A few things to do before you arrive...

• Watch a little bit of YouTube

• Think about your experience of pain and ponder the questions we will be discussing in our group session to kick the day off (explore the resources at the bottom of this page)
• Think about what questions you would like to ask a patient about dealing with having chronic pain
- the excellent Pain Toolkit website has suggestions for patients to help them cope with living with chronic pain

Timetable

Time

Activity

Preparation/ notes
09.30-11.00

Group discussion

What is pain?
What different types of pain are there?
Why do we feel pain?
Can we measure pain?
(use the resources below)
Think about your experience of pain
Discussion about the YouTube clip and anything you have picked up from the links below
Think about how to take a narrative history, a clinical history and a 'brief pain inventory' from someone suffering from pain.
11.00-12.15

Meeting patients

Meeting patients with chronic pain
Take a comprehensive history
12.15-13.00

Debrief/Lunch

Compare experiences with each other about the patients you have met today
13.00-14:30

Write up
Personal review of learning objectives

Write reflective logs based on this morning's experiences to be discussed in the afternoon
Look at the learning objectives for the sessions that you've had so far - do you feel you have met them? If so, how would you show evidence of having met the learning objectives
Please read:
14.30-16.00

Mid course review

Discussion of reflective logs for today and review of the course so far
Please bring your own suggestions for what you would like more (or less) of
Aim for the session: To introduce this common disabling condition, its effects on individuals, families and societies, and to clinical management of this condition

Learning Objectives

• Describe the factors that are important in development of chronic disabling pain
• Summarise the socio-economic impact of this condition on individuals, the community and the health services
• Identify pharmacological and non-pharmacological treatments for chronic pain
• Discuss the effect of chronic pain on the doctor patient relationship
• Practise interview skills

Reflective writing
How did dealing with chronic pain affect the patient you interviewed?
How do you think you would deal with this situation?
How did you feel meeting a patient with chronic pain?
How did you think they were coping with their situation?
What sources of support were they drawing on?
What can doctors do to help patients with chronic pain?
How do you think doctors feel about patients with chronic pain?

Essential reading

What is pain?
The Welcome Trust Website has some well-written articles on pain which explain some of the science behind what causes pain
[Click on the "SCIENCE" tab and speed-read the ones that interest you!]
"Sensing damage" - covers how sensory neurons work to inform the body about tissue damage
"Viceral pain" - talks about a pain we have all experienced at some point in our lives and how it comes about
"Pain hypersensitivity" - tells us what happens when the messages from the nerves become less helpful

For a more medical perspective look at the website for the British Pain Society and look at their FAQs especially, What is pain?
This introduces more detail into the picture of pain briefly covered in the YouTube clip

For more detail about the history and culture of pain, go to the Lawson MedSoc reading list

How do we measure pain?

  • Look at the Brief Pain Inventory (notes about it how it was developed and how to use it are here)


  • Look at the McGill Pain Questionnaire


What are advantages and differences of each, and why do we need them?


Further reading

Back pain

Its an enormous problem in primary care and there is a vast amount of information and advice out there.

Patient information
There is some excellent reading about low back pain and myofascial pain, trigger points and massage at SaveYourself.ca.
  • This site, run by Paul Ingraham, a registered massage therapist from Canada offers an impressively evidence based review of the science that supports, or more often does not support a wide range of conventional and alternative treatments including physiotherapy, chiropractic, acupuncture, surgery, osteopathy etc. There are hundreds of free articles, as well as several extremely detailed tutorials that you have to pay to access.
  • This appears to correlate with all the conventional guidelines including NHS BMJ & RCGP - (the RCGP eGuidelines are only available for registered doctors unless you pay)

There is an excellent British website backcare.org
  • This has plenty of patient information, but much less criticism of the evidence

www.patient.co.uk is another source of patient information, which also has a search function to trawl the web for other sources of patient information

Medical guidelines are available from:

This case study and teaching article from the BMJ in 2003 gives a very brief medical overview
(note the criticism, quoted below from the electronic responses to the original article)

A longer 2001 article about back pain from the New England Journal of Medicine is here.

