In addition to a standard medical and surgical history, special attention is given to determining the extent to which historic
factors may have an impact on future function. The following are typical scenarios that may be encountered with a patient with chronic pain:

The ways in which patients take their medication is just as important as what they take. Frequent use of short-acting analgesics can encourage learned helplessness and passivity
about self-management of pain and may imply that the patient has no internal resources to cope with normal fluctuations in pain intensity. As a correlate to this, it is important to determine whether patients use any other nonpharmacologic approaches to pain management such as distraction, relaxation, ice, heat, and stretching. Assess whether there is large affective component to the painful sensations and the use of medications by the words the patient uses to describe his or her symptoms. Analgesics are often used to relieve emotional distress more than to treat nociceptive pain. Sustained release formulations or agents with a long half-life are much less likely to treat emotional distress rather than nociceptive pain. Assess whether there is a functional improvement in addition to pain relief while using analgesics. In other words, does the patient do more if he or she is in less pain? This assessment can help determine whether a patient truly benefits from a medication.

In addition to determining what interventional treatments have been performed, the patient’s attitudes about these treatments should be explored. Overuse of interventional approaches can lead to passivity and learned helplessness in the face of chronic pain and should be avoided. The nature of prior physical rehabilitation should be determined. There are two broad categories: passive, or modality-driven and hands-on treatments, versus active, or patient-driven, participatory treatments. An active approach is preferable in a chronic situation and should be ordered if the patient has not taken this approach. If patients have failed an active rehabilitation program, it is important to determine the cause. Patients who are fearful of increased pain during treatment or who believe that they are at risk of harm because of the pain will often require active psychological treatment in conjunction with continued active therapy to address this issue. Some increase in pain, initially, is unavoidable in an active functional restoration process. Often, appropriate therapeutic injections and medications can be used to ameliorate the pain to help encourage more active participation in the rehabilitation process. Medications or invasive treatments alone are unlikely to improve function in a chronic situation.

An accurate assessment of a patient’s functional status can be difficult to ascertain in a medical interview. Specifically asking “What can’t you do?” rather than “What can you do?” can often make it easier to pinpoint the patient’s functional limitations. If patients don’t give details, assess the status of major functional domains such as self-care, household chores, shopping, driving, and, if relevant, work. Determine the patient’s level of function prior to the onset of the pain syndrome; this will help set the goals of treatment. If it seems unreasonable to return a patient to his or her former functional status on the basis of the clinical presentation, vocational counseling may be indicated. However, do not assume that because other doctors, including surgeons, have reinforced the patient’s disability, they are right. Numerous studies have shown that even after spinal surgery, patients can return to their former work capacity if motivated to
do so. Determine the drive time to the office visit to better assess a patient’s sitting tolerance. Always ask about the patient’s leisure and avocational activities. This information may help determine inconsistencies with reported functional intolerances and may also give clues about possible anergia and depression.

It is important to assess the patient’s emotional support system. Will the patient’s home environment interfere with treatment or be supportive of treatment? Emotional traumas, either as a child or as an adult, can have a negative impact on prognosis, and appropriate psychologic assessment should be instituted if there is evidence of these historic factors. Depression is a common comorbid problem in chronic pain and should not require any alterations in the treatment plan other than the inclusion of psychiatric assessment and management. In the case of severe psychomotor retardation or mania, however, mental health stabilization would be required before any other pain treatments are initiated. A similar approach should be taken if Axis II pathology, such as sociopathic behavior, severe narcissistic personality disorder, or borderline personality disorder, is suspected. Readiness to change or motivation can be assessed. If the patient has realistic goals and plans that do not depend on the complete elimination of pain, the readiness to change is a positive indicator of treatment success.

Family history of disability can be a negative prognostic indicator. If there are strong role models of disabled family members, the patient’s perception of these family members may help predict the patient’s potential for functional recovery. Ongoing litigation can interfere with instituting a successful treatment plan. Probe what the patient’s thoughts are about the case and ask if returning the patient to their former functional status would have negative legal or financial repercussions. In some cases, it is best to put treatment on hold until the litigation is settled. Financial status should be assessed because this may be a barrier to treatment. At times, financial duress also can be a motivator.

Structural assessment is an essential component of a physiatric physical examination both for diagnostic and functional purposes. Pain—and, in particular, chronic pain—causes considerable alteration in body mechanics. Even when the principal nociceptor involved has been successfully treated, pain perpetuation and continued disability can often occur if normal structure, strength, and physical conditioning have not been restored.

Antalgic gaits are common in patients with chronic pain. Pain behaviors can be seen during this phase of assessment. Use of assistive devices, except in the older patients, is usually a sign of illness behavior and is rarely necessary for safety. A compensated Trendelenberg gait is a sign of hip abductor weakness, due either
to true neurologic weakness (rare) or to reflex inhibition of the hip abductor caused by sacroiliac (SI) joint inflammation from hip joint disease. A vaulting gait over one leg may indicate leg length discrepancy, which puts stress on postural structures and may be a perpetuating factor in spinal pain syndromes.

Congenital scoliosis can be distinguished from a functional or acquired scoliosis by forward flexion of the spine bringing out the rotatory component of congenital scoliosis, indicated by a hump sign in the thoracic region (Adams test). Acquired scoliosis is due to asymmetric muscle shortening of spinal extensors and lateral flexors. This asymmetric muscle shortening will often cause a cross pattern of pain, with discomfort on the ipsilateral side of the shortened muscles in the low back and on the contralateral side in the scapular and cervical regions. Regardless of the cause, if not addressed in physical rehabilitation, acquired scoliosis will be a cause of pain perpetuation. Apparent short leg syndrome (ASLS)

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