This is a proposed "grading system" for soft tissue tenderness.
It is also a method for documenting patient responses to
"provocative" tests, such as orthopaedic tests or the
McKenzie analysis. References for the primary articles from
which they are derived are noted after each section.
We have all heard it before...document, document, document. This
proposed system of documentation is effective for clarifying what
we observe. It is also "prescriptive" in nature. When you
observe that extension at the lumbar spine reduces leg pain and
centralizes the patient's pain to the low back, this may drive
your future care plan.
This material derives in part from the class notes of the LACC
Rehabilitation Diplomate Program. Thanks to the course director
Craig Liebenson, D.C. and to Steve Yeomans, D.C.
1. SOFT TISSUE TENDERNESS GRADING SCHEME
0 No tenderness
I Tenderness to palpation WITHOUT grimace or flinch
II Tenderness WITH grimace &/or flinch to palpation
III Tenderness with WITHDRAWAL (+ "Jump Sign")
IV Withdrawal (+ "Jump Sign") to non–noxious stimuli
(ie. superficial palpation, pin prick, gentle
Hubbard, D.R., & Berkoff, G.M. "Myofascial trigger points show spontaneous needle EMG activity"
Spine 1993; 18: 1803–1807
2. PROVOCATIVE TEST GRADING SCHEME:
A. LOCATION of the provoked pain
B. TYPE and INTENSITY of provoked pain
(ie. "sharp pain 4/10 = a 4 out of a 1–10 scale)
1 = no pain and 10 = worst pain possible
SP = Sharp pain
DP = Dull pain
3. PAIN RESPONSE uses this scale:
+1 = the pain WORSENS with movement &/or
0 = NO CHANGE in pain
–1 = the pain REDUCES &/or CENTRALIZED
NOTE: Disc pain often centralizes with
peripheralizes with flexion, so this is a simple way to make note
of the patient response during testing.
McKenzie, R.A. The Lumbar Spine: Mechanical Diagnosis and Therapy
Waikanae, New Zealand; Spinal Publications Ltd.; 1989
Erhardt, R.E., Delitto, A., Cibulka, M.T. "Relative effectiveness of an extension program and a combined program of
manipulation and flexion and extension exercises in patients with acute low back syndrome"
Phys Ther 1994; 74: 1093–1100
Donaldson, R., Silva, G., Murphy, K. "Centralization phenomenon: It's usefulness in evaluating and treating referred
Spine 1990; 15: 211–213
Donaldson, R., Grant, W., Kamps, C., et al. "Pain response to sagittal end–range spinal motion: A prospective, randomized, multicentered trial"
Spine 1991; 16(suppl): S206–S212
4. ESTIMATED POINT OF PAIN ONSET
= at what point of the
test's range of motion did the pain provocation occur. (ie. the
first 20% of movement, or at 25 degrees)
The Formula = L. SI, SP, 5/10, +1, L gluts/post thigh, 25
degrees..... translates into:
Sharp pain of a 5/10 severity occurred at the left SI joint,
radiating into the left gluteal and posterior thigh region with a
straight leg raise (SLR) of 25 degrees.
The importance of this grading becomes apparent when a 3rd
party payor reviews the file, seeking information demonstrating
that improvement over time is occurring, or when a fellow
practitioner who may be resuming care of the patient reviews your
file, or if the file is being reviewed for medicolegal reasons or
for a malpractice suit.
Return to the REHABILITATION DIPLOMATE Section