What is pain management, and what is its relevance to the rheumatologist?

When confronted with patients whose pain is becoming more chronic and disabling, GPs and hospital physicians alike must recognize the risks of maladaptive psychosocial factors, and especially their own potential for inducing iatragenic distress. Chronic symptoms without discernible cause, or where the cause is not amenable to a curative approach, is the rule rather than the exception in chronic LBP. Indeed, even in inflammatory diseases such as RA, the degree of disability may be disproportionate to the degree of damage or disease activity. When thorough medical examinations and investigations are normal, or demonstrate incurable causes for chronic pain, it should not be assumed that the sufferers are imagining their symptoms or seeking gain. Secondary psychological distress is predictable, and could be minimized by accurate and honest early communication. Correcting patients' misattributions about intractable pain, and addressing misplaced fears of activity-related tissue damage, is a necessary first step in the therapeutic process. In this respect, the pain management approach, used early on in a patient's pain career, could potentially pre-empt the development of chronic pain-related disability. However, this hypothesis has yet to be formally tested. Pain management is not the same as pharmacological pain manipulation, although the latter may form an essential element of the former. Other rheumatological skills are logically used along-side pain management, for example steroid injections in LBP patients who develop trochanteric bursitis. An understanding of the mechanisms leading to chronic pain, and an acquisition of pain management skills, would allow rheumatologists to deal with chronic, benign musculoskeletal pain patients in a more sympathetic, relaxed and confident manner, and gain increased job satisfaction through reductions in distressing heart sink emotions. Fewer review appointments, more rapid discharge rates and improved health-care utilization may ultimately offset concerns about the increases in initial consultation time. Specialist interdisciplinary teams will still be needed for the more complex cases, which currently consume so much health-care and welfare resource.