Medically unexplained symptoms: (Letter 1 of 2 (original) (raw)
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Why must pain patients be found deserving of treatment?
The virtual mentor : VM, 2008
CLINICAL CASE Why Must Pain Patients Be Found Deserving of Treatment? Commentary by Jay M. Baruch, MD Dr. Maier entered the small curtained room in the emergency department and introduced himself to the patient, Mrs. Winter. Then he asked whether the fourthyear medical student with him, Miss Malloy, could be present for the encounter. "I suppose so," Mrs. Winter said. "But I can't promise that I won't be cranky. I'm in considerable pain." "Tell me about it." Dr. Maier said. Mrs. Winter explained that her doctor, Dr. Caruso, had diagnosed fibromyalgia about a year ago. She was generally tired, had low energy, and almost always had some pain in her shoulders, neck and head. But the pain flared up from time to time. Right now, her neck was so sore that she couldn't move it; it even hurt when she walked. When this happened, she said, she just had to give in and spend a few days on the sofa "knocked out" until whatever had caused the painful episode resolved. She used the word "resolved." Mrs. Winter gestured with her hands as she spoke, letting her manicured finger tips hover over the areas she mentioned as she described the pain. Her several gold bracelets lent a jingling flourish to the account. When Dr. Maier asked Mrs. Winter to rate the pain from 1 to 10, compared to the worst she had experienced, she said, "8.7. Of course I've had worse or I wouldn't have been able to get here. But I certainly couldn't wait until Monday to see Dr. Caruso." Dr. Maier asked Mrs. Winter a few more questions about the nature of the pain, then examined her to determine whether some injury or inflammatory condition unrelated to her diagnosis could be the cause of her current pain. Dr. Maier said he had found nothing to indicate that Mrs. Winter was experiencing anything different from the flare-ups she described having had in the past. "What does Dr. Caruso usually prescribe?" he asked. "He usually gives me Tramadol," she said. "Twenty-four will get me through the duration of the bout."
The clinical reasoning of pain by experienced musculoskeletal physiotherapists
Manual Therapy, 2007
There is currently no research within Physiotherapy to explain the extent to which current theories and models of pain influence clinicians' reasoning related to clinical presentations of pain. The purpose of this qualitative study was to investigate the clinical reasoning of experienced musculoskeletal physiotherapists in relation to three different presentations of pain. A qualitative multiple-case studies method was used in this study. A purposive sample of seven experienced musculoskeletal physiotherapists viewed three videotaped patient-therapist clinical interviews describing three different pain presentations. An audio taped, semi-structured interview was carried out with each participant during which the participants were encouraged to verbalize their thoughts regarding aspects of each patient's pain presentation. All interviews were subsequently transcribed, coded and analysed. Results showed a dynamic, multidimensional nature to the therapists' clinical reasoning, which was found to be grounded in a number of established models of pain. Five main categories of pain-based clinical reasoning were identified. These were (i) biomedical, (ii) psychosocial, (iii) pain mechanisms, (iv) chronicity and (v) irritability/severity. Reasoning within these categories influenced therapists' prognostic decision-making as well as the planning of physical assessments and treatment. The clinical reasoning of pain by the participants in this study appeared to reflect the integration of diverse models and theories of pain into current clinical practice. Mechanisms-based clinical reasoning has not been previously observed amongst physiotherapists.
Patient-centered consultations for persons with musculoskeletal conditions
Chiropractic & Manual Therapies
Consultations between practitioners and patients are more than a hypothesis-chasing exploration, especially when uncertainty about etiology and prognosis are high. In this article we describe a single individual's account of their lived experience of pain and long journey of consultations. This personal account includes challenges as well as opportunities, and ultimately led to self-awareness, clarity, and living well with pain. We follow each section of this narrative with a short description of the emerging scientific evidence informing on specific aspects of the consultation. Using this novel structure, we portray a framework for understanding consultations for persistent musculoskeletal pain from a position of patient-centered research to inform practice.
Sociology of Health and Illness, 1992
Chronic pain is a problematic reality at least for two reasons. First, pain is a person's private experience, to which no one else has direct access. Second, chronic pain is lasting proof of a failure that questions the validity of actions and explanations, both past and future, of all involved. Because pain is a private sensation that cannot be reduced by objectification, it cannot, ultimately, be stablised as an unquestionable fact that can serve as the basis of medical practice and thus organise relations between professional and lay persons. This fragile factuality increases the work a physician has to do to decipher a patient's pain. The aim of this paper is to examine how physicians specialising in pain medicine work at this deciphering. Because of these characteristics of pain, physicians are forced to work on the elusive information provided by patients so as to bring into being something called chronic pain. When doing this they tap various, nearly incompatible, resources. I shall study the way these multiple resources are put to use by physicians as they form judgements about cases. By using as a field experiment two pain centres with opposite conceptions and practices, it can be shown how physicians in each centre determine patients' pain situations and formulate advice to them, how the characteristics of this work involve physicians in specific systems of relations with patients, and how these systems are related to dimensions of this work: either to a justification of physicians' actions or else to a confirmation, or realignment, of the initial doctor-patient agreement.
