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.
If we sprain an ankle the pain signals rush up the nerve towards the spinal cord and cross over onto the next relay of nerves up to the brain. This next relay of nerves is made highly sensitive by the incoming pain and they start to react more and more strongly to the incoming barrage, amplifying the pain we experience in our mind. This will settle down as the injury heals and the system resets to normal, however this does not always occur or a pain can start without any incoming tissue pain at all. This is a pain syndrome, a collection of painful and other symptoms which do not appear to have an underlying pathology.
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.
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. Osteopathy 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.
Psychological therapy in an FMS pain management programme covers education about the condition, validation that it is real, group discussion so they meet others with FMS to reduce isolation, negative and realistic thinking, communication and assertiveness, goal setting and planning, acceptance and mindfulness and pacing to reduce overactivity. Many FMS sufferers communicate very passively with their close relatives and others, leading to frustration and anger that their needs are not being met. A negative bias in thinking is typically present due to the large number of negative experiences connected with the condition.
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.
Andrew Mitchell, editor of the Osteopath Network, writes articles about physiotherapists in Harpenden, back pain, neck pain, injury management. Andrew is interested in many aspects of alternative medicine.
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