Pain Paper

Shifting the Pain
Paradigm
Rebecca Stevens 2012
Rebecca J Stevens
Jonathan Watson
Jennifer Hile
Community College of Allegheny County

Physical Therapist Assistant Program
Poster Night Project
PTA 201: PT Principles and Procedures 3
10/31/2013
This paper details the history of pain theories, current

pain scales, and pain myths, and suggests the role of four
non-traditional chronic pain management techniques for
clinical use by the Physical Therapist and Physical
Therapist Assistant to promote management and healing.
By focusing and expanding on the use of communication,
therapeutic exercise, touch, and music within the context
of chronic pain management, physical therapy may be
able to further accommodate patients with chronic pain
on a multidimensional scale, rather than treat pain
conditions as a singular event.
Shifting the Pain Paradigm

Rebecca J Stevens, Jonathan Watson, Jennifer Hile
TABLE OF CONTENTS
INTRODUCTION ........................................................................................................ 2
WHAT IS PAIN? ........................................................................................................... 2
THE HISTORY OF PAIN............................................................................................ 3
MODERN PAIN THEORIES .....................................................................................6
PAIN SCALES ............................................................................................................. 14
PAIN MYTHS ............................................................................................................. 18
CLINICAL TECHNIQUES ....................................................................................... 21
CONCLUSIONS ......................................................................................................... 34
WORKS CITED ........................................................................................................... 35
PHOTOGRAPHS CITED .......................................................................................... 39
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INTRODUCTION
Pain is a subject all humans have experienced. In the field of physical therapy, clinicians
have a unique chance to work with patients who are actively in physical pain. However, chronic
pain is not just a physical component to injury; it is not simply a number on a scale of 1 to 10.
Patients may experience chronic pain cognitively, through emotions, and socially during their
physical recovery, all of which contributes to their physical pain. By first detailing the history of pain
theories, pain scales, and pain myths, the role of non-traditional chronic pain management
techniques will be explored for clinical use by the physical therapist and physical therapist assistant
to promote management and healing. By focusing and expanding on the use of interpersonal
communication, therapeutic exercise, touch and massage, and music within the context of chronic
pain management, physical therapy may be able to further accommodate patients with chronic pain
on a multidimensional scale, rather than treat pain conditions as a singular event.
WHAT IS PAIN?
Pain plays a vital role in the nature of human. Pain serves as a warning system, a way for the
body to let the mind know something is wrong and to react. How exactly this occurs has been a
controversy for centuries. Today, scientists continue to strive towards an accurate model of how
pain works within our system. Theories have come and gone, and many older theories remain today
comprising the mythos of pain. However, until we have an accurate and functional theory of how
the brain works, pain theory and pain management will remain theoretical (Melzack 1279).
Currently, pain is understood in two forms: acute pain and chronic pain. Tabers Cyclopedic
Medical Dictionary definition of pain is over six pages long, but briefly defined as an unpleasant
sensory and emotional experience arising from actual or potential tissue damage or described in
terms of such damage. Pain includes not only the perception of an uncomfortable stimulus but also
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the response to the perception (Taber 1680). While this definition is all inclusive of acute and
chronic pain, it must be made clear that each subtype of pain is distinct. Acute pain not only begins
with injury or pathology, but ends with the removal of the stimulus. Chronic pain, or persistent
pain is discomfort that lasts beyond the normal healing period (Taber 1680). While adequate, the
definition of chronic pain provides no answers for the reasons behind the chronic pain, no duration,
and no hope for treatment. Brain mapping, fMRIs, and other examination tools have allowed
scientists to better understand the mechanisms of chronic pain, the perception aspect of pain
remains in the highly theoretical realm with concepts such as consciousness.
THE HISTORY OF PAIN

Since modern humans were able to comprehend pain with higher cognitive functioning,
descriptions and theories of pain have been established, refuted, and redefined. The earliest pain
theories, much like our earliest civilizations, revolved around external forces acting upon our bodies
and were tied to our spiritual beliefs (OSullivan 1117). In human prehistory and early history,
humans practiced a form of medicine intentioned to remove spirits and demons from the body.
Disease, including pain, was thought to be an invasion of the body and soul from external sources.
In addition to ceremonies and rituals, trepanning, a prehistoric surgery where the skull is cut or
drilled to remove the source of the pain, demons and spirits, was used to remove unwanted spirits
from the body.
In 1876, Paul Broca, professor of External Pathology
and Clinical surgery at the University of Paris, published
papers detailing trepanning surgeries which were performed in
the Pre-Columbian Peruvian civilization.
Broca, who later

Figure 1 One of the perforated skulls recently
unearthed in Spain. (Credit: Plataforma SINC)
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discovered the localization of speech in the third convulsion (Gross 308) of the frontal cortex,
was criticized because anthropologists felt the surgical procedure would be too difficult to be
successful.
Seven years later, more evidence of trepanning use in Neolithic sites in France
confirmed Brocas theory.

Evidence of world-wide trepanning exists, from Hippocrates medical journals to Luo
Guanzhongs historical novel Romance of the Three Kingdoms (Guanzhong) to the Dark Ages medical
practice in Europe. The notion that the external or supernatural world caused illness and pain
persisted into the Greek Civilization in the 4th century BCE.
In the 4th c., the Greeks reached the height of their civilization, and philosophers such as
Hippocrates, the Father of Western Medicine, Aristotle, Socrates, Galen, and Plato all expressed
their opinion of pain and its root cause. These philosophers were unable to dissect bodies, so their
findings were only based upon visual observation.
Hippocrates views were based upon the
knowledge that the human was comprised of the soul and body. Illness was a result of an imbalance
of bodily fluids. These bodily fluids were known as the Four Humours, and were influenced by
the external world, although not the supernatural world.
The Humours, or Temperaments in Roman, were: 1)
Sanguine, 2) Choleric, 3) Melancholic, and 4) Phlegmatic.
Each Humour has specific characteristics which must be
sated to achieve proper balance. For example, someone with
an abundance of Sanguine is optimistic, energetic, and
daydreamy. In excess, the person may appear to be manic or
hyperactive.
To cool the sanguine imbalance, one must
restore the balance between the other Humours, using them

to cancel out the Sanguinity (Balance of Passions).
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Figure 2 The four temperaments (Clockwise from

top choleric; melancholic; sanguine; phlegmatic).
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The Four Humours, in some variation, was continued through medical vernacular until the
late 19th/early 20th century, until the advent of psychology and more detailed internal anatomy and
physiology research could be conducted. Evidence of the Four Humours can be found in the
writings of the Monks of the Middle Ages, Shakespeare, German philosopher Immanuel Kant, and
the physiologist Wilhelm Wundt.
Wundt, however, was the first physiologist to separate the
personality from the human body functions (Balance of Passions).

Aristotle also proposed a contending theory of pain. He also believed pains arouse from an
imbalance in the body; however, Aristotles imbalance was of the hot influences of the heart and the
cool influences of the brain (OSullivan 1118). His theory is similar to the 14th c. BCE Chinese Yin
and Yang. Yin represents female, cool, and South and Yang represents male, hot, and North. While
independent in nature, yin and yang cannot exist without each other. Four basic imbalances can
occur: 1) Preponderance (Excess) of Yin, 2) Preponderance (Excess) of Yang, 3) Weakness
(Deficiency) of Yin, and 4) Weakness (Deficiency) of Yang (Sacred Lotus). For both the Chinese
and Aristotle, pain could be controlled by realigning the imbalance, through either external
modalities such as acupuncture for yin and yang imbalances and rhetoric for hot and cold
imbalances.
Avicenna, an 11th century physician and the Father of Persian Medicine, wrote two books
based upon the works of the Greek philosophers Aristotle and Hippocrates, called The Canon of
Medicine and The Book of Healing (Beckford). In addition to medicine, Avicenna wrote over 250 books,
ranging from the soul, pain, religion and spirituality, politics, and astronomy, though the medical
books are still considered the most famous. His theory notes that pain is a sense, one which is
similar to touch or titillation. Rather than dismissing pain as a symptom, he treated it as though it
were truly equal to the disease or injury through both herbal (opiates) and holistic remedies
(Beckford).
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MODERN PAIN THEORIES
Modern pain theories can be linked back to Descartes Specificity Theory. Many theories
have evolved from Descartes first move away from the philosophical pain theories. The new
theories often overlap and clash with one another. For example, Allan Basbaums June 2011 article
Specificity Versus Patterning Theory: Continuing the Debate claims Gate Control Theory is based upon
Peripheral Pattern Theory, and this many not be a correct assumption. He states that the theory you
subscribe to is relevant to the development of approaches to the clinical management of pain
(Basbaum). He is correct that an understanding of each is important to an understanding of
modalities.
In
the
16th
century,
Descartes
established the Cartesian Intensive Theory,

based on the idea that the body and mind were
separated and that the pain center was located
in the pineal gland. From the pineal gland,
information was then disseminated throughout
the brain (OSullivan 1118), including emotions,
thoughts, feelings, and experiences. Descartes
explained
the
brain
as
the
center
of
perception and described the nerves as tubes

