Family Practice

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Family Practice Vol. 16, No. 5, 475-482
© Oxford University Press 1999

Chronic pain in primary care

Blair H Smith, Jane L Hopton^a and W Alastair Chambers^b

Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Drive, Aberdeen AB25 2AY,
^a Department of General Practice, University of Edinburgh, Edinburgh and
^b Pain Management Clinic, Aberdeen Royal Infirmary, Aberdeen, UK.

Smith BH, Hopton JL and Chambers WA. Chronic pain in primary care.Family Practice 1999; 16:475–482.

Received 27 August 1998; Revised 29 March 1999; Accepted 13 May 1999.

	Abstract

Top Abstract Introduction Epidemiology Defining chronic pain Sites and causes of... The impact of chronic... Clinical management Self-help groups Pain management and the... Conclusions References

 
Chronic pain is a very common cause of suffering, disability and economic adversity in the community. It is a complex problem that needs to be understood in a multi-dimensional way for effective management. Most research to date has been based in specialist clinics rather than in primary care, with consequently limited findings. Chronic pain differs from acute pain in that management follows a rehabilitative rather than a treatment model, though these are not mutually exclusive. Full assessment of the patient, preferably multi-disciplinary, will improve his or her outlook. Management should be holistic, rigorous in the application of conventional therapies (including analgesics and physical therapy) and ready to admit an improved understanding of psychological and social techniques. There may be a role for complementary therapies. As a large proportion of chronic pain presents only in the community, there may be a role for greater primary care input to management.

Keywords. Chronic pain, complementary therapies, pain management.

	Introduction

Top Abstract Introduction Epidemiology Defining chronic pain Sites and causes of... The impact of chronic... Clinical management Self-help groups Pain management and the... Conclusions References

 
Chronic pain may be seen as presenting a fundamental challenge to medicine. The experience of chronic pain is very common and chronic pain is part of the experience of many illnesses. However, the links between the experience of chronic pain and visible or detectable pathology or diagnosable illness are often non-existent or unclear. In philosophical terms, chronic pain challenges the distinction between mind and body which much medical knowledge assumes. It also challenges the notion of cure as a goal of medical practice.

This review
Most research on chronic pain management in the community has been condition-specific rather than considering chronic pain as a distinct entity or syndrome. We reviewed critically the existing chronic pain literature in the context of primary care, validating our summary of the evidence against a large systematic review of chronic pain outpatient treatment.¹ Although a systematic review of particular interventions or pathologies can provide useful information which can be helpful in drawing up patient management plans, too much emphasis on this approach is likely to detract from an appropriately multi-disciplinary and holistic approach to management. We attempted to combine the need for scientific rigour and holism in this review, in a way that mirrors the approach to management required in primary care.

	Epidemiology

Top Abstract Introduction Epidemiology Defining chronic pain Sites and causes of... The impact of chronic... Clinical management Self-help groups Pain management and the... Conclusions References

 
Doctors, patients and insurance companies know that chronic pain is extremely common. Precisely how common is difficult to gauge, and depends upon the case definitions and methods of case ascertainment employed by epidemiological studies.² Estimates of prevalence to date range from 7.6 to 45%.^3–9 More women than men are affected, and prevalence increases with age. Use of health services as an indicator of clinical relevance identifies that between 10 and 15% of the population suffer ‘clinical’ chronic pain. This suggests that many more people suffer in silence or manage their own symptoms.

A small proportion of the chronic pain population is managed through specialist pain clinics, and others will attend other medical specialties for investigation and treatment of specific aspects of their conditions. The overwhelming majority of people seeking medical help will attend and be treated in primary care,^10–12 and in most cases primary care offers the potential to address all aspects of chronic pain, including its prevention.

	Defining chronic pain

Top Abstract Introduction Epidemiology Defining chronic pain Sites and causes of... The impact of chronic... Clinical management Self-help groups Pain management and the... Conclusions References

 
Defining chronic pain is difficult. The International Association for the Study of Pain (IASP) define pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described by the patient in terms of such damage".¹³ This fundamental subjectivity renders it resistant to objective definition and classification. Chronic pain in particular is essentially a subjective experience,^11,14 and attempts to define and measure it are best seen in pragmatic terms, assisting research, evaluation or clinical assessment rather than providing objective evidence of pain or its intensity.

The IASP defines chronic pain as "pain which has persisted beyond normal tissue healing time", taken, in absence of other criteria, to be 3 months.¹⁵ Drawbacks of this definition are that it does not take account of severity, disability or health service needs, and makes no allowance for pain of intermittent nature or pain that is not obviously associated with physical insult.

