli. The
pain from skin is diameter myelinated A-delta neurons and small diameter, unmyelinated C fiber neurons.

Muscles
Similar to the skin, A-delta and C-fibers are situated in the muscles. In addition to the above pain receptors
there are pain sensitive units in the muscles which receive information of muscle guarding and soreness and
carry it to the higher centers.

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Appendix ▶ Pain and Functional Limitation

Joints
The physical properties of the joints is maintained by various encapsulated receptive units situated in and
around the joints. The subcutaneous receptors similar to the skin receptors are also present in the skin but
they are slightly different from them in terms of functions.

THEORIES
Many authors have proposed pain perception and transmission theories. One of the oldest theories of pain
was postulated by Aristotle, who believed that pain was a reaction to excessive stimulation.

Specificity Theory
In 1894 Von Frey proposed a doctrine of specific nerve energies- the specificity theory of pain. The doctrine
implied that each sensory modality was sub-served by morphologically specific nerve endings. Von Frey
includes four distinct types of sensation at the skin: warmth, cold, touch, and pain. He identified free nerve
endings as pain receptors based on their widespread distribution in the skin. According to the theory
the specific nerve endings always elicit an identical sensation no matter how it is stimulated. The specific
stimulation is transmitted along specific pathways in the spinal cord to reach specific projection areas in the
brain, where it is appreciated/recognized.

Pattern Theory
Pattern theory first formalized by Goldscheider in 1894 is based on empirical observation. The absence of
specific pain receptors, pathways, or groups of neurons dedicated to the 8 transmission of painful stimuli is
its basic assumption. According to the theory there is a group of nerve ending and associated nerve fibers
which form a pain spot. The stimulation of pain spot with the sufficient intensity and frequency produces
pain which results in initiation of train of impulses in the pathways.9 Summation of neural impulses is relayed
to the cerebral structures concerned with localizations and interpretation of intensity. In 1943 Livingston
expanded on the pattern theory to explain how pain could occur long 10 after an initial injury. The drawback
of the theory was that receptor specialization does not exist to a great extent.

Gate Theory
In 1965 Melzack and Wall proposed the gate theory of pain which they subsequently reviewed in 1978. They
originally postulated that interneurons in the substantia gelatinosa in the dorsal horn of 10 the spinal cord
acted as a gate to modulate sensory input. This theory has been credited with rekindling interest in electrical
control of pain and inspiring research with important scientific and clinical 11 ramification. The essence of
this theory is that small diameter myelinated A-delta neurons and small diameter, un-myelinated C fibers also
known as pain carrying nociceptives project to the spinal cord where they synapse directly or via interneurons
with the transmission cells (T cells) in the dorsal horn of the grey matter. The T cells relay the small diameter
pain carrying sensation to the higher centers.

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 Electrotherapy: Principles and Practice

Figure: Schematic diagram. Pain gate control

Large diameter myelinated A beta and alpha fibers also known as pain inhibiting fibers arise from the
peripheral part and terminate on T cells through substantia gelatinosa of the spinal cord. The stimulation of
the mechanoceptors large diameter fibers inhibit the nociceptors at the T cells and prevent transmission to the
higher centers. The inhibitory input caused by activation of the large diameter, mechanosensitive afferent is
said to close the gate to nociceptor transmission. This is also known as “Pain Gate Control Theory”

ASSESSMENT OF PAIN
Pain is a very complex and subjective experience. A comprehensive assessment is required to determine
the source of the pain. Many authors have designed tests and measures to quantify pain and attempts have
been made to objectify the pain experience. However, no scale is made to assess the pain objectively as it is
the experience of an individual which is explained to the examiner, hence, the assessment of pain remains
subjective.

Pain Rating Scales

Numeral Rating Scale (NR)
The patient is given a scale marked from 0 to 10 or 0-100. Zero is no pain and ten or hundred is worst possible
pain which is not tolerable. The patients are asked to tell the point that best describes their level of pain on
the scale.

Figure: Numeral rating scale

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Appendix ▶ Pain and Functional Limitation

Verbal Rating Scale (VRS)

The verbal rating scale consists of a list of adjectives describing different levels of pain intensity. An adequate
VRS of pain intensity should include adjectives that reflect the extremes of this dimension; from ‘no pain’ to
‘extremely intense pain’ and sufficient additional adjectives to capture gradations of pain intensity that may
be experienced between these two extremes. Patients are asked to read over the list of adjectives and select the
word or phrase that best describes their level of pain on the scale.

Visual Analogue Scale

A verbal analogue scale consists of a line, usually 10cms long whose ends are labelled as the extremes of pain
- ‘no pain’ to ‘worst pain’. Visual Analogue Scale may have specific points along the line that are labelled with
intensity denoting adjectives or numbers. Those scales that use adjectives are called graphic rating scales.
Patients are asked to rate their pain along the line that best represents the intensity of their pain. This distance
between the number end and the mark provided by the patient is measured and this gives the pain intensity
score.

