Fam Pract. 2012 (Apr); 29 (2): 203Ė212 ~ FULL TEXT
S Parsons, G Harding, A Breen, N Foster, T Pincus, S Vogel and M Underwood
Department of Infectious Disease Epidemiology,
School of Public Health,
Imperial College School of Medicine,
Imperial College London,
BACKGROUND: Chronic musculoskeletal pain (CMP) is treated in primary care by a wide range of health professionals including chiropractors, osteopaths and physiotherapists.
AIMS: To explore patients and chiropractors, osteopaths and physiotherapists' beliefs about CMP and its treatment and how these beliefs influenced care seeking and ultimately the process of care.
METHODS: Depth interviews with a purposive sample of 13 CMP patients and 19 primary care health professionals (5 osteopaths, 4 chiropractors and 10 physiotherapists).
RESULTS: Patients' models of their chronic musculoskeletal pain (CMP) evolved throughout the course of their condition. Health professionals' models also evolved throughout the course of their treatment of patients. A key influence on patients' consulting behaviour appeared to be finding someone who would legitimate their suffering and their condition. Health professionals also recognized patients' need for legitimation but often found that attempts to explore psychological factors, which may be influencing their pain could be construed by patients as delegitimizing. Patients developed and tailored their consultation strategies throughout their illness career but not always in a strategic fashion. Health professionals also reflected on how patients' developing knowledge and changing beliefs altered their expectations. Therefore, overall within our analysis, we identified three themes: 'the evolving nature of patients and health professionals models of understanding CMP'; 'legitimating suffering' and 'development and tailoring of consultation and treatment strategies throughout patients' illness careers'.
CONCLUSIONS: Seeking care for any condition is not static but a process particularly for long-term conditions such as chronic musculoskeletal pain (CMP). This may need to be taken into account by both CMP patients and their treating health professionals, in that both should not assume that their views about causation and treatment are static and that instead they should be revisited on a regular basis. Adopting a shared decision-making approach to treatment may be useful particularly for long-term conditions; however, in some cases, this may be easier said than done due to both patients' and health professionals' sometimes discomfort with adopting such an approach. Training and support for both health professionals and patients may be helpful in facilitating a shared decision-making approach.
Keywords: Beliefs, health professionals, pain, patients, qualitative
From the FULL TEXT Article:
Chronic musculoskeletal pain (CMP) is a complex
and costly health problem, which is treated by a wide
range of health professionals [National Health Service
(NHS) and private, mainstream and complementary]. 
Despite the range of treatment options available, it
appears to be difficult to treat CMP to the satisfaction
of both patients and health professionals. 
As part of a programme of research exploring the
process of care for CMP, we undertook a systematic
review in which we reviewed studies exploring the
influence of patientsí and health professionalsí beliefs
and expectations about CMP and its treatment on the
process of the primary care consultation.  Within this
programme of work, we defined the process of care as
looking at the patientsí perception of their problem,
its management and the dynamic interaction between
the condition, the patientsí perception and the practitionersí
Within the review, we found that the eligible studies
primarily focused on GPs and that the lack of satisfaction
reported by patients and health professionals
may be due to both incorrectly Ďsecond-guessingí one
anotherís expectations, presenting mismatching understandings
of the patientsí pain to one another and perceiving
that each is making unrealistic demands. 
Therefore, we found that the majority of previous
work had mainly explored the GP perspective despite
a wide range of physical therapists also being consulted
by patients with chronic pain, and so, we felt
that it would also be important to explore the perspectives
of these practitioners.
Within this study, we aimed to explore patients and
chiropractors, osteopaths and physiotherapistsí beliefs
about CMP and its treatment and how these beliefs
influenced care seeking and ultimately the process of
Within this paper, we have focused on exploring
themes about the overall process of care rather than
on patientsí experiences of receiving care from a particular
Design and methods
This was a qualitative study of patients reporting
unspecified CMP and of NHS and private physiotherapists,
osteopaths and chiropractors. We took
a phenomenological approach to the research. We defined
unspecified CMP as long-lasting pain, which
lacked specific pathological features. In-depth interviews
and focus groups were undertaken with both patients
and health professionals.
