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Transcript – Medical Investigations

Doc­tors and patients can both get caught up in an almost end­less search for a cure or a clear diag­no­sis of what’s caus­ing the pain. Search­ing for a med­ical solu­tion is under­stand­able, but it can delay peo­ple in start­ing to learn to man­age their pain.

With the right sup­port and guid­ance from health­care pro­fes­sion­als, peo­ple can move towards play­ing an active role in their care, often becom­ing less depen­dent on medication.

Top tip: results on MRI scans don’t usu­al­ly help us to under­stand what’s behind per­sis­tent back pain – many peo­ple with­out pain will have ‘bulging discs’.

Find out more: Pain Concern’s leaflets on med­i­cines, such as Opi­oids, Anti­de­pres­sants, Amitripty­line and Gabapentin & Pre­ga­balin have real­ly help­ful advice on using pain med­ica­tions effec­tive­ly and how to reduce your med­ica­tions safe­ly. 


Paul Cameron: There’s bar­ri­ers relat­ed to the atti­tudes of peo­ple. There’s bar­ri­ers relat­ed to the under­stand­ing of chron­ic pain and that can be with patients and health pro­fes­sion­als, so, for exam­ple, patients who have chron­ic pain but are look­ing for a cure or are look­ing for more inves­ti­ga­tions to find a way to get it cured. They have their own bar­ri­ers in terms of being able to move for­ward and actu­al­ly man­age their pain because they’re still look­ing for that cure, and they’re look­ing for more inves­ti­ga­tions, pos­si­bly surgery. These are ulti­mate­ly going to be delays that will stop them real­ly from being able to man­age their own pain.

Across spe­cialisms, orthopaedics, neu­rol­o­gists, GP’s, every­one wants to ensure they don’t miss some­thing. You would­n’t want to be the one that miss­es some­thing seri­ous, so that’s why these inves­ti­ga­tions all end up being done for a lot of peo­ple in chron­ic pain.

Steve Gilbert: When we see some­body with pain that has become a prob­lem for the patient, then we’re want­i­ng real­ly to lis­ten to them and find out if there’s some­thing that has start­ed the pain, if there’s any­thing that we could iden­ti­fy that has made it worse or if there’s any­thing that’s helped it. And what we look for in med­i­cine are red flags. These are indi­ca­tors that we might have to do some more tests. They’re not nec­es­sar­i­ly an indi­ca­tor that there is an under­ly­ing seri­ous problem.

Lars Williams I sup­pose the bread and but­ter of the pain ser­vice is back pain. That’s prob­a­bly the most com­mon con­di­tion that we see and that’s a sit­u­a­tion in which there is usu­al­ly a clear diag­no­sis – mus­cu­loskele­tal or mechan­i­cal back pain. There might be an MRI [Mag­net­ic Res­o­nance Imag­ing] scan that shows wear and tear changes, but it does­n’t real­ly mat­ter – we know the extent of changes on an MRI scan bear very lit­tle rela­tion to how much pain peo­ple experience.

So, although patients will come to us want­i­ng some fur­ther clar­i­fi­ca­tion of the prob­lem – ‘I’ve still got this prob­lem. It’s not been fixed. Is there any fur­ther test we can do to show exact­ly where it is? Because if you find exact­ly where it is, then I’ll be able to have the prop­er treat­ment.’ But from our point of view any fur­ther inves­ti­ga­tion would be point­less. In that sense, that par­tic­u­lar option… you’ve gone as far as you can in that direc­tion, look­ing for a diag­no­sis, look­ing for an explanation.

Gilbert: If you go on look­ing for some­thing and doing more tests, what many patients expe­ri­ence is, they’ll get an MRI scan and they’ll be told ‘Oh, look, there’s some disc bulging there’ or alter­na­tive­ly they’ll be told ‘there’s noth­ing to see on this scan, we haven’t got an expla­na­tion for your pain’. And in that sit­u­a­tion the patient can feel they’re not believed, the doc­tors say­ing there’s noth­ing real­ly wrong with them.

Williams: The expec­ta­tion of a patient when they see an orthopaedic sur­geon is, they’ve got some­thing bro­ken and it’s easy enough to fix and the orthopaedic sur­geon will be oper­at­ing in a sim­i­lar mind set. They’re used to deal­ing with things which are bro­ken. They’re able to see where the break is and they’re able to fix it and every­one goes home hap­py. So I think what we often see when patients come to us is after hav­ing seen orthopaedic sur­geons and they’re still in pain, is the sense of frus­tra­tion that their expec­ta­tions haven’t been met. That this – what­ev­er it was – as far as the orthopaedic sur­geon is con­cerned, it’s fixed but the pain’s still there.

Gilbert: And of course what we’ve seen on the MRI scan is only the struc­tur­al com­po­nents of the spine. Many peo­ple get discs that bulge and don’t have any symp­toms at all, so when you get to my age, round about two thirds of peo­ple have got bulging discs and they’re wan­der­ing around absolute­ly fine – it’s not giv­ing them any trou­ble at all. But telling them they’ve got bulging discs might plant a wee bit of wor­ry in the patient’s mind.