Von Korff⁹ proposes the assessment of chronic pain in three dimensions—severity (intensity), duration and impact (disability and dysfunctional illness behaviour). A useful pragmatic development of the IASP definition of chronic pain might combine these dimensions of subjective experience in a way that describes and predicts health service use. For example, chronic pain might be defined as "current continuous or intermittent pain or discomfort which has persisted for more than 3 months, with recent or frequent seeking of treatment or use of analgesic medication".¹⁶ This too is imperfect as it omits many people, but it will include only pain of clinical significance, irrespective of objective severity.

The difference between acute and chronic pain is more than semantic or an arbitrary transition point at 3 months. It is important for management, in that while treatment of the former focuses on the cause (including repair of damage), treatment of the latter focuses on the effects,¹⁰ including maximization of function and management of depression, disability and socio-economic problems.

	Sites and causes of chronic pain

Top Abstract Introduction Epidemiology Defining chronic pain Sites and causes of... The impact of chronic... Clinical management Self-help groups Pain management and the... Conclusions References

 
Of chronic pain presenting to the GP, around 20% is due to malignancy.¹⁷ The commonest sites of chronic non-malignant pain in the community are limbs and joints (accounting for around a half of all cases) and the back (accounting for around a third).^3,4 The neck and the head are other important sites.

The prevalence of specific diagnoses as causes of chronic pain in the community are more difficult to estimate. In specialist pain clinics, diagnoses are probably more rigorously recorded than in general practice. Even here the commonest first diagnosis of attending patients is "unspecified low back pain" (around 10%),¹⁸ though postherpetic neuralgia is very frequent (also around 10%).^18,19

Classification of chronic pain patients into diagnostic subgroups is therefore difficult and may be unhelpful. Many patients have multiple pain sites or diagnoses. Diagnostic classification is often vague or impossible, and even where there is an identifiable cause of pain (such as nerve root compression), other multiple and diverse factors contribute to the clinical picture. These include general physical health, and psychological, emotional, social and spiritual factors. Conversely, pain may frequently be overlooked as part of the experience of conditions which are well defined in medical terms, such as rheumatoid arthritis. These issues have led some to propose the concept of a "chronic pain syndrome",²⁰ placing emphasis on the important common strands to the management of all causes and effects of chronic pain.

	The impact of chronic pain

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Chronic pain can have a profound impact on sufferers' lives, their sense of self and identity. Patients can often feel that they have lost their ‘life’,^21,22 and chronic pain is often associated with loss of confidence and self-esteem. Although it is possible to delimit aspects of people's lives which are affected by considering the functional, psychological, social and economic implications, these are clearly interrelated.

For people in formal employment, chronic pain and associated loss of functional ability can lead to loss of employment which in turn can have profound economic consequences.²³ For people who are not in formal employment, particularly those who are bringing up families or running a household, chronic pain can lead to loss of this role. As the economic consequences of this loss of role are less well documented, the distress caused can be substantial and may often be overlooked.²⁴ For people of all ages, chronic pain can lead to social withdrawal and social isolation. It can also affect intimate personal and sexual relationships.

A patient of ours described chronic pain as "a shadow on your life that is always with you, like another member of the family that must be consulted before doing anything".

Chronic pain frequently disrupts sleep and this in turn can have an impact on mood and psychological well-being as well as energy and physical activity. The experience of chronic pain is often associated with depression. Whilst a considerable amount of research has been devoted to attempting to determine whether depression causes or increases perceptions of pain or whether chronic pain causes depression, this debate may now be seen as unhelpful. Attempting to distinguish between somatic and psychogenic pain perhaps with the aim of ascribing a value to each component is similarly misplaced and also the result of a dualistic approach based on an implicit distinction between the mind and the body.²⁵

	Clinical management

Top Abstract Introduction Epidemiology Defining chronic pain Sites and causes of... The impact of chronic... Clinical management Self-help groups Pain management and the... Conclusions References

 
Management of chronic pain may be subdivided into treatment and rehabilitation.

Making a distinction between acute and chronic pain can provide a prompt to move towards an ongoing rehabilitative model of management (see Table 1),¹¹ but this model and a treatment model are not mutually exclusive. Indeed, there are important gains to be made in terms of prevention by combining these approaches early in management.⁹

View this table: [in this window] [in a new window]   TABLE 1 Components of rehabilitative approach to chronic pain management11

 
Clinical assessment
Assessment and re-assessment, whether by patient, generalist or specialist, formal or informal, are fundamental to all stages of the management of chronic pain. Constructive (re-)assessment can be useful for reassuring both professionals and patients that nothing has been missed and for taking a fresh look at the problem. In general practice it may be appropriate to achieve this by ‘referring’ patients to another GP. A key function of pain clinics is to provide a detailed and comprehensive assessment which would typically include:

• a full history including functional effects of pain, and the patient's experiences to date;
  
• examination;
  
• assessment by other professionals where appropriate, such as physiotherapist, occupational therapist, nurse, psychologist, psychiatrist, etc.; and
  
• recording previous and current treatments and their effects (including prescribed, proprietary and alternative preparations and procedures).
  