We sampled patients from responders to a population
survey of CMP.  We surveyed 330 randomly selected
patients from each of 16 Medical Research Council
General Practice Research Framework practices in
the south-east quadrant of England.
GPs excluded patients who had
(i) terminal illness,
(ii) severe psychiatric disorder or dementia,
(iii) if the patient had requested not to be involved and
(iv) if the GP considered it inappropriate for the patient to be involved.
We left this final criteria open to allow the GP to use
their knowledge of the patient to identify any patient
for reasons other than the three specified reasons who
they would prefer us not to approach.
All participants received a postal questionnaire, with
two reminders, in which they indicated whether they
would be willing to take part in the qualitative study.
We conducted two focus groups with general practice
patients with CMP, to map out the issues of importance
to them. The data from these groups were used to further
develop and refine our topic guides for both patients
and health professionals (see Boxes 1 and 2).
For the patientsí in-depth interview study, we selected
a purposive sample of 15 patients using age,
gender, pain severity, pain location and care seeking
behaviour as our sampling criteria to enable us to capture
a broad range of experiences.
We developed a sampling frame by sending a short
survey to random samples of osteopaths, chiropractors
and physiotherapists (both NHS and private) based in
the south-east quadrant of England, selected from
their professional registers. The questionnaire solicited
their age, gender, years since qualification, experience
of treating patients with CMP and their willingness to
We held a focus group with eight health professionals,
which allowed us to map the issues of importance
to them. Data from this group were used to further develop
and refine our topic guide for both patient and
health professional interviews. For the interview study,
we selected a purposive sample of NHS physiotherapists,
private physiotherapists, osteopaths and chiropractors.
Prior to approaching patients, we asked their GP to
confirm that this was appropriate. Each potential interviewee
(patients and health professionals) was sent
a covering letter and information sheet detailing the
study and their involvement and was contacted after
one week to determine whether they were willing to
be interviewed. Written informed consent was obtained
at the beginning of the interview.
Topic guides were developed for both the focus
groups and the in-depth interviews, from our systematic
review of this area, from brainstorming within the
research team and by using the data from both the patient
and the health professional focus groups (Boxes 1 and 2).
For the health professionalsí interviews, patientbased
scenarios were developed by the study authors,
to explore their beliefs about the management of
chronic pain (Box 3). The scenarios depicted a Ďtypicalí
patient with chronic pain and were designed to act as
a trigger for health professionals to explore how they
would treat the patient described in the scenario and
their beliefs about patientsí beliefs about the pain and
its treatment. All interviews were audio taped and
transcribed with the intervieweesí permission.
Within our data collection, where possible, we tried
to achieve data saturation and so were there were no
new themes occurring, we halted our data collection.
However, we also had to bear in mind the resources
available to undertake the study, which also influenced
the data collection process. The process of data collection
is described in more depth in Figure 1.
Data were analysed using the Framework method, with
the analysis being further informed by the application
of social theory. [6, 7] We used this method as it allows
data to be managed and analysed transparently within
a large research team. We used the topic guides as our
starting point of a priori codes and then SP along with
other members of the research team (GH, SV and NF)
independently read through the transcripts and identified
recurrent themes, which were used along with the
a priori codes from the topic guides to develop the thematic
framework. This framework was applied to the
data and further refined where necessary. We identified
emerging themes from the data by reading through
transcripts, listening to recordings and coding by hand.
We then compared these codes to the a priori framework
and adapted it accordingly. Coding was also undertaken
independently by a number of the team
members. We then met to compare our coding and
identify and discuss any areas of discrepancy. On the
whole, we tried not to reach consensus but instead tried
to identify, explore and document the various range of
interpretations of our data. We used EXCEL to develop
charts for each group of participants, which allowed
for both within and across case analysis. These
charts were organized around the themes and subthemes
enabling both within and between case analyses.
A key element of our approach to analysis was the
multidisciplinary research group discussing their own
beliefs about the issues being studied and how these
beliefs might influence the process of data collection.
We also revisited these discussions during our regular
team meetings. With regard to how, we analysed the
different types of data that we collected (focus group
and in-depth interview, health professionals and patients).
