Approach Considerations
Management of chronic pain in patients with multiple problems is complex,[11] usually requiring specific treatment, simultaneous psychological treatment, and physical therapy (PT). A good relationship between the physician and patient should be established.
Treatment of chronic pain syndrome (CPS) must be tailored for each individual patient. The treatment should be aimed at interruption of reinforcement of the pain behavior and modulation of the pain response. 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.
Psychological interventions, in conjunction with medical intervention, PT, and occupational therapy (OT), increase the effectiveness of the treatment program.[12] Family members are involved in the evaluation and treatment processes.
Appropriate caution must be taken during CPS treatment in patients who exhibit any of the following behaviors:
- Poor response to prior appropriate management
- Unusual, unexpected response to prior specific treatment
- Avoidance of school, work, or other social responsibility
- Severe depression
- Severe anxiety disorder
- Excessive pain behavior
- Physician shopping
- Noncompliance with treatment in the past
- Drug abuse or dependence
- Family, marital, or sexual problems
- History of physical or sexual abuse
Inpatient and outpatient care
Hospitalization usually is not required for patients with chronic pain syndrome, but it depends on how invasive the treatment choice is for pain control and on the severity of the case.
Patients with chronic pain syndrome generally are treated on an outpatient basis and require a variety of health care professionals to manage their condition optimally. [#FollowupComplications] [#FollowupPatientEducation]
Physical Therapy
A self-directed or therapist-directed physical therapy (PT) program, individualized to the patient's needs and goals and provided in association with occupational therapy (OT), has an important role in functional restoration for patients with chronic pain syndrome (CPS).[13]
The goal of a PT program is to increase strength and flexibility gradually, beginning with gentle gliding exercises. Patients usually are reluctant to participate in PT because of intense pain.
PT techniques include hot or cold applications, positioning, stretching exercises, traction, massage, ultrasonographic therapy, transcutaneous electrical nerve stimulation (TENS), and manipulations. (According to a double-blind study, exercise groups have significant benefit over TENS.) Heat, massage, and stretching can be used to alleviate excess muscle contraction and pain. Other intervention should be offered to enable greater confidence and comfort when patients do not progress in a reasonable amount of time.
TENS
This therapy has significant benefit in the treatment of rheumatoid arthritis and osteoarthritis. Electrodes should be applied over or near the area of pain with the dipole parallel to major nerve trunks. TENS application should be avoided near the carotid sinus, during pregnancy, and in patients with demand-type pacemakers. The most common adverse effect of TENS is skin hypersensitivity.
Application of heat and cold
Use of these modalities is encouraged for the treatment of CPS, although the use of cold in neuropathic pain is controversial.
Occupational and Recreational Therapy
Occupational therapy (OT) is very important for initiating gentle, active measurements and preliminary desensitization techniques among patients who have chronic pain, especially regional chronic pain syndrome.
Recreational therapy can help the patient with chronic pain to take part in pleasurable activities that help to decrease pain. The patient finds enjoyment and socialization in previously lost recreational activities or in new ones. Usually, patients with chronic pain are depressed because of intense pain. Recreational therapists may play an important role in the treatment process as they help enable the patient to become active.
Vocational Therapy
Vocational therapy should be recommended and initiated early for all appropriate patients. It can provide work capacities and targeted work hardening so that the patient may return to gainful employment, the ultimate functional restoration.
Each patient is evaluated to determine work history, educational background, vocational skills and abilities, and motivation level to return to work. The patient should get help from a vocational counselor regarding legal rights and obligations in each state (eg, workman's compensation). Each patient needs to set realistic goals.
Nerve Blocks, Spinal Cord Stimulation, and Intrathecal Pumps
Nerve blocks
Nerve blocks are used for diagnostic, prognostic, and therapeutic procedures. (Nerve block ̶ related anatomy is depicted below.) Sympathetic blocks, including stellate ganglion and lumbar sympathetic blocks, commonly are used and are more effective therapeutic tools for chronic pain.
Schematic anatomical representations, sympathetic chain and stellate ganglion. 
Stellate block, important anatomical landmarks (surface and cross-sectional views). 
Pertinent anatomy for lumbar sympathetic block (cross-sectional view). Spinal cord stimulation
Spinal cord stimulation commonly is used to treat neuropathic pain refractory to other forms of treatment. Spinal cord stimulation also is used for patients with a failed back syndrome with radicular pain. Careful evaluation is recommended before patient selection.
Intrathecal morphine pumps
Intrathecal morphine pumps, either fully implantable or external, are used to treat chronic pain. Use of these devices should be considered very carefully for pain of nonmalignant origin.
Psychophysiologic Therapy
This type of therapy consists of reassurance, counseling, relaxation therapy, stress management programs, and biofeedback techniques. With these treatment modalities, the frequency and severity of chronic pain may be reduced.[12]
Biofeedback may be helpful in some patients when combined with medications, while behavioral techniques have been successfully used to treat myofascial and sympathetically mediated pain syndromes.
Relaxation training, including autogenic training and progressive muscle relaxation, commonly is used. This approach is as effective as biofeedback.
A randomized, controlled study by Wetherell et al determined that acceptance and commitment therapy (ACT) and cognitive-behavioral therapy (CBT) are effective treatments for chronic pain, positively affecting mood and pain interference. However, ACT may be more beneficial, since patients gave this treatment a higher satisfaction rating than CBT.[14]
In another randomized, controlled evaluation, researchers tested the efficacy of an online chronic pain management program using 305 adult participants with chronic pain. While 162 individuals used the program unsupervised for about 6 weeks, the other 143 people were assigned to the wait-listed control group with treatment as usual. A detailed assessment was conducted before the study and after about 7 and 14 weeks. Results indicated that those using the online program had significant decreases in pain severity, pain-related interference and emotional burden, perceived disability catastrophizing, and pain-induced fear. In addition, participants found that the online program lessened their depression, anxiety, and stress and gave them more information about chronic pain management.[15]
Consultations
Consultation with a psychologist, a urologist, a neurologist, an obstetrician-gynecologist, a GI specialist, or other appropriate specialist is very important, especially before considering invasive or aggressive management of a patient with chronic pain syndrome (CPS).
The high incidence of personality pathology in CPS may represent an exaggeration of maladaptive personality traits and coping styles caused by chronic, intense pain. A psychological evaluation should be performed to identify the stressor and to obtain information about the distress of the patient. The evaluation should consist of a structural clinical interview and a personality measure (eg, Minnesota Multiphasic Personality Scale, Hopelessness Index).
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