FACULTY OF HEALTH, PSYCHOLOGY AND SOCIAL CARE
DEPARTMENT OF PHYSIOTHERAPY
M.Sc. PHYSIOTHERAPY
MANAGEMENT OF CHRONIC MUSCULOSKELETAL PAIN ESSAY
I.D: 11501941
Total word count: 2712
Total pages: 12
The following essay will firstly, consider the assessment of chronic musculoskeletal pain, then it will intent to look at different evaluation strategies that will lead to a treatment intervention and will suggest that a biopsychosocial approach to management of chronic musculoskeletal pain has been very beneficial.
Chronic pain is defined as the pain which is relentless, either constant or periodic and the pain which negatively affects patients well being, level of function and quality of life due to prolong intensity and duration (Institute for Clinical System Improvement, 2011). The pain which is constant or intermittent and has persisted for more than 3 months is labeled as chronic pain (Smith et al., 2001). Epidemiology shows that the prevalence of chronic pain in the general population ranges from 7% to 55% (Andersson et al., 1993). The persistent pain in the bones, soft tissues and different joints of the body due to musculoskeletal disorder, injury or unknown cause is termed as chronic musculoskeletal pain (Jordon et al., 2010). Pain encompasses many clinical conditions; they are often classified by their site of injury for example (Back, head) and according to the type of injury example neuropathic, arthritic (Apkarian et al., 2009). Chronic musculoskeletal pain is a common problem in the community which affects general health, psychosocial status and economic wellbeing (Salaffi et al., 2004).
Why do you need to assess chronic pain? The assessment of chronic pain is required as it determines the cause of pain, what effect this pain has on the quality of life of the patient, assessment allows proper documentation and gives important insight on the treatment intervention which would be effective (Taylor, 2010). What do patients really want? The answer to this question is a dilemma but they do want a certification of their disorder and patients want to play an active part in the decision of the management plan (Yelland, 2011).
Pain experienced by the patient is a subjective phenomenon and measurement of pain is dependent on verbal feedback (Farrar et al., 2000). Rehabilitation will be decided by an accurate assessment of pain intensity and there is no objective marker for measuring pain and thus measurement of pain is clinically challenging (Salaffi et al., 2004). Reduction of pain, disability and psychological stress are the main aim of treatment management and to achieve this reliable outcome measure for assessment are needed (Koho et al., 2001). Pain is a multi factorial phenomenon and there is no single outcome measure or assessment tool that captures all important aspects of pain (Turk, 2002). Pain assessment requires a multidimensional approach which leads to the development of an accurate treatment plan for an individual patient (Clark et al., 2010). Pain management requires a multidisciplinary team consisting of a Physician, physiotherapist, occupational therapist, nurse and psychologist and in metropolitan cities anesthetist, neurologist and orthopedic surgeons are also actively involved in the team (Meyer, 2007). Pain is a biopsychosocial disorder; hence it requires careful assessment of three dimensions which are: biological, psychological and social (Disorbio et al., 2006). The Biopsychosocial assessment focuses on the person as a whole rather than the painful part (Zoppi and Beneforti, 2003). The Biomedical assessment: this includes pain related to structure or anatomical source, the intensity and severity, biomechanical problem and the etiological and pathological process. Psychological assessment: the assessment of pain related to thoughts or cognition, feelings or emotion and behavior or attitude . The social aspect consists of assessment of pain related to the work related stress, family, social life and financial issues (Disorbio et al., 2006; Smart and Doddy, 2007).
Biomedical aspect:
Chronic pain requires a complete documentation of patient’s pain history, physical examination including subjective as well as objective evaluation and specific diagnostic tests or scales (Breivik et al., 2008). General history and pain history is important as it tends to reveal related co morbidities, specific location of pain, the pain descriptors and possible pathology and etiology. Pain assessment contains documentation of pain location, the onset and nature and the aggravating and relieving factors (Institute for clinical system improvement, 2011). Six main factors are essential during a general pain evaluation these are, location: where the present pain is, description: what is the pain like for example burning, shooting it gives an indication of the cause of pain, duration: how long has the pain lasted, intensity: how much is the pain, influencing factors: the easing and worsening activities and previous treatment: was the treatment effective in the past. An accurate pain assessment is mandatory or else pain won’t be relieved effectively and usefulness of different treatment modalities cannot be quantified (Mackintosh, 2005).
