PAIN

Characteristics of Pain:
Many characteristics of pain can be elicited from the client during the Core Interview to
help define the source or type of pain in question. These characteristic include:
• Location
• Description of sensation
• Intensity
• Frequency and Duration
• Pattern
• Aggravating factors
• Relieving factors

Location of Pain:
Questions related to the location of pain focus the client's description as precisely
as possible. An opening statement might be as follows:
FOLLOW UP QUESTIONS
• Show me exactly where your pain is located.
Follow up questions may include
• Do you have any other pain or symptoms anywhere else?
• If yes, what causes the pain or symptoms to occur in this other area?
Pain in a small, localized area without spreading, the cause is likely to be a superficial
lesion and is probably not severe.
Pain in a small, localized area with spreading, this is more likely to be a diffuse,
segmental, referred pain that may originate in the viscera or deep somatic structure.

Description of Pain:
FOLLOW UP QUESTIONS
• What does it feel like?
After giving the client time to reply, offer some additional choices in potential
descriptors.
Follow-up questions may include:
• Has the pain changed in quality since it first began?
• Changed in intensity?
• Changed in duration (how long it lasts)?
Type of Pain Potential Source
Cramping, dull, sore, aching Muscle
Dull, aching Ligament, joint capsule
Sharp, shooting, pinching, gnawing Nerve root
Sharp, burning, shooting Nerve
Burning, pressure like, sting, smarting Sympathetic nerve
Deep, nagging, dull Bone
Sharp, severe, incapacitating Fracture
Throbbing, pulsing, beating, diffuse Vasculature
Cramping, dull, sore, aching Muscle
Intensity of Pain:
FOLLOW UP QUESTIONS
• How strong is your pain?
1 = Mild
2 = Discomforting
3 = Distressing
4 = Horrible
5 = Excruciating
Scales:
Visual analogue scales

Pain chart:

McGill questionnaire:
Legend:
McGill pain questionnaire: the descriptors fall into four major groups: sensory, 1 to 10;
affective, 11 to 15; evaluative, 16; and miscellaneous, 17 to 20. The rank value for each
descriptor is based on its position in the word set. The sum of the rank values is the pain-rating
index (PRI). The present pain intensity (PPI) is based on a scale of 0 to 5. (Reproduced with
permission from Prentice. Therapeutic Modalities in Rehabilitation. 4th ed. New York:
McGraw-Hill; 2011.

Numeric Pain Scale:

Legend:
The Numeric Rating Scale (NRS) is the most common acute pain profile. (Reproduced with
permission from Prentice. Therapeutic Modalities in Rehabilitation. 4th ed. New York:
McGraw-Hill; 2011.)

Frequency and Duration of Pain:

The frequency of occurrence is related closely to the pattern of the pain, and the client
should be asked how often the symptoms occur and whether the pain is constant or
intermittent.
FOLLOW UP QUESTIONS
• How long do the symptoms last?
For example, pain related to systemic disease has been shown to be a constant rather
than an intermittent type of pain experience. Clients who indicate that the pain is
constant should be asked:
• Do you have this pain right now?
• Did you notice these symptoms this morning immediately when you woke up?

