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10 Assessing pain in those with communication barriers

In those with communication barriers, pain assessment requires adaptations depending on the nature of the barrier.

Speech barriers

Speech barriers can include dysarthria, aphasia, and developmental disturbances of speech. Dysarthria is a motor difficulty in speech production that makes it difficult to understand what a person is saying but without cognitive defects consider writing, picture boards, or alternative words. Dysarthria may arise from damage to the right frontal region which can also result in personality changes making people more critical and less flexible. These personality changes can frustrate family members and may lead to behavioral challenges. Conversely, expressive aphasia reflects dysfunction of the left frontal lobe, it limits a patient's ability to verbalize what they wish to communicate, they will know what they want to say and can understand instructions well, these patients can participate effectively in physical therapy. Receptive aphasia, in which patients cannot understand what is being said, is more challenging as patients cannot always understand instructions and depending on the baseline personality may have variable inclinations to mimic gestures by cueing. There are more complex aphasias as well. Unfortunately, patients with aphasia often cannot communicate through written mediums. In this case, pain assessment may be limited to behavioral assessments. It is feasible in this context to utilize gentle provocative testing to elicit relevant pain features. For example, rebound tenderness in the abdomen will still produce the clinically relevant response. A systematic effort to uncover painful areas, painful movements, or pain on palpation may be the best available information. Sometimes pantomiming, drawing pictures or bringing pictures up on the computer screen can elicit the bright smile of understanding from a patient who is otherwise withdrawn and absorbed in morose frustration.

Hearing barriers

These may be surmountable using communication tools: written questionnaires, computer assistance, or a signing interpreter. If a patient has not been formally educated, as can happen in low resource countries, a family member may be essential for communicating in the “home language.” Be aware that patients may nod to indicate receptiveness not necessarily understanding or assent. It is important to check for understanding affirmatively despite communication barriers.

Language barriers

The use of professional translation is preferred for obtaining a multidimensional pain history. Family members should generally not provide translation services as there is a complex interaction between culture and pain communication.

Socioemotional barriers

Some patients have psychological or socioemotional barriers to communicating about pain. Clinically‐diagnosed malingering and factitious disorder are rare; addiction can be associated with manipulation of clinical findings but this is complex (Chapter 46). Occasional patients are reluctant to return to work, attempt to assuage difficulties with medication, or simply wish to have more time off. More commonly, patients reporting persistent pain have not experienced sufficient therapeutic relief or functional improvement to resume normal activity. It is important to establish a differential diagnosis and support rehabilitation in a structured manner. Noncompliance with an appropriate therapy plan should be addressed in an open and accountable manner as psychological or psychiatric disturbance often underlies failure to engage appropriately in treatment and should be addressed appropriately for optimal outcomes. Documentation is key.

Managing affect and negotiating boundaries with pain patients

Patients with pain are highly motivated to seek pain relief and those with chronic pain often have some degree of anger or frustration with the medical system for real or perceived failings. One common feature that unites almost every patient with pain is an eagerness for someone to listen to their illness narrative and vigorously pursue solutions to their problem. Some patients, especially those who have been very frustrated by previous medical experiences, may be impatient with students and younger physicians (Murinson et al. 2008) (Figure 10.1). Too often, patients with chronic pain have been told that nothing can be done. Others have become dependent on pain medicines or recurrent procedures and have fallen into a role of passivity and conditioned behavior. Some patients have experienced healthcare harms. All these may be suspicious until a healthy therapeutic alliance is built.

Figure 10.1 Affect and cognition are both communicated in the pain‐focused clinical visit. (a) Schematic of communication. (b–d) Trainees acquire skillfulness in managing cognitive information and enhancing the affective dimensions of the interaction. This develops from unidirectional (b) to effective cognitive communication, reducing affective overloading (c) to effective, bidirectional communication that is supportive of patient and rewarding for provider.

Source: Adapted from Murinson (2015) and Murinson et al. (2008).

Remember that safety of patient and provider is the primary concern in any clinical setting. If a patient is overly personal, aggressive, or threatening, seek help immediately (Figure 10.2). Curse words or a harsh tone of voice may be early signs of an evolving hostile state, it is important to maintain an atmosphere of mutual respect and insist that the boundaries of a professional relationship are respected. Patients who are seeking opioids from a position of dependency will sometimes be overly agreeable or flattering, Exercise caution with the patient who seems too nice, showering you or your staff with compliments, gifts, or favors. Receipt of gifts and acceptance of personal favors is not acceptable as this undermines the provider's ethical stance. Remember that in many patients, some resistance to a new idea may signal the change process is starting, indicating that the patient is engaging and seriously considering behavior change. Some patients have difficulty expressing emotions, these patients may need support from you to open to their feelings, a reflective statement such as “It seems like this might be really hard for you” can give the patient permission to share and can help a clinician identify specific ways to help (Roter et al. 2006). “Cognitive impairment is addressed in Chapter 51, pediatric pain assessment in Chapter 50, and pain assessment in the context of medication or drug dependence in Chapter 46.”

Figure 10.2 Recognizing and modulating the emotional range of a pain‐focused clinical visit.

In summary, communication barriers to pain assessment take many forms. Some pertain to the mechanics of communication while others primarily impact the affective dimensions. Openness, skill, adaptability, and compassion are necessary in building a therapeutic alliance to overcome pain.

References

1 Murinson, B. (2015). Expertise, skillfulness and professional comportment: preparing clinical trainees for effectiveness in pain care. Invited lecture at Pain Research, Education and Policy Program, Tufts School of Medicine, Boston, Massachusetts. https://www.youtube.com/watch?v=L_pY7cTDygs (accessed 20 December 2017).

2 Murinson, B.B., Agarwal, A.K., and Haythornthwaite, J.A. (2008). Cognitive expertise, emotional development, and reflective capacity: clinical skills for improved pain care. The Journal of Pain 9 (11): 975–983.

3 Roter, D.L., Frankel, R.M., Hall, J.A., and Sluyter, D. (2006). The expression of emotion through nonverbal behavior in medical visits. Mechanisms and outcomes. Journal of General Internal Medicine 21 (Suppl 1): S28–S34. Review.