Our current assessment procedure is still widely used and taught throughout physiotherapy training. It is in my opinion, an area that requires serious reform. The emergence of the biopsychosocial model has shifted our understanding to a wider clinical landscape, one that lies outside of a biomedical paradigm. Shouldn’t our own assessment procedure reflect that and is there an opportunity for it to change?
Now I hope you didn’t think I was gonna answer that? Nah, I decided to draft in a willing guest who also shares the same gripes about the current physiotherapy assessment. Robin Higginson is a physiotherapist for Nuffield health and likes to dabble in a bit of chronic pain, which was the focus of his dissertation for his MSc in Advanced physiotherapy. You can follow Robin on twitter @RobinHigginson
So without further ado take it away Robin!
As Physiotherapists I think we have all been here: Mrs. Evans walks into out treatment room post operatively after having orthopedic surgery for a chronic condition, and 5 sessions later she is no better. We ask ourselves ‘what have I done wrong?’, and often start to doubt in our own abilities as therapists. More recently, I have seen many patients post TKR that present in the same way.
Unless we are able to see pain in a wider, more holistic perspective as therapists, we may fail to take a step back and realise that it most probably not any fault in our clinical approach. What about if we now know that Mrs. Evans has had a 20 year history of anxiety and depression, she doesn’t exercise, she lost her husband 2 years ago, she presents as a catastrophiser, and she has large amounts of fear avoidance behavior in many aspects of life. Does this then change our reasoning? If so how?
Even though our knowledge of pain has overwhelmingly changed in the past 10 years, the Physiotherapy world is still concerned about performing a structured assessment that is based upon the old Maitland type of structure. For example, aggravating factors, eases, 24 hour patterns, and for most patients we treat this remains a great approach to use for clinical reasoning and hypothesis generation. However, for persistent pain presentations, this information arguably becomes less useful. O’Sullivan (2005) explains that there remains a lack of consideration for the underlying mechanisms and symptoms pain disorders. Pain management in clinical settings is more complex – it needs to be based on the biopsychosocial model of healthcare. This model allows us to classify pain not just a direct physiological consequence of dysfunction, but explains that pain is an integration of psychological difficulties or behaviours that include; beliefs, coping strategies, illness behaviours, and social interaction (Moseley 2003).
Many authors agree that there is conclusive amounts of overlap of psychosocial variables in persistent pain presentations including; psychosocial characteristics of patients (Walsh and Radcliffe 2002, Meeus and Nijs 2007); and subjective and objective clinical assessment findings (Nijs et al. 2010, Bradley et al. 2000). The degree to which a patient believes that they are disabled by their pain is a powerful factor in the extent of their physiological impairment, and there have been demonstrated links in cross sectional studies between individuals who have long term pain and the presence of psychological characteristics such as catastrophising, depression, anxiety disorders, hyper-vigilance, avoidance behaviours, and the belief that pain signifies harm (Walsh and Radcliffe 2002, Linton 2000, Linton and Boersma 2003). Research is unsure exactly what effect the above behavioural characteristics have on the CNS, and how it changes its processes and interpretation of sensory information. Essentially they appear to contribute to cortical re-organisation of the neuromatrix (Seifert and Maihofner 2009).
Therefore what becomes the point of asking our traditional subjective questions? Do they still add value to our reasoning? Psychosocial profiling’ of persistent pain patients pre physiotherapy treatment gives us room to generate a more reasoned approach to identification and treatment of this challenging patient group. With the right patient, maybe this information is what I need to ask as a priority.
It is widely accepted that in order to improve outcomes in this complex and multi-dimensional patient group, changing these cognitive factors may be of greater importance than attempting to treat physiological factors (Woby et al. 2004, Woby et al. 2008, Grotle et al. 2010, Pincus et al. 2002). Most recently, a systematic review by Kamper et al (2015) has shown that, based on the largest collection of trials and participants reviewed to date, there are robust positive effects of multidisciplinary biopsychosocial rehabilitation programs. Patients participating in these programs are likely to gain small, long term benefits in improved pain and disability compared with usual care or physical treatments. And therefore addressing is considered a priority when constructing a Physiotherapy treatment approach for patients with persistent pain presentations. The reason we are left scratching our heads with patients like Mrs. Evans, is usually only because we have missed the identification of some of her main limiting factors – not physical, but psychosocial in nature. It may be helpful if we probe her, ask her about her social or psychological history. This has been, and sadly still is, a ’no go’ area for many therapists, that may see this as outside of our scope of practice. Arguably, I don’t think it is. I think Physiotherapists, and the knowledge base on pain that we hold, are ideally placed at increasing our clinical skill base surrounding these problems. But this is something that therapists have done better than other areas of practice.
There is quite clearly a need to address these factors at some point in the patient’s journey. Why is there not better focus at changing them pre-surgery? What does the research suggest?
Celestin et al (2009) concludes that current literature suggests that psychological factors such as somatization, depression, anxiety, and poor coping, are important predictors of poor outcome post-surgery. Adogwa et al (2014) conclude that independent of surgical effectiveness, baseline depression levels influences patient satisfaction with health care, two years after revision lumbar surgery. Rosenberger et al (2006) indicate that psychosocial factors play a significant role in recovery and are predictive of surgical outcome, even after accounting for known clinical factors. Attitudinal and mood factors were strongly predictive. This suggests that preoperative consideration of these factors will assist in estimating postoperative recovery. A systematic review by Wilhelm et al (2015) concludes that there are a number of psychological variables that are associated with a poorer outcome with lumbar fusion surgery.
There is clearly a suggestion that psychosocial factors are important pre surgery. Therefore the answer to the question, is there a need, is an overwhelming ‘yes’. Maybe a better question is how can this be done? That question creates a whole host of applying this research into practice.
The evidence base surrounding psychosocial profiling is poor. We know that these characteristics are important, but which ones are more important than others. Isn’t every patient different? Do we give patients a dozen pre-screening questionnaires to complete pre-surgery? How can we deliver treatment pre surgery that addresses these factors on an individual level? Research has difficulty with finding a form of hierarchy of these variables, or what predicative values each of them have. And as always, more research is needed to show if treatment of these factors pre surgery will enhance treatment outcome in the future.
In the meantime, the Mrs Evans of this world will continue to present for treatment in much the same way as they have always done. But it’s probably not too late. If we just start asking the right questions, and probing her history in the right kind of area, maybe there is hope to bring change to the patients that want it.
Thanks to Robin for providing his expert opinion on an area that all medical care (not just physiotherapy) requires drastic reform. Particularly if we are to keep abreast of the changing landscape.
As always please don’t hesitate to drop me or Robin a comment or you can always catch us on social media.
Thanks for reading