Pattern of Pain:
After listening to the client, describe all the characteristics of pain the therapist may
recognize a vascular, neurogenic, musculoskeletal (including spondylogenic),
emotional, or visceral pattern.
FOLLOW UP QUESTIONS
• Tell me about the pattern of your pain/symptoms.
• Alternate question: When does your back/shoulder (name the involved body part)
hurt?
• Alternate question: Describe your pain/ symptoms from first waking up in the
morning to going to bed at night. (See special sleep-related questions that follow.)
• Have you ever experienced anything like this before?
o If yes, do these episodes occur more or less often than at first?
• How does your pain/symptom(s) change with time?
• Are your symptoms worse in the morning or evening?
Aggravating and Relieving Factors
A series of questions addressing aggravating and relieving factors must be included
such as:
FOLLOW UP QUESTIONS
• What brings your pain (symptoms) on?
• What kinds of things make your pain (symptoms) worse (e.g., eating, exercise,
rest, specific positions, excitement, stress)?
To assess relieving factors, ask:
• What makes the pain better?
Follow-up questions include:
• How does rest affect the pain/symptoms?
• Are your symptoms aggravated or relieved by any activities?
• If yes, what?
• How has this problem affected your daily life at work or at home?
• How has this problem affected your ability to care for yourself without
assistance (e.g., dress, bathe, cook, drive)?
 Vital signs
The triad of pulse, respiration rate, and blood pressure is often considered as a baseline
indicator of a patient's health status, which is why each is called a vital or cardinal sign. All
four practice patterns in the Guide to Physical Therapist Practice include the measurement of
pulse, blood pressure, and respiration as a routine part of any physiologic examination.
Temperature is not included in the practice patterns because it is not routinely assessed by
physical therapists. However, temperature can often provide an important clue to the severity
of the patient's illness, particularly the presence of infection and should be taken.
Variables That Can Influence Vital Signs Data:
Hormonal status
Age
Stress
Obesity
Diet
Gender
Family history
Time of day
Menstruation
General health status
Pain

HEART RATE:
When the heart muscle of the left ventricle contracts, blood is ejected into the aorta and the
aorta stretches. At this point, the wave of distention (pulse wave) is most pronounced and can
be detected as a pulse at certain points around the body. The pulse rate (or frequency) is the
number of pulsations (peripheral pulse waves) per minute.
The pulse, measured in beats per minute (bpm), is taken to obtain information about the
resting state of the cardiovascular system and the system's response to activity or exercise and
recovery. Such information includes the resting heart rate, the pulse quality, the pulse
amplitude, and the presence of any irregularities in the rhythm.
• Resting heart rate: The normal adult heart rate is 70 bpm, with a range of 60 to 80 bpm. A
rate of greater than 100 bpm is referred to as tachycardia. Normal causes of tachycardia
include anxiety, stress, pain, caffeine, dehydration, or exercise. A rate of less than 60
bpm is referred to as bradycardia. Athletes may normally have a resting heart rate
lower than 60 bpm. The normal range of resting heart rate in children is between 80
and 120 bpm. The rate for a newborn is 120 bpm (normal range 70 to 170 bpm).
• Pulse quality: The quality of the pulse refers to the amount of force created by the ejected
blood against the arterial wall during each ventricular contraction.
• Pulse amplitude: The pulse amplitude is an indication of the heart's efficiency in pushing
blood into the arteries and the pressure being placed on the vessel's walls. A high
volume may result in a bounding pulse, whereas a low volume may present as a weak
or thready pulse.
• Rhythm irregularities: The pulse rhythm is the pattern of pulsations and the intervals
between them. In a healthy individual, the rhythm is regular and indicates that the time
 intervals between pulse beats are essentially equal. Arrhythmia or dysrhythmia refers to
an irregular rhythm in which pulses are not evenly spaced.
• The pulse can be taken at a number of points including:
Pulse Location Fig.
Temporal At a point anterior and adjacent to the ear.

Carotid The carotid artery is located to the side of

the larynx and medial to the
sternocleidomastoid muscle.

Brachial In an adult, the brachial artery is located in

the antibrachial fossa, just medial to the
biceps brachii tendon.
In an infant, the brachial artery can be
located at the middle of the upper arm.
Radial The distal radial artery is located on the
lateral (thumb) side of the anterior surface
of the wrist.

Femoral At the femoral triangle, slightly lateral and

anterior to the inguinal crease.
Popliteal At the midline of the posterior knee crease
between the tendons of the hamstring
muscles.

Dorsal Along the midline or slightly medial on the

pedal dorsum of the foot.