For complicated cases this can involve a full day for the patient seeing a number of individuals who will later confer about management. A version of this assessment can be carried out or co-ordinated in primary care, within appropriate time and resource limits. Time spent at this stage obtaining an accurate assessment and formulating a management plan which is agreed with the patient is very worthwhile. Many patients with chronic pain will have seen a wide range of specialists over time and the history can be complicated.

From the patient's point of view a crucial aspect of (re-)assessment is that of a clinician showing genuine interest. Where this is not perceived to be the case, patients may complain of having to repeat themselves. Patients are less likely to accept advice from doctors who have not examined the source of their complaint with genuine concern.

When noting effects of any previous treatment it is important to ensure that any ‘ineffective’ treatment has been given a full and proper trial. Patients may have abandoned treatments because they did not meet their current expectations—most obviously, it may not have cured their problem. Analgesics may have been taken with inappropriate dose or timing, or transcutaneous electronic nerve stimulation (TENS) may have been rejected because it only provided temporary relief. It may be effective to encourage patients to revisit some of these options, as their experience of living with pain may change their priorities. Medication, for example, may be presented as part of an overall rehabilitative strategy rather than as a cure or solution.

Instruments for pain measurement
Many attempts have been made to develop measures of chronic pain severity.²⁶ They range from a simple Likert scale²⁷ to the more complicated McGill Pain Questionnaire,²⁸ and include interview and patient-administered instruments. One of the most successful, because of its simplicity and applicability, is the Chronic Pain Grade,^9,16 based on Von Korff's three dimensions (above). Some measures are specific to particular causes of chronic pain, such as the Oswestry Low Back Pain Disability Questionnaire.²⁹ Most of these are used primarily for research purposes or in the evaluation of specialist treatment programmes.

Questionnaires measuring other aspects of health status may be helpful as part of a comprehensive assessment. Screening questionnaires such as the Hospital Anxiety and Depression Scale³⁰ or the Distress Risk Assessment Method³¹ are used routinely in some pain clinics.³² Much effort is currently being devoted to the development and testing of questionnaires which provide an even more detailed psychological assessment. These might include assessments of beliefs about pain and styles of coping and adjustment.³¹ In clinical use these measures may usefully highlight the need to assess more than simply intensity of pain, and provide a guide for planning a comprehensive individually tailored management approach.

Drug therapy
Minor analgesics have been shown to provide definite benefit in chronic pain,³³ though there is little research on very long-term effectiveness. Although compound analgesics produce a greater effect in acute pain this is at the expense of more side-effects in the chronic situation. Paracetamol has about 95% of the efficacy of compound preparations if administered regularly,³⁴ and a combination of paracetamol and a non-steroidal anti-inflammatory drug (NSAID) is more effective than either alone. If pain is not controlled with these, use of stronger analgesics should be considered. The incidence of addiction is very low where strong analgesics are used appropriately.^35,36 An overcautious attitude to the use of strong opioids will deny patients with severe pain optimal pain relief. ‘Pseudo-addiction’ has been described as the result of routine under-prescription of analgesics, when the patient's demands for more medication appear similar to those made by opiate abusers.³⁷ Clearly, however, rigorous monitoring and recording is important.

The World Health Organization analgesic ladder³⁸ provides a rational basis for progressive therapeutic management of cancer pain (see Table 2), and provides good pain control in over 90% of cases. Fundamental to this approach is the need to anticipate and prevent rather than treat pain with medication, and to move up a step if pain is inadequately controlled. Adjuvant therapies are particularly relevant to treatment of cancer pain, and include corticosteroids and radiotherapy. In theory there is little to be gained from trying alternative preparations on the same step.

View this table: [in this window] [in a new window]   TABLE 2 The WHO Analgesic Ladder38

 
There is strong evidence for the effectiveness of ‘unconventional’ analgesics, including antidepressants, anticonvulsants and systemic local anaesthetic-type drugs in neuropathic pain.³⁹ There is little evidence of any showing greater benefit, though many clinicians prefer antidepressants to anticonvulsants, perceiving a lower incidence of side-effects, particularly in the elderly. The idea that the character of neuropathic pain is associated with a differential response to anticonvulsants (in the case of shooting pain) or antidepressants (burning pain) has been disputed by a study which showed that both types of pain responded to tricyclic antidepressants.³³ No difference in the analgesic effectiveness of different antidepressants has been shown, and choice of type of antidepressant both within and between groups may be dependent on the patient's experience of side-effects.

Topical non-steroidal preparations may be effective in chronic pain—especially where a single joint is affected by arthritis. The higher cost may be offset by lower rates of serious complications associated with oral NSAIDs. However, much of the existing evidence is based on trials with methodological limitations using preparations not available in the UK.¹ A good large-scale trial, including an economic evaluation, is required to establish effectiveness, efficacy and safety.

