If you have ever worked with a patient with a pain complaint (of course you have), you know how frustrating defining pain can be. Pain is extremely subjective, and every patient interprets pain differently. Even worse, pain perception is easily manipulated by any number of factors including medications, weather changes and the patient's personal mindset.
The Patient Perspective
It has been my experience that patients will often try to compare their pain to someone else for validation. For example, "I have a higher pain tolerance than most people" actually means "My pain is really bad; worse than what most people could take." On the flip side, patients will try to convince you of the validity of their pain – not because they are malingering, but because they don't think you really believe they have pain, so they feel the need to exaggerate.
Unlike a broken bone, which can be seen on radiographs – or a joint problem that can been evaluated with orthopedic testing – there is no good clinical way to measure the pain a patient is experiencing. This makes pain assessment problematic. Unfortunately, most third-party evaluators often default to a pain score as the prime measure of a patient's pain level.
Why Pain Scores Aren't Enough
I have previously shared in this column an experience I had with an injured worker. With care, we got him off medications and back to work, but he still had a level of pain – even with his improved functional capacity. The case reviewer only focused on the pain score and dismissed the other data regarding decreased medications and increased work status: since he was still in pain, the patient still had a problem. We have to get past that limited notion.
When treating a pain patient, a pain score is helpful, but do not rely on that as the sole measure of a patient's progress. Orthopedic testing, palpation and range-of-motion findings should all be monitored regularly to show changes in the patient's status – and ideally, improvement with your care. As noted above, decreased medication usage and increased work status also represent measured improvements in care.
Oswestry and Neck Disability Index: Are We Using Them Effectively?
Outcomes assessment questionnaires are also easy tools to show a patient's response to care. There are several out there; let's focus on the Neck Disability Index and the Oswestry. These are considered condition-specific tools to measure how patients' perception of their pain affects their ability to perform daily activities. These are considered objective measures and should be a part of baseline examinations and your regular interim re-evaluations.
It has been my experience with file reviews that a few docs use the NDI and/or OSW – but those who do often just perform them and throw the results in the patient's file without any clinical correlation. Documentation in today's health care world requires more.
Each of these questionnaires is 10 questions long. Each question focuses on a specific ADL, with six possible answers ranging from "no pain" to "worst imaginable." Each of these answers scores from 0 to 5. Add up each question and multiply by two – this gives you a score out of 100. Then interpret the scores as follows:
Using these questionnaires regularly as part of your evaluation provides you with another piece of objective data to validate your care. If a patient with lower back pain initially at 46/100 changes to 28/100, you have shown a measured improvement in that patient's functional status with your care!
The Documentation Difference
These outcomes questionnaires are easy to use, but they must also be documented properly. Don't just have the patient fill out the form, bill for it, and then throw it in the file – doing that brings no credibility to your patient care.
I have talked to a number of claim adjusters who note how easy this evaluation is to dispute if the provider never correlates the findings to the patient or the care plan. If you do this component of an evaluation, you must document both the findings and your interpretation in the patient record. A simple notation that it was done, what the score is, and how that impacts your care plan makes all the difference.
To be able to state that you performed an evaluation which measured change in the patient's perception of their pain levels, discussed it in the records, and used it as a measure to continue or modify the care plan can make all the difference.
Let's face it – doing exams is a pain, paperwork is endless, and having to do reports is time consuming. The reality is that your diagnosis must be supported and your care must be justified. I like these tests because they are quick and simple. Copies are easily found online.
It should be easy to add these tests to your exam protocol. Certainly there are other tests, signs and observations to be made in the individual case. The more information you have to confirm your findings, the more secure you will be in your diagnosis and treatment protocol.
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