Is pain relief one of the main reasons that you are seeking physiotherapy treatment? When you attend your first appointment, your physiotherapist will ask you a variety of questions about your pain. This blog will walk you through what a physio wants to know and why, and what to tell your physio about your pain.
Pain is defined as an unpleasant sensory and emotional experience.1 It is important to understand that pain is a personal experience. A lot of the time we want to ignore our pain messages, but some of this information can provide some useful clues.
If you are currently attending physiotherapy or thinking of coming along to see a physiotherapist for your pain, it might be helpful to think about the answers to some questions that the physiotherapist is likely to ask about your pain. This can help your physio apply the most appropriate physical tests and develop the most successful management plan for your individual situation.
Although we don't want you to over-focus on your pain, it can help us, to help you, if you consider your answers to the following questions about the area, type, severity and behaviour of your pain.
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WHERE IS YOUR PAIN?
What does area of pain tell us?
One of the first questions a physiotherapist will ask you is “What is the main problem I can help you with today?” If pain is one of your top responses, then the physio will want to know where you feel your pain.
A body chart is used to help record the area(s) of your pain. The location(s) of your pain can provide important information about your condition. Is it very localised or is it widespread? If your pain is localised to one area, it may suggest a specific structure in that area may be involved.
If your pain is widespread, the pain is less likely to be related to a structure immediately in that area.2 For example, if you have a localised area of pain over the bony prominence at the side of your hip, one of the most likely problems is a program with the gluteal tendons that join into the bone there. However, if you had pain more generally around the outer hip, that runs down the legs to the foot, together with some lower back pain, this presentation may direct us to examine the lower back as a potential cause of your symptoms.
The longer you have pain for, the more indistinct the area of pain tends to be. It might spread and creep to other areas. This is not usually due to a spread of the damage in the tissues, but to the way your nervous system is processing information. If you can remember, always tell your physio where you first experienced pain and how that area of pain changed over time.
TYPE OF PAIN:
How would you describe your pain?
Once the physiotherapist knows where your pain is, they may ask something like: “How would you describe your pain?”.
What are some of the words you can think of to describe your pain? Some of the common ones are sharp, dull, aching or burning. Those descriptions can already give the physiotherapist an initial idea about the nature of your pain. Burning, pricking or squeezing pain may indicate a potential nerve involvement,3 whereas a dull ache or a throb may suggest injuries from tissues like muscles, tendons, ligaments or joints within the musculoskeletal system.4
Can you rate the level of pain you experience?
If you have seen a physiotherapist for a pain condition before, you will have almost certainly been asked to rate the level of your usual and/or worst pain. A scale of 0-10, where 0 means no pain and 10 means worst pain imaginable, is used to measure your pain intensity at a point of time. This might be pain over the last week, pain during a particular activity or pain right now.
Many people get a little flustered with this question, sometimes offering that their pain tolerance is high so their levels might be lower than others. Just remember that we are not comparing this level of pain intensity to anyone else. Pain is a very individual experience, and you only need to consider your own pain experiences to rate your own pain levels.
Pain intensity is quite a poor indicator of the level of structural damage, so this is not the reason we ask this question. Your level of pain gives us an indication of how bothersome the pain is to you and by rating it, we can use a change in your pain level as one means of tracking your progress – your response to treatment.
How often do you experience your pain?
Interestingly, often a change in pain intensity is not as closely matched to overall progress as a change in pain constancy – how much of the time you are aware of the pain. For example, some people’s pain comes and goes, and other people’s pain is constant – there all the time. The physiotherapist may ask you ‘Over the last week, what percentage of time have you been aware of your pain, where 0% is not at all and 100% is all the time?’.
We find that sometimes the first improvement we see is not a change in the pain intensity but a change in the pain constancy. If you initially had pain for 80% of the time and after some treatment you pain was only present for 20% of the time, even if the pain intensity was the same, this is a very large improvement. Reducing pain constancy, can provide a lot of mental as well as physical relief, freeing up your brain to get on with other things you need to do.
When did your pain first start?