Invasive therapies and nerve blocks
A wide variety of invasive treatments have been used to treat chronic pain and as few are appropriate for primary care, they will not be considered in detail. Early attempts at the management of intractable pain included the provision of nerve blocks, with the aim of preventing afferent stimuli via the peripheral nervous system, and thereby preventing pain. This rationale is now seen as naïve, failing to acknowledge the multi-dimensional nature of pain, even within a purely physiological model. It is often relatively easy to block afferent input on a short-term basis, for instance with the injection of a local anaesthetic agent, and this can produce analgesia for the duration of the block. However, attempts to produce longer-term afferent blockade are not without problems. Pure blockade of pain fibres without affecting other neural transmission cannot be reliably produced in all cases and this can lead to unwanted effects such as motor and sensory loss. The mechanism of producing longer-term blockade, for example with the injection of a neurolytic such as phenol or alcohol, may itself give rise to neurogenic pain. Finally, the results of such blocks are not permanent and in time regeneration of neural pathways can lead to a recurrence of pain. Neurolytic or neuro-ablative procedures can be useful in the terminally ill but in patients who have a reasonable life expectancy their usefulness is very limited.

Implanted stimulator devices or drug delivery systems are available but their usefulness is confined to a relatively small proportion of specialized cases in secondary or tertiary care.

Physiotherapy
Management of acute back pain includes as a key early mobilization and physical rehabilitation with the aim of prevention of chronic back pain.¹⁰ Manipulative and physiotherapy have been shown in one trial to be superior to GP or placebo management in chronic back and neck pain.⁴⁰ However, physiotherapy with the aim of treating chronic back pain is of optimal benefit only if given over a prolonged period, and patients left to exercise independently fare worse than those under continuous supervision.⁴¹ Resources for this are rarely available, and long-term effectiveness may therefore be limited. A recent review of physical therapy in chronic musculoskeletal pain⁴² concluded that there was no benefit relative to placebo treatment of equal length, though there was a significant benefit when compared with no treatment.

Psychological approaches
A range of psychological techniques has been shown to be beneficial in management of chronic pain, particularly in improving function and perceived quality of life, reducing depression and health service use (visits to the doctor and use of medications).^43–46 There is a difficulty of attributing apparent gains to specific psychological approaches when these form part of a wider programme.⁴⁷

Communication is a key issue when considering psychological approaches to the management of chronic pain. Although from a professional perspective there is now recognition that dualistic distinctions between mind and body are unhelpful, people experience pain as fundamentally physical¹⁴ and will discuss it in these terms. Although some people may recognize the role of stress or other psychological or social factors in their experience of pain, the suggestion of psychological approaches to management could be interpreted as a suggestion that the pain or the patient is not genuine. It is important therefore to explain clearly the specific aims of any psychological approach intervention, and careful selection of vocabulary is crucial.

A substantial strand of the psychological literature subdivides chronic pain patients into two groups: those in search of relief or cure, and those who have accepted their pain, the latter being more likely to benefit from psychological intervention.²² There is now evidence to suggest that this is another unhelpful distinction,^48,49 and many people whom professionals would assess as coping well and getting on with their lives would still be hoping that the pain might go away. Broader psychological research on the relationship between realism and depression or conversely self-deception and positive thinking points to the need to avoid crude distinctions about ‘facing reality’ or ‘seeking a cure’.^48,50

Three principal psychological techniques are summarized: behavioural, cognitive and relaxation therapy. Behavioural (operant) therapies are based on a theory of learning (operant conditioning or instrumental learning).⁵¹According to this theory, behaviours are learned and maintained because of their consequences. Behaviours can be learned unconsciously and can include psychological responses as well as social behaviour and the taking of medications. The broad aim of behavioural therapies is to reduce behaviour associated with pain and disability while reinforcing behaviour associated with health and activity. Behavioural approaches may include periods of activity and rest on specified or time-contingent schedules, and goal-setting and pacing. They include techniques such as bio-feedback (feedback on measures of physiological responses such as electromyographic activity) to train patients to control apparently involuntary negative responses, such as the tensing of muscles in response to pain.⁵² Partners are often included in behavioural therapy on the grounds that behaviour occurs in a social context, and partners or other close family members may be maintaining or reinforcing certain behaviours. Behavioural approaches make no explicit attempts to address the cognitive and affective aspects of pain.

