Chapter 9
Patients with Complex Pain
Aim
This chapter reviews the management of patients with persistent facial pain, complicated by resistance to apparently appropriate treatment.
Outcome
Having read this chapter, the reader should understand why some patients pose a diagnostic challenge and do not respond to treatment.
Introduction
Clinical problems such as headaches, trigeminal neuralgia, toothache and temporomandibular disorders (TMDs) are all mediated by the trigeminal nervous system. It is not surprising, therefore, that these problems can occur alone or in combination, with variation over time. Failure to recognise that two or more problems are present will most likely result in treatment failure. Individual patients will occasionally experience a change in symptoms over time, representing transformation of the original problem, for example transformation of trigeminal neuralgia to migraine, or migraine to cluster headache. Such changes in the patient’s condition require a dynamic, changing approach to patient management.
Patients may fail to respond to treatment for a variety of reasons. Common problems include:
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lack of patient compliance with the treatment programme
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inaccurate or incomplete diagnosis
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iatrogenic effects of treatment.
Lack of Patient Compliance
Poor compliance with the treatment programme is not always the result of poor motivation. Clinicians tend to “blame” the patient in circumstances in which cooperation is not ideal. Negativity towards the patient will adversely affect the relationship between patient and clinician. Patients should not be labelled as “good” or “bad”. No one wishes to continue experiencing chronic pain, suffering and lifestyle disruption. However, some patients have difficulty in cooperating with treatments that restore their problem. The assessment process should take into consideration factors that might influence the patient’s behaviour and ability to respond to treatment regimens. Ideally, a full psychological assessment and profile should be carried out by a competent professional. In many clinical environments, this “ideal approach” is not feasible.
Comorbid factors, including anxiety, depression, sleep disruption, poor concentration, poor appetite and lack of energy in vulnerable patients, should serve as “red flags” for difficulties in patient management, if not the need for referral. Some patients lack the physical, emotional or intellectual capacity to fully understand and cooperate with treatment proposals. In addition, difficult personal circumstances, including limited finances and lack of appropriate health insurance, distance from the treatment centre, problems taking time off work and lack of childcare facilities, may negatively affect the patient’s outlook. Where issues of compliance are recognised, they should be immediately addressed. The simplest approach is to interrupt treatment with a review of the assessment findings, diagnosis and treatment proposals. Communication is enhanced by moving away from a potentially threatening clinical environment (the surgery) into a more comfortable setting. Patients may benefit from a new opportunity to review all the relevant information in a more relaxed and informal way. With further explanation of the issues involved in achieving recovery, the patient may be persuaded to share in the treatment programme. In other words, the patient becomes an equal partner in the process and accepts responsibility for full participation. The more traditional view that the patient is the recipient of the treatment considered most appropriate should be dispensed with as soon as possible. Continued failure by the patient to recognise the importance of shared ownership and their participation is indicative of a poor treatment outcome.
The use of a “treatment contract” is favoured by some as a means of maximising cooperation and patient benefit. This involves writing a document that details the stages of treatment and outlines the patient’s involvement. This is laid out in a step-by-step fashion so that the patient understands exactly what level of cooperation is expected. The patient is then asked to sign the “contract”. When compliance issues arise, the patient is reminded of the commitment previously agreed in the contract. This method of maximising patient cooperation is not suitable in all circumstances. Patient characteristics, including personality, cultural background, intellectual capacity and educational status, may preclude this approach with some patients.
Inaccurate or Incomplete Diagnosis
In ideal circumstances, the signs and symptoms associated with facial pain or headache fit with a particular set of diagnostic criteria. Thankfully, some disorders such as trigeminal neuralgia are relatively easy to identify. However, other cranial neuralgias pose a considerable diagnostic challenge.
The use of diagnostic criteria has many advantages. The adoption of evidence-based treatment protocols raises the standard of patient management with the prospect of enhanced clinical outcomes, and effective record keeping and audit help to inform future care. Unfortunately, many patients present with problems that do not allow such an approach. The pain quality, temporal course, location and associated symptoms may offer a baffling set of circumstances.
Clinical management may be compromised by:
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difficulties in making an accurate primary diagnosis
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failure to recognise a secondary pain disorder that may coexist with the primary condition
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failure to recognise that the initial problem has transformed over time, invalidating the primary diagnosis.
The following case histories illustrate the issues.
Case 1: Difficulties in Making the Primary Diagnosis
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Complaint. A 30-year-old male patient presented with episodic, severe throbbing pain in the upper left premolar reg/>
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