“Evaluate and treat for…pain”. A familiar physician order received not only in therapy outpatient clinics but also across the continuum in both acute and post-acute care. Chronic pain is the most common reason patients see a provider as it accounts for 40% of all visits in primary care. According to the Department of Health and Human Services, Pain Management Best Practices Report, “Effective multidisciplinary management of the potentially complex aspects of acute and chronic pain should be based on a biopsychosocial model of care. Restorative Therapies, including those implemented by physical therapists and occupational therapists (e.g. physiotherapy, therapeutic exercise, and other movement modalities) are valuable components of multidisciplinary, multimodal acute and chronic pain care.”
From a therapy standpoint, pain is typically the first symptom patients are open to discuss with their therapist. Relieving that pain will keep them coming back for their scheduled therapy sessions. Mitigating that pain will influence patient satisfaction. As physical and occupational therapists, we not only are pain treaters but also pain educators. For our part, it always helps to have a versatile bag of tricks for pain treatments and, also important, how to tell the story of our patient’s pain journey in our documentation. Here are a few tips to help:
1) Use More Than One Pain Assessment Tool
Pain assessments are an integral part of determining the patient’s plan of care and recording progress in treatment strategies, yet it is an area where our documentation in everyday clinical practice can be stronger. Our goal is to achieve a person-centered assessment and approach to the management of pain. Pain is personal and multi-factorial. Therefore, selecting the right valid and reliable assessment tools is key to “capturing the physical, biological, and psychosocial factors that contribute to pain, impairment, and disability.” (IASP)
Following is a short summary of the guidelines and recommendations from multiple respected sources listed at the end of this article:
- Pain is a personal experience, therefore, despite the patient’s level of cognition therapists are encouraged to strive to use a self-report tool, such as a Visual Analog Scale, Verbal Rating Scale, Numerical Rating Scale, Wong-Baker Faces Pain Scale, McGill Pain Scale, Mankoski Pain Scale, Brief Pain Inventory, etc. When assessing pain in seniors with cognitive impairments, it has been recommended to start with a Mini-Mental Status Exam or other cognitive tests to help the therapist decide if the patient is capable of a sound self-report.
- When observational assessments are warranted, for example, FLACC, CRIES, COMFORT, PACSLAC, DOLOPLUS-2, etc., take into consideration that these truly are more screening instruments versus deciding factors of the patient’s pain experience, and therefore therapist should exercise caution. Establishing baseline scores and regularly observing changes in behaviors pre-and post-treatment interventions, both at rest and with movements, is more likely to provide a clearer picture of their experience.
- Document other related factors such as socio-economic, environmental and psychological functioning that affect the patient’s pain experience.
- Selection of more than one pain assessment is recommended to capture key information to be able to better zero-in on probable cause, as well as allow the therapist to evaluate the effectiveness of their pain management interventions. Document a pain score pre- and post-intervention (either immediate, an allotted time period, or with specific activities that previously induced pain) to determine progress and justify medical necessity of the therapist’s skilled therapy inventions.
- Once the pain assessment tools have been selected, administration of the tests during movement-based tasks are presumably likely to lead to recognition of primary or key pain problems than at rest. Also, documentation of any pain medication and when it was taken relative to when the pain assessment tool was administered is highly recommended.
2) Prescribe a Patient-Specific and Function-Specific Exercise Protocol
The Center for Disease Control (CDC) recognizes exercise as a non-opioid recommended treatment for common chronic pain conditions such as low back pain, osteoarthritis and fibromyalgia. Exercise-induced hypoalgesia (EIH), though variable, can be achieved in chronic pain patients. An article in the Journal of Pain reported that “even in the presence of impaired EIH, people with localized pain conditions might be able to obtain pain-relieving effects by exercising remote, non-painful parts of the body, because this strategy may still elicit EIH.”
Exercise prescription is most effective when the parameters provided are specific to the individual patient’s ability and goals. Body position, range of movement, frequency, duration, intensity, speed, patient response, and vitals (for aerobic exercise) are fundamental to documenting skilled therapeutic exercise.
Aerobic exercises such as cycling, swimming, brisk walking, etc., have significant improvements in chronic pain where increasing the frequency of exercise sessions per week is most likely to have a positive effect on chronic pain patients versus just intensity. Key parameters such as time of exercising per week, frequency of exercise per week, duration and intensity of exercise, and patient’s pain levels (before, during and after) help strengthen the documentation of aerobic exercise as a pain treatment.
Resistance exercise, including isometric, isotonic and isokinetic also have variable effects on improvements in pain with movement and so pain pressure threshold measurements immediately after exercise can be taken and documented. Of course, patients are encouraged to exercise within their pain-free zone.
Active and Passive Range of Motion exercises to improve movement, maintain anatomical alignment, and/or preserve range of motion of specific joints or movement are another component of pain treatment when documentation is tied to a specific function and patient response to treatment is noted.
