Introduction
This page aims to provide clinicians with guidance on pain management including how to have structured consultations with individuals regarding their pain and it’s subsequent management.
Practice Guidelines
NICE Guidelines
Below is a link to the NICE Guideline (NG193) – Chronic Pain (primary and secondary in over 16s)
External Links
The following link contains the British Pain Societies professional publications in relation to pain, several of which have a specific focus on spinal procedures.
https://www.britishpainsociety.org/british-pain-society-publications/professional-publications/
Education Videos
The following videos provide an overview of the nature of pain and also guidance to clinicians on how to have a structured and staged discussion with an individual regarding their pain and it’s proposed management.
The videos 3a, 3b, 3c and 3d provide an overview of differing approaches to a consultation regarding a pain flare up and how this can be supported using agenda setting and exploring a patients own experiences.
Pain Management – The Curious Nature of Pain
This video aims to provide Clinicians with an overview of the nature of Chronic Pain and Pain management
Stage 2 – Explaining pain – Dividing out hurt from harm.
For most people the presence of pain is a call to action. Something needs to be sorted out. This consultation explores the possible meaning of pain, disconnecting the hurt = harm implication belief.
The consultant takes care to progress this gradually, avoiding an authoritative information-giving stance. Instead, he checks each step for agreement and thus, a shared understanding between them.
Stage 3B – Pain flare up – after assessment
In this video (3b) the consultant’s feedback is reassuring. He moves the discussion on to medication, the area he can offer something of substance.
The patient seeks further reassurance through scan investigations. The consultant explains why this is unhelpful and he offer a medication change instead along with a further follow-up contact.
Stage 3D – Pain flare up – agenda setting after assessment
In this video (3d) the consultant reports back on his perspective following the physical examination as they had agreed. He then asks the patient (John) about an area of patient-expertise, what he has learned about self-managing flare-up episodes. This is based on a previous consultation between them and acknowledges John’s efforts to make the best adaptation to chronic pain that he can.
He completes the agenda that they had agreed. Their discussion reflects a closer degree of collaboration and underlines greater autonomy John could use for managing flare-up episodes.
When comparing a+b with c+d consider the different outputs. In a+b John was provided with the reassurance he was seeking. How long might this be hoped to last? John’s medications were increased and he was booked for a further check. Is he likely to return again with his next flare-up?
In c+d the process of agenda setting offers a degree of rebalance of power in the discussion. Both bring in their separate sources of expertise. Ultimately it is John who makes numerous daily decisions about how best to manage his pain and his consultant health professional looks to strengthen his confidence for doing that whilst acknowledging he can offer reassurance and support at intervals when it is needed. He brings in their previous contact as useful reference material and does not allow a starting point of treating what is going on as an entirely new episode.
Stage 1 – Initial Consultation
Living with long term pain is a huge challenge, especially when there has been a disappointing result from an intervention.
This consultation is a role play between someone who is genuinely living with an incapacitating degree of unremitting pain and a senior pain consultant. It is an initial contact between them in a specialist pain service and reflects the patient’s frustrations from the position he is facing.
The consultant avoids taking a defensive stance and instead explores the present situation. Their discussion moves towards common ground setting the tone of shared constructive purpose.
Stage 3A – Pain flare up
The following segments (a,b,c & d) are quite similar but the difference between them is important. A surge in pain symptoms can be frightening but flare-up episodes arise at intervals for most people with chronic pain. It is a natural step for a patient to seek expert reassurance. If it is apparent that there is no underlying worsening of physical pathology it is a natural step for an expert to offer reassurance. Care is needed in how this is delivered, however.
Potentially it can set the scene for either increasing longer term dependency or constructing a greater sense of confidence for coping using self-management strategies.
In (a&b) there is no doubt about the respective roles of NHS pain expert and a patient seeking further help. This is cast as a Pain Clinic consultation but it might also be a consultation between a patient and their GP.
In this video (3a) the consultant has acknowledged the patient’s concerns and agreed to a physical examination to check for any indications of significant change in the pathology.
Stage 3C – Plain flare up – agenda setting
In this video (3c) we rewind to the same consultation as in 3a but one that employs agenda setting. The time taken and the actions that follow are the same, but the conversation reflects a different power balance between them both. It sets the scene for a different end to the process.
Stage 4 – After a pain management programme
For some the challenge of living with chronic pain can become overwhelming, or at least a descent into an inordinately restricted everyday life, emotional distress, disempowerment and dependence on health care support. Turning that around can be a tricky and challenging process which cannot be achieved by information and the support of peers.
This last consultation between John and his consultant is acted but nevertheless spoken from the heart based on his personal experience of attending a pain management programme.