Chronic Pain Syndrome

Chronic pain syndrome tend to be very difficult to manage because of is its complex natural history, unclear aetiology and poor response to therapy. There is no clear definition and the minimum duration of pain varies between 3 and 6 months. Some argue that any pain that persists longer than the reasonable expected healing time for the involved tissues should be considered as chronic pain. The impact of chronic pain on patients' lives varies from minor restrictions to complete loss of independence.

Chronic pain is a common problem, affecting around 10% of adults.

Sternbach's 6 D 's of chronic pain syndrome are as follows:¹

• Dramatisation of complaints
• Drug and/or alcohol misuse
• Dysfunction
• Dependency
• Depression
• Disability

There are no relevant signs indicating the cause of pain, e.g. no joint swelling, muscle weakness, weight loss or fever. The disability is usually out of proportion to the impairment and the objective findings.

Causes of diffuse musculoskeletal pain, including:

• Rheumatoid arthritis
• Spondyloarthropathy, e.g. ankylosing spondylitis, Reiter's Syndrome
• Vasculitis
• Polymyositis, dermatomyositis
• Polymyalgia rheumatica
• Toxin related, e.g. eosinophilia myalgia syndrome, silicone implants
• Osteomalacia
• Chronic fatigue syndrome
• Fibromyalgia
• Complex regional pain syndrome
• Hyperthyroidism
• Hypothyroidism
• Neoplasm
• Multiple sclerosis
• Entrapment neuropathy

The diagnosis is by exclusion of other specific causes of chronic pain. Although it is essential to rule out any underlying aetiology for the pain, a great deal of care and skill is often required to avoid unnecessary and inappropriate investigations and referrals, which only serve to increase the underlying anxiety of the patient and their family. An endless quest for a non-existent diagnosis must be avoided.

There are no proven, comprehensive treatments in primary care for patients with medically unexplained symptoms.² Management must be tailored for each individual patient. The treatment should be not just aimed at pain relief but also aimed at changing pain behaviour and improving function. The goals of treatment must be realistic and should be focused on restoration of normal function (minimal disability), better quality of life, reduction of use of medication and prevention of relapse of chronic symptoms.

• Relaxation methods, patient education³
• Antidepressants: both tricyclics and SSRIs have been shown to be effective
• Simple and compound analgesics, non-steroidal anti-inflammatory drugs: long-term and excessive use of all symptomatic analgesics should be avoided because of the risk of dependence and abuse
• TENS machine
• Physiotherapy and occupational therapy have an important role in functional restoration for patients. Recreational therapy can help the patient with chronic pain take part in pleasurable activities that help decrease pain
• Psychotherapy: behavioural and cognitive psychotherapies⁴
• Vocational therapy
• Nerve blocks and other spinal interventions, e.g. epidural injections for chronic back pain⁵
• Sympathetic blocks are more effective therapeutic tools for chronic pain

• Prolonged physical suffering
• Sleep disturbance
• Marital or family problems
• Loss of employment
• Disability
• Adverse medical reactions from long-term therapy

• The prognosis is variable but often poor.
• However considerable improvement is possible with suitable support and management.