Background & Aims

Chronic pain management presents a significant burden in healthcare due to its complex nature. The reluctance of traditional medicine to abandon the mind/body dualism and the resulting misaligned incentive structure combined with the unidisciplinary approach leads to much frustration for the pain patient. This clinical complexity often defies traditional management approaches, is different from multimorbidity and necessitates innovative frameworks that reflect the nature of the complex adaptive system that is pain. The Cynefin framework, originally developed in the context of knowledge management offers a valuable perspective on understanding the inherent non-linearity and unpredictability in chronic pain. Applying the Cynefin framework could provides healthcare professionals a valuable lens to help patients manage their condition. It also helps reframe the problem for the patient and while making aware of the inherent uncetainity in the solutions, also empowers the patient.

Methods

There is no conceptual framework to identify economically sustainable approaches appropriate to the level of pain complexity. Biomedical reductionism is useful when cause and effect are well understood but fall short when pain has multiple interacting causes. Cynefin is that conceptual framework that helps choose action appropriate to context. When used as a sense-making tool, it can help clinicians understand the complexity of chronic pain, identify appropriate strategies, and avoid the pitfalls of applying reductionist approaches . The framework divides issues into four quadrants: Clear, Complicated, Complex, and Chaotic. A fifth domain of Confusion reflects challenges where there is no clarity about which of the other domains apply. In pain management, this reflects pain flare ups – potentially, an exacerbation of the chronic pain or a more acute pain that needs investigation. Such a conceptualisation allows for a more pragmatic approach to decision making that is contextual.

Results

The application of the Cynefin framework in chronic pain management shows great potential for enhanced decision making. The clear domain allows for best practice – cause and effect is proven and validated guidelines can be implemented. In the complicated domain, only good practice is possible and often there is need for expertise to identify hidden causalities and relationships. The complex domain is where daily pain management resides. It is a dynamic space that is representative of the interconnectedness and biopsychosocial nature of pain. In this space, there is no role for a reductionist mindset. The aim is to understand the interactions and the emergent causality to get a proper diagnosis. A cause–effect relationship in only known in retrospect. The chaotic and confused domains are exemplified by pain flare ups. Overall, the domains are not isolated compartments and patients can move into other domains and the framework could enhance the principles of value based health care.

Conclusions

Employing the Cynefin framework supports the implementation of more effective, context-sensitive pain management interventions. Understanding that daily pain management rests in the complex domain means acknowledging the role of the lived experience of the patient and the limited role of guidelines. It has the potential to reduce clinican burnout. Success in pain control is a consequence of learning from mistakes and repetition/pattern recognition. It advocates a shared decision making model and trauma informed approach. It encourages a shift from one-size-fits-all approaches to more nuanced, contextually informed strategies that can better meet the diverse needs of patients and acknowledges the role of their social determinants of health and inherent health inequalities. The Cynefin Framework can help pain clinicians and patients make that paradigm shift and communicate the value and meaning of chronic pain in a system that at present favours biomedical reductionist approaches.

References

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Presenting Author

Deepak Ravindran

Poster Authors

Deepak Ravindran

MD FIPP DipIBLM/BSLM

Royal Berkshire NHS Foundation Trust

Lead Author

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Topics

  • Economics, Ethics, and Law