Management of patients with pain
in routine clinical practice
A practical guide for the doctor’s surgery team
Part 1: Pain background knowledge
DEFINITION OF PAIN

An unpleasant sensory
and emotional experience

Pain as a warning signal


Information about imminent
or actual damage
Protective function

Preserves integrity
IASP (International Association for the Study of Pain) 1994. http://www.iasppain.org/AM/Template.cfm?Section=Pain_Definitions&Template=/CM/HTMLDisplay.cfm&C
ontentID=1728
ORIGIN OF PAIN

4
Perception of the pain stimulus


Transmission of the pain signal


2
1
2
3
Pain receptors (1)
Nerves (2)
Pain processing in the central nervous
system

Spinal cord (3)

Brain (4)
DURATION OF PAIN
ACUTE
CHRONIC

External or internal injury

Lasts longer (> 3 months)

Intensity depends on the pain
stimulus

Disconnected from the event that
triggered it

Precise localisation

Independent disorder

Clear warning and protective
function

Intensity independent of the pain
stimulus

No warning or protective function

Therapeutic challenge
TYPES OF PAIN
NOCICEPTIVE
PAIN
 Pain affecting the
musculoskeletal
system (e.g. arthrosis)
 Pain associated with
chronic inflammation
(e.g. arthritis)
Typical symptoms
•
•
•
•
dull
pressing
cramping
often colicky
MIXED
PAIN
e.g.
Back pain
Cancer pain
NEUROPATHIC
PAIN
 Peripheral damage
(e.g. post-herpetic neuralgia,
diabetic peripheral neuropathy)
 Central damage
(e.g. inflammation in the
CNS, spinal cord injury)
Typical symptoms
• shooting
• electrifying
• burning
• tingling
PAIN THERAPY

Starting treatment early

Medicines and supplementary measures

Focusing on pain intensity (WHO) and
pain duration is not always optimal

New pain therapy additionally
considers the type of pain
PAIN MEDICATION
NOCICEPTIVE
PAIN
MIXED PAIN
Antidepressants:
e.g. amitriptyline,
doxepin, imipramine,
duloxetine, venlafaxine
NSAIDs:
e.g. aspirin, diclofenac,
ibuprofen
Other non-opioids:
e.g. paracetamol,
metamizole
Opioids:
e.g. tramadol, morphine,
buprenorphine, oxycodone,
hydromorphone
MOR-NRI:
tapentadol
NEUROPATHIC
PAIN
Anticonvulsants:
e.g. carbamazepine,
gabapentin, pregabalin
COMBINATION
TREATMENT
Opioids
e.g. tramadol,
buprenorphine, oxycodone,
MOR-NRI:
tapentadol
TYPICAL SIDE EFFECTS
NON-OPIOID
ANALGESICS
Nausea, gastric pain, impaired
renal function
(NSAIDs, paracetamol, etc.)
OPIOIDS
Nausea, vomiting, constipation,
drowsiness
MOR-NRI
Drowsiness, dizziness, nausea
ANTIDEPRESSANTS
Fatigue, drowsiness, dry mouth,
dizziness
ANTICONVULSANTS
Disturbance of co-ordination,
dizziness, fatigue
COMPROMISES IN PAIN THERAPY
Low dose
High dose
EFFECT
potent
weak
Insufficient
effect
Acceptable
tolerability
Sufficient
effect
Unacceptable
tolerability
high
low
SIDE EFFECT RATE
Successful therapy: sufficient pain relief and good tolerability
THE PATIENT WITH PAIN ON THE TELEPHONE
Impaired mobility
Fewer contacts
PAIN
Isolation
Increased pain sensation
SUMMARY

The new pain therapy takes account of the intensity, duration
and type of pain. It is important to start treatment at an early stage.

Successful pain medication provides sufficient pain relief
with good tolerability.

In chronic pain patients, the pain increasingly becomes the central, all-pervading
topic in their daily lives. This leads
to isolation and promotes depression.
26
GOOD LUCK WITH THE IMPLEMENTATION!
Management of patients with pain
in routine clinical practice
A practical guide for the doctor’s surgery team
Part 2: Pain patients on the telephone
THE PAIN PATIENT ON THE TELEPHONE

The pain patient is a special patient because:

Chronic pain patients are suffering physically and
psychologically

Chronic pain patients are thus more often
pessimistic, insecure and impatient
THE FIRST IMPRESSION

The first impression is a key stimulus and develops within the first 10 seconds

Over 90% of first impressions are determined by non-verbal factors

We always form an opinion, mostly unconsciously. This is necessary, in order to gain
certainty when dealing with new and unknown factors
YOU AFFECT THE PATIENT THROUGH YOUR
LANGUAGE
7%
TONE OF VOICE
38%
BODY LANGUAGE
55%
YOUR TONE OF VOICE AND LANGUAGE YOU USE

Are particularly important on the telephone

Replace the missing body language in making the
first impression

Transmit your mood

The questions are:

How do I say it?

