Article ABC of Psychological Medicine Musculoskeletal Pain
Article ABC of Psychological Medicine Musculoskeletal Pain
Article ABC of Psychological Medicine Musculoskeletal Pain
BMJ 2002;325;534-537
doi:10.1136/bmj.325.7363.534
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Clinical review
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immediate psychiatric referral. These two groups of patients Working conditions Occupational
need to be managed separately. Work characteristics factors
For the vast majority of patients, however, the identification Social policy
of contributory psychological and social factors should be seen
as an investigation of the normal range of reactions to pain The clinical flags approach to obstacles to recovery from back pain and
rather than the seeking of psychopathology. Questions in the aspects of assessment
form of interview prompts have been designed to elicit
potential psychosocial barriers to recovery in the yellow flags
system. They can be used at the time of initial presentation by Structured interview prompts
the general practitioner. x What do you understand is the cause of your back pain?
x What are you expecting will help you?
Establish collaboration x How are others responding to your back pain (employer,
Recent studies of miscommunications between doctors and coworkers, and family)?
x What are you doing to cope with back pain?
patients with pain show that adequate assessment and
x Have you had time off work in the past with back pain?
collaborative management cannot be achieved without good x Do you think that you will ever return to work? When?
communication between doctors and patients: only then will
patients fully disclose their concerns.
The essence of good communication is to work toward
understanding a patients problem from his or her own Guidelines for collaborative management of patients with
perspective. In order to do this, the doctor must first gain the pain
patients confidence. A patient who has been convinced that the x Listen carefully to the patient
doctor takes the pain seriously will give credence to what the x Carefully observe the patients behaviour
x Attend not only to what is said but also how it is said
doctor says. Unfortunately, the converse is more common, and
x Attempt to understand how the patient feels
patients who feel that a doctor has dismissed or under-rated x Offer encouragement to disclose fears and feelings
their pain are unlikely to reveal key information or to adhere to x Offer reassurance that you accept the reality of the pain
treatment advice. x Correct misunderstandings or miscommunications about the
consultation
Enhance accurate beliefs and self management strategies x Offer appropriate challenges to unhelpful thoughts and biases
It is easy to overlook the value of simple measures. Many (such as catastrophising)
patients respond positively to clear and simple advice, which x Understand the patients general social and economic
circumstances
enables them to manage and control their own symptoms.
The photograph of a man with back pain is reproduced with permission Further reading
of John Powell/Rex. The figure showing the biopsychosocial model of low
back pain is adapted from Waddell G, The back pain revolution, Edinburgh: x Clinical Standards Advisory Group. Clinical Standards Advisory
Churchill Livingstone, 1998. The figure showing the clinical flags Group report on back pain. London: HMSO, 1994
approach to assessing back pain and the box of defining characteristics of x Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial
modern pain management programmes are adapted from Main CJ and yellow flags in acute low back pain: risk factors for long term disability and
Spanswick CC, Pain management: an interdisciplinary approach, Edinburgh: work loss. Wellington, NZ: Accident Rehabilitation and
Churchill-Livingstone, 2000. The boxes of guidelines for collaborative Compensation Insurance Corporation of New Zealand and the
management of patients with pain, of key strategies for managing distress National Health Committee, 1997
and anger associated with pain, of structured interview prompts, and of x Royal College of General Practitioners. Clinical guidelines for the
ways to enhance positive self management are adapted from Main CJ and management of acute low back pain. London: RCGP, 1996
Watson PJ, in Gifford L, ed, Topical issues in pain, vol 3, Falmouth: CNS x Waddell G, Burton K. Occupational health guidelines for the
Press (in press). The figure showing effects of confrontation or avoidance management of low back pain at workevidence review. London: Faculty
of pain on outcome of episode of low back pain is adapted from Vlaeyen of Occupational Medicine, 2000
JWS et al, J Occup Rehabil 1995;5:235-52. x Roland M, Waddell G, Klaber-Moffett J, Burton AK, Main CJ. The
back book. 2nd ed. Norwich: Stationery Office, 2002
BMJ 2002;325:5347
A memorable patient
A thousand leagues under the sea
Having recently served as the medical officer of a that the preservative was vodka, the histology was
Royal Navy nuclear powered submarine, sometimes reported as cavernous haemangioma. Although some
isolated for up to 12 weeks without communications, I cellular detail was lost because shrinkage from cell
was occasionally confronted with vexing clinical dehydration, the histology on this occasion was clear
dilemmas. enough. Alcohol is in fact routinely used with cervical
About four weeks from the end of a patrol, a 24 year cytology and frozen section in most histopathology
old sailor presented with an itchy, raised, irregularly labs.
pigmented lesion on his back that had been bleeding Cavernous haemangiomas are normally found in
over the past two days. He had first noticed it over six the central nervous system and are associated with
months ago but had failed to seek advice. It was hard, subarachnoid haemorrhage. There is often a family
non-blanching, and surrounded by erythema; I was history. Rarely there are extensive cutaneous
instantly concerned by its appearance, suggestive of manifestations, which usually present in infancy and
malignant melanoma. Physical examination was are associated with thrombocytopenia and other
normal in all other respects. haemangiomas.
I decided that it was in the patients best interest to Subsequent magnetic resonance imaging showed no
have such a suspicious lesion removed immediately, evidence of any intracerebral lesions, and the sailor was
rather than adding further to the already substantial passed fit to continue service at sea on submarines.
delay. The only problem was what to preserve the
F J H Brims Royal Hospital Haslar, Gosport
specimen in, as specimen preservative is not routinely
held on board. Although most submariners do not We welcome articles up to 600 words on topics such as
drink at sea, some stock is held, and I decided that A memorable patient, A paper that changed my practice, My
some of our finest Smirnoff vodka was more most unfortunate mistake, or any other piece conveying
appropriate than rum, and so this was selected instruction, pathos, or humour. If possible the article
as the preservative of choice. I then performed should be supplied on a disk. Permission is needed
the minor operation somewhere at sea, several from the patient or a relative if an identifiable patient is
hundred feet under the waterquite an interesting referred to. We also welcome contributions for
experience. Endpieces, consisting of quotations of up to 80 words
Once we had returned to dry land, and after a (but most are considerably shorter) from any source,
telephone call from a confused pathologist on reading ancient or modern, which have appealed to the reader.