General Guideline Principles for History Taking
and Physical Examination of Non-Acute Pain
for workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for History Taking and Physical Examination of Non-Acute Pain.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.

The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

History Taking and Physical Examination of Non-Acute Pain

The development of a medical diagnosis is based on a patient’s medical history and physical examination, which also set the stage for and guide following phases of therapeutic and diagnostic treatments.

The clinical outcome findings should be given precedence when the results of clinical assessments and those from other diagnostic methods do not complement one another. The following should be listed in the medical records.

Pain History, History of Present Illness

An extensive pain history is crucial to the assessment of non-acute pain. One of the main components in creating a treatment plan over the course of such a history is characterizing the patient’s discomfort and their reaction to pain.

History should discover the following elements:

• Site of Pain: The location and pattern of the pain might assist identify the patient’s kind of pain (i.e., central versus peripheral). It could be helpful to use a pain diagram to show how the pain is distributed.

• Situations that led to the pain’s development (e.g., an illness, an incident full of stress or spontaneous and an accident) onset.

• Duration.

• Features of pain include searing, searing, stabbing, or aching. The frequency, duration, quality, and radiation of the pain provide information about the diagnosis and possible treatments. Finding the type of pain might be aided by the quality of the pain. The physical implications of the agony, or absence thereof, should be considered.

• Utilizing a recognized pain scale (e.g., Visual Analog Scale [VAS]).

• List of activities that either aggravate or worsen, relieve, or have no effect on pain level, such as walking, weight bearing, or resistance. discussing the spectrum of pain experienced during the day as well as how activities, the use of techniques, and other acts impact pain intensity.

• Numbness or numbness or tingling, dysesthesia, tiredness, bowel or bladder incontinence, a drop in body temperature, increased perspiration, cyanosis, or edema are some of the symptoms that may be present. Is there any allodynia, hyperalgesia, hyperesthesia, or local tenderness?

  disruptions in sleep.

• Functional Restrictions: Which functional tasks or ADLs does the patient say they are unable to perform due to pain? (For instance, you can’t lift groceries, you can’t walk for more than five minutes, etc.)

• Fear Prevention: Does the client mention being reluctant to move or participate in everyday activities out of concern for potential self-inflicted harm? (See Appendix A)

• Diagnostic Tests: A review and summary of all prior radiological and laboratory tests should be done

• Prior Therapeutic: A chronological review of the patient’s medical history, which includes earlier assessments and responses to treatment treatments. Which treatment does the patient think has previously been beneficial?

• Prior Surgical Treatment: The effect of prior surgical intervention on the discomfort.

• Medication: history and current use are examined to ascertain drug consumption (or abuse), drug interactions, and therapeutic effectiveness. This includes over the counter and herbal/dietary supplements.

  Drug allergies as well as other negative consequences from using medications in the past or present. It is important to keep track of drug compliance. Ideally, this would contain the patient’s or patient’s representative’s stated dose regimens.

• Psychosocial Functioning: Determine whether any of the following psychosocial functioning factors are present: signs of current sadness or anxiety, indications of pressures at work or at home, and a history of psychological issues.

• Other complicating psychosocial difficulties, such as the existence of psychosocial, neuropsychiatric, or social elements, should be investigated.

• Treatment Expectations: What does the client believe is the source of his or her pain? What does the patient hope to get out of the therapy? Does the patient anticipate being able to perform more tasks at their present employment or going back to their previous position?

Past Medical History

History ought to confirm the following facts:

• Language and education levels: These factors may affect a person’s capacity to comprehend instructions, information, and take part in treatment decisions. The patient’s degree of knowledge may impact responsiveness to treatment.

• Work history, job title, mechanical requirements, length of employment, and employee satisfaction should be included, as should the impact of the injury on the ability to execute job tasks and daily life activities. Had there been any injuries or accidents at work before?

• Current employment status

• Status of marriage

• Family Situation: Does the patient reside with relatives or close friends? Such responses might reveal information about the type of the support system.

• Cultural considerations: For instance, the patient’s ethnicity, as well as any language difficulties that may exist, may affect how they perceive and react to pain.

