Most pain is related to injury or tissue damage and the treatment is relatively straightforward in theory: the tissue at fault is searched for and investigated, a cause is found and the treatment is aimed at improving the underlying abnormality. This is the medical model of disease and injury and it works exceptionally well, diagnosing our fractured leg, pneumonia, arthritic joint or heart attack and then treating it so the problem is solved. The difficulty starts with the many pain conditions which don't fit into this model and which are not well diagnosed or treated by medical doctors.
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.
Examples of pain syndromes are fibromyalgia syndrome (FMS), chronic widespread pain (CWP) and complex regional pain syndrome (CRPS). A minor or moderate wrist or ankle injury, followed by immobilisation, can develop into a tight, stiff, swollen and painful joint with very poor function, leading to the diagnosis of CRPS. The plaster or splint should be removed as soon as possible to allow physiotherapy rehabilitation to start, educating the patient about the pain they need to cope with as they exercise their joint every hour. The physio will work on passive, active and functional movements, reassuring the patient that the pain they are suffering is vital to their recovery.
Widespread pain syndromes are very challenging problems for the patient and are very difficult to treat with any success. CWP shows trigger point hypersensitivity in the bellies of the muscles, specific points which are very painful to palpate and refer pain down to structures nearby. Physiotherapy treatment consists of an exercise programme, stretching, acupressure, postural correction advice and acupuncture. Fibromyalgia has the typical symptoms of CWP with the addition of difficulties concentrating, IBS, severe fatigue, unrestored sleep, poor sleep, hypersensitivity to pressure and an over-reaction to activity.
Psychological interviewing of these patients is vital as having a long-term pain problem is very likely to produce low mood, depression and anxiety which in turn lead to poor coping and difficulties engaging with therapy. The clinical psychologist may find that the patient discloses a significant history of abuse, either in childhood and/or in adult relationships. This will have lead to important difficulties in dealing with other people, negative thinking, passive communication, anger and problems sticking to a treatment once agreed. The clinical psychologist will have an important role in supporting these patients through a course of treatment.
Psychological therapy in an FMS pain management programme covers education about the condition, validation that it is real, group discussion so they meet others with FMS to reduce isolation, negative and realistic thinking, communication and assertiveness, goal setting and planning, acceptance and mindfulness and pacing to reduce overactivity. Many FMS sufferers communicate very passively with their close relatives and others, leading to frustration and anger that their needs are not being met. A negative bias in thinking is typically present due to the large number of negative experiences connected with the condition.
Doctors are unable to treat pain syndromes with any degree of success but some medication, such as amitriptyline, can be of benefit, reducing pain and helping sleep. Morphine related drugs may increase confusion, fatigue and lack of mental sharpness. Physiotherapists prescribe a graded exercise programme, for which there is reasonable scientific support, and monitor it closely to improve fitness, strength and ability. Stretching can also be taught and is useful where the pain prevents exercise. A multidisciplinary approach and a graded, structured treatment plan are essential for these patients.
