Evaluation Process Flow Chart

Full evaluation includes the following:

Medical Evaluation

Objective:

The emphasis in the history is on the pain. It is no longer adequate to record the specific elements of the medical history and physical examination that led to the initial differential diagnosis. The essential points include the circumstances at the onset of the pain and its initial presentation. Particularly of import is the description of the present pain.

A thorough history is taken, as it is not unusual for the history to be the major source of data for the diagnostic work up. The Care Center physician will use the history and any other medical records obtained to develop an understanding of the relationship between the chief complaint and the patient’s overall current health status.

Any and all past illnesses will be documented. Old pain will be separated from new pain, as well as new exacerbations of the old pain mechanisms. The amount of analgesics used by the patient will be quantified, and specific treatment is determined in order to reduce the patient’s medication intake.

A thorough system review is performed to identify symptoms that are ordinarily associated with a dysfunction in different somatic systems.

Behavior Modification/Cognitive Restructuring Evaluation:

Objective:

The goals of cognitive behavioral therapy ( CBT) are focused on changing maladaptive behaviors and thoughts, attitudes, or beliefs that precede those behaviors. Results of successful therapy include increased functional ability and decreased pain-related anxiety and depression.

For those patients who do not respond to acute care, the thirty-day point marks the beginning of the acquisition of the role and mental framework of the chronic pain patient. As time goes by, and unsuccessful treatments and modalities increase, iatrogenically introduced problems increase.

A history of failed interventions, numerous referrals to specialists, and experience with care-giver frustration, impatience or indifference can have profound psychological consequences--destroying all motivation to actively work to "get better".

The purpose of the psychological evaluation is to:

• Identify and assess factors that might contribute to the experience of pain.
• Identify factors that adversely affect the patient's response to treatment.
• Identify problems secondary to pain complaint.
• Assist in identifying a reasonable set of treatment goals.
• Formulate a plan to meet the goals.

A full behavioral work-up and evaluation are done, identifying any red flag areas such as secondary gain, possible addiction problems or counterproductive socio-familial situations.

The goal of intervention is to correct faulty thought processes that contribute to prolonged suffering, disability, and maladaptive beliefs. Cognitive-Behavioral techniques (CBT) attempt to alter patterns of negative thoughts and dysfunctional attitudes in order to foster more healthy and adaptive thoughts, emotions, and actions. Behavioral treatment is done within a therapeutic mileu with a goal of dealing with the direct effects of the pain upon the patient.

The professional staff meets at regular intervals to discuss each patient’s problems and progress. Any modification in treatment and/or goals are discussed at this time. The patient is both in attendance and encouraged to share any input. As in all areas of the program, the patient's active participation is necessary for success.

PHYSICAL THERAPY/FUNCTIONAL EVALUATION

Objective:

The role of physical therapy in the management of patients with pain is to evaluate their involved tissue for stage of healing and possible biomechanical causative factors that contribute to the pathology. We work to increase circulation in treatment areas, which assist in blood and lymph, return. We use friction techniques to soften and loosen adherent scar tissue or dense connective tissue bands. We work to shift the emphasis from applying pain-relieving modalities to developing pain relieving behaviors.

Physical therapy requires total patient participation in an active rather than passive program. Restoration of full function and endurance is the primary goal. The patient is educated in anatomy, body mechanics, work ergonomics that will enable the individual to return to a previous lifestyle and employment with new and improved postures and body mechanics.

The patient learns appropriate exercises to recondition and strengthen the muscles. The focus is not only in the area of strength and endurance of the injured areas but also on the general condition of the individual. There is emphasis on work simplification with appropriate proper body mechanics, activity assimilation, psychologic support, job analysis and functional capacity assessments.

The patient is also required to transfer these exercises to a home program as soon as possible. The Care Center then monitors the home program with regards to adjustments and outcome. Passive "shake and bake" modalities are avoided.

OCCUPATIONAL EVALUATION

Objective:

Activity levels and functional status are evaluated in the areas of work, play and self-care. The focus is on a wellness. The patient’s strengths are determined and treatment is begun by building upon established strengths. The goal is to increase well behaviors and functional activities in areas where a role dysfunction is identified. Purposeful activity is used in intervention.

In occupational therapy the behavior frame of reference is used to guide assessment procedures and treatment considerations. Work and play histories are taken, daily activity levels are assessed and current vocational and avocational interests and skills are reviewed. The individual’s future plans, personal concept of health and wellness and expectations of the Care Center pain team are determined. Recommendations are then made to bring into balance levels of activity and inactivity and the areas of work and play. In addition, patient education regarding individual responsibility for health care is often recommended.

ACUPUNCTURE EVALUATION

Objective:

Acupuncture is an adjunct to any active physical therapy program. It is not intended to act as long-term palliative treatment, but in conjunction with aggressive physical therapy, as a functional restoration program with a focus on returning to work.

The physiological effects of acupuncture include mild analgesia, improvement in blood circulation in areas where injury-healing process has obstructed normal blood flow and resulted in ischemia. It is also helpful in relieving pain secondary to muscle spasm and muscle tightness and tension. Acupuncture reduces pain levels by raising endorphin levels in various parts of the central nervous system. Acupuncture as analgesic helps to alleviate stiffness/soreness associated with the rigors of the proactive type of physical therapy accomplished in the program. Acupuncture-responsive patients have a higher level of pain tolerance and perceive it less than the average patient.

Acupuncture also assists in more difficult to quantify areas such as relaxation and mood elevation. In a rigorous treatment program requiring total and active compliance by the patient, acupuncture enables manipulation with regards to attitude and adherence.

BIOFEEDBACK EVALUATION

Objective:

The goals of biofeedback are to enable the patient to identify and modify muscle tension in the body. Biofeedback focuses on teaching the patient to become aware of their body response by targeting specific muscles. The patient may not be aware of the tension decreases or increases and the affect, the training and the equipment assists in awareness. It will further decrease autonomic arousal in general and decrease emotional distress as well. Biofeedback goals include locus of control, teaching the patient not to internalize outside stressors resulting in increased pain.

Biofeedback addresses the interrelation of distorted patterns that develop between muscle dysfunction, poor ergonomic habits, autonomic nervous system reactivity and the individual's unique response to stress.

This modality assesses the patient’s current level of performance and teaches the patient self-regulation skills to help ameliorate these specific and generalized problem areas.

An evaluation may include multiple site surface EMG muscle assessment, work site ergonomic analysis using EMG and video, and a multi-modality psychophysiological profile (EMG, peripheral thermal, electrodermal activity), and a personal interview.

Once problem areas are identified, biofeedback together with various ancillary techniques can facilitate muscle, ergonomic, and autonomic nervous system reeducation-- thus helping the patient moderate affecting dysfunctional response to stress.

Reduction in autonomic arousal can lead to a corresponding reduction in pain. Patients must become more aware of their own contribution to the pain experience and their ability to influence the pain. The patient is taught to bring involuntary responses under voluntary control.