The art of history taking in patients with pain is an ignored but very important component in making diagnosis. In this tutorial we take you through a basic structure for taking history from someone presenting with pain.

1. HISTORY
(PAIN IN HISTORY TAKING)

2. Hafiza Azka Samreen
DPT- SMC (batch 2016-21)

3. DEDICATED TO MY PARENTS
SPECIAL THANKS TO HAFSA HAFEEZ
UMER IQBAL

4. PAIN
“ Unpleasant sensory & emotional experience
associated with actual or potential tissue damage
or described in terms of damage”
This implies that;
a. Pain is not necessarily or always associated
with ongoing tissue damage.

5. b. Pain is a subjective sensation & it has 2
components;
1. Sensory
2. Emotional

6. CLASSIFICATION
Pain is classified according to;
1. Aetiology & pathogenesis
2. Duration
3. Site

7. AETIOLOGY & PATHOGENESIS
•Physiological___acute response to injury
•Inflammatory
•Cancer related(multifactorial)
•Neuropathic___arising from injury or
dysfunction of CNS & PNS

8. •Central___ by lesion & dysfunction of CNS(can
affect brain or spinal cord or both)
•Ischemic___ dec. blood supply to organs or
nerves that supply the organs or both
•Psychogenic___ pain( especially the chronic
pain) ___ has a strong emotional & behavioral
component___Pure psychogenic pain is rare.

9. Duration
• Acute
• Chronic___ Arbitrarily, if pain persists
for longer than 3 months ; it is
associated with
disability & significant behavioral
response.

10. Site
• Somatic___ usually well localized,
may follow a dermatomal
distribution.
• Visceral___ poorly localized , does
not follow dermatomal distribution.
• Referred___ That originates in one
site but is perceived as being
present in a closely related or
distant site.

11. BIOPSYCHOSOCIAL MODEL OF PAIN

12. Noxious stimuli,
Tissue Damage
Pain Sensation
Individual factors
Sex , Age , Culture
Cognitive level, Previous pains
Family learning
Situational Factors
Expectation
Control
Relevance
Psychological factors
Fear
Anger
Frustration

13. stimulus nociceptors impulses
Dorsal horn
Primary afferents
synapse in lamina
I,II,IV & some in V
2nd 0rder neurons
Spinothalamic &
spinoreticular
tracts
thalamus
3rd order
neurons
Somatosens
ory cortex
Pain pathway

15. Nociceptive & Neuropathic pain
1. Nociceptive pain
• Arises from various kinds of troubles in tissues
• Due to noxious stimuli or stimuli that become
noxious when prolonged
• Reported to the brain by nervous system.
2.Neuropathic pain
• Arises from damage to the nervous system itself,
central or peripheral ; either from disease, injury
or pinching.

16. Nociceptive Neuropathic
Description of pain Aching, Localized,
toothache like,
sharp, squeezing.
shooting, radiating,
stabbing, burning,
electric shock like.
Movement impact Associated with
movement
Independent
Physical
Examination
Normal response Allodynia,
hyperalgesia,
Vasomotor changes
Examples Injury, post-
operative pain
Peripheral
neuropathies,
shingles, cancer
pain
Treatment
strategies
More classic
approach,
conventional
analgesics
More
biopsychosocial
approach,
conventional
analgesics ± non-
conventional (anti-

17. PAIN
•Subjective experience , so what the patient
describes as their experience is of paramount
importance.
•Most useful tool in assessment & diagnosis.

18. HISTORY
1ST STEP
• Evaluate the complaint of pain to understand
it’s pathophysiology including the
mechanisms that sustain it.
• Characteristics of pain suggest the most likely
cause , explore these to make a differential
diagnosis.

19. SOCRATES approach(characteristics of pain)
 Site
Somatic pain(well localized e.g; sprained ankle)
Visceral pain(more diffuse e.g; angina pectoris)

20.  Onset____ rapidity of onset(acute or
chronic)
 Character____ described by adjectives;
• Sharpdull
• Burningtingling
• Boringstabbing
• Crushingtugging
Preferably using patient’s own description
rather than offering suggestions.

