E-22 Chronic pain
The relief of pain and suffering must be the pre-eminent goal of healthcare. Diagnosis and treatment come next. The palliative care competency has already addressed these issues, but given the crucial importance of reducing pain and the effects of pain, a specific competency is required. Rehabilitation experts should all be experts at assessing and managing patients with pain, just as competent as specialists in pain management; the primary difference is that pain management experts may have additional technical skills in invasive techniques that a rehabilitation expert lacks. In the UK, pain management medically is part of anaesthetic medical training.
Conversely, the rehabilitation service will have knowledge and skills concerning a holistic approach. Although the anaesthetic curriculum mentions the biopsychosocial model three times, most pain specialists will need a greater understanding of it. Rehabilitation is mentioned four times, but only in the context of anaesthetists assisting rehabilitation. Therefore, rehabilitation should be involved with all patients except the few who need some specific invasive procedure such as spinal cord stimulation.
Table of Contents
Competency in chronic pain
The competency is that the rehabilitation expert is “Able to assess the severity and nature of chronic pain, identifying precipitating and maintaining factors, and planning a systematic and multi-modal approach to its management.” Of note, it does not mention treating or curing the pain. Additional information can be downloaded on the indicative behaviours, knowledge, and skills expected with some relevant references.
Diagnosing and managing pain is something all healthcare services should undertake. The increasing specialisation over the last 50 years since the Oxford Pain Relief Unit became the first specialist service in the UK has resulted in other specialities devolving some of their responsibility to pain services. A multidisciplinary society, The British Pain Society was founded in 1979 and has over 800 members. Medical specialisation led to a Faculty of Pain Medicine within the Royal College of Anaesthetists, founded in 2007. The Anaesthetic medical training curriculum includes pain management, but only as a small part of the whole. This shift may have reduced the expertise of other services; hopefully, it engendered research and the development of better management approaches.
However, there have been ‘side-effects’, mainly centred on confusion between a human right to have access to pain management and that “Pain Relief is a Civil Right”. The former is reasonable – society should do what it can to reduce suffering from pain; the latter is unrealistic because pain cannot always be relieved. Unfortunately, many believe opioids can be effective, safe, and avoid dependence; none of these are true. The continuing epidemic of opioid misuse arises from the over-prescription of opiates to control chronic pain; there is insufficient evidence to support their use, and the risks outweigh the benefits.
Chronic pain can only be managed by people who use the biopsychosocial model of illness to inform all areas of clinical work. Rehabilitation is the only speciality with the biopsychosocial model as its central framework for all clinical work. Other specialities interested in pain only have a weak link to the model. They are usually interested in one part of the disorder, such as its management at the end of life or invasive treatments.
Terminology and classification.
There is no single, agreed, straightforward classification of chronic pain. This section will summarise one recently agreed, simple framework.
Mary-Ann Fitzcharles and colleagues suggest three main types of pain:
- Nocioceptive, arising from tissue injury
- Neuropathic, arising from damage to the nervous system, centrally or peripherally
- Nociopathic, which possibly arises from neurophysiological dysfunction affecting sensory or pain pathways.
Nocipathic pain is an umbrella term that includes many separately named pain syndromes such as fibromyalgia, temporomandibular joint dysfunction, irritable bowel pain, and low back pain. (see the table in their article).
The main features to recognise are the following:
- The biopsychosocial model of illness “is particularly relevant for nocioplastic pain disorders.”
- The three identified types of pain are part of a chronic pain syndrome and are not mutually exclusive,
- A range of non-pain symptoms usually accompanies nociopathic pain disorders.
- The content of interventions available and used is large; their effectiveness is limited; and evidence is minimal,
- Nociopathic pain is multifactorial, and a causal factor is rarely found.
Rehabilitation and chronic pain.
Chronic pain occurs in many disabling disorders, frequently seen in rehabilitation patients, such as neuropathic pain from brain damage, pain in the affected shoulder, or pain related to spasticity and spasms. Additionally, many patients attend rehabilitation with chronic pain as their primary diagnosis or main symptom, such as fibromyalgia, chronic regional pain syndrome, or painful sensory neuropathy.
The first skill needed is understanding the nature of the pain and the many factors that may be causing, exacerbating, or prolonging it. This requires careful listening, sometimes seeking additional information in a way the patient will not find judgemental. One vital part of the assessment is discovering the person’s beliefs about the pain, its causes, and any interventions they expect or have tried. Another crucial aspect is learning how the pain affects their lives, especially their activities, and how or why.
