1. Apply subjective assessment skills.
2. Apply objective assessment skills.
3. Use clinical judgement.
4. Integrate an inclusive approach to pain assessment.

Consider the last time you experienced pain. What did it feel like? How did it affect you? (e.g., physically, emotionally, socially). Was there tissue damage? These questions help us understand the nature of pain and how it affects each person.

Pain is a complex phenomenon, so we need to understand how it is conceptualized, classified, and the various types of pain. All of these components influence best practices related to pain assessment. It is important to be aware of the RNAO (2013) best practice guidelines related to pain assessment and management. These guidelines provide information and resources related to assessment, planning, implementation and evaluation of pain, among other recommendations.

Let’s begin by exploring the phenomenon of physical pain.

References

RNAO (2013). Assessment and management of pain. 3rd edition. https://rnao.ca/bpg/guidelines/assessment-and-management-pain

• More emphasis on the subjective nature of pain in terms of how it is personalized to the client.
• The need to emphasize the somatic nature of pain in terms of how it is embedded within the body (Cohen et al., 2018).
• A more comprehensive descriptor of pain than “unpleasant”, which may act to minimize what may be described as quite distressing for some (Craig & MacKenzie, 2021).
• The cognitive and social features of pain (Craig & MacKenzie, 2021) in terms of how pain affects one’s cognitive capacity (how one thinks, reasons, and remembers) and social functioning (engaging in social interactions and interpersonal relationships).
• Also, keep in mind, that not all physical pain is associated with tissue damage.

References

Acute Pain

• Changes in vital signs: tachycardia, tachypnea, shallow breathing, elevated blood pressure, and elevated temperature. Sometimes oxygen saturations can decrease, particularly when clients are breathing fast and shallow and as such not taking a full inspiration. Prolonged changes in these vital signs can lead to ischemia, thus pain management is essential.
• With increased body temperature, the nervous system stimulates the sweat glands to help cool the body. Thus, clients may experience diaphoresis.
• Digestive enzymes and peristalsis are reduced which leads to difficulty with digestion and gastrointestinal upset including nausea, vomiting, and constipation.
• Other signs of pain may include increased blood glucose levels and pupil dilation.

Chronic Pain

• Secondary chronic pain refers to a type of pain that manifests as a result of a disease or condition such as arthritis, cancer, or ear infection – it is “secondary” to these pathological conditions (Treede et al., 2019). It can also be pain that is secondary to, or a result of, treatment such as cancer-related treatment.
• Primary chronic pain is a more recent classification. It is a type of pain based on a condition that is often poorly understood and cannot be accounted for by another cause or disease process (Nicholas et al., 2019; Treede et al., 2019, 2015). Common types of primary chronic pain include many types of neck and back pain, fibromyalgia syndrome, and irritable bowel syndrome (Nicholas et al., 2019).

• Sleep disruptions.
• Mood disturbances including depression.
• Interference with daily activities.
• Cognitive impairment including the ability to think clearly.
• Social and relational effects.

Nociceptive Pain

• Mechanical (e.g., stubbing your toe, receiving a needle, straining a muscle).
• Thermal (e.g., touching a hot surface like a stove).
• Chemical (e.g., exposure to a chemical such as bleach).

(Bonezzi et al., 2020).

Neuropathic Pain

Nociplastic Pain

Idiopathic Pain

Referred Pain

Activity: Check Your Understanding

References

Bonezzi, C., Fornasari, D., Cricelli, C., Magni, A., & Ventriglia, G. (2020). Not all pain is created equal: Basic definitions and diagnostic work-up. Pain and Therapy, 9(Suppl 1), 1-15. https://doi.org/10.1007/s40122-020-00217-w

• How would someone know that you are in pain?
• Could they tell by your facial expression or body position?
• What behaviours would you display if you were in pain? Would you be quiet, grimacing, or smiling? Would you isolate yourself? Would you be trying to sleep, walk around, or talk to others?
• Would you tell someone you were in pain or keep it to yourself? How bad would the pain have to be for you to be concerned or for you to tell someone?
• Would you exaggerate or minimize the level of pain (or pain of a family member) when describing it to a healthcare provider due to fear of discrimination?

References

• Disparities are visible through elevated risks of prematurity and low birthweight, lower income, and lack of access to education, resources, and opportunities for non-dominant racialized groups – all affecting their health and well-being (Williams et al., 2019). 
• The stress of racism is very real. It is a vicious circle that perpetuates racial inequities negatively affecting mental and physical health in many ways for nondominant racial groups (Levy et al., 2013). 
• A specific example is research funding. Cystic fibrosis mainly affects white people and receives 7–11 times more funding than sickle cell disease, which mainly affects Black people with sub-Saharan African ancestry (Power-Hays & McGann, 2020). This is a clear example of systemic racism: sickle cell disease affects substantially more North Americans, but receives substantially less research funding.
• Some racism is blatant (verbal slurs), but it is also important to consider subtle racism, such as a healthcare professional’s overuse of medication as a restraint or way to control a client. 

• Hoffman and colleagues (2016) discuss the false and dangerous belief that Black people are different biologically (e.g., thicker skin, fewer nerve endings) and thus, feel less pain. This will lead to an inaccurate assessment of pain and also to disparities and inequities in pain management (Hoffman et al., 2016). 
• Another example highlights the existence of racial bias in pain perception. In a multi-stage experiment, participants were shown a series of Black and white faces in pain. The researchers found that white participants had more stringent thresholds to perceive pain on Black versus white faces and would perceive pain earlier on white versus Black faces (Mende-Siedlecki et al., 2019). In addition to affecting assessment practices in terms of observations, this effect is likely to result in Black clients being provided less medication, or to be given non-narcotic pain medication, compared to white clients who often receive narcotic pain medications (Mende-Siedlecki et al., 2019).
• Another study found that Indigenous clients in Canada reported feeling judged by healthcare providers and reporting discrimination when in pain or requesting medication for conditions involving chronic pain (Nelson & Wilson, 2018). This kind of experience has negative effects on the quality of care that Indigenous clients receive, and may result in them choosing not to access needed services. 
• Another example of anti-Indigenous racism involves Joyce Echaquan, an Atikamekw client in Quebec. She had gone to the emergency room for stomach pain and described being overmedicated by healthcare providers (APTN News, n.d.). The coroner concluded that systemic racism played a role in how Joyce was treated and in her death (Richardson, 2021). This case highlights the importance of individualized pain assessment and listening, believing, and responding to the client.