21.  Radiation;
• Through local extension
• Referred by a shared neuronal pathway to a
distant site e.g; diaphragmatic pain at the
shoulder tip via the phrenic nerve.
 Associated symptoms e.g; numbness in the
leg with the back pain suggesting nerve root
irritation.

22.  Timing(duration , course , pattern)
• Since onset
• Episodic or continuous
 If episodic, then duration & frequency of
attacks
 If continuous then, any changes in severity?

23.  Exacerbating & relieving factors____ specific
activities or postures & any avoidance
measures that have been taken to prevent
onset.
 Severity ___ difficult to assess ,as so
subjective. Sometimes helpful to compare
with other common pains e.g; toothache.
 Variation by day or night ,during the week or
month e.t.c

24. 2nd step – Evaluate current & past treatments for pain
 Past medical history ; with an emphasis on relevant system ,
taking full medical history must not be overlooked, it may
give invaluable cues as to etiology & genesis of pain.

25. MEASURING PAIN
Single dimensional scales
•simple
Multidimensional scales
•Complex

26. SINGLE DIMENSIONAL SCALES
Very commonly used , simple , sensitive ,
reproducible , quickly applied & give a
numerical value to the pain severity.
Single
dimensional
scales
discret
e
numeri
cal
verbal
analogu
e

27. Visual Analogue Scale(VAS) 0-10
• 10 cm horizontal line
• Left hand side ____ no pain
• Right hand side ____ worst possible pain
• Patient is asked to mark the line according
to severity of pain.

29. Numerical Scale
• Similar to VAS.
• Patient is asked to assign a number from 0
to 10 to their pain.
• 0 ( no pain)
• 10( worst imaginable pain)

31. Verbal Rating Scale
Patient rate their pain into one of the following
categories ;
mild
moderate
severe

32. Pictorial Facial expression scale ( in children)

35. MULTIDIMENSIONAL SCALES
• Complex scales
• Acknowledge multidimensional impact of
pain on sufferer’s life
• McGill Questionnaire ____ commonly used

36. IMPACT OF PAIN ; consider the effect of pain on
the patient’s activity , work ,mood ,sleep ,
relationship e.t.c

37. Chronic
pain
money
relationshipleisure
workHave you
had to
take time
off work?
Have you
lost
money
because of
illness?
What can
you no
longer do
which you
used to
enjoy?
How has this
affected your
relationship
with your
family?

38. Terms used to describe pain :
Throbbing , shooting , stabbing , sharp , dull ,
cramping , gnawing , hot-burning , aching , heavy ,
tender , splitting , tiring , exhausting , sickening ,
fearful , punishing , cruel…….. etc.

39. Pain threshold increased
Exercise
Positive mental attitude
personality
Pain threshold decreased
Financial & personal worries
Anxiety & fear about the cause
Past experience
analgesia

43. QUESTIONS ( open & closed)
• What is your main problem? (open)
e.g, I feel it difficult to walk…….
• Can you tell me more about your
problem?(open)
Well it is worse all the time but more so in early
morning………..
• Can you tell me about the pains? (open)
Yes , it is on this side of my leg when I walk.

44. • Does anything else bring on the pains?( open
& prompting)
Yes, climbing stairs & brisk walking brings on the
pain.
 Clarify by asking such questions.
 Closed questions ; focus on the symptoms
offered by the patient , more specifically
addressing the main problem.

45. You may ask;
• How did your pain start?
• What do you think is causing your pain?
• How long you had the pain?
o Is it occasional?
o Is it continuous?
• When do you notice it most ? (am/pm)
• How long does it last?
• What makes the pain better?
• What makes the pain worse?

46. • Is it due to an ;
o Accident(MVA)
o Injury ???????
• Ho does your pain feel? burning/tingling etc
• Do you have any other symptom in addition
to pain? e.g, numbness , weakness , itching.

47. • Does the pain disturb your
 Sleep
 Work
 Self care
 Mood
 Relationships
 Recreation
 Enjoyment of life…….. etc

48. • Does the pain make you feel depressed?
• What have you tried to treat the pain? Did it
help? How much? Side effects?
• Do you have any important medical
problems? Edemaswelling , hypertension ,
diabetes, etc .
• Have you ever had this problem in the past?
Hospitalized/treated by another
physiotherapist/received care for this
problem?