Pain is one of the oldest medical complaints and even today remains the most frequent reason for which people seek care.1 There are very few in the healthcare system—chiropractors, physical therapists, dentists, nurses, physicians– who do not regularly help patients manage pain.
Still, patients may neglect to talk about their pain in meaningful ways or may not even bring pain up at all. This can lead to unrelieved (and unnecessary) suffering, dissatisfaction with treatment, poor adherence, and patients lost to follow-up. Here are 10 ways that can help your patients discuss pain with you in clinically relevant ways.
- Ask the patient about pain at every single visit.
Adopt a “do ask, do tell policy” Many patients, even when they are experiencing intense or limiting pain, may hesitate to bring it up. Sometimes the hectic atmosphere of a busy clinic causes patients to forget to mention all they want to talk about; sometimes they feel like they are “bothering” clinicians when they talk about pain. The quickest way to make sure the patient sees an opening to talk about pain is to introduce the topic yourself. It is better to use the word pain than ask simply, “How are you?” or “How have you been feeling?” which patients may evade or dismiss as social pleasantries.Instead, ask directly: “Are you feeling any pain?” or “How are your pain levels?” If you know the patient has had pain before ask directly, “Is your pain better or worse since I last saw you?” It is important to understand how the impact that pain is having on their activities of daily living (ADLs), functionality, their ability to work, and the quality of life (QoL). Ask patients if pain is interfering with how they get along with family and friends and if pain limits them socially and personally. These answers will help build an individual pain management treatment plan.
- Measure pain using a validated tool.
There are numerous validated instruments to help measure pain but one of the easiest to use is a simple scale from 0 to 10, where 0 is no pain and 10 is the worst possible pain imaginable. Ask the patient to assign a number to the pain he or she is experiencing right then. Document these pain records. As the patient gets more familiar with this analog scale, you may ask them to keep a pain diary where they note the number associated with their pain several times a day, every day, between visits. A numerical scale like this works much better than the verbal scale of asking, “Is your pain bad today?”But it’s not just about a number! There are other validated tools that should be used to understand the magnitude of pain on the patients ADL, QOL and functionality such as the SF-36 questionnaire. Some even combine measuring these aspects along with their pain like the Brief Pain Inventory Scale and the Roland Morris Scale. When using pain assessment tools, it is less important which specific tool(s) you use than that you use tools consistently.
- Talk about all pain sites.
Many patients have pain in more than one location. Have the patient identify all pain sites, either by describing them (“my knee” and “my neck”), pointing out the painful area, or using a drawing of the body on paper and allowing the patient to color in painful areas. It is not unusual for a patient to have pain at multiple sites. These painful areas may or may not be related. Using a Body Map is helpful to gather this information. This is a good example of the sort of simple diagram that can be helpful in pinpointing pain sites.
- Ask the patient to describe the characteristics of the pain.
In everyday language, we do not have good adjectives to describe types of pain. In fact, when you ask a patient to describe his or her pain, you may find the patient struggling to articulate how the pain feels. It may be helpful to prompt the patient with some pain words. Ask if the pain is dull or sharp, stabbing, electrical, deep or throbbing. Furthermore, ask if the patient ever experiences numbness at any of the pain sites or a sensation of heaviness, thickness, or “pins and needles.” Ask if the pain comes and goes or if it is more or less the same all of the time. Chronic pain may be migratory; ask if the pain moves around. All of these characteristics can help you better determine the type of pain the patient is experiencing. Also note that some patients experience neuropathic pain as a sensation of numbness or unusual (but not painful) sensation punctuated by occasional sudden, sharp pains. Paradoxically, numbness can be an important characteristics of neuropathic pain.
|If the pain can be described as||It may be this type of pain||And it may be treated with this type of regimen|
|Sharp, stabbing||Nociceptive||Topical analgesic|
|Deep, dull, throbbing||Visceral||non-pharmacological (manipulation, manual therapy, cold/heat therapy, other modalities)|
|Very localized||Nociceptive||Topical analgesic|
|Specific to joints, muscles, tendons||Somatic||Topical; non-pharmacological (manipulation, manual therapy, cold/heat therapy, other modalities)|
|Shooting, electrical, shocks||Neuropathic||Topical; non-pharmacological (manipulation, manual therapy, cold/heat therapy, other modalities)|
|Vague, diffuse, migratory||Chronic pain||Topical; non-pharmacological (manipulation, manual therapy, cold/heat therapy, other modalities )|
- Ask the patient if there are certain things that make the pain better or worse.
