The Assessment of Persistent Pain
The difficulty with the current method
for the assessment of persistent pain is that current expensive or invasive
diagnostic tools have been shown to be associated with complications, greater
expense and do not consistently improve outcomes for treatment. It is being
proposed in the literature that the assessment of persistent pain focusses on a
systematic approach with a mechanism-based target for treatment instead. This
involves, firstly, to identify the pain state; either nociceptive, inflammatory, neuropathic, nocipathic/dysfunctional or
a combination. Secondly, the likely
mechanisms involving psychosocial, sensitisation or physical functioning
problems are then explored. Psychosocial mechanisms involve beliefs (appraisal
and thoughts), behaviours, mood or social elements; Sensitisation mechanisms
can be regional or central; Physical functioning mechanisms may be related to
posture or movement patterns as well as issues of cortical reorganisation like
sensory motor integration, tactile acuity problems, laterality recognition, imagined
movement association with pain, or the lack of inhibition of primitive reflexes.
The collated information provides the
evidence to identify the likely targets for treatment where best practice
guidelines show more effective outcomes if treatment takes care of the
whole person, taking into consideration the life environment and relationships
with caregivers or family. In New
Zealand, completion of the electronic persistent pain outcomes collaboration
(ePPOC) questionnaires are now mandatory for all persistent pain assessment.
These cover most domains for an easily administered and comprehensive mechanism
based assessment.
Physiotherapy for Persistent Pain
Physiotherapy is essential in the multi modal and multi-disciplinary
approach to manage persistent pain. An effective assessment is essential to
identity the appropriate target for treatment. Evidence is overwhelming for the
benefits of movement and active exercise. However, for persistent pain a) what exercise
or intervention method to apply b) how to apply the prescription of effective physiotherapy
interventions for specific targets are sparse. Clinical practice shows a broad
variety of interventions are available and are applied concurrently, not
sequentially. Patient centred goals aim to improve understanding, restore
function to optimal level, normalise the central threshold to nociception, facilitate
self-efficacy, restore coping ability, normalise everyday activity level. Understanding
pain mechanisms is a cornerstone for both Physiotherapist and patient where education
is essential. The prescription of exercise with an algorithm of either graded
or pain exposure accompanied with mirror exercise, sensory motor training,
exercise in water, graded motor imagery, TENS or psychological and problem
solving techniques can be used effectively for positive treatment outcomes.