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Physiotherapy in Assessment and Management of Pain
Rebecca McLoughlin, Katrine Petersen, and Suzanne Brook
INTRODUCTION
This chapter describes the approach to assessment and management of chronic abdominal pelvic pain (CAPP) used by physiotherapists working within an interdisciplinary pain management centre. We discuss why pain management physiotherapists work in the way they do, look at the evidence-base for our practice, and describe how we utilise knowledge from relevant evidence in clinical practice. We hope this will provide insights into both current research and clinical strategies and skills.
BASIC ASPECTS
Evidence-Based Pain Management Physiotherapy
Evidence-based medicine is espoused by many governments and healthcare organisations [28] and has been recognised as a concept of growing importance for physiotherapy [21]. As the underlying neurophysiological mechanisms of CAPP reflect those of other chronic pain syndromes, it has been stated that CAPP syndromes should be managed with the same general approach as is used for other pain syndromes [3]. Therefore, pain management physiotherapy approaches, for which there is strong evidence in other forms of chronic pain, can be utilised in the management of CAPP and outcomes measured in order to improve the evidence-base.
Pain management physiotherapy is delivered within a cognitive behavioural therapy (CBT) framework. Evidence suggests that rehabilitation and exercise programmes delivered using a CBT approach produce better long term outcomes than other approaches [17, 26, 34]. Therefore, CBT provides an ideal framework for the delivery of physical rehabilitation [32].
A recent systematic review of psychological therapies for the management of chronic pain [43] confirmed that the evidence-base is dominated by studies of treatment stemming from behavioural or cognitive behavioural theories. Of these two approaches, CBT is more effective in reducing pain-associated disability [43]. It should be noted that there is a distinction between physiotherapists utilising the principles of CBT, and formal delivery of a cognitive behavioural intervention by a trained cognitive behavioural therapist. Few physiotherapists are trained cognitive behavioural therapists. The approach that we describe is not a cognitive behavioural therapy intervention; it is physiotherapy delivered within a CBT framework and utilising cognitive behavioural principles alongside and within other physiotherapy interventions.
DESCRIBING THE SUBJECT
Pain Management Physiotherapy Assessment
Physiotherapy within a CBT pain management model has a core aim of increasing patients’ ability to manage their own pain and become more active despite it [2]. In order to support patients in achieving this, it has been suggested that the clinician’s role ‘is that of a teacher or guide, who’s main responsibility is to encourage or assist the patient in learning and making better use of pain self-management skills’ [20]. Therefore, pain management physiotherapy assessments focus on listening to the patient’s experience of pain, their beliefs about the nature and mechanism of their pain and the journey that has brought them to the clinic. The clinician might say, “I know that you might have told this story many times before, but it’s really helpful for me to hear from you about what has happened since your pain began”. The patient might later be asked to describe the impact that their pain has on their life in terms of daily activity, work, family and social interactions, intimate relationships and valued activities. An impression of the patient’s thoughts and beliefs about movement and activity can be elicited from this explanation. Additional information might be gleaned from a question like: “Are there any movements that you think you should not do because of your pain? What do you think will happen if you move in that way or do that movement?” The specific content of a pain management physiotherapy assessment will vary according to the needs and goals of the individual patient, but the assessment is led by the patient’s answers. The physiotherapist can demonstrate understanding and empathy by posing questions in an order that follows the patient’s fears, concerns and questions [3]. Some typical physiotherapy specific questions included in an assessment are shown in Table 1, however, this should not be considered as a complete assessment outline. In Table 1, an explanation is given as to why each topic is discussed and suggestions for the type of open question that might elicit the most complete and useful answer are provided.
A CBT guided assessment concludes with the clinician highlighting or summarising what she thinks she has heard and what she hopes she and the patient can work on together, using phrases and key words from the conversation with the patient. The final decision about whether to engage in further sessions and begin working towards identified goals must come from the patient, rather than being assumed by the clinician. As mentioned above, ensuring goals are meaningful to the patient, based around functional activities rather than being pain reduction-based can help patients engage in a pain management physiotherapy approach. It is also helpful to support the discussion from the assessment with relevant resources that the patient can read prior to the next appointment, or copies of diagrams or images that were used in explanation during the session.
