With such a wide array of factors influencing a person’s pain experience, it can be difficult to decide exactly what to include in a pain assessment.
We do know that the model we use to view pain will influence the factors that are included – and although the internationally accepted model of pain is a biopsychosocial one, there are any number of versions of this model that can be adopted.
Within each domain of the biopsychosocial model the research over the past few years has exploded, meaning there are more and more factors than can be considered – and these need to be organised in a systematic way so that we can make sense of them, make good clinical decisions about interventions and then work with the person who has the pain so they can understand them and contribute.
There are a couple of fundamental things we should always have as guiding principles:
- No single element in the biopsychosocial model of pain is more (or less) important than any other
- All three domains must be assessed to fully understand the ‘four p’s’ of a pain presentation:
- Predisposing factors
- Precipitating factors
- Perpetuating factors
- Protective factors
- The fundamental questions to be answered through assessment are
- ‘What brought this person to this place with this problem today?’
- ‘What can be done to reduce distress and disability?’
- Simply asking the person with pain provides some good information, but on its own is probably inadequate. Interviews need to be supplemented with:
- History – from relevant documentation (from the referrer, other health care notes, previous consultations within your facility)
- Observation – structured or unstructured observation from the moment the person enters your clinic, to the time they leave
- Clinical examination or testing – including functional performance as well as pen and paper questionnaires
- Other people – particularly partners or other family members
- Assessment only begins the process of developing a working set of hypotheses about what might be ‘true’ for this person at this time for these problems
A couple of models that can be helpful:
This one is from Robert Gatchel (Gatchel, 2004).
Another model I like is by Tim Sharp, published in 2000, which is somewhat less complicated than Gatchel’s one, but still has a whole lot of arrows! Dr Sharp now runs a successful consulting practice listed in my blogroll, worth a look!
Of course, no matter what model you use, under each ‘heading’ you will need to continue to update relevant research into specific factors to include (eg ‘appraisals’ would now routinely include catastrophising and pain-related anxiety, while ‘motor behaviours’ would include avoidance, safety behaviours, as well as task persistence). And after deciding what to include, it will be just as important to determine the best way to access the information – through questionnaire, observation, history, testing or interview.
Finally, it will be important to work out a structured way to put the information collected together so it can be readily understood and used as the basis for hypothesis testing.
I’m not sure I’ve got a handle on this part yet – but I’m keen to hear what you use, or how you think this part can be structured. I think we’ll have to draw on research from small group/teamwork literature into decision-making, and on human cognition and information processing to inform us on the best way to integrate such complex information without jumping to conclusions.
Isn’t it great the way that answering one question leads to a whole lot of new bits of research? Can ya tell how much I love questions?!
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Gatchel, R. (2004). American Psychologist, 59, 792-805
Sharp, T. (2000). Chronic pain: A reformulation of the cognitive-behavioural model. Behaviour Research and Therapy, 39, 787–800