Managing Chronic Pain Biopsychosocial
Managing Chronic Pain Biopsychosocial
Managing Chronic Pain Biopsychosocial
MARTIN DUNITZ
CRC Press
Taylor & Francis Group
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Contents
1. Introduction 1
2. A reasonable approach to chronic pain
reduction 5
3. Anatomy and physiology 9
4. Plasticity and neuropathic pain 17
5. The biopsychosocial model in
chronic pain 27
6. Biopsychosocial pain and diagnostic
systems 37
7. Pain and psychiatric comorbidity 43
8. Pain and somatization 49
9. Fear of movement and pain 59
10. Relaxation, hypnosis and meditation 63
11. Psychotherapy in chronic pain 81
12. Fibromyalgia 91
13. Headache 105
14. Low back pain and sciatica 119
15. Pharmacotherapy 129
Index 159
670_Chronic Pain.prelims 19/02/2002 9 27 am Page vi
Introduction
Introduction 3
approach. In other cases they are an chronic pain. A particular aim is to provide
alternative to the invasive therapeutic material that will be useful to Psychiatrists and
techniques. When the invasive therapeutic General Practitioners.
techniques are the treatment of choice, the
addition of complementary non-invasive
References
techniques ensures comprehensive care.
Invasive techniques in chronic pain Bouckoms A. Chronic pain:
neuropsychopharmacology and adjunctive
comprise an array of diagnostic and psychiatric treatment. In: Rundell J, Wise M
therapeutic manoeuvres that rest on an (eds) Textbook of Consultation-Liaison Psychiatry.
extensive scientific base. It is unreasonable to American Psychiatric Press, Washington, DC,
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expect invasive therapeutic techniques to
Cheville A, Caaceni A, Portney R. Pain: definition
bring relief if the evidence for a treatable
and assessment. In: Massie MJ (ed) Pain: What
organic pathology is doubtful or when similar Psychiatrists Need to Know. (Review of
past treatments have brought little lasting Psychiatry Series, Vol. 19, No 2; Oldham J and
relief. Riba M, series eds). American Psychiatric Press,
Washington, DC, 2000; 1–22.
The biopsychosocial model of illness,
Loeser J, Melzack R. Pain: an overview. Lancet
which emphasizes the contribution of 1999; 353: 1607–9.
biological/medical, psychological/psychiatric Merskey H. Pain terms: a list with definitions and a
and social/environmental factors in aetiology note on usage. Recommended by the
and management, has been a guiding concept International Association for the Study of Pain
(IASP) Subcommittee on Taxonomy. Pain
in psychiatry and comprehensive family
1979; 6: 249–52.
medicine for more than two decades. It is the
Roth R. Psychogenic models of chronic pain: a
ideal recommended approach in all forms of selective review and critique. In: Massie MJ
pain (Cheville et al, 2000). The (ed) Pain: What Psychiatrists Need to Know.
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ethnic groups demonstrate different responses 89–131.
to the experience of pain (Zborowski, 1969), Russo C, Brose W. Chronic pain. Annual Review of
and it is argued that ‘pain and suffering in Medicine 1998; 49: 123–33.
society are manifested in pain and suffering in Ware N, Kleinman A. Culture and somatic
experience: the social course of illness in
the body’ (Ware and Kleinman, 1992).
neurasthenia and chronic fatigue syndrome.
This book contains theoretical and Psychosomatic Medicine 1992; 54: 546–60.
practical information that will assist a range of Zborowski M. People in Pain. Jossey-Bass, San
professionals in their work with patients with Francisco, 1969.
670_Chronic Pain.ch.02 19/02/2002 9 28 am Page 5
A reasonable approach to
chronic pain reduction
15. Logical thinking is more helpful than also be indicated where physically based
illogical thinking. Thoughts influence pain necessitates difficult psychological
the way one feels. This is the basis of the adjustments.
original cognitive behaviour therapy. 18. Medication is indicated, almost without
Thoughts such as ‘I cannot pick my exception. Excessive or inappropriate
children up so I am a failure as a parent’ medication, however, is to be avoided.
result in demoralization and depression, This is particularly the case with the
and must be challenged and corrected for short-acting opioids and certain
the patient to achieve the best possible benzodiazepines. Such medications have
result. limited beneficial effects in chronic pain
16. Relaxation training, self-hypnosis and and carry the risk of addiction.
medication have all been shown to 19. Excessive health-care utilization is
relieve chronic pain. The patient should discouraged. It not only wastes the
be taught and encouraged to practise at patient’s resources and delays recovery,
least one such technique. but is also wasteful of community
17. Psychotherapy has a place when there is a resources. It usually arises from excessive
need for the patient to adjust human patient concern about the pain.
relationships, sense of self or goals. It is Reducing undue utilization is not an easy
particularly indicated where task and may, after clear and repeated
psychological factors are important in the reassurance and a period of support, call
aetiology or maintenance of pain. It may for limit-setting.
670_Chronic Pain.ch.03 19/02/2002 9 30 am Page 9
A beta
Dorsolateral
Tract
C
I
II
III
IV
V
Figure 3.1
Termination of peripheral sensory neurones in the laminae of the dorsal horn (much simplified). Touch (A
beta) fibres terminate in lamina III, IV or V. Pain (C) fibres terminate predominantly in lamina II. The
dorsolateral tract is superficial to laminae I and II.