We analysed the focus groups for both health
professionals and patients initially to help further develop
the topic guides for the in-depth interviews with
both groups. However, we also compared the themes
identified in the focus groups and in-depth interviews
to check that we were covering all of the areas. We initially
analysed the patient and health professional data
separately (both focus groups and in-depth interviews)
comparing both within and across cases, and finally, we
then compared our findings from the patient and health
We obtained a 60% response rate (2504/4171) to the
questionnaire survey.  Three hundred and thirteen patients
had Chronic Pain Grades III and IV and of
these, 69% (217) agreed to be interviewed.  Twenty-two patients from the responders to the survey within
the study pilot practice took part in the focus groups
(Tables 1 and 2). Thirteen patients with CMP drawn
from responders to the population survey agreed to
be interviewed (Table 3). One hundred health professionals
were approached (25 private physiotherapist,
25 NHS physiotherapists, 25 osteopaths and 25 chiropractors).
The first 20 respondents were approached
to participate in the focus group (Table 4). Of the remaining
80 approached, 40 agreed to be interviewed,
and from these 40, we sampled 19 health professionals
who were interviewed (Table 5).
We identified the following themes related to the
process and outcomes of the consultation:
a) The evolving nature of patients and health professionalsí models of understanding CMP;
b) Legitimating suffering and
c) Development and tailoring of consultation and treatment strategies throughout patientsí illness careers.
The evolving nature of patients and health
professionalsí models of understanding CMP
Patients and health professionalsí beliefs about pain
causation. Patients and health professionals incorporated
both physical and psychological models into their
understanding of CMP. Physical models included joints
wearing out and acute injuries not being managed
properly leading to CMP. Psychological models included
the influence of stress on both causation and exacerbation
of pain and the acceptance of pain. The
extent to which physical or psychological models were
evoked appeared to be influenced by the length of time
that patients had experienced pain for and the length of
time that the health professional had been treating the
patient for. It was also influenced by the extent to
which patients had strong biomedical views about causation
compared to those who were more willing to accept
psychological explanations. Those who were more
accepting of the psychological models of causation appeared
to be more positive about developing coping
strategies to manage their pain and those espousing
a particularly vehement biomedical perspective seemed
to be more likely to consult further to find a cure for
their pain. The quote below, however, demonstrates
a third approach of not trying to identify causation as
long as you were able to do what you wanted to do
within your life.
I seem to have always had back pain of some description,
whether it stems from when I had my
son, I donít know. The doctor says its wear and
tear. Iím not a person who delves into things too
much if I can cope.
(Patient eleven: Female aged 72)
Patientsí adaptation of causation beliefs.
Patientís ideas about pain causation appeared to be influenced
by their perception of themselves and their beliefs
about how their health should be at a particular age.
For example, older patients appeared more accepting
of their pain seeing it as a part of growing old, whereas
this quote from a younger person demonstrates how
she felt that she had had to rather grudgingly accept
her pain and the damage to her body.
They said, when youíre about 70 you will stabilise
as your back gets more. I thought fine; Iím only
30! And I just thought well itís gonna take time to
get better and it did and so I got back to normal
but thereís nothing else they can do, they canít operate
or you know, canít put back the damage, its
(Patient nine: Female aged 39)
Patients described how they adapted their causation
beliefs as their problems persisted, and as they were
introduced to new ideas, when they consulted a range
of different health professionals. Some patients initially
related their problems to physical dysfunction,
but subsequent consultations made them question particularly
if they were provided with alternative explanations.
The extent to which patients accepted or
rejected these explanations depended on how congruent
they were with their original beliefs. The quote below
describes the experiences of a patient who felt
that her experiences with a chiropractor had not been
particularly useful and how the approach of a physiotherapist
felt more congruent with her belief system.
I saw the chiropractor because it was getting to
the point where I just couldnít live with the pain,
he said my pelvis is twisted and he pulled this and
twisted that and it didnít do me any good at all.
And then someone said have you tried physiotherapy,
which I had, but this woman, she believed
that exercise was the way out of the pain, not just
to treat it. And literally doing the exercises she
gave me pulled me out of the pain
(Patient twelve: Female aged 36)
An alternative interpretation of this quote may be that patients may adopt a model retrospectively in order to support interventions that they found useful.
