PHYSICAL EXAMINATION

Physical examination, and further questioning, usually leads to the impression that the complaint of pain is excessive compared with the physical findings and that emotional factors have significantly contributed to the pain — the presence of which medical treatment cannot offer a reasonable expectation of cure.

Common denominators are often lack of relief from medication and often depression, addiction and decreased ability to function normally as a result of over-medication. Frequently, there is also disability beyond that justified by the physical findings and the contribution of psychological and social factors for the reinforcement and perpetuation of pain behaviour is overlooked.

People often tend to over-value their pain. That is, the pain plays a central part in how they relate to themselves or others. In such cases, the pain controls the person rather than the reverse! Manipulation of others happens more often than most doctors would like to admit. Histories reveal that the patient has often succeeded in manoeuvring physicians into attempting ill-advised medical treatments or surgical procedures.

All this can be very tricky for the physician trying to make a diagnosis and decide the correct treatment. Often the presence of medical illness unrelated to pain is overlooked because of the patient’s restricted focus on the pain complaint. Most patients convey a sense of urgency, complain of distress and disability, and expect that the illness will be named and a definitive treatment started. Little pain management can be achieved until both patient and physician exchange the patient’s expectations, or desires for pain relief, for that of a mutual goal of rehabilitation.

After all, effective pain management involves an unwritten contract between patient and therapist.

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