Cognitive therapies address sufferers' attitudes, thoughts and beliefs relating to pain and its effects, including their sense of self-worth or self-efficacy. Approaches include education about pain mechanisms, challenging the idea of pain as harm, positive thinking, avoidance of negative thinking such as ‘catastrophizing’, and the development of effective coping mechanisms including communication assertiveness training. A large area of research and practice is based on the importance of positive thinking and positive coping skills, and inevitably ideas about these two areas form an important part of professionals' approach to their work with patients. Work in this area involves the difficult balance of being positive but realistic, and acknowledging the real difficulties that people face in their everyday life, whilst encouraging and supporting them in developing their own management strategies instead of labelling people as non-copers.^22,49

Relaxation training combines many of the above theoretical approaches and is based on the close relationship between physical and psychological stress and the distress associated with chronic pain. Many different relaxation techniques may be used, including progressive relaxation, bio-feedback, autogenic training, hypnosis, meditation and yoga.⁴⁴

TENS
Transcutaneous Electronic Nerve Stimulation (TENS) in pain relief is based on the gate control theory of pain, with peripherally sited electrodes providing recurrent stimuli to block nociception. There have been conflicting reports of the benefits of TENS,^53–55 but two studies of long-term use have shown clear advantages, suggesting that for some patients this can be an effective treatment which has minor, if any, adverse consequences. A retrospective survey of 1582 patients attending one pain clinic over a 10-year period found that TENS had been successful for 59% of the sample.⁵⁶ A more in-depth study carried out in the same centre of people with low back pain⁵⁷ found that for 47% of the sample the use of TENS reduced their pain by more than half. Spinal cord stimulation was developed on the same theoretical basis as TENS but is a highly invasive and expensive technique for which there is no good evidence of effectiveness.¹

Complementary therapies
Professional and public interest in the role of complementary therapies is growing. For chronic pain management the main complementary therapies are acupuncture, reflexology, osteopathy, chiropracty, homeopathy and hypnotherapy. Provision of these therapies is still predominantly private although acupuncture, homeopathy and osteopathy are increasingly available within NHS pain management centres,⁴⁰ or in the case of homeopathy, in separate clinics.

Use of complementary health care is increasing,⁵⁸ particularly for problems that are associated with pain. A recent survey found that 78% of people consulting a UK sample of complementary practitioners did so for musculoskeletal problems.⁵⁹ Although there are social class differences in the use of complementary therapies, with people from higher social classes being more likely to use these, research has shown that this pattern is a result of financial accessibility rather than a lack of interest or negative perceptions amongst people from lower social classes.⁵⁸ As many people experiencing chronic pain experience a reduction in income, this often makes the cost of ongoing therapy for symptom relief prohibitive.

As these therapies are predominantly outside the provision of mainstream health care, this has had research implications. Commentators on complementary therapies in general and in reviews of research on specific therapies frequently cite a lack of rigorous trials as a problem in evaluating their efficacy. It is also difficult to summarize findings from the rigorous research that has been done, some of which has been carried out on a cross-section of people experiencing chronic pain and some on specific subgroups. A further issue, as with evaluation of psychological approaches, is of finding an appropriate ‘control’ or placebo group for comparison.

Despite these problems, several studies are worth noting. A trial that compared chiropracty in the management of low back pain with the usual hospital out-patient treatment found that chiropracty brought clear benefits,⁶⁰ particularly in severe or chronic pain. This benefit was maintained at 3-year follow-up.⁶¹ This was a pragmatic trial and patients were not randomly allocated to treatment groups.

Two recent meta-analyses of acupuncture have drawn conflicting conclusions. The first review of 14 publications of randomized control trials which met the criteria for inclusion in the review concluded that whilst few of the individual studies showed significant results, pooling these results showed significance in favour of acupuncture.⁶² The second was a meta-analysis of 51 studies⁶³ which concluded that no definitive conclusions about the efficacy of acupuncture could be drawn owing to the poor design standards of the studies.

Hypnotherapy, including self-hypnosis, is used to assist relaxation and can be used in the management of chronic pain. Whilst evidence supports its efficacy in this context,⁶⁴ there is also evidence that effectiveness depends on the suggestibility of patients—for recurrent headaches, a study found that less-hypnotizable people derived no greater benefit than with simple relaxation.⁶⁵

Although the standard and range of evidence available on the effectiveness of these therapies makes any conclusions controversial, there is evidence of benefit for some groups of patients. Note also that there is often little evidence of the efficacy of conventional medical therapies.⁴¹

Comprehensive pain-management programmes
A range of approaches to the management of chronic pain can be integrated in a pain-management programme. These intensive specialist programmes explicitly aim to maximize quality of life with chronic pain. Key features are acceptance both of the patient's pain and that the purpose of the programme is not to cure or alleviate pain. Programmes typically combine a range of psychological, physical and social therapies, and a combination of individual and group work. There is evidence and consensus to support the benefits of this approach.^32,40 A recent meta-analysis of multi-disciplinary treatments for chronic back pain showed clear superiority to no treatment, waiting list controls and single-discipline treatments such as medical or physical therapy.⁶⁴

Advice and assistance about financial issues
People experiencing chronic health problems may benefit from encouragement to seek advice from agencies such as the Citizens Advice Bureau (CAB) about a range of issues relating to employment, compensation and benefits. A study of citizen's advice in general practice found that people with health problems were significantly more likely to be entitled to unclaimed benefits.⁶⁷ Whilst some benefits relevant to people with health problems are means tested, others are not and are based solely on the level of disability and support or assistance required. The range of benefits and the apparent complexity of the criteria can often act as a deterrent, particularly to people in distress. CAB offer a database of keynotes with updates where appropriate on a wide range of advice issues which are designed to be accessible to the lay public.

