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.
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.
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.
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.
It is vital that the clinical psychologist teaches FMS sufferers psychological strategies to help them manage the condition and make their wishes clear. Pain management programmes address developing realistic thinking, positive coping strategies, assertive communication, acceptance of the condition, mindfulness, pacing activity and meeting others in the same boat to reduce the feeling of isolation. Sufferers typically communicate with their relatives and others in very passive ways, leading to conflict, anger and resentment as they do not make their needs clear. Realistic thinking addresses the understandable bias towards thinking negatively due to a longstanding pain 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.
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