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.
Complex regional pain syndrome (CRPS), fibromyalgia syndrome (FMS) and chronic widespread pain (CWP) are typical pain syndromes. CRPS can develop in a wrist or ankle after a moderate or minor injury such as a small fracture or a sprain, with the joint rapidly becoming painful, stiff and swollen. A wrist and hand like this has very limited function and needs to be free of immobilisation as soon as possible to start rehabilitation. Early Osteopathy intervention is vital to get the passive and active ranges of movement as soon as possible and educate the patient in what they have to do.
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. Osteopathy 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.
Anger, depression, anxiety or low mood are common accompaniments to a chronic pain syndrome, necessitating the skills of a clinical psychologist if the patients are to be successfully managed. Patients find sticking to a treatment plan very challenging and exhibit anger, irrational thinking, poor coping, non-assertive communication and negativity. FMS patients often disclose an abuse history either as children or in adult relationships and this can be the dominating feature of their presentation. Isolated Osteo treatment is unlikely to work and the psychologists input is vital.
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.