Rebecca Rosen is a member of the Rethinking Medicine working group.
For a myriad of reasons, Covid has caused a build-up of people living with pain: delayed investigation of new symptoms; treatments deferred; injuries and accidents self-managed for fear of exposure to Covid in A&E. Add to this people with conditions like Crohn’s Disease that periodically flare up and the prevalence of people living with significant pain increases further.
As part of a project to improve continuity in my South East London GP practice, we’ve been looking at attendance patterns over the last 5 years and have identified a subgroup of patients with on-and-off pain which is typically triggered by a life stress. Covid has added to this in spades. A mixture of job losses and money worries, the pressures of home schooling young children and anxiety about isolated relatives or catching the virus have all triggered long standing joint pains, headaches and backaches in people of all ages.
Managing pain in a medical setting
A typical consultation is booked under the problem heading ‘back ache’ or ‘shoulder pain’ and often includes accounts of painkillers that aren’t working, disturbed sleep, reduced function, low mood and more. Looking back through the notes, these patients have had similar consultations several times over the years: tried most types of painkillers, been through physio a couple of times and occasionally they have been seen in a pain clinic.
It’s fairly typical that painkillers have only ever helped a bit and physio was useful while it lasted. But for one reason or another people have stopped doing the exercises and struggle to find the motivation to start again when the pain returns.
So the call to the GP represents hope over experience and typically a request for a stronger painkiller than can be obtained over the counter. ‘Does that make sense if they haven’t worked in the past?’ I ask. Well perhaps not, but something needs to be done. ‘What about trying the exercises you’ve been shown in the past – it’s important to strengthen the muscles around painful joints…’ Sometimes people have forgotten how to do them. Sometimes they lack the motivation to restart. Sometimes they hadn’t thought of trying them again. And with the backlog of post-Covid demand what chance is there of getting access to a physio?
Where digital comes in
Fortunately, emerging digital technology is helping to de-medicalise the response to some chronic joint pains. Our local Musculoskeletal service has an app underpinned by AI that triages symptoms, designs a physio regime, ‘watches’ as you exercise and corrects wrong moves. It also sends you motivational messages if you miss a session.
It’s hard to know what the net effect of the technology will be. For some people who would otherwise wait several months for a physio appointment and risk exposure to Covid during the journey to a clinic the app is an easy and convenient alternative.
How it will work on the cohort of patients described above, for whom physical pain is linked to psychological stress, is unclear. Will motivational messaging act as the ‘nudge’ needed to get going with exercises or drive them to throw their phone at the wall? I haven’t yet seen research to answer that question, but with huge post-Covid NHS waiting lists it will surely be worth a try. Combined with input from social prescribers to address the wider triggers of pain, the app may offer a way to increase use of alternative therapies and perhaps also reduce use of opiate painkillers.
With the post-Covid NHS landscape of huge waiting lists starting to come into focus, finding ways to live with pain and other symptoms during the long wait for an outpatient appointment will become increasingly important.
There is a bit of me that recoils from responding to physical manifestations of social and psychological problems with a link to an app. But research suggests that one of the groups which most values digital consultations is young men with mental health problems. Another group is older people with reduced mobility for whom travelling to a clinic is physically difficult. Both of these demographics were present in our analysis of higher users of GP appointments presenting with recurrent pain. Not all of them will have a smartphone and the necessary data to access the internet and some in the older cohort may struggle to download and use a physio app. But some will no doubt be able to make use of this kind of technology and a key challenge for service providers is to ensure there is local support to access digital services for those who cannot currently use them.
With the post-Covid NHS landscape of huge waiting lists starting to come into focus, finding ways to live with pain and other symptoms during the long wait for an outpatient appointment will become increasingly important. And for clinicians looking for alternatives to prescription medications, this kind of technology, combined with empathic professional consultations and support from social prescribers, could prove useful.
It won’t be a universal panacea, but it starts to demonstrate how a mix of human and digital approaches can work together in people with long standing complex health problems.