Activity: Check Your Understanding

References

Dimensions of Pain Assessment

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References

• Admission to a healthcare setting.
• Primary healthcare visit. 
• Start of shift when first assessing a client. 
• Change in the client’s condition (e.g., change in vital signs) or other potential physiological or behavioural signs of pain.
• Prior to a procedure or activity to establish a [pb_glossary id="347"]baseline[/pb_glossary] (e.g., walking for the first time postoperatively) as well as during and after a procedure or activity. 
• After treatment (e.g., after the provision of pain medication such as [pb_glossary id="348"]analgesics[/pb_glossary]) and continued reassessment until treatment takes effect. Reassessment is often based on the medication’s onset of action (how long the medication takes to begin taking effect), peak effectiveness (how long it takes for the medication to be at its maximum concentration in the body, thus its greatest therapeutic effect) and duration (length of time that a medication produces a therapeutic effect) (Chippewa Valley Technical College, n.d.). Continued reassessment of pain may be needed so that you can determine whether additional treatment is required.
• When there is a written order for pain assessment. For example, physicians and nurse practitioners sometimes provide written orders for pain assessments (e.g., pain assessment every four hours or pain assessment every eight hours).

Activity: Check Your Understanding

References

• Presence of pain: do they have pain? If so, how long have they had it?
• Location of pain: where is it located?
• Severity/quantity of pain: how bad is the pain?
• Descriptors of pain: how do they describe the pain? Is it constant or intermittent?
• Associated factors and triggers of pain: are there any associated signs or symptoms with the pain? Is there anything that triggers their pain or makes it worse? What were they doing when the pain started?
• Impact of pain: how is it affecting them?
• Management of pain: have they tried to manage or treat it?

• The reason for assessing. For example, are you assessing the pain to obtain an overview or comprehensive perspective of the pain? Are you assessing the pain to determine the effectiveness of a treatment?
• The client’s developmental stage. There are validated tools based on a client’s capacity to cognitively appraise their pain and communicate it.
• The client’s health status. At times, you will need a quick assessment of pain because the client’s health status is critical, or the client is deteriorating. Other times, you will need a more comprehensive understanding of the pain.
• The institution and unit. Many units specify the pain assessment tools to be used so that consistency of assessment is maintained; they may also offer training for all healthcare providers in that specific tool.
• Culture. Some people from different cultural backgrounds in terms of ethnicity and language may not be able to cognitively appraise their pain using some of the common pain tools. Thus, it is important to recognize the limits of pain tools.

References

• Provide a baseline of the severity of a client’s pain.
• Determine the need for pain management/treatment.
• Evaluate treatment effectiveness.

Numeric Rating Scale

• It is simple to use.
• It gives a quick assessment of the client’s pain intensity and provides a baseline.
• It is useful for frequent or repeat pain assessments such as after a treatment or medication is provided.

Visual Analogue Scale

Verbal Descriptor Tool

FACES Pain Scales

Sun-Cloud-Pain Scale

Activity: Check Your Understanding

References

1. PQRSTU mnemonic.
2. Brief Pain Inventory.
3. Pain scales related to cognitive impairment.
4. FLACC Pain Tool.
5. Behavioural Pain Scale and Critical Care Pain Observation Tool.

Activity: Check Your Understanding

References

• It focuses on assessing pain intensity over the past week and interference with a client’s daily life.
• It takes 5–10 minutes to complete.
• It can be self-administered by clients who are literate or administered by healthcare professionals when the client has reduced literacy.
• It can be translated into other languages for clients who do not speak English, and has already been validated in many languages including French, Japanese, Chinese, Korean, Italian, Russian, German, and Spanish, among others.

References

Abbey Pain Scale 

• Vocalization.
• Facial expression.
• Changes in body language.
• Behavioural changes.
• Physiological changes.
• Physical changes.

Pain Assessment in Clients with Impaired Cognition (PAIC15)

• Facial expression.
• Body movements.
• Vocalization.

References

• Face.
• Legs.
• Activity.
• Cry.
• Consolability.

References

Behavioral Pain Scale (BPS)

• Facial expression.
• Upper limb movement.
• Compliance with ventilation.

(Payen et al., 2001).

Critical-Care Pain Observation Tool (CPOT)

• Facial expression.
• Body movement.
• Muscle tension.
• Compliance with the ventilator for intubated clients or vocalization for extubated clients.

• While at rest, observe the client’s facial expression, body movements, and presence of vocalization for one minute.
• Next, perform a passive range of motion of the lower arm (flexion and extension of elbow) while holding the client’s hand and elbow to assess for muscle tension.
• Upon movement (such as turning them on their side), observe the client’s facial expression, body movements, and presence of vocalization.

(Kaiser Permanente National Patient Care Services, 2011).

References

Activity: Check Your Understanding

References

• Full set of vital signs. Vital signs can be affected by pain, particularly acute pain. Collection and assessment of vital sign data may provide important information related to the client’s stability and the potential for clinical deterioration. Vital signs are also an important component of pain tools that include physiological measures; these can be particularly helpful in clients who are pre-verbal or non-verbal such as newborns, young children, clients that may have a developmental challenge, and clients who are unconscious. However, vital sign changes cannot help you differentiate between pain and other forms of distress such as fear and anxiety. You should always consider the context when interpreting vital signs, because they can be affected by level of consciousness, medications, and sedation. Therefore, your clinical judgement will be based on a comprehensive subjective and objective assessment, along with critical thinking.

• Inspection of the area. Typically, you will inspect the area on the body where a client indicates they are having pain. Inspection is performed bilaterally in which you compare the left side to the right side. For example, if a client is having eye pain, you should compare the left eye to the right eye. Inspect for and note any abnormalities such as discoloration (e.g., redness), bruising, swelling, scarring, incisions, masses, deformities, asymmetry, lesions, non-intact skin, and pressure injuries. With chest pain, you should also inspect for cardiac heaves (forceful movements observed on the skin over the chest wall) and epigastric pulsations. With abdominal pain, you should also inspect for abdominal contour and peristaltic movements.

