Living with Disability and Pain

Chronic pain and disability is not simply a physical problem. It is associated with severe and extensive psychological, social and economic factors, with high demand on the health services as a result, particularly primary care. Apart from poor general physical health and disability there may also be depression, unemployment, and family stress. Many of these factors interact, and the whole picture needs to be be considered when managing individual patients.

Chronic pain is extremely common within the community, but there is little substantial data.
Many studies of chronic pain prevalence have been based in secondary care, including pain clinics, or are biased towards particular subgroups of individuals and types of chronic pain.¹ One review identified 15 studies of prevalence of chronic pain in the community, with most data collection between 1980 and 1990.² The findings revealed a median prevalence of 15% with a range of 2% to 40%. Chronic pain was found to be more common among women, in older age groups and in lower income groups.

The following definitions may be useful³:

Patient assessment questionnaires currently available include:

• Health Assessment questionnaire (HAQ); this is a measure of physical disability associated with arthritis
• Chronic pain grade questionnaire (CPG)
• Pain Self-Efficacy questionnaire; this refers to the patient's ability and confidence to cope with pain, live a normal lifestyle and work^4,5
• Level of expressed need questionnaire (LEN)⁶
• Chronic Illness Job Strain Scale (CIJSS)⁷
• World Health Organization's International Classification of Functioning Disability and Health (ICF)

The Chronic Pain Grade questionnaire

The CPG has 5 grades:

• 1: pain free
• 2: low disability and low intensity
• 3: low disability/high intensity
• 4: high disability/moderately limiting
• 5: high disability/severely limiting

It comprises 7 questions:

Chronic pain has a detrimental effect on physical health, daily activity, psychological health, employment and economic well-being; 45 million working days/year in the UK are lost due to back pain.³ Chronic pain is associated with:

• Reduced ability to work; more strain is perceived with regard to future uncertainty, balancing multiple roles and difficulties accepting the disease than the workplace itself. Patients who have inflammatory arthritis, more frequent severe pain, greater workplace activity limitations, fewer hours of work and less co-worker support reported most strain.⁷
• Difficulty in performing everyday tasks
• Physical disability
• Depression; Rheumatoid Arthritis (RA) sufferers have higher rates of depression than found in the general population)⁴
• Helplessness
• Clinical, psychological and demographic variables have an impact on reported pain
• Self-efficacy

The optimum approach is likely to involve other members of the primary care team, including nurses, pharmacists, physiotherapists, counsellors and occupational therapists. It may also include liaison with social services, employers, and benefits agencies. Encouraging the patient to have an attitude of positive coping is beneficial.

Psychological interventions

Cognitive Behavioural Therapy (CBT) involves education, training in various types of relaxation approaches and other coping skills, and the application of these skills in the patient's home and work environment. CBT includes the teaching of life and coping skills that can assist the patient in productive problem solving and prevent or minimize future pain episodes and stressful events.⁸ Some studies suggest that CBT is efficacious in rheumatoid arthritis, osteoarthritis and fibromyalgia in improving not only the psychological adjustment during the course of the disease, but also physical function.⁹

Medications

The efficacy of analgesics may be limited and of best use in short-term symptom management.

When considering coping strategies, they can be primarily emotion-focused or problem-focused.^10,11 Trying to avoid 'catastrophising' and rest as strategies and increasingly using 'task persistence' have been shown to be associated with decreases in depression over a 6-month period.
Coping styles that include 'seeking social support' and 'confrontation' are important predictors for positive social adjustment; low social self-esteem and high social anxiety are linked with depression and poor outcome.^11,12Coping can be classified as passive or active.

Passive coping

Passive coping is deemed detrimental to health outcomes and is associated with increased pain, increased disability and depression.⁴

• Praying or religious (more common in women and ethnic groups)¹³
• Giving-up social activities
• Relying on health professionals and medications to relieve pain

Active coping

Active coping is associated with less pain, disability and depression, and is therefore most recommended. However increased disability itself may cause less active coping. Patients take responsibility for their own pain management¹⁴ such as:

• Physical, complementary and relaxation therapies.
• Active management of stress.¹⁵ Stress has not been proved to be a causal factor, but it seems to act as an exacerbating factor in disease activity and to have an impact on the quality of life.