Authors:

Dr David McGavin – GpwSI in Chronic Pain Management and Medical Director of Kairos

Dr Ellen Wright – GP and Clinical Academic Fellow, Trustee of Kairos

Contact david.mcgavin@nhs.net 

Introduction

There are few effective treatments for chronic pain. Medication often adds little and may even harm (viz the opioid crisis) and resources for non-pharmaceutical approaches are limited. Furthermore, chronic pain cannot be targeted as a single illness, like diabetes, because it is so often complicated by other long-term conditions, social issues and polypharmacy.

Kairos Rehabilitation Trust is a small anthroposophic1 medical charity, funded by the NHS, which has been working in Greenwich for 12 years. 120 -140 patients with chronic pain are treated each year, referred by their GPs via the local MSK hub. The emphasis is on working with the patient in a rehabilitation program, rather than just against the condition, which has not previously responded to usual treatments.

The team consists of a GPwSI in chronic pain and 3 anthroposophically trained therapists.

• The GP receives, explains, coordinates therapies and reviews progress regularly.

• Rhythmical Massage is a gentle, restorative and enlivening method which often induces sleep, proving that sleep is possible.

• Eurythmy Therapy is a harmonious form of movement, where one learns to move more confidently again and without pain. It can be practiced at home. 

• Anthroposophic1 art therapy is guided experimentation with colour and form. It broadens awareness of oneself and the world and builds self-esteem.

All anthroposophic1 therapies take account of where the person is in the healing process, needing care and protection at first and thereafter gradual, increasing and appropriate challenge. Therapy sessions last an hour, are all 1:1, and weekly for 6 weeks. A GP review follows, with referral to the next therapy or to an exit interview if appropriate. Social group activities include a weekly choir, art group and patient-led discussion group.

Evaluation and Cost

Evaluation shows significant reduction in patient-reported pain severity, depression and improvement in quality of life. 2 There was also a reduction in medication and specialist appointments and improved social integration. Costs average about £1500 per patient for one year of treatment including all GP and therapy appointments.

We see many patients that have been referred to us ‘as a last resort’. In this situation we have noticed 3 common factors liable to obstruct progress:

1 Exhaustion: Ongoing tiredness undermines clear thinking and decision making, mood and motivation. All chronic pain and mental health conditions are exaggerated by exhaustion. Finding sleep and energy are therefore high priorities. The bodily therapies described above can induce relaxation and increase vitality.

An initial simple warm ginger compress applied to the spine is often quickly helpful in reducing pain. Its effect may last for up to a few days and it can be taught to continue at home. Massage commonly induces sleep, revealing that it can be possible. Several home tips and remedies promote sleep adding to the impetus of the therapies.

A change of symptoms or just feeling ‘more together’ after therapy always surprises. It encourages and engenders enthusiasm, adding new hope of attaining improvement. 

2 Unhelpful habits: Habits make life possible but valuable habits drilled in when well can get in the way when one becomes chronically ill. It is naive, especially with someone exhausted or living in chaos, to expect more than short term change with cognitive methods alone.

Rhythmical massage moves fluid inclusively throughout the body. A tense stiff lower back may thereby be gradually persuaded to belong again within general spinal function. Eurythmy teaches how to bring movement and balance more consciously through the affected area. Little by little, the musculature can be encouraged to soften and re-integrate.

Even small improvements raise hope and enthusiasm that replace old responses (like requests for different medication) with new ones, (like new interests and seeking supportive company).

3 Wariness of doctors: This is particularly relevant when dealing with patients who have become defensive. Over recent years GPs have become distanced from patients. It is harder to consistently see the same doctor, one who knows one well enough to take one’s particular circumstances into account. Mutual trust can no longer be taken for granted. Furthermore, GPs’ aims for safety, economy and getting the job done quickly don’t necessarily coincide with the patient’s hopes and needs. 

If the patient has found confidence to take the lead, co-managing their path and/or reducing medication, things are straight forward. But for those who are daunted, frightened of change or who have become protective of their condition, preparatory work will be needed to avoid resistance, stalemate and even acrimony. 

1Gunver S. Kienle et al. Anthroposophic medicine: An integrative medical system originating in Europe. Global Adv Health Med 2013;2(6):12.

2Wright et al A clinical evaluation of a community-based rehabilitation and social intervention programme for patients with chronic pain and associated multi-morbidity. J Pain Manage 2017;10(2):00-00.