containing delicate threads that connected
sensation in the periphery with awareness
Figure 3 Descartes' concept of the withdrawal reflex.
(OSullivan 1118). In regards to pain, there is little interaction between the pain signals and other
tracts in the nervous system. The pain receptors are independent of all other receptors in the skin,
and function only to sense pain. Pain caused from other sensations and from trigger points remains
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unaccounted for (Melzack, Wall 971). Most importantly, Specificity Theory accounts only for
physical pain and discounts all psychological influences (Calgary). In the 19th century, the theory
gained credibility through the neurologic experiments published by Head and vonFrey. VonFreys
experiments were specific to sensation testing and pain spots, which were later to be known as
dermatomes (Freeman). Unfortunately, the Specificity theory led to a practice of removing the
cause of the pain, which may lead to unnecessary amputations, removal of skin or organs of the
body (OSullivan 1118).
The Intensive Summation Theory, suggested by Erb in 1874 and was built on Aristotles
theory of temperature imbalance, proposed that pain was not a unique sense but an emotional state
induced by noxious stimuli. When a stimulus produced enough pain, the stimulus intensity and
central summation (OSullivan 1119) will determine the quality and quantity of pain. The same
year, Strong proposed his own theory which combined the noxious stimulus and the reaction to the
stimulus as the cause of pain (OSullivan 1119). In the 20th century, theories began to surface which
expanded on previous theories. In the 1930s when Livingston proposed the creation of abnormal
reverberating circuits which overloaded the brain with the stimulus thus creating pain (OSullivan
1119). Hardy, Wolff, and Goodell expanded Strongs Theory in the 1940s, separating pain into the
categories of perception and reaction (OSullivan 1119). In the early 1980s, on model, which is
inspired by the Cartesian Intensive Theory, was Loesers model of pain.
It incorporates the
biosocial element missing from Descartes original theory.

John D. Loeser, M.D. is regarded as an expert in multidisciplinary pain management. From
1982-1997 he was the director of the Multidisciplinary Pain Center at the University of Washington
School of Medicine (UW). In 1982 he developed a conceptual model of the components of pain
that combines cognitive, perceptual, and learning factors in the formation of chronic pain.
Nociception derived from tissue damage is not the sole determinant of pain and its behavioral
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expression, and the nervous system can modulate nociceptive stimuli by physiological and
psychological mechanisms (Loeser 266). He proposed this model to communicate to fellow medical
professionals that a patients pain experience is internal, personal, and private and not an objective
measure or observation. The existence of pain can only be inferred by the assessment of pain
behaviors and clinician should take caution when considering diagnostic testing and potentially
harmful surgical procedures (Loeser 266). Recently, Loesers model of pain has been referenced by
the International Association for the Study of Pain. John Loesers famously depicted concentric
series of domains effectively informs a more enriched stepped care model (IASP 2) in the
management of chronic pain. It depicts the enveloping layers of suffering and maladaptive
behaviors that patients with chronic pain often demonstrate (IASP 2).
His model proposed that pain can be separated into four encapsulated components:
nociception, pain, suffering and pain
behaviors. It is often represented as a
series
on
concentric
circles;
PAIN BEHAVIOR
the
components are separate factors which
SUFFERING
can influence each other. It holds

nociception, the biophysical factors, in the
center. These factors are either initiators
PAIN
(acute pain) or maintainers (chronic pain)

of the pain. The pain component exists
NOCICEPTION
when it is perceived and experienced by

the individual. The degree of suffering,
the third component, is determined by an individuals awareness and interpretation of sensations and
their possible ramifications to overall
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Figure 4 Loeser's Concentric Circles, Stevens 2013
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well-being. The patient may internalize these ramifications leading to anxiety, fear, and depression
which subsequently lead to more suffering. Finally, pain behavior encompasses the patients actions
and dialogue, and is based on personal beliefs. These behaviors will lead the observer to infer that an
individual is suffering from a noxious stimulus (Loeser 7).
Loeser stated that All pain behaviors can be quantified and used as measures of pre- and
post-treatment status to evaluate outcomes (Loeser 266). Pain behaviors are real and sensitive to
the effects of the environment and social context (Loeser 266). Factors such as those who are
around the patient, others reactions and responses to the situation, home environment, and cultural
effects will alter a patients perception and response to pain.
While not a theory, Richard Sternback, of the Pain Treatment Center at Scripps Clinic and
Research Foundation, offered a seven step guide to live with pain. His 1977 pamphlet provides an
outline of a patient centered approach to living life with pain called How Can I Learn to Live with Pain
When It Hurts So Much? Coupled with pain theory and modalities, the following guidelines offer
short-term and long-term goals to patients and therapists, which are reasonable and attainable
(Regents).
1. Accept the fact of your pain
2. Set specific goals of work, hobbies and social activities towards which you will work
3. Let yourself get angry at your pain if it seems to be getting the best of you
4. Pace your activities
Get in shape, and keep fit
Learn to relax, and practice it
5. Time your medications, then taper off them

