CLARA Clinical Analysis, Research and Application
Chronic and acute pain have very different effects on patients. Chronic pain has recently been the focus of more attention due to its depressing impact on patients and the huge costs, both direct and indirect, on the healthcare system and in the workplace. Better management of chronic pain is important because of the potential for cost reduction. In addition, better care could be provided by following guidelines; European guidelines have now been released for chronic back pain (see Resources).
When does chronic pain start?
According to the International Association for the Study of Pain (IASP), pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. This definition of pain underlines the subjectivity of pain and acknowledges the importance of emotional as well as sensory factors, without a causal link between tissue damage and pain reaction. Thus, in this definition, an anatomical lesion is neither a necessary nor a sufficient condition for pain.
During the continuum from acute to chronic pain, disease management by the patient becomes increasingly important. Transient interference with daily activities will increasingly have consequences on the quality of life (see Figure 1),(1) which is an indication of how patients perceive and react to their health status. Pain patients have severe interference both on physical and psychosocial levels, and rate much lower in the SF36 than patients with other chronic diseases, such as heart failure and cancer.
All of these aspects should be considered during the first meeting with the patient. Patients start seeking professional help when their personal resources (as well as those of friends and relatives) diminish. The way they perceive their disease will guide their search (see Table 1). In this regard, first contacts are much more important than later ones – an argument in favour of seeing pain specialists as early as possible. However, patients are often referred to one therapist after another, and are referred to an interdisciplinary specialist only after some years (see Figure 2). Despite differences in the number and types of therapists and therapies between the European healthcare systems, this specific problem is a very common one.
Diagnosing chronic pain
It is still not possible to define chronic pain precisely using the International Code of Diseases (ICD10) and the diagnosis-related group (DRG) systems that are based on this code. When treating chronic pain, it is necessary to diagnose the pain and concomitant aspects first, as they influence prognosis and outcome, as well as the need for therapeutic efforts. A paper-and-pencil pain questionnaire can be used as a written protocol to list all important questions, save time in viewing the individual features in one patient and, finally, compare patients, both within an institution and outside of it. If pain specialists throughout a country can agree on a pain questionnaire, studies with analgesics or other treatment options will be facilitated. The German Pain Questionnaire, for example, is based on a biopsychosocial pain model developed by a working group and validated by a multicentre study in 1996.(2)
Further prognostic value is gained from the status of chronicity,(3) considering pain frequency, duration and change (first axis), pain sites (second axis), drug intake and withdrawals, including central agents such as opioids and antidepressants (third axis), and healthcare utilisation with physicians, inpatient stays, pain-related surgery and rehabilitation (fourth axis). According to a study in 13 pain centres in Germany (n=3,294), about 20% of patients are at stage I when reaching a pain care specialist.(4) This measure and its goal are thus different from the grading of chronic pain introduced by von Korff and colleagues,(5) which relates to pain intensity and disability defined as interference with daily activities and work.
Provision of services for chronic pain management
Evidence shows that, in the case of chronic pain, only “multimodal” treatment is truly effective. This includes medical treatment, physiotherapy for the management of bodily dysfunctions, and psychological therapy for the evaluation and management of psychological and behavioural disturbances. Continuing the unimodal process does not have a lasting effect on chronic pain, pain-related comorbidities or interference with social participation.
Depending on the status of chronicity, patients need intense education and training in a conceptual framework.
Multiprofessional and interdisciplinary chronic pain treatment programmes are easier to provide in hospitals. Recently, more daycare services, in which treatments are intensified, have been set up in Germany. However, for patients who are unable to follow all-day schedule and group treatment offers, inpatient stay may be needed. Drugs are used to get patients started, but cognitive and motivational exercise and support are necessary for compliance and adherence to recommended treatment. In Germany, this kind of treatment is provided, with important regional differences being observed between specialised pain treatment facilities.(6)
Design of treatment in chronic pain
The factors that are relevant for the design of a treatment in chronic pain are also important for clinical research(7) and quality assurance programmes, as well as for quality reports and interfacility comparisons. These factors are as follows:
- Thorough anamnesis of pain and its consequences on quality of life on the basis of patient reports (such as the German Pain Questionnaire [see Resources]), analysing (and working on) the disease and treatment concept for the patient.
- Evaluation of the impact of comorbidities on pain, and vice versa.
- Analysis of the chronicity status of the pain patient.
- Interdisciplinary treatment approach in all aspects of the disease. Motivational work on mobility and ending bad habits.
- Defining goals with the patient for disease and treatment.
- Guidance of patients through interdisciplinary treatment, communication between specialists during stay, backup and feedback to the patient.
- Control of outcomes and long-term benefits by personal visit or at least follow-up questionnaires six months after treatment.
- Ware JE. How to score the SF-36 Health Survey. Boston: The Health Institute, Medical Outcomes Trust, 1994.
- Nagel B, et al. Schmerz 2002;16:263-70.
- Gerbershagen HU. Internist 1986;27:459-69.
- Gerbershagen HU, et al. Schmerz 2002;16:271-84.
- Von Korff M, et al. Pain 1992;50:133-49.
- Lindena G, et al. Schmerz 2004;18:10-6.
- Turk DC, et al. Pain 2003;106:237-45.
European guidelines for chronic low back pain
German Pain Questionnaire