Physical examination is essential it involves a general physical examination, neurological examination in its assessment of myotomes, dermatomes and reflexes, a detailed musculoskeletal examination involving range of motion, posture, gait and power (Breivik et al, 2008). Isokinetic (that is with constant velocity) and isoinertial (that is with constant resistant) testing can be performed to measure the strength, endurance, power and coordination (Zoppi and Beneforti, 2003). The validity and reliability of these machines are questionable as the calibration and normative values in chronic pain patients differ from that of the normal population (Zoppi and Beneforti, 2003). A physiotherapist plays a key role in facilitating functional activity in chronic pain patients, the therapeutic intervention include, exercise regimes which have self management strategies and also a home exercise program, joint mobilization and modalities are used effectively to promote physical function (Zoppi and Beneforti, 2003).
The intensity of pain is assessed by widely used visual analogue scale (VAS), numerical rating scale (NRS) and also a four point verbal rating scale (VRS) (Breivik et al., 2008). The VAS is a unidimensional scale used almost in all pain management clinics, it has a description of the extremes of pain intensity that is “no pain” and “worst pain”, the scale has quite good validity and reliability (Gagliese and Melzack, 1997). The NRS is similar to the VAS having similar end points that is no pain and worst pain but the only difference is the numerical scale in between from 0 to 10 thus making it an 11 point scale, the patient translates intensity of pain into a numerical value (Conn, 2005). The VAS, NRS and VRS were compared in a computerized simulation study in which sampling was randomly done 10,000 times and the results showed that NRS and VAS have equal sensitivity and both of them general give the same results for chronic pain (Breivik et al., 2000). In comparison between the outcome measures for assessment of intensity of pain the NRS and VRS were preferred by both physician and the patient over VAS (Breivik et al., 2000). The numerical rating scale is chosen by chronic pain patients because of the ease of understanding in contrast the VAS is widely accepted but the elderly and patient with cognitive impairment have complexity in understanding the scale (Hawker et al., 2011). In a clinical trial NRS was appreciated more, by the less educated over the VAS (Salaffi et al., 2004). The scales for measuring intensity of the pain give a baseline record of the pain as well as the actual presence of pain hence they are of prognostic and diagnostic value in the treatment intervention and they can be used as important criteria for defining the efficacy of different physiotherapeutic treatments (Salaffi et al., 2004). Scales represent only a single dimension of pain while a questionnaire encompasses different or many aspects of pain (Clark et al., 2010). The McGill pain questionnaire is a multidimensional measure which assesses the affective, sensory, temporal and the quality of pain (Clark et al., 2010). The patient rates the intensity of each descriptor on a scale of 0 to 3 (Breivik et al., 2008). The questionnaire is valid and reliable the main drawback is the complex use of vocabulary for description of pain (Hawker et al., 2011). The brief pain inventory helps in the assessment of the severity of the pain and to what extent it interferes with function, the questionnaire can be administered as a clinical interview. Pain severity and intensity is measured over last 24hours and it also includes important aspects like walking, mood, sleep etc. BPI is widely used to rate the relief of pain during the ongoing treatment (Breivik et al., 2008).
Impairment is any loss of function, anatomical, physiological or psychological and disability is a hindrance in one’s ability to perform any ability (Zoppi and Beneforti, 2003). The Roland and Morris disability questionnaire are a self report form of assessment which is universally used to measure disability caused due to persistent low back pain, this questionnaire has 24 items ranging from 0 that is no disability caused due to pain to 24 that is worst or extreme disability caused due to the pain. The questionnaire has shown to be sensitive to change after treatment along with being extremely valid and reliable especially for chronic low back pain patients (Sharp and Nicolas, 2000). The Oswestry low back pain disability index is a questionnaire that assesses the impact of pain on the activities of daily life and the disabilities related to it, this questionnaire was found to be highly valid and reliable (Frost et al., 1998). Both the questionnaire are devised to assess disability caused due to low back pain, hence they are disease specific assessment tools and they do not consider the other clinical conditions.