CORTEX
limbic
forebrain medial/ ventroposterolateral
structures intralaminar nucleus and medial
thalamic nuclei part of the posterior
thalamus
hypothalamus palaeospinothalamic
tract
neospinothalamic
tract
periaqueductal reticular
grey formation
Figure 3.2
Projection of spinothalamic tract. The spinothalamic tract (composed of palaeospinothalamic and
neospinothalamic fibres) is passing upward at the bottom right.
The fibres which are to become the palaeospinothalamic tract relay at the reticular formation. Projections
then proceed to the hypothalamus and thalamus, and subsequently, the limbic system and cortex. This
arrangement may provide the anatomical substrate for the emotional and motivational aspects of pain. The
neospinothalamic tract bypasses the reticular formation and relays at the thalamus before reaching the
cortex. It is believed to provide an anatomical substrate for the informational aspects of pain. Projections
from the reticular formation to the periaqueductal grey matter are part of a feedback pathway to the dorsal
horn cells.
670_Chronic Pain.ch.03 19/02/2002 9 30 am Page 13
CORTEX
limbic forebrain
structures
medial/intralaminar
thalamic nuclei
reticular
hypothalamus formation
periaqueductal
grey
Figure 3.3
Projections of spinoreticular tract. The spinoreticular tract is passing upward at the bottom right. It ends at
the reticular formation. Output from the reticular formation goes to the hypothalamus, thalamus and the
limbic system. Projections then reach the cortex. This arrangement may provide the anatomical substrate for
the emotional and motivational aspects of pain in the human.
As with the spinothalamic tract, output from the reticular formation goes to the periaqueductal grey
matter which projects to the dorsal horn cells, thus providing a mechanism for the reduction of nociceptive
input.
670_Chronic Pain.ch.03 19/02/2002 9 30 am Page 14
Pain
Physiological/ Clinical
normal pain pain
Acute Chronic
Figure 4.1
The pain tree, Physiological/normal pain is a distant relative of neuropathic pain and the other forms of
chronic pain. There is, at most, a slight family resemblance.
and the ‘inflammatory diseases’. An important on change in gene expression and phenotype
recent finding is that neuropathic changes (Hunt and Mantyh, 2001). For example, the
may be associated not only with direct trauma biology of sensory neurones is maintained by
to neural tissue, but also with continuous or growth factors for the innervated tissues, and
severe nociceptive input from inflammatory following inflammation, changes in
lesions (Terayama et al, 2000). phenotype are triggered by changes in the
Neuropathic pain is defined as ‘pain factors released at the injury site.
initiated or caused by a primary lesion or The symptoms that suggest neuropathic
dysfunction in the nervous system’ (Mersky pain include spontaneous pain, hyperalgesia
and Bogduk, 1994). It may manifest very and allodynia. The spontaneous pain is
severe symptoms; it is usually chronic, always characteristically burning or shooting in
difficult to treat. It is poorly understood, and nature. Hyperalgesia is an increased pain
deserves special consideration. Neuropathic response to a suprathreshold noxious stimulus
pain depends on neuroplasticity, that is, (that is, a painful stimulus hurts more than it
change in the function, chemistry and should). Allodynia is the sensation of pain
structure of neurones. Accordingly, it depends elicited by a non-noxious stimulus, such as the
670_Chronic Pain.ch.04 19/02/2002 9 31 am Page 19
gentle touch of clothes or the bending of a mechanisms is helpful to the clinician. It gives
cutaneous hair by a puff of wind. Spontaneous a better understanding of the mode of action
pain may be conceptualized as ‘stimulus- of some of our rudimentary interventions. For
independent’ and hyperalgesia and allodynia example, in neuropathic pain the tricyclic
as ‘stimulus-dependent’ pain. antidepressants function not only on
Focusing on symptoms and aetiology has neurotransmitters but also as sodium channel
not provided a productive model for blockers, thus reducing ectopic discharges (see
understanding or intervention. It has become below). Importantly, these mechanisms give a
clear that neuropathic pain does not have a more complete understanding of the
single underlying mechanism. In fact an neuropathic pain patient. They give
extensive range of mechanisms has been legitimacy to a range of claimed symptoms
discovered. No particular injury or disease that have often been doubted by clinicians.
process is associated with a unique pain They explain how pain can be felt when there
mechanism, and many different mechanisms is no activity and how activity may make pain
may produce the same symptom. In any given worse. They explain how pain can be triggered
patient suffering neuropathic pain, a number by the slightest touch, how pain can spread
of mechanisms are usually operating at the beyond the site of trauma and, with the
same time, and they usually change over time. change of mechanisms over time, how one
The newly described neuropathic agent may be useful at one time but become
mechanisms operate at the peripheral, spinal frustratingly useless later on.
cord and supraspinal levels (Taylor, 2001).
