Soft Tissue Grading Format

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

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.

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1.    SOFT TISSUE TENDERNESS GRADING SCHEME

     GRADE       DEFINITION
       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
                  percussion)

Hubbard, D.R., & Berkoff, G.M. "Myofascial trigger points show spontaneous needle EMG activity"
Spine 1993; 18: 1803–1807

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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

Modifiers
SP = Sharp pain
DP = Dull pain

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3.    PAIN RESPONSE uses this scale:

+1 = the pain WORSENS with movement &/or PERIPHERALIZATION occurs
  0 = NO CHANGE in pain
–1 = the pain REDUCES &/or CENTRALIZED

NOTE:    Disc pain often centralizes with extension and 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 pain"
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

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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.

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