6. Have family and friends support only your healthy behavior, not your invalidism
7. Be open and reasonable with your doctor
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The Gate Control Theory was put forward in 1965 by Ronald Melzack, a Canadian
psychologist, and a Patrick Wall, an English physician. Gate Control Theory proposes that pain is
not activated directly by the stimuli, but caused by an interaction between different neurons with the
peripheral and central nervous systems. When a noxious stimulus is introduced, gates located within
the spinal column may be opened or closed. When the gates are open pain is experienced, and when
the gates are close pain is blocked off (Melzack, Wall 972). Whether a gate is opened or closed is
based on physical, emotional, behavioral and therapeutic factors. Physical factors, such as injury and
inflammation, emotional factors, such as stress, anxiety and anger, and behavioral factors, such as
focusing on the pain, can cause the gates to be open. However, using therapeutic agents, such as
behavioral modification, physical modalities, and psychotherapy, can influence the gates to close
thereby reducing pain (Deardorff).
Three sets of spinal fibers in the dorsal horn are involved in the open and closing
mechanisms of the gates: 1) substantia gelatinosa, 2) dorsal column fibers that project toward the
brain and 3) central transmission cells, commonly referred to as T cells. The substantia gelatinosa
consists of small cells that extend the length of the spinal cord. They are connected by both long
and short fibers of Lissauers tract. Research has shown that the substantia gelatinosa acts as the
control system that separates the synaptic impulses from peripheral fibers to T cells and that it
modulates afferent patterns before influencing the T cells. The afferent patterns in the dorsal
column system act in part as a central control trigger which activates selective brain processes that
influence the modulating properties of the gate control system. The T cells activate mechanisms
responsible for proprioception.
Melzack and Wall found that pain can be determined in the
combined actions of these three systems (Melzack Wall 974-975).
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Significant to pain, in terms of afferent input, are the activity that precedes the stimulus,
evoked activity of the stimulus, and the balance of large versus small fibers. In the absence of
obvious stimulation, the spinal cord may continue to receive incoming nerve pulses.
The
continuous nerve pulses are carried by both myelinated and unmyelinated small fibers, which hold
the gates in an open position, thus creating pain. When a stimulus is then introduced, the large
fibers, previous inactive, are become activated. This not only signals the T cells, but also closes the
presynaptic gates. Therefore, when the gates are closed, signals are not able to activate the dorsal
horn transmission neurons. When the gates are open, pain signals excite the dorsal horn transmitter
cells and produce pain (Melzack Wall 974-975).
During the Gate Control research, evidence was found that cognitive-behavioral approaches
can be used to manage pain (Nursing Theories). Interventions which include auditory and visual art
may distract the mind, creating a form of pain therapy. Because concentration on pain increases
pain, theoretically, distraction from pain will assist in closing the gates thus decreasing pain from
noxious stimuli.
Figure 5 The gate-control theory of pain. From Linton et al., 2000.
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The Neuromatrix Theory was presented by Ronald Melzack as an expansion of the Gate
Control Theory. His research was spurred by observations made in paraplegics that just do[es] not
fit the theory (Melzack 1378). The Neuromatrix Theory attempts to redefine chronic pains role in
disease and injury.
Melzacks research on phantom limb phenomenon led him to four conclusions about the
nervous system, which he calls a new conceptual nervous system (Melzack 1379). First, phantom
limb pains feel real because the body and the brain both use the same neural processes; however,
they may act without input from each other.
Second, patterns of neural inputs reside in the brain
and may act as the body input when the brain detects no actual body input. Third, the body is
perceived as an independent self, it is different than the world and those around it. This self is
perceived by the central nervous system and is uniquely separate from the peripheral nervous
system. Fourth, while the brain processes the Self, it must include both genetic specification and
experiences (Melzack 1379).
These conclusions led Melzack to outline the Neuromatrix as a large, widespread network
of neurons that consists of loops between the thalamus and cortex as well as between the cortex and
limbic system (Melzack 1379). The loops much like a plexus diverges and merges at various points
in the Neuromatrix and eventually come together for synthesis creating the Neurosignature. This
Neurosignature creates patterns which are stored and accessed as needed to create the whole BodySelf, otherwise known as the Neuromatrix.
Each part which feeds into the loop is unique,
representing different facets of the sensory experience, such as injury or erotic stimulation. Once
these experiences through the Neurosignature are received, they are synthesized together and are
bifurcated into the sentient neural hub and back into the Neuromatrix. In the sentient neural hub,
the pattern is converted into the experience of movement (Melzack 1379); the experience is
comprehended and stored as memory.
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Although Melzack specifies areas of the brain, such as the thalamus and limbic system, as
part of the sentient neural hub, he continues to discuss the Neuromatrix is used throughout the
entire brain through networks of neurons. The patterns stored could be used to effect movement in
the motor cortex or in the sensory cortex to effect sensations. These patterns may be triggered by
multiple determinants (Melzack 1381), such as stress, genetics, cognitive events, and physical injury.
He proposes that the Neuromatrix guides us away from the Cartesian concept of pain as a
sensation produced by injury, inflammation, or other tissue pathology and toward the concept of
pain as a multidimensional experience produced by multiple influences (Melzack1381). Rather than
a direct correlation between injury and pain, clinicians can view pain in a more holistic light.
Melzack further documents the need to expand pain research away from the external experiences
and more internally, into endocrinology and immunology, to help relieve chronic pain.
Figure 6 "Factors that contribute to the patterns of activity generated by the body-self Neuromatrix"
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PAIN SCALES
With so many historical and current pain theories competing for attention in the academic
and clinical worlds, it is difficult to come to one cohesive conclusion about how pain works. Even
pains function is disputed, especially within the realm of chronic pain. Physical therapists or
physical therapist assistants are required to determine and document the level of pain a patient.
Regardless of which scale is used, the pain scale is a physical representation of the patients level of
pain. However, it is more difficult to assess pain on a multidimensional scale, which include the
physical, emotional, cognitive, behavioral, and social aspects; rather, the focus is strictly on physical
and present pain. By examining the pain scales currently available and presenting options for
assessing pain, therapists will be able to determine the accuracy of the scales they choose to use in
their clinics.
Pain scales can be categorized into two types: single dimension and multidimensional. The
single dimension pain scale uses a simple descriptor which the patient aligns to their pain level
(Loeser 311). A simple and often used scale is the Numeric Rating Scale or NRS, which is a type of
Category or verbal/visual description self-report scale (Loeser 311). The NRS is simple, efficient,
and requires the least amount of patient and staff burden (Loeser 311) to collect results. The pain
intensity is recorded on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain
imaginable. Often, 1-3 indicates mild pain, 4-6 is moderate pain, and 7-10 severe pain (Krebs). The
patient is prompted to select a whole number as close to their perceived pain level. Various versions
of the NRS have been created, such as the Color Coded Scale or Faces Pain Scale (Loeser 311).
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Figure 7 Numeric Pain Intensity Scale
However simple the NRS may seems, certain patients may not be able to use the test.
Patients with cognitive functioning and motor functioning problems, unresponsive patients, and
young children most likely will not be able to accurately use the Numeric Rating Scale, if at all
(Health Communities).
In addition, the scale only measures intensity of pain (Health
Communities). It does not account for chronic pain, peripheral or referred pain, or variations
through the patients day and activities. In one study, the NRS was indicated as having fair or
modest accuracy, and when compared to the Brief Pain Inventory (BPI) interference scale, the NRS
was only 0.76 accurate (Krebs). With a moderate accuracy and focus only on intensity, the NRS
does not represent a valid representation of chronic pain.
Created in 1975 by Ronald Melzack, the McGill Pain Questionnaire, or the MPQ, is a selfreport on pain in three dimensions. Sensory, affective, and evaluative pain dimensions are tests
through the use of sets of words which describe the pain. The patient selects a word from each set
which they feel describes their pain. The patient is also given opportunity to draw the location of
their pain on a blank human form, associate words with their pattern of pain, and use a modified
numerical scale to rate their intensity. In addition, they can write words they feel are descriptive of
their pain and other pains they have had in the past (Loeser 312-314).
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Overall, the MPQ is considered reliable and valid. The test takes between 5 and 15 minutes
to complete, however it places more of a burden on the patient than the NRS or other single
dimension tests (Loeser 313). In a Swedish study of the MPQ, fibromyalgia (FS) and rheumatoid
arthritis (RA) patients were asked to fill out the MPQ (Burckhardt). The test was considered
consistent but scored lower in validity for the RA patients (Burckhardt). Additionally, patients must
be able to handle the vocabulary (Loeser 313). Another study, by Walsh, indicates that a spouse may
offer alternatives or urge[ing] changes (Loeser 313). Turk et al. also evaluated the scoring method
of the MPQ, citing that it is valid as a general measure of pain but lacks validity when interpreting
individual scaled scores (Loeser 313). However, the MPQ used as an assessment tool in conjunction
with other pain scales will allow the physical therapist to document the pain in greater detail than the
simple NRS.
Figure 8 McGill Pain Questionnaire

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The Global Pain Scale (GPS) is a newer pain scale, introduced by the Arizona Pain
Specialists and PainDoctor.com in 2010 (HCPLive). The GPS is designed to specifically ask patients
about chronic pain conditions by body regions. The questions are asked on a scale of 0 to 10, 0
being no pain and 10 being extreme pain. Questions relate to specific pain, emotions, clinical
outcomes, and activities of daily living (Gentile 65). Questions also relate to current, past, and
average pain levels, which help the therapist, assess chronic pain over a longer period of time
(Gentile 63). While the GPS addresses pain on a multidimensional scale, it also scores pain on an
individual basis, allowing comparison
to averages nationally and per patient
(Gentile 63-64).
The GPS was found to be
both reliable and valid in and of itself
as well as compared to the NRS, MPS,
and other scales such as the West
Haven Yale Multidimensional Pain
Inventory (WHY) and the Perceived
Stress
Scale
(PSS)
(Gentile
64).
Correlation studies have shown that