We currently lack reliable methods of
Predisposition
preventing the development of these
mechanisms. We are unable to determine Trauma and inflammatory conditions are of
reliably, in the clinical setting, which aetiological importance, leading to local
particular mechanism/s is/are operating in a changes and subsequent phenotypic
given patient. Finally, we lack a specific and modification (Hunt and Mantyh, 2001).
effective therapeutic intervention for each However, by no means all of those people
mechanism. Understanding of these exposed to trauma and inflammatory
mechanisms, however, is growing, new conditions develop neuropathic pain. There is
interventions are being developed, and there is now evidence of an inherited predisposition to
promise for the future. There is a basis for chronic pain (Mogil et al, 1999).
progress. There is evidence that a disturbed early life
Even at this early stage, knowledge of the may result in brain changes and a
670_Chronic Pain.ch.04 19/02/2002 9 31 am Page 20
After injury, however, there are at least two of C fibres in lamina II. There may be
mechanisms by which coupling between the numbness. The central projections of
sympathetic and sensory motor systems may surviving A-beta fibres in laminas III and IV
be established, providing mechanisms for may sprout into the territory vacated by the
neuropathic pain. First, both injured and C-fibre terminals in lamina II and make
uninjured neurones develop alpha- contact with second-order pain transmission
adrenoreceptors, which makes them neurones (Woolf et al, 1995). Thus non-
responsive to noradrenaline from sympathetic noxious information, such as proprioceptive
nerve terminals. (Injured neurones are also information or touch, may be interpreted as
believed to be responsive to circulating being of noxious origin. This is a
adrenaline and noradrenaline.) Second, pathophysiological explanation for pain from
sprouting of sympathetic axons into the movement and allodynia (Kohama et al,
DRGs forms baskets around the cell bodies of 2000).
sensory neurones and appears to be capable of
causing depolarization (Woolf and Mannion,
Spinal cord increased excitability
1999).
In spite of these potential mechanisms, the Any prolonged or excessive sensory input
actual proportion of cases of neuropathic pain from persistent inflammation or nerve injury
in which there is significant contribution from may result in increased excitability in the
the sympathetic nervous system is probably spinal cord (Woolf and Wall, 1986). This has
small. Current treatments of neuropathic pain been called ‘central sensitization’. Several
that are aimed at the sympathetic system have mechanisms have been described. Nociceptor
produced equivocal results (Kingery, 1997). input may lead directly to sensitization of
secondary dorsal horn neurones. Peripheral
nerve injury may lead to elevated spinal
Spinal cord reorganization
dynorphin (endogenous opioid), which may
The normal arrangement is that primary sensitize the second-order neurones in the
afferent neurones terminate in particular cord. Such elevation may be ‘multisegmental’,
layers of the dorsal horn of the spinal cord, occurring at levels distant from the segment of
synapsing with particular, predetermined the injured nerve, causing ‘extraterritorial’
second-order neurones. Lamina II receives neuropathic pain, or pain in a region not
nociceptor C-fibres exclusively. After nerve supplied by the damaged nerve (Malan et al,
injury, however, there may be substantial 2000).
degeneration and loss of the central terminals With healing, central sensitization may
670_Chronic Pain.ch.04 19/02/2002 9 31 am Page 22
subside. However, through ectopic activity in The above findings are largely from single-
A-beta neurones, it may be sustained cell neurophysiology studies of experimental
indefinitely. animals. These techniques are not at present
available in clinical practice. Valuable human
information, however, can be derived from
Spinal cord decreased inhibition
imaging and related studies.
Nerve injury may result in death of inhibitory The thalamus is believed to experience
dorsal horn interneurones, which leads to pain-related plastic change (Lenz et al, 2000).
disinhibition and the increased likelihood of Quantitative sensory testing and
dorsal horn neurones firing spontaneously or neurophysiological and psychological
in an exaggerated manner (Woolf and examination of patients with complex regional
Mannion, 1999). Decreased spinal cord pain syndrome suggest thalamic plasticity in
gamma amino butyric acid (GABA) chronic pain (Rommel et al, 2001). Regional
concentration and GABA receptor binding blood flow changes have been observed in the
sites have been reported (Castro-Lopes et al, basal ganglia of patients with chronic pain
1993). Thus the ‘gate’ can no longer be closed (Mountz et al, 1998). Altered facilitation and
by stimulating intact peripheral A-beta fibres inhibition of the motor cortex using
or via descending impulses from higher transcranial magnetic stimulation in two
centres. groups of patients with two painful disorders,
fibromyalgia and rheumatoid arthritis, have
been demonstrated by Salerno et al (2000).
Supraspinal influences
They hypothesized these findings were
The ability of descending fibres to inhibit secondary to pain-induced changes in the
nociception is well established. More recently, basal ganglia.
descending fibres with an ability to facilitate Chronic back pain (Flor et al, 1997) and
nociception have been reported. Evidence amputation (Wiech et al, 2000) are associated
indicates that injury and persistent noxious with spatial reorganization of somatosensory
input associated with inflammatory pain cortical mapping. Birbaumer et al (1995) have
causes long-term changes in the activity of described ‘corticalization’ of chronic pain.
brain stem neurones that enhance facilitation Such changes have yet to be thoroughly
and contribute to neuropathic pain (Ossipov investigated; however, it is probable that
et al, 2000). This facilitation appears to be plastic brain changes secondary to pain are
driven by brain-stem cholecystokinin important in causing and maintaining
(Kovelowski et al, 2000). neuropathic pain.