More serious back pain: Red flags and yellow flags.

There is a good student BMJ article about red and yellow flags.

'Red Flags' may indicate serious (but relatively rare) causes of back pain, including infective, neoplastic and inflammatory causes.
Last month I admitted a 42y old man to hospital with cauda equina syndrome caused by a spinal abscess and saw a 27y old with a disc prolapse and foot drop.

'Yellow Flags' refer to psychosocial factors that increase the risk of prolonged pain and disability.

Difficult pain.


Brief BMJ overview here in relation to palliative care

Other reading.
GP perspective and management of low back pain, By Paul Coffee Chapter 1 in Management of low back pain in primary care Edited by Richard Bartley and Paul Coffee. Butterworth Heinemann, 2001, p 3 – 18.
ISBN 0 7506 4787 6

Bandolier summary of the epidemiology, cost and management of back pain
http://www.jr2.ox.ac.uk/bandolier/band19/b19-1.html

BMJ article
Samanta J, Kendall J, Samanta A.10-minute consultation: Chronic back pain. BMJ 2003 326; 535
http://www.bmj.com/cgi/reprint/326/7388/535

N.B. This criticism of the BMJ article:
Jennifer A Klaber Moffett,
Deputy Director, Institute of Rehabilitation,
University of Hull//
Send response to journal:
Re: A missed opportunity to improve the management of chronic back pain
Editor, I was somewhat amazed by this misleading article which was scarcely based on any scientific evidence. It reviewed a case of a 40 year old man presenting with a two year history of chronic back pain with a recent exacerbation of symptoms and intermittent radiating down his leg (Samanta J, Kendall J, Samanta A BMJ 8thMarch 2003).
This was described to the patient as a nerve root problem in spite of this being highly unlikely. Suggesting nerve involvement to the patient (even in the unlikely circumstances that this was the actual cause of pain) might unnecessarily raise anxiety levels about the seriousness of the condition. It would be much better to treat this as a case of non specific low back pain and tell the patient that this type of problem is extremely common, not due to any serious damage or disease and will settle over the course of a few weeks 1. Although some of the main messages from the RCGP guidelines are provided in a box, they are undermined in the text. The most important advice to stay active is negated by telling the patient “Let pain be your guide”.
There is very little evidence to link obesity with back pain so it is surprising that this is given as the first risk factor. In contrast, evidence shows that psychosocial factors are stronger predictors of outcome than the biomedical ones listed 2. The importance of eliciting and alleviating the patient’s concerns 3 was not addressed. This may be achieved using open questions and active listening, which has been found to require an average time of 18 seconds and not more than 2 minutes at the beginning of a consultation 4. The importance of fear and avoidance of physical activity were not discussed 5. In this article far too much emphasis was put on serious pathology which is likely to increase the patient’s reluctance to return to normal activities. There was no mention of the importance of using non threatening language, and providing appropriate reassurance.
This was a great opportunity lost to provide busy clinicians with some simple guidance on how to manage patients with chronic back pain.
References
1. Klaber Moffett, J. & Frost, H. 2002. Non operative management of simple back pain (type 1), Oxford Textbook of orthopaedics and Trauma, Vol. 2: 512-515. Oxford: Oxford University Press.
2. Burton, A., Tillotson, K., Main, C., & Hollis, S. 1995. Psychosocial predictors of outcome in acute and sub-chronic low-back trouble. Spine, 20: 722-728.
3. Von Korff, M. & Moore, J. 2001. Stepped care for back pain: activating approaches for primary care. Annals of Internal Medicine, 134: 911-917.
4. Larsen, J., Risor, O., & Putnam, S. 1997. P-R-A-C-T-I-C-A-L: a step-by-step model for conducting the consultation in general practice. Family Practice, 14: 295-301.
5. Vlaeyen, J., Kole-Snijders, A., Boeren, R., & van Eek, H. 1995. Fear of movement/(re)injury in chronic low back pain and its relationship to behavioural performance. Pain, 62: 363-372.
Competing interests: None declared