We grow up with the medical model of injury and disease in our heads, it's our way of understanding what happens to us. When a pain or other problem occurs, the doctor investigates and pins down the fault to a particular organ or body system, targeting the treatment to improve the malfunctioning of the part. The problem then goes away or is managed such as healing in a fracture, recovery from pneumonia after antibiotics and replacing an arthritic joint. However, there is a group of pain conditions which do not fit well into this system and are not widely recognised or treated.
In normal pain, such as from a sprained ankle, the pain messages pass up to the spinal cord in the back, exciting the nerves there which take the pain on towards the brain. These incoming messages cause the spinal cord nerves to become highly excitable, amplifying the messages as they are sent on, making us feel a lot of pain. This excitation settles down as the inflammation and pain reduces and the spinal cord nerves return towards normal. However, this amplification process can be very powerful and create a pain problem without incoming pain signals. When this happens a person has a pain condition but no underlying physical tissue damage or injury.
Complex regional pain syndrome (CRPS), fibromyalgia syndrome (FMS) and chronic widespread pain (CWP) are typical pain syndromes. CRPS can develop in a wrist or ankle after a moderate or minor injury such as a small fracture or a sprain, with the joint rapidly becoming painful, stiff and swollen. A wrist and hand like this has very limited function and needs to be free of immobilisation as soon as possible to start rehabilitation. Early physiotherapy intervention is vital to get the passive and active ranges of movement as soon as possible and educate the patient in what they have to do.
The other pain syndromes exhibit all over body pain with hypersensitive areas in muscle bellies known as trigger points, which are very sensitive to pressure but can also run pain away from their origins. Physiotherapy treatment for CWP includes stretching, general exercise, positioning advice, acupressure and acupuncture. Fibromyalgia has the symptoms of CWP but adds IBS, mental difficulties with concentration, sleep problems, excessive tiredness on waking, hypersensitivity to pressure and a severe reaction to overactivity. This syndrome overlaps with chronic fatigue syndrome (CWP) or ME and can be exceptionally challenging for the sufferer.
A clinical psychologist is vital if successful management of people with pain syndromes is to be accomplished as they will tend to produce anxiety, anger, low mood and depression. Patients exhibit poor coping, non-assertive behaviour, aggression, negative thinking and difficulties sticking to a therapy plan. A history of abuse, both in adult relationships or as a child, is common especially in FMS and can have a dominant effect on the patient's approach and their relationships with others. Helping these patients through this time needs a clinical psychologist and treatment solely from a physio is unlikely to be helpful.
A FMS pain management programme covers several psychological skills and strategies, including pacing activity, realistic and negative thinking, assertiveness and communication skills, mindfulness and acceptance, goal setting and planning, validation of the reality of the condition and reduction of isolation by meeting others with the same condition. Passive communication with families, friends and others is very common and this leads to anger and frustration as they are unable to make their needs clear. The overall very negative nature of the pain experience leads to a negative bias in thinking about the world and their problems.
Pain syndromes are not amenable to normal medical management but medication can be helpful if it does not increase mental confusion or fatigue. Drugs such as amitriptyline, used initially for depression, are given to reduce pain and improve sleep. A graded exercise programme, guided by a physiotherapist, can improve strength, fitness and so functional ability. Patients report stretching is helpful and especially so if the pain is severe enough to preclude exercise. Pain syndrome sufferers benefit from a multi-disciplinary approach and a structured strategy.