	Self-help groups

Top Abstract Introduction Epidemiology Defining chronic pain Sites and causes of... The impact of chronic... Clinical management Self-help groups Pain management and the... Conclusions References

 
Interest in self-help is growing. Examples of relevant bodies include The Arthritis and Rheumatism Council (Copeman House, St Mary's Court, St Mary's Gate, Chesterfield S41 7TD); the Patients Association ‘Action on Pain’, PO Box 5333, Syston, Leicester LE7 2ZU (‘PainLine’ 0116 269 5568); and Pain Concern UK (Scotland) (Wood's Cottage, Nungate, Haddington, East Lothian EH41 4BE). There are many other local and national groups.

	Pain management and the primary health care team

Top Abstract Introduction Epidemiology Defining chronic pain Sites and causes of... The impact of chronic... Clinical management Self-help groups Pain management and the... Conclusions References

 
In the introduction we argued that primary care constituted an appropriate setting for developing the management of chronic pain. Indeed, the majority of formal health care for chronic pain is provided here. There is growing interest in the development of specialized pain therapists with generic pain-management skills who would be based in primary care. In more immediate terms we recognize that much multi-disciplinary assessment and management already takes place in primary care, mirroring the specialist programmes and including physiotherapists, pharmacists and social workers. There is scope for developing a more structured approach and the new primary care groupings may provide a framework. In the short term, there may be room for gains to be made in ensuring that there is a shared understanding of the elements of a rehabilitative approach and active consideration of the potential of different team members to undertake aspects of this process.

	Conclusions

Top Abstract Introduction Epidemiology Defining chronic pain Sites and causes of... The impact of chronic... Clinical management Self-help groups Pain management and the... Conclusions References

 
An improved understanding of chronic pain has led to significant advances in the management of this major and complex health problem. In particular, moves away from concentration on physical aspects, specific diagnoses and simple drug therapy have allowed the benefits of a holistic approach to be recognized. At the same time, research has led to improvement in all these areas of knowledge. Nonetheless, there is still room for more education of patients and professionals, and for more research in order to establish the effectiveness of the wide range of management options available, particularly in primary care.

	References

Top Abstract Introduction Epidemiology Defining chronic pain Sites and causes of... The impact of chronic... Clinical management Self-help groups Pain management and the... Conclusions References

 
¹ McQuay HJ, Moore RA, Eccleston C, Morley S, Williams A. Systematic review of outpatient services for chronic pain control. Health Technol Assess 1997; 1: 1–135.

² Smith BH, Smith WAC, Chambers WA. Chronic pain—time for epidemiology. J R Soc Med 1996; 89: 181–183.

³ Bowsher D, Rigge M, Sopp L. Prevalence of chronic pain in the British population: a telephone survey of 1037 households. The Pain Clinic 1991; 4: 223–230.

⁴ Brattberg G, Thorslund M, Wikman A. The prevalence of pain in the general population. The results of a postal survey in a county in Sweden. Pain 1989; 37: 215–222.[ISI][Medline]

5 Croft P, Rigby AS, Boswell R, Schollum J, Silman A. The prevalence of chronic widespread pain in the general population. J Rheumatol 1993; 20: 710–713.[ISI][Medline]

⁶ Crook J, Browne G. The prevalence of pain complaints in a general population. Pain 1984; 18: 299–314.[ISI][Medline]

⁷ James FR, Large RG, Bushnell JA, Wells JE. Epidemiology of pain in New Zealand. Pain 1991; 44: 279–283.[ISI][Medline]

⁸ Smith BH, Read JRM, Grimshaw JM, Watt BG, Chambers WA. Researching chronic pain: identification of a community based sample. The Pain Clinic 1996; 9: 73–76.

⁹ Von Korff M, Dworkin SF, Le Resche L. Graded chronic pain status: an epidemiologic evaluation. Pain 1990; 40: 279–291.[ISI][Medline]

¹⁰ Clinical Standards Advisory Group. Back Pain. London: HMSO, 1994.