A physiotherapist should be familiar with both the red and the yellow flags as they require a detailed assessment which leads to a prompt treatment (Walsh et al., 2008). The notion of red flag which indicates a serious pathology has been extended to comprehending the idea of yellow flag which denotes psychosocial barrier to improvement (Kendall, 1999). The red flags such as widespread neurodeficit, lower limb weakness, drug abuse, HIV, age more than 55 or less than 20, weight loss and previous history of cancer should be considered during assessment and management as they might be a linked to a serious pathology (Ferguson et al., 2010). The yellow flag has been identified as a potential barrier to recovery they are, belief that the pain is harmful and disabling, depression, reduced activity, fear and avoidance and occupational factors like dissatisfaction with working condition or job as a whole (Searle and Bennett, 2007). Screening of the yellow flags is required as they are good markers for a detailed assessment before deciding a treatment regime.
Along with good clinical knowledge and hands on skills a physiotherapist needs to have an effective communication, which are needed during the evaluation, he should be willing to listen to the patients issues as completely as possible, ask those questions which are concerning to the patients pain, in the united kingdom the GP consultation last for approximately 10 minutes which is the reason for dissatisfaction among patients as they think enough information wasn’t imparted to the doctor (Vincent and Coulter, 2002). A good physiotherapist should always react with empathy to patient’s feelings and worries. Important communication skills needed during assessment are: use of language that the patient understands, taking appropriate time for communication and a display of optimism (Farin et al., 2011). Effective communication can be beneficial as the patients can actively take part in planning the treatment and potential risks of the therapy should be explained by the therapist to the patient (Walsh et al., 2008).
A Pain diary is an important method of self assessment, it allows the patient to actively contribute during the course of the treatment and give realistic insights of pain perception (Gaertner et al., 2004) the drawback of pain diary is that the patient tend to exaggerate their pain and a fabricated information is given which indirectly has an effect on the treatment.
In the authors experience diagnosing and treating chronic pain patients is a challenge, the author remembers a patient with chronic low back pain for more than 3 years telling him “ just imagine waking up early morning with the same unrelenting pain.” the writer feels that the pain becomes a disease in chronic conditions rather than a mere symptom. In the authors clinical experience the assessment of chronic musculoskeletal conditions like Fibromyalgia, Rheumatoid Arthritis, chronic neck pain and back pain is done by a general history taking , physical examination involving testing of range of motion by goniometer, muscle strength by manual muscle testing , posture by plumb line and pain assessment was done by visual analogue scale, but the social and psychological assessment was lacking hence the treatment revolved around pain reduction by therapeutic exercises and physical modalities.
Psychological aspect:
Fear of pain can be assessed by a 40 item questionnaire called pain anxiety symptom scale (PASS) it measures anxiety , cognition , fear of pain and depression , this scale has shown to have good validity, internal consistency and temporal stability (McCracken and Eccleston, 2003). The fear avoidance belief questionnaire is a multidimensional outcome measure designed to quantify pain associated with the patient’s belief of physical functioning and how the pain affects patients work (Fritz et al., 2001). Fear of movement is evaluated by the Tampa scale of kinesiophobia (TSK) which is a 17 item questionnaire it measures the fear of pain and injury due to movement, the scale is found to be sufficiently valid and reliable (Vlaeyen and Linton, 2000). Catastrophizing is a term which denotes increased negative orientation to painful stimuli; usually it is a precursor to fear of pain (Vlaeyen and Linton, 2000). Coping strategy questionnaire is used to assess catastrophizing, the questionnaire is a 42 item measure that evaluates six strategies they are distracting, reinterpreting and avoiding pain sensation, hoping, praying and coping with self statement, CSQ shows good internal consistency and validity (McCracken and Eccleston, 2003). If psychological factors are noted during assessment then the patient must be referred to a specialist psychology practitioner, as physiotherapist have less experience or training in psychology management (Watson, 1999). The Physiotherapist can be actively involved in treating psychological factors by relaxation, diaphragmatic breathing and education of coping strategies (Harding and Watson, 2000). Recent trends show that physiotherapist and mental health professionals are building a work relationship for management of chronic pain patients (Watson, 1999).
Social aspect:
Chronic pain has a pessimistic impact on the patients physical functioning, the patients have noted be having pain in normal activities like walking, sitting and bending and strenuous activities like lifting is avoided by the patient (Turk et al., 2008). The family life of the patient has been majorly affected by chronic pain; it has a profound effect on the spousal relationship and the relationship with the children (Turk et al., 2008). Recreational activities like sports and social gatherings with family and peer group are affected too due to chronic pain, as the patient has a constant fear that the pain will arise if he does any activity for a longer duration. The patient is generally very stressed about his condition; they are worried about employment, relationship, sleep and the feeling that the emotional wellbeing is distorted (Turk et al., 2008).