Pain Management Programmes (PMP) and Individual Pain Management Physiotherapy
CBT guided physiotherapy can be delivered in one-to-one sessions, but it is more commonly delivered within interdisciplinary pain management programmes (PMPs). Interdisciplinary PMPs have been identified by the British Pain Society as the treatment of choice for people with persistent pain which adversely affects their quality of life [8]. The multidisciplinary approach is supported in the literature of female chronic pelvic pain [24]. The overall aim of physiotherapy in a PMP is ‘to reduce the disability and distress caused by chronic pain, by teaching sufferers physical, psychological and practical techniques to improve their quality of life, [19]. Whether working with a patient within a group or individually, pain management physiotherapy does not focus on pain reduction as a principle aim of treatment, the focus of pain management physiotherapy is to facilitate return to normal daily activities even if the pain is not completely resolved [15]. Physiotherapists have a key role in supporting patients in improving function through behavioural change, including reduction of; avoidance, pain and illness behaviours, and increasing well behaviours [19]. This can support a shift away from behaviour that is contingent on pain or providing pain relief, and promote development of behaviour that is contingent on goal achievement related to the values of the individual with pain [43].
TABLE 1 Physiotherapy Specific Questions in Assessment
Topic | Reason | Suggestions |
Expectations of pain management physiotherapy | Opportunity to identify unrealistic/inaccurate expectations and discuss if patient wants to engage in a CBT focused self-management approach. | “What are your hopes or expectations of pain management physiotherapy and your appointment today?” |
Pain History | To gain an understanding of what the patient has experienced, how their pain has changed, and where they are in terms of needing, wanting, undergoing investigations or treatments. This is not an acute assessment of nature, irritability, and severity as this will be misleading in chronic pain. | “Please tell me about your pain, when you think it started, and how it has been over the past…years?” “Who have you seen for treatment or advice about your pain?” “Do you think you need more investigations” |
Previous experience of physiotherapy | Open discussion about previous difficult or helpful experiences. | “I’ve obviously read through your notes, but I couldn’t tell whether you’ve had any physiotherapy in the past…“ |
Previous investigations/ explanations/ treatments | To get an impression of the patient’s understanding of investigations and treatments that they’ve had in the past and why they did or didn’t help. | “What do you think your investigations show?” “Was it explained to you?” “Is there anything else that you think should be looked at?” |
Perception of pain: what is the cause of the patient’s pain | To gain insight into what the patient believes is causing their pain, the reasons it persists, and possibly, what this means for the future. Elicit beliefs about pain, for example pain being a sign of injury or damage. At a later appointment this information can help the physiotherapist to provide alternative models and explanations if the patient’s beliefs are based on inaccurate information. | “What do you think is causing your pelvic pain? |
Impact of pain: 24 hours/ weekly routine | To get an impression of the relationship between pain and activity. Is the person avoiding activity, or pushing to their limit and having to recover with hours/days of rest? Pain can often be unhelpfully used by a patient as a guide to dictate whether they should do more or less activity. | “What’s a normal day like for you?” “Do you have days which are better than others or days of more pain than others? If so, what you do on a good pain day and on a bad pain day?” |
Avoided movements/ activities | Links with beliefs about pain and injury or damage and can lead to insight into where beliefs come from. For example, a patient might say, “After surgery 4 years ago, the doctor told me not to bend, so I try not to bend because it’s bad for me.” | “Are there any movements or activities that you think you should avoid because of your pain?” |
Exercise | Increase understanding of relationship with exercise before and alongside pain and possible thoughts about increasing exercise. | “Do you think exercise is helpful in managing pain?” “Is exercise something that you enjoy? Is it part of your routine at the moment? Would you like it to be?” |
Helpful strategies | Identify positive/helpful coping strategies that the patient is using to reinforce what they are doing well and to engage the patient in building on their current strategies. Rest and avoidance are not considered helpful but for the patient they may avoid increases in pain in the short term. |
