Chronic Pain Syndrome Treatment & Management

Management of chronic pain in patients with multiple problems is complex, usually requiring specific treatment, simultaneous psychological treatment, and physical therapy (PT). ^{[6, 7]} 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. ^[20] 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.

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). ^{[7, 23, 24]}

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.

A prospective study by Masterson et al suggested that physical therapy using pelvic floor rehabilitation may offer an effective treatment for men with idiopathic chronic pelvic pain syndrome. Treatment response was considered robust in five out of 10 patients (50%), and moderate in two out of 10 (20%), with therapy involving the following ^[25] :

• Internal and external manual therapy of the pelvic floor and abdominal musculature to promote muscle relaxation
• Therapeutic exercises aimed at improving range of motion, mobility/flexibility, and muscle strength
• Biofeedback aimed at strengthening and relaxing the pelvic floor musculature
• Neuromodulation to relax the pelvic floor musculature and relieve pain

A literature review by Andrade et al did not find clear evidence regarding exercise’s impact on inflammatory markers in patients with fibromyalgia. However, none of the studies used in the report indicated that treatment-related exercises caused patients’ symptoms to worsen. ^[26]

A study by Grinberg et al of female patients with chronic pelvic pain syndrome indicated that myofascial physical therapy (MPT) is not only associated with long-lasting alleviation of pelvic pain, but also with anatomic, neurophysiologic, and psychological benefits. The investigators state that MPT leads to hypertonicity relief, reduction in sensitivity to experimental pain, improvement in endogenous inhibitory system functionality, and lowering of psychological distress (with regard to anxiety, pain catastrophizing, somatization, and depressive symptoms). ^[27]

A literature review by Haller et al indicated that in patients with chronic pain, craniosacral therapy (CST), which employs fascial palpation, is superior to sham treatment with regard to improvement in pain intensity and disability at 6 months. The study included patients with neck and back pain, migraine, headache, fibromyalgia, epicondylitis, and pelvic girdle pain. ^[28]

A randomized, controlled trial by Rodríguez Torres et al indicated that a neurodynamic mobilization program can reduce pain and fatigue and improve neurodynamics and function in patients with fibromyalgia. The study included 48 patients with fibromyalgia who were randomized to a twice-a-week active neurodynamic mobilization program or to a control group, with results evaluated using the Brief Pain Questionnaire, the Pain Catastrophizing Scale, neurodynamic tests, the Health Assessment Questionnaire Disability Index, and the Fatigue Severity Scale. ^[29]

A phase II, randomized, sham-controlled clinical trial by Mendonca et al indicated that the use of a combination of transcranial direct current stimulation (tDCS) of the primary cortex and aerobic exercise is more effective in managing in fibromyalgia than is either of these modalities by itself, having significantly impacted pain, anxiety, and mood. However, motor cortex plasticity response did not differ between the three groups, with the investigators suggesting that perhaps the combination of tDCS and aerobic exercise influenced other neural circuits. ^[30]

A literature review by Knijnik et al indicated that repetitive transcranial magnetic stimulation (rTMS) has a better effect on quality of life than does sham stimulation in patients with fibromyalgia, with the superior impact seen after 1 month of treatment. However, although reductions in pain intensity were found, changes in depressive symptoms were not. ^[31]

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 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 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

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.

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Stellate block, important anatomical landmarks (surface and cross-sectional views).

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Pertinent anatomy for lumbar sympathetic block (cross-sectional view).

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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 for this treatment, including a preprocedure psychological/psychiatric evaluation, and a successful spinal cord stimulator trial is required prior to implantation of the stimulation device.

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, with a preprocedure psychological/psychiatric patient examination being included in the evaluation. A successful intrathecal morphine pump trial is required prior to implantation of the pump.

Noninvasive brain stimulation

A literature review by Baptista et al yielded consensus recommendations on the use of noninvasive brain stimulation in the management of chronic pain in Latin America and the Caribbean region. These include the following, with the investigators specifying that low to moderate analgesic effects can be obtained in association with level A recommendations, while potential, but uncertain benefits, are associated with level B recommendations ^[32] :

• The use of anodal transcranial direct current stimulation (tDCS) over the primary motor cortex was recommended for the control of fibromyalgia pain (level A), as well as for peripheral neuropathic pain, abdominal pain, and migraine (level B)
• Bifrontal (F3/F4) tDCS and high-definition (HD) tDCS over the primary motor cortex were recommended for the treatment of fibromyalgia (level B)
• Occipital/top-of-the head (Oz/Cz) tDCS was recommended for migraine treatment (level B)
• High-frequency repetitive transcranial magnetic stimulation (HF rTMS) over the primary motor cortex was recommended for fibromyalgia and neuropathic pain (level A), as well as for myofascial pain, musculoskeletal pain, complex regional pain syndrome, and migraine (level B)
• A recommendation was made against the treatment of low back pain with primary motor cortex tDCS
• A recommendation was made against the treatment of chronic pain with HF rTMS over the left dorsolateral prefrontal cortex

Other

A study by Colini Baldeschi et al indicated that peripheral nerve stimulation can also effectively reduce chronic neuropathic pain resulting from a peripheral nerve lesion. In the study, patients in whom this condition had proven refractory to conventional surgical or pharmacologic treatment underwent peripheral placement of an implantable pulse generator near the stimulation site. By 6-month follow-up, 69% of these patients had experienced a reduction in the pain numeric rating scale of over 50%, while quality-of-life physical and mental indices in the study patients rose by 18% and 29%, respectively. In addition, 55% of patients no longer needed analgesic drugs, while 16% underwent a reduction of these agents. ^[33]

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. ^[20]

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. ^[34]

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. ^[35]

A study by O’Sullivan et al indicated that cognitive functional therapy can be effective in the management of nonspecific chronic low back pain. Patients in the study underwent approximately eight cognitive functional therapy treatments, with 1-year posttherapy follow-up. The subjects demonstrated significant improvements in functional disability and pain immediately after completing treatment and maintained these gains over the follow-up period. ^[36]

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).