670_Chronic Pain.ch.04 19/02/2002 9 31 am Page 23
the physician leads to an exacerbation of trials for peripheral neuropathic pain and
symptoms. complex regional pain syndromes. Pain 1997;
73: 123–39.
Kohama I, Ishikawa K, Kocsis J. Synaptic
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670_Chronic Pain.ch.05 19/02/2002 9 31 am Page 27
Biomedical model
The biomedical model conceptualizes disorders as arising
from physical causes. It looks to eradicate such causes with the
expectation that the resolution of the disorders and a return to
normal function will automatically follow.
This model is well suited to the treatment of certain
infections and fractures. It is less well suited to the
management of mental illness.
The biomedical model is suited to the management of
acute pain where a close relationship usually exists between
the symptom and the degree of tissue injury. Narrow focus,
however, renders the biomedical model unsatisfactory in
chronic pain. Slavish devotion to the biomedical model in
chronic pain, with progression to repeated invasive
670_Chronic Pain.ch.05 19/02/2002 9 31 am Page 28
techniques, is unlikely to be beneficial and but that this was not the case with chronic
may end in iatrogenic complications. pain behaviour, as some environmental figures
provided support while others withdrew from
the patient. Jaynes (1985) pointed out that
Operant model
the reinforcer/rewards should have the same
This model of chronic pain has roots in effect on every patient, but that does not hold
learning theory (Fordyce, 1976). For a critical in the chronic pain scenario either, as some
review see Roth (2000). The observations patients find money positively rewarding,
were made that pain is communicated by while others are relatively indifferent. Roth
‘pain behaviours’ and that chronic pain (2000) points out that some losses that are
persists beyond the expected healing time. generally regarded as among the unwanted
This led to the theory that while acute pain consequences of chronic pain, such as the loss
was associated with appropriate acute pain of work status, are regarded as gains in
behaviour, chronic pain behaviour was operant pain theory.
reinforced or maintained by environmental While some pain behaviours communicate
factors. In operant theory, chronic pain that the patient is experiencing pain, this does
behaviours are maintained by financial not necessarily imply that such behaviour is
rewards, the attention of others and the under conscious control. There is strong
avoidance of duty. Pain behaviour rather than evidence that facial pain behaviour has an
pain experience became the focus of clinical evolutionary (survival) basis and that much of
attention. It is unclear whether proponents it is involuntary in origin (Williams,
believe that chronic patients are suffering pain unpublished). It is possible to exert some
and whether or not changing behaviour control over the pain behaviour of facial
reduces any such suffering. expression, but it cannot be completely
The operant pain model was hidden and is detectable by observers (Poole
enthusiastically embraced. It became and and Craig, 1992). There is evidence that
remains, a central plank of some intensive patients may openly demonstrate pain
multidisciplinary treatment programmes, behaviour when in the presence of supportive
supported by cognitive therapy, occupational and caring people (Block et al, 1980). But this
therapy, physiotherapy and medication may be interpreted in many ways. Williams
reduction. (unpublished) offers a credible interpretation,
However, theoretical objections have been proposing that when suffering patients are in
raised. Lacy (1985) pointed out that operant the presence of supportive people they are able
behaviours should result in predictable results, to release the control they have been exerting
670_Chronic Pain.ch.05 19/02/2002 9 31 am Page 29
over their pain behaviour, which may lead to that predispose the individual to depression in
an apparent but not an actual exaggeration. adult life. They speculate that these changes
An analogy is drawn with grieving: the ‘brave’ also predispose the individual to chronic pain,
individual is able to remain composed until a as sensitization of similar corticolimbic
supportive or ‘safe’ individual expresses structures could be involved. This theory
sympathy. might help to explain the high prevalence of
While some chronic pain patients are comorbidity of chronic pain and psychiatric
undoubtedly motivated by secondary gains, disorders and the pain-prone disorders that
operant pain theory cannot be accepted as a are discussed below.
generalized explanation of chronic pain
(Schmidt, 1987).
The biological/medical component
The biological/medical or physical basis of pain
Biopsychosocial model
is not contested. The chapters on Anatomy and
The biopsychosocial model of illness (Engel, physiology, Plasticity and neuropathic pain,
1977) highlights the importance of and Pharmacotherapy give relevant information
biological/medical, psychological/psychiatric on aetiology and therapy.
and social/environmental contributions to Other physical/medical forms of pain
aetiology and therapy. It is a guiding concept therapy include trigger point injection,
in psychiatry and comprehensive family temporary neural blockade, chemical and
medicine. radiofrequency neurolysis, cordotomy,
The biopsychosocial model is a useful massage, acupuncture, intraspinal drug
concept in pain medicine and is consistent administration, transcutaneous electrical nerve
with the International Association for the stimulation (TENS), dorsal column
Study of Pain definition: ‘Pain is an stimulation and deep brain stimulation.
unpleasant sensory and emotional experience
associated with actual or potential tissue
damage, or described in terms of such
The psychological/psychiatric
component
damage’ (Merskey, 1979).