Posterior On the medial aspect of the foot inferior to

tibial the medial malleolus
Factors that can affect the pulse rate:
• Medications. Medications can cause the pulse rate to either increase or decrease.
• Emotional status. The pulse rate typically increases during episodes of high stress,
anxiety, and fear.
• Age. Adolescents persons and younger typically exhibit an increased rate, whereas
persons older than 65 years may exhibit a decreased rate.
• Gender. Male pulse rates are usually slightly lower than female rates.
• Temperature of the environment. A pulse rate tends to increase with high temperature
and decrease with low temperature.
• Physical conditioning. Individuals who perform frequent, sustained, and vigorous
aerobic exercise exhibit a lower than normal pulse rate.
Procedure:
The clinician washes his or her hands, obtains a timepiece that measures seconds, and explains
the procedure to the patient. The patient is typically positioned in sitting but may also be
recumbent or standing. The clinician selects an arterial site and gently places two or three
fingertips over the artery. Gentle pressure is applied to the point when the patient's pulse can
be detected. The count typically begins with the first beat that occurs after a time interval.
Alternatively, the clinician starts the time frame when the first beat is felt. The length of time
for taking the pulse depends on the patient's situation. For example, the clinician can palpate
for 15 seconds and multiply by 4 (or 30 seconds and multiply by 2) with a regular rhythm
(evenly spaced beats), or 60 seconds for a baseline measurement, or in the presence of a
regularly irregular rhythm (regular pattern overall with "skipped" beats) or irregularly
irregular rhythm (chaotic, no real pattern) rhythm. The clinician documents the findings in
terms of beats per minute, any variation in rhythm or volume, the location used, and the
patient position.
RESPIRATORY RATE:
The primary function of the respiratory system is to exchange gases between tissue, the blood,
and the environment so that arterial blood oxygen, carbon dioxide, and pH levels remain
within specific limits throughout many different physiologic limits. The pulmonary system
also plays a number of other roles, including contributing to temperature homeostasis via
evaporative heat loss from the lungs and filtering, humidifying, and warming or cooling the air
to body temperature. This process protects the remainder of the respiratory system from
damage caused by dry gases or harmful debris
Factors that influence respiration include:
• Age: the resting rate of the newborn is between 25 and 50 breaths per minute, a rate
which gradually slows until adulthood, when it ranges between 12 and 20 breaths per
minute.
• Body size and stature: men generally have a larger vital capacity than women, and
adults larger than adolescents and children. Tall, thin individuals generally have a larger
vital capacity than stout or obese individuals.
• Exercise: resting rate and debt increase with exercise as a result of increased oxygen
demand and carbon dioxide production.
• Body position: the recumbent position can significantly affect respiration through
compression of the chest against the supporting surface and pressure from abdominal
organs against the diaphragm.
• Environment: exposure to pollutants such as gas and particle emissions, chemical
waste products, or coal dust can diminish the ability to transport oxygen.
• Emotional stress: can result in an increased rate and depth of respirations.
• Pharmacologic agents: any drug that depresses central nervous system (CNS) function
will result in respiratory depression. Examples include narcotic agents and barbiturates.
Conversely, bronchodilators decrease airway resistance and residual volume with a
resultant increase in vital capacity and airflow.