In many cases, patients may already know some of the answers about how to control their own pain. If the patient seems at a loss to answer the question, ask if specific movements or activities (standing up from a sitting position, turning the head, and so on) affect pain. It is also useful to ask about lifestyle issues and their potential effect on pain: is pain worse when the patient did not get enough sleep? Ate a lot of junk food? Did not get much exercise?
- Ask the patient if there are things he or she would like to do or used to do that they no longer can do because of the pain.
Understanding functional limitations can greatly help the healthcare professional and also be used to set relevant goals for the patient. While healthcare professionals tend to favor quantification scales for pain intensity, functional deficits (and their remedy) may actually be more relevant and motivational to the patient. Since pain can limit the patient’s ability to move, work, socialize, and enjoy life, regaining things that had been given up can be particularly meaningful to patients and families. Individual patients may feel particularly chagrined at giving up certain activities and it may be useful to use those to set functional goals in a pain control regimen. Examples of functional goals might be the ability to: walk to the mailbox, sit through a movie, sleep all night without middle-of-the-night pain, walk upstairs, or carry a sack of groceries.
- Encourage the patient to talk freely and openly about pain.
Many individuals feel that discussing pain or other physical discomforts is a form of “complaining.” Patients may not wish to appear weak or needy. As much as possible, convey to the patient that talking about pain is helpful because pain is a medical condition and understanding pain more fully will help to formulate a better treatment plan. Pain is subjective, so you must rely on your patient to describe and discuss it. Be sensitive also to personal, familial, and cultural influences that may limit how your patient talks about pain. Some people feel that pain is a natural part of life and should simply be accepted without complaining. Others believe that pain is part of aging and should be ignored as much as possible. Finally, some patients worry that their pain may indicate they have a serious or even potentially fatal medical condition and will avoid discussing it to prevent hearing any bad news. As much as possible, coax reticent patients to describe pain as part of the therapeutic relationship.
- Help the patient to build realistic assumptions about pain.
Set realistic expectations and achievable treatment goals! Patients sometimes seem to cluster into one of two extremes when it comes to pain: either they believe there is nothing that can be done about pain or they believe that the clinician should be able to make them 100% pain-free. Discuss pain solutions with the patient but make sure they understand that it may not always be possible to completely eliminate pain. Talk about “pain control” and “pain management” rather than getting rid of pain entirely.
- If your patient is being treated for pain by another physician, ask about side effects.
For pharmacological therapy, many side effects of specific drugs are well known to clinicians but not necessarily patients. Ask the patient, for example, if nonsteroidal anti-inflammatory drugs (NSAIDs) are upsetting their stomach or if opioid analgesics are causing constipation. In many cases, these side effects can be managed or the drugs can be rotated to drugs of the same class that are more tolerable or eliminated altogether depending on your progress with treatment. Topical products may irritate the skin. Even nonpharmacological therapy can be problematic (for example, the patient does not always find enough time to exercise or pool exercises cause eye irritation, etc.) Ask about possible side effects and allow the patient to explain other problems with pain control regimens. This will be very helpful when it comes time to create an individualized pain management plan. This sort of approach promotes shared decision making and can be more empowering to the patient.
- Encourage compliance.
Lack of compliance is an important consideration for any pain control regimen. Whether the patient is treating pain with or without medications, ask about compliance in ways that allow the patient to save face but admit non-adherence if that is the case. Discuss ways that might improve adherence, whether it be an important supplement or exercise they are supposed to be doing outside of the clinic or an ADL, they need to be responsible in taking an active role in their care and being honest about what they did or didn’t do. For example, a patient may dislike taking pills (and a high pill burden is often associated with noncompliance) so a topical analgesic may be a better solution. Patients may need to go to water aerobics three or four times a week to get moving, but not be able to find the time.
These ten strategies might seem as though they add to the clinician’s burden but in reality, they can reduce both your net time and your frustration in dealing with pain patients when practiced systematically. Many problems with pain occur because the patient did not fully discuss pain with the clinician in a meaningful way, failed to comply with therapy, or discontinued treatment because of side effects. These can all be pre-emptively managed by using this checklist.
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- NCCIH. Pain. 2017; https://nccih.nih.gov/health/pain. Accessed October 11, 2017.