Professor Michael Nicholas, Director, Pain Education Unit, Sydney Medical School, and Pain Management Programs, Royal North Shore Hospital
In clinical practice, pain has traditionally been understood as a warning signal — something that alerts us to a possible injury or threat of injury. Sometimes, the pain is due to the person having had surgery and they would have been advised this was possible before the surgery.
This is what is described as acute pain. It is usually self-limiting and resolves as the initiating injury heals. Sometimes, a treatment for an underlying cause of the pain might be needed but most of us will seek to understand it and advice on how it might be managed while healing takes place. We have all experienced this type of pain, so it should be familiar to you.
Examples of this type of pain include an ankle sprain, a torn ligament, back ache after activities we haven’t done for a while, a burn, and a toothache.
In that situation, you would expect a clinician to assess the injury, explain what has happened, and provide guidance on how best to manage it. In the case of a burn, for example, this may include wound care, advice about likely recovery, and sometimes medication to make the pain more bearable.
This traditional model of pain care works well for many acute pain experiences. However, it becomes less straightforward when pain persists beyond the normal healing period.
For many clinicians, this is where the conversations about modern pain care and its basis usually begin.
It has long been recognised that the experience and impact of pain are not determined solely by the extent of tissue damage. The concerns of the person in pain, their emotional state (for example anxiety or stress), and their behavioural responses (such as avoiding activity or focusing on the pain) can all influence how pain is experienced and how much it affects their daily life.
Modern pain care encourages clinicians to take all of these factors into account. In practice, this means understanding pain within a biopsychosocial framework. This means we recognise that biological, psychological and social factors interact to shape the person’s experience and its impact.
Most clinicians will recognise that this represents an important shift in thinking. Rather than focusing only on the injury itself and the report of how bad the pain is or conducting endless investigations once the likely basis of the pain has been identified and serious problems like cancer have been excluded, the aim is to understand the broader context in which pain occurs, how the person is responding and how it affects the individual.
This perspective becomes particularly important when pain persists. This is called chronic pain.
Chronic pain is defined as pain lasting longer than three months and often continues beyond the normal healing time for an injury. In these situations, the goal of care typically shifts. Instead of focusing solely on the pain and trying to relieve it, clinicians need to develop a working relationship with the person in pain as they must play a critical role in its management. Rather than trying to relieve pain alone, which is often disappointing when the pain is chronic, the focus needs to shift to the psychological, behavioural and social/environmental contributors to their pain that were identified in the assessment of the person’s pain. This means if we can help the person in pain to better understand their pain and its effects on them, we can help them to develop ways of reducing the impact pain has on their daily life. A critical starting point is to reassure the person in pain that even though nothing serious has been found to explain their pain, we accept their pain is real and not imaginary. Importantly, it can also be modified by helping them to develop effective self-
management methods to be undertaken by the person in pain.
This approach also entails our recognising there is no ‘one size fits all’ approach to chronic pain and we need to be flexible in how we work with them, often well-beyond what happens in the clinic. This might include supporting someone to return to work or study, re-engage in family roles, or participate in activities that are important to them.
While there are similarities between approaches to acute and chronic pain, the expected outcomes can be different. Acute pain care often focuses on pain relief as the injury heals. In chronic pain management, the emphasis is often on improving function, participation in normal activities and improving their quality of life, even though pain may persist. The frequent refrain from those who have accepted and implemented this approach is ‘they still have their pain, but it doesn’t bother them as much’.
Throughout the OPEN program we support healthcare providers from all disciplines to develop practical skills for assessing and working with people experiencing both acute and chronic pain within this biopsychosocial approach to pain care. The basic premise is that if all clinicians dealing with a person in pain agree to follow a plan worked out with each person in pain, we should achieve better outcomes. The OPEN program should help us all to achieve this.
