Psychosocial Issues
It is important to introduce patients (and family members) to
the idea of pain psychology evaluation at an early point in the contemporary comprehensive
evaluation scheme.[8]
[12]
[15]
[16]
[27]
[28]
[30]
[31]
This may be accomplished at the patient's first visit in some practice models or
may be obtained in sequence as other evaluation information is collected. The assessment
aims to explore the breadth of the patient's emotional range (anxiety, depression,
frustration), identify negative behaviors that are being reinforced, reveal positive
coping skills that the patient possesses, and investigate the reality of the patient's
expectations about treatment of the pain. The patient may interpret this referral
as implying that his or her pain isn't "real" or that it's "all in my head." Thus,
an honest explanation about the genuine rationale for the request will go a long
way in establishing an environment in which the evaluation and any subsequent treatment
will be likely to have a contributory effect in helping the patient achieve the goals
of neuropathic pain management.
The specific tools and techniques of assessment vary with the
pain practice and the expertise of the specialists available. Because patients with
neuropathic pain can develop changes in their attitudes and behaviors, some form
of behavioral analysis is logical.[129]
[130]
There are a variety of standardized evaluative tests. An analysis of the factors
that increase and decrease the pain, and the relation between daily activity and
the pain should be gained. It is important to understand how the patient has handled
stress in the past and assess the existence of dependent personality traits, endorsement
of an external locus of control, and the lack of responsibility with harmful substances
or other health care decisions. Screening can be provided to identify patients with
psychiatric disorders (who will best be co-managed by other specialists), enabling
partners, neuropsychological deficits, and those who might be best served in an inpatient
pain management program.
When patients are able to benefit from therapeutic pain psychology
techniques such as biofeedback, relaxation training, cognitive therapy, pacing therapy,
and sleep architecture recommendations, there are concordant reductions in medication
use; increased participation in activities of daily living and rehabilitative physical
therapy; improvement in mood and attitude; graduated activity participation with
lessening of non-productive downtime; a decrease in the total amount of life stressors;
an increase in endurance of the physical and emotional realities of life; and a decrease
in health care costs.[131]
[132]
[133]
The patient reassumes control of his/her
life.
Pain management programs contribute substantially to the rehabilitation
of cooperative patients with neuropathic pain.[134]
[135]
[136]
There
is evidence that the more intensive the program, the greater the improvement. That
said, one of the fundamental tenets of the outpatient pain management style, the
most common model in the United States, is that the patient bears the ultimate responsibility
to follow through with the treatment program. The burden on the patient for cooperation
with all aspects of a therapeutic program and for manifesting patience while the
benefits from it accrue, often slowly, is immense.
Return to work as a measure of success is not the most realistic
or practical yardstick for the majority of patients with enduring neuropathic pain.
The matter of determining how disabled is an injured worker with neuropathic pain
can be exceedingly complex and even controversial. The stress because medical and
non-medical issues become intertwined can be high.[27]
[28]
[130]
[131]
One can only appreciate the tensions created when the patient's mindset is obtaining
disability, whereas the pain practitioner is working to decrease the pain with a
number of modalities used in concert to expand the patient's physical activities!
One of the strongest predictors of developing disabling back pain on the job is work
dissatisfaction.[137]
This information may be discovered
through the expertise of a pain psychology evaluation. "It is hard to get well if
you have to prove that you are sick."[137]
Although
far removed from the anatomy and physiology of nociception, the issues of disability,
wage replacement, and job satisfaction are pivotal in the assessment and management
of disabled workers.[137]
[138]
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