Figure: Visual analogue scale

McGil Pain Questionnaire

The McGill pain questionnaire was developed at McGill University by Melzack and Torqerson in 1971. The
scale is also known as McGill pain index. It is a self report questionnaire that helps the clinician in describing
the quality and intensity of pain that the patient experiences. There is a list of words which describes the
complaint of the patient. The patients carefully observes the list of words or the questionnaire and selects
three words from groups 1-10 that best describe their pain, two words from groups 11-15, a single word from
group 16, and then one word from groups 17-20. After completing the questionnaire, the patient will have
selected seven words that best describe their pain. The patient can use some words more than once.

Questionnaire
Group Words
1. Flickering, Pulsing, Quivering, Throbbing, Beating, Pounding
2 Jumping, Flashing, Shooting
3 Jumping, Flashing, Shooting
4 Sharp, Cutting, Lacerating
5 Pinching, Pressing, Gnawing, Cramping, Crushing
6 Tugging, Pulling, Wrenching
Contd…

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 Electrotherapy: Principles and Practice

Group Words
7 Hot, Burning, Scalding, Searing
8 Tingling, Itchy, Smarting, Stinging
9 Dull, Sore, Hurting, Aching, Heavy
10 Tender, Taut (tight), Rasping, Splitting
11 Tiring, Exhausting
12 Sickening, Suffocating
13 Fearful, Frightful, Terrifying
14 Punishing, Grueling, Cruel, Vicious, Killing
15 Wretched, Blinding
16 Annoying, Troublesome, Miserable, Intense, Unbearable
17 Spreading, Radiating, Penetrating, Piercing
18 Tight, Numb, Squeezing, Drawing, Tearing
19 Cool, Cold, Freezing
20 Nagging, Nauseating, Agonizing, Dreadful, Torturing

Pain Quality Assessment Scale (PQAS)

There are different aspects and types of pain that patients experience and that the examiner measure. The
patient can experience pain as sharp, hot, cold, dull, and achy. Some pains may feel like they are very superficial
(at skin-level), or they may feel like they are from deep inside your body. The pain quality assessment scale
helps in measuring the sharp, hot, cold, dull, achy, shooting, numb, tingling, cramping throbbing and radiating.
PQAS has twenty rating scales of different types and quality of pain. Each rating scale has ten score.
1. Please use the scale below to tell us how intense your pain has been over the past week, on average. Zero
is no pain, where ten is the most intense pain sensation imaginable
No pain 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most intense pain sensation imaginable
2. Please use the scale below to tell us how sharp your pain has felt over the past week. Words used to
describe sharp feelings include “like a knife,” “like a spike,” or “piercing.”
Not sharp 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most sharp sensation imaginable (“like a knife”)
3. Please use the scale below to tell us how hot your pain has felt over the past week. Words used to describe
very hot pain include “burning” and “on fire
Not hot 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most sensation imaginable (“burning”)
4. Please use the scale below to tell us how dull your pain has felt over the past week
Not dull 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most sensation imaginable
5. Please use the scale below to tell us how cold your pain has felt over the past week. Words used to
describe very cold pain include “like ice” and “freezing.”
Not cold 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most cold sensation imaginable (“freezing”)

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Appendix ▶ Pain and Functional Limitation