The social factors can be assessed by Short form SF- 36 which is a health related quality of life questionnaire , the validity and reliability of SF – 36 is well verified (Breivik et al., 2008). The SF-36 gives vital information regarding physical, emotional and bodily functions (Zoppi and Beneforti, 2003). The SF-36 questionnaire was found to be highly sensitive to change after therapeutic intervention in chronic musculoskeletal conditions but the drawback was in imprecise writing instruction and unclear pain descriptors (Hawker et al., 2011). The multidimensional pain inventory scale is used to evaluate the dysfunction at work, activities of daily living, social and recreational activities (Turk et al., 2008). The social assessment will only give an indication of barrier to recovery or treatment; it would not suggest a specific physiotherapy treatment (Watson, 1999). According to Nicolas (2004) a multidisciplinary approach is required which involves patient education, goal setting for return to work, recreational activities, reassurance and counseling.
In conclusion from the above mentioned hypothesis, chronic musculoskeletal pain is a multifactorial problem, therefore suitable assessment is the prerequisite to formulate a treatment program, a physiotherapist role has drastically changed from a healer to a helper, and hence a positive outcome can be expected in a patient with chronic musculoskeletal pain when a holistic biopsychosocial approach is used for their management.
REFERNCES:
Andersson, H., Ejlertsson, G., Liden, I. and Rosenberg, C. (1993) ‘chronic pain in a geographically defined general population: studies of differences in age, gender, social class and, pain localization.’ Clinical Journal of Pain, Vol.9, pp. 174-182
Apkarian, A., Baliki, M. and Geha, P. (2009) ‘Towards a theory of chronic pain.’ Progress in Neurobiology, Vol. 98, pp. 81-97
Breivik, E., Bjornsson, G., Gudmundur, A. and Skovlund, E. (2000) ‘A comparison of pain rating scales by sampling from clnical trial data.’ The clinical Journal of Pain, Vol. 16, no. 1, pp. 22-28
Breivik, H., Borchgrevink, P., Allens, S., Rosseland, A., Romundstad, L., Balivikhal, E., Kvarstein, G. and Stunbhaugh, A. (2008) ‘Assessment of pain.’ British Journal of Anesthesia, Vol. 101, no. 1, pp. 17-24
Clark, W., Chokhavatia, S., Kashani, A. and Clark, S. (2009) ‘pain measurement.’ In Argoff, C. and McCleane, G. Pain Management Secrets 3rd ed,. Philadelphia: Mosby, pp. 42-52
Conn, D. (2005) ‘Assessment of acute and chronic pain.’ Anesthesia and Intensive Care Medicine, Vol. 6, no. 1, pp. 14-15
Disorbio, J., Bruns, D. and Barolat, G. (2006) ‘Assessment and treatment of chronic pain: A physicians guide to a Biopsychosocial approach.’ Practical Pain Management, pp. 1-10
Farin, E., Gramm, L. and Kosiol, D. (2011) ‘Development of a questionnaire to assess communication preferences of patients with chronic illness.’ Patient Education and Counseling, Vol. 82, pp. 81-88
Farrar, J., Portenoy, R., Berlin, J., Kinman, J. and Strom, B. (2000) ‘Defining the clinically important difference in pain outcome measures.’ Pain, Vol. 88, pp. 287-294
Ferguson, F., Holdworth, L. and Ratferly, D. (2010) ‘Low back pain and Physiotherapy use of red flags: The evidence from Scotland.’ Physiotherapy, Vol. 96, pp. 282-288
Fritz, J., George, S. and Delitto, A. (2001) ‘The role of fear avoidance belief in acute low back pain: Relationship with current and future disability and work status.’ Pain, Vol. 94, pp. 7-15
Frost, H., Lamb, S., Moffett, k., Fairbanks, J. and Moser, J. (1998) ‘A fitness programme for the patients chronic low back pain: 2 year follow up of a randomized control trial.’ Pain, Vol. 75, pp. 273-279
