Rehabilitation presentations
The speciality of rehabilitation medicine is involved in the management of multiple pain presentations.
Referrals are made to rehabilitation medicine physicians for diagnostic and therapeutic advice and as part of a multidisciplinary team, spanning inpatient, outpatient, and community care.
A biopsychosocial approach is central to the management of pain conditions by rehabilitation medicine physicians.
Conditions
- Cancer-related pain
- Central pain due to brain damage, multiple sclerosis, Parkinson disease, spinal cord
- Central sensitisation
- Chronic inflammatory and non-inflammatory arthritides
- Chronic pain syndrome
- Complex regional pain syndrome (CRPS)
- Degenerative changes and mechanical pain of the spine
- Headache
- Myofascial pain
- Nerve root and peripheral nerve syndromes, including nerve entrapments, small fibre neuropathy
- Persistent post-surgical pain syndromes – abdominal, chest, joints, pelvic, spine
- Postoperative pain
- Somatic referred pain
- Spinal pain including zygapophysial and sacroiliac joints, disc, stenoses, muscle origin
- Stump and phantom pain
Associated conditions
- Addiction
- Dependence
- Tolerance
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Conditions
- Deafferentation pain
- Trigeminal neuralgia
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients' needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
- Biopsychosocial model of chronic pain and illness
- Define the following terms and describe their neurobiological basis:
- allodynia
- central sensitisation
- hyperalgesia
- hyperpathia
- Epidemiology of chronic pain:
- common causes
- incidence
- morbidity and mortality
- natural history
- prevalence
- Number needed to treat (NNT) success rates, statistical significance, placebo, and nocebo, with respect to clinical assessment and treatment
- Placebo, nocebo, and expectancy
Major dichotomies
- Acute pain versus chronic pain
- Chronic non-cancer pain versus chronic cancer-associated pain
Somatic descriptors of pain
- Neuropathic, including central pain due to spinal cord and brain damage, nerve root and peripheral nerve syndromes, including nerve entrapment, phantom pain, post-stroke pain, and some cases of post-operative pain
- Nociceptive, such as arthritis, fractures, ischaemia, soft tissue injuries, and some cases of post-operative pain
- Nociplastic, such as “fibromyalgia”, and conditions characterised by visceral hyperalgesia, such as chronic pancreatitis or irritable bowel syndrome
Special understanding
- Incident pain versus “breakthrough” pain versus background pain:
- end-of-life pain
Investigations
- Radiological and electrodiagnostic investigation
- CT scan
- MRI
- nerve conduction studies
- precision image-guided diagnostic and therapeutic procedures
- single photon emission computerized tomography (SPECT)
- X-Ray
Clinical assessment tools
- Functional capacity, including but not limited to:
- Oswestry Disability Index
- Rowland–Morris Pain Questionnaire
- Pain-related factors, including:
- Depression, Anxiety, Stress Scale
- Fear Avoidance Behaviour Questionnaire
- McGill Pain Questionnaire
- Pain Catastrophising Scale
- Pain perception – personal beliefs and perceptions inventory
- Visual Analogue Scale, Numerical Rating Scale
- Psychological consequences, including:
- Beck Depression Scale
- Coping Strategies Questionnaire
- Illness Behaviour Questionnaire
- Minnesota Multiphasic Personality Inventory (MMPI)
- Quality of life, including:
- short form health survey
- Sickness Illness Profile
Assessing function
- Establish treatment goals and expectations of patients and their families or carers
- The impact of chronic pain on functioning, e.g. activities of daily living, depression, sleep, social functioning, social isolation, reduced mobility
Awareness of risks, benefits and expectations of procedures in pain medicine, including but not limited to:
- Epidural anaesthetics, steroids
- Intrathecal pump
- Ketamine infusion
- Local anaesthetic and regional blockade, including fluoroscopic and ultrasound-guided procedures
- Medial branch block
- Multifidus muscle stimulation
- Nerve root injection
- Percutaneous electrical nerve stimulation (PENS)
- Provocation discography
- Radiofrequency neurotomy
- Spinal cord stimulator
- Sympathetic blocks including ganglion impar, lumbar sympathetic, and stellate ganglion
Awareness of techniques of surgical management (past and present), including:
- Cordotomy, neurectomy, and stereotactic procedures
- Describe a multidisciplinary pain management program
- Implanted spinal pumps
- Spinal and multifidus stimulation and implanted nerve stimulators
Drug interventions for chronic benign pain
- Corticosteroids
- Drug rationalisation and detoxification
- Non-narcotic analgesics
- Opioid analgesics
- Placebo response
Functional restoration activities
- ADL retraining
- Energy conservation
- General activity and fitness training
- Leisure, sport, and domestic activities
- Work hardening and vocational resettlement
General principles
- Aggravating and relieving factors
- Cognitive impairment and the impact on patient’s ability to report pain
- Components of, and expectations of, multidisciplinary pain programs
- Current pain severity
- Dignity and pain
- Factors associated with engagement and adherence to treatment
- Nature and efficacy of present treatment
- Nature of, and effectiveness of, rehabilitation interventions
- Nonorganic signs
- Signs of deconditioning
- Pain descriptors
- Patient expectations of future treatment
- Patient perception of the nature of pain
- Psychosocial aspects of pain in assessment and management
- Role of a multidisciplinary team approach for management of persistent pain
- Type and effectiveness of past treatment
Physical modalities and therapies
- Acupuncture
- Exercise therapy
- Interferential therapy
- Microwave
- Short wave diathermy
- Therapeutic heat and cold
- Transcutaneous electrical nerve stimulation (TENS)
- Low level laser therapy
Psychotropic drugs
- Antidepressants
- Antineuritics
Psychological intervention
- Cognitive and behavioural strategies, behaviour modification
Social contexts of chronic pain
- Assessment of anxiety, depression, PTSD
- Assessment of pain behaviour and lifestyle
- Behavioural responses to pain
- Lived environment, including financial impacts
- Neuroscience pain education
- Psychology and pain management
- Relaxation training and hypnosis
- Resource accessibility, affordability, and availability
- Societal attitudes and beliefs
- Stress management
- Workplace factors
