Individual Planning: A Treatment Plan Overview for Adult with Chronic Pain Problems

Transcription

1 COURSES ARTICLE - THERAPYTOOLS.US Individual Planning: A Treatment Plan Overview for Adult with Chronic Pain Problems A Treatment Plan Overview for Individuals for Adult with Chronic Pain Problems. Duration: 3 hours Learning Objectives: Obtain a basic understanding of how to identifying, causes, symptoms and learning different options to complete a treatment plan that includes: a. Behavioral Definitions b. Long Term Goals c. Short Term Goals d. Strategies to Achieve Goals e. DSM V diagnosis Recommendations ***For a full list of 20 short term goals with dozens strategies listed next to each goal check the Child Treatment App for Windows or Apple PC and Android Devices, under our main menu Windows-Apple Apps. Download the Free Demo to Evaluate*** Course Syllabus:

2 Introduction Pathophysiology Pain management Epidemiology Comorbidities Symptoms Diagnosis and Management Steps to Develop a Treatment Plan that includes Behavioral Descriptors, Long Term Goals, Short Term Goals, Interventions/Strategies and DSM V CODE Paired with ICD_9 and 10-CM Codes for ODD Sample Treatment Plan Introduction: Chronic pain syndrome (Chronic Pain Syndrome) is a common problem that presents a major challenge to health-care providers because of its complex natural history, unclear etiology, and poor response to therapy. [1] Chronic Pain Syndrome is a poorly defined condition. Most authors consider ongoing pain lasting longer than 6 months as diagnostic, and others have used 3 months as the minimum criterion. In chronic pain, the duration parameter is used arbitrarily. Some authors suggest that any pain that persists longer than the reasonably expected healing time for the involved tissues should be considered chronic pain. (See Presentation and Workup.) Chronic Pain Syndrome is a constellation of syndromes that usually do not respond to the medical model of care. This condition is managed best with a multidisciplinary approach, requiring good integration and knowledge of multiple organ systems. Chronic pain has several different meanings in medicine. Traditionally, the distinction between acute and chronic pain has relied upon an arbitrary interval of time from onset; the two most commonly used markers being 3 months and 6 months since the initiation of pain, though some theorists and researchers have placed the transition from acute to chronic pain at 12 months. Others apply acute to pain that lasts less than 30 days, chronic to pain of more than six months duration, and subacute to pain that lasts from one to six months. A popular alternative definition of chronic pain, involving no arbitrarily fixed durations is "pain that extends beyond the expected period of healing."

3 Chronic pain may be divided into "nociceptive" (caused by activation of nociceptors), and "neuropathic" (caused by damage to or malfunction of the nervous system). Nociceptive pain may be divided into "superficial somatic" and "deep", and deep pain into "deep somatic" and "visceral". Superficial somatic pain is initiated by activation of nociceptors in the skin or superficial tissues. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly-localized pain. Visceral pain originates in the viscera (organs). Visceral pain may be well-localized, but often it is extremely difficult to locate, and several visceral regions produce "referred" pain when injured, where the sensation is located in an area distant from the site of pathology or injury. Neuropathic pain is divided into "peripheral" (originating in the peripheral nervous system) and "central" (originating in the brain or spinal cord). Peripheral neuropathic pain is often described as burning, tingling, electrical, stabbing, or pins and needles. Bumping the "funny bone" elicits peripheral neuropathic pain. Pathophysiology: The pathophysiology of chronic pain syndrome (CPS) is multifactorial and complex and still is poorly understood. Some authors have suggested that CPS might be a learned behavioral syndrome that begins with a noxious stimulus that causes pain. This pain behavior then is rewarded externally or internally. Thus, this pain behavior is reinforced, and then it occurs without any noxious stimulus. Internal reinforcers are relief from personal factors associated with many emotions (eg, guilt, fear of work, sex, responsibilities). External reinforcers include such factors as attention from family members and friends, socialization with the physician, medications, compensation, and time off from work. Patients with several psychological syndromes (eg, major depression, somatization disorder, hypochondriasis, conversion disorder) are prone to developing CPS. Various neuromuscular, reproductive, gastrointestinal (GI), and urologic disorders may cause or contribute to chronic pain. Sometimes multiple contributing factors may be present in a single patient. Under persistent activation nociceptive transmission to the dorsal horn may induce a wind up phenomenon. This induces pathological changes that lower the threshold for pain signals to be transmitted. In addition it may generate non nociceptive nerve fibers to respond to pain signals. Non Nociceptive nerve fibers may also be able to generate and transmit pain signals. In chronic pain this process is difficult to reverse or eradicate once established.