• Palpation of the area. After conducting a subjective assessment, you should palpate the area (and related areas) in which the client is having pain. Palpation is performed bilaterally: compare the left side to the right side. For example, if a client is having left shoulder pain, you should palpate the right shoulder first and then the painful left shoulder. Similarly, if a client is having abdominal pain, you should palpate the painful area last. During palpation, you should assess skin temperature, swelling, masses, deformities, and [pb_glossary id="228"]crepitation[/pb_glossary] if associated with a joint. You should also observe any signs of pain during palpation, such as a change in respiration (e.g., holding their breath), facial grimacing, withdrawing their body/limb, and guarding.

• Auscultation and percussion. Perform auscultation and percussion when a client is describing chest or abdominal pain. For example, with chest pain, you should auscultate the lungs, and the apical pulse and cardiac valves. With abdominal pain, you should auscultate the abdomen for bowel sounds and percuss the abdominal area.

Musculoskeletal System Components

• Skull, including the cranial and facial bones.
• Vertebral column with intervertebral discs.
• Thoracic cage with sternum and ribs.
• Clavicle and scapula.
• Upper and lower limb bones.
• Hip/pelvis bones.

Activity: Check Your Understanding

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References

Table 3: MMT Scale (based on Medical Research Council (MRC) Manual Muscle Testing scale, 1943).

References

1. Assess the type of footwear and the presence of prosthetics and mobility aids such as canes, walkers, braces, splints, or wheelchairs.
   • If aids are present, you should ask further questions. You need to understand the need for the aid and should assess whether it is being used properly.
2. Assess the client’s posture and balance when they enter the room and their ability to sit or stand upright and maintain this position.
   • Abnormal findings may include hunched over, unequal weight bearing, and lateral lean.
3. Assess for the presence of tremors or obvious deformities. Normally, no tremors or deformities are present.
   • Abnormal findings may include deformities, which could include fractures.
   • Abnormal findings may include unilateral or bilateral tremors in head/neck region, upper or lower limbs.
4. Assess the client’s symmetry of limbs in terms of length and [pb_glossary id="205"]gait[/pb_glossary]. This can be done informally when the client walks in the room from the waiting room. Otherwise, you can ask them to walk about 10 feet. This may not be required if a client is in a wheelchair, particularly if they are unable to stand up.
   • Normally, limbs are symmetrical, and gait is balanced. Cues of asymmetry and a gait that is not balanced should be probed further.
5. Note the findings.
   • Normal findings might be documented as: “Client’s body is symmetrical, no deformities, posture straight, steady gait and balance. No mobility aids used.”
   • Abnormal findings might be documented as: “Client has a slow and unsteady gait. Left arm hangs lower than the right arm.”

Inspection

1. Inspect the face for colour, symmetry, swelling, masses, and deformities with a focus on the muscles, bones, and joints.

• • Normally, the face has no discolourations such as erythema and is symmetrical with no swelling, masses, or deformities. Describe the appearance and location of any discolouration, swelling, masses, and deformities.

• • Normally, the head is upright and centred and the cranium and the neck are symmetrical with no masses, swelling, deformities, or discolourations. Describe the appearance and location of any asymmetry, masses, swelling, deformities, and discolourations (these will be further assessed with palpation).

• • Normal findings might be documented as: “Client’s head is upright and centred. No masses, swelling, deformities or discolouration on the head, face and neck.”
  • Abnormal findings might be documented as: “Client’s face has swelling over the right zygomatic (cheekbone) area with bluish-purple discolouration.”

Palpation

1. Palpate the temporomandibular joint (where the maxilla and mandible meet anterior to the tragus). Do both sides at the same time and place two to three finger pads on each side and move in a circular motion in two to three areas. Then, use dorsa of hands and palpate the posterior side of neck for temperature. The rest of the facial structures are normally not palpated unless the client has indicated a concern or has experienced a physical injury.

• • Normally, the temperature is equal bilaterally, muscles are firm to touch, and no pain is felt on palpation.

• • Normally, the cervical spine and muscles are symmetrical with no pain, masses, swelling, deformities, or paravertebral muscle spasms. The description and location of abnormal findings should be noted. Description of masses and swelling may include size and consistency (soft or hard).

• • Normal findings might be documented as: “Temperature warm to touch and equal bilaterally with no pain on temporomandibular joint. Cervical spine and muscles are symmetrical with no pain, masses, swelling, or deformities noted on palpation.”
  • Abnormal findings might be documented as: “Client noted pain as a 6/10 upon palpation of the cervical spine. Swelling palpable from C6–7.”

Range of Motion (ROM)

1. Ask the client to open and close their mouth (vertical motion). Then, place your index and middle fingers on the temporomandibular joints on both sides of the face and ask them to repeat the movement
   • Normally, there should be no pain and the temporomandibular joint should open and close smoothly. Sometimes, you may hear and/or feel a click (clunk) of the jaw. This is usually not of concern unless associated with pain and affecting the ability to chew food.
2. Ask the client to perform neck flexion by attempting to touch their chin to their chest and bring it back to neutral position.
3. Ask the client to perform neck extension by gently tilting their head back.
4. Ask the client to perform neck lateral bending by tilting their head to the right then the left (e.g., “attempting to touch their ear to their shoulder”).
5. Ask the client to perform neck rotation by turning their head to the right, back to neutral position, and then to the left.
6. Note the findings:

• • Normal findings might be documented as: “Client’s temporomandibular joint and neck has full ROM, movements of joints are smooth and symmetrical with no obvious misalignments, no crepitus or pain noted.”
  • Abnormal findings might be documented as: “Client’s neck has limited ROM in flexion with no crepitus. Pain noted as a 3/10 while flexing.”

Manual Muscle Testing (MMT)

1. Begin with the client’s head in a neutral position looking straight ahead. To perform cervical/neck flexion, stand slightly lateral to the client, place one hand on the thoracic spine for stability and the other on the client’s forehead, ask them to bend their neck bringing their chin to their chest while you apply force with your hand on their forehead. Ask them to resist your force. Release the force and ask them to return their head to neutral. Note if the client tries to move their shoulders or thoracic body during the procedure.
2. Next, place one hand on the posterior occipital bone and the other on the client’s shoulder for stability. To perform neck extension, ask the client to look up to the ceiling to extend the cervical spine, while applying force with the hand on the occipital bone. Ask them to resist your force. Release the force and ask them to return their head to neutral. Note if the client tries to use their back during the procedure.
3. Move in front of the client. For stability, place one hand on their right shoulder and the other on the client’s head above the left ear over the temporal bone structures. To perform lateral bending, ask the client to touch their left ear to their left shoulder, while you apply force to the movement. Ask them to resist your force. Release the force and ask them to return their head to neutral. Repeat the procedure on the opposite side. Note if the client tries to flex the lateral thoracic spine during the procedure.
4. To perform rotation, place one hand on the right shoulder for stability and the other on the lateral side of the client’s face with fingers pointing toward the temporal bone structures. Ask the client to look left to rotate the cervical spine while you apply force. Ask them to resist your force. Release the force and ask them to return their head to neutral. Repeat the procedure on the opposite side. Note if the client tries to rotate the thoracic spine during the procedure.
5. Note the findings:

• • Normal findings might be documented as: "“full resistance equal bilaterally on all neck ROM with no pain.”
  • Abnormal findings might be documented as: "partial resistance equal bilaterally on all neck ROM with mild pain.”

