Typical features of patients with chronic pain

Chronic pain is a special therapeutic challenge

The patient with chronic pain will display a number of key features including a long pain history including ineffective attempts at pain management.

  • Many patients may have comorbid conditions and treatments that need to be considered during a thorough evaluation of the patient
  • Very few patients truly “accept” that they have to live with pain and most hope their physician will be able to take their pain away
  • Pain that continues for months and years despite attempts at treatment can be disabling, frightening and frustrating
  • Most chronic pain patients display evidence of psychosocial factors contributing to and compounding their pain condition

Goals of treatment

Common understanding of treatment goals is crucial

The goals of pain management are

  • to reduce pain
  • to reduce psychological distress
  • to improve patients’ functioning
  • to improve patients’ quality of life

Efficient communication between physicians and patients is crucial for a common understanding of chronic pain and its impact – the basis for adequate pain management.


A motivated patient-physician team

Jointly improving pain management.

Effective pain management depends on a motivated patient-physician team that have devised a realistic management plan.

  • In addition to selecting the most appropriate pain therapies and management strategy, the patient’s readiness to adopt a self-management, positive attitude to their chronic pain is important to a successful outcome.1
  • Physician and patient need to form a partnership based on good communication in order to support the patient in developing a change in mind-set regarding their perception of pain and achievable pain reduction goals. Actively involved patients are empowered and motivated
  • Active cooperation may be aided by use of a pain diary to catalogue pain and monitor the effects of therapy
  • A diary can capture information on pain occurrence, intensity, medication use, side effects, patient activity and well-being.
  • The outcome of successful team work should be improvement in pain.
Kerns RD, Rosenberg R, Jamison RN, et al. Readiness to adopt a self-management approach to chronic pain: the Pain Stages of Change Questionnaire (PSOCQ). Pain. 1997;72:227-34


Principles of communication

Good communication is paramount

Effective communication between patient and physician is very important to appropriate evaluation and management of chronic pain.

  • Conversation can be the physician’s most powerful instrument
  • In consultations with a patient with chronic pain, there is a need to be truly patient focused.
  • This requires good verbal and non-verbal communication skills. Messages and language should be carefully chosen to match patient understanding. Patients need to understand and provide key facts and this may require sufficient time, repetition and checking to ensure that both physician and patient convey and comprehend relevant information.

Principles of communication

Anatomy of a message

Conversation is a complex human interaction involving messaging, appeal, self-revelation and relationship.

  • The principles of good communication as listed require that conversations are conducted and started in appropriate settings and with empathy and attention
  • Non-verbal communication and conducting conversations in an atmosphere that allows true patient focus are each important. Patients can be helped to overcome their reservations by empathizing, making and keeping eye contact.
  • The physician needs to send and recognize non-verbal signals in order to engender trust and build a relationship of cooperation and partnership.

Start of conversation

  • Optimise external conditions
  • Overcome reservations of the patient
  • Show interest, friendliness and attentiveness
  • Recognise non-verbal signs (mouth, eyes, hands) of fear and inhibition
  • Send non-verbal signs (facial expression, eyes, posture)
  • Eye contact – same eye level
  • Indicate possible time frames

Principles of communication

The four ears of the receiver

Physicians have to appreciate that facts may or may not be well understood, messages must appeal and that by building good relationships with a patient, communications can be more successful for both parties.

The four ears of the receiver

  • Expert ear (How do we understand the facts?)
  • Self-revelation ear (What kind of a person is he/she, what is the matter with him/her?)
  • Appeal ear (What should I do, think, feel based on his/her information?)
  • Relationship ear (How does he/she talk to me? Who does he/she think he/she is talking to?)

Principles of communication

Anatomy of a message

When communicating messages, the physician and patient both deal in facts and self-revelation and appeal and relationship building happens through frank, open and honest conversation.

Physicians have to appreciate that facts may or may not be well understood, messages must appeal and that by building good relationships with a patient, communications can be more successful for both parties.

In pain consultations, it is vital to remember that patients with chronic pain often have a pain history of failed treatments and are demoralized by persistent pain.

The patient wants help and expects the physician to provide that help.


Establishing a trustful relationship

Patient-doctor relationship

Exploring and developing a plausible explanatory model for the patient’s pain, which integrates all previously known and suspected somatic and psychosocial factors, is a sound basis for developing physician-patient cooperation.

  • Trust and respect between physician and patient are also vital for good patient evaluation and for planning pain management.
  • Exploration and discussion of psychosocial aspects of chronic pain therefore need to be integrated into consultations from the earliest possible stage in the patient-doctor relationship.
  • Developing a plausible biopsychosocial explanation not only fosters trust but can help allay patient fears that pain poses a threat or danger. Gaining patient trust and cooperation is also important to avoid alibi solutions to diagnosis or to management, which again are more likely to arise if a purely somatic approach to appraising and managing pain are adopted.
  • Close cooperation between physician and patient is also key to realistic setting of treatment goals and to engendering patient motivation. Few management strategies can hope to achieve complete resolution of pain. More realistic is to aim for some improvement in pain and goals of improved function and quality of life.

Quick check

How can a physician establish a trusting relationship with the patient? Chose the statement that is not correct.
Develop a plausible biopsychosicial model for the patient
Promise the patient to remove pain altogehter
Allay the patientís fears
Avoid alibi solutions
Which factors are paramount for a good communication between physician and patient?
Listen to patient carefully before respond
Improve understanding and speak simple language
Check understanding
All of them


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