Over the past couple of posts I’ve described one way to assess a person’s chronic pain presentation from a medical, psychosocial and functional perspective. I don’t think there is much difficulty in seeing how these three perspectives can help us develop a biopsychosocial explanation, or formulation, for why this person is presenting in this way at this time – and that’s what assessment is about, when it comes to chronic pain.
A quick note on why explanations or formulations are useful when working in chronic pain. Acute pain is, as most people know, usually directly related to some sort of tissue damage, potential or actual. The usual rule for helping someone with acute pain is to diagnose the underlying cause of the pain, remediate that causal factor, and behold! the pain goes. And yes, it’s also helpful to attend to the biopsychosocial aspects of that experience, but there is probably more emphasis on the biomedical or biophysical aspects than on others. In chronic pain it’s rarely that easy. We have multiple systems involved, intrapersonally and interpersonally, and the ways those systems interact influence the experience the person has of their pain – and contributes to their disability, or functional limitations. Giving a person a ‘diagnosis’ only gives them a label, it doesn’t explain their unique presentation. A diagnosis may give us a hypothesis about what is influencing their pain from a biophysical point of view, but it doesn’t provide any clues as to why the person has the experience he or she has. And unfortunately, simply abolishing the pain doesn’t inevitably ameliorate all the other aspects of the painful experience such as memories of the experience, expectations for the next time it occurs, attitudes towards having pain like this. Sadly, for many people, having a diagnosis only means ‘I can give you a name for this pain, but I can’t do anything about it’ – consider fibromyalgia for an example.
So, if we have information from a biomedical, psychosocial and functional perspective, how do we pull all of this together?
From the outset, I think it’s vital to remember that no single dimension has all the answers, and for this reason alone I think we need to work as an interdisciplinary team – that is, one that values the contributions from all members of the team equally. No hierarchy please! For about 19 years now, the team I work with has used the same format for reporting on the patient’s presentation. This ‘order of service’ was based on small group decision-making research, showing that within a group, those members who are thought to have greatest authority often dominate discussion, with other members who have important information that is not known by all, being rather less confident about sharing it. Team discussion can turn into sharing of already shared information rather than exploring new information that may be relevant. So, this is our order:
- Psychometric results – the questionnaire results are shared first, because these are the patient’s own responses. Usually these results are available before assessments start, and can indicate areas for further exploration (such as mood, avoidance, catastrophising). They’re also shared first because they remind the team of the areas that may be important but not always recognised during team feedback. Because they refer to norms derived from our population of patients, they help us to anchor our observations in a common ‘severity’ scale.
- Biomedical assessment – this is where the medical person shares his or her examination and diagnostic work-up. If there is a diagnosis to be had, even if it is as unhelpful as ‘post-surgical neuropathic pain’, it can help guide some of the decision-making by the team. Biomedical management options are often discussed at this point. Usually this means stopping or starting medications, but can also mean trying some procedures such as nerve blocks. A feature of the medical feedback can be in identifying the number of previously tried treatments! The biomedical examination usually includes some ROM, strength testing, and sensation testing, which can then be compared with the functional assessment.
- Functional assessment – key points from this part of the assessment are shared. This can include comparing the physical testing carried out by the medical with that elicited by the functional assessor, which can help to identify changes during the assessment process. While consistency between assessments isn’t a certain indicator of sincerity, variability is often an opportunity to ask ‘I wonder why’ questions about why the person might give different responses in different contexts. (It’s totally unhelpful to ask whether the person is being fraudulent because, as far as I’ve ever been able to identify, none of us possess an infallible lie detector. It’s also therapeutically unhelpful. It’s far more useful to try to understand why the person might demonstrate different behaviour. ) Other aspects that are shared are the person’s daily routine, activity level and activity profile, approach to activities (planned? rushed? avoidant?), and to establish baseline performances for comparison after treatment. I need to add here that we’re not trying to identify causal factors for the pain from a musculoskeletal physiotherapy point of view – most of the people we see have had pain for 2 – 5 years or more, so ‘hands-on’ treatment has been tried multiple times and the purpose of this assessment is to establish the functional effects of pain, and the person’s approach to movement.
- Psychosocial assessment – similarly to the functional assessment, this is not usually the time when DSM iv diagnoses are identified, although it’s important to recognise low mood, health anxiety, pain anxiety and poor sleep at the very least. It’s much more important to identify pain-specific attitudes and beliefs, to understand what the person has learned from encounters with health care providers, to explore the factors reinforcing disability or impeding recovery – and these are the factors that are shared in this part of the team feedback.
Then the team starts to discuss what appears to be the most important elements that have lead this person to present in this way at this time. The discussion starts to assemble the various contributing factors to develop a series of hypotheses that together will explain the presentation – and then guide intervention. More on this tomorrow!