4 Chronic pain of different etiologies has been characterized as a disease affecting brain structure and function. Magnetic Resonance Imaging studies have shown abnormal anatomical and functional connectivity, even during rest involving areas related to the processing of pain. Also, persistent pain has been shown to cause grey matter loss, reversible once the pain has resolved. Pain management: Complete and sustained remission of many neuropathies and most idiopathic chronic pain (pain that extends beyond the expected period of healing, or chronic pain that has no known underlying pathology) is rarely achieved, but much can be done to reduce suffering and improve quality of life. Pain management (also called pain medicine) is that branch of medicine employing an interdisciplinary approach to the relief of pain and improvement in the quality of life of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists, and nurse practitioners. Acute pain usually resolves with the efforts of one practitioner; however, the management of chronic pain frequently requires the coordinated efforts of the treatment team. Epidemiology: In a recent large-scale telephone survey of 15 European countries and Israel, 19% of respondents over 18 years of age had suffered pain for more than 6 months, including the last month, and more than twice in the last week, with pain intensity of 5 or more for the last episode, on a scale of 1(no pain) to 10 (worst imaginable) of these respondents with chronic pain were interviewed in depth. Sixty six percent scored their pain intensity at moderate (5 7), and 34% at severe (8 10); 46% had constant pain, 56% intermittent; 49% had suffered pain for 2 15 years; and 21% had been diagnosed with depression due to the pain. Sixty one percent were unable or less able to work outside the home, 19% had lost a job, and 13% had changed jobs due to their pain. Forty percent had inadequate pain management and less than 2% were seeing a pain management specialist. Comorbidities:

5 Chronic Pain Syndrome can affect clients in various ways. Major effects in the client's life are depressed mood, poor-quality or nonrestorative sleep, fatigue, reduced activity and libido, excessive use of drugs and alcohol, dependent behavior, and disability out of proportion with impairment. Chronic pain may lead to prolonged physical suffering, marital or family problems, loss of employment, and various adverse medical reactions from long-term therapy.parental chronic pain increases the risk of internalizing symptoms, including anxiety and depression, in adolescents. A study by van Tilburg et al indicates that adolescents who have chronic pain and depressive thoughts are at increased risk for suicide ideation and attempt. Chronic pain is associated with higher rates of depression and anxiety. Sleep disturbance, and insomnia due to medication and illness symptoms are often experienced by those with chronic pain. Substance abuse is highly prevalent in some segments of the chronic pain population such as those with chronic headache. Chronic pain may contribute to decreased physical activity due to fear of exacerbating pain. Chronic pain impact on cognition is an under-researched area, but several tentative conclusions have been published. Most chronic pain clients complain of cognitive impairment, such as forgetfulness, difficulty with attention, and difficulty completing tasks. Objective testing has found that people in chronic pain tend to experience impairment in attention, memory, mental flexibility, verbal ability, speed of response in a cognitive task, and speed in executing structured tasks. In 2007, Shulamith Kreitler and David Niv advised clinicians to assess cognitive function in chronic pain clients in order to more precisely monitor therapeutic outcomes, and tailor treatment to address this aspect of the pain experience. Symptoms: Chronic pain is often defined as any pain lasting more than 12 weeks. Whereas acute pain is a normal sensation that alerts us to possible injury, chronic pain is very different. Chronic pain persists-often for months or even longer. Chronic pain may arise from an initial injury, such as a back sprain, or there may be an ongoing cause, such as illness. However, there may also be no clear cause. Other health problems, such as fatigue, sleep disturbance, decreased appetite, and mood changes, often accompany chronic pain. Chronic pain may limit a person s movements, which can reduce flexibility, strength, and stamina. This difficulty in carrying out important and enjoyable activities can lead to disability and despair.

