Rheumatology Vol. 43 No. 6 © British Society for Rheumatology 2004; all rights reserved
LETTER TO THE EDITOR |
What is pain management? What can rheumatologists do with no pain management team?
Arthritis Centre, Northwick Park Hospital, Harrow HA1 3UJ, UK
Correspondence to: A. Frank. E-mail: andrew.frank1{at}btinternet.com
SIR, Having run a back pain clinic for 23 years and a neck clinic for over 10 years I entirely understand the thoughtful editorial by Cooper, Booker and Spanswick [1]. I have faced the emotions related to ‘heart sink’ patients and totally understand the inadequacies of the diagnostic model of history taking. Indeed, medical students from Imperial College School of Medicine joining the musculoskeletal firm at Northwick Park are taught the differences between taking a history in the acute situation and the more complex issues of chronic medicine. Specifically, they are taught that the history must elicit (i) what the patient wants from the consultation; (ii) what the patient fears (or worries) about their symptoms, and (iii) how to communicate so that compliance with an agreed plan is enhanced. This is in addition to triaging, through history-taking, those with: (i) diseases presenting with musculoskeletal complaints; (ii) inflammatory processes; (iii) non-inflammatory arthropathy; and (iv) soft-tissue symptoms.
At Northwick Park we have reached the stage of having a common referral form for those with back pain, agreed between the pain, orthopaedic, rheumatology and therapy services. We have not however, tried to send out screening questionnaires to the 3000 or more patients seen by these services annually with back pain. Indeed, even with the aid of a trained researcher to give assistance, conversant with relevant Indian languages, there were major gaps in the data collected prospectively in the back pain clinic [2]. Cross-cultural differences in the psychometric properties of self-report psychological and disability questionnaires have also been noted (J. H. McAuley, personal communication). This makes preclinic assessment by questionnaires even more complex than the logistical issues of numbers.
Whilst agreeing with the statement that ‘patients are often fearful of inducing damage and pain’, patients may express other fears when asked directly. Of 86 consecutive new patients with low back pain asked ‘what is it that worries you most about your back pain?’, 55 (64%) admitted to fears about future disability, e.g. loss of independence or work or both, or being confined to a wheelchair [3]; and 18 (19%) were worried about the cause of their pain (cancer, arthritis, degeneration).
We certainly agree that it is vital to exclude previously missed treatable causes of pain. In our sample of 657 referrals to a secondary rheumatology back pain clinic, 8% had other conditions, the commonest being metabolic bone disease (15, 2.3%) and peripheral osteoarthritis (8, 1.2%) [4].
The potential of doctors to make a difficult situation worse through inadequate communication in clinic has recently been discussed by Page and Wessely [5]. They identified aspects of the doctor–patient encounter that may ‘iatrogenically’ maintain symptoms, e.g. through trying to reassure patients about symptoms prior to establishing what the patient thinks is wrong! [5]. Thus, guidelines developed for our clinic recommend that, in order to avoid engendering unrealistic hopes, doctors explain to patients that physiotherapy (for example) will not cure their pain but will help them to achieve more with their life in spite of pain [6]. Dictating the letter to the general practitioner in front of the patient (and others with them) and sending copies of this letter to them at home, and to physiotherapy, reinforces this message. Our physiotherapy department, unable to offer a multidisciplinary pain service, finds this means of communication helpful in agreeing appropriate goals with their patients for their programmes.
Likewise, in referring a patient to the X-ray department, the reason for the investigation is given in advance, together with the value that a negative finding would have for doctors and therapists. Thus, we hope to avoid raising hopes of a diagnosis (with the therapeutic possibilities implied by this) and facilitate their rehabilitation back into a more active life [6].
Finally I, welcome very much the introduction of what the authors called a ‘vocational pain management intervention’. There is a growing recognition that individuals need the financial and psychosocial benefits that work brings [7, 8]. The elements of back pain rehabilitation that have been shown to be beneficial are cognitive behavioural therapy, education, reassurance and advice, exercise, pain management and vocational rehabilitation in an occupational setting [9]. It is the marriage of pain management and rehabilitation philosophies that many now believe holds the best route to better lives for those disabled with low back pain [10].
A. Frank is a Medical Adviser for Kynixa Ltd, a rehabilitation company.
References
- Cooper RG, Booker CK, Spanswick C. What is pain management, and what is its relevance to the rheumatologist? Rheumatology 2003;42:1133–7.
[Free Full Text] - McAuley, JH. Cultural influences on low back pain: extending the biopsychosocial model. PhD Thesis, Brunel University, 2001.
- Grogan E, Frank AO, Keat A. Patients in rheumatology clinics need reassurance. BMJ 2000;321:300.
[Free Full Text] - Frank AO, De Souza LH, McAuley JH, Sharma V, Main CJ. A cross-sectional survey of the clinical and psychological features of low back pain and consequent work handicap: use of the Quebec Task Force Classification. Int J Clin Pract 2000;54:639–44.[Web of Science][Medline]
- Page LA, Wessely S. Medically unexplained symptoms: exacerbating factors in the doctor–patient encounter. J R Soc Med 2003;96:223–7.
[Free Full Text] - Mackie SL, Frank AO. Medically unexplained symptoms. J R Soc Med 2003;96:422.
[Free Full Text] - British Society of Rehabilitation Medicine. Vocational rehabilitation: the way forward. Report of a Working Group (Chair Frank AO). 2nd edn. London: British Society of Rehabilitation Medicine, 2003.
- Frank AO, Sawney P. Vocational rehabilitation. J R Soc Med 2003;96:522–4.
[Free Full Text] - Carter JT, Birrell LN. Occupational health guidelines for the management of low back pain at work: evidence review and recommendations. London: Faculty of Occupational Medicine, 2000.
- Frank AO. Back pain. Rheumatology 2002;41:1069–70.
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