Patient says she has constant pain but is 'looking comfortable'
- "Pain is what the patient says hurts"
- Pain often NOT easily recognised
- Patient says they have pain but "does not look like they are in pain"
- May be no obvious cause
- Patient may be distressed - feels they are not believed or labelled as drug seekers
- Cardiovascular/respiratory signs may NOT be present - e.g. tachycardia, dyspnoea
She reports a whiplash injury over 2 years ago which she did not seek help for. The pain is burning in nature, constant, poorly localised and usually 'moderate' with severe exacerbations. The pain is the same as it always has been.
The exacerbations are often related to stressful life events. She has become depressed and is unable to work.
A pain diagram reveals she also has pain in her lumbar spine. Physical examination and recent blood tests, X-rays, CT and MRI scans are all normal.
- What is the cause of the pain?
- Has the pain changed/anything new? - this may require further investigation
- Previous history of minor injury? Previous poorly managed acute pain? May not be easily identified - pathological mechanisms?
- Severity
- May be mild/moderate/severe
- Acute exacerbations can occur
- Use VAS or Faces pain scale if appropriate?
- "Pain diagrams' - can reveal pain in multiple sites
- Classify the pain
- This patient has chronic, non-cancer, neuropathic pain
- Other patients may have chronic, non-cancer nociceptive pain (e.g. osteoarthritis) or a mixed nociceptive/neuropathic pain
- Other factors contributing to the pain?
- Physical - other illness? other symptoms/signs that accompany pain - vomiting, drowsiness, papilloedema on fundoscopy? Musculo-skeletal examination? Have all relevent x-rays/scans etc. been done recently?
- Psychological - anxiety, depression? Social stressors?
- Use SOCRATES??
- Can help diagnose cause of pain
SOCRATES assessment
- Site
- Onset
- Character ….. Dull, sharp, ache, burning, pins and needles, shooting
- Radiation
- Associations
- Time course
- Exacerbating/relieving factors
- Severity …. Mild, moderate, severe…….”out of 10”
Psychological Assessment
Consider the following factors that can impact on coping with pain, adherence to treatment recommendations and recovery.
- Listen to patients concerns and beliefs
- Current strategies for managing pain (e.g. exercise, relaxation, heat packs, avoidance, attending GP, medication escalation)
- Depression (current or previous)
- Anxiety (particularly related to health)
- Beliefs about the cause of pain
- Beliefs about medications (likelihood of taking prescribed medication)
- Belief about safety of physical activity (fear avoidance)
- Patterns of activity (intense bursts of activity followed by pain and movement avoidance)
- Social circumstances and stressors (caregiver for others, financial pressures)
- Sleep
Treat cause if possible - otherwise manage the patient's pain
The patient is reassured that she is 'not mad' and that the staff do not think she is drug seeking. The emergency department doctor explains that she most likely has chronic, non-cancer, neuropathic pain.
She is started on a small dose of Amitriptyline at night (10mg) and the ED doctor phones her GP to discuss the treatment options. Advice to the GP includes increasing the dose of Amitriptlyine if tolerated and referral to the out-patient Chronic Pain Clinic if her pain does not resolve.
In the Chronic Pain Clinic she would be seen by the multi-disciplinary team including the clinical psychologist and the physiotherapist.
Note: Non drug and drug treatments are equally as important and can be initiated at the same time
Non-Drug
Psychological treatment options:
- Listen to patient concerns.
- Identify patient beliefs about cause of pain and address their fears or understanding
- Engage in appropriate activation and exercise
- Consider functional impact of pain and patient goals and priorities
- Treat depression if required
- Consider sleep management
- Evaluate patient’s usual coping strategies and encourage non-pharmacological methods such as relaxation
- Referral to a clinical psychologist if needed
- Cognitive behavioural therapy and other psychological techniques
Physical treatment options:
- 'Active' rather than 'passive' treatments are more effective
- Physiotherapy - graded exercise 'active' rather than 'passive' is more effective
- Mirror therapy
- Acupuncture
- Heat packs
Drug
Analgesics used for acute pain may not be effective .....avoid the use of opioids!
Simple Analgesics
- Paracetamol and NSAID may not be all that helpful this patient
- Adjuvant analgesics should be trialled one at a time and uptitrated appropriately - amitriptyline, gabapentin, clonidine patches
- Drug treatment may not be all that effective for this patient - non-drug management should be the main way of helping this patient
Refer to Important Medication for more information
How would you manage her pain?