the GPS scores rate higher in validity
than other commonly used scales
(Gentile 66). While promising, the
GPS is still clinically a new pain scale
and will continue to receive peer
Figure 9 Global Pain Scale
review.
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As noted, there are a multitude of pain scales available for use in the physical therapy setting.
In addition to pain scales, patients may be asked to keep record of their daily pain in a journal or
online log. This allows a doctor or physical therapist to look closer at the activities, causes, and pain
behaviors exhibited by each patient (Pain Treatment Topics). Journals and logs are time consuming
and rely heavily on patient adherence. Therefore, a single combined scale would be advantageous to
the physical therapist in assessing and evaluating a patients chronic pain.
Often in clinics, the constraints of time and insurance requirements pressure the physical
therapist to use certain general pain scales rather than address the specific needs of the patients and
their health care team. In addition to a lack of ICD-9 codes for chronic pain conditions, a
discussion of pain scales within the documentation for patients is not included under Medicare
(CMS) (Medicare). While a longer pain scale, such as the MPQ or GPS may be used at the initial
examination, in reevaluation scenarios the NRS is often used to quickly assess the patients current
level of pain. While this method may be acceptable for acute, injury, and recovery pain scenarios, it
does not address patients with chronic pain. By using a more comprehensive scale, such as the
MPQ or GPS, chronic pain may be addressed and managed during therapy visits. In only using the
most basic pain scales which may not fully address the needs of the individual patient, physical
therapists may not know all the information they require to make sound and ethical clinical
decisions, required by the Code of Ethics under the American physical therapist Association
(APTA).
PAIN MYTHS
As shown, pain not only has a long history with humans, but humans have a long history
trying to understand pain. In spite of new theories such as the Gate Control Theory and the
Neuromatrix Theory, many myths are still propagated by patients, family and friends, pseudoscience
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websites, and, sometimes, even medical professionals. By understanding that patients may have
misconceived notions regarding pain and where they came from, physical therapists and physical
therapist assistants can tactfully correct these notions.
Myth #1: No Pain, No Gain
The no pain no gain myth is dangerous for both those in pain and their caregivers. Pain is
the body's way to signal that there is a problem and to seek attention. It is normal to feel discomfort
while starting an exercise program; however, severe pain should not be induced by physical therapy
intervention. If there is severe pain during physical therapy, advise the therapist right away (PSU
Fitness Clubs).
Myth #2: A Doctor Can Rate Your Pain By Looking At You!
Many people believe that doctors, physical therapists, nurses, and other medical
professionals can tell how much pain you are in by looking at you. Perhaps they can glean pain
levels through a grimace, grunt, or clenched fist. However, medical professionals cannot really tell
pain levels this way. When dealing with pain, especially chronic pain, people learn to use defense
mechanisms to hide their pain levels. In addition, because pain is personal, it cannot be assumed
that all patients with certain conditions will have the same pain experiences (Einstein Healthcare
Network).
Myth #3: Pain Is A Natural Part Of Aging!
As the body ages and endures normal wear and tear, it is possible to feel some discomfort
from time to time. Conditions such as arthritis, degenerative joint disease, and previous injuries can
increase pain levels, especially in the knees and elbows. Chronic pain, however, is not a normal part
of aging and should be addressed. There is no age in which a person should or will experience pain
because aging, like pain, is in individual experience (Cleveland Clinic). Alice Bell, of the American
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Physical Therapy Association says that "experiencing any kind of pain would be a meaningful trigger
because pain's not normal at any age (HuffPost50).
Myth #4: You will have to learn to live with your pain!
Many chronic pain sufferers believe that they have to learn to live with their pain because
they have had it for so long. However, this is not true. There are currently several pain relieving
modalities as well as ongoing research into chronic pain treatment. Many chronic pain sufferers
often give up on therapy as an option because of their own fear, belief in pain myths, and because
chronic pain relief is not immediate (Overcoming Pain).
Myth#5: Bed Rest Is The Best Way To Treat Pain!
In the past, doctors prescribed bed rest to relieve pain and assist in healing. Bed rest,
however, can increase pain due to immobility. As the patient remains in bed and reduces mobility,
the fascia in the body dries out and crosslinking increases causing stiffness and possible joint
adhesions. Muscles begin to atrophy after prolonged bed rest, which also will limit mobility. With a
decrease in mobility, pain can increase. Some conditions do require rest during flare ups, such as
Rheumatoid Arthritis; however, unless prescribed by the doctor, it is best to continue with daily
activates as much as possible. This will not only improve mobility, it will help reduce fatigue and
increase immune and mental health (Tiffany).
A quick internet search on pain myths will result in hundreds of common myths which have
been propagated in the United States. By widening the search globally, the number increases
substantially. Myths can involve gender, age, race, height, personality, temperament, antiquated
science and pseudoscience. With an increased access to the internet as well as family and cultural
beliefs taught in homes and public settings, it is vitally important that physical therapists and physical
therapist assistant are armed against these myths.
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CLINICAL TECHNIQUES
As illustrated through history, mythos, and assessment tools, chronic pain is far more
complicated that acute pain. Chronic pain is derived from acute pain and learned by the body and
the mind. It has both physiological and psychological elements, with one often promoting the other
in a vicious cycle. Patients learn adaptive and maladaptive behaviors, called pain behaviors, in order
to cope with their chronic pain. Extrinsic elements, such as a perpetuated mythos, societal norms,
and believe structures, strongly influence a patients behavior, further solidifying improper coping
mechanisms and pain behavior. The entire cycle will continue to spiral out of control, leaving
chronic pain patients helpless and hopeless in trying to alleviate their pain. However, physical
therapists and physical therapist assistants have several tools available to them to help chronic pain
patients not only cope with their suffering but alleviate their pain. While some tools require a simple
adjustment or proper application, others require the physical therapists and physical therapist
assistants to combine current techniques or think slightly outside of the box.
Proper communication coupled with alterations in the current techniques of therapeutic
exercise, massage and touch, and the use of music during visits may help to improve patient
functioning, adherence, compliance, and overall pain reduction. It is important to combine each
technique with proper communication in order to accurately assess the usefulness of each modality
and further tailor it to the individual patient.
Like current techniques and assessments, it is
important to adjust each modality to the patients cognitive level, learning abilities, and individual
pain and pain behaviors. The overall goal is to use these techniques to break the pain behaviors
which lead to a sedentary lifestyle and promote pain relief through activity, including therapeutic
exercise and functional activities.
Individuals with chronic pain often have difficulty discerning psychological distress from
physical pain and avoid subsequent exercise. This inability is termed kinesiophobia and was
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introduced by Miller, Kori and Todd in 1990 at the Ninth Annual Scientific Meeting of the
American Pain Society. Kinesiophobia describes a situation where a patient has an excessive,
irrational, and debilitating fear of physical movement and activity resulting from a feeling of
vulnerability to painful injury or reinjury (Hudes 223).
Through proper communication between the patient and the physical therapist and physical
therapist assistant, kinesiophobia can be reduced or extinguished the physical therapist and the
physical therapist assistants role is to help these individuals separate the difference between their
fears of moving from actual pain. This will allow the patient to return to their daily activities,
including work, home life, and leisure activities. With the use of verbal guidance, encouragement,
and empathy physical therapists and physical therapist assistants can help individuals face and defeat
their fears and unhelpful beliefs.
In a study conducted by Dianna T. Kenny patients suffering from chronic pain and
clinicians were interviewed post consultation. Several clinicians admitted: I think the patients
believe what they say and if you are hearing them, you have an opportunity to turn their feelings and
beliefs about the pain and themselves around (Kenny 301). In this same study, one patient
reported: The doctors dont seem capable of giving reassurance or caring. Any kind of reassurance
would have been helpful. I just wanted help, not to be fobbed off (Kenny 301). Kennys study
shows that active listening and reassurance are skills that both the patient and their health care team
need to utilize to succeed.
Legitimization of the pain and the treatment that follows provide the chronic pain patient
with a respectable way of getting better and giving up the chronic pain patient role without losing
credibility (Kenny 303). Through the use of encouragement during exercises, physical therapists
and physical therapist assistants can remind patients that some soreness and discomfort is
foreseeable and is not necessarily indicative of any further wear and tear on their body. Proper
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communication can also convey that exercise and modalities aid in working toward a less sedentary
lifestyle (OSullivan 1156), which is key towards a reduced pain or pain free active lifestyle.
In addition to encouragement and educational communication, an important strategy for a
successful rehabilitation of chronic pain patients is collaborative management (Nicholas 769).
VonKorff defines collaborative management as the arrangement between patient and clinician that
underlines the goals of treatment and the roles and responsibilities of both parties. This will allow
the patient to understand how the treatment activities and compliance to them will lead the
individual to their desired goals (Nicholas 769). For example, simply explaining how the exercises
that lead to improved range of motion in trouble areas will enable them to do something they value.
For example, using collective management with a patient will not only allow them to understand the
exercises they are asked to perform, but why the exercises will help them return to their normal
activities.
In turn, the patient will offer compliance and adherence to the plan of treatment
(Nicholas 769).
Additionally, the use of simple techniques will allow the physical therapist and physical
therapist assistants to communicate more efficiently with the patient. The use of open-ended
questions can lead to more specific pain and pain perception. Questions beginning with what,
when, or how will open the doorway of better communication between the patient and the
clinician in hopes of a better treatment plan, reduced treatment time and perpetuation of
performance of previously avoided activities by the individual (Nicholas 769). When a question
asked by the clinician such as: How do you usually respond when your pain increases? is more
likely to evoke specific and informative answers from the individual and enable the clinician to
address it directly when formulating a plan of treatment (Nicholas 769).
The use of eye contact and active listening are also important methods to use while
communicating with patients.
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provided by the patient allows their pain to be validated (Nicholas 770). The clinician is also able to
clarify any points which might have been misunderstood or misinterpreted. Incorporating these
techniques into each visit, rather than just at the examination, will allow the physical therapist and
physical therapist assistant to access to the patient regarding changes in the patients pain, coping
mechanisms, and make adjustments leading to a more active lifestyle.
In 2010, Christine Miserandino wrote a story on her website which details a conversation she
had with a friend about having Lupus. In trying to explain her pain and how she manages it, she
shares The Spoon Theory (Miserandino). Each day, she has a limited amount of spoons. Each
spoon represents the energy she needs to accomplish her activities of daily living. For each activity,
she removes at least one spoon. As the day progresses, she removes more and more spoons. Her
friend watches as the spoons disappear for activities such as showing, buttoning shirts, eating
breakfast, taking medication, and going to work. Christine makes sure to save a spoon in reserve
just in case she runs out during her everyday routine (Miserandino). Not only does Christines story
offer the listener or reader a chance to understand what daily activities are like for those in chronic
pain, but it allows better communication between the people talking. The Spoons Theory is an
excellent example of a way to communicate between those with chronic pain and those without
chronic pain. The analogy, the physical representation of spoons as energy, and the level of speech
all contain elements of proper communication.
Chronic pain usually results in a decrease in overall activity and general deconditioning
occurs. (OSullivan 1156) Tabers Cyclopedic Medical Dictionary definition of deconditioning is defined
as A loss of physical fitness due to failure to maintain an optimal level of physical activity or
trainingindividuals may experience overall deconditioning of the skeletal, muscular, circulatory,
and respiratory systems. (Taber 587) According to several studies fitness programs with aerobics,
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stretching and strengthening components have been evaluated and found effective for patients who
are slow to recover(Turk 22).
Chronic pain affects the whole individual and the use of therapeutic exercises, in conjunction
with other modalities, can significantly help to manage its symptoms. Exercise increases endorphin
levels (natural pain-damping chemicals) and distracts from pain and emotional distress (Selby 6).
The intention is not to eliminate all the pain, but to use exercises to address the learned pain
behaviors and encourage the individual to live and function despite the pain. The basic therapeutic
exercises can be combined and progressed to become function-based exercises, which improves
tolerance for functional activity (OSullivan 1156).
Each exercise program must be tailored for the individual considering the impact of the
chronic pain and pain behaviors, such as complaining, fear of moving. The exercise program should
also elicit self-motivation and self-regulation for the individual.
To prevent further injury,
overtiredness, or feeling of failure it is best to set goals and slowly increasing the pace or number of
exercises for the individual (Selby 6).
The therapeutic exercise of stretching will reduce soreness and stiffness of muscles, as well
as, promote flexibility of muscles and range of motion in joints. Strengthening exercises for the
musculoskeletal system will reduce chronic stress to musculoskeletal structures and increase muscle
tone. Low impact aerobic exercise, such as walking, is essential in improving cardiopulmonary
status. Increasing low impact aerobic exercise is a progression to an endurance exercise that helps
over-all conditioning. Increasing the number of repetitions within a strengthening exercise is a
progression into endurance exercises for individual muscles or muscles groups. Some exercises, such
as lower trunk rotations, promote flexibility, range of motion and strengthening. If an individual has
impaired balance, there are many balance and proprioceptive exercises available to work on
improving postural control. Braided walking, shifting weight from foot to foot, stepping over
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objects, and obstacle courses require an individual to work on dynamic stabilization. The
aforementioned exercises combined with balancing exercises stabilize body movements. Aquatic
Therapy and creating new exercises that demand the attention of the patient are useful as well.
These combined exercises are implemented to the exercise program with intention of
restoring the bodily functions of the individual. Seven studies assessed the effects of exercise in
managing chronic pain, on its own or in combination with psychosocial interventions. These studies
reported that participants in exercise programs experienced significant reduction in chronic pain and
perceived success of pain management (Park 557).
A common physical therapy technique currently used to alleviate pain and elicit more patient
comfort is transcutaneous electrical nerve stimulation (TENS). TENS is described by Melzack and
Wall as an electroanalgesia, which suppresses pain through the use of electrotherapy (Michlovitz
345). TENS is applied to both motor and sensory levels to modulate peripheral nociceptive or
neurogenic mediated pain (Michlovitz 345), it can be applied to acute and chronic pain types.
Currently, many TENS units are used prior to exercise in combination with moist heat. In effort to
assist a chronic pain patient ease both their pain and trepidation of pain during exercise, applying the
TENS unit during therapeutic activity may prove beneficial.
In the same vein, it may be prudent to use thermotherapy and cryotherapy throughout the
therapeutic intervention, rather than respectively at the beginning and end of the session.
Thermotherapy, including moist heat, raises tissue temperature by increasing vasodilation. This, in
turn, can promote healing and ease of joint movement thereby alleviating certain types of pain
(Michlovitz 343-344). Cryotherapy reduces blood flow and inflammation through vasoconstriction
but can increase pain tolerance and threshold through its analgesic effect (Michlovitz 342-343).
Using thermotherapy and cryotherapy as part of an individual treatment plan throughout the
exercise regime may not only promote healing and pain levels, but will allow the patient time to
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recover both physically and emotionally from a painful or stressful exercise. By accounting for both
physical and emotional elements of the therapeutic exercise process, the physical therapists and
physical therapist assistants are tackling chronic pain in a multidimensional fashion, allowing for a
more comprehensive plan of care.
Despite restrictions of billing coding and timing as determined by the insurance companies
and the profit desired by the business aspect of physical therapy; chronic pain patients could receive
a more involved and pain reducing integrated plan of treatment.
Ideally, physical therapist and physical therapist assistants should spend more one-on-one
time with the chronic pain patient, especially at the beginning of implementation of the treatment
plan. This will afford encouragement and praise to those patients that are easily discouraged or
prone to be fearful that moving will cause them more pain.
Physical therapy is not simply assigning therapeutic exercises to patients to enable recovery
or using modalities to achieve optimal mobility and stability. Physical treatments began as early as
5,000 BCE through the Chinese use of massage, gymnastics, and other physical modalities.
Unfortunately, physical therapy has lost touch with its roots in Eastern medicine, which seeks to
treat patients with a range of holistic treatments such as herbal (pharmacological) remedies, physical
engagement such as gymnastics, movement, massage, and acupuncture, and emotional engagement
through breathing, relaxation, and meditative exercises. The combination of all three elements
creates a whole body or holistic approach to healing. Because physical therapy aims to bring
patients to a healthy state, the inclusion of Eastern modalities should not seem foreign. By returning
to the art of touch, physical therapy can both non-verbally communicate and elicit a positive
response from patients.
Western medicine seeks to alleviate pain through the use of pharmaceutical and therapeutic
modalities. Western culture seeks to devalue pain through the use of stereotyping and myths. Pain
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has been relegated to a symptom that must be resolved. Chronic pain is more complex than acute
pain, and, therefore, must be treated in a more complex manner. Fortunately, physical therapists
and physical therapist assistant have ample opportunity to assist with the treatment of chronic pain
using tools they already have acquired through school and life. Touch and massage may be a
powerful tool used in the clinic to communicate, educate, and manage pain.
Tabers Cyclopedic Medical Dictionary defines touch as 1) to perceive by tactile sense; to feel
with the hands 2) the sense by which pressure on the skin or mucosa is perceived; the tactile sense
and 3) examinations with the hand (2341). However, touch is more comprehensive than simply
tactile sense. In addition to tactile perceptions, touch communicates. Touch tells us about an
object, what it is and some of its characteristics. Touch allows for tactile communication, which
occurs when there are systemic changes in anothers perception, thoughts, feelings, or behavior
(Hertenstein 4). Tactile communication, touch, is part of a greater scope of communication: nonverbal communication.
With an entire hemisphere of our brains devoted to non-verbal
communication (Martin13), why not take advantage of our innate ability for touch and utilize it to
benefit chronic pain patients?
Physical therapists and physical therapist assistants currently employ touch methods in the
clinic.
Manual therapy, stretching, manual muscle testing, massage, and proprioceptive
neuromuscular facilitation (PNF) are just a few methods of hands-on contact between the therapist
and the patient. However, one key component to the use of touch as a therapy is intention
(Hertenstein 5). Intention can dictate what the therapist wishes the patient to do, such as in PNF.
Through a combination of tactile and verbal cueing, a patient can easily identify whether the
therapist wants a certain movement, resistance of a manual force, or change of direction. Without
proper hand placement; however, verbal cueing alone could prove ineffective. The techniques of
rhythmic initiation and timing for emphasis rely on tactile cueing to propel a patients movement
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forward (Martin 231-281). Massage is employed to not only stimulate the skin and underlying
tissues but to create a relaxed state of both the body and the mind (Beck 2-30). While PNF and
massage do utilize verbal cueing elements, this does not prevent therapists from treating deaf and
cognitively impaired patients.
In the treatment of chronic pain, the use of massage goes beyond the standard soft tissue
manipulation (Beck 2). Patient with chronic pain must have both verbal and tactile interaction,
both with clear intention, to assist in pain alleviation. Because the Neuromatrix Theory constantly
receives signals from the periphery, and is able to both recall previous pain memory and adapt to
new stimulations, massage can help to override the previous pain memory which creates the chronic
pain and imprint a new healthy and pain free or pain reduced memory. Currently, many clinics
either do not offer massage or only offer site-specific massage. Site-specific or localized massage
can be effective in that the pain gates massage seeks to close are directly connected to the localized
area. Chronic pain, however, bypasses these gates negating site specific massage. Holistic touch and
massage will work to rewrite the Neurosignature thus creating a new memory of relation and
reduced pain for the brain to call upon in times of stress and pain.
Incorporating a more holistic touch and massage approach into standard physical therapy is
not the challenge it seems. Having massage therapists on hand to work with chronic pain patients,
either as a referral or in clinic, is one choice. However, with the increasing reliance on billing and
insurance, having a full-time or part-time massage therapist as part of the therapy team may not be
an option. Many insurance companies do not accept massage therapy as part of the coverage, and
patient will need to pay out of pocket. Even at reduced rates, multiple full-body massages per week
would be expensive for patients and therapists. Other Complementary and Alternative Medicine
(CAM) therapies, such as reflexology and acupuncture are also either billed separately or not covered
at all.
However, studies show that massage can decrease self-reported persistent pain even when
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administered infrequently (Munk 612). If a patient only requires one or two massages to help
decrease pain, as opposed to repeated lengthy massages, therapists may be able to employ massage
therapists or massage therapist techniques less often, thus reducing cost.
In cases where massage therapy is contraindicated, unwanted, or unwarranted, other touch
therapies should be employed to decrease chronic pain. In babies and young children, touch is a
form of emotional communication (Hertenstein 19). Because pain is linked to emotion through
adulthood, using touch to explore these emotions is imperative. Therapists often see patients of
both acute and chronic pain demonstrate pain with a grimace, holding their breath, and struggling
with exercises. Although speaking with the patient about their pain is effective, the use of touch will
significantly facilitate their relief much more. A simple hand touch can communicate trust, empathy,
and support. Partner dancing not only facilitates balance and coordination, but requires the hands
and body of the therapist to impart trust, support, and compassion. New modalities and exercises
may incite fear or anxiety in patients, especially elderly, frail elderly and cognitively impaired patients.
By adding a simple touch element along with verbal cueing, patients use the emotional energies from
the therapist to help overcome pain behaviors and fear based behaviors (Brand 708).
Simple touch can communicate movements, intention, and emotions. Physical therapists
and physical therapist assistants already employ touch into patients daily therapeutic interventions.
However, by supplementing the intention of touch with empathy and reassurance, rather than a
strictly utilitarian purpose, patients can utilize the new stimulus to recreate their Neuromatrix and
thus reducing the chronic pain. The addition of massage therapy holistically can also greatly increase
the patients ability to relax and non-noxious stimuli can thus be introduced. Touch and massage
therapy can help the chronic pain patients alter their perception of their pain and alter the brains
memory of pain, creating a pain-free or reduced-pain existence.
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In addition to the common modalities seen in the physical therapy practice, music and music
therapy can be added to many treatment plans. Music can be used in conjunction with therapeutic
exercise to help alleviate pain and increase motivation and participation during patients visits.
Music has been used in rituals, community gatherings, and personal experience for thousands of
years. Music can come from the instruments or the voice; it can be self-created or come from
others.
Music can be individual or communal.
The diversity of both music creation and
appreciation can be applied to any individual, group, or culture. Both the diversity and longstanding history of music lends itself to be a feature in the clinical setting.
Music Therapy is a discipline whose professionals make use of clinical and evidence-based
music interventions to accomplish individualized goals within a therapeutic relationship by a
credentialed professional who has completed an approved music therapy program (AMTA). Music
therapy began in the United States during World War I in response to the returning soldiers physical
and psychological trauma. Music therapy modalities have shown to improve response, lower blood
pressure, improve cardiovascular output and to relax muscle tension (AMTA). Plus, it has also been
known to reduce opioid requirements (Hasner).
Using music, however, goes beyond turning on the radio and listening to random music.
The music must be guided and used appropriately. There are categories within the field of music
therapy including: classical music therapy, voice music therapy, and drumming. The use of music,
either by a trained music therapist or by the physical therapy team, should be individualized for the
needs of the patient. Not only should the style of music be considered, but also the chronological
age of the patient, cognitive ability, the medical diagnosis, cultural background, and personal
preference.
Several studies have been published documenting the use of music for patients with complex
diagnosis. Wendy L Magee and Ceri Bowen conducted a study which focused on the use of music
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with patients that suffer from neurological pathologies (Magee). Magee and Bowen conclude that
Music is considered an action oriented way of coping with an emphasis on the social partner or
family member being adaptive, creative, and meeting the patient at their level (Magee). Music often
is a way for a patient with a low level of verbal and non-verbal communication skills to express their
emotions. The use of music helps to stimulate the patient, often providing the motivation for
movement and communication (Magee).
Rhythmic Auditory Stimulation (RAS) is a technique used with in Parkinsons disease
treatment. RAS uses a specific beat and rhythm to establish a primary auditory signal pathway which
cues movement and works specifically by stimulating the reticulospinal pathway, thereby increasing
normal muscle tone and increasing voluntary motor control by the patient (Rogers). The use of a
metronome or songs which have the same tempo and rhythm of the normal gait speed can induce a
positive outcome (Rogers).
Because music can be made using a variety of instruments, including the voice, modality
options are truly endless. Larry Satariano, a physical therapist at an assisted living facility in Mars,
PA, is known as the singing physical therapist (Byko). In order to build rapport and motivate
patients, he sings various songs during portions of each patients therapy session.
However,
Satariano only uses song for part of his plan of care. He engages each patient with thoughtful
communication such as stories and conversation. During the banter that is practically a part of the
treatment, Ms. Graham notes, Mr. Satariano often helps the patients do challenging exercises that go
practically unnoticed. The whole time he preoccupies them, she said (Byko). Using music and
proper communication allows Satariano to work successfully with patients and help to alleviate their
pain.
Working with patients on motor control and weight bearing exercises may be a time to
utilize percussion instruments. The drum beats will help patients engaged in walking or weight
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bearing activities maintain a pace. Another benefit of using hand-held drums, such as bongos, is
that any patient may be able to play them. By playing a hand held drum, patients can work on
strength, endurance, and motor control (Watson). Multiple patients can be involved in treatment,
and drum circles can be used as part of a large group warm up or cool down exercise. By adding
foot tapping or ankle pumps to the upper body drumming, patients receive a full-body workout.
The type of music used will influence the type of therapeutic activity. Weight shifting
exercises can be done to a waltz or cha-cha (Byko). Line dancing or square dancing can be broken
down into smaller parts and can be used to not only teach upper and lower body movement skills
but to reinforce cognitive learning skills in patients with neurological disorders. Even patients who
are not yet ambulating can benefit from music and dance. Not only will upper body movements
increase motivation and happiness, it can increase the patients sense of community and wellbeing.
Music is also incorporated into simple childrens games, such as Patty Cake and The Bear
Went Over the Mountain, through the use of rhythm and the sing-song spoken word. Dementia
patients who carry childhood memories may be able to participate by using personal childhood
rhymes and songs. If clapping or drumming component are included in the session, patients will be
functionally utilizing much of their upper body range of motion and trunk control. In addition to
using these techniques individually and part of group therapy, they can be taught as part of a home
exercise program, which allows the entire family to participate.
By looking at music as a tool of physical therapy and combining it with therapeutic exercise,
relaxation techniques, and proper communication, Physical therapists and Physical therapist
Assistants can motivate patients to continue with movement which, in turn, can lead to pain
reduction. Music is often tied to emotion, much like chronic pain and emotion. These links overlay
and provide the therapist the opportunity to help the patient rewrite the pain neurosignature into a
pain free neurosignature.
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CONCLUSIONS
Through an investigation of pain theories throughout history, pain scales, myths, and clinical
techniques, one can deduce that the subject of chronic pain is a vast and ongoing part of the human
condition. Chronic pain moves beyond the simple stimulus-reaction and includes the entire body
and mind. Because chronic pain is multidimensional, the Physical therapist and Physical therapist
Assistant must also move beyond the standard acute pain approach and work on different levels
with the patient to help alleviate chronic pain.
By no means can physical therapy accomplish this task alone. The physical therapist must be
willing to refer patients to outside professionals in addition to working in the clinical setting. By first
understanding the patients condition and needs, the physical therapy team will be able to utilize and
expand on their current skills to provide clinical chronic pain relief; this will serve as a starting point
for healing and motivation for the patient. In addition to providing the patient greater mobility and
stability, the chronic pain conscious physical therapist and physical therapist assistant will be able to
provide motivation and self-efficacy to each patient. In turn, the physical therapy team will help to
stop the chronic pain spiral, allowing each patient to move toward a pain-free future full of hope.
Understanding peoples difficulties andjust as crucialhelping