What comes across to the patient?
THE 4 SIDES OF A MESSAGE
Message
Appeal
Self-revelation
Factual level
Receiver
Relationship level
mod. acc. to: Friedemann Schulz von Thun, 4 sides of a message
THE 4 SIDES OF A MESSAGE
What information does my
message contain?
Message
Appeal
What am I revealing
about myself?
Self-revelation
Factual level
What do I expect from
Receiver
the
patient?
Relationship level
What is my relationship to the
patient?
mod. acc. to: Friedemann Schulz von Thun, 4 sides of a message
A PATIENT ASKS YOU
“How much
longer is this
going to take?”
Relationship level
Appeal
Self-revelation
Factual level
A PATIENT ASKS YOU
“How long is it going to take?”
“How much longer
is this going to
take?”
Relationship level
“I thought we had a good
relationship?”
Appeal
“I don’t want to
wait.”
Self-revelation
Factual level
“I want to be seen
next!”
YOU MIGHT UNDERSTAND
“My patient wants to know
how long it’s going to take.”
“How much longer
is this going to
take?”
Appeal
“The patient
doesn’t want to
wait.”
Self-revelation
Factual level
Relationship level
“Despite our good relationship, the
patient is pressurising me!”
“Give me priority!
I want to be seen next!”
YOU SAY TO THE PATIENT
“You can’t speak to
the doctor
immediately!”
Relationship level
Appeal
Self-revelation
Factual level
YOU SAY TO THE PATIENT
“It’s not possible to speak
to the doctor right now.”
“I’m very busy
at the moment.”
“Please phone
again later!”
“You can’t speak to
the doctor
immediately!”
Relationship level
“You’re not important enough.”
Appeal
Self-revelation
Factual level
THE PATIENT MIGHT UNDERSTAND
“The doctor has no time.”
“You can’t speak to
the doctor
immediately!”
Appeal
“I’m disappointed
that my pain is
not being taken
seriously.”
Self-revelation
Factual level
Relationship level
“I don’t have a good relationship with
my doctor’s surgery.”
“Call again
later!”
YOUR TONE OF VOICE AND LANGUAGE
“Dr Brown’s
surgery, Mrs Smith
speaking.”

Communication is what comes across to the
patient!

Emphatic and respectful communication helps you
to make a positive first impression
THE IMPATIENT PATIENT
“I need an appointment
very urgently!”

The patient expects a positive response

Remain friendly and answer in a calm and pleasant
voice
THE IMPATIENT PATIENT
“I would like to speak to
Dr Brown immediately!”

The patient expects a positive response

Remain friendly and answer in a calm and pleasant
voice
POSITIVE RESPONSE
“Mr Johnson, I’ll be happy to
attend to it.”

Give your pain patient a positive signal

Support your pain patient with your calm and
pleasant voice
ASSUME PATIENT MANAGEMENT

The pain patient is anxious and feels insecure and
needs leadership

Guide the patient with your self-assured and
convincing first impression
LET YOUR PATIENT DECIDE
“Certainly, Mr Johnson. Dr Brown
is with a patient at the moment.
Could you please call back at 12
 Give a brief positive reason
or at 3.”
 Offer several solutions and ask
for a decision
(give the patient time!)

Avoid using filler words and subjunctive forms
(would have, could have etc.)

Repeat the solutions, if necessary
PUT THE IMPORTANT INFORMATION AT THE END
“You’re welcome to come at any time, but
please be prepared to wait or come the
day after tomorrow at 10.”

Always place what you would like the patient to do
at the end of your statement.
SUMMARY

Chronic pain patients are suffering physically and psychologically. As a result of their
illness, they are more likely to be pessimistic, anxious and insecure.

When communicating by telephone, your tone of voice and the language you use
replace your body language as the most important factor in making a positive first
impression

Communication is what comes across to the patient. Your self-assurance and
your calm, pleasant voice are important.