Activity: Check your Understanding 

References

Inspection

1. Inspect for colour, symmetry, swelling, masses, deformities, and length of limbs with a focus on the muscles, bones, and joints on the whole arm and hand. This involves asking the client to stretch arms and hands out in front of them (pronation) and then turn them over (supination) so that you can inspect the anterior and posterior sides. You may need to ask the client to spread their fingers apart while they are moving their outstretched arms from pronation to supination. Next, ask the client to rest their hands on their lap while you inspect the shoulders and elbows as these cannot be fully visualized when pronating and supinating.

• • Normally, there is no discolouration, swelling, masses, and deformities, and the arms and hands and joints are symmetrical.
  • Describe the appearance and location of any discolouration, swelling, masses, and deformities.

• • Normal findings might be documented as: “Client’s shoulders, arms, wrists and hands are symmetrical with no redness, swelling, masses, or deformities.”
  • Abnormal findings might be documented as: “Client’s right wrist is red and swollen on the dorsal side of wrist, 5 cm x 3 cm area.”

Palpation

1. Palpate for temperature from shoulders to fingertips bilaterally. Palpate over the shoulder, elbow, wrist, and finger joints as you move down the client’s arm.
   • Temperature is normally warm to touch and equal bilaterally. Temperature may get slightly cooler toward the fingertips.
   • Abnormal findings include increased temperature over a joint and sometimes a muscle.
2. Palpate for pain, masses, swelling, deformities, palpable fluid, and muscle twitching from shoulders to fingertips. Palpate the whole arm and hand including the full joint. If the client reports pain prior to assessment, assess that area last.
   • Normally, there is no pain, masses, swelling, deformities or palpable fluid.
   • If pain is present, note the location and ask client to rate the severity and describe the quality. Describe the location and characteristics of any masses, swell, deformities, or palpable fluid.
3. Note the findings:
   • Normal findings might be documented as: “Client’s shoulders, arms, wrists and hands are warm to touch to fingertips, equal bilaterally. No pain, swelling, masses, deformities, or palpable fluid noted.”
   • Abnormal findings might be documented as: “Client’s right elbow is warmer to touch in comparison to left elbow. Swelling over the olecranon area. Client reported pain as a 6/10 upon palpation.”

Range of Motion

1. To perform shoulder flexion, ask the client to stand with their arms hanging straight at their sides (neutral position/extension), then lift their arms in front of them above their head (keeping their arms straight) until their fingertips point toward the ceiling, and finally bring them back to a neutral position.
2. To perform shoulder extension, start with the client in a neutral position and ask them to move their arms/hands back as far as possible (keeping their arms straight with an upright posture and not leaning forward), and then return to a neutral position.
3. To perform shoulder abduction, start with the client in a neutral position and ask them to move their arms out from their body (laterally) and up over their head until the hands meet, and then back to a neutral position. Assess movement anteriorly and posteriorly.
4. To perform shoulder adduction, start with the client in a neutral position and ask them to move their arm across the midline of their body to the opposite side, keeping the arm straight, and then repeat with the other arm.
5. To perform shoulder external rotation (also called lateral rotation), ask the client to bend their arm at the elbow to a 90-degree angle keeping their elbow tightly close to their side, then ask them to move their hands out to the side while keeping their elbows tight to the side of their body until their palms face forward (this externally rotates the shoulder).
6. To perform shoulder internal rotation (also called medial rotation), ask the client to have their arms hanging straight down at side with thumbs pointing inward/medial to the body, and then move their thumbs/arms up their back as high as they can, and then back to a neutral position.
7. To perform elbow flexion, start with the client in a neutral position, and then ask them to lift their forearm/hand arms up by bending at the elbow, moving their hands toward their shoulders while keeping the elbow joint still, and finally return to a neutral position (which is elbow extension).
8. To perform elbow supination and pronation, start with the client in a neutral position, and ask them to bend their elbow at a 90-degree angle with thumbs facing up. Next, rotate the thumbs/forearms internally for pronation (palms of the hands should be facing down to the floor), and then externally for supination (palms of the hands should be facing up to the ceiling).
9. To perform wrist flexion and extension, ask the client to rest their forearms and hands on a table.
   • For wrist flexion, the client’s forearms should be resting on the table in supination position (palms of the hands facing up). Ask the client to bend at the wrist joint with fingers pointing to the ceiling while keeping the forearms/wrists on the table.
   • For wrist extension, the client’s forearm should be resting on the table in a prone position (palms of the hands facing down). Ask the client to bend their wrist joint back with fingers pointing to the ceiling by keeping the forearm and wrists on the table.
10. To perform wrist radial and ulnar deviation ask the client to rest their forearm on the table in a prone position (palms of the hands facing down).
    • For radial deviation, ask the client to flex their wrists inward/medially keeping the forearm/hands/fingers on the table as the fingers deviate midline and point toward each other, and then return to a neutral position.
    • For ulnar deviation, ask the client to flex wrists outward/laterally keeping the forearms/hands/fingers on the table as the fingers deviate away from midline and point away from each other, and then return to a neutral position.
11. To perform finger flexion and extension/abduction, first ask the client to make a fist (flexion) by bending the fingers and then stretch and spread their fingers out straight (extension). This is also considered abduction as the fingers are spread out from one another. Ask the client to put their forearm/hands/fingers flat in a prone position on a table and lift their fingers off the table in extension, while keeping their palms flat.
12. To perform thumb flexion, extension, abduction, and opposition, ask the client to rest their forearms on the table in a prone position (palms of the hands facing down), then ask the client to externally rotate their forearms so the palms are facing each other.
    • For thumb flexion and extension, ask the client to bend their thumbs into the base of the palm, and then up, pointing the tip toward the ceiling for extension.
    • For thumb abduction and adduction, ask the client to abduct their thumbs internally pointing toward each other, and then adduction moving back beside the first digit.
    • For thumb opposition, ask the client to touch their thumb tips to the tip of the 5th digit.
13. Note the findings:

• • Normal findings might be documented as: “Full ROM of shoulders, elbows, wrists and hands, movements of joints are smooth and symmetrical with no obvious misalignments, crepitation, or pain bilaterally.”
  • Abnormal findings might be documented as: “Client shoulder abduction 100 degrees, no crepitation, reported tenderness 3/10.”