people understand their own difficulties and teaching them concrete ways
to help themselves will help them better deal with their own lives and, in
turn, ours.
Kathryn Erskine, Mockingbird
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WORKS CITED
Adams J. Massage and Other CAM in Pregnancy. International Journal of Childbirth Education [serial online]. July 2012;
27(3):37-42. Available from: CINAHL with Full Text, Ipswich, MA. Accessed 28 September 2013.
Ambulatory Surgery Patients. AORN Journal. June 2013 Vol. 97 No 6. 708-717. Available at
http://dx.doi.org/10.1016/j.aorn.2013.04.003 Accessed on 29 September 2013.
AMTA. Music therapy and music-based interventions in the treatment and management of pain: selected references and
key findings. 2010. Available at: http://www.musictherapy.org/assets/1/7/MT_Pain_2010.pdf.
APTA. Code of Ethics for the Physical Therapist. 15 February 2013. Available at:
http://www.apta.org/Policies/Ethics/. Accessed on 28 September 2013.
Basler A. Pilot Study Investigating the Effects of Ayurvedic Abhyanga Massage on Subjective Stress Experience. Journal
of Alternative & Complementary Medicine [serial online]. May 2011; 17(5):435-440. Available from: CINAHL with
Full Text, Ipswich, MA. Accessed September 28, 2013.
Beck, M. Theory & Practice of Therapeutic Massage. 5th Ed. Milady: New York. 2011: pg. 2-30, 269-289.
Beckford, A. Avicenna, 11th Century Persian Physician, Philosopher of Science and Author. 13, June 2013. Available at
http://theinvisiblementor.com/avicenna-11th-century-persian-physician-philosopher-of-science-and-author.
Accessed 20 September, 2013.
Brand L, Munroe D, Gavin J. The Effect of Hand Massage on Preoperative Anxiety in Ambulatory Surgery Patients.
AORN Journal [serial online]. June 2013; 97(6):708-717. Available from: CINAHL with Full Text, Ipswich, MA.
Accessed 28 September 2013.
Burckhardt CS, Bjelle A. A Swedish version of the short-form McGill Pain Questionnaire. Scand J Rheumatol. 1994;
23(2):77-81. Available at http://www.ncbi.nlm.nih.gov/pubmed/8165442. Accessed on 28 September 2013.
Byko, Maureen. Music is Good Therapy, Singing Physical Therapist Finds. Pittsburgh Post Gazette.http://www.postgazette.com/stories/local/neighborhoods-north/music-is-good-therapy-singing-physical-therapist-finds460456/ published 22 November 2006.
Cambron J, Dexheimer J, Coe P, Swenson R. Side-effects of massage therapy: a cross-sectional study of 100 clients.
Journal of Alternative & Complementary Medicine [serial online]. October 2007; 13(8):793-796. Available from:
CINAHL with Full Text, Ipswich, MA. Accessed 28 September 2013.
Carli, G. Historical perspective and modern views on pain physiology: from psychogenic pain to hyperalgesia priming.
Italiennes de Biologie. 2011. Vol. 149 (suppl.): 175-186. Available at www.architalbiol.org/aib/article/view/1437.
Accesses 20 September 2013.
Cherkin D, Sherman K, Deyo R, et al. A comparison of the effects of 2 types of massage and usual care on chronic low
back pain: a randomized, controlled trial. Annals of Internal Medicine [serial online]. July 5, 2011; 155(1):1-9.
Available from: CINAHL with Full Text, Ipswich, MA. Accessed 28 September 2013.
Cleveland Clinic: Chronic Conditions Team. 7 Common Myths about Chronic Pain. Cleveland Clinic. Available at
http://health.clevelandclinic.org/2012/07/7-common-myths-of-chronic-pain/. Published 16 July 2012.
CMS Centers for Medicare and Medicaid Services. Physical, Occupational & Speech Therapy Billing Guide. July 2010.
Available at www.medicarenhic.com. Accessed on 28 September 2013.
10/10/13
Page 35 of 39
rjs

