Treating Beyond Pain
More often than not, when a patient presents to the office, it is for a pain complaint. Headache, neck pain, low back pain, sciatica, carpal tunnel. . . The pain is often the focus of the patient's mindset, and they don't often have any thought of what comes after the pain. When talking with attorneys or case managers, I often comment that my primary job is not to fix the patient's pain – my job is to fix the problem. That may sound like semantics, but the difference can be significant.
Think about someone with a broken arm – a cast is not comfortable or convenient, but it is necessary for support while the bone heals. I am quite sure there are medications that would take the pain away from the broken arm, but that won't set the bone or keep it in position to heal. Not all care is about pain relief, often the more important care is about fixing the problem. You must address the pain, but you must be able to move beyond the complaint of pain to address the root problem and get the patient better.
First and foremost, pain is a symptom. It is subjective. Pain is a personal experience that will differ from one to another. Every patient's perception of and tolerance for pain is different, and that can change with activity, environment, and mental investment. That is not wrong, and it is not misleading, but the individual experience of pain does change. You may find one patient with a sprained ankle who ends up in a soft cast on crutches for a month, and another who will lace up their work boot tight and limp back to the job site. When documenting a patient's complaints of pain, just keeping a tally of the daily pain score is inadequate – there must be some discussion about how the pain affects their individual daily routine.
Perhaps the best example of this I can give is a patient I had a few years ago. He had a lower back disc injury, and was looking at a surgery he did not want. With care, we were able to get him off medications and back to work. The problem – his pain level would drop to a 2/10, then bounce back up to a 7/10. When the case went to hearing, the argument was made that my care was ineffective because the patient started with a pain score of 7/10 and six months later his pain score was the same. Obviously, no change in his condition. When I had the opportunity to discuss my care, I was able to elaborate: Yes, the patient did still have a recurring complaint of pain, but with care he had discontinued all narcotic medications, and had progressively increased his work status. At the time of the hearing, he was back to working full-time. His pain was back up that particular day because he had just worked a 12-hour shift in the rain in December. Safe to say that most people would be tight and sore with that activity. While it could be argued that his overall pain level would occasionally flare, I was able to show that my care had measurably improved his condition.
The difference can be defined as quantitative vs. qualitative measures. As noted above, pain is personal – it is qualitiative. There is no serum level of pain we can measure. The 1-10 pain score is one tool, but that is probably the least reliable measure of a patient's true condition. A patient's perception can be quickly modified by any number of influences, including medications and recreational drugs. However, quantitative measures are objective – these can show a measured change in the status of the person.
Taking less medication, increased work time or capacity, improved range of motion – these are quantitative, measured improvements that can document that your care is making a measured change in the patient's status. Many insurance companies now require evidence of measured improvement to authorize additional or continued treatment. During the course of your care, make sure you regularly discuss not just the pain levels, but how the patient is doing: Are they more active? Are they taking less medications? How are they different with your care? These changes can carry much more weight in how beneficial your care is than just a simple change in a pain score.
Another tool that can be easily employed are the Outcomes Assessment Questionnaires. Forms like the Neck Disability Index or the Oswestry Low Back Pain Questionnaire are considered objective because they have the patient discuss not pain, but how their perception of their pain affects their daily activities. With effective care, the scores on these forms should progressively come down over a period of time. The McGill Pain Questionnaire also assesses a patient's psychodynamics and can be used to identify symptom magnification. Waddell's testing is a great set of pseudo-orthopedic maneuvers to indicate non-organic pain or symptom magnification. Use of an algometer to measure how much pressure is used to produce pain at a certain location. Computerized dual inclinometry is the current standard of care for measuring range of motion. There are many other outcomes questionnaires, orthopedic tests and functional studies that will provide legitimate, objective data of the change in a patient's condition with care.
Don't be afraid of pain. Pain is typically what drives people to your door. But be willing to explain to your patient that you want to not only address their pain, but the cause of the pain so that the problem does not recur. In the end, fixing an acute lower back today only to have the pain return tomorrow does not help the patient. Tell the patient your findings and plan right up front – if you wait until they are out of acute pain to say "now we are going to fix the real problem" - you have lost their attention. The perception then becomes more that you are trying to drag them in for uneccesary care. I will tell my patients that I have to get the inflammation (and the pain) down before I can fix the problem – they get that. Remember, we are here to help the patient. We are more than an aspirin for pain – we can help to fix the problem.
As always, remember to completely and clearly document your findings, correlate with the patient's case history and logically outline your care plan. These extra notes help document the severity the patients' complaints and can then show the progressive response to care. This extra documentation can also help make the difference if you must justify your diagnosis to an insurer or third party. Take the extra few seconds to note the quantitative changes into your exam routine – it will only validate your care.