Physiotherapy and Pain Management of Pain Syndromes
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.
Normal tissue injury pain occurs when the injured area transmits a volley of pain impulses up towards the spinal cord nerves in the back, which take the signals and carry them on towards the brain. The volleys of incoming pain excite the spinal cord nerves strongly and they react by amplifying their reactions to them, giving us higher levels of pain. We then protect the area, it settles and heals and the system settles down to its normal state. However, some conditions do not fit this picture, do not have a precipitating injury or event and do not settle down with time, fitting poorly into the normal picture. These pain syndromes are not well understood or diagnosed.
Typical pain syndromes are complex regional pain syndrome (CRPS), chronic widespread pain (CWP) and fibromyalgia syndrome (FMS). CRPS occurs after minor or moderate injury to a limb such as the ankle or wrist and the underlying reasons are not well understood. In the wrist the person may be in plaster for a few weeks for a minor fracture or sprain but complains of high levels of pain and has difficulty keeping the fingers moving. The fingers are stiff and swollen and moving them elicits significant pain, at which stage immobilisation is removed if possible to allow rehabilitation.
Chronic widespread pain occurs, as the title implies, all over the body, with multiple trigger points in muscle bellies. Trigger points are areas of acute sensitivity to pressure which occur in specific places in muscles and can refer pain away from those sites causing a persistent pain condition. Physiotherapists treat trigger point pain with acupuncture, acupressure, stretches and positional advice. Fibromyalgia syndrome occurs mostly in women, and consists of widespread pain, fatigue, hypersensitivity to pressure, poor sleep, feeling unrestored in the morning, "brain fog", IBS, reduced physical ability and pain unpredictability.
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.
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.
Medical treatment is not very successful in pain syndromes but drugs such as amitriptyline can be useful with their nerve transmission altering affects. Many FMS sufferers react adversely to drugs and this limits their usefulness, especially if morphine-related chemicals add to lack of mental clarity and fatigue. A graded exercise programme, carefully guided to avoid overdoing, is useful in the longer term as these patients have lost of lot of strength and fitness. Stretching is often reported to be helpful and may be all a person can do if they are having a worsening but overall a structured plan is necessary for a pain syndrome.
by Jonathan Blood Smyth