Deardorff, W.W. Modern Ideas: The Gate Control Theory of Chronic Pain. Spine Health. 22 Sep 2013 Available at
http://www.spine-health.com/conditions/chronic-pain/modern-ideas-gate-control-theory-chronic-pain.
Dickenson A.H. Gate Control Theory of pain stands the test of time. British Journal of Anesthesia. 2002. Vol. 88 (6):755757. Available at http://bja.oxfordjournals.org/content/88/6/755.long.
Donoyama N, Ohkoshi N. Effects of Traditional Japanese Massage Therapy on Various Symptoms in Patients with
Parkinson's Disease: A Case-Series Study. Journal of Alternative & Complementary Medicine [serial online]. March
2012;18(3):294-299. Available from: CINAHL with Full Text, Ipswich, MA. Accessed 28 September 2013.
Einstein Healthcare Network. Myths about pain busted. Einstein Healthcare Network.
http://www.einstein.edu/news/myths-about-pain-busted/. Published 12 September 2013.
Fernndez-Lao C, Cantarero-Villanueva I, Daz-Rodrguez L, Cuesta-Vargas A, Fernndez-Delas-Penas C, ArroyoMorales M. Attitudes towards massage modify effects of manual therapy in breast cancer survivors: a
randomized clinical trial with crossover design. European Journal of Cancer Care [serial online]. March
2012;21(2):233-241. Available from: CINAHL with Full Text, Ipswich, MA. Accessed 28 September 2013.
Freeman, C., Okun, M.S. Origins of Sensory Examination in Neurology. Semin Neurol. 2002; 22(4) Available at
http://www.medscape.com/viewarticle/447787_3. Accessed 20 September, 2013.
Gentile, D., Woodhouse, J., Lynch, P., Maier, J., and McJunkin, T. Reliability and Validity of the Global Pain Scale with
Chronic Pain Sufferers. Pain Physician. Vol. 14. 2011. pg. 61-70. Available at
http://www.painphysicianjournal.com/crrent_issue_vw.php?journal= 59&code=1430&issue=current_issue.
Accessed on 28 September 2013.
Gross, C. Trepanation from the Paleolithic to the Internet. Trepanation. Lisse, The Netherlands: Swets & Zeitlinger
Publishers; 2003: 307-322.
Guanzhong, L. Romance of the Three Kingdoms. Translated by C.H. Brewitt-Taylor. Available at
http://threekingdoms.kongming.net/ Accessed: 27 September 2013.
Hanser, S., Mandel, S. Music Therapy for Pain Management. Practical Pain Management. Available at:
http://www.practicalpainmanagement.com/treatments/complementary/music-therapy-pain-management.
Published 12 June 2012. Accessed on: 7 October 2013.
Harris M, Richards K. The physiological and psychological effects of slow-stroke back massage and hand massage on
relaxation in older people. Journal of Clinical Nursing [serial online]. April 2010; 19(7-8):917-926. Available from:
HCPLive. Forget Faces and Numerical Scales; New Pain Test on the Way. Health Care Professionals Live Available at
http://www.hcplive.com/articles/Forget-Faces-and-Numerical-Scales-New-Pain-Test-on-the-Way. Accessed
on 28 September 2013.
Health Communities. Chronic Pain: Pain Rating Scales. 5 August 2011. Available at:
http://www.healthcommunities.com/chronic-pain/rating-pain.shtml. Accessed 24 September 2013.
Hertenstein, M., Verkamp, J., Kerestes, A., Holmes, R. The communicative Functions of Touch in Humans, Nonhuman
Primates, and Rates: A Review and Synthesis of the Empirical Research. Genetic, Social, and General Psychology
Monographs. 2006. Issue 132 vol. 1, 5-94. Available at www.depauw.edu/. Accessed on 29 September 2013.
Hudes, K. The Tampa Scale of Kinesiophobia and neck pain, disability and range of motion: a narrative review of the
literature. The Journal of the Canadian Chiropractic Association. 2011 September; 55(3):222-232.
10/10/13
Page 36 of 39
rjs