And sim­i­lar­ly, we can’t see what the nerves are say­ing to each oth­er or the mes­sages they’re send­ing. So, if we don’t see any­thing on the inves­ti­ga­tion, the MRI scan or the X‑ray, that does­n’t mean the pain sens­ing nerves aren’t send­ing pain mes­sages. Usu­al­ly, peo­ple don’t come and make up pain.

****

Williams: The patien­t’s sto­ry is what you’d expect from the refer­ring let­ter. So often the refer­ring let­ter would be say­ing ‘This woman has knee pain. We’ve done every­thing we can for her knee, her knee looks fine to us but she’s still com­plain­ing bit­ter­ly of knee pain’. But then when we have the lux­u­ry of 45 minute appoint­ments and dur­ing that 45 min­utes a dif­fer­ent sto­ry often emerges. It’s not just the knee, that’s a small part of it – it’s lots of oth­er things as well.

Cameron: If any indi­vid­ual has pain that starts to be per­sis­tent, that changes and devel­ops over time, it’s absolute­ly under­stand­able that some­one is going to try and find out what it is. Part of our cul­ture, I think – West­ern Cul­ture – is we’re brought up to go and see our doc­tor. Our doc­tor will find the prob­lem, they’ll send you to a spe­cial­ist, the spe­cial­ist will cut out the prob­lem or give you the right med­ica­tion for the prob­lem. When that sort of process does­n’t hap­pen – and it’s one that’s quite ingrained in all of us I think – I think that’s where the dif­fi­cul­ties come.

Williams: An orthopaedic sur­geon might have said some­thing along the lines of ‘We’ve done every­thing we can. This is some­thing you’ll have to live with. You’ll have to accept that you have pain, just go on and live your life.’ And it’s seen by the patient con­cerned as a very sort of glib and unsym­pa­thet­ic way of dis­miss­ing them. So it’s quite a hard sell to take that mes­sage and present it as some­thing a bit more positive.

Cameron: You’d think well I must be at the wrong spe­cial­ist, so I’ll have to go back to my GP and try and get to a dif­fer­ent spe­cial­ist and that goes on and on and on, until even­tu­al­ly every­one realis­es, that actu­al­ly, there is noth­ing else that can be done in terms of surgery, in terms of dif­fer­ent med­ica­tions, for exam­ple. And the patients them­selves come to that real­i­sa­tion, but that can be a long process. Some peo­ple come to that real­i­sa­tion very ear­ly but oth­ers – in the main I would say in my expe­ri­ence – come to it a lot later.

****

Gilbert: If a patient has some wor­ries that there might be some­thing seri­ous under­ly­ing, then I’ll explain I’ve had a look at you and I’m pret­ty sure that every­thing is struc­tural­ly sound here and I’ve found a good expla­na­tion for why you’ve got pain. I’ve found a bit that’s real­ly sen­si­tive and is real­ly tight­ened up and oth­er­wise healthy, so I think we can go ahead with a reha­bil­i­ta­tion approach.

Car­men Mur­ray: To under­stand my pain, he [Dr Steve Gilbert] said to begin with it would be a mas­sive help to me to under­stand what this pain is that I’m going through. So like, he was always rec­om­mend­ing books for me to read, web­sites for me to go on… some peo­ple might go home and think this isn’t going to help me, [but] it has helped. So that’s what they’ve done to begin with, just tried to be there to sup­port me.

My consultant’s real­ly good. He gives me a phone call every two weeks to see how I’m doing, which is great. You just feel like some­body is on your side, that you’re not try­ing to bat­tle against some­body, some­body’s there with you, they’re going through it with you in a way.

Gilbert: Car­men had her surgery on her spine and she con­tin­ues hav­ing an awful lot of pain, which was man­aged with real­ly strong painkillers and when I had a look at her back, there was the scar there, but there was­n’t any pain in the scar, and the mus­cles were very tight and there was lots of sen­si­tiv­i­ty. And that was despite her hav­ing tak­en all her painkillers.

Mur­ray: Under­stand­ing the prob­lems of being on long term painkillers and how maybe reduc­ing them… to begin with I thought, well, sure­ly if I’m going to reduce the painkillers, I’m going to be in more pain. But then try­ing to learn that this might not be the case, that my body’s own painkillers will start to kick in and might even do a bet­ter job. And I have a lot of prob­lems sleep­ing, bad dreams con­stant­ly and I’ve learned that this could be a prob­lem with the painkillers as well.

Gilbert: The way that the nerves were all work­ing was fine, so there was­n’t any defor­mi­ty and the nerves were all work­ing and I would say to her ‘Your spine’s quite strong now. We need to try and get things to be more relaxed and less sen­si­tive’. And she’s made a mas­sive improve­ment just because of that – a lot more con­fi­dence in her back and the way things are working.

Mur­ray: What they’ve helped me with is knowl­edge and just being there to sup­port me through this, is the main thing, just feel­ing like I’m not com­plete­ly alone in all this.


Con­trib­u­tors:

  • Paul Cameron, Nation­al Chron­ic Pain Co-ordi­na­tor – Scot­tish Government
  • Lars Williams, Con­sul­tant in Anaes­the­sia and Pain Med­i­cine, Glas­gow Pain Man­age­ment Programme
  • Steve Gilbert, Con­sul­tant in Anaes­the­sia and Pain Med­i­cine, NHS Fife
  • Car­men Murray

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