Arthritis and rheumatism, 2005
ObjectiveTo explore the experiences of diagnosis and management among patients who attended a specialist musculoskeletal pain clinic and the factors influencing their interpretation of these experiences.To explore the experiences of diagnosis and management among patients who attended a specialist musculoskeletal pain clinic and the factors influencing their interpretation of these experiences.MethodsA postal questionnaire was sent to potential participants 6–20 months after their first clinic attendance. Data were collected on pain presence, severity, and location; health-related quality of life; psychological distress; and care-seeking behavior. Questionnaire data were used to inform combined purposive and theoretical sampling. In-depth interviews were conducted that probed participants' understanding of their chronic musculoskeletal pain and its management in a specialist musculoskeletal pain clinic.A postal questionnaire was sent to potential participants 6–20 months after their first clinic attendance. Data were collected on pain presence, severity, and location; health-related quality of life; psychological distress; and care-seeking behavior. Questionnaire data were used to inform combined purposive and theoretical sampling. In-depth interviews were conducted that probed participants' understanding of their chronic musculoskeletal pain and its management in a specialist musculoskeletal pain clinic.ResultsFifteen patients were interviewed. Four main themes were identified: spoiled identity (pain limited patients' activities so extensively that it affected their sense of self); diminishing faith in medicine (patients were disappointed with aspects of their care-seeking experience); making sense of pain (patients made sense of their pain by locating their pain within the context of their lives); and learning to live with the pain (an issue for all patients was whether or not their pain would stop or whether they had to learn to live with it).Fifteen patients were interviewed. Four main themes were identified: spoiled identity (pain limited patients' activities so extensively that it affected their sense of self); diminishing faith in medicine (patients were disappointed with aspects of their care-seeking experience); making sense of pain (patients made sense of their pain by locating their pain within the context of their lives); and learning to live with the pain (an issue for all patients was whether or not their pain would stop or whether they had to learn to live with it).ConclusionDeveloping, implementing, and evaluating approaches to address patients' spoiled identities might allow us to improve patient-centered outcomes in chronic musculoskeletal pain.Developing, implementing, and evaluating approaches to address patients' spoiled identities might allow us to improve patient-centered outcomes in chronic musculoskeletal pain.
Journal of pain research, 2016
The first consultation at a specialist pain clinic is potentially a pivotal event in a patient's pain history, affecting treatment adherence and engagement with longer term self-management. What doctors communicate to patients about their chronic pain and how patients interpret doctors' messages and explanations in pain consultations are under-investigated, particularly in specialist care. Yet, patients value personalized information about their pain problem. Sixteen patients in their first specialist pain clinic consultation and the doctors they consulted were interviewed shortly after the consultation. Framework analysis, using patient themes, was used to identify full match, partial match, or mismatch of patient-doctor dyads' understandings of the consultation messages. Patients and doctors agreed, mainly implicitly, that medical treatment aiming at pain relief was primary and little time was devoted to discussion of self-management. Clinically relevant areas of misma...
Pragmatic but flawed: the NICE guideline on chronic pain
The Lancet, 2021
With the publication of 'Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain NICE guideline [NG193]' NICE has stumbled clumsily into a complex field. Arrogantly refusing any help, the guidelines are likely to make a terrible situation worse, substantially increasing the risks of harm patients face from mistreatment and the absence of care. We consider three examples of egregious failure in this report. The first is nosological, the second evidential, the third communicative. Chronic primary pain is a recent category adopted in ICD11 (https://icd.who.int/en) to capture the experience of pain as the primary problem when there is no identified disease and thus disorder of the nociceptive system is the positive feature to assess. When recommending 'thinking about the possible causes of pain' (points 1,1,3-1.1.7), NICE falls into the trap of presenting 'primary pain' as something out of proportion with observable disease or injury, or a diagnosis of exclusion. "1.1.4 … if there is no clear underlying (secondary) cause or the pain or its impact is out of proportion to any observable injury or disease, particularly when the pain is causing significant distress and disability." This category error is well known in pain science and one that should have been avoided. Propagating it can only do people with chronic pain a serious disservice. Further, this group of pain disorders is highly heterogeneous, including fibromyalgia, complex regional pain syndrome, chronic primary headache and orofacial pain, chronic primary visceral pain, and chronic primary musculoskeletal pain. That we cannot describe in detail the mechanism for each is testimony to the poverty of our science: ignorance should humble us. Too often ignorance in chronic pain emboldens observers to claim that patient suffering is disproportionate, exaggerated, unnecessary, and unworthy of medical attention.