By knowing the onset and duration of your pain, physiotherapists can categorise your pain into acute, subacute, chronic or acute-on-chronic. These terms simply refer to the duration of pain – how long you’ve had your pain for – and not the pain intensity.
Acute pain does not necessarily mean severe pain, just that it has come of relatively recently. Chronic pain is usually classified as having had the same type of pain for over 3 months.6
It is also possible to have some chronic pain for a period of more than 3 months with intermittent acute flare ups of pain – periods where the pain changes quickly. This can be referred to as an acute-on-chronic pain presentation. Those bouts of flare ups may last a few days to a few weeks then subside. Symptoms of the flare ups may be similar or different to your usual pain pattern; therefore, tuning into your pain messages can help your physiotherapist understand what might be occurring.
AGGRAVATING & EASING FACTORS:
What hurts and what helps your pain?
Your physiotherapist will always be very interested in things that make your pain better and worse. This information has important clues for determining the underlying problem and the best ways to help you.
Try to take note of the sort of things that tend to aggravate your pain – either at the time, or later e.g, is you pain bad that night after you’ve been for a run, a step uphill walk or done a heavy gardening or gym session? Do you feel your pain most when you are in the same position, such as sitting or standing, for a period of time (more than 20-30 minutes), or is it worst with particular movements?
This information highlights whether your pain is position-related, movement-related or a combination of both. If your pain tends to be more position-related, does getting out of that position ease your pain? Does gentle movement in that position help reduce your pain? Those questions are so valuable to consider for everyone experiencing pain. If the answer is yes, straightaway that provides some ideas of how you can actively modify your position to manage your pain.
If your pain tends to be more movement-related, is there a particular direction of movement that aggravates your pain? Or is it all kinds of movements? Does your pain increase as soon as you start those movements? Or does your pain gradually creep in during those movements? Does stopping the painful movement reduce your pain straight away or does it take a while to settle?
These are some examples of questions your physiotherapist may ask to better understand the things that aggravate and ease your pain. Once we know how this, we have a better idea of what structures might be involved and how we can modify positions and movements to keep you more comfortable.
How does your pain change over the day?
We have covered a bit on how complex and changeable each individual’s pain experience can be. Pain may also change throughout a 24-hour period. Do you have pain from the minute you wake up? Or does your pain gradually increase as the day goes on?
Some patients may report no to minimal pain when waking in the morning. For example, people with plantar fasciopathy (pain under the heel) often report short-lived stiffness and more intense pain when they take their first few steps in the morning. Once warmed up, pain usually eases quite a bit, but might return later in the day if you are on your feet a lot.
Pain associated with the musculoskeletal system (muscles, tendons, ligaments, bones and joints) often increases with cumulative loading – sustained postures or repetitive activity during the day. So, your pain may feel worse as the day goes on. When it comes to the evening, is your pain at its worst after a day of accumulation of aggravation? Or does your pain lessen once you stop doing things and start resting?
Another key question to consider is night pain. Do you have pain going to sleep? Does your pain go away, become worse or stay the same when you lie down? Do you have a restful sleep? Or does your pain keep you awake at night? Night pain may indicate signs of joint inflammation, nerve related pain or it may be positional – related to the particular position you are in. For example, patients with an unhappy gluteal tendon at the side of the hip, might have localised pain over the bone here when sleeping on the side.7 If we better understand the 24-hour behaviour of your pain, we will better understand your condition, the underlying causes and what we can do to help you modify and better control the behaviour of your pain.
Another very important aspect to highlight in the 24-hour pain picture is that sometimes the cause of your pain may not be related to the musculoskeletal system. A physiotherapist might be the first health professional you see about your pain, but sometimes that pain is not a musculoskeletal pain and may require assessment by your general practitioner or a medical specialist.
There are other systemic causes that affect the entire body rather than a single body part, such systematic inflammatory conditions or infections, and we also need to keep malignancy (cancer) as a potential cause when the pain is not behaving in a typical manner for a musculoskeletal condition.8
Some may describe pain that is not affected by particular positions or movements at all. Some may describe pain at its worst at night only. Or some may describe very fast and unexplained worsening of their pain.8 If your physiotherapist suspects your pain may be something other than musculoskeletal pain, referral to other medical professionals will be advised or arranged.