¹¹ Sullivan MD, Turner JA, Romano J. Chronic pain in primary care: identification and management of psychosocial factors. J Fam Pract 1991; 32: 193–199.[ISI][Medline]

¹² Crombie IK, Davies HTO. Selection bias in pain research. Pain 1998; 74: 1–3.[ISI][Medline]

¹³ Merskey H. Pain terms: a list with definitions and notes on usage recommended by the IASP subcommittee on taxonomy. Pain 1979; 6: 249–252.[Medline]

¹⁴ Good MD, Brodwin PE, Good BJ, Kleinman A. Pain as Human Experience. Oxford: University of California Press, 1992.

¹⁵ International Association for the Study of Pain. Classification of chronic pain. Pain 1986; Suppl 3: S1–S226:

¹⁶ Purves AM, Penny K, Munro C et al. Defining chronic pain for epidemiological research—assessing a subjective definition. The Pain Clinic 1998; 10: 139–147.

¹⁷ Sutherland B. Pain problems in general practice. Presentation to XXV11th Annual Scientific Meeting of the Pain Society of Great Britain and Ireland, 1994.

¹⁸ Davies H, Crombie I, Elliot A. Basic Patient Survey. Dundee: North British Pain Association, 1990.

¹⁹ McQuay HJ, Machin L, Moore RA. Chronic non-malignant pain: a population prevalence survey. Practitioner 1985; 229: 1109–1111.[ISI][Medline]

²⁰ Spitzer WO, LeBlanc FE, DePuis M. Scientific approach to the assessment and management of activity-related spinal disorders. Spine 1987; 12 (Suppl): S1–S55.[Medline]

²¹ Charmaz K. Loss of self: a fundamental form of suffering in the chronically ill. Sociol Health Illness 1983; 5: 1161–1172.

²² Hopton JL. The management of chronic non-malignant pain in Lothian: general practitioner and patients' perceptions. Final Report to Scottish Office PHHSR Research Committee, 1997.

²³ Locker D. Disability and Disadvantage. London: Tavistock Publications, 1983;

²⁴ Reisine ST, Goodenow C, Grady KE. The impact of rheumatoid arthritis on the homemaker. Soc Sci Med 1987; 25: 89–95.

²⁵ Large RG. Psychological aspects of pain. Ann Rheumatic Dis 1995; 55: 340–345.[Free Full Text]

²⁶ McDowell I, Newell C. Measuring Health: a Guide to Rating Scales and Questionnaires. Oxford: Oxford University Press, 1987.

²⁷ Huskisson EC. Measurement of pain. Lancet 1974; 304: 1127–1131.

²⁸ Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975; 1: 277–299.[ISI][Medline]

²⁹ Fairbank JCT, Couper J, Davies JB, O'Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy 1980; 66: 271–273.[Medline]

³⁰ Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983; 67: 361–371.[ISI][Medline]

³¹ Main CJ, Wood PLR, Hollis S, Spanswick CC, Waddell G. The distress and risk assessment method. A simple patient classification to identify distress and evaluate the risk of poor outcome. Spine 1992; 17: 42–52.[ISI][Medline]

³² Williams ACD, Nicholas MK, Richardson PH et al. Evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain. Br J Gen Pract 1993; 43: 513–518.[ISI][Medline]

³³ McQuay HJ, Moore RA, Eccleston C, Morley S, de C Williams AC. Systematic review of outpatient services for chronic pain control. Health Technol Assess 1997; 1: 15–30.

³⁴ Craen AJM, Di Giulio G, Lampe-Schoenmaeckers AJEM, Kessels AGH, Kleijnen J. Analgesic efficacy and safety of paracetamol codeine combinations versus paracetamol alone: a systematic review. Br Med J 1997; 313: 321–325.[Abstract/Free Full Text]

³⁵ Portenoy RK. Chronic opioid therapy in non-malignant pain. J Pain Symptom Management 1990; 5 (Suppl): S46–S62.[Medline]

³⁶ Portenoy RK, Foley KM. Chronic use of opioid analgesic in non-malignant pain: report of 38 cases. Pain 1986; 25: 171–186.[ISI][Medline]

³⁷ Weissman DE, Haddox JD. Opioid pseudoaddiction—an iatrogenic syndrome. Pain 1989; 36: 363–366.[ISI][Medline]

³⁸ World Health Organization. Cancer, Pain Relief and Palliative Care. Technical Report Series 408. Geneva: WHO, 1990.

³⁹ McQuay HJ, Moore RA. Antidepressants and chronic pain. Br Med J 1997; 314: 763–764.[Free Full Text]

⁴⁰ Working Group of the National Medical Advisory Committee. The management of patients with chronic pain, 1994.