6 Chronic pain can range from mild to severe. It can continue day after day or come and go. The pain can feel like: A dull ache Throbbing Burning Shooting Squeezing Stinging Soreness Stiffness Sometimes pain is just one of many symptoms, which can also include: Feeling very tired or wiped out Not feeling hungry Trouble sleeping Mood changes Weakness A lack of energy Other Symptoms to Check for: 1. Pain has lasted for more than 6 months 2. Physical routines limited due to severe pain

7 3. Suffers from generalized muscle pain 4. Suffers from generalized bone pain 5. Suffers from generalized joint pain 6. Debilitating normal functioning 7. Medication offers little relief 8. Medication offers no relief 9. High levels of tension 10. Cluster or chronic headaches 11. Back pain commonly experienced 12. Neck pain commonly experienced 13. Fibromyalgia commonly experienced 14. Neuropathy commonly experienced 15. Interstitial cystitis commonly experienced 16. Experiences irritable bowel movements 17. Intermittent pain of rheumatoid arthritis 18. Pleasurable activities decreased or stopped due to pain 19. Work decreased or stopped due to pain 20. Daily routines decreased or stopped due to pain Diagnosis and Management: Pain is a very personal and subjective experience. There is no test that can measure and locate pain with precision. So, health professionals rely on the patient s own description of the type, timing, and location of pain. Defining pain as sharp or dull, constant or on-and-off, or burning or aching may give the best clues to the cause of the pain. These descriptions are part of what is called the pain history, taken during the start of the evaluation of a patient with pain. Since chronic pain may occur in a variety of locations in the body and for many different reasons, patients and their health professionals need to work together to identify the causes and symptoms of that pain and how it can be relieved.

8 Although technology can help health professionals form a diagnosis, the best treatment plans are tailored to the person, with input from healthcare team members, who each have different training backgrounds and understand chronic pain. The person with pain and his or her loved ones also must be actively involved in the treatment. With chronic pain, the goal of treatment is to reduce pain and improve function, so the person can resume day-to-day activities. Patients and their healthcare providers have a number of options for the treatment of pain. Some are more effective than others. Whatever the treatment plan, it is important to remember that chronic pain usually cannot be cured, but it can be managed. The following treatments are among the most common ways to manage pain. Medications, acupuncture, electrical stimulation, nerve blocks, or surgery are some treatments used for chronic pain. Less invasive psychotherapy, relaxation therapies, biofeedback, and behavior modification may also be used to treat chronic pain. These methods can be powerful and effective in some people. When it comes to chronic pain treatment, many people find adding complementary or alternative medicine (CAM) approaches can provide additional relief. These may include tai chi, acupuncture, meditation, massage therapies, and similar treatments. Self-management of chronic pain holds great promise as a treatment approach. In self-management programs, the individual patient becomes an active participant in his or her pain treatment-engaging in problem-solving, pacing, decision-making, and taking actions to manage their pain. Although self-management programs can differ, they have some common features. Their approach is that the person living with pain needs help learning to think, feel, and do better, despite the persistence of pain. Improving communication with the healthcare provider is part of that empowerment. Individuals who participate in these programs have significantly increased their ability to cope with pain. They improve their ability to be active, healthy, and involved members of their communities. In fact, new research suggests that the best self-management programs teach people different ways of thinking about and responding to pain, making their actions to relieve it more effective. Steps to Develop a Treatment Plan:

9 The foundation of a good treatment plan is based on the gathering of the correct data. This involves following logical steps the built-in each other to help give a correct picture of the problem presented by the client or patient: The mental health clinician must be able to listen, to understand what are the struggles the client faces. this may include: issues with family of origin, current stressors, present and past emotional status, present and past social networks, present and past coping skills, present and past physical health, self-esteem, interpersonal conflicts financial issues cultural issues There are different sources of data that may be obtained from a: clinical interview, Gathering of social history, physical exam, psychological testing, contact with client s or patient s significant others at home, school, or work