Rome and Rome (2000) have proposed a The contention of the International
structural process for the biopsychosocial Association for the Study of Pain that pain
model of chronic pain. They reviewed involves ‘emotional experience’ raises the
information suggesting that disturbing early question of mechanism. In exploring this issue
life experiences lead to plastic brain changes some material is presented here that could
670_Chronic Pain.ch.05 19/02/2002 9 31 am Page 30
also have been listed under the above heading Neurones from the medullary region of
of ‘The biological/medical component’ – this the reticular formation form the ventral
testifies to the unity of mind and body. noradrenergic bundle (VNB), which also
Darwin (1872) conceptualized emotion as passes upwards in the MFB, projects to the
having evolutionary significance, as being a hypothalamus, and provides the
mechanism that facilitates communication neurophysiological link between tissue injury
and behaviour, and thereby, survival of the and the endocrine system. Hypothalamic
individual and the species. Later, Papez activity releases cortisol, which has wide-
(1937) described the limbic brain as ‘the ranging effects on the brain, including
hypothalamus, the anterior thalamic nuclei, modification of the firing rate of the limbic
the gyrus cinguli, the hippocampus and their forebrain. Also, the hypothalamus has neural
connections’ and proposed it as ‘a harmonious links with the limbic brain and the autonomic
mechanism which may elaborate the functions nervous system.
of central emotion’. These observations were Melzack (1999) has emphasized the
elaborated by MacLean (1952, 1990) who importance of the interconnections between
emphasized the importance of the limbic the endocrine, autonomic and limbic systems,
system and its functions to evolution. which, in addition to the neural and
Communication between the periphery endocrine factors, include the endogenous
and the brain was reviewed by Chapman opioids.
(1995). He found that, in the nervous system, The immune system is another mechanism
the differentiation between sensory and by which tissue damage results in limbic brain
emotional processing begins at the dorsal horn activation. Within seconds of tissue damage,
of the spinal cord. Information serving the cytokines are released from blood cells. They
sensory experience proceeds via the immediately cross the blood–brain barrier and
spinothalamic pathways and that serving the stimulate the hypothalamus, and thus the
emotional experience proceeds via the adrenal medulla and the limbic system. The
spinoreticular pathways. With respect to cytokine interleukin-1 stimulates the
emotion, important among the reticular hypothalamus to produce fever. Dantzer and
formation projections is the dorsal Kelley (1989) report that increased cytokine
noradrenergic bundle (DNB), which release results in malaise, fatigue, sleepiness,
originates in the pontine locus coeruleus (LC) anorexia, apathy and irritability. Experimental
and passes upward in the median forebrain immune activation using an endotoxin
bundle (MFB) to project throughout the produced negative emotional states and
limbic brain and the neocortex. decreased performance in memory function
670_Chronic Pain.ch.05 19/02/2002 9 31 am Page 31
tests (Reichenberg et al, 2001). These effects ‘splinting’ or tightening of muscles occurs to
were considered to be due to cytokine release, reduce the movement of painful structures.
and this study has relevance to a range of Thus, positive feedback loops develop, in
clinical conditions, including infectious and which pain leads to emotional tension or
autoimmune diseases (including multiple splinting, which lead to further pain.
sclerosis), cardiac disease, brain trauma and It is also a common experience that pain is
neuro-degenerative diseases. experienced as more intense at night. While a
circadian explanation could be involved, an
important feature is the reduction of stimuli.
Psychological factors in aetiology
Other people are asleep and unavailable, and
Common sense and clinical experience both the television offers little of interest. There is
suggest that the mental state can impact on thus no distraction, and pain that prevents
pain. Most forms of mental distress result in sleep becomes the focus of attention.
increased muscle tension, which leads to ‘Worry’ or apprehension, concern and
increased pain. (Mental distress, here, includes anticipation of future adverse events or
normal emotional arousal as well as the misfortunes are a very common human
diagnosable conditions of anxiety and problem. They form a feature of generalized
depression. It also includes other mental anxiety disorder, but are also present to a
disorders in which emotional arousal may be a lesser extent in a much broader section of the
feature, such as schizophrenia.) population. Such worries may focus on
The physiology of increased muscle external possibilities, such as floods or loss of
tension leading to increased pain has not been spouse or job, or on internal events such as
definitively elucidated. Contributing factors, loss of beauty or virility or onset of disease.
however, include an increased Worry is unpleasant, and often
mechanoreceptor inflow, increased mechanical uncontrollable. A frequent accompanying
forces applied to nociceptor endings and feature is muscle tension. Thus what can be
increased local metabolites with the potential called ‘normal’ worrying may accentuate
to sensitize nociceptor endings. muscle tension and pain. Worry is even more
Pain also leads to increased muscle tension likely and potent when there is ‘something to
by various mechanisms. It triggers the worry about’, that is, when disease or injury
autonomic fight or flight reaction, in which has brought loss or potential loss of income or
increased muscle tension prepares the family, or the prospect of long-term health
organism to respond to threat with quick problems. Finally, particular difficulties can be
strong movements. Also, an automatic anticipated when the worrying of the past has
670_Chronic Pain.ch.05 19/02/2002 9 31 am Page 32
focused on concerns about disease or strain injury’ because they imply a single
disability. uniform aetiology and neglect major
Various formal psychological theories have psychosocial contributions.