⁴¹ Frost H, Klaber Moffett JA, Moser JS, Fairbank JCT. Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. Br Med J 1995; 310: 151–154.[Abstract/Free Full Text]

⁴² Feine JS, Lund JP. An assessment of the efficacy of physical therapy and physical modalities for the control of chronic musculoskeletal pain. Pain 1997; 71: 5–23.[ISI][Medline]

⁴³ Caudill M, Schnable R, Zuttermeister P, Benson H, Friedman R. Decreased clinic use by chronic pain patients: response to behavioural medicine intervention. Clin J Pain 1991; 7: 305–310.[ISI][Medline]

⁴⁴ Keefe FJ, Dunsmore J, Burnett R. Behavioral and cognitive-behavioral approaches to chronic pain: recent advances and future directions. J Consulting Clin Psychol 1992; 60: 528–536.[ISI][Medline]

⁴⁵ Nicholas MK, Wilson PH, Goyen J. Comparison of cognitive-behavioral group treatment and an alternative non-psychological treatment for chronic low back pain. Pain 1992; 48: 339–347.[ISI][Medline]

⁴⁶ Turner JA, Jensen MP. Efficacy of cognitive therapy for chronic low back pain. Pain 1993; 52: 169–177.[ISI][Medline]

⁴⁷ Jensen MP, Turner JA, Romano JM. Correlates of improvement in multidisciplinary treatment of chronic pain. J Consulting Clin Psychol 1994; 62: 172–179.[ISI][Medline]

⁴⁸ Taylor SE, Brown JD. Illusion and well-being: a social psychological perspective on mental health. Psychol Bulletin 1988; 103: 193–210.

⁴⁹ Williams AC, Erskine E. Chronic pain. In Broome A, Llewelyn S (eds). Health Psychology: Processes and Applications. London: Chapman and Hall, 1997.

⁵⁰⁴ Goodhardt DE. Some psychological effects associated with positive and negative thinking about stressful event outcomes: was Pollyanna right? J Personality Soc Psychol 1985; 48: 216–232.[ISI][Medline]

⁵¹ Fordyce WE. Behavioral Methods for Chronic Pain and Illness. St. Louis: WC Mosby, 1976.

⁵² Phillips K. Biofeedback. In Pitts M, Phillips K (eds). The Psychology of Health. London: Routledge, 1991.

⁵³ Bremerich A, Wiegel W, Thein T, Dietze T. Transcutaneous electric nerve stimulation (TENS) in the therapy of chronic facial pain. J Craniomaxillofacial Surgery 1988; 16: 379–381.

⁵⁴ Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S. A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. N Engl J Med 1990; 322: 1627–1634.[Abstract]

⁵⁵ Lehmann TR, Russell DW, Spratt KF et al. Efficacy of electroacupuncture and TENS in the rehabilitation of chronic low back pain patients. Pain 1986; 26: 277–290.[ISI][Medline]

⁵⁶ Johnson MI, Ashton CH, Thompson JW. Long term use of transcutaneous electrical nerve stimulation at Newcastle Pain Relief Clinic. J R Soc Med 1992; 5: 267–268.

⁵⁷ Johnson MI, Ashton CH, Thompson JW. An in-depth study of long term users of transcutaneous electrical nerve stimulation (TENS). Implications for clinical use of TENS. Pain 1991; 44: 221–229.[ISI][Medline]

⁵⁸ Sharma U. Complementary Medicine Today: Practitioners and Patients. London: Routledge, 1992.

⁵⁹ Thomas KJ, Carr J, Westlake L, Williams BT. Use of non-orthodox and conventional health care in Great Britain. Br Med J 1991; 302: 207–210.

⁶⁰ Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J 1990; 300: 1431–1437.

⁶¹ Meade TW, Dyer S, Browne W, Frank AO. Randomised control trial of chiropractice and hospital outpatient management for low back pain: results from extended follow up. Br Med J 1995; 311: 349–351.[Abstract/Free Full Text]

⁶² Patel M, Gutzwiller F, Paccaud F, Marazzi A. A meta-analysis of acupuncture for chronic pain. Int J Epidemiol 1989; 18: 900–906.[Abstract/Free Full Text]

⁶³ Ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteria based meta-analysis. J Clin Epidemiol 1990; 43: 1191–1199.[ISI][Medline]

⁶⁴ NIH Technology Assessment Panel on integration of behavioral and relaxation approaches in the treatment of chronic pain and insomnia. Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. JAMA 1996; 276: 313–318.[Abstract]

⁶⁵ ter Kuile MM, Spinhoven P, Linssen ACG, Zitman FG, Van Dyck R, Rooijmans HGM. Autogenic training and cognitive self-hypnosis for the treatment of recurrent headaches in three different subject groups. Pain 1994; 58: 331–340.[ISI][Medline]

⁶⁶ Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 1992; 49: 221–230.[ISI][Medline]

⁶⁷ Paris JAG, Player D. Citizen's advice in general practice. Br Med J 1993; 306: 1518–1520.

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