Jonathan Blood-Smyth asked:




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 recognized 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.

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 program, 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.

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 program 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 program, 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.

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