Evaluation of a patient-centred approach in generalized musculoskeletal chronic pain/fibromyalgia patients in primary care

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Abstract

The aim of this paper is to assess whether patient-centred consultations are more effective than the usual style of consultations used by general practitioners with patients suffering from benign chronic musculoskeletal pain and fibromyalgia. It also seeks to evaluate the differential characteristics of these two clinical groups of symptoms. The study was designed as a cluster randomised and simple blind trial. Twenty general practitioners took part and 110 patients were recruited. Compared with patients who received the usual treatment from their family physician, those who received a patient-centred approach showed greater improvement after 1 year in terms of psychological distress (anxiety) and number of tender points, as well as showing positive trends in some important outcomes such as pain intensity. Significantly better results were observed in those patients suffering chronic pain than in those with fibromyalgia, particularly as regards associated symptoms, self-rated pain and physical mobility as measured by the Nottingham health profile.

Introduction

Chronic musculoskeletal pain (CMP), benign in nature is a prevalent health problem, as much for the general population [1] as in primary care surgeries [2], the socio-economic repercussions of which are exceeded only by cardiovascular diseases and cancer [3]. Fibromyalgia (F) represents a form of this which may be defined, in addition to pain, as a series of associated symptoms and the existence of a number of tender points. The role of psychological and social factors [4] has emerged in the etiology and development of these symptoms, which also represent the best predictors of the chronicity of acute pain [5], [6], [7]. The multifactorial nature of these symptoms may explain two relevant facts: firstly, perhaps this is one of the reasons why simple therapeutic pharmacological approaches [8] like other types [9], [10], [11], [12], [13], [14], [15], [16] have not significantly modified the chronic evolution of these syndromes, although in some cases they have produced better results in the short and medium term. Secondly, and as a consequence of the previous point, frustration generated by this problem in doctors and patients is typical; fibromyalgia patients are not generally satisfied with the way in which this problem is approached by professionals [17] nor with the results obtained [18]. These patients are catalogued as ‘difficult patients’, ‘heartsink patients’ or ‘frequent attendees’ by their doctors, which generates attitudes leading to a major deterioration in the clinical relationship. Certain aspects of the patient–doctor relationship have been associated with good consultation outcomes, particularly those related with offering clear information to the patient, reaching of agreements, patient participation in decision-making and aspects of appropriate communication: empathy, support and positive affect [19]. Furthermore, from a patient perspective, the importance given to the different areas of this focus has recently been identified [20]. Patients preferring a communicative ‘patient-centred’ approach are identified as those who feel unwell and worried, high attendees with a raised incidence of anxiety and depression and without paid employment [20]. This profile matches that of a typical CMP/F patient.

The present study seeks to evaluate the effectiveness of an approach based on mutual discussion and partnership, clear information provided by the doctor and a search for common ground, along with the doctor offering support and being friendly, approachable and empathetic, for CMP/F patients attending general practice surgeries. Secondarily, it seeks to evaluate the usefulness for the clinician in the actual diagnostic differentiation established between CMP and F.

Section snippets

Methods

An experimental, multicentre study randomised by cluster was undertaken.

Results

The study began with 110 patients and concluded with 81. Fig. 1 shows the progress of the same throughout the study. Of the three patients who were initially excluded from the study, two of these were excluded because they had already received treatment at a specialised level and the other because symptom development was only 2 months. The most frequent causes for earlier losses were the transfer of the doctor to another place of work (48.4%) and withdrawals (31%). Of the 29 drop-outs, 15 were

Conclusions

The study demonstrates that patients suffering from CMP/F who receive a “patient-centred” approach show clear tendencies, some of them significant, in the improvement on the majority of variables studied for 1 year as opposed to the patients who receive conventional approach. It is important to emphasise the positive trends in a study whose main limitation was not having enough statistical power. The difference between the doctors in the two groups in the use of the experimental approach was

Acknowledgements

We would like to thanks to the following doctors for her/his participation in this study: Luisa Campos, Antonio Montero, José Almazán, Antonio Valero, Juana Redondo, Ahmed Zouer Sarraj, Ma Reyes Martı́nez, José Ma Caballero, Enrique Martı́n, Manuel Aires, Carlos Ortega, Francisca Ceinos, Ana Ma Roldán, Gema Moreno, Nieves Crespo, Angel Valverde, José Ma Bueno, Isabel de Andrés, Borja Ranz, Mercedes Jiménez, Francisco Pozo y Josefina Vicente. This study has been supported by a Grant by the FIS

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