Physiotherapy and Pain Management of Pain Syndromes
The medical model of injury and illness is the dominant way of thinking about medical problems. When we are hurt we and the doctor search for the faulty structure, diagnose the type of fault present and aim treatment at rectifying this fault and return the area to normal. If we have a broken bone, a chest infection, a heart attack or an arthritic knee we expect the treatment to either cure the problem completely or to minimise the symptoms. Overall this approach works extremely well but it falls down when presented with a series of pain conditions which do not fit the model and are resistant to normal treatment.
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.
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.
