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Today's post isn't about the science of pain... I've done a fair amount of that in the posts linked above. Instead, this looks at how a patient experiencing chronic pain can be evaluated from a multidisciplinary perspective. Each patient was started off with a whole group of healthcare providers interviewing the patient (and their accompanying parent). The providers included a physician, a pain psychologist, and a physical therapist. This was done so that the patient's story didn't have to be repeated numerous times when each provider evaluated them individually. Since all of these patients had already seen a handful of healthcare providers to examine their symptoms, their stories have been told countless times.
When evaluating a patient experiencing chronic pain, it's important to discuss their medical history fairly extensively. They started with the symptoms being experienced currently, and then worked backwards through pain experiences and previous conditions. Things like how did your pain start? When did it start? What has been done to try to make it feel better? What makes it worse? Describe your pain in words. Describe your pain in numbers on the pain scale. What do you think is the reason for your pain? It was very thorough - and sometimes the pain has been going on for so long that details have been lost along the way. If I had stubbed my toe three years ago and ultimately developed chronic pain from that experience, I'm not sure I would be able to remember the details of my toe injury. So the recall of the history is challenging enough - and then you go into so many other areas of life.
The group did a really great job at explaining to each family that pain can be really complex and that sometimes it takes a team working together to help guide patients through it. While the conversation began with pain, it certainly didn't end there. Further questioning regarding previous treatments trialed up to this point were recorded. All of today's patients had seen multiple doctors of different specialties - cardiologists, rheumatologists, surgeons, orthopedic physicians, and physical therapists - and they had also received multiple potential diagnoses for what may have been causing their pain. This has to be super confusing for children and frustrating for parents. It's also difficult to recall all the treatments that have been attempted over extended periods of time. Painting a complete picture of the past is challenging.
And then the discussion transitioned into activities that pain impacts in their lives. Are they going to school? Are they regularly bathing? Do they exercise despite the pain or can they not tolerate that? What activities do they like to do? Does it impact their time with their family and friends? Is it at the same time of the day or does it come and go? How is sleep? It was a lengthy discussion, for all the right reasons. It was interesting to see what came up from asking some questions that seem rather simple - but then exposed patterns in these kids lives.
After completing the medical history, the providers individually worked with each patient to further examine their areas of specialty. The physician discussed past medical history of more extended family members, medications, hospitalizations, surgeries, things documented in the medical record, bowel and bladder function. He did many components of a typical physical exam looking in the mouth, palpating areas of the body that are known "pain points," assessing flexibility, mobility, and strength and checking reflexes as well as using tools to assess response to temperature, sharp pressure, and light touch.
The psychologist also had an opportunity to have a one on one conversation with the child and parent as well as with the child alone to try to rule out any concerns with abuse or neglect and to further examine mental health. These conversations further explored relationships with family members and friends, participation in school and recreational activities, any interactions with a therapist or counselor in the past, self assessment of mood, emotions, sadness, anxiety, depression, and suicidal ideation. She asked questions about dating and relationships and about friendships. It was interesting to see moments when the patient would feel as though their pain is worst when stressors int heir personal life were also increased - which doesn't always occur but did in one case today.
And the physical therapist also did an examination. This is what I was most interested in observing, because I'm hoping to have the chance to use this knowledge more in my evaluation and treatment of this patient population. The number of tests available to a physical therapist is extensive - so I kept wondering if we would have the patient do certain movement patterns or choose other components instead to prioritize the use of time. The patients were observed walking and running, balancing, a cardiovascular test was done, squat pattern and plank form were screened, strength and mobility were assessed. It was a more global assessment than is frequently used in the clinic for a more localized patient in an acute or shorter term pain pattern.
Then the providers sat down and compared notes on each patient and discussed what should be included in the patient care plan. Were medications indicated? Should they participate in PT and are there any particular recommendations for the patient to follow as a component of that treatment? Should acupuncture be trialed? Follow up with the pain psychologist for some counseling? It was very interesting hearing the different providers discuss each patient with their pertinent findings and then each patient was provided with a plan and appropriate referrals for follow up.
My key takeaways of the morning were:
1) Pain presents very differently from person to person and oftentimes requires a collaborative effort to help move patients forward.
2) A child's perspective of their pain or what's going on in a child's mind is generally not the same experience their parent is having. Even when kids discuss their pain or their mood or troubles at school with their parents - it may not be the complete picture. Sometimes opening up to a complete stranger is more comfortable than potential embarrassment in front of a parent.
3) As a healthcare provider, the language we use with patients is a BIG DEAL. To treat this patient population means working to change their beliefs about pain, how their bodies work, what they're able to do, and their perspective of themselves relative to the world. I wrote down quotations from each patient session that were negative images that had to come from somewhere. We have to do better with the words we use with our patients so they don't think their backs are "out." They're not so fragile!
4) Learning about how long it took for these patients to be seen demonstrates a likely high demand for this type of patient care. Physical therapists are a vital contributor to this team as we're likely to be the ones seeing the patients for follow up visits most frequently to get them moving in new ways and to regularly reinforce pain science education. This is optimized by a collaborative effort - but also - physical therapists with interest in working with this patient population need to have a better understanding of how pain works than we get in PT School.
5) Don't give up hope. If you've experienced pain for a long time - or your child has experienced pain for a long time - it may be frustrating that you haven't found the answers to improve your quality of life yet. But the key is - YET.
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