Assessment of the respiratory system involves measurement of the rate, rhythm, depth, and
character of the patient's breathing using observation and palpation.
 • Rate: the rate of breathing refers to the number of breaths per minute. Normal
respiration rates for an adult person at rest range from 12 to 20 breaths per minute (the
normal rate for a newborn is between 25 and 50 breaths per minute). Respiration rates
over 25 breaths per minute or under 10 breaths per minute (when at rest) may be
considered abnormal. The expirations are normally approximately twice as long as the
inspirations. The opposite occurs in conditions such as chronic obstructive pulmonary
disease (COPD).
• Rhythm: the rhythm of breathing refers to the regularity of the breathing pattern and the
interval between each breath.
• Depth: the depth of breathing refers to the amount of air exchange (volume of air that is
being exchanged in the lungs) with each respiration. Deep breathing is associated with
greater thoracic expansion, whereas shallow breathing is associated with minimal chest
expansion. The clinician should compare measurements of both the anterior–posterior
diameter and the transverse diameter during rest and at full inhalation.
• Character: the character of breathing refers to a deviation from normal, resting, or quiet
respiration. A normal breathing response would be an increase in the respiratory rate
and depth with exercise. The Borg scale of Rate of Perceived Exertion (RPE) is
commonly used to assess breathing intensity based on activity. An abnormal breathing
response would be difficulty with breathing (dyspnea) in a patient at rest. In addition,
normal breathing is barely audible.
Procedure:
A number of pieces of equipment are required to assess the respiration rate, including a timing
device and a tape measure. A full assessment of a patient's respiration rate includes all of the
following:
• Observation for signs or symptoms of abnormal respiration, including the quality of the
breathing in relation to the patient's activity level.
• Palpation of the patient's radial pulse and a recording of the pulse rate.
• Observation of the patient's rate of breathing. The rate is usually measured when a person
is at rest and simply involves counting the number of breaths for 30 seconds and
multiplying the total by 2. If the total appears abnormal, the clinician should count the
breaths for one minute.
• A measurement of chest expansion with inspiration compared to the relaxed state.

BLOOD PRESSURE:
Blood pressure (BP), a product of cardiac output and peripheral vascular resistance, is defined
as the pressure exerted by the blood on the walls of the blood vessels, specifically arterial
blood pressure (the pressure in the large arteries).
• Peak pressure in the arteries occurs during contraction of the left ventricle (systole) and
provides the clinician with a measurement called the systolic pressure.
• The lowest pressure in the arteries occurs during cardiac relaxation when the heart is
filling (diastole) and provides the clinician with a measurement called the diastolic
pressure.
The assessment of BP provides information about the effectiveness of the heart as a pump and
the resistance to blood flow. It is measured in mm Hg and is recorded in two numbers. The
systolic pressure is the pressure that is exerted on the brachial artery when the heart is
contracting, and the diastolic pressure is the pressure exerted on the artery during the
relaxation phase of the cardiac cycle. BP is recorded as the systolic pressure over the diastolic
pressure.

A category of prehypertension has established more aggressive guidelines for medical

