Management of chronic pain in older adultsBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h532 (Published 13 February 2015) Cite this as: BMJ 2015;350:h532
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It's with great enthusiasm I read Carrington Reid M et al. clinical review on chronic pain in older adults. The subject at hand is by no means simple or narrow. As noted, many of the modalities lack strong evidence, but are still encouraged by the authors. I'm thus curious on their take on Mindfulness meditation as a possible treatment option.
Studies targeting chronic pain with mindfulness is limited and frequently lack controls, but still shows promising results (1, 2, 3). However, risk factors for pain, like the physical and psychological consequences of chronic disease, can also be targeted with this intervention (4). The effectiveness varies with the underlying condition, and some controlled research, unfortunately, seems to indicate unreliable effects for depression and anxiety (5).
Competing interests: No competing interests
Re: Management of chronic pain in older adults: symptoms of post-traumatic distress should be sought
I welcome, very much, the authoritative review by Reid et al and particularly its concentration on practical issues . Much is of relevance to the management of chronic pain irrespective of age.
Having run spinal pain clinics for those of all ages for nearly 30 years until my retirement, and as a consultant in rehabilitation medicine who frequently visited patients in their homes, I would like to make some comments. Reid et al are correct in identifying the tension between unrewarding searches for potential treatable causes for the pain – and their potential for over investigation and consequent side effects on the one hand; and missing potential treatable conditions on the other. This is particularly acute for trainees - in any branch of medicine. There is widespread agreement that about 10% of patients referred to spinal pain clinics have non spinal or treatable disorders  e.g. the osteoporosis noted by Reid et al , thus requiring great sophistication to avoid overmedicalising the patient’s condition.
For those with spinal pain, the key questions regarding function are how far can you walk? how long can you stand for? and how long can you sit for? These questions are of great value in any follow-up to determine change and may give clues to conditions such as spinal stenosis or vascular claudication.
Reid et al ['1] made no comment on the presence of post-traumatic psychological distress (PTSD). This has been known to be a potential influence on chronic pain for many years . When this condition is ‘active’, its sympathetic overdrive may well exacerbate the pain experience . In my clinics, post-traumatic psychological distress has been frequently seen [4;5] and the diagnosis of this treatable condition usually missed by other clinicians . Patients who may deny any previous history of abuse may well describe nightmares. I agree with Reid et al  that the sleep history is very important  and in this context, enquiring about dreams, particularly unpleasant ones often gives the clue to PTSD.
Reid et al made  no reference to wheelchair users pain, a very neglected area, where distinguishing between nociceptive or neuropathic pain relating to the disorder giving rise to the inability to walk, problems associated with prolonged sitting in a wheelchair, or both can be difficult to untangle. Considering that there are about 1.2 million wheelchair users in England , most of them will be older adults and although they may not be frail elderly, they are definitely disadvantaged and this area needs greater study.
Finally, I strongly endorse Reid et al’s views  of the value of the home visit. Information gained through the visit is often greater than that obtained from clinics. In their home, the clinician is a guest and the atmosphere less formal. Spouses, and/or other family members, may be present to enhance the history. Psychological and relationship issues may become evident. The value of the home visit from the rehabilitation perspective has been reported  and is seen to have many benefits but has not been evaluated to my knowledge.
(1) Reid MC, Eccleston C, Pillemer K. Management of chronic pain in older adults. BMJ (Clinical research ed ) 2015; 350:h532.
(2) Frank AO. Diagnosis and management of neck and back pain. Indian J Rheumatol 2014; 9:S42-S53.
(3) Linton SJ. A population-based study of the relationship between sexual abuse and back pain: establishing a link. Pain 1997; 73:47-53.
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(9) NHS Modernisation Agency. Improving services for wheelchair users and carers - good practice guide: learning from the Wheelchair Services Collaborative. Eds Sedgewick M, Frank AO, Kemp P, Gage P. London: Department of Health; 2004.
(10) Gibson J, Frank AO. Supporting individuals with disabling multiple sclerosis. J R Soc Med 2002; 95(December):580-586.
Competing interests: No competing interests