We grow up with the medical model of injury and disease in our heads, its 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 recognised or treated.
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 Osteopathy rehabilitation to start, educating the patient about the pain they need to cope with as they exercise their joint every hour. The Osteo 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. 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.
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.
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 Osteopath, 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.
Andrew Mitchell, clinical editor at the Osteopath Network , writes papers about musculo-skeletal conditions, drug-free treatment, pain management and how to find a physiotherapists in Kent . He is interested in the treatment of back pain, neck pain and injury and pain management.
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on Feb 26 2011. Filed under .
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