6. Please use the scale below to tell us how sensitive your skin has been to light touch or clothing rubbing
against it over the past week. Words used to describe sensitive skin include “like sunburned skin” and
“raw skin.”
Not sensitive 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most sensitive sensation imaginable (“raw skin”)
7. Please use the scale below to tell us how tender your pain is when something has pressed against it over
the past week. Another word used to describe tender pain is “like a bruise.”
Not tender 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most tender sensation imaginable (“like a bruise”)
8. Please use the scale below to tell us how itchy your pain has felt over the past week. Words used to
describe itchy pain include “like poison ivy” and “like a mosquito bite.”
Not The most itchy itchy 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 sensation imaginable (“like poison ivy”)
9. Please use the scale below to tell us how much your pain has felt like it has been shooting over the past
week. Another word used to describe shooting pain is “zapping.”
Not shooting 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most shooting sensation imaginable (“zapping”)
10. Please use the scale below to tell us how numb your pain has flet over the past week. A phrase that can
be used to describe numb pain is “like it is asleep”
Not numb 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most numb sensation imaginable (“asleep”)
11. Please use the scale below to tell us how much your pain sensations have felt electrical over the past week.
Words used to describe electrical pain include “shocks,” “lightning,” and “sparking.”
Not electrical 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most electrical sensation imaginable (“shocks”)
12. Please use the scale below to tell us how tingling your pain has felt over the past week. Words used to
describe tingling pain include “like pins and needles” and “prickling.”
Not tingling 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most tingling sensation imaginable (“pins and needles”)
13. Please use the scale below to tell us how cramping your pain has felt over the past week. Words used to
describe cramping pain include “squeezing” and “tight.”
Not cramping 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most cramping sensation imaginable (“squeezing”)
14. Please use the scale below to tell us how radiating your pain has felt over the past week. Another word
used to describe radiating pain is “spreading.”
Not radiating 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most radiating sensation imaginable (“spreading”)
15. Please use the scale below to tell us how throbbing your pain has felt over the past week. Another word
used to describe throbbing pain is “pounding.”
Not throbbing 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most throbbing sensation imaginable (“pounding”)
16. Please use the scale below to tell us how aching your pain has flet over the past week. Another word used
to describe aching pain is “like a toothache”.
Not aching 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most aching sensation imaginable (“like a toothache”)
17. Please use the scale below to tell us how heavy your pain has felt over the past week. Other words used
to describe heavy pain are “pressure” and “weighted down.”
Not heavy 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most heavy sensation imaginable (“weighted down”)

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18. Now that you have told us the different types of pain sensations you have felt, we want you to tell us
overall how unpleasant your pain has been to you over the past week. Words used to describe very
unpleasant pain include “annoying,” “bothersome,” “miserable,” and “intolerable.” Remember, pain can
have a low intensity but still feel extremely unpleasant, and some kinds of pain can have a high intensity
but be very tolerable. With this scale, please tell us how unpleasant your pain feels.
Not unpleasant 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most unpleasant sensation imaginable (“intolerable”)
19. We want you to give us an estimate of the severity of your deep versus surface pain over the past week.
We want you to rate each location of pain separately. We realize that it can be difficult to make these
estimates, and most likely it will be a “best guess,” but please give us your best estimate.
How Intense Is Your Deep Pain?

No deep 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most intense deep pain sensation pain imaginable

How Intense Is Your Surface Pain?

No surface 0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 The most intense surface pain sensation pain imaginable

20. Pain can also have different time qualities. For some people, the pain comes and goes and so they have
some moments that are completely without pain; in other words the pain “comes and goes”. This is called
intermittent pain. Others are never pain free, but their pain types and pain severity can vary from one
moment to the next. This is called variable pain. For these people, the increases can be severe, so that
they feel they have moments of very intense pain (“breakthrough” pain), but at other times they can
feel lower levels of pain (“background” pain). Still, they are never pain free. Other people have pain that
really does not change that much from one moment to another. This is called stable pain. Which of these
best describes the time pattern of your pain (please select only one):

FUNCTIONAL LIMITATION
Pain greatly affects the activities of daily living. Pain in the shoulder may limit the hand of the individual to
reach to the back of spine to fasten bra, to the head to comb hair, to the back pocket (gluteal region) to place
wallet. Pain in the knee joint can cause gait abnormalities, reduce tolerance to standing, difficulty in climbing
and descending stairs. The limitation in the functional activities such as reduced tolerance to standing due
to knee joint osteoarthritis and difficulty in walking due to prolapsed intervertebral disc result in difficulty
in performing the task at the work place. No appropriate treatment for improving functional limitation can
cause disability. The osteoarthritis and prolapse intervertebral disc is the primary impairment and reduce
tolerance to standing and difficulty in walking is the secondary impairment. The physical therapist administers
appropriate physical modality to prevent and improve the secondary impairment (functional limitation).
The physical therapist administers physical therapeutic modalities to eliminate functional limitations and
disability in collaboration with the therapeutic exercises. American Physical Therapist Association (APTA)
has defined functional Limitation as restriction of the ability to perform a physical action, activity, or task 18
in an efficient, typically expected, or competent manner. Nagi Model has referred functional limitation as
restriction in performance of basic tasks that includes basic activities of daily living (BADL) such as personal
hygiene, feeding, dressing and instrumental activities of daily living (IADL) such as preparing meals, house
work, grocery, shopping.

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 AQ: Please check the highlighted text for its accuracy (Incomplete sentence)

Appendix ▶ Pain and Functional Limitation

ASSESSMENT OF FUNCTIONAL LIMITATION

Many functional scales and questionnaires have been designed in the literature for the assessment of functional
limitation and disability resulting from primary impairment or pain. The scales not only help in assessing
the pain subjectively but also provide significant feedback of the progression or improvement in the pain
and symptoms. The periodical reevaluation of the functional limitation by using the functional scale enables
therapist to determine appropriate scheme of therapeutic modality.

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