Manual Muscle Testing (MMT)

1. To perform MMT for shoulder flexion and then extension, ask the client to stand with their arms hanging straight down at the side (neutral position). With their shoulder joints still and arms straight, place your hands on the client’s forearm and apply force while you ask the client to raise their arm straight up in front of them and resist your force. Release the force and ask them to return their arm to a neutral position. Repeat on the other arm. Then, have the client raise one arm straight out in front of them and above their head. Place your hands on their elbow/forearm, apply pressure and ask them to resist your force while pushing their arm down back to a neutral position. Release the force and ask them to return their arm to a neutral position. Repeat on the other arm.
2. To perform MMT for shoulder abduction and then adduction, ask the client to stand in a neutral position. Place your hands over the elbow/top of the forearm. Ask the client to try to raise their straight arm out to the sides while you apply force and they try to resist it. Release the force and ask them to return their arm to a neutral position. Repeat on the other arm. For adduction, assess one arm at a time: place your hand on their inner forearm and ask them to move their straight arm across the midline while you apply force and they resist it. Release the force and ask them to return their arm to a neutral position. Repeat on the other arm.
3. To perform MMT for elbow flexion and then extension, ask the client to stand in a neutral position. Place your hands in the middle of one forearm and ask the client to flex/bend their arm (at the elbow) in front of them while you apply force and they resist it. Release the force. Repeat on the other arm. Next, ask the client to bend their arm about 100 degrees (at the elbow) in front of them; place your hands on the middle area of the forearm and ask them to attempt to straighten their arm while you apply force and they resist it. Repeat on the other arm.
4. To perform MMT for wrist flexion and then extension, ask the client to rest their forearms/hands on a table in a supination position. Place one of your hands on their forearm and the other touching the palm of their hand. Ask the client to bend their wrists by pushing their palm up into your palm while you apply force and they resist it. Repeat on the opposite side. Next, ask the client to rest their forearm/hands on the table in a pronation position. Place one hand on their forearm to stabilize the arm; place the other on the dorsal side of their hand. Apply force to the dorsal side of the hand and ask the client to bend their wrist back by pushing their hand up into yours while resisting your force. Repeat the procedure on the opposite side.
5. To perform MMT for finger flexion, ask the client to grasp your two fingers with their hands (or with a handshake) to assess their strength bilaterally.
6. Note the findings:

• • Normal findings might be documented as: “full resistance equal bilaterally on all upper limb ROM with no pain.”
  • Abnormal findings might be documented as: “partial resistance on left wrist ROM with mild pain.”

Activity: Check your Understanding 

References

Inspection

1. Inspect for colour, swelling, masses, and deformities with a focus on the muscles, bones, and joints. This involves inspecting from the hips/upper leg to the toes on the anterior, lateral, and posterior sides of the legs. To inspect the posterior side, you can either ask the client to lift their leg into the air or to reposition on their lateral side. Then, you should expose the full area of the hip ensuring the client is draped. Inspect all of the joints (hip, knee, ankles, and toes). 
   • Normally, there will be no discolouration, swelling, masses, or deformities.
   • Describe the appearance and location of any discolouration, swelling, masses, and deformities.
2. Inspect for symmetry in terms of leg size and length. This can be done by just looking at the legs: compare the thigh size and the calf size from one limb to the other and from the hips to the feet. You can evaluate with a tape measure for accuracy if upon inspection you notice a potential discrepancy, or the client has indicated a concern. For circumference, measure at the largest point around the thigh and the calf. For leg length, place the tape measure at the anterior-superior point of the iliac crest to the inferior point of the bony prominence of the medial malleolus and repeat again. Begin at the umbilicus as opposed to the iliac crest. Because many factors can affect accuracy, it is best to measure twice and take an average of the two measurements (Applebaum et al., 2021). 
   • The legs are usually of equal length and circumference. 
   • Describe any asymmetry that is greater than 10 mm (1 cm).
3. Note the findings:
   • Normal findings might be documented as: “Thigh and calf circumference and leg length are equal bilaterally. No discolouration, swelling, masses, and deformities noted on hips, legs, knees, ankles, or toes.”
   • Abnormal findings might be documented as: “Swelling and purple-blue discolouration over lateral side of left knee. No deformities noted. Client reported they were ‘side tackled’ during rugby.”

Palpation

1. Palpate for temperature from the hips/upper legs to the toes bilaterally. Palpate around each of the joints as you move down the client’s legs.
   • Temperature is normally warm to touch and equal bilaterally. Temperature may get slightly cooler toward the feet.
   • Abnormal findings include increased temperature over a joint and sometimes a muscle. Describe the characteristics and the location.
2. Palpate for pain, masses, swelling, deformities, and palpable fluid from hips to toes. Palpate the whole leg and foot including the full joint. If the client reports pain prior to assessment, assess that area last.
   • Normally, there will be no pain, masses, swelling deformities or palpable fluid.
   • If present, describe the characteristics and the location.
3. Note the findings:
   • Normal findings might be documented as: “Client’s hips, legs, knees, ankles, and toes are warm to touch and cooler at toes, equal bilaterally with no swelling, masses, deformities, pain, or palpable fluid noted.”
   • Abnormal findings might be documented as: “Client’s left ankle to toes are cool to touch in comparison to right ankle. Swelling around the base of the ankle. Client reported discomfort as a 4/10 upon palpation. Client reported ‘twisting ankle’ stepping off a ladder.”

