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A Short History Of Pain

The bulk of MTs in Canada use a case history form, or intake form, with new patients. These forms may vary greatly in length and in the amount of information and detail that the therapist wishes to gather initially from the patient, but they do have basic common elements.

I want to mention just a few ways that this initial information from an intake form may help us to develop some specific questions or areas of questioning that need to be organized before we begin to interview the patient. The questions that arise from the intake form may not be the first things we ask, but rather, they will be asked when appropriate. The order of questions, what and when to ask, will be covered later within this article.

The first type of information that case history or intake forms gather is the patient’s personal information.

Those who follow in James Cyriax’s footsteps1 have used the phrase “age and occupation” to name this category of information. Others affectionately refer to this category as “the Tombstone” – that short list of name, age, address, phone numbers, emergency contacts, and any other pertinent personal information required.

The forms give us some initial clues about what may be causing a patient’s pain; their occupation can be a big clue. Some forms may even ask about recreational activities. All of this can at least supply us with some questions we may wish to ask about possible causes of pain, (and other impairments).
The patient may come in because their pain arose from a car accident or fall, but this personal information may still supply clues to:

1. How well they are healing or not, (i.e., How could their activities of daily living – occupation, sports, recreation – be impacting on their healing?);
2. About precipitating factors that may have led to their injury, or made their injury worse (e.g., their job has them at a computer all day); and
3. How they might prioritize their goals for therapy (i.e., they are more bothered by their headaches than the wrist pain they have).

This personal information provides a few possible areas to explore during the interview with the patient.

The next type of information gathered on an intake form is a general medical history. Also affectionately known as ‘the organ recital,’ it identifies any medical conditions concerning one’s heart, lungs, digestive system, kidneys, etc. We certainly need this information to understand the indications and
contraindications for massage and related modalities (e.g., hydrotherapy). But also, specific to pain, we need to know if the patient’s pain could be the result of an organ/visceral referral.

We need the medical history to rule out sources of pain that speak to a pathology that requires us to refer the patient out, etc.

The next step in getting the necessary information about the history of pain has to be obtained specifically during the interview with the patient. This can be done in a number of ways.

Some therapists ‘just go for it’ and begin a long list of questions such as “what makes it better? … what makes it feel worse?” etc., etc. Certainly  information will be gathered using this method, but usually in a jumble which impedes the information’s full usefulness. Also, the odds are that many
pertinent questions may be skipped by accident. If this is the case, we may well miss information that will not only hamper how useful our treatments are, but may lead us to implement a treatment plan that could make things worse.

One of the most common tools taught to therapists to help them get the appropriate type and scope of questions asked is the acronym “OL’ DR FICARA” which stands for (as one variation has it): Onset, Location, Duration, Radiation, Frequency, Intensity, Character, Aggravation, Relieving, & Associated symptoms.

This is certainly better than ‘just going for it,’ but often the student does not understand (or is often not taught) that there are different types of questions, categories of information, hidden within this acronym, and that asking these questions in a specific order helps us organize and better understand the patient’s pain and its possible sources, expressions, and gradations/acuity, etc.

The way I have found most useful goes back to James Cyriax and those who continued to develop his way of understanding orthopaedic assessment.
After the first two categories (“age and occupation” and “medical history”) the information required for a thorough case history includes three more categories that explore the source and nature of the pain (or any impairment):

• Onset & Duration
• Site & Spread
• Symptoms & Behaviour 2

There are two reasons why I like this list of categories:
First, it nicely divides the whole range of possible questions into three basic categories or types of questions that each speak to the source of pain
in a different manner.

Onset & Duration: These questions deal with “when & how” – the possible origin or mechanism of injury; and any previous history of such. This talks to us about the mechanics of the injury and hence gives us clues regarding the structures involved and the amount or acuity of the injury initially; also we may get more information about predisposing factors; and we can inquire about initial treatments or first aid received.

Site & Spread: Specific questions about location of pain, and if it travels or radiates/refers to anywhere else – which gives us clues such as whether we are dealing with superficial or deep structures as being the source; possible clues to types of tissues, (muscle, connective tissue, nerve).

Symptoms & Behaviour: How the pain has and is presenting and expressing itself; clues to its present acuity; what is being done for it now, and by whom, and how it is responding; how activities of daily living are affecting recovery; and so on.