10 The integration of all this data is very critical for the clinician s effect in treatment. It is important to understand the client s or patient s present awareness and the basis of the client's struggle, to assure that the treatment plan reflects the present status and needs of the client or patient. There 5 basic steps to follow that help assure the development of an effective treatment plan based on the collection of assessment data. Step 1, Problem Selection and Definition: Even though the client may present different issues during the assessment process is up to the clinician to discern the most significant problems on which to focus during treatment. The primary concern or problem will surface and secondary problems will be evident as the treatment process continues. The clinician may must be able to plan accordingly and set some secondary problems aside, as not urgent enough to require treatment at this time. It is important to remember that an effective treatment plan can only deal with one or a few problems at a time. Focusing in too many problems can lead to the lost of direction and focus in the treatment. It is important to be clear with the client or patient and include the client s or patient s own prioritization of the problems presented. The client s or patient s cooperation and motivation to participate in the treatment process is critical. Not aligning the client to participate my exclude some of the client s or patient s needs needing immediate attention. Every individual is unique in how he or she presents behaviorally as to how the problem affects their daily functioning. Any problems selected for treatment will require a clear definition how the problem affects the client or patient. It is important to identify the symptom patterns as presented by the DSM-5 or Diagnostic and Statistical Manual or the International Classification of Diseases (ICD).

11 BEHAVIORAL DEFINITIONS FOR ADULTS SUFFERING CHRONIC PAIN: 1. Physical routines limited due to severe pain that has lasted six months or more, beyond standard time of healing process. 2. Suffers from generalized joint, muscle, and bone pain, debilitating normal functioning. 3. Medication offers little or no relief, even with strengthened dosage. 4. Tension, cluster or chronic headaches, and migraines common. 5. Back and or neck pain, fibromyalgia, neuropathy, and interstitial cystitis commonly experienced. 6. Experiences irritable bowel movements and intermittent pain of rheumatoid arthritis. 7. Pleasurable, work, and or daily routines decreased or stopped due to pain. 8. Strengthened occurrences of fatigue, insomnia, body aches, muscle tension, night sweats, loss of concentration, and memory loss. 9. Shows symptoms of depression. 10. Negative and victimizing statements such as, Why did this happen to me? or, I give up. Step 2, Long Term Goal Development: This step requires that the treatment plan includes at least one broad goal that targets the problem and the resolution the problem. These long term goals must be stated in non-measurable terms but instead indicate a desired positive outcome at the end of treatment. LONG TERM GOALS FOR ADULTS SUFFERING CHRONIC PAIN: 1. Develop and apply pain management skills. 2. Learn to regulate pain to strengthen daily performance and go back to active `

12 employment. 3. Emancipate self from pain and develop improved gratification in accomplishing everyday routines. 4. Develop a defense and or escape mechanism from pain. 5. Decrease amount of daily suffering from pain. 6. Obtain control again over his or her life. Step 3, Objective or Short Term Goal Construction: Objectives or short term goals must be stated in measurable terms or language. They must clearly specify when the client or patient can achieve the established objectives. The use of subjective or vague objectives or short term goals is not acceptable. Most or all insurance companies or mental health clinics require measurables objectives or short term goals. It is important to include the patient s or client s input to which objectives are most appropriate for the target problems. Short term goals or objectives must be defined as a number of steps that when completed will help achieve the long-term goal previously stated in non measurable terms. There should be at least two or three objectives or short-term goals for each target problem. This helps assure that the treatment plan remains dynamic and adaptable. It is important to include Target dates. A Target day must be listed for each objective or short-term goal. If needed, new objectives or short-term goals may be added or modified as treatment progresses. Any changes or modifications must include the client s or patient s input. When all the necessary steps required to accomplish the short-term goals or objectives are achieved the client or patient should be able to resolve the target problem or problems. If required all short term goals or objectives can be easily modify to show evidence based treatment objectives. The goal of evidence based treatment objectives (EBT) is to encourage the use of safe and effective treatments likely to achieve results and lessen the use of unproven, potentially unsafe treatments. To use EBT in treatment planning state restate short term goals in a way that steps to complete that goal and achieve results. For example, the short term goal 13. Increase positive self-descriptive statements. Can be restated as; By the end of the session the patient or client will list at least 5 positive self descriptions of himself or herself, and assess how they can help alleviate the presenting problem Remember, that it must be stated in a way one can measure effectiveness.

