What makes up a comprehensive pain assessment? I could begin and never end this particular topic, I know, so I’ll try to confine myself to some of the major themes as I see it. While this is my opinion, and readers should always remember this, there are some very good researchers and clinicians who hold this view as well – and I’ll cite one or two at least!
The first aspect to determine in any assessment is its purpose. I’ll explore this much further in future posts – the process I’ll describe is to guide initial case formulation and broad direction for pain management. That is, it’s to identify any medical strategies required, to ascertain the basic coping ability (and thus the need for self management), and finally, to gauge the general functional impact of pain, that is, the disability level. It’s not detailed enough for a comprehensive formulation because this takes time and trust, but it does provide a broad brush guide.
Most people with chronic pain are referred to an interdisciplinary, specialist center after many years. I’ve previously estimated that people are referred to the place I work on average about two to five years after the onset of their pain. This means that, in most cases, people have seen at least two or more medical specialists, many other health professionals such as physiotherapists – and may have had about two or three different diagnoses. They’re often confused, and I find it incredible that many haven’t yet had an explanation that they can recall, or perhaps that they can understand.
For this reason, a comprehensive pain assessment needs to include a medical examination and review of past investigations and treatments. The medical assessment often focuses on identifying whether there is pathology that can be addressed through medical means, ensures that any investigations that may have been omitted are completed, and arrives at a diagnosis. The diagnosis may be unsatisfactory because it may simply be ‘non-specific chronic low back pain’ (although one medical practitioner wrote recently saying “If we accept that lumbar sprain is a rather nebulous concept, then ‘chronic non-specific low back pain’ is an even more meaningless and useless diagnostic label. It says absolutely nothing apart from ‘I cannot understand this pain so here is my label'”. Erm, so far I’m not sure we have the technology to diagnose many of the pains we see on a daily basis.) Unfortunately, at this stage of our diagnostic development, we can’t always identify anything more than the fact pain is now the problem – and in chronic pain, pain is now the primary problem.
A further contribution made by the medical assessment is to rationalise medications. Very often people have been prescribed an enormous range of medications, often not necessarily reviewed again to establish the effectiveness of the prescription, and they can end up with this concoction of pills that they’re not entirely sure about, and don’t take in a very systematic fashion.
The second aspect of a pain assessment is to review the person’s thoughts about their pain, and the impact of their pain on their life. I call this the ‘psychosocial’ part of the assessment, and in our Center at least, it’s carried out by occupational therapists, nurses, social worker and clinical psychologists. I am personally wary of the current tendency in New Zealand to call this assessment ‘psychological’ and confine it to psychologists only, because while people with chronic pain are often demoralised, may have low mood and can be worried about their pain, after working in the area for nearly 20 years, I don’t see all that many with frank psychopathology. It also fails to recognise or acknowledge the technical skills and professionalism of other clinicians which I find somewhat disturbing.
There is also a very strong possibility that by conducting a ‘psychological’ assessment, the incredibly important social aspects of having pain can fail to be assessed – or this aspect can be given less emphasis than it deserves.
The purpose of the psychosocial assessment is to identify factors that influence the person’s experience of their pain, and to start to explore factors that may be influencing pain behaviour. Possibly the simplest way to remember the basic psychosocial factors is to use the mnemonic ‘A B C D E F and W’. These stand for:
Attitudes and beliefs – things like catastrophising, believing that hurt = harm, the ‘You treat me’ attitude (passive), or the belief that all the pain must be gone before life (and returning to work) can resume.
Behaviours – identifying not only pain behaviours (more on this in the functional assessment) but more importantly, the factors that reinforce pain behaviour and limit the return to functional activity. The behaviours we need to be concerned about are those that interfere with engaging in normal activities – this means identifying how the person manages flare-ups, how the person uses medication, the use of aids and appliances, alcohol and other drug use, and seeking medical treatment and engaging with social agencies.
Compensation issues – simply engaging with a compensation system can be problematic (try the paperwork for starters!), but if there are problems or delays in determining cover, if case management is poor (perhaps it’s difficult to get hold of the case manager, or the case manager doesn’t maintain effective communication) then return to function can be delayed, and if a legal representative or advocate is involved along with litigation, recovery can be delayed.
Diagnostic issues (and other iatrogenic influences) – it’s really important to understand how and why the person has sought treatment, and what they’ve learned from each encounter with health providers, what kind of prognosis has the person been given, have the messages from providers been consistent and have they been encouraged to start doing things – or have they been offered a ‘techno-fix’. Friends and colleagues: this is where we need to assess what we do and the influence we have on maintaining disability.
Emotions – exploring mood/affect, response to the daily grind of having pain as well as the response to flare-ups, exploring anger and frustration, anxiety and fear, and looking at how past emotional health may influence current coping, looking at distress. I read a report yesterday where the person said their pain was “50/10” and reduced to “30/10”. What does this kind of language tell you about distress and a feeling of being out of control?
Family and friends – how do the people around this person respond to pain, how do they know the person is experiencing pain? What changes have there been in terms of role responsibilities and how has this affected relationships and communication dynamics in those relationships. It’s worth considering past family history of pain and disability and how this may have influenced the behavioural repertoire of the person. Colleagues are often the people who interact with the person with pain, so it’s important to discuss their attitudes and behaviours too.
Work – finally, work factors that promote disability or reduce the potential for recovery – things like an employer who doesn’t allow suitably selected duties, or lacks the skill to be able to provide these duties, the person’s satisfaction with their job, their stress levels in the job, and don’t forget the physical demands of the work.
What we’re exploring under each of these headings are the factors known to promote or support disability and distress.
The final component of a comprehensive pain assessment is functional assessment. This is probably the only area that currently lacks a really good literature. I’ve been unable to identify physical performance testing that provides reliable and valid assessment of the functional effects of pain on individuals, and that is able to be tested and retested to provide good outcome measures. Now I know as soon as I write this someone somewhere will say ‘yes but what about …?’ and a bunch of commercial testing procedures or equipment will come out of the woodwork – but I’m not convinced that things that simulate work activity provide any better estimation of function than simply observing the person in the real workplace. So, let’s put that aside for a moment and consider the reason for conducting functional assessments.
To me a functional assessment provides one of the best opportunities to observe pain behaviour. To challenge and therefore elicit the person’s beliefs about their ability to cope with pain. Many of the people I see are deactivated – that is, they don’t do normal activity, and their overall activity level is quite low.
Some of the research looking at daily activity has identified that while people with chronic pain may have the same level of activity as people without chronic pain, the profile of that activity pattern is quite different. People with chronic pain can demonstrate a ‘saw-tooth’ pattern – that is, they do something, then stop for a bit, do something more, then stop for a bit. The stopping can be associated with the onset of pain, or it can actually be an inappropriate way of avoiding flare-up. Some people call this ‘pacing’, but pacing (a word I don’t like anyway!) is not well-defined. This particular pattern can often lead to gradually deteriorating activity levels, and because the driver for it is to avoid a painful flare-up, it can actually reinforce pain avoidance.
Back to functional assessments. I’ll write more about this tomorrow, and also more about the way in which this type of comprehensive pain assessment can all be put together. I’ll also give some references because, believe it or not, I’m not pulling this stuff out of my head!