HuffPost50. When Is It Time To Seek Physical Therapy? Posted: 29 September 2013. Available at:
http://www.huffingtonpost.com/2013/09/29/physical-therapy_n_4009973.html Accessed on 30 September
2013.
International Association for the Study of Pain. Pain Clinical Updates. Vol.XX, Issue 8, December2012. Available at:
http://www.iasppain.org/. Accessed 22 September 2013.
Kenny DT. Constructions of chronic pain in doctor-patient relationships: bridging the communication chasm. Patient
Education and Counseling.2004; 52:297-305.
Krebs, E., Carey, T., and Weinberger, M. Accuracy of the Pain Numeric Rating Scale as a Screening Test in Primary
Care. J Gen Intern Med. 2007 October; 22(10): 14531458. Published online 1 August 2007. Available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2305860. Accessed 24 September 2013.
Lil Aussie Prems Foundation. Touching Your Baby in the NICU and Beyond. 2013. Available at:
http://www.lilaussieprems.com.au/touching-your-premature-baby-in-nicu-beyond/. Accessed on 29
September 2013.
Loeser JD, ed. Bonicas Management of Pain. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001: 266.
Loeser JD, Egan KJ, eds. Chapter 1: History and Organization Managing the Chronic Pain Patient: Theory and Practice at the
University of Washington Multidisciplinary Pain Center.. New York: Raven Press; 1989: 1-7.
Magee W, Bowen C. Using music in leisure to enhance social relationships with patients with complex disabilities.
Neurorehabilitation [serial online]. August 2008;23(4):305-311. Available from: CINAHL with Full Text, Ipswich,
MA. Accessed 8 October 2013.
Martin, S., Kessler, M. Neurologic Interventions for Physical Therapy. 2nd Ed. Saunders Elsevier. 2007; 8-27, 231-281.
Medicare. Chapter 15. Medicare Benefit Policy Manual Publication. Revision Issued 10 May 2013. Available at:
http://cms.hhs.gov/manuals/downloads.bp102c15.pdf. Accessed 28 September 2013.
Melzack, R. Gate Control Theory: On the evolution of pain concepts. Pain Forum. 1996. Vol. 5(1), 128138.
Melzack, R. Pain and Neuromatrix in the Brain. Journal of Dental Education. 1 December 2001 vol. 65 no. 12 1378-1382.
Melzack, R., Wall, P.D. Pain Mechanisms: A New Theory. Science. 19, November 1965; vol. 150, 971-979.
Michlovitz, S., Bellew, J., Nolan, T. Modalities for Therapeutic Intervention. 5th Ed. F.A. Davis Company, Philadelphia. 2012.
Pg. 333-359.
Miserandino, C. The Spoon Theory. But You Dont Look Sick. 2010. Available at
http://www.butyoudontlooksick.com/wpress/articles/written-by-christine/the-spoon-theory.
Munk N, Kruger T, Zanjani F. Massage Therapy Usage and Reported Health in Older Adults Experiencing Persistent
Pain. Journal Of Alternative & Complementary Medicine [serial online]. July 2011; 17(7):609-616. Available from:
Muscolino J. Clinical Orthopedic Neck Massage. Journal Of The Australian Traditional-Medicine Society [serial online].
September 2011;17(3):147-150. Available from: CINAHL with Full Text, Ipswich, MA. Accessed 28 September
2013.
Nicholas MK, George SZ. Psychologically Informed Interventions for Low Back Pain: An Update for Physical
Therapists. Physical Therapy.2011; 91:765-776.
OSullivan, S., Schmitz, T. Physical Rehabilitation. 5th ed. F.A. Davis Company. Philadelphia: 2007. pg. 1117-1148.
10/10/13
Page 37 of 39
rjs

