Ideally, patients with pain-related disability resulting from chronic pain are treated by a team of health professionals, commonly consisting of physicians, psychologists, physical and occupational therapists, social workers and nurses, to address the biopsychosocial nature of pain. Within the interdisciplinary team, the physical therapist is responsible for a comprehensive assessment with emphasis on the musculoskeletal system, including assessment of impairments, limitations in activities, restrictions in participation, environmental and personal factors that may influence physical functioning, as well as the management of the physical rehabilitation process. Physical therapists are thus intimately involved in pain management and, where possible, pain treatment.
Patients come to our clinics with certain expectations of evaluation and treatment. One study investigated the expectations of patients with chronic pain of their first outpatient visit to a pain management program. In that study, most patients expected an explanation or an improved understanding of their pain problem. The most common satisfying outcome was relief or control of pain and the most common disappointing outcome was being told nothing could be done. The majority of patients expected further medical investigations and changes to the prescribed medication. There was no mention of patients expecting a referral for pain management, and only a small percentage of patients wanted advice on coping with pain, or self-management of pain. Although this study needs to be duplicated in other centers, it has a great deal of face validity. Many patients with chronic pain resist referral to physical rehabilitation. Part of the difficulty lies in the history of treatment failures with which patients often present. A number of factors may be responsible for past treatment failures, including persistent failure of physical therapists to recognize and treat the differences between acute and chronic pain states, past treatment that did not address the emotional and cognitive aspects of chronic pain, and an inability of the patient to recognize anything less than total pain relief as success. It is therefore important to identify patient expectations at the initial visit to prevent disappointment with referrals to physical rehabilitation for pain management.
Physical Therapy Evaluation
In evidence-based practice, clinical decisions must include consideration of, first, the patient’s clinical and physical circumstances to establish what is “wrong” and what treatment options are available to address this problem. Second, the latter need to be tempered by research evidence concerning the efficacy, effectiveness, and efficiency of the treatment options. Third, given the likely consequences associated with each option, the clinician must consider the patient’s preferences and likely actions (in terms of what interventions she or he is ready and able to accept). Clinical expertise is needed to bring these considerations together and recommend a treatment that the patient agrees to accept. Accordingly, the purposes of a physical therapy evaluation are to establish a baseline from which to plan and begin interventions, assist in the selection of appropriate interventions, and evaluate the efficacy of interventions.
As described in the biopsychosocial model of pain introduced by Fordyce, contributing factors to disability can be biologic, psychological, as well as social. Essential in this model is the idea that factors maintaining the pain problem are not necessarily the same as those initiating pain. To establish a baseline, therefore, a thorough inventory of all factors contributing to a patient’s perceived level of disability is important. The International Classification of Functioning, Disability and Health (ICF) provides a biopsychosocial model that identifies three concepts described from the perspective of body systems, the individual, and society. Within the context of health, the ICF defined bodily functions and structures as physiologic functions of body systems or anatomic elements, such as organs, limbs, and their components. Activity is defined as the execution of specific tasks or actions by an individual, whereas participation is envisioned as encompassing involvement in a life situation. In the ICF, functioning refers to all body functions, activities, and participation. Disability is the ICF umbrella term for impairment, activity limitation, and participation restrictions. Contextual factors are provided within the ICF framework ( Fig. 47.1 ), consisting of external environmental factors (such as significant others, employers, medications, and health care providers) and personal factors (such as age, education, income, worry that activity will exacerbate pain or injury resulting in avoidance of activity to prevent anticipated negative consequences).
Qualifiers for the Activities and Participation classification make it possible to clearly separate the patient’s inherent capacity to perform actions within a domain and performance in his or her actual environmental context. Capacity refers to the environmentally adjusted inherent ability of the individual or, in other words, the highest probable functioning of a person in a given domain at a given point in time, in a standardized environment. Capacity can be measured by physical tests or by questionnaires that ask, “Can you?” Performance describes what a person actually does in her or his current environment and thus describes the person’s functioning as observed or reported in the person’s real-life environment with the existing facilitators and barriers. Performance can be measured by direct observation. As this is often highly impractical, self-report measures can be substituted that ask, “Do you?”
The Rehabilitation Problem Solving (RPS) form is based on the ICF and is a practical tool to use to visualize the patient’s state of functioning and disability. The form is used to specify precise and relevant target problems, discern factors that cause or contribute to these problems, and plan the most appropriate intervention. In addition, the form was designed as a tool to facilitate both intra- and interprofessional communications and improve the communication between health care professionals and their patients. The form is divided into three parts: (1) the header provides basic information, (2) the upper part is used to describe the patient’s perspective, and (3) the lower part is used for the analysis of the health care professionals.
The form can visualize the current understanding of the patient’s state of activities and participation, his or her target problems, and how the health care team relates them to hypothetical mediators and contextual factors ( Fig. 47.2 ).
