Previous chapters have defined chronic pain in very broad terms– basically, as pain that lasts for more than three months. As you have seen,chronic pain has almost universal biopsychosocial consequences, no mat ter what its etiology may be. This has allowed for the development of the pain program presented in this book. I would like to take this opportunity, however, to comment on some of the most common or perhaps least understood pain syndroms I’ve seen. Althought I resepect the power of the skills and attitudes presented in this book, I believe that state-of-the art medical treatment must accompany chronic pain treatment as well. I am also aware that there is considerable ignorance about chronic pain syndromes among health care professionals. Therefore, I have chosen the particular syndromes discussed here for one of more of three reasons:
- They are frequently overlooked
- Certain aspects of their causes or treatment considerations are not well known by health care providers.
- There are medical treatments, usually aimed at the abnormality contributing to the pain syndrome, that might help reduce the pain experience.
Fibromyalgia
Fibromyalgia is a chronic pain syndrome that is currently throught to affect primarily women ( the ratio of women to men with fibromyalgia is 10 to 1). Many terms are used to describe this syndrome, and overlaps among several of the terms suggest points along a symptom continuum. These terms include ” fibrositis,” ” Myofascial pain,” “postviral fatigue syndrome,” ” Chronic fatigue syndrome,” ” Tension myalgia,” and ” generalized tendomyopathy.” In 1990, the American COllege of Rheumatology developed the following criteria for the classification of fibromyalgia:
- History of widespread pain.
- Pain in 11 or 18 tender point sites on digital palpation.
For classification purposes, patients are said to have fibromyalgia if both criteria are satistifed. Widespread pain must have been present for at least three months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia, but the diagnosis is made many times after other diseases have been excluded. (e.g., thyroid disease, luus, rheumatoid arthritis,etc.). Many patients with fibromyalgia will also have associated complaints, such as headache, irritable bowel, irritable bladder, painful menstrual periods, intermittent blurred vision, and short-term memory problems. These complaints imply that the disorder involves more than the musculoskeletal system. The symptoms are quite variable and are marked by their intermittent, waxing-wanning, and migratory pattern. This probably contributes to the long lag time between development of symptoms and diagnosis. The cause is unknown, and so far the two abnormal components that have been consistently reported are sleep disturbance and depression. The treatment to date has focused on the sleep disorder by using drugs such as imipramine, atitriptyline, and cyclobenzaprine to restore restful sleep. Regular, moderate exercise and cognitive therapy are also recommended. If patients have access to natural bodies of warm water or to a heated pool, I find that swimming or moving in warm water is very helpful to them. Many communities have support groups for fibromyalgia, and your stats’s Arthritis Foundation may sponsor such groups in your locale. There is also an informative, proactive newsletter available from the Fibromyalgia Network, which makes a good effort to report the latest developments and advocated for more research funding. Wire to the Fibromyalgia Network, P.O. Box 31750, Tucson, AZ 85751-1750, For more information on how to subscribe to this newsletter.
Chronic Neck and Low Back Pain
Chronic pain in the neck or lower back is very difficult to diagnose and treat, particularyly if no obvious structural abnormalities are found, such as a herniated disc, a tumor ( a common fear of many who have developed chronic pain symptoms), or significant bony abnormalities ( arthritis with or without clearn nerve impingement, fractures). Many times , surgery in the presence of a herniated disc does not always result in postoperative pain relief. This has caused many surgeons to recommend conservative or nonsurgical treatment if only pain is present. ( i.e., if there are no nerve compression signs on examination). Since i see either the people who have had unsuccessful surgery or those who have ” no abnormalities” on X-ray or MRI studies, I have developed a different way of looking at these individuals in an atetmpt to discover whether there is some other treatable reason for their symptoms. In postsurgical patients whose pain is not coming from scar tissue pressing on a nerve or from an unstable spine, and in those patients without any surgically correctable problem, the pain is often the result of deconditioning in both the abdominal and back muscles. In addition, poor body mechanics and misalignment may contribute to abnormal forces on sensitized nerves and soft tissue. A good conditioning program to strengthen the muscles of the abdomen and back can be very beneficial. For alignment problems and poor techniques as myofascial release, Jones trigger point therapy, and muscle energy techniques can be very helpful. The use of Alexander and Feldenkrais therapies can be useful for poor body mechanics as well. One of my frusturations as a pain specialists has been the realization that physical therapists and physical therapy treatments vary enormously. Physical therapy, like many medical disciplines, is very much of an art. However, Physical therapists do need to have some experience in working with chronic pain patients. What I look for in a physical therapist is someone who is comfortable with a patient’s not getting total pain relief; who can help educate a patient regarding his or her body and how it moves; and whose goal is to get the patient into an independent program of self-management. I expet the therapists not to persist in treatment once the patient has stopped responding or progressing or is noncomliant with a home program. With regard to chiropractic treatment in chronic neck and back pain, evidence has been presented that in acute flare-ups of low back pain this form of treatment can be quite beneficial for some individuals. I believe that chiropractic and manipulative medicine has been instrumental in stimulating the dialogue that is now taking place on the contribution of abnormal body mechanics to neck and back pain, particularly in those acute and chronic pain patients with no X-ray abnormalities(in the conventional sense). Many chronic neck pain problems are complicated by what i prefer to label as ” posttraumatic fibrositis.” After traumatic events such as motor vehicle accidents and lifting injuries, many of my patients with chronic neck pain report not sleeping well and having multiple tender points that were not present, according to the patients, before their accidents. Whether this syndrome is the same as fibromyalgia ( see above) is not clear. It does not seem to be associated with the nonmusculoskeletal symptoms present in primary fibromyalgia. In addition to physical therapy addressing posture and conditioning of the upper back and extremities , medication to induce restorative sleep can be helpful ( e.g., amitriptyline, imipramine).