Range of Motion

1. To perform hip flexion with straight leg and hip flexion with knee flexion, ask the client to lie with their hips/pelvis still. Ask the client to lift one leg up (with leg straight) while bending it at the hip and moving it as close to the upper body as they can, then return to a neutral position (this is hip flexion with straight leg). Next, ask the client to lift the leg up as high as they can while bending it at the hip and the knee (hip flexion with knee flexion). Perform on the other leg.
2. To perform hip extension, ask the client to stand and move one straight leg back while keeping their body facing forward and upright. This is normally done at the end of the exam when the client stands up for you to assess their spine. If the client cannot stand, you may assess in the prone position. NOTE: this ROM can be performed toward the end of the assessment when asking the client to stand to assess the spine.
3. To perform hip abduction and adduction, ask the client to lie in a neutral position. For hip abduction, ask the client to move their leg out (keeping leg straight) toward the side (moving off the bed) and back to neutral. Repeat on the opposite leg. Next, for hip adduction, place one hand proximal to the ankle and one proximal to the knee on the underside of the leg and lift the client’s legs up enough so that the client can slide their other leg underneath. Next, ask the client to slide the opposite leg underneath the leg that you are holding up. Return to a neutral position and repeat on the opposite leg.
4. To perform hip internal rotation (also called medial rotation) and external rotation (also called lateral rotation), first ensure the client does not engage the spine with any sort of spinal rotation. For hip internal rotation, ask the client to bend one leg up at the knee, keeping their foot flat on the table with the knee pointing to the ceiling, then tip their knee inward (medially) and keeping their heel fixed to the table and their hips still (flat on table). Then, return the leg so that the knee is pointing to the ceiling. For external rotation, ask the client to tip their knee outward (laterally) while keeping the heel fixed to the surface and keeping their hips still (flat on table). Then, return to the leg to a neutral position with both legs straight. Repeat on the opposite leg. Note, both of these ROM can also be done in sitting position, which is commonly seen in practice.
5. To perform knee flexion and extension, ask the client to bend their leg at the knee by sliding their foot/heel toward their buttocks (knee flexion), and then back to a neutral position (extension). Repeat on the opposite leg.
6. To perform dorsiflexion and plantar flexion, ask the client to point and move their toes on both feet toward their shin or head (dorsiflexion), and then back to a neutral position. Next, ask the client to point and move their toes away from the body with the soles of the feet facing down (plantar flexion), and then return to a neutral position.
7. To perform ankle inversion and eversion, place one hand on the client’s lower leg to stabilize their tibia and ask the client to tilt/move the sole/bottom of the feet inward (medially) facing each other (inversion), and then back to a neutral position. Next, for ankle eversion, ask the client to move the sole/bottom of the feet outward (away from each other), and then return to a neutral position.
8. To perform toe flexion and extension, ask the client to curl their toes toward the bottom of the foot, and then ask the client to uncurl their toes and point the tips of their toes up as much as possible, and then back to a neutral position.
9. Note the findings:

• • Normal findings might be documented as: “Full range of motion, no crepitation, and pain of hip, knees, ankles, and toes bilaterally, smooth and symmetrical movements of joints with no obvious misalignments.”
  • Abnormal findings might be documented as: “Right knee flexion is 110 degrees and extension 10 degrees, no crepitation. Reported muscle tightness on movement.”

Manual Muscle Testing (MMT)

1. To perform hip flexion with straight leg, place one hand proximal to the ankle and the other proximal to the knee. Ask the client to bend/flex their leg at the hip as if they were going to lift their leg up (keeping leg straight) while you apply force and they resist it. Return to a neutral position and then repeat the procedure on the opposite side.
2. To perform hip extension, ask the client to raise their  straight leg up (hip flexion with leg straight), place one hand proximal to the ankle and the other proximal to the knee (both on the underside of the leg), and then ask the client to move their leg back down to the table while you apply force and they resist it. Return to a neutral position and repeat on the opposite leg.
3. To perform hip abduction and adduction, place one hand proximal to the knee and the other proximal to the ankle on the lateral side of the leg. Ask the client to move their leg out toward the side (moving off the bed) while you apply force and they resist it. Return to a neutral position and repeat on the opposite leg. Next, ask the client to move their leg out/abduct toward the edge of the bed (about 15 degrees). Place one hand proximal to the knee and the other proximal to the ankle on the medial side of leg. Ask the client to move their leg in toward the centre (moving their leg toward the other leg) while you apply force and they resist it.
4. To perform knee extension and flexion, ask the client to bend their leg/knee keeping their foot flat on the table (about 90 degrees) with the other leg remaining straight in neutral position. Place one hand proximal to the knee for support and the other proximal to the ankle so that you can apply force. Ask the client to extend their leg by moving their foot off the bed (like a kicking action) while you apply force and they resist it. Return to the 90-degree position with the foot flat on the table. Next, for flexion, place one hand proximal to the knee for support and the other proximal to the ankle to apply force on the posterior side of the leg. Ask the client to move their foot off the table so that their lower leg is parallel to the table and knee at about 90 degrees, and then bend their knee and bring the heel of their foot back down to the table while you apply force and they resist it. Repeat on the opposite leg.
5. To perform ankle dorsiflexion and plantarflexion, place your hand on the top (dorsal) side of one foot. Ask the client to point and move their toes toward their shin or head while you apply force and they resist it. Repeat on the other foot. For plantar flexion, place your hand on the bottom (plantar) side of the foot. Ask the client to point and move their toes away from the body, with the sole of the foot facing down, while you apply force and they resist it. Repeat on the other foot.
6. Note the findings:

• • Normal findings might be documented as: "“full resistance equal bilaterally on all lower limb ROM with no pain.”
  • Abnormal findings might be documented as: "partial resistance with left hip ROM with mild pain.”

Activity: Check Your Understanding

References

As always, use a trauma-informed approach. You will need to expose the thoracic cage and back, so you should explain what you are doing and why and provide a drape as needed. The thoracic cage is part of both MSK and respiratory systems, so these assessments are often combined.