The management of pain patients is supported by offering them decision options.
Always place your preferred solution at the end of your statement.
GOOD LUCK WITH THE IMPLEMENTATION!
Managing pain patients in routine
clinical practice
A practical guide for the doctor’s surgery team
Part 3: Professional communication
techniques
YOUR FIRST STEP

Show sympathy and understanding
towards your pain patient

As soon as your pain patient feels that he
is understood, it is easier for him to
understand what you are saying

Satisfied patients facilitate the dialogue
with the doctor

Save time

Keep appointments
FOCUSING ON THE MOST IMPORTANT PERSON
FOCUSING ON THE MOST IMPORTANT PERSON
“I’m going on holiday to
Greece.”
“And we’re going to
Turkey.”
FOCUSING ON YOUR PAIN PATIENT

Your pain patient needs attention, to feel valued and supported

Focus on your pain patient
THE THEORY OF THE “CUSHION” TECHNIQUE

When your patient reports his/her pain, he is communicating with you on the
relationship level

In order to communicate with him on the factual level, you first have to
collect him from the relationship level

Then you go together with him to the factual level
THE “CUSHION” TECHNIQUE IN PRACTICE

Pick up the patient on the relationship level:
1. Show understanding (“place a cushion”)

Go together to the factual level:
2.
3.
Ask questions
Follow a very specific line of argument
A PRACTICAL EXAMPLE OF “CUSHIONING”
“The medicine does not help much and
I feel sick all the time.”
A PRACTICAL EXAMPLE OF “CUSHIONING”
“Yes, Mrs Johnson, I can appreciate
how you feel. How do you rate your
pain over the past two days?“
“The medicine does not help much and
I feel sick all the time.”
A PRACTICAL EXAMPLE OF “CUSHIONING”
“Oh, the pain never really went away, but since
yesterday it has got much worse. I can’t stand it any
longer.”
A PRACTICAL EXAMPLE OF “CUSHIONING”
“So how have you been taking your
medicine, Mrs Johnson? Maybe we can find a way to
make you feel better again?“
“Oh, the pain never really went away, but since
yesterday it has got much worse. I can’t stand it any
longer.”
SHOW UNDERSTANDING THROUGH REPETITION
“In my job, nobody must notice that
I’m in pain – I need a medicine that
I can rely on.”
“Mrs Stevens, I can really appreciate
how important the reliable effect is in your job.
So how are you feeling today?”
EVERY PATIENT IS DIFFERENT

Every pain patient is an individual and needs to be addressed individually

In order to be able to find the right words, first of all listen very carefully!
YOU CAN RECOGNISE THE MOTIVE BY LISTENING

Recognition?

Security?

Relief?
THE CUSHION FOR THE RECOGNITION MOTIVE
“You know, as Head of
Department with a lot of staff,
I simply can’t afford to miss
work because of pain.”
THE CUSHION FOR THE RECOGNITION MOTIVE
“You know, as Head of
Department with a lot of staff,
I simply can’t afford to miss
work because of pain.”
“Mr Farmer, I appreciate that very well,
given your responsible position. I can see
that freedom from pain is particularly
important for you.”
THE CUSHION FOR THE SECURITY MOTIVE
“Is this medicine also safe? What
side effects does it have? Will I
really get pain relief?”
THE CUSHION FOR THE SECURITY MOTIVE
“Is this medicine also safe? What
side effects does it have? Will I
really get pain relief?”
“Mrs Hill, those are certainly important
questions and I would like to assure you that
this medicine has already helped many
patients.”
THE CUSHION FOR THE RELIEF MOTIVE
“Does this treatment also work in a simple
way? Is it really not too complicated?”
THE CUSHION FOR THE RELIEF MOTIVE
“Does this treatment also work in a simple
way? Is it really not too complicated?”
“Mr Johnson, I appreciate your question and I
assure you that this pain therapy is very easy
to integrate into your daily routine.”
SUMMARY

In chronic pain patients, the pain increasingly becomes the central, all-pervading
topic in their daily lives. This leads to isolation and promotes depression.

By giving your pain patients your attention, the feeling that they are valued and your
support, they feel that they are the main focus for you.

The technique of “placing cushions” allows you to show understanding and then to
communicate effectively with your patients on the factual level.

Listen very closely to your pain patients, firstly in order to recognise their motive and
then to place the appropriate cushion for the motive.
GOOD LUCK WITH THE IMPLEMENTATION!
57