Health professionals Ďadaptation of causation
beliefs. Most of the health professionals reported
how they adapted their beliefs when they became
more experienced at managing CMP patients. For example,
where once they had prioritized physical explanations,
they now also recognized psychological
explanations. Others reported how they recognized
both the physical and the psychological aspects of patientsí
pain but that the extent to which they prioritized
one aspect over the other depended on their
perceptions of patients and their beliefs about their
own abilities to manage certain aspects of patientsí
pain. However, despite recognizing the potential for
psychological explanations for patientsí pain, not all
the health professionals interviewed were comfortable
with managing these aspects and did not feel that it
was within their remit.
I think itís fine saying yes, well you know that is
part of the pain, you know if it makes you feel
down at the time, you feel depressed with it. I
donít really feel Iím at all competent in knowing
what to say to try and help them round that
Patients and health professionals appear to incorporate
both physical and psychological models into their
explanations of CMP, but the extent to which one or
both of these explanations are evoked is likely to
change during the process of providing and seeking
care for CMP. This emphasizes the importance of
health professionals ascertaining the belief systems of
patients regarding their CMP to ensure that the approach
taken to treatment is congruent with their beliefs
and to revisit patients and their own beliefs
regularly throughout the course of treatment, to ensure
that any decisions made about the care provided
are shared between patients and health professionals,
which should hopefully increase the success of treatment
Patientsí beliefs about receiving a diagnosis/label for
Many of the patients interviewed felt as
their pain did not have a specific cause that they were
under pressure to convince their health professionals
that their problem was real. This need to obtain legitimation
for their pain may have been a key reason for
patients continuing to consult a wide range of different
health professionals for their pain.
Health professionalsí beliefs about being able to
Many of the health professionals interviewed
felt under-confident about the identification
and management of the psychological aspects of pain,
which may have impacted negatively on the degree of
trust that patients had in them. It may have also increased
some patientsí feelings of delegitimation if
they were presented with a psychological explanation
for their pain, which their health professional did not
appear to be comfortable in managing. Health professionals
also spoke about how they wanted to be
trusted by their patients and about the pressure they
felt to provide a diagnosis for patients who had been
unable to obtain a diagnosis prior to consulting them.
They spoke about how immediately they felt that they
might have little different to offer such patients and
how this could impact negatively on their relationships.
Oh, the other one just we can get, you reminded
me caricatures of patients are the people whoíve
been everywhere you know they come and they
say uh "I donít think thereís anything you can do
um, but Iím here anyway. Iíve been to see a Dr
X, rheumatologist, Dr X, orthopaedic surgeon,
Dr," this, doctor that, doctor the other. The chiropractors,
the physios, the acupuncturists, the homeopaths,
the faith healer. And now Iíve come to
see you, and I just think well you know. I know
that next week youíre gonna be saying "And I
went to see the osteopath," X, "and he was no
good, he didnít help me either."
But I think itís hard, I think itís very hard addressing,
itís fine saying yes well you know that is part
of the pain, you know if it makes you feel down
at the time, you feel depressed with it. I just donít
know how to, I donít really feel Iím at all competent
in knowing what to say to try and help them
round that without. And I think people as you
say, if people have been referred to a clinical psychologist
or something like that they, I think they
do definitely feel very much you know oh my
God itís in my head or whatever
The interaction between patientsí and health professionalsí beliefs about pain causation.
that there was some dissonance between patients and
health professionalsí beliefs about the psychosocial aspects
of care, which appeared to impact both on the
legitimation of pain and on the degree of trust within
the patientóhealth professional relationship. Patients
appeared to want emotional support from their health
professionals to help them to cope with their CMP.
They did not always appear to be comfortable with instead
being offered psychological explanations for
their pain and in some cases felt that this delegitimated
Well yeah, I didnít see any reason why (the pain)
shouldnít go, because initially they tend to say,
well thereís nothing wrong and they take an X-ray,
an ordinary straightforward X-ray and say
well thereís nothing wrong, so you think itís all in
here (gestures to head) itís all in the mind, so then
the self blame starts so that adds to the depression
bit as well
Legitimation of suffering.
