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The assessment of pain; how much does it hurt?
CONFERENCES
Pain is a subjective experience and, as such, is complex, messy and complicated. Today, it is widely accepted that the experience of pain is best explained by a biopsychosocial model. This means that pain is difficult to measure if, indeed, it is measurable at all. To date, almost all measurement of pain occurs within the positivist paradigm of inquiry which argues for factual observations and parts that can be observed in isolation from the whole. Hence, pain intensity and psychological scales; measures of patients’ attitudes and beliefs and disability scales are all available to measure and quantify pain. There is now, however, an increasing shift to inquiry in the interpretivist paradigm which observes the parts as a whole. This presentation highlighted how these different approaches can be applied to pain assessment and how chiropractic research might include these in the future.
The primary reason that patients seek chiropractic care is for the treatment of back and neck pain. One of the major incentives for the recognition of chiropractic is the high cost of back and neck pain to society in terms of both treatment and disability and the hope that chiropractors can ease this burden. It is therefore important that chiropractors understand the pathophysiology of spinal pain and the relationship between this pathology and disability. Research over the past few years has demonstrated that patients can have considerable pathology in the form of disc herniation, spinal stenosis and degenerative changes without any pain. On the other hand, patients can have significant pain and perceived disability with normal x-rays, MRI studies and other tests for pathology. Radiological evidence of misalignment associated with the classical chiropractic subluxation has similarly not been associated with either spinal pain or disability. Before one can properly interpret clinical findings and test
46
results and thus adequately care for patients with spinal pain, it is necessary that a chiropractor or other clinician fully understand the factors that appear to precipitate or are associatecl with complaints of pain and disability. There are at least six different factors that have been associated with spinal pain and/or disability. The first factor is the degenerative changes associated with aging. The entire population can anticipate degenerative changes to occur in the discs, bones and joints of the spine. The discs tend to lose their elastic fibres and water content and become stiffer with greater collagen as one ages. This is associated with narrowing of the disc space and the formation of osteophytes. Many of these changes occur without pain, but they can reach a point where the osteophytic growth results in foraminal or central stenosis and resultant symptomatology. The second factor is acute trauma to the spine, which can cause damage to muscles, ligaments, discs and facets resulting in pain. There is a natural healing process from acute trauma and patients often will recover from the effects of most forms of trauma without residuals. A few, however, will go on to develop chronic pain. The third factor is repetitive overloading of the spine as commonly seen in occupations which require a great deal of heavy lifting and bending or where an individual is subjected to high vibration loads. These conditions result in fatigue of the spinal structures and greater degrees of degeneration and symptoms. The last three factors which are associated with high degrees of spinal pain and disability have to do with a patients general health status, physical activity and fitness and psychosocial situation. There is a correlation between spinal pain and disability and such disorders as diabetes and heart disease as well as poor habits such as smoking. These conditions may impact upon the ability of the blood to deliver oxygen and nutrients to spinal structures. Physical exercise, on the other hand, has the ability to increase the strength of spinal muscles, discs and bones and create a feeling of well-being that can result in lesser amounts of pain. Finally, there is a strong correlation between the psychological and social wellbeing of a patient and the likelihood of being considered disabled from spinal pain. One of the greatest predictors of loss of ability to
work is the satisfaction of the individual with their employment. It is therefore important that a clinician develop a model in his or her mind when assessing a patient that takes into account all of these factors. It is insufficient to rely solely on the clinical examination or imaging tests to recommend treatment. A complete evaluation is dependent on a detailed history and should reveal what factors are influencing a patients pain and resulting disability. Classical chiropractic theory has always taken into account the function of the person ’ in their environment and has always included advice on how the body can heal itself given a healthy life style and avoidance of physical, environmental and psychological stresses. These principles are being demonstrated to be valid by increasing amounts of research and should not be forgotten in clinical practice.
After back and neck pain, the most common reason for a patient to seek chiropractic care is headache. The relationship between headaches and disorders of the cervical spine remains controversial. There is considerable disagreement amongst clinicians from different disciplines as to the definition, characteristics, pathological mechanism, diagnosis and treatment of cervicogenic headaches. Simon Dagenais, a senior student at the Los Angeles College of Chiropractic, has assisted me in a review of this topic and has found over 100 papers referencing headaches originating from the cervical spine. The definition of cervicogenic headaches has varied greatly from one author to another and from one society to another. They have been variously described as cervical migraine, spondylitic headache, verfebrogenic headaches and third nerve-occipital headaches. The earliest reference to headaches originating from the cervical spine appears to be by the French neurologist, Barre in 1926. It was, however, Sjaastad who first defined cervicogenic headaches in 1983 and described in detail the characteristics he felt were important in describing this form of
The British Journal
of Chiropractic,
2000; Vol 4, No 2
Pain is a subjective experience and, as such, is complex, messy and complicated. Today, it is widely accepted that the experience of pain is best explained by a biopsychosocial model. This means that pain is difficult to measure if, indeed, it is measurable at all. To date, almost all measurement of pain occurs within the positivist paradigm of inquiry which argues for factual observations and parts that can be observed in isolation from the whole. Hence, pain intensity and psychological scales; measures of patients’ attitudes and beliefs and disability scales are all available to measure and quantify pain. There is now, however, an increasing shift to inquiry in the interpretivist paradigm which observes the parts as a whole. This presentation highlighted how these different approaches can be applied to pain assessment and how chiropractic research might include these in the future.