Inspection and Palpation

Steps for inspection and palpation include:

1. Inspect the thoracic cage for deformities that may be related to injury/trauma or congenital anomalies.
   • The thoracic cage is normally symmetrical.
   • Abnormal findings may be related to fractured ribs that can appear as a deformity or a sunken chest such as with [pb_glossary id="151"]pectus excavatum[/pb_glossary]. If you note these abnormal findings, auscultate the lungs because both conditions can affect breathing. For example, a broken rib can be associated with a risk of [pb_glossary id="152"]pneumothorax[/pb_glossary].
2. Use your four finger pads to palpate the thoracic cage for masses, swelling, and deformities. You may also palpate for [pb_glossary id="153"]subcutaneous emphysema[/pb_glossary], which can result from a rib fracture. Ask the client if they have pain.
   • Normally, no pain, masses, swelling, and deformities are present.
   • Describe the characteristics and location of any pain, masses, swelling and deformities.
3. To palpate for temperature, use the dorsa of your hands to palpate down the spine from T1 to the lower back (about L4 at the superior iliac crest).
   • Temperature is normally warm to touch.
   • Be attentive to areas that are excessively warm and possibly associated with redness, swelling, and deformities.
4. Using two or three finger pads, including the index and middle finger, palpate down spinous processes to feel for deformities and pain from T1 to L4. A moderate pressure with a circular motion is best. Use the same technique, with both hands, to palpate down the paravertebral muscles on either side of the vertebra for pain and spasms.
   • Normally, there are no deformities or pain along the spinous process and no pain and spasms on the paravertebral muscles.
   • Describe the location and characteristics of pain, deformities, or spasms.

5. From a posterior view, inspect the spinal alignment from C1 to L4. At this point, you have already inspected the neck, but it can be helpful to look at the whole spine to assess alignment as well as head position. Also inspect the back for symmetry: compare the level of the shoulders, scapula, iliac crest, gluteal folds, and arm hang bilaterally. Ask the client to keep their legs straight and bend down toward their toes; this can accentuate any asymmetry if present.
   • Normally, the spine is straight with no curvature from a posterior view and the back is symmetrical and arms hang at an equal length.
   • Any curvature and asymmetry should be described including the location. One type of curvature is a spinal condition called scoliosis (Figure 4). It appears as an S or a C curve affecting either or both thoracic and lumbar sections of the spine. This curvature also affects the head position and asymmetry of the arm hang.

6. From a lateral view, inspect the spinal curvature.
   • Note the normal thoracic convex (outward) curve and the cervical and lumbar concave (inward) curve.
   • Note any variations in curvature such as kyphosis and lordosis (Figure 4). Kyphosis is increased curvature of the thoracic section of the spine (the upper back). A person can be born with it (congenital) or it can develop as a result of poor posture (postural kyphosis) or MSK-related conditions such as osteoporosis. Lordosis is an inward curve of the lumbar section of the spine. It can occur for pathological reasons in various age groups, but especially during pregnancy as a way to realign the centre of gravity as the fetus grows.

Figure 4: Scoliosis, kyphosis, and lordosis.

Attribution: Gordon Betts, J., Young, K.A., Wise, J.A., Johnson, E., Poe, B., Kruse, D.H., Korol, O., Johnson, J.E., Womble, M., & DeSaix, P. (2013). The Autonomic Nervous System. In Anatomy and Physiology. OpenStax. Creative Commons Attribution License v4.0. Book URL: https://openstax.org/books/anatomy-and-physiology/pages/1-introduction. Section URL: https://openstax.org/books/anatomy-and-physiology/pages/7-3-the-vertebral-column

7. Note the findings:

• • Normal findings might be documented as: “Client’s thoracic cage is symmetrical with no reported pain, and no swelling, masses, or deformities, temperature warm to touch and equal bilaterally. Spinal column is straight with no abnormal curvatures. No deformities and pain along the spinous process and no pain and spasms on the paravertebral muscles.”
  • Abnormal findings might be documented as: “Swelling at L4-5, tender to touch, with tingling and radiating pain to the right buttock and upper thigh area. Client reported tenderness as 4/10 upon palpation.”

NOTE: See Video 13 for inspection and palpation of thoracic cage and spine.

Video 13: Inspection and palpation of thoracic cage and spine (note, you can also inspect the spinal curvature from the lateral view) [3:17]

Range of Motion (ROM)

When possible, ROM of the spine is best performed in a standing position to ensure full movement. Start with the client standing straight, looking forward with the face and body, and arms/hands hanging at the side (neutral position). When assessing cervical spine ROM, you will assess the gross ROM, which is the cumulative ROM of all of the spinal segments together. See Table 6 for normal ROM for each movement.

Steps for assessing ROM:

1. To perform lumbar spine flexion and extension, ask the client to bend forward at the waist, keeping their legs straight and bending down toward their toes, and then return to a neutral position. Next, ask the client to bend back at the waist, keeping their pelvis and hips still, and then return to a neutral position.
2. To perform lumbar spine lateral flexion, ask the client to bend to the right side with arms/hands reaching toward their toes while looking forward and keeping pelvis/hips still and facing forward. Repeat on the opposite side.
3. To perform lumbar spinal rotation, ask the client to twist to the right while keeping arms/hands at the side and legs/pelvis/hips facing forward. Repeat on the opposite side.
4. Note the findings:

• • Normal findings might be documented as: “Full ROM of lumbar spine with symmetrical and smooth movements, no crepitation and pain noted.”
  • Abnormal findings might be documented as: “Client has limited ROM of lumbar spine flexion of 30 degree, no crepitation. Rates pain 3/10 during movement.”

Table 6: ROM of spine (adapted from Luttgens & Hamilton, 1997).

NOTE: There are many variations of what is described as “normal” spine flexion; we have based these numbers on “lumbar” spine flexion specifically. Always ensure that the client does not engage/move the hips when assessing spine flexion.

Video 14: ROM of spine [1:07]

Manual Muscle Testing (MMT)

You should assess MMT after completing your assessment of ROM. Demonstrate the procedure before applying resistance, and then perform MMT on each joint bilaterally. Ask the client if they experience any pain and where. Grade the resistance according to the institution’s grading scale (e.g., MRC or Oxford testing scale).

MMT of the spine begins with the client in a standing position with feet placed under hips (slightly apart) for stability and arms hanging down at the side (neutral position).

Steps for MMT of the spine:

1. To perform MMT of spinal flexion, stand in front of the client with each hand on the anterior aspect of the shoulder applying force, and ask the client to flex the spine by bending (at the waist) forward toward their toes while resisting your force. Apply resistance once the client begins to bend (about 10 degrees). This technique can also be performed in a supine position if needed. Note any engagement of surrounding muscles to compensate for the movement.
2. To perform MMT of spinal extension, stand behind the client with each hand on the posterior aspect of the shoulders and scapula applying force, and ask the client to extend the spine by bending back at the waist while resisting your force. Apply resistance once the client begins to extend (about 10 degrees). This technique can also be performed in a prone position if needed. Note any engagement of surrounding muscles to compensate for the movement.
3. Note the findings:

• • Normal findings might be documented as: "“full resistance on spine ROM with no pain."
  • Abnormal findings might be documented as: "partial resistance equal bilaterally on spine ROM with mild pain.”