Therefore, legitimation of
both suffering and of the course of action decided upon
by a health professional appeared to be key within this
study. Patientsí wanted a diagnosis to legitimate their
pain, and in some cases, health professionals wanted their
clinical judgement that the patientsí pain was unspecified
to be trusted. The identification and management of the
psychological aspects of CMP appeared to be important
when considering the issue of legitimation of suffering as
many patients wanted emotional support and not to be
provided with a psychological explanation of their pain
in place of a physical diagnosis. Health professionals reported
discomfort with and lack of confidence in managing
the psychological aspects of pain may mean that
patients might not obtain an explanation of the psychological
aspects of their pain, which makes sense to them
and does not make them feel that their suffering is being
Patientís need to be trusted and believed regarding
the legitimacy of their pain should be at the forefront
of health professionalís minds during their consultation.
The health professional groups included in this
study may also need further training regarding the
management of their psychological aspects of pain,
particularly in not labelling patientsí need for emotional
support in the management of their pain as
a need for psychological treatment.
Development and tailoring of consultation and treatment
approaches throughout patientsí illness careers
Patientsí beliefs about consulting for and treatment of
CMP. For patientsí at the heart of sustained relationship
with a health professionals appeared to be
a shared consensus over the underlying cause of the
patientsí pain as patients appeared to consult health
professionals models of causation were congruent with
theirs. If their health professionals did not hold similar
models of causation to them, then patients were likely
to discontinue their relationship and either try to identify
someone whose beliefs were similar to theirs or go
down a self-management route.
I think thatís the first line of defence for the GP is
pain relief. Letís get rid of the pain and that will
be it, but of course it can go on for so long that
the stuff thatís used for pain relief makes you ill
in itself. So then you are back thinking, well thatís
not going to work, I canít keep taking this, Iíve
got to find something else, so you start looking at
alternatives well anything. I mean Iíve even got
a blinking Zimmer frame out in the garage and
aids, things to help you pick things up and when
you are looking at those sorts of things thatís very
depressing. Because with these possibly small injuries,
relatively small itís causing absolute havoc
with your body and your life. So you can go from
losing hoping to thinking well letís get on top of
this and do something about it so your expectations
of help from other people rapidly dry up.
Other influences on patientsí consulting strategies
where the lay referral network and the patientsí
perceptions of their self-identity. In terms of the lay
referral network, patients were more likely to take notice
of recommendations if they had observed that
a particular treatment had been successful for a friend,
and in terms of patientsí self-identity, patients who
had previously been active and were no longer able to
achieve their previous level of function may have perceived
their problem to be greater than someone who
was previously inactive. Finally, another influence on
care seeking related to the individual was the extent
to which they were willing to take responsibility for
Health professionalsí beliefs about consulting for and treatment of CMP.
Health professionalsí beliefs about consulting for and
treatment of CMP. In many ways, health professionalsí
beliefs about patientsí consultation strategies
appeared to mirror patientsí beliefs. In that, they believed
that some patients were unlikely to seek care
as they had adapted to their pain, whereas others
would consult more as they were finding it more difficult
to adapt to their pain as it had become a key part
of their identity/biography which needed managing.
Health professionals felt that a large part of their role
was to help patients manage their unrealistic expectations
We try to move as far away as we can from hands-on
dealing with people, with the chronic patients,
I mean a lot of them, they come with a folder of
all of the places they had been to, all the tests that
theyíve had. So you just have to start at the beginning
and say realistically, weíre not going to make
your pain go away
Health professionals also felt that the degree to
which patients were willing to take responsibility for
their condition impacted on their care seeking. They
reflected on how responsibility for care seeking appears
to exist along a continuum, from responsibility
lying solely in the hands of the patient, through to the
patient completely abdicating responsibility for care
seeking decisions to health professionals.
Youíve got to get you and the patient on the same
side facing the problem and not become identified
with the problem. And thatís when people become
dissatisfied; itís when they associate the problem
and the doctor together. And to some extent
I guess youíve got to get the patient to own the
problem as well as take some responsibility
Adaptation and tailoring of consulting strategies.
Patients developed and tailored their consultation
strategies throughout the course of their illness careers.
