Understand Pain for GPs
With 28 million people suffering chronic pain in the UK, a sizeable proportion of patient visits will be due to pain. There are many painful conditions beyond musculoskeletal complaints, which is one of the reasons why chronic pain is the No.1 global health burden. The other main reason is that pain is misunderstood.
One challenge is time. How can a consultation be effective with the constraint of minutes for assessment, explanation and action? This page aims to serve as a guide for GPs who want to create a process by which the key points can be addressed, step by step.
Firstly, however, we will look at the modern understanding of pain. This is the key first step for the person (patient), reducing their fear and worry, increasing engagement and seeing a way forward.
Chronic pain: a brief guide
Pain is complex. Our knowledge has grown enormously over the past 10 years. The challenge is to replace a simple model that does not explain pain with one that does, but is more complicated.
Pain is part of the way we protect ourselves in the face of a perceived threat. The perception we refer to can be conscious and subconscious (i.e. expecting something to hurt and it usually does; not necessarily thinking about it but then it does hurt as the brain predicts pain as the best explanation for the current state). This is useful when there is an injury or condition that requires attention and treatment. However, in some cases the pain persists. This can be called chronic or persistent pain.
For a number of reasons, the systems that have a role in protecting us continue to do so. This could be prior pain (protection), an early adverse event(s), a traumatic episode (e.g. an RTA), emotional stress (especially on-going; e.g. caring for a relative) or chronic stress. We must consider the life-story, as the priming for the moment when pain emerges can start at any time. The questions are: why is pain persisting in this person? What are the unmet needs in this person’s life? You can usefully think of pain as a need state (see the pain points).
There is no pain system or pain signals, only a biological state that involves many body systems, predicted or inferred to be painful. This becomes a habit, an association with certain situations such as emotional states, movements, positions or places. Of course we are complex, meaning that there can be any number of variables. However, we can say that pain is always embodied and embedded.
It is the person who suffers pain, not the body part. We must treat and coach the person; the whole person.
Pain emerges in the person, felt in a particular part of the body where our attention is needed. This is even if there is no injury, tissue damage or pathology. Pain is poorly related to these states, but is better related to the state of the person. We have known this for many years (the famous Bonica lecture and paper by Pat Wall was in 1979!). This is why stress, anxiety, tiredness and beliefs can all have an impact on the both the experience of pain and how the person meets their pain. We must get to know the person and their existing approach.
The meaning that the person gives to their pain, which is a feature of their narrative (what do they tell themselves), becomes their truth. The problem lies with the misunderstanding of pain and outdated beliefs driving actions that are not in alignment with desirable results. This is why understanding pain is so important from the outset. For example, the belief that pain and tissue damage are equated usually results in on-going conscious guarding, avoidance and other behaviours that promote further protection.
In essence, chronic pain is much more about the person and their life than anything else. We must consider the whole person, any conditions, their circumstances, life experiences, their expectations, beliefs, culture, social setting and network. We can use the biopsychosocial model, when the actual experience of pain is where the dimensions (biology, psychology and social factors) meet and integrate. The silos that society use (e.g./ mental health, physical health) are not a true reflection of reality and only serve to move us away from the right thinking. Enactivism and embodied cognition offer far more with regards to the experiences that unfold, where each moment is the meeting of cognition, action and perception.
Reconnecting with what is important
In focusing on the person, we can ask them about their life and what they hope to achieve. This gives us, the therapeutic alliance, a direction to work towards. Pain often becomes a dominant feature of the person’s life, meaning that they disconnect with what is truly important to them. These are the things that bring wellness and a sense of purpose, both of which are frequently lost. Helping people reconnect with the 3 Ps is a vital part of overcoming pain and gaining control. The 3 Ps are people, purpose and the planet. Without these, our health suffers.
Consider the known effects of perceived loneliness as an example of disconnection. We know that in these circumstances, there is a switch to being pro-inflammatory at a gene level. Biologically, inflammation is an important factor the underpins the sickness response, pain and depression. Loneliness and chronic stress cause life-itis, which in turn is the mechanism for many common modern day ills. The answer is not anti-inflammatories! It is connection and building wellness. Going upstream to address the reasons rather than downstream delivers the best results.
The more the focus is upon the pain and treating the pain in a reductionist way, the worse the outcome. The more the focus is upon the person and what they want to achieve in their life, the better the outcome. We don’t wait to get better so we can live. We live to get better.