Activity: Check Your Understanding

References

American Academy of Orthopaedic Surgeons. (1965). Joint motion: Method of measuring and recording. AAOS.

Arthritis Society. (2022). Support for Childhood Arthritis. Retrieved from https://arthritis.ca/support-education/support-resources/support-for-childhood-arthritis

Edgecombe L, Sigmon DF, Galuska MA, et al. Thoracic Trauma. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK534843/

Luttgens, K. & Hamilton, N. (1997). Kinesiology: Scientific basis of human motion, 9th Ed., Brown & Benchmark.

Šavlovskis, J. & Raits, K. (2021). Range of the motion (ROM) of the cervical, thoracic and lumbar spine in the traditional anatomical planes. https://www.anatomystandard.com/biomechanics/spine/rom-of-spine.html Washington State Department of Social & Health Services. (2014). Range of motion evaluation chart. https://www.dshs.wa.gov/sites/default/files/forms/pdf/13-585a.pdf

Activity/Exercise

A sedentary lifestyle with limited activity/exercise is a risk factor that contributes to MSK conditions. Many clients will sit for long periods at work, and then sit at home to relax. Oftentimes, activity is described as one's general activity in the day (such as the activity they do around the house or at work). Exercise is a form of activity, but is considered intentional and planned physical activity often referred to as "working out."

Listen to Murat Dalkilinç TED-Ed on Why sitting is bad for you [4:50]. 

Exercise, including aerobic and strength-training exercise, strengthens the muscles, bones, and joints of the MSK system. Guidelines vary based on age and health, but in general individuals should engage in about 30–60 minutes of aerobic activity, 5–7 times a week. Stretching is also an important element of activity in the workplace or during exercising. Watch the video by Physiopedia called Musculoskeletal Disorders (MSD) & Work Place to learn more about MSD and how stretching can help decrease the risk. Strength training is also important throughout life, and can include weight lifting, resistance bands, and using one’s own body weight for resistance, e.g., squats and push-ups.

• Do you have any concerns about your level of activity or exercise?
• Tell me about your daily pattern of activity? What activities are you involved in?
• What exercise do you engage in? How long do you engage in this type of exercise? How many days of the week do you participate in exercise? (If the client plays sports, ask about their use of protective equipment.)
• What does an active lifestyle mean to you?

Many interventions are available to support clients to achieve their activity goals: community walking groups, fitness apps, and joining a local gym or group activity. The participACTION website is a helpful resource related to activity guidelines: https://www.participaction.com/en-ca. Consider activity interventions from a structural health promotion approach, considering the financial costs associated with many of these resources. 

Ergonomics and Back Health

Ergonomics is essential to back health and the overall health of the MSK system. Many injuries and chronic health issues are related to inattention to ergonomics science.

Broadly speaking, ergonomics refers to designing a space for the body to move and function based on the needs of the human body. For example, consider body positioning when sitting at a desk, during repetitive actions, or picking up and moving heavy objects. Teach the client about how to maintain proper body alignment by using large muscle groups, keeping the objects close to their centre of gravity, avoiding twisting motions, and instead using pivoting motions or asking for assistance. For example, when picking an object up from the ground, a client should stand directly in front of the object, place their feet hip distance apart to create a supportive centre of gravity, bend down using the knees to engage the large quadricep muscles, keep the object close to the body’s centre of gravity during lifting and standing, engaging their quadriceps and glutes. Maintaining proper body alignment by stabilizing the centre of gravity and core can decrease the risk of injuries. The ultimate aim is to increase comfort and decrease injuries and pain. The workspace is often a focus when considering ergonomics, but it is also important to also consider common spaces in the home. 

Listen to Murat Dalkilinç TED-Ed on The benefits of good posture [4:11].

• Tell me about any concerns you have related to ergonomics and your back health at work or at home?
• What physical position are you typically in at work (e.g., sitting, standing)?
• Are you engaged in any repetitive motions at home or at work (e.g., typing at a computer, lifting heavy objects, or other activities such as dishes/sewing)?
• Additional probing questions may be required based on the client’s answers:
  • Tell me more?
  • How does it affect your back or body?
  • Do you experience any pain?

Diet

• Tell me about your usual diet?
• What have you eaten in the last 24 hours? Is that your usual diet?
• How much fluids do you typically drink in a day? What fluids do you drink (e.g., water, caffeinated beverages, alcohol)? 
• Have you had any recent changes in your life that have affected your diet? 
• With rising food costs, purchasing food can be difficult. Do you have enough money to buy healthy food? 

• Water should be the drink of choice: hydration can help keep muscles and joints lubricated.
• A meal/dinner plate should have half vegetables/fruit, one-quarter protein, and one-quarter whole grains. 
• Cook whenever possible, as opposed to eating processed meals and purchasing fast foods.

Stress

• Change and disrupt sleep patterns. 
• Cause tooth-grinding, which can affect the temporomandibular joint.
• Lead to feelings of self-consciousness and subsequent self-isolation. 
• Increase muscular tension in the trapezius muscles, causing neck or lower back pain.
• Affect breathing, thereby decreasing oxygen to muscles. 
• Release hormones that increase inflammation in the body. 
• Lead to injury due to distractions caused by a trigger.

• Tell me about stressors in your life?
• Have you experienced stress recently? Physically? Socially? Emotionally?
• Have you had any recent changes in your life? Tell me more?
• How does stress affect you?
• How often do you experience stress?
• How do you handle this stress?
• Tell me about the coping strategies you use?

• Engaging in regular physical activity.
• Spending time with family and friends.
• Practicing relaxation techniques such as yoga, deep breathing exercises, and tai chi.
• Taking time for oneself and personal interests.
• Getting adequate sleep (usually 7–9 hours). (Wang et al., 2022).    

Activity: Check Your Understanding

References

The client has been diagnosed with strained lower back muscles and inflammation along the L4-5. The client is being discharged and requires health teaching. Identify which health teaching strategies are required by dragging and dropping each strategy in the Indicated or Not Indicated columns.