The primary reason that patients seek chiropractic care is for the treatment of back and neck pain. One of the major incentives for the recognition of chiropractic is the high cost of back and neck pain to society in terms of both treatment and disability and the hope that chiropractors can ease this burden. It is therefore important that chiropractors understand the pathophysiology of spinal pain and the relationship between this pathology and disability. Research over the past few years has demonstrated that patients can have considerable pathology in the form of disc herniation, spinal stenosis and degenerative changes without any pain. On the other hand, patients can have significant pain and perceived disability with normal x-rays, MRI studies and other tests for pathology. Radiological evidence of misalignment associated with the classical chiropractic subluxation has similarly not been associated with either spinal pain or disability. Before one can properly interpret clinical findings and test
46
results and thus adequately care for patients with spinal pain, it is necessary that a chiropractor or other clinician fully understand the factors that appear to precipitate or are associatecl with complaints of pain and disability. There are at least six different factors that have been associated with spinal pain and/or disability. The first factor is the degenerative changes associated with aging. The entire population can anticipate degenerative changes to occur in the discs, bones and joints of the spine. The discs tend to lose their elastic fibres and water content and become stiffer with greater collagen as one ages. This is associated with narrowing of the disc space and the formation of osteophytes. Many of these changes occur without pain, but they can reach a point where the osteophytic growth results in foraminal or central stenosis and resultant symptomatology. The second factor is acute trauma to the spine, which can cause damage to muscles, ligaments, discs and facets resulting in pain. There is a natural healing process from acute trauma and patients often will recover from the effects of most forms of trauma without residuals. A few, however, will go on to develop chronic pain. The third factor is repetitive overloading of the spine as commonly seen in occupations which require a great deal of heavy lifting and bending or where an individual is subjected to high vibration loads. These conditions result in fatigue of the spinal structures and greater degrees of degeneration and symptoms. The last three factors which are associated with high degrees of spinal pain and disability have to do with a patients general health status, physical activity and fitness and psychosocial situation. There is a correlation between spinal pain and disability and such disorders as diabetes and heart disease as well as poor habits such as smoking. These conditions may impact upon the ability of the blood to deliver oxygen and nutrients to spinal structures. Physical exercise, on the other hand, has the ability to increase the strength of spinal muscles, discs and bones and create a feeling of well-being that can result in lesser amounts of pain. Finally, there is a strong correlation between the psychological and social wellbeing of a patient and the likelihood of being considered disabled from spinal pain. One of the greatest predictors of loss of ability to
work is the satisfaction of the individual with their employment. It is therefore important that a clinician develop a model in his or her mind when assessing a patient that takes into account all of these factors. It is insufficient to rely solely on the clinical examination or imaging tests to recommend treatment. A complete evaluation is dependent on a detailed history and should reveal what factors are influencing a patients pain and resulting disability. Classical chiropractic theory has always taken into account the function of the person ’ in their environment and has always included advice on how the body can heal itself given a healthy life style and avoidance of physical, environmental and psychological stresses. These principles are being demonstrated to be valid by increasing amounts of research and should not be forgotten in clinical practice.
After back and neck pain, the most common reason for a patient to seek chiropractic care is headache. The relationship between headaches and disorders of the cervical spine remains controversial. There is considerable disagreement amongst clinicians from different disciplines as to the definition, characteristics, pathological mechanism, diagnosis and treatment of cervicogenic headaches. Simon Dagenais, a senior student at the Los Angeles College of Chiropractic, has assisted me in a review of this topic and has found over 100 papers referencing headaches originating from the cervical spine. The definition of cervicogenic headaches has varied greatly from one author to another and from one society to another. They have been variously described as cervical migraine, spondylitic headache, verfebrogenic headaches and third nerve-occipital headaches. The earliest reference to headaches originating from the cervical spine appears to be by the French neurologist, Barre in 1926. It was, however, Sjaastad who first defined cervicogenic headaches in 1983 and described in detail the characteristics he felt were important in describing this form of
The British Journal
of Chiropractic,
2000; Vol 4, No 2