13 It is important to note that traditional therapies usually rely more heavily on the relationship between therapist and patient and less on scientific evidence of proven practices. EXAMPLES OF SHORT TERM GOALS FOR ADULTS SUFFERING CHRONIC PAIN: 1. Express the description of, record of, and the causes for chronic pain. 2. Recognize how pain has made an influence on daily routines. 3. Express the mood and attitude modifications that have been tied with the experience of chronic pain. 4. Finish a Finish medical assessment to cancel out any other causes for the pain and any new treatment possibilities. 5. Continue on suggestion to pain management or rehabilitation program. Step 4, Strategies or Interventions: Strategies or interventions are the steps required to help complete the short-term goals and long-term goals. Every short term goal should have at least one strategy. In case, short term goals are not met, new short term goals should be implemented with new strategies or interventions. Interventions should be planned taking into account the client s needs and presenting problem. EXAMPLES OF STRATEGIES OR INTERVENTIONS FOR ADULTS SUFFERING CHRONIC PAIN: 1. Gather a record and current condition of the chronic pain being or been experienced. 2. Acknowledge the modifications in social, occupational, domestic, and intimacy roles that

14 have happened in adjustment to the pain. 3. Acknowledge the client's emotional reaction and thought process in response to the chronic pain. 4. Recommend client to a physician, complete an assessment to cancel out any undiagnosed condition and to receive suggestions on any other treatment options. 5. Inform client on the different options of pain treatment specialists or rehabilitation programs that are accessible and help him or her decide on which would be the optimum choice for him or her. Step 5, Diagnosis: The diagnosis is based on the evaluation of the clients present clinical presentation. When completing diagnosis the clinician must take into account and compare cognitive, behavioral, interpersonal, and emotional symptoms as described on the DSM-5 Diagnostic Manual. A diagnosis is required in order to get reimbursement from a third-party provider. Integrating the information presented by the DSM-5 diagnostic manual and the current client s assessment data will contribute to a more reliable diagnosis. it is important to note that when completing a diagnosis the clinician must have a very clear picture all behavioral indicators as they relate to the DSM-5 diagnostic manual. DSM V Code Paired with ICD_9-CM Codes (Parenthesis Represents ICD-10-CM Codes Effective ): Possible Diagnostic Suggestions for Adults Suffering Chronic Pain: Somatic Symptom and Related Disorders (F451) Somatic Symptom Disorder Specify if: With predominant pain - Persistent Specify current severity: Mild, Moderate, Severe

15 300.7 (F45.21) Illness Anxiety Disorder Specify whether: Care seeking type, Care avoidant type (. ) Conversion Disorder (Functional Neurological Symptom Disorder) Specify symptom type: (F44.4) With weakness or paralysis (F44.4) With abnormal movement (F44.4) With swallowing symptoms (F44.4) With speech symptom (F44.5) With attacks or seizures (F44.6) With anesthesia or sensory loss (F446) With special sensory symptom (F44J) With mixed symptoms Specify if: Acute episode, Persistent Specify if: With psychological stressor (specify stressor), Without psychological stressor 316 (F54) Psychological Factors Affecting Other Medical Conditions Specify current severity: Mild, Moderate, Severe, Extreme (F68.10) Factitious Disorder (includes Factitious Disorder Imposed on Self, Factitious Disorder Imposed on Another) Specify Single episode, Recurrent episodes (F45.8) Other Specified Somatic Symptom and Related Disorder (F45.9) Unspecified Somatic Symptom and Related Disorder (F34.8) Disruptive Mood Dysregulation Disorder

