Most pain is related to injury or tissue damage and the treatment is relatively straightforward in theory: the tissue at fault is searched for and investigated, a cause is found and the treatment is aimed at improving the underlying abnormality. This is the medical model of disease and injury and it works exceptionally well, diagnosing our fractured leg, pneumonia, arthritic joint or heart attack and then treating it so the problem is solved. The difficulty starts with the many pain conditions which don't fit into this model and which are not well diagnosed or treated by medical doctors.



If we sprain an ankle the pain signals rush up the nerve towards the spinal cord and cross over onto the next relay of nerves up to the brain. This next relay of nerves is made highly sensitive by the incoming pain and they start to react more and more strongly to the incoming barrage, amplifying the pain we experience in our mind. This will settle down as the injury heals and the system resets to normal, however this does not always occur or a pain can start without any incoming tissue pain at all. This is a pain syndrome, a collection of painful and other symptoms which do not appear to have an underlying pathology.

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.

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. Physiotherapy 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.

A clinical psychologist is vital if successful management of people with pain syndromes is to be accomplished as they will tend to produce anxiety, anger, low mood and depression. Patients exhibit poor coping, non-assertive behaviour, aggression, negative thinking and difficulties sticking to a therapy plan. A history of abuse, both in adult relationships or as a child, is common especially in FMS and can have a dominant effect on the patient's approach and their relationships with others. Helping these patients through this time needs a clinical psychologist and treatment solely from a physio is unlikely to be helpful.

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.

Doctors are unable to treat pain syndromes with any degree of success but some medication, such as amitriptyline, can be of benefit, reducing pain and helping sleep. Morphine related drugs may increase confusion, fatigue and lack of mental sharpness. Physiotherapists prescribe a graded exercise programme, for which there is reasonable scientific support, and monitor it closely to improve fitness, strength and ability. Stretching can also be taught and is useful where the pain prevents exercise. A multidisciplinary approach and a graded, structured treatment plan are essential for these patients.