intervention of hypertension.
The normal values for resting BP in adults are:
systolic blood pressure diastolic blood pressure
Adults Normal values <120 mm Hg <80 mm Hg
Prehypertension 120 to 139 mm Hg 80 to 90 mm Hg
Stage 1 hypertension 140 to 159 mm Hg 90 to 99 mm Hg
Stage 2 hypertension ≥160 mm Hg ≥100 mm Hg
Normal birth to 1 month 60 to 90 mm Hg 30 to 60 mm Hg
Children up to 3 years of age 75 to 130 mm Hg 45 to 90 mm Hg
over 3 years of age 90 to 140 mm Hg 50 to 80 mm Hg
Physical factors that influence blood pressure:
• Age: The normal systolic range generally increases with age. BP normally rises
gradually after birth and reaches a peak during puberty. By late adolescence (18 to 19
years), adult BP is reached. In older adults, the rise in blood pressure is primarily
because of the degenerative effects of arteriosclerosis.
• Rate of pumping (heart rate): the rate at which blood is pumped by the heart—the
higher the heart rate, the higher (assuming no change in stroke volume) the blood
pressure.
• Volume of blood: the amount of blood present in the body. The more blood present in
the body, the higher the rate of blood returned to the heart and the resulting cardiac
output.
• Dehydration: a significant decrease of body fluids may cause low blood pressure.
• Cardiac output: the rate and volume of flow—product of the heart rate, or the rate of
contraction, multiplied by the stroke volume, the amount of blood pumped out from the
heart with each contraction—the efficiency with which the heart circulates the blood
throughout the body.
• Resistance of the blood vessel walls (peripheral vascular resistance): the higher the
resistance, the higher the blood pressure; the larger the blood vessel, the lower the
resistance. Factors that influence peripheral vascular resistance include arteriolar tone,
vasoconstriction, and to a lesser extent, blood viscosity.
• Viscosity, or thickness, of the blood: if the blood gets thicker, the result is an increase
in blood pressure. Certain medical conditions can change the viscosity of the blood. For
instance, low red blood cell concentration, anemia, reduces viscosity, whereas
increased red blood cell concentration increases viscosity.
• Body temperature: an increase in body temperature causes the heart rate to increase.
Conversely a decrease in body temperature causes the heart rate to decrease.
• Arm position: BP may vary as much as 20 mm Hg by altering arm position. The
pressure should be determined in both arms (see later).
• Exercise: physical activity will increase cardiac output, with a consequent linear
increase in blood pressure. Greater increases are noted in systolic pressure owing to
proportional changes in the pressure gradient of peripheral vessels. Systolic readings
 greater than 250 mm Hg or diastolic readings greater than 115 mm Hg during exercise
or other high-level activity should serve as serious warnings. Similarly, a drop in the
systolic pressure more than 10 mm Hg from baseline or failure of the systolic pressure
to increase with an increasing workload should also give cause for concern.
• Valsalva maneuver: An attempt to exhale forcibly with the glottis, nose, and mouth
closed. This results in:
o An increase in intrathoracic pressure with an accompanying collapse of the veins
of the chest wall
o A decrease in blood flow to the heart, and a decreased venous return
o A drop in arterial blood pressure
Procedure:
The less accurate, but less invasive, method is the auscultation method, which uses manual
measurement using a sphygmomanometer, an inflatable (Riva Rocci) cuff placed around the
upper arm, at roughly the same vertical height as the heart in a sitting person, using the
brachial artery. BP measurements are usually taken on the left arm because it is physically
located nearer the aorta, but the right arm can also be used.

The patient should be allowed to sit quietly for 1 to 2 minutes before the measurements are
taken and should not have been exercising for 15 to 30 minutes. The clinician washes his or her
hands and obtains a clean stethoscope and a sphygmomanometer. The procedure is explained to
the patient while the patient is positioned in sitting with the forearm supported approximately at
the level of the heart, and the feet are on the floor with the legs uncrossed. The clinician exposes
the antecubital space of the patient's arm while making sure that any clothing that is rolled up
does not create additional constriction, and palpates the brachial pulse for future placement of
the cuff and stethoscope diaphragm.
The deflated cuff is applied to the arm with the center of the bladder over the medial aspect of
the arm (approximately 2 to 3 cm or 11/2 fingerbreadths above the antecubital space) so that it
will occlude the artery when it is inflated. The clinician applies the stethoscope to his or her ears
with the earpieces directed forward and places the diaphragm on the skin where the brachial
artery was palpated. Firm but gentle pressure is applied on the diaphragm.

The clinician ensures that all of the air is out of the cuff bladder, the valve on the pump is
closed, and the pressure gauge reading is zero. While listening with a stethoscope placed over
the brachial artery at the elbow, the clinician uses the same hand to slowly inflate the blood
pressure cuff by squeezing the bladder pressure cuff by squeezing the bladder.

The clinician uses the other hand to palpate the patient's radial pulse, and the cuff is slowly
inflated until when the pressure level reaches either 20 to 30 mm Hg above the first Korotkoff
sound or 30 mm Hg above the point at which the radial pulse disappears. Some consider 200
mm Hg as the upper limit of inflation, but this can lead to a measurement error in patients with
hypertension. At this point, the clinician uses the thumb and index finger of the hand used to
squeeze the pump to slowly open the valve and release the pressure in the cuff.