The development of their consultation approaches
appeared to be influenced by their developing models
of causation of CMP, their continued need for
legitimation of their problem, their contact with a lay
referral network and their individual characteristics
such as their willingness to take some responsibility for
managing their health problems. Patients also reflected
on how the nature of their expectations changed as
they continued to consult, for example, they reported
on how their expectations were lowered as they gained
more experience of consulting and that their expectations
changed from cure or diagnosis to obtaining
symptom relief. Despite this, there was a sense from
patients that although they had accepted that obtaining
a cure was highly unlikely, that they had not completely
relinquished all hope of obtaining one.
Strengths and weaknesses of the study
The non-directive exploratory approach taken to the
interviews allowed the process of care to be described
by patients and health professionals in their own
words, and using framework to analyse, the data increased
the transparency of the data analysis process
and allowed us to involve the multidisciplinary research
team in the analysis and interpretation of the
data more easily. [6, 9] We were able to incorporate the
multidisciplinary teamís own perspectives on these issues
into the analysis process by ensuring that they all
had some involvement in the process, with data and
interpretations of the data being discussed at a regular
basis within the research team meetings.
Undertaking a systematic review of studies exploring
the process of primary care for CMP provided us
with a method of determining what may be the issues
of importance to explore in our qualitative studies.  It
also helped us to identify that the majority of previous
work in this area had been undertaken with GPs and
that it might be important to also explore the views of
other key health professional groups involved in caring
for patients with CMP.
We used a combination of focus groups and indepth
interviews within the study, which was invaluable
in terms of both scoping out the issues of importance
to explore in more depth within the in-depth
interviews, and it also enabled us to triangulate data
from the focus groups and in-depth interviews. On the
whole, we did find similar issues raised in the in-depth
interviews as were raised in our earlier focus groups,
which gave us some confidence that we were exploring
the majority of the key issues within this area. The discrepancies
where mainly in terms of a wide range of
perspectives on particular issues being identified
within the in-depth interviews.
In terms of the study weaknesses, we would have
liked to interview individual patients and a sample of
the health professionals whom they consulted, to discuss
actual care seeking and care delivery experiences
from the perspectives of the patients and health
professionals involved in the interaction. This would
have added another dimension to the data. Therefore,
it will be important for future research to match patient
and health professional data over time. A further
limitation of this study was that we were just able to
interview patients and health professionals at one time
point, a more useful approach may be to recruit a qualitative
prospective cohort to explore changes in models
We identified our study participants from the responders
to a population questionnaire survey. In some
respects, this was a strength of the study as we were
able to identify a wide range of patients in terms of
both demographic characteristics and consulting strategies;
however, we were limited to the responders to
the questionnaire survey. The questionnaire survey
responders were more likely to be older, white and to
have completed their education at 16 years of age.
Therefore, we were less able to sample patients from
ethnic minority groups, younger people and those with
higher education levels who may have a different approach
to their care seeking.
In terms of our sampling of health professionals, we
approached 80 health professionals, of which 40
agreed to participate and we sampled 19 from this
group of 40. In the main, we gained a good response
to our screening survey, although it is possible that
those who responded may have had a particular interest
in this area.
Discussion of findings
The systematic review we undertook as part of this
work demonstrated how many CMP patients expressed
some dissatisfaction with their GP care, which
may have been a driver for them to seek care elsewhere.
3 The findings from this study confirmed this.
Patientsí dissatisfaction appeared to be rooted in their
GPs perceived inability to get to the root cause of
their problem and in them feeling that they were not
given enough treatment choices.
Within this study, we were exploring the process of
care for CMP. A process by definition is not static but
fluid and perhaps, this may need to be taken into account
by both patients and health professionals when
seeking and providing care for CMP. In that patients,
will be seeking care on a long-term basis for a chronic
health problem such as CMP and that they and their
health professionalsí views and beliefs about their condition
will be likely to change throughout the process
of their care and may need to be revisited on a regular
basis to ensure that treatment and management of the
patientsí condition is working from both the patientsí
and the health professionalsí perspectives. For example,
we found that patients and health professionals incorporated
both physical and psychological models
into their explanations of CMP but that the extent to
which one or both of these explanations are evoked
was likely to change during the process of care. We
also found that patients wanted to have ongoing emotional
support to help them to manage their CMP and
the effects on their lives but that health professionals
often misconstrued this need for emotional support as
a need for psychological treatment. Patients appeared
to want to establish relationships with health professionals
who they could trust and who they could get
involved in the joint management of their condition.