3) Biophysical Agent Modalities Require Skilled Therapist Knowledge and Intervention
The treatment of pain is likely the most popular condition therapists use electrical, electromagnetic, acoustic and other biophysical energies. Evidenced-based practice guidelines emphasize dosage as a major component of efficacy for electrical stimulation, ultrasound, short-wave diathermy and other biophysical agent modalities for pain management. Modalities are skilled therapy interventions. Each modality has its own set of parameters, as well as variables that influence outcomes. Here are some key list items to help demonstrate strong documentation:
- Electrical Stimulation: Include in documentation 1:1 skilled intervention of skin assessment pre- and post-treatment, pain assessment pre-treatment, the waveform (e.g. IFC motor, TENS sensory), location of the pain, location of the treatment area, electrode placement, intensity (e.g. visible muscle twitch or sub-motor tingling sensation), duration of treatment, patient’s body position, additional interventions during treatment (e.g. pain education), pain assessment in various planes or tasks post-treatment, and patient’s subjective response to treatment.
- Ultrasound: Document indication of treatment for post-traumatic/post-surgical, acute or chronic pain tied to a functional task/movement with skin and pain assessments pre- and post-treatment. Parameters and variables to include are pulsed (e.g. 20%, 50% duty cycle) or continuous (e.g. 100% duty cycle) settings, thermal or subthermal effects, depth of penetration (e.g. 3 MHz or 1 MHz), treatment area, target tissue, treatment time, output (in W/cm2), sensation, position of patient, and patient’s subjective response to treatment.
- Short-wave Diathermy: Document the pain type (acute, subacute, chronic) and include the indication of your pain treatment by tying it to a functional task/movement. Always include skin and pain assessments pre and post-treatment. Parameters and variables to include pulse rate, pulse duration, output power, treatment area, target tissue, position of drum, draping, time of treatment, additional interventions during treatment (e.g. Lymphedema massage proximal to treatment site), sensation, position of patient and patient’s subjective response to treatment.
4) Provide the Details on Manual Therapy and Massage Techniques
The power of touch with the human hand continues to be a powerful tool for therapists. Manual therapy and massage techniques include muscle stretching and mobilization of soft tissues, distraction and traction techniques, specific or general high-velocity manipulation, joint mobilization, lymphedema massage, effleurage, petrissage, compression, percussion, and more. Naming and describing these techniques provide evidence of strong documentation, as well as including supporting variables such as the joint or muscle of the extremity or spinal level being mobilized, the direction of the movement (e.g. anterior to posterior), the mechanism for the technique (e.g. decrease hypomobility and pain or decrease pain and muscle tightness/spasms), description of movement (or lack thereof), pre- and post-treatment as it relates to a specific function/activity/task, pre- and post-treatment pain assessment, and patient response to treatment.
5) Pain Patients Are Neuro Patients
Normalization of signals between the brain and body and the nerves used for them to communicate with each other is a category in itself. Techniques used in this category may include postural education with biofeedback (e.g. visual mirror feedback for phantom limb pain) and peripheral nerve gliding, Proprioceptive Neuromuscular Facilitation (PNF), virtual rehabilitation, guided imagery, progressive muscle relaxation, and desensitization techniques can be used to quiet, distract, manipulate, or normalize the body’s response to a pain sensation. Documentation can include the name of the technique, its indication of use, the patient’s position(s), target area, pre- and post-treatment pain assessment, therapist instruction, additional tools used (e.g. soft bristle brush, mirror, screen-based virtual reality program), mechanism of treatment (e.g. heat, cold, deep pressure, vibration), duration of technique provided and patient’s response to treatment.
6) Food Can Fight Pain
According to the Study in Multidisciplinary Pain Research workshop: “FYD (Feed Your Destiny): Fighting Pain, patients with chronic pain would benefit from a nutritional assessment and counseling, as there are foods and supplements that “can be recommended in an individualized treatment plan that may improve clinical outcomes of analgesic therapy and result in considerable improvement of patient compliance and quality of life.” For example, geriatric patients who suffer from musculoskeletal disorders may significantly benefit from daily recommended amounts of protein according to body weight, intake of soy, egg, and cod and tryptophan-rich foods such as milk and peanuts, supplementation of vitamin D and magnesium, weekly consumption of fish or supplements of omega-3 fatty acids, and other “botanicals” such as curcumin and gingerol. Assessment and documentation of the patient’s current dietary habits can help support a referral to a licensed nutritionist who can create a personalized nutrition plan by using a non-pharmacological approach that may reduce the dosage of analgesic drugs needed.
