Improving outcomes for chronic pain in primary care.

Although the patient's goal is often complete pain relief, this is rarely a realistic outcome, so the role of the physician in managing chronic pain involves optimising pain relief as far as possible. Careful explanation and education may be needed to enable the focus to shift from cure to better management of pain, and improvement of function and quality of life. Chronic pain is defined as pain continuing beyond the normal time for tissue healing. Pain may be broadly classified on the basis of mechanism, as neuropathic, nociceptive or mixed. A thorough biopsychosocial assessment is essential so that an individualised multidisciplinary approach to management can be developed. The aims of assessment of chronic pain are to rule out any underlying serious pathology, identify the pain mechanism and identify and evaluate risk factors that contribute to chronicity. SIGN emphasises the need for a multidisciplinary team approach to improve outcomes, and highlights five broad categories of care: supported self-management, drug treatment, psychologically-based interventions, physical therapies and complementary therapies. Exercise, regardless of its type and the source of pain, is recommended for the management of chronic pain. In chronic low back pain, exercise therapy can improve strength and range of motion across joints, cardiorespiratory fitness and sense of wellbeing. Pain management programmes reduce anxiety and depressive symptoms, increase function and improve mood. They may be considered in patients with poor functional capacity, pain-related social and occupational problems and in cases where other management strategies have failed.