The second reason I like these categories concerns the very order these categories are listed in, as they are on the previous page.

Questions about the onset & duration of the impairment are relatively limited in number: When did you hurt yourself or how long have you been experiencing this pain? Do you know how you hurt yourself or when did you first notice – i.e., was the injury sudden or gradual, cause known or unknown. Did you have anything done for it at the time, or since – i.e., any first aid at the time or treatment to date. Have you experienced this before? If so, how Often? How long where you in pain? How was it treated – i.e., the history of previous occurrences and previous treatments, if any? “How did the pain feel originally? And now, today?

This type of information will usually help inform us about pertinent questions that we need to ask further along in the interview. Though there are more questions that could be asked, initially we can get enough information about the mechanism of injury so that we can move on to site & spread: And again, these questions can be initially few in number: Can you point with one finger to where you feel the pain, or do you have to draw a boundary around it – i.e., the more indistinct the site the deeper the source of the pain, or the farther away (referral) the source of the pain is from where it is being felt? If the pain travels or radiates anywhere else, could you please show me (draw with your finger) the path it takes and to where it travels – i.e., for nerve pain specifically, but also for pain arising down the course of a structure or muscle?

Even if you think it is unrelated, have you, or are you experiencing any pain anywhere else in your body? If so, did you notice this before or since your current problem – i.e., speaks to possible referred pain, trigger points etc., or, to predisposing (pre-existing problems/pain), or, to adaptive, compensatory problems arising since the onset of the current complaint?

Now, that we have clarified the origin and the location of symptoms, we can go onto the almost unlimited category of questioning, symptoms & behaviour. It is here that we really want to explore the nature of the pain.

We may be tempted to explore the nature of the pain when dealing with the onset, or when dealing with the site & spread, but we should resist doing so. The main reason being that the symptoms & behaviour category of questions is so large. If we either begin here, or enter into this realm before clarifying the onset and site issues we may in fact never get around to clarifying them at all. And, hence we could miss some very pertinent information contained in these two categories that is required if we are to give a safe and effective treatment, if we are going to be able to formulate a coherent and efficient treatment plan, and, if we are to develop re-assessment strategies for the future.

Examples of symptoms & behaviour questions are: the ever-popular (and the first out of the mouths of students!) What makes it better? Worse? Is it worse or better at certain times of day? Worse or better after rest … or activity? Does it wake you up at night? Does it interfere with your daily tasks and activities? How so?

But even here we should order the questions somewhat. A good way to begin, after clarifying the site & spread, is to say something like: Let us return to how the pain feels, especially how it may be different at different times or during different situations.

So, first, in your own words please describe how the pain feels right now How intense is the pain on a scale of 1-10? This starts off with the symptoms.
Once the client has described the nature of the pain, then go into those “behavioural” or situational questions listed above – how the pain is altered by activities and the client’s specific living environment.

A tip about staying on topic, i.e., staying within each of the categories, is to use your “active listening skills.” You may remember this from your schooling: when you feel that you have got enough information from the patient on a specific topic repeat the information back to the patient, in their own words, to clarify for both of you if you, the therapist, have their description right and to let them alter the story if something they said was not how they really wanted to put it, etc. Once you have the summary, or clarification, then move onto the next topic or category of questioning.

If you follow this advice you can get a precise and compact history of the patient’s pain, or impairments. And, it should take a lot less time than it did to read this article!

REFERENCES
1 For example, The Society of Orthopaedic Medicine – www.soc-ortho-med.org  See also Cyriax’s classic texts, Textbook of Orthopaedic Medicine Vol. I & II, or the more resent summary: Cyriax’s Illustrated Manual of Orthopaedic Medicine  Butterworth &Heinemann, 1993. Cyriax coined the term orthopaedic medicine and really was a genius in developing the organized orthopaedic model we use today. Unfortunately, his work in the 1930s and since blamed the bulk of back pain as having its source in intervertebral disc lesions; and he was adamant that sacroiliac joints were not a source of pain. The impact on allopathic medicine was enormous and it has taken decades to return to a more balanced view where we again see other causes, such as facet joint dysfunctions, S.I. joint dysfunction, muscle and ligament lesions, as the greatest sources of back pain.

2 Usually the term is “behavior & symptoms,” but I have turned it around so that it follows how I like to present the ordering of questions in this article.