Therefore, it seems reasonable to suggest that longterm
conditions such as CMP may require both patients
and health professionals to invest more in their
relationships than for other more acute conditions.
However, this may be difficult though due to the
current models of care seeking that patients appear to
be adopting, in that their dissatisfaction with their GP
is in some cases driving them to seek care (often on
a short-term basis due to financial reasons) from a wide
range of health professionals, where they are looking
for an answer and a cure for their condition rather
than developing a strategy for its management alongside
a trusted health professional.
A good starting point may be to work to improve
the relationship between such patients and their GPs
or with whichever health professional the patient feels
most comfortable with. With this relationship being
based on mutual respect, which will allow the patients
and their health professional to continually revisit
their own beliefs about pain causation and its treatment
throughout the process of patientsí care. Key
aspects of the relationship that may need to be improved
upon are both patientsí feelings of delegitimation
with regard to pain causation and health
professionalsí feelings of being distrusted by patients
because they are unable to provide a cure or a solution
to their pain. Health professionals (particularly the
groups included in this study) may also require further
training on the identification and management of the
psychological aspects of CMP, so that a patientsí need
for emotional support is not misconstrued and those
with a need for psychological intervention can be
readily identified. Egeri et al. also found, in a study of
patients with fibromyalgia that as patients often feel
disempowered by their interactions with their clinicians
that working with patients to identify ways in
which their relationships with clinicians can be improved
may be invaluable in improving the quality of
their care. They concluded that there was a need for
supportive, empathetic care and increased knowledge
among health professionals of the alternative treatment
A shared decision-making approach is likely to be
the most appropriate for long-term conditions, where
both patient and health professionals feel able to
openly discuss their concerns and views with one another,
their beliefs about their pain and the suggested
courses of action with regard to treatment. Within such
an approach, patients and health professionalís expectations
of one another and of the treatment process
could also be usefully explored on a regular basis. Allegretti
et al. in their study of chronic low back pain concluded
that it may be important to reconceptualize
doctors and low back pain patients as a single teachable
unit with regard to the management of back pain,
which provides further support for the suggestion that
improving the relationship between patients and health
professionals may be key to the improvement of CMP
management.  Health professionals may need to facilitate
patientsí understanding of their condition and their
involvement in its management as soon as possible in
their illness career. Patients and health professionals
working together may help to increase levels of trust
and prevent both the patient consulting with unrealistic
expectations and the health professional feeling that
they cannot possible meet these expectations. A randomized
controlled trial of a shared decision-making
intervention undertaken by Bieber et al. found that although
there was no improvement in pain scores that
both patientsí and providers believed, their subsequent
clinical encounters to be more productive and less difficult.
Patients reported feeling more understood and
practitioners reported having fewer negative feelings
about their patients. 
However, this may be easier said than done. Health
professionals may also need to assess patientsí level of
comfort with adopting a shared decision-making approach
to their care and they may also need to assess
their own level of comfort with adopting such an approach.
For example, a study by Teh et al. found that
older adults varied in their willingness to be involved
in their treatment decisions, with some preferring to
let the provider make the decisions and others participating
by asking for or refusing particular treatments. 
However, regardless of the approach taken by patients,
it was concluded that it was important to have a mutually
respectful relationship between patient and provider.
Training may be required for both health
professionals and patients to help them to take a shared
decision-making approach and to understand the likely
benefits for patient care.
Seeking care for any condition is not static but a process
particularly for long-term conditions such as
CMP. This may need to be taken into account by both
CMP patients and their treating health professionals,
in that both should not assume that their views about
causation and treatment are static and that instead
they should be revisited on a regular basis. Adopting
a shared decision-making approach to treatment may
be useful particularly for long-term conditions; however,
in some cases, this may be easier said than done
due to both patientsí and health professionalsí sometimes
discomfort with adopting such an approach.
Training and support for both health professionals
and patients may be helpful in facilitating a shared decision-
Arthritis Research Campaign, now Arthritis UK.
The London Multi-Centre Research
Ethics Committee provided ethical committee approval.
All relevant LRECS were informed that the study was
being undertaken and I held an honorary contract with
the local primary care trust.
Conflict of interest:
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