been offered as explanation for medically There is a high prevalence of psychiatric
inexplicable pain. Freud (1953 [1893]) disorder among those with chronic pain
described hysteria as the transformation of disorder (see the chapter on Pain and
unacceptable unconscious conflicts into bodily psychiatric comorbidity). One disorder may
pain as a means of preventing conscious exacerbate the other: hence psychiatric
awareness. In his seminal and sensitive paper, disorders need to be considered in the
‘Psychogenic pain and the pain-prone aetiology and treatment of chronic pain.
patient’, Engel (1959) emphasized the
importance of guilt in the generation of
Psychological factors in
chronic pain. Blumer and Heilbronn (1982)
treatments
argued that chronic pain is a variant of
depressive disorder or ‘masked depression’. The psychological support provided by
They introduced the term ‘pain-prone clinical staff and family and friends is
disorder’ in which hard-working people with important in maintaining a positive attitude
limited capacity to express emotions and encouraging efforts to regain function.
(alexithymia), after loss or disappointment, Where psychological contributions are
with or without painful injury or ailment, particularly important, psychological
become dependent and anergic and suffer treatments such as dynamic psychotherapy or
continuous pain. All these psychological cognitive behaviour therapy have an
explanations probably explain the symptoms important place. Psychotherapy also has a
of occasional chronic pain patients, but not place where biological contributions are of
the majority. primary importance, but adjustment to
In a large prospective study of the onset of changed circumstances is proving difficult.
forearm pain (Macfarlane et al, 2000), The pain-management ‘system’ and the
mechanical and psychological factors were less than optimal current treatments are a
identified. The important mechanical factors cause of great frustration and anger (Walker et
were repetitive movements of the hand and al, 1999). While these emotions may not have
wrist. The most important psychological initiated the pain, they play an important role
factor was dissatisfaction with support from in perpetuating distress. It is important to
colleagues or supervisors. The authors treat patients with respect and without
cautioned against terms such as ‘repetitive unnecessary delay. It is best to keep them
670_Chronic Pain.ch.05 19/02/2002 9 31 am Page 33
informed and involved as a means of helping Cultural factors are also important in the
them to deal with demoralization and anger. expression of illness and the granting of the
sick role. Considerable ethnic differences can
be found between groups living in the same
Social/environmental/cultural
country. Zborowski (1969) looked at whites
component
living in the USA. Italo-Americans were very
• Disease: biological or pathological changes ‘present-orientated’ about pain and were
that one ‘has’. primarily concerned about obtaining
• Illness: psychological or the way one ‘feels’ immediate relief. Jews were more ‘future-
when diseased. orientated’ and more concerned about the
• Sick: one acts or behaves the role ‘given’ by long-term meaning of pain. Anglo-Saxons
society. complained less and took a more detached,
‘unemotional’ view of symptoms.
In sociological terms there are distinctions Asians living in Britain are twice as likely,
between illness, disease and sickness. Illness is in comparison to Europeans, to consult their
the subjective sense that one is not well. Disease general practitioner (Balarajan et al, 1989),
is an objective pathology of the body such as and musculoskeletal pain is one of the most
cancer. Sickness is the condition of those who common reasons for consultation (OPCS,
are socially recognized as unwell. To put this in 1995). Non-specific musculoskeletal pain, low
another way, illness is a ‘psychological’ back pain and soft-tissue conditions are more
phenomenon in that one ‘feels’ ill, disease is a common in Pakistanis living in England than
‘biological’ phenomenon in that one ‘has’ a in those living in Pakistan (Hameed and
disease and sickness is a ‘social’ phenomenon in Gibson, 1997). However, Pakistanis required
that one ‘acts or behaves’ in the manner of a sick less postoperative analgesia than European
person (Twaddle and Hessler, 1986). patients, although pain scores were observed
Difficulties may arise when an individual has to be similar (Houghton et al, 1992).
one or two of these without the third. An Research indicates that Asians living in Britain
individual with cancer and obvious signs of the are significantly disadvantaged, and this may
disease may refuse to accept the sick role, be reflected in the difference in pain
including consulting a doctor. A more common complaints.
disjunction is when an individual claims the sick Cultural values and the potency of stigma
role but others do not accept that there is influence whether the distress is perceived and
disease. The term ‘abnormal illness behaviour’ reported in psychological or in somatic terms
can be applied in both of these examples. (Raguram et al, 1996). Depressed Chinese
670_Chronic Pain.ch.05 19/02/2002 9 31 am Page 34
patients most commonly present to general stop hiding, their pain behaviour. There is
practitioners with complaints of somatic evidence that pain behaviour has evolutionary
symptoms, including pain (Cheung et al, origins and that animals are ‘hard-wired’ to
1981). Ware and Kleinman (1992) compared elicit care that may promote survival.
Chinese suffering neurasthenia and North Nevertheless, common sense and clinical
Americans suffering chronic fatigue syndrome. experience suggest that a patient whose pain
They argued that ‘pain and suffering in behaviour elicits excessive attention and
society are manifested in pain and suffering in protection from the social environment will
the body’. They supported the claim that often be slower to move out of this role than a
somatic symptoms form part of a ‘hidden patient whose social environment is less
transcript’, a covert unofficial discourse that attentive and protective. Optimally, a balance
takes place out of sight of the wielders of is found when the patient feels valued and
power, and a way of addressing the desire for supported but also encouraged to strive for
change in social life. independence.