Overcoming Pain. Overcoming Pain. http://overcomingpain.com/the-eight-most-unhelpful-myths-about-chronic-pain/
published 2 July, 2012.
Oyston E, McCee M. Oncology Massage Research and Training Update. Journal Of The Australian Traditional-Medicine
Society [serial online]. March 2012; 18(1):11-14. Available from: CINAHL with Full Text, Ipswich, MA.
Pain Treatment Topics. Pain and Disability Assessment Tools. 24 March 2013. Available at: http://paintopics.org/clinical_concepts/assess.php Accessed on 28 September 2013.
Park J, Hughes A. Nonpharmacological Approaches to the Management of Chronic Pain in Community-Dwelling Older
Adults: A Review of Empirical Evidence. Journal Of The American Geriatrics Society [serial online]. March 2012;
60(3):555-568. Available from: CINAHL with Full Text, Ipswich, MA. Accessed 30 September 2013.
Partners Against Pain. Measuring Pain. Available at http://www.partnersagainstpain.com/measuring-pain/assessmenttool.aspx. Accessed 22 September 2013.
PSU Fitness Club. Myths of Fitness. PSU Fitness Club. http://www.clubs.psu.edu/FitnessPrograms/myths.htm.
Rahlin M, Cech D, Rheault W, Stoecker J. Use of Music during Physical Therapy Intervention for an Infant with Erb's
Palsy: A Single-Subject Design. Physiotherapy Theory & Practice [serial online]. March 2007; 23(2):105-117.
Available from: CINAHL with Full Text, Ipswich, MA. Accessed 6 October 2013.
Rodgers, Kara. The physiology of music, part 3, rhythm movement and physical therapy. Britannica Blog. 2008. Available
at: http://www.britannica.com/blogs/2008/12/the-physiology-of-music-part-3-rhythm-and-movement.
Sacred Lotus Arts. Traditional Chinese Medicine: Philosophy and Theory of Yin and Yang. Available at:
http://www.sacredlotus.com/theory/yinyang.cfm. 2013. Accessed 27 September 2013.
Selby, M. Managing chronic pain. Practice Nurse [serial online]. February 11, 2011; 41(2):14-19. Available from: CINAHL
with Full Text, Ipswich, MA. Accessed 30 September 2013.
iko P, Videmek M, Karpljuk D. The Effect of a Corporate Chair Massage Program on Musculoskeletal Discomfort
and Joint Range of Motion in Office Workers. Journal Of Alternative & Complementary Medicine [serial online].
July 2011;17(7):617-622. Available from: CINAHL with Full Text, Ipswich, MA. Accessed 28 September 2013.
Smeltzer SC, & Bare BG. [Edrs] Brunner and Suddarth's Textbook of Medical-Surgical Nursing. 10th edition. Philadelphia:
Lippincott Williams & Wilkins: 2004.
Smith J, Sullivan S, Baxter G. Massage therapy: more than a modality. New Zealand Journal Of Physiotherapy [serial online].
July 2010;38(2):44-51. Available from: CINAHL with Full Text, Ipswich, MA. Accessed 28 September 2013.
Tabers Cyclopedic Medical Dictionary. 21st ed. Philadelphia, PA: F.A. Davis Company; 2005.
The Regents of the University of California at the The Louise M. Darling Biomedical Library of the University of
California Los Angeles. Relief of Pain and Suffering: John Bonica Pain Champion and Multidisciplinary Pain Clinic.
1998. Available at http://unitproj.library.ucla.edu/biomed/his/painexhibit/panel7.htm Accessed 22 September
2013.
Tiffany. 5 Myths About Chronic Pain. Costal pain solutions. Available at: http://blog.coastalpainsolutions.com/paintreatment/5-myths-about-chronic-pain. Published 31 May 2013.
Turk D, McCarberg B. Non-pharmacological treatments for chronic pain: a disease management context. Disease
Management & Health Outcomes [serial online]. February 2005; 13(1):19-30. Available from: CINAHL with Full
Text, Ipswich, MA. Accessed 30 September 2013.
10/10/13
Page 38 of 39
rjs

University of Calgary. Theories of Pain Perception. 2013. Available at: http://ucalgary.ca/pip369/mod7/tempain/theories.
University of Washington. A-Z Listing of Biographies. Available at:
http://www.uwmedicine.org/bios/view.aspx?CentralId=17172. Accessed 22 September 2013.
University of Washington. The History of Physical Therapy. 25 May 2007. Available at:
http://depts.washington.edu/lend/seminars/modules/pt/history.htm. Accessed 29 September 2013.
US National Library of Medicine at the National Institute of Health. Balance of Passions. 8 March 2000. Available at
http://www.nlm.nih.gov/exhibition/emotions/balance.html. Accessed 20 September 2013.
Watson, Chrissy. Rhythm for rehabilitation music therapy as a part of the stroke rehabilitation team. 2010. Available at:
http://www.musictherapy.org/assets/1/7/MT_Pain_2010.pdf.
Web MD. 5 Common Pain and Pain Relief Myths. WebMD. http://www.webmd.com/pain-management/5-commonmyths-about-pain-and-pain-relief. Published 1 August 2013.
PHOTOGRAPHS CITED
Stevens, R. Lotus. Beijing, China. 2012.
Figure 1 One of the perforated skulls recently unearthed in Spain. Credit: Plataforma SINC. Available at :
http://www.history.com/news/perforated-skulls-from-middle-ages-found-in-spain. Accessed on 10 October
2013
Figure 2 The Four Temperaments (Clockwise from top right: choleric; melancholic; sanguine; phlegmatic). Available at:
http://en.wikipedia.org/wiki/Humorism. Accessed on 10 October 2013.
Figure 3 Stevens, R. Loesers Concentric Circles Model. 10 October 2013.
Figure 4 Linton et al., 2000. Available at http://medical-dictionary.thefreedictionary.com/gate-control+theory.
Accessed 12 October 2013
Figure 5 Ren Descartes. L'Homme de Rene Descartes. Paris: Charles Angot, 1664. Courtesy of the French National
Ministry of Education.
Figure 6 Neuromatrix Model from Melzack, R: Pain and the Neuromatrix in eh brain, J Dent Educ 65: 1378-1382, 2001.
And Updated Neuromatrix Model. Waldman SD; Pain Management, 2nd Ed. (Saunders) 2011 pg. 5. Ch. 1: A
Conceptual Framework for Understanding Pain in the Human. Joel Katz and Ronald Melzack. Available at:
http://www.truemovement.net/a-primer-on-pain. Accesses on 10 October 2013.
Figure 7 Numeric Pain Intensity Scale. Available at: http://www.vicburns.org.au/management-of-a-patient-with-a-minorburn-injury/pain-management/pain-assessment.html. Accessed on 10 October 2013
Figure 8 McGill Pain Questionnaires. Philippe Harari and Karen Legge (2001), Psychology and Health, Heinemann, 0-43580659-9 Available at: http://homepage.ntlworld.com/gary.sturt/health/pain2.htm. Accessed on 10 October
2013.
Figure 9 Global Pain Scale. The Pain Doctors. Available at: http://www.paindoctor.com/global-pain-scale. Accessed on:
10 October 2013.
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Shifting the Pain

Rebecca Stevens 2012

Community College of Allegheny County

This paper details the history of pain theories, current

Shifting the Pain Paradigm

Shifting the Pain Paradigm

Shifting the Pain Paradigm

THE HISTORY OF PAIN

Broca, who later

Shifting the Pain Paradigm

confirmed Brocas theory.

Hippocrates views were based upon the

To cool the sanguine imbalance, one must

restore the balance between the other Humours, using them

Figure 2 The four temperaments (Clockwise from

Shifting the Pain Paradigm

Wundt, however, was the first physiologist to separate the

personality from the human body functions (Balance of Passions).

Shifting the Pain Paradigm

established the Cartesian Intensive Theory,

perception and described the nerves as tubes

Figure 3 Descartes' concept of the withdrawal reflex.

Shifting the Pain Paradigm

biosocial element missing from Descartes original theory.

Shifting the Pain Paradigm

components are separate factors which

can influence each other. It holds

(acute pain) or maintainers (chronic pain)

when it is perceived and experienced by

Figure 4 Loeser's Concentric Circles, Stevens 2013

Shifting the Pain Paradigm

Get in shape, and keep fit

Learn to relax, and practice it

5. Time your medications, then taper off them

Shifting the Pain Paradigm

Melzack and Wall found that pain can be determined in the

combined actions of these three systems (Melzack Wall 974-975).

Shifting the Pain Paradigm

Figure 5 The gate-control theory of pain. From Linton et al., 2000.

Shifting the Pain Paradigm

Second, patterns of neural inputs reside in the brain

Each part which feeds into the loop is unique,

Shifting the Pain Paradigm

Shifting the Pain Paradigm

Shifting the Pain Paradigm

Figure 7 Numeric Pain Intensity Scale

In addition, the scale only measures intensity of pain (Health

Shifting the Pain Paradigm

Figure 8 McGill Pain Questionnaire

Shifting the Pain Paradigm

Correlation studies have shown that

Figure 9 Global Pain Scale

Shifting the Pain Paradigm

Shifting the Pain Paradigm

Shifting the Pain Paradigm

Shifting the Pain Paradigm

Like current techniques and assessments, it is

Shifting the Pain Paradigm

Shifting the Pain Paradigm

By paraphrasing, summarizing, and repeating the information

Shifting the Pain Paradigm

Shifting the Pain Paradigm

To prevent further injury,