Page 106 Guide to Pain Management in Low-Resource Settings

94 Claudia Schulz-Gibbins

consequence the lessened activity leads to an increase of Th e “vicious cycle” of pain is begins: Th e pain
pain because of degeneration of muscles. Th e result can leads to physical inactivity out of fear that the pain
be chronic pain. Th e main aims of treatment depend on could increase through strain. Fear for the future leads
the complexity of chronic pain and demand consider- to constant increased muscle rigidity and increased agi-
ation of all the factors involved. tation at night, resulting in sleep disturbances, which
weaken the body additionally. Th e patient retreats due
Case report 1 to depression and avoids social contact. Attempts to
solve problems are avoided, which increases the anxiety
A 40-year-old farm worker suff ers years of increasing and helplessness.
back pain. All attempts at treatment have so far been
What are the consequences for
without success. He says that a doctor told him that he
patient assessment?
could not fi nd the exact cause of his pain, but that prob-
ably has a “crumbling” spine, and he can see no way to Th e complex interactions of somatic and psychological
treat him or relieve his pain. Because of the pain, he has processes make it very diffi cult for any one individual to
been unable to work and earn enough to support his be aware of all relevant information and to appraise their
family. He rarely has enough money to buy pain killers. relevance. Psychological assessment should be an inher-
Increasingly, he feels helpless, he cannot sleep at night be- ent part of the pain diagnostic investigation, in a multi-
cause of his pain, and he worries about the future. For disciplinary setting[9]. A thorough medical assessment is
the past year, he has tried as much as possible to avoid an important part of any chronic pain management pro-
strenuous movements, and as soon as he gets home he tocol, but a psychological interview should be integrat-
goes to bed. He says he has no strength left, and his wife ed as promptly as possible. Patients should not get the
feels helpless. It makes him even sadder to see how his feeling that they are being sent to a psychologist because
wife suff ers because she cannot help him. He does not nothing was diagnosed on the somatic level that could
know how to continue, and he fears that, if his physical explain the pain and its intensity. Patients may interpret
restrictions and pain increase further, he will not be able such a referral as being “shoved off ” or stigmatized.
to care for his family. His employer has told him that he As mentioned earlier, pain aff ects the whole
cannot be lax at work, and he fears for his job. He has “body and soul” of our patients. Since the perception of
not yet told his wife of his problems at work, fearing that pain is always more than just a signal from our nerves,
she might leave him. His colleagues have complained to every patient with chronic pain should be evaluated
his employer that they had to take over some of his work. thoroughly. To accomplish this goal, in the diagnostic
His social life is poor because of his pain. process, “somatic” and “psychological” aspects should
be included from the beginning. Th e physician will then
What are the dimensions of the biopsychosocial have a complete picture of the patient and will be able to
concept within this case report? understand several things better: the nature of the pain,
Biological dimensions: how the pain is perceived by the patient, and how it af-
fects the life of the patient. On the other hand, the pa-
Possibly some early degeneration of the vertebral col-
tient may learn from the beginning that his pain may be
umn and muscular dysfunction, enhanced by physical
more than just an alarm sign for an injury. From the be-
inactivity.
ginning, pain and its psychological implications should
Psychological dimensions: be part of the conversation between the patient and the
a) Aff ective dimension: increased sadness and anxiety. physician: the patient should never feel that the physi-
b) Cognitive dimension: feelings of helplessness, cian doubts his pain and its eff ect on his or her life.
“pain and impairment will go on, and no one can help
What would be an appropriate technique for
me,” and decreased self-esteem, “I am not able to care
taking the history of a patient?
for my family,” “physical activity harms my body.”
Th e psychological assessment includes the clinical in-
Social dimensions: terview, the use of standardized psychological question-
Possible loss of work, confl icts with his colleagues and naires, and early supervision of the patient’s behavior.
employer, and family confl icts. In clinical practice, the interview is an important way