16 Major Depressive Disorder Single episode (F32.0) Mild (F32.1) Moderate (F32.2) Severe (F32.3) With psychotic features (F32.4) In partial remission (F32.5) In full remission (F32.9) Unspecified Recurrent episode (F33.0) Mild (F33.1) Moderate (F33.2) Severe (F33.3) With psychotic features (F33.41) In partial remission (F33.42) In full remission (F33.9) Unspecified (F34.1) Persistent Depressive Disorder (Dysthymia) Specify if: In partial remission, In full remission \ Specify if: Early onset, Late onset Specify if: With pure dysthymic syndrome; Willi persistent major depressive episode; With intermittent major depressive episodes, will current episode; With intermittent major depressive episodes, without current episode

17 Specify current severity: Mild, Moderate, Severe (N94.3) Premenstrual Dysphoric Disorder Substance/Medication-Induced Depressive Disorder Depressive Disorder Due to Another Medical Condition Specify if: (F06.31) With depressive features (F06.32) With major depressive-like episode (F06.34) With mixed features 311 (F32.8) Other Specified Depressive Disorder 311 (F32.9) Unspecified Depressive Disorder Obsessive-Compulsive and Related Disorders The following specifier applies to Obsessive-Compulsive and Related Disorders where indicated: Specify if: With good or fair insight, With poor insight, With absent insight/delusional beliefs (F42) Obsessive-Compulsive Disorder Specify if: Tic-related (F45.22) Body Dysmorphic Disorder Specify if: With muscle dysmorphia (F63.2) Trichotillomania (Hair-Pulling Disorder) (L98.1) Excoriation (Skin-Picking) Disorder Substance/Medication-Induced Obsessive-Compulsive and Related Disorder (F06.8) Obsessive-Compulsive and Related Disorder Due to Another Medical Condition

18 Specify if: With obsessive-compulsive disorder-like symptoms (F42) Other Specified Obsessive-Compulsive and Related Disorder (F42) Unspecified Obsessive-Compulsive and Related Disorder Trauma- and Stressor-Related Disorders (F43.1 0) Posttraumatic Stress Disorder (includes Posttraumatic Stress (F43.0) Acute Stress Disorder Overall Integration of a Treatment Plan: Choose one presenting problem. This problem must be identified through the assessment process. Select at least 1 to 3 behavioral definitions for the presenting problem. if a behavior definition is not listed feel free to define your own behavioral definition. Select at least one long-term goal for the presenting problem. Select at least two short-term goals or objectives. Add a Target Date or the number of sessions required to meet this sure term goals. If none is listed feel free to include your own. Based on the short-term goals selected previously choose relevant strategies or interventions related to each short term goal. If no strategy or intervention is listed feel free to include your own. Review the recommended diagnosis listed. Remember, these are only suggestions. Complete the diagnosis based on the client's assessment data. Sample Treatment Plan: Behavioral Descriptors of Problem:

19 Physical routines limited due to severe pain that has lasted six months or more, beyond standard time of healing process. Tension, cluster or chronic headaches, and migraines common. Long Term Goals: Develop and apply pain management skills. Develop a defense and or escape mechanism from pain. Short Term Goals Objectives: Continue on suggestion to pain management or rehabilitation program. Recognize dysfunctional attitudes about pain that serves as the basis for pain being the focal point of life. Strategy or Intervention for Goal 1: Recommend client to a physician, complete an assessment to cancel out any undiagnosed condition and to receive suggestions on any other treatment options. Inform client on the different options of pain treatment specialists or rehabilitation programs that are accessible and help

20 Strategy or Intervention for Goal 2: Acknowledge the client's emotional reaction and thought process in response to the chronic pain. Process pain journal with client to increase insight into triggers of pain and the nature of the pain and what interventions. Diagnostic Suggestions: (F451) Somatic Symptom Disorder With predominant pain - Persistent Copyright 2011 THERAPYTOOLS.US All rights reserved