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.
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.
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. Osteopaths 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.
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 director of the Osteopath Network, writes papers about musculo-skeletal conditions and physiotherapists in London. The Osteopath Network has more than 550 clinics located throughout the UK and offers treatment at weekends and after hours.