At the point when the clinician begins to hear a "whooshing" or pounding sound (first
Korotkoff sound) the pressure reading (systolic) is noted. The cuff pressure is further released
until a muffling sound can be heard (fourth Korotkoff sound). This is the diastolic blood
pressure.
TEMPRATURE
Body temperature, a balance between the heat that is produced and lost in the body, is one
indication of the metabolic state of an individual. Temperature measurements provide
information on basal metabolic state, possible presence or absence of infection, and metabolic
response to exercise. The "normal" core body temperature of an adult, found in the pulmonary
artery, is generally considered to be 98.6°F (37°C). However, a temperature in the range of
96.5 to 99.4°F (35.8 to 37.4°C) is not at all uncommon. Fever or pyrexia is a temperature
exceeding 100°F (37.7°C). Hyperpyrexia refers to extreme elevation of temperature above
41.1°C (or 106°F). Hypothermia refers to an abnormally low temperature (below 35°C or
95°F).
Normal Temperatures Based on Site:
Rectal 36.6°C to 38°C (97.9°F to 100.4°F)
Tympanic 35.8°C to 38°C (96.4°F to 100.4°F)
Oral 35.5°C to 37.5°C (95.9°F to 99.5°F)
Axillary 34.7°C to 37.3°C (94.5°F to 99.1°F
ORAL PROCEDURE
The oral temperature is generally taken by placing a probe thermometer under the patient's
tongue. The thermometer can be a standard one or a battery-operated electronic thermometer.
After washing his or her hands, the clinician inserts a clean probe into the patient's mouth,
positioned under the tongue, and held in place by the lips (not with the teeth). The patient is
asked to breathe through the nose. Typically, the probe remains in place for 30 to 90 seconds.
Electronic devices emit an audible alarm when the temperature reaches its final value. The
clinician notes the value and then removes the probe from the patient's mouth, discards the
probe cover, and turns the unit off. The clinician then washes his or her hands before recording
the result.

TYMPANIC PROCEDURE
The tympanic measurement involves placing a specially designed electronic monitor into the
ear canal that reads the infrared energy emitted from the tympanic membrane (eardrum),
detects when the maximum temperature has been reached, and then provides a liquid crystal
display (LCD) of the temperature. The electronic monitor uses disposable, single-use probe
covers. Newer designs of these monitors convert the tympanic temperature to an estimated
core temperature. A number of precautions must be taken when using a tympanic device.
Ideally, the clinician should:
• Ensure that there is no excessive earwax present.
• Confirm that the patient's ear has not been resting against a pillow or similar object. If it
has, the clinician should wait for 2 to 3 minutes before taking a reading.
• Take readings from both ears, as measurements can vary between sides. Alternatively,
the clinician can take a reading from one ear and document which ear was used.
To take a tympanic temperature, the clinician washes his or her hands before applying a clean
lens filter. As appropriate, the clinician selects the correct setting (some units have both an
"oral" and a "rectal" setting) and then gently but firmly pulls on the patient's ear to straighten
the ear canal. For an infant, the ear is pulled straight back, whereas for anyone who is older
than one year, the ear is pulled up and back. The clinician then insert the thermometer lens
cone, with its clean filter applied, into the ear opening, rocking it back and forth gently to
insert it far enough to seal the ear canal. The clinician then depresses and holds the activation
button for one second until the temperature reading appears in the display window, and
mentally records the value. The lens cone is then removed from the patient's ear and discarded.
Depending on the facility, the lens filter is also discarded or is thoroughly washed before being
used again. The clinician washes his or her hands and records the temperature reading.
RECTAL PROCEDURE
Specifically designed rectal thermometers are used to record rectal temperatures. After
washing his or her hands, the clinician applies a lubricant to the thermometer probe, and with
the patient positioned in sidelying with the hips and knees flexed, the thermometer is inserted
into the rectum far enough for the probe to be within the cavity but not so far as to push into
tissue resistance. The thermometer remains in place for three minutes or until the electronic
device indicates completion and the temperature reading is noted. The clinician then removes
and cleans the probe, washes his or her hands, and then records the temperature.