Headaches
Hundreds of books and research papers have been written, and many clinics hae been created, to help with the very common and disabling problem of headaches. Fortunately, most headache syndromes are chronic but intermittent problems. As in the case of back pain, multiple factors are possible as triggers or causes. I would like to mention some overlooked factors that can be responsibile for chronic headaches. The overconsumption of caffeine and chronic use of anti-inflammatory agents such as aspirin or ibuprofen may lead to ” rebound headaches” (i.e., headaches related to the chronic use of either substance). The same thing can happen with headache drugs like fioricet, Fiorinal, and Esgic. In addition, these latter drugs can be habit-forming because they contain a barbiturate-like component. When i see patients with complaints of daily headaches, I frequently find that they are suffering from muscle tension or spasm of their neck muscles. ( Variations on this theme are patients with temporomandibular joint strain caused by clenching or grinding of their teeth; a night gaurd for the teeth may be helpful in such a case.) Therapy directed at strengthening of the upper extremeties and good posturing of the head, neck, and upper back are extremely valuable, sometimes eliminating the problem altogether. Patients who experience increased headaches after exercising their upper extremities should take special care: They are probably using muscles incorrectly because of weakness and straining, and should have supervision at the beginning. The avoidance of long fasting periods during the day can be helpful to those individuals who may be prone to low blood sugar. Skipping meals is often associated with headaches in susceptible individuals.
Interstitial Cystitis
Interstitial cystitis is a chronic inflammation of the bladder that occurs primarily in women; the cause is unknown. Symptoms include pain and pressure in the pelvis, urinary frequency( both day and night), painful sexual intercourse, and backaches. THe urine is negative for the presence of infection, though it may feel as though infection exists. The diagnosis is usually made by passing a scope into the bladder (cystoscopy), looking at the blader all, and taking a sample of tissue. Treatment is available, but does not always resolve or help with the symptoms. They are both national and local organizations to support women with interstitial cystitis and keep them informed as to the latest research and treatment developments. You can contact the national group, The Interstitial Cystitis Association, at P.O. Box 1553, Madison Square Station, New York, NY 10159, or call (212)979-6057.
Endometriosis
Endometriosis is a disorder of women involving the appearance of uterine tissue ( endometrium) outside of the uterine cavity ( womb). It is unknown why the tissue becomes embedded in areas outside of the uterus. The pain associated with endometriosis is thought to be the result of the microhemorrhages that occur with the monthly menstrual cycle, and the resultant irritation of surrounding tissue. However, the number of abnormal tissue implants does not correlate with the amount, intensity, or frequency of the pelvic pain experienced, so there may be several complicated mechanisms for pain production. Treatments may vary from simple birth control pills to testosterone-like medications to hysterectomy. This pain syndrome also has national and local groups for patient support and inforamtion resources. Contact the Endometriosis Association at 8585 North 76th Place, Milwaukee,WI 53223, or call (414) 355-2200 for more information.
Neuropathies
Several well-known pain conditions are associated with nerve damage or irritation, and are thus known as ” neuropathies.” One of these is postherpetic neuralgia. This is caused by the same virus that causes chicken pox, herpes zoster. It can infect any peripheral nerve and is associated with a funny sensation of the skin, followed by a small blistery rash that over the course of about two weeks becomes crusted and weepy. It may be associated with fever and flu-like symptoms. In individulas over 65 years of age, there is a high likelihood of developing nerve pain that lasts long after the rash has gone. Currently, it is recommended that older individuals at high risk receive nerve blocks from an anesthetist within days to weeks after the rash appears. Another potentially effective treatment is to apply Zostrix, to the painful skin after the rash has healed five times a day. Follow the instructions in the box. Zostrix is available without a prescription, but consult your health care provider to confirm the diagnosis. Diabetes can be associated with a painful neuropathy, in additionto the neuropathy characterized by numbness in the hands and lower extremeities. Most of the painful diabetic neuropathies are time-limited and ” burn out” after 12 to 18 months. Amitriptyline, baclofen, and mexiletine are medications used for this condition that may help. Sympathetically medicated pain, also known as ” reflex sympathetic dystrophy,” ” Sudecks dystrophy,” or ” hand/shoulder syndrome,” is a condition that develops after major or minor trauma to the extremities. It is unclear what the true abnormality is, but the result is that the sympathetic nervous system– which controls blood vessel diameter and leakiness, as sweating in the extremeities– becomes involved in the pain process as well. Thus the syndrome is characterized by swelling, increased sweating, blood vessel constriction ( causing the skin to dark red to blue), and sever pain in the involved extremeity. Even light touch can cause excruciating pain. It is a very complicated syndrome and needs to be treated by pain specialists or by someone familiar with the diagnosis. I mention it so that if you have such symptoms but have not been diagnosed yet, you can bring this description to the attention of your health care provider. Sometimes nerve blocks aimed at blocking the sympathetic nervous system can be very effective altering this pain syndrome, but early intervention is critical. Certain blood pressure medication, such as calcuim channel blockers, alpha-, and beta-blockers, are also used for treatment. Physical therapy, using contrast baths, desensitization of the painful limb, and high voltage galvanic skin stimulation, may help as well. The presence of a burning, tingling, sensitive-to-light-touch area with any chronic pain problem probably implies the presence of a neuropathy. The use of low-dose amitriphtyline or imipramine may be beneficial.