The time spent eliciting the most thorough formulation possible is time well spent.
The second essential skill is to discuss your formulation with the person and their family in an open way, frequently checking their understanding and asking their opinion. The discussion must be non-judgemental and emphasise that no one questions their experience.
Third, one should expect the patient to use the biomedical model to explain their pain and determine the desired treatments. Consequently, you should first discuss a biomedical formulation and only then move on to a holistic explanation so that the person feels their views are respected.
Last, one should aim to alter the focus of management from pain scores to activities achieved. It is unwise to measure pain and target a reduced pain score. It is better to set goals regarding activities – what or how much.
Knowledge and skills.
I have written several posts about pain, considering the qualitative experience of chronic non-malignant pain, whether people in a prolonged disorder of consciousness experience pain (no, I doubt it) and the 2021 NICE (National Institute for Health and Care Excellence) guideline. The NICE guideline NG193 has been criticised as pragmatic but flawed by pain experts. Many review articles, books, websites, etc., provide information about mechanisms, causes, and management. Some are given in the accompanying document.
As always, you will learn most from seeing patients, mainly when you fail but someone else succeeds. The crucial skills you need to develop are:
- Listening carefully, exploring all aspects of a patient’s pain without guiding them or showing any signs of doubt about their experience or hypotheses;
- Realising that drugs or active medical and surgical interventions rarely make much difference in chronic pain and that you will rarely remove pain in the long term;
- Remembering that expectation (and hope) have remarkable short-term effectiveness in controlling pain, so you are not surprised when pain recurs.
- Understanding that you can help in many other ways.
Soon, a General Medical Council credential in Pain Medicine will be available for doctors. It is not yet published (check here). Still, from the initial version, I anticipate it focuses on invasive procedures suitable for a tiny proportion of people with pain and will require anaesthetic training for anyone who has not had it.
On the other hand, the multi-professional British Pain Society has many resources, including valuable reports, listed with links on their site.
Beliefs about pain.
Understanding the beliefs a patient with chronic has about their pain is crucial. What do they think its cause and mechanisms are, the implications and prognosis, what treatments are likely to work, how much previous treatments have helped, and any other thoughts they have? If you say, tell me about your pain, and then listen for 5-10 minutes, you will learn most of what you need to know. Listen actively; do not interrupt except to check on your understanding if essential.
A study from Sweden on people with chronic widespread pain found that illness beliefs that constrained the patient’s activities were associated with mood disturbance, anxiety or depression. The authors considered illness beliefs part of a patient’s ‘personal context’ and suggested rehabilitation should aim to improve mood and alter beliefs. Andrew Baird and David Sheffield used the Pain Beliefs Questionnaire to study ideas in people with low back pain. They found that the patient’s thoughts about the nature of pain and their ability to control it affected outcomes.
Samantha Bunzil and colleagues undertook a qualitative study on patients with chronic back pain and identified five themes from the patient accounts:
- Pain intensity was unpredictable and uncontrollable
- Experience of similar pain reinforced beliefs of a systemic back problem
- Close friends and family members reinforced beliefs about an underlying problem with the back
- The patients felt that the pain was undiagnosed, without any explanation, which petrified them
- The failure of earlier attempts to reduce pain further stressed them.
The authors suggested that the beliefs arose from the person’s attempts to make sense of their threatening experience, which otherwise had no explanation.
Yoni Ashar and colleagues evaluated pain reprocessing therapy in people with chronic back pain. This therapy aims to alter the patient’s attribution to the pain from a local pathology in the back to an abnormality in pain processing within the brain. It succeeded in reducing pain. A secondary analysis found that the patients’ pain attributions were often inaccurate and that the therapy successfully altered the attribution.
People with chronic pain, currently classified as nociopathic pain, challenge healthcare systems and professionals because it is not consistent with the biomedical model of illness, it is a frequent cause of long-term disability, and it is not easily managed using traditional analgesic treatments. The precise aetiology and mechanism has not been established, but it is usually multifactorial, with many associated symptoms, and related to mood disturbance, mistaken beliefs, and social stressors. Rehabilitation experts are skilled at using the biopsychosocial model of illness to analyse such complex problems, arriving at a diagnosis in the form of an explanatory formulation which may reduce the person’s misattributions. Various approaches may help, such as exercise and reduction of emotional distress. Altering beliefs through cognitive behavioural therapy or pain reprocessing therapy may be specific and practical approaches.