We don’t wait to get better so we can live. We live to get better.
Coaching people to use their own strengths and resources, with support, encouragement and empowerment gives people a route to follow to overcome their pain. This means that pain is no longer the dominant force in their life. They may resolve their pain or they may have periods of pain if they have a particular condition. In the latter case, we give the person knowledge, practical tools and ways to deal with those moments. Then pain is no longer a problem. Instead, simply an experience to deal with now, in this particular way with skill and a knowing that nothing is permanent.
Giving people the knowledge, skills and tools to live and live well is one of the keystones of successfully dealing with chronic pain. This must be from the outset. Teach people what is really happening and why they feel the way they do, and then coach them to coach themselves, to get the best of themselves.
As I stated at the start, pain is complex. You may be wondering how to get these messages over to a patient. There is only one way. To learn about pain yourself and devise ways to deliver the facts in a compassionate manner that acknowledges where the patient currently sits on the belief spectrum. Often our role is to offer insights that allows the person to move towards the truth. Time being an issue, you may decide to refer to a specialist in pain. This could be a doctor, a physiotherapist or another clinician who has the necessary background and capability.
This is a brief look at an enormous subject that itself draws upon many fields: neuroscience, cognitive sciences, perception, consciousness and more. The Pain Points page on this site is a more detailed look at some of the key elements. You are welcome to share this with your patients.
For deeper learning about pain and how to apply the knowledge in a practical way, you may like to consider 1:1 Pain Coaching for clinicians. This is coaching that develops your practice to effectively work together with people who suffer complex and chronic pain and health issues. Contact Richmond for further details: firstname.lastname@example.org
If you see patients with chronic pain, you may like to collate a list of resources that you have to hand. Chronic pain is a specialist area, so it is important to make sure that the people you refer patients to see are capable, have the right skill set and knowledge base. Whilst this takes some time and must be maintained, it is worthwhile because it means you have choices at your fingertips. Meeting the needs of the patient requires that we have tangible and practical options to offer them.
- Who might I refer to?
- What services are locally available?
- What activities are available that match this person’s strengths and interest profile?
- Which websites have quality and up to date information?
What do patients need?
- an explanation for their experience
- to know what they need to do
- to know what you will do for them
- roughly how long
Dealing with these points will usually result in a positive consultation and set the scene. You may decide to cover certain aspects of the problem and set up a series of subsequent appointments to address the important issues.
Set up a series of sessions to cover the areas you have identified as being important to this person. Help them to meet the needs in their life.
How can this person build their life? How can they practice the skills of being well? Pain is a need state and hence there are unmet needs in this person’s life. How can we help the person to reconnect with what is important and take steps each day towards a picture of success? Who can support this journey? What can I offer? These are some of the basic questions.
Pain being related to the perception of threat, we must answer the person’s questions having explained their pain. We must ensure that they understand how they arrived at this point, but then encourage a focus on where they want to go and how to get there.
There maybe a place for medication and other interventions, but the bulk of what the person needs is within their own understanding and their range of choices of how to improve their life. This approach from the outset is empowering and positive. Coaching offers a way to help people achieve results, in particular strengths based coaching that lays the foundation for Pain Coaching together with the latest science of pain.
When you are prepared with your resources, explanations, and choices to offer, the consultations with people suffering chronic pain are taken to a different level. You are offering a positive way forward. Of course, it is up to the person to choose that way, but you know what is possible if they do and how your manner and approach influences this decision. We must love our work.
Take a few moments to consider the answers to: I’d love it if……..
Which seeds are you going to water? Which thoughts will you feed? Because whichever they are, they will grow. What we focus on governs how we feel and the quality of our lives.
Pain Coaching for GPs
Coaching is a skill set that we can incorporate into our day to day approach. We focus on getting the best of the person we are working with by tapping into their strengths and resources. No matter what the start point, we can all improve our lives with the right support and encouragement. As clinicians we can play the encourager: i.e./ in what we say, how we say it and the choices we offer.
A Pain Coach is someone who understands pain and seeks to use this knowledge skilfully to enable another. The approach is steeped in compassion. You can choose this way, and also discover how it helps you develop as a person. Part of being a Pain Coach is learning how to self-care each day, through the day. The importance of this cannot be underestimated. To engage with your work, with the patients and be energised takes skill and practice.