The operant model of pain has been Group activities as well as group therapy
described above under a dedicated heading. It have a place, providing for ventilation and
is built on learning theory, and could be listed inspiration through association with similarly
with psychological contributions; however, afflicted peers.
the purported rewards are derived from the
social environment, and include the promise
of money, the attention of others and the References
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cannot be universally applied, however: for differences in general practitioner consultations.
British Journal of Medicine 1989; 299: 958–60.
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of duty to be a positive, just as many others Block A, Kremer E, Gaylor M. Behavioral treatment
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Blumer D, Heilbronn M. Chronic pain as a variant
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pain was not comprehensively classified by the symptom of an anxiety disorder. The other is
other taxonomies. This system incorporates all called ‘psychological origin’, and examples
forms of chronic pain and codes according to include ‘conversion hysteria’ and ‘depressive
five axes. hallucinations’.
Axis I records the site of the pain. This is Classification of Chronic Pain is a valuable
relatively straightforward. Example categories contribution to the field of pain medicine.
are head, face and mouth, cervical region and The psychological/psychiatric and
upper shoulders and upper limbs. social/environmental contributions receive
Axis II records the system that is involved. some attention. Axis II is designed to code the
Systems such as the gastrointestinal and relevant system, and has two categories for the
genitourinary systems have a single category nervous system, depending on whether there
each. The nervous system has two categories, is a physical disturbance or dysfunction, or a
one for the presence of a physical disturbance psychological, psychiatric or social problem.
or dysfunction and the other for Thus this axis, which deals with systems, is in
psychological, psychiatric and social danger of being confounded by aetiological
conditions. factors. Further, Axis V, which is designed to
Axis III records the temporal code for aetiology, has a category called
characteristics and the pattern of occurrence ‘dysfunctional’ that may have an anxiety
of the pain. Examples of options include disorder as a root cause, and another category
single episode, recurring regularly and called ‘psychological origin’ that may have
recurring irregularly. ‘conversion hysteria’ as a root cause (a
Axis IV records the patient statement of condition that may result from an anxiety-
intensity and the time since onset. The provoking situation such as warfare). Thus
intensity is recorded as mild, moderate or pain with similar psychological/psychiatric
severe. The duration options are less than one contributions may be placed in different
month, one month to six months and greater aetiological categories. Finally, in the
than six months. ‘psychological origin’ category, of the two
Axis V records aetiology. There are examples given, one is a psychiatric disorder
relatively straightforward categories such as (conversion hysteria) and the other is a
neoplasm. There are two categories that psychiatric symptom (depressive
involve psychological issues. One, called hallucination). Thus, the
‘dysfunctional’, includes pains with a psychological/psychiatric and social/cultural
psychophysiological basis. Examples include contributions are superficially and confusingly
tension headache, which may or may not be a presented.
670_Chronic Pain.ch.06 19/02/2002 9 33 am Page 39
Pain can be experienced as a hallucinatory Axis I records the main mental diagnoses
phenomenon during the course of (one or more), except Personality Disorder
schizophrenia. However, in such cases other and Mental Retardation.
symptoms will be present on examination and Axis II records Personality Disorders and
the diagnosis should not be difficult. Mental Retardation. It may also be used to list
The ICD-10 alerts to the possibility that maladaptive personality features and defensive
reports of pain may be exaggerated (histrionic mechanisms. The listing of Personality
elaboration) and recognizes that psychological Disorder and Mental Retardation on a
factors may exacerbate organically caused pain separate axis ensures that these important
to cause what has been classified as a painful aspects receive attention.
organic disorder (‘psychological and Axis III records any General Medical
behavioural factors associated with disorders Conditions. These are coded according to
or diseases elsewhere classified’). It also ICD-9CM.
describes pain arising from psychiatric Axis IV reports Psychosocial and
disorders (persistent somatoform pain Environmental Problems that may affect the
disorder, depression and schizophrenia). diagnosis, treatment and prognosis. Included
The ICD-10 is predominantly a here are negative life events, familial or other
biological/medical classificatory system. As has interpersonal stresses, and inadequacy of social
been detailed in the above paragraph, there is support.
some effort to credit the importance of Axis V is the patient’s Global Assessment
psychological contributions. There is mention of Functioning. It is useful in determining the
of the use of ‘a culturally acceptable impact of the condition, in planning
explanation’ under the heading of treatment and in predicting outcome.
‘somatoform disorders’, but this is An Axis I diagnosis of Pain Disorder
exceptional. While a most useful diagnostic requires the satisfaction of five criteria.
system, the ICD-10 does not fully incorporate Important features are that pain is the
the biopsychosocial model. predominant focus of clinical attention, that it
causes significant distress and impairment and
that psychological factors are judged to have
Diagnostic and Statistical
an important role in the onset, severity,
Manual, 4th Edition (DSM-IV) exacerbation, or maintenance of the pain.