7) An “I” In Pain But No “I” in Team
Experts say that although pain is a personal and subjective experience, treating pain should be a multi-disciplinary team approach. The International Association of Pain (IASP) supports an all-hands-on-deck approach to pain management with its mission statement, “IASP brings together scientists, clinicians, health-care providers, and policymakers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide.” Be it physicians, nursing, social workers, nutritionists/dieticians, psychologists/psychiatrists, trauma specialists, and etc. including the patient’s healthcare team and their interactions on the patient’s journey of care in the therapy documentation helps tell the story of the patient’s support system of pain professionals.
Efficacious therapy documentation identifies the functional, physiologic and psychosocial effects of pain, establishes medical necessity, includes valid pain assessment tools and functional measures, describes patient-centered and specific treatment protocols, includes the patient’s response to treatments, and outlines a plan of care.
Contrary to popular belief, the subject of pain science has not been a foundational study in healthcare education. Currently, the majority of medical schools in the United States provide between 0-10 contact hours in pain science, assessment, intervention, and management categories. As far physical therapy schools, according to an eye-opening lecture presented at this year’s APTA Combined Sections Meeting, “21st Century Pain Education: Implementing Recommended Core Competencies Into Physical Therapist Education”, 50% of the modalities courses are devoted to pain while other curriculum courses, such as orthopedics and neurology have pain education contact hours intertwined.
On June 26, 2018, APTA House of Delegates moved to endorse and promote pain curriculum guidelines for PT schools. A revolutionary move in education that takes us another step forward to fight the good fight for the undertreatment and underdiagnosis of pain that is still an epidemic in our country. For those of us already in practice, we can benefit from up-to-date resources to enhance our knowledge as we navigate this pain management revolution. Here are a few of those resources:
- Department of Health and Human Services, National Institutes of Health released a National Pain Strategy in March of 2016. This was a coordinated effort for a comprehensive population health strategy plan for pain. Access here.
- #SeePainMoreClearly is a social media campaign, led by Dr. Hadjistavropoulos, an international leader in the area of pain assessment in dementia to increase awareness of the underassessment of pain in dementia. Access here.
- International Association of the Studies of Pain (IASP) is a global pain community of researchers, clinicians, those living with pain, and the general public to better understand the nature of pain and available treatment modalities through their website. Links to abstracts from various articles via the search of specific topics are free though paying membership will provide access to on-demand continuing education for pain professionals. Access here.
- American Physical Therapy Association created a campaign called “#ChoosePT” to position evidence-based therapy interventions as a solution for chronic pain management over opioid use. Access here.
The information in this post is for information purposes only. Please refer to your state licensure practice act, CMS regulations, NCD’s, LCD’s and company-specific policies and procedures for specific guidelines as practices may vary.
- Vadieu N, Mitra S, Hines R, Elia M, Rosenquist R. Acute pain undergraduate medical education: an unfinished chapter! Pain Pract. 2012;12 (8): 663-671
- Mezei L, Murinson BB. Pain education in North American Medical Schools. J Pain 2011;12:1199-208.
- APTA CSM 2021 lecture “21st Century Pain Education: Implementing Recommended Core Competencies Into Physical Therapist Education”. Presenters/Educators: Shana Erin Harrington, Meryl Alappattuu, Mary Hoeger Bement, Craig Andrew Wassinger, Kathleeen Anne Sluka, Kory J. Zimney
- International Association for the Study of Pain. Mission and Vision available at. Access here.
- IASP International Association for the Study of Pain: IASP Curricula. 2017. Available here.
- Department of Health and Human Services. “Pain Management Best Practices Inter-agency Task Force Report. Available here.
- De Gregori M, Belfer I, De Giorgio R, Marchesini M, Muscoli C, Rondanelli M, Martini D, Mena P, Arranz LI, Lorente-Cebrián S, Perna S, Villarini A, Salamone M, Allegri M, Schatman ME. Second edition of SIMPAR’s “Feed Your Destiny” workshop: the role of lifestyle in improving pain management. J Pain Res. 2018 Aug 27;11:1627-1636
- See Pain More Clearly. Available here.
- Polaski AM, Phelps AL, Kostek MC, Szucs KA, Kolber BJ (2019) Exercise-induced hypoalgesia: A meta-analysis of exercise dosing for the treatment of chronic pain. PLoS ONE 14(1): e0210418. Access here.
- Rice D, Nijs J, Kosek E, Koltyn K, Graven-Nielsen T, Polli A. Exercise-Induced Hypoalgesia in Pain-Free and Chronic Pain Populations: State of the Art and Future Directions.Journal of Pain v20, issue11, p1249-1266, Nov 01, 2019. Available here.
- Perna S, Alalwan T, Al-Thawadi S, et al. Evidence-Based Role of Nutrients and Antioxidants for Chronic Pain Management in Musculoskeletal Frailty and Sarcopenia in Aging. Geriatrics (Basel) 2020 Mar 6;5(1):16.