complicating factors.
Table 9.3 Biopsychosocial model: with examples for each Bio – Psycho – Social model: the details.
| Biological | Psychological | Social |
|---|---|---|
| Disc/vertebral degeneration | Depression | Smoking |
| Facet joint arthritis | Anxiety | Poor ergonomics |
| Ingrowth of pain‐type nerve endings | PTSD | Lack of exercise |
| Ligamentous stretch or hypertrophy | Post‐TBI | Stress |
| Muscle strain | Other mental illness | Physical demands |
| Radiculopathy | Dysphoria | Poor sleep |
| Altered central pain processing | Somatic focus | De‐conditioning |
| Low self‐efficacy | Lack of social support | |
| Substance abuse | Expectations | |
| Personality d/o |
Openness to treatments – foundations of MI
A useful way to assess openness to treatments is, besides asking the patient what treatments they are interested in, is to use a check sheet as part of the check‐in or counseling process. See Chapter 16 and Appendix 5.
Social history and work–life
The role of professional work–life in the social history has fallen from vogue but serves a central purpose in understanding the patient's everyday jargon and cognitive frame.
A check‐in form (or tablet protocol) that efficiently assesses pain can allow a provider to track changes over time, screen for opioid abuse risk, and provide valuable diagnostic information, in addition to conveying information about other prescription medicines, dietary supplements, exercise patterns, social habits, and comorbid conditions.
References
1 Cole, S.A. and Bird, J. (2013). The Medical Interview: The Three Function Approach with Student Consult Online Access, 3e. Philadelphia, PA: Saunders.
2 Frankel, R.M. and Stein, T. (2001). Getting the most out of the clinical encounter: the four habits. The Journal of Medical Practice Management 16 (4): 184–191.
3 McCormack, L., Treiman, K., Olmsted, M. et al. (2013). Advancing Measurement of Patient‐Centered Communication in Cancer Care. Effective Health Care Program Research Report No. 39. (Prepared by RTI DEcIDE Center under Contract No. 290‐ 2005‐0036‐I.) AHRQ Publication No. 12(13)‐EHC057‐EF. Rockville, MD: Agency for Healthcare Research and Quality.
4 Miller, W.R. and Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change, 2e. New York: Guilford Press.
5 Murinson, B.B., Agarwal, A.K., and Haythornthwaite, J.A. (2008). Cognitive expertise, emotional development, and reflective capacity: clinical skills for improved pain care. The Journal of Pain 9 (11): 975–983.
6 Rogers, C. (1967). The interpersonal relationship in the facilitation of learning. In: Humanizing Education (ed. R. Leeper), 1–18. Alexandria, VA: Association for Supervision and Curriculum Development.
10 Assessing pain in those with communication barriers
In those with communication barriers, pain assessment requires adaptations depending on the nature of the barrier.
Speech barriers
Speech barriers can include dysarthria, aphasia, and developmental disturbances of speech. Dysarthria is a motor difficulty in speech production that makes it difficult to understand what a person is saying but without cognitive defects consider writing, picture boards, or alternative words. Dysarthria may arise from damage to the right frontal region which can also result in personality changes making people more critical and less flexible. These personality changes can frustrate family members and may lead to behavioral challenges. Conversely, expressive aphasia reflects dysfunction of the left frontal lobe, it limits a patient's ability to verbalize what they wish to communicate, they will know what they want to say and can understand instructions well, these patients can participate effectively in physical therapy. Receptive aphasia, in which patients cannot understand what is being said, is more challenging as patients cannot always understand instructions and depending on the baseline personality may have variable inclinations to mimic gestures by cueing. There are more complex aphasias as well. Unfortunately, patients with aphasia often cannot communicate through written mediums. In this case, pain assessment may be limited to behavioral assessments. It is feasible in this context to utilize gentle provocative testing to elicit relevant pain features. For example, rebound tenderness in the abdomen will still produce the clinically relevant response. A systematic effort to uncover painful areas, painful movements, or pain on palpation may be the best available information. Sometimes pantomiming, drawing pictures or bringing pictures up on the computer screen can elicit the bright smile of understanding from a patient who is otherwise withdrawn and absorbed in morose frustration.
Hearing barriers
These may be surmountable using communication tools: written questionnaires, computer assistance, or a signing interpreter. If a patient has not been formally educated, as can happen in low resource countries, a family member may be essential for communicating in the “home language.” Be aware that patients may nod to indicate receptiveness not necessarily understanding or assent. It is important to check for understanding affirmatively despite communication barriers.
Language barriers
The use of professional translation is preferred for obtaining a multidimensional pain history. Family members should generally not provide translation services as there is a complex interaction between culture and pain communication.
Socioemotional barriers
Some patients have psychological or socioemotional barriers to communicating about pain. Clinically‐diagnosed malingering and factitious disorder are rare; addiction can be associated with manipulation of clinical findings but this is complex (Chapter 46). Occasional patients are reluctant to return to work, attempt to assuage difficulties