• Belief System: Patients’ belief systems, which may include spiritual and cultural beliefs, should be elicited to ascertain how they may affect how they and their families react to their illness and treatment recommendations. Exist any cultural or religious beliefs that could influence how a patient is treated?

• Examining Systems, a checklist Check to see whether the pain pledge and other medical problems interact in any way.

  It is important to conduct a system review, which may include signs or symptoms from the following organ systems: integumentary/breast; neurological; psychiatric; hematologic/lymphatic; allergic/immunologic; constitutional symptoms; eyes; ear, nose, and throat; heart and blood vessels; respiratory; stomach and the intestines; genitourinary; musculoskeletal;

  The scope and focus of the assessment of systems might vary from case to case depending on the underlying ailment being treated and clinical judgment.

• Pre-existing Conditions: When a pre-existing condition interferes with a patient’s ability to recover from non-acute pain, therapy of the condition is necessary. The which was before condition(s) should be plausibly connected to the anguish complaint and to the late recovery. Specific objectives that have been set in advance, tracked, and achieved as part of the entire treatment plan, must be addressed by this treatment

• Has the patient ever used any medications or substances that weren’t given to them by their treating physician or another prescriber? Has the patient utilized medication in a way that didn’t follow directions?

• Drinks consumed each week in terms of quantity.

• Include any usage of nicotine replacements in your smoking history.

• Sexual, emotional, and physical abuse in the past.

Physical Examination of Non-Acute Pain

Suitable tests and exam procedures that are accepted in the field being evaluated should be included:

• signals of life

• a recognized method for measuring pain, such as the Visual Analog Scale (VAS) or the Numerical Rating Scale (NRS).

• general examination: Including gait, stance, and posture.

• To rule out any other potential origins of non-acute pain, a general physical examination should be performed, including checks of the chest, abdomen, vascular, and other systems. Depending on the clinical situation, a more detailed exam could be conducted.

• Detailed tactile inspection, motor evaluation (station, gait, coordination), spinal cord and outlying nervous system examination, reflexes (normal tendon reflexes and presence or absence of abnormal reflexes like frontal lobe release signs or upper motor neuron signs), cerebellar testing, and provocative neurological maneuvers are all included in a neurologic evaluation (i.e., nerve tension testing).

  When the League test (Straight Leg Raise test) is done, a result is typically not deemed to be positive at an elevation less than 25 or higher than 60 degrees (and degrees should always be stated) (and degrees should always be reported).

• Sensory Evaluation: To detect sensory abnormalities, routine custom quantitative sensory testing, such as Semmes-Weinstein monofilaments, may be helpful.

• Musculoskeletal Evaluation: This includes palpation, observation, functional activities, segmental mobility, range-of-motion testing, and musculoskeletal provocative maneuvers. Asymmetry, edema, laxity, and discomfort should be checked in all tissue, ligaments, muscles, tissue texture, all joints, and tendons. The myofascial examination is a component of the musculoskeletal assessment. In the myofascial examination, soft tissues are probed for signs of spasm and trigger points.

• Assessment of non-physiologic findings:

  • If appropriate, use the Waddell Signs, which are divided into five categories of clinical symptoms: (1) superficial, non-anatomical tenderness; (2) pain with simulation; (3) regional findings; and (4) sensory and motor findings not consistent with spinal nerve patterns (5) Overreaction to physical examination techniques, traction, and inconsistent straight leg raising results.

    Positive results in three of these categories out of the five may be significant, but isolated results are not. Malingering cannot be predicted or identified using Waddell Signs.

    A “yellow flag,” or screening test, should be used to identify individuals who need a more thorough review when three out of five warning indicators are present (i.e., psychosocial, or psychological evaluation).

  • Variability on the formal exam, such as varying sensory examination, inconsistent discomfort, and/or edema brought on by extrinsic sources.

  • Range-of-motion, motor strength, gait, and cognitive/emotional state inconsistencies between the formal exam and observable abilities should be mentioned in the evaluation.

Red Flags of Non-Acute Pain

The review of the history and physical examination should involve looking for warning signs. Fractures, dislocations, infections, tumors, and increasing deficits are only a few examples of these findings or signs.

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