The DSM-IV (American Psychiatric Two subtypes are available: (1) Pain
Association, 1994) is concerned with mental Disorder Associated With Psychological
disorders. It is a multiaxial (five axes) system. Factors (here psychological factors are judged
670_Chronic Pain.ch.06 19/02/2002 9 33 am Page 41
mental disorder and is placed on Axis III. Blumer D, Heilbronn M. Chronic pain as a variant
of depressive disease: the pain prone disorder.
The DSM-IV, through the multiaxial
Journal of Nervous and Mental Disease 1982;
arrangement, approximates to the 170: 381–406.
biopsychosocial model. Axis I records whether
Engel G. ‘Psychogenic’ pain and the pain-prone
psychological factors play the major or an patient. American Journal of Medicine 1959; 26:
ancillary role. Axis II also calls for attention to 899–918.
be paid to psychological factors. Axis III Freud S. On the psychical mechanisms of hysterical
records potentially contributing biological phenomena. In: The Standard Edition of the
Complete Psychological Works of Sigmund Freud,
factors. Axis IV takes special account of the
Vol 3. Edited and translated by James Strachey.
psychosocial and environmental problems, Hogarth Press, London, 1953 [1893]; 25–42.
while Axis V takes account of the impact on Merskey H, Bogduk N. Classification of Chronic
the ability to function, which will determine Pain. 2nd edn. IASP Press, Seattle, 1994.
the response of the environment. Nicholson B. Taxonomy of pain. Clinical Journal of
Pain 2000; 16: S114-17.
World Health Organization. The ICD-10
Summary Classification of Mental and Behavioural
Elements of the biopsychosocial model have Disorders Clinical Descriptions and Diagnostic
Guidelines. World Health Organization,
been incorporated into Classification of Geneva, 1992.
Chronic Pain, ICD-10 and DSM-IV. The last
of these systems appears to contain more such
features than the other two systems.
670_Chronic Pain.ch.07 19/02/2002 9 33 am Page 43
reported in the general population. Probably, unrecognized in chronic pain, because the
one-third of those with a range of chronic symptoms are attributed to the pain condition
pain suffer major depression Roth (2000). or to minor depression. Atkinson et al (1986)
found no cases of anxiety disorders in 52
chronic pain patients. In an extensive review
Anxiety
of chronic back pain Fishbain (1999) found a
Fear is akin to anxiety, and differentiation is prevalence of anxiety disorders higher than
often difficult. Fear/anxiety is a response to expected for the general population.
threat and is ubiquitous in acute pain. In
chronic pain it is less common, but
nevertheless frequently present. Wise and
Personality disorder
Taylor (1990) confirm that anxiety is Merskey (1992) described the selection
commonly associated with most chronic process preceding presentation at the pain
medical conditions. As has been mentioned, clinic. Faced with chronic non-terminal pain,
depression is frequently present and anxiety many individuals will tolerate the condition
symptoms are common in depression. and get on with their normal activities as best
By contrast with depression, no theory has as they can. Some will take over-the-counter
been advanced that chronic pain is a variant of medicines. Only a proportion will consult
anxiety. Certain conditions have been their general practitioner, and a small number
identified, however, such as tension headache, of these will keep returning to the doctor after
for which a significant aetiological initial examination, reassurance and
contribution from anxiety has been generally conservative treatment. Those who reach the
accepted. pain clinic are a tiny, highly filtered and
Fear avoidance leading to disability has selected population. For those patients who
begun to receive attention in the literature. reach the chronic pain clinic with similar
Such constructions are consistent with the physical pathology to those who do not, other
clinical observations of the present author, factors, including personality features, may
and are considered in greater detail in drive the presentation.
Chapter 9. Friedman et al (1963) described a
Merskey et al (1987), using the ‘demanding, hypochondrical’ form of
Irritability/Depression and Anxiety depression. In most instances, this reflects
Questionnaire, found that 37% of 387 depression in an individual with demanding
chronic pain patients were pathologically and hypochondrical personality features.
anxious. Perhaps anxiety is frequently Pilowsky et al (1977) compared pain clinic
670_Chronic Pain.ch.07 19/02/2002 9 33 am Page 46
patients to family medicine clinic patients looking for and treating concurrent
using the Illness Behavior Questionnaire and psychiatric disorders whenever they are
found that pain patients demonstrated detected.
significantly more ‘disease conviction’ and
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Davidson J, Krishhnan R, France R, Pelton S.
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Overlapping conditions
Somatization
Somatization is defined (Lipowski, 1988) as the propensity to
experience and report somatic symptoms that have no
pathophysiological explanation, to misattribute them to
670_Chronic Pain.ch.08 19/02/2002 9 34 am Page 50
disease, and to seek medical attention for Alexithymia, which means being ‘without
them. The elements of this definition deserve words to describe emotions’, has also been
individual examination. There is a reported to be an important factor (Sifneos,
‘propensity’: thus particular personality traits 1996). It is proposed that, in the absence of
or beliefs are present and repetition of the the ability to describe emotions, individuals
behaviour can be expected. The symptoms are respond to life situations in maladaptive ways.
‘experienced’, not just reported. Thus, Alexithymic individuals focus on facts, details
somatizing patients are not feigning and external events, and tend to have a