OUR RELATIONSHIP & UNDERSTANDING OF PAIN:
How it changes over time
Do you know we are constantly learning about pain through our lives? Our beliefs about pain may be shaped from our childhood experiences, family culture and society values. Our perception about pain can be expanded and adapted to aid our own pain management.
Have you ever asked yourself how do you feel about pain? What are some emotions you recognise when you think about or experience pain? Where did you learn those beliefs about pain? Verbal description is only one of the several expressions of pain.1 This means if a person is unable or lacks capability to verbally express their pain, it doesn’t mean they experience no or less pain comparative to others. A person with poor mental health, unsupportive social circumstance, childhood trauma or over-reactive nervous system may experience more intense pain, widespread pain and longer-lasting pain.9
Research has demonstrated that pain might be associated with tissue damage; however, most of the time, structural damage in joints, muscles or tendons may not be the reason or only part of the reason for ongoing or persistent pain.2 Pain is complex, and it can be triggered by other non-physical factors, such as mental distress and social (home or work) environment.1
Hopefully this information will help you prepare for physiotherapy or help you understand more about the questions health professionals ask about your pain. If you are interested in learning more about your pain and getting some help with developing an individualised management plan with one of our physiotherapists, we’d love to help you.
Do you you need help recovering from an injury? Improving your performance? Or just getting back to doing the things that you love? Visit us at PhysioTec, and let one of our physios assess you and provide you with a personalised program to help you get on-top of your condition, and feel at your best.
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- International Association for the Study of Pain (IASP); 2021; Definition of pain; URL: https://www.iasp-pain.org/resources/terminology/#pain; retrieved on 20th October 2021.
- Wang, VC; Mullally, WJ; 2020; Pain neurology; Am J Med.; 133(3):273-280. doi: 10.1016/j.amjmed.2019.07.029.
- Finnerup, NB; Kuner, R; Jensen, TS; 2021; Neuropathic pain: from mechanisms to treatment; Physiol Rev.; 101(1):259-301. doi: 10.1152/physrev.00045.2019.
- Smart, KM; Blake, C; Staines, A; Thacker, M; Doody, C; 2012; Mechanisms-based classifications of musculoskeletal pain: part 3 of 3: symptoms and signs of nociceptive pain in patients with low back (± leg) pain; Man Ther.; 17(4):352-7. doi: 10.1016/j.math.2012.03.002.
- Maughan, EF; Lewis, JS; 2010; Outcome measures in chronic low back pain. Eur Spine J.; 19(9):1484-94. doi: 10.1007/s00586-010-1353-6.
- Treede, RD; Rief, W; Barke, A; Aziz, Q; Bennett, MI; Benoliel, R; Cohen, M; Evers, S; Finnerup, NB; First, MB; Giamberardino, MA; Kaasa, S; Korwisi, B; Kosek, E; Lavand'homme, P; Nicholas, M; Perrot, S; Scholz, J; Schug, S; Smith, BH; Svensson, P; Vlaeyen, JWS; Wang, SJ; 2019; Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain;160(1):19-27. doi: 10.1097/j.pain.0000000000001384.
- Grimaldi, A; Mellor, R; Hodges, P; Bennell, K; Wajswelner, H; Vicenzino, B; 2015; Gluteal Tendinopathy: a Review of mechanisms, assessment and management. Sports Med.;45(8):1107-19. doi: 10.1007/s40279-015-0336-5.
- Leerar, PJ; Boissonnault, W; Domholdt, E; Roddey, T; 2007; Documentation of red flags by physical therapists for patients with low back pain. J Man Manip Ther.; 15(1):42-49. doi:10.1179/106698107791090105
- Edwards, RR; Dworkin, RH; Sullivan, MD; Turk, DC; Wasan, AD; 2016; The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain. J Pain.;17(9 Suppl):T70-92. doi: 10.1016/j.jpain.2016.01.001.