The main sites of chronic pain syndromes are the head ,face ,neck ,lower back ,abdomen and genitalia.Quite often a minor abnormality will be found on in........
OTHER CHRONIC PAIN SYNDROME
A chronic pain syndrome is a condition of chronic disabling pain for which no medical cause can be found .The psychiatric classification would be a persistent somatoform pain disorder ,but this is unsatisfactory since the criteria include the stipulation that emotional factors must be the main cause ,and it is clinically difficult to be tat certain.The main sites of chronic pain syndromes are the head ,face ,neck ,lower back ,abdomen ,genitalia and all over ( CWP :fibromyalgia ) " Functional " low bac pain is the commonest ' physical ' reason for being off sick long-term in the UK .Quite often a minor abnormality will be found on investigation ( such as mild cervical spondylosis on the neck X-ray ,but this will not be severe enough to explain the severity of the pain and resultant disability .These pains are often unremitting and repond poorly to analgesics.Sleep disturbance is almost universal and co-morbid psychiatric disorders are found in a large minority.
AETIOLOGY
The perception of pain involves sensory ( nociceptives ) emotional and cognitive processing in the brain.Functional brain scans sugest that the brain may respond abnormality to pain in these conditions .This could be related to conditioned behavioral and physiological responses to the initial acute pain .The brain may then adapt to the prolonged stimulus of the pain by changing its central processing .Tprefrontal cortex, thalamus and cingulate gyrus seem to be particularly affected and some of these areas are involved in the emotional appreciation of pain in general .Thus it is possible to start to understand how beliefs ,emotions and behaviors might influence the perception of chronic pain.
MANAGEMENT
- Management involves the identification and treatment of maintaining factors ( e.g dysfunctional beliefs and behaviors ,mood and sleep disorders ).
- Communication
- Explanation of ill-health ,including diagnosis and causes .
- Education about management ( including self-help leaflets ).
- Stopping drugs ( e.g caffeine causing insomnia ,analgesics causing dependence ).
- Rehabilitative therapies.
- Cognitive behavior therapy ( to challenge unhelpful beliefs and change coping strategies ).
- Supervised and graded exercise therapy ( to reduce inactivity and improve fitness ).
- Pharmaco therapies .
- Specific antidepressants for mood disorders ,analgesia and sleep disturbance.
- Symptomatic medicines ( e.g appropriate analgesia ,taken only when necessary ).
Since analgesics are rarely effective ,and can cause long-term harm, patients should be encouraged to gradually reduce their use .It is often helpful to involve the patient's immediate family or partner ,to ensure that the partner is also supported and not unconsciously discouraging progress.
Specific drug treatment are few .Nerve blocks are not usually effective.Anticonvulsants such as carbamazepine and gabapentine may be given a therapeutic trial if the pain is thought to be neuropathetic.
The antidepressants dosulepine ( dothiepin ) is an effective treatment in half of patients with atypical facial pain, and this effect seems to be independent of dosulepine's effect on mood.Another tricyclic antidepressant,amitriptyline,is more effective than a selective serotonin reuptake inhibitor ( SSRI ) in tension headaches ,which might be related to its independent analgesic effect.
Amitriptyline has the added bonus of increasing slow wave sleep ,which may be why it is more effective than Non Steroidal Anti Inflammatory Drugs in chronic widespread pain.
Tricyclic antidepressants that affect both serotonin and norepinephrine ( noradrenaline ) reuptake seem to be more effective than more selective norepinephrine reuptake inhibitors e.g in neuropathic pain.
There is some preliminary evidence that tricyclics are superior to Selective Serotonin Reuptake Inhibitors in chronic pain syndrome.