Gaertner, J., Elsher, F., Pollmann, K., Radbruch, L and Sabasuska, R. (2009) ‘Electronic pain diary: A randomized cross over study.’ Journal of pain and symptom management, Vol. 28, no. 3, pp. 259-267
Gagliese, L. and melzack, R. (1995) ‘Chronic pain in elderly.’ Vol. 17, pp. 3-14
Harding, V. and Watson, P. (2000) ‘Increasing activity and improving function in chronic pain management.’ Physiotherapy, Vol. 86, no. 12, pp. 619-630
Hawker, G., Mian, S., Kendzerska, T. and French, M. (2001) ‘Measures of adult pain.’ Arthritis care and Research, Vol. 63, no. s11, pp. s240-s252
Institute for Clinical System Improvement (2011). ‘Health care guideline: Assessment and Management of Chronic pain.’ [Online][Accessed on 8th May], http://www.icsi.org/pain__chronic__assessment_and_management_of_14399/pain__chronic__assessment_and_management_of__guideline_.html
Jordan, L., Holden, A., Mason, J. and Foster, E. (2010) Intervention to improve adherence to exercise for chronic musculoskeletal pain in adults (review), The Cochrane collaboration, Vol.1, pp. 1-62
Kendall, N. (1999) ‘psychosocial approach to the prevention of chronic pain: The low back pain paradigm.’ Baillieare’s Clinical Rheumatology, Vol. 13, no. 3, pp. 545-554
Koho, P., Aho, S., Watson, P and Hurri, H. (2001) ‘Assessment of chronic pain behavior: Reliability of the method and its relationship with the perceived disability physical impairment and function.’ Journal of Rehabilitation Medicine, Vol. 33, pp. 128-132
Mackintosh, C. (2005) ‘Appraising pain.’ In Banks, C. and Mackrodt, K. Chronic Pain Management, London: Whurr publishers Ltd, pp. 92-112
McCracken, L. and Eccleston, C. (2003) Coping or acceptance: What to do about Chronic pain? Pain, Vol. 105, pp. 191-204
Meyer, P. (2007) ‘Pain management in primary care – current perspective.’ SA FAM PRACT, Vol. 49, no. 7, pp. 20 – 25
Salaffi, F., Stancati, A., Silvestri, C., Clapetti, A. and Grass,W. (2004) ‘Minimal clinical important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale.’ European journal of pain, Vol. 8, pp. 283-291
Searle, R. and Bennett, M. (2007) ‘Pain assessment’ Anesthesia and Internal Care Medicine, Vol. 9, no. 1, pp 14-15
Sharp, T. and Nicolas, M. (2000) ‘Assessing the significant others of chronic pain patients: The psychometric of significant others questionnaires.’ Pain, Vol. 75 pp. 272-279
Smark, K. and doody, C. (2007) ‘The clinical reasoning of pain by experienced musculoskeletal physiotherapist.’ Manual therapy, Vol. 12, pp. 40-49
Taylor, A. (2010) ‘Principles of: Pain assessment.’ Wound Essentials, Vol. 5, pp. 104-110
Turk, D. (2002) ‘Clinical effectiveness and the cost effectiveness of the treatment for patients with chronic pain.’ The Clinical Journal of Pain, Vol. 18, pp. 355-365
Turk, D., Dworkin, R. and Revicki, D., Handing, G., Burke, L., Cella, D., Cleeland, C., Cowan, P., Farrar, J., Hertz, S., Max, M. and Kappaport, B. (2008). ‘Identifying important outcome domains for Chronic Pain Trials: An IMMPACT survey of people with pain.’ Pain, Vol. 137, pp. 276-285
Vincent, C. and Coulter, A. (2002) ‘Patient safety: what about the patient?’ Quality Safety Health care, Vol. 11, pp. 76-80
Vlaeyen, J. and Linton, S. (2000) ‘Fear avoidance and its consequences in chronic musculoskeletal pain: A state of the art.’ Pain, Vol. 85, pp. 317-332
Walsh, N., Brook, P., Hazes, J., Walsh, R., Dreinhofer, K., Woolf, A., Akesson, K. and Lidgren, L. (2008) ‘Standards of acre for acute and chronic musculoskeletal pain: the Bone and joint decade (2000-2010).’ Arch Phys Med Rebabil, Vol. 89, pp. 1830-1845
Yelland , M. (2011) ‘What do patients really want?’ International Musculoskeletal Medicine, Vol. 33, no.1, pp. 1-2
Zoppi, M. and Benefortim, M. (2003) ‘The role of rehabilitation in chronic pain management.’ Fizyoterapi Rehabilitasyon, Vol. 14, no. 1, pp. 32-48
