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Individualising explanations with case formulation


One of the assumptions of a multidimensional model of pain, particularly chronic pain, is that somehow all the various elements get pulled together to explain why this person is presenting in this way at this time. It’s also one of the least-discussed aspects of pain management: case formulation.

Case formulation is the process of generating a set of hypotheses to explain what is going on when a person has chronic pain. It needs to reflect what is known about biological mechanisms, including comorbidities; psychological aspects such as beliefs, attitudes, expectations, pre-existing strengths and capabilities; and social and contextual aspects such as supportive relationships, availability of health services, employment and so on. It should help explain how facets of the situation have arisen, and what is maintaining them.  It should guide intervention, and identify treatment targets, and most importantly, it should help the person feel he or she is being heard and help them understand why certain approaches are taken.

What often happens, however, is that a person with pain is assessed comprehensively – and the findings are filed away, or used only as “baseline recordings”, treatment carries on using “I have a hammer, all I’ll use are nails”, and the particular concerns of the person remain untouched.  Alternatively, the assessments are discussed by the team (if there is one) and the most socially capable or dominant person holds sway, or the training orientation of one or more clinicians, or even the “programmes we deliver” guides choice – and the same recipe given out. I can recite a couple in my sleep “home exercise programme, hydrotherapy, relaxation and pain education” with OT, PT, and psychology.  The particular needs of this person at this time are not identified, and treatment is pretty generic.

We’ve come a long way in understanding that people who have chronic pain are not one big homogenous group: they are all unique although they may share some similarities. We also know that our treatments don’t fit for everyone – or at least, some of us recognise this. The vast majority of people with chronic pain do not have a tidy diagnosis, a treatable disease process with known mechanisms. This means our treatments need to target things that can be changed, and accommodate those things that can’t be changed. Herein lies the challenge of deciding whether pain intensity should be The Target, or whether helping the person move towards acceptance, function and a future focus might be more helpful.  What I know, both from experience and my research, is that while the offer of reduced pain is present, people hold onto the hope that life will return to “normal”. It’s very hard to consider a new future when the hope of things returning to normal remains.

Breaking it down, case formulation begins by identifying problem areas, then identifying factors that maintain the problem or get in the way of recovering. The person with pain must be part of this process – it’s their life we’re talking about, and because most of what we’re hoping to do involves them doing things differently we need to ensure they’re part of the process from the beginning.

There are numerous domains typically included in pain assessments: the one I’m most familiar with involves biomedical details including diagnosis, comorbidities, presence/absence of neurological deficits, history of trauma/injury/central sensitivity and current medications. Psychosocial information includes looking at the pain experience (intensity, qualities, location, pattern), beliefs, emotions, distress, self-efficacy, substance use, family relationships, social reinforcements. Functional information includes work, physical performance across a set range of activities, strength, range of movement and cardiovascular fitness.

But what is this person’s problems? What does this person identify as bothering them the most? What would they be doing if pain was less of a problem?

Beginning there, a person might point out that he just doesn’t know what his pain means, so it’s highly threatening. He’s really worried about his job because he’s been told he should avoid “heavy lifting”, and he believes this is because he has “desiccated discs” and “bone grinding on bone”, and he lies awake at night worrying that he’ll never be able to be a good Dad who plays ball with the kids. The person might also mention that his partner is really worried, and tries to stop him doing normal things around the home because she’s worried he’ll have a flare-up. She’s also inclined to fuss over him, and he feels increasingly useless because he thinks he should be caring for her, rather than her caring for him.

Untangling all of this might take time, but often by using a diagram like the one below (I’ve used this as a template for years), a team can begin to consider the mechanisms involved. This is taken from Sharp, Timothy J. (2001). Chronic pain: a reformulation of the cognitive-behavioural model. Behaviour Research and Therapy, 39(7), 787-800. doi: http://dx.doi.org/10.1016/S0005-7967(00)00061-9

formulation sharp2001So, let’s plug in some of the information we’ve got.

formulationI use questionnaires, history-taking, observation and clinical testing to gather this information – and compare this person’s scores with normative data from other people from a similar demographic. This helps identify how differently this person presents from other people I’ve seen, and guides where to prioritise intervention. Along with the person’s main priority, which in this case was sleep and work, and the “logic” from published literature developed from empirical studies, the team and the person with pain can identify where to start.

The only place I’ve found a good description and discussion of this process of clinical reasoning is from Linton & Nicholas, 2008, from a book edited by Harald Breivik, Michael Nicholas, William Campbell, Toby Newton-John, called Clinical Pain Management Second Edition: Practice and Procedures, 2008: CRC Press. It’s not available electronically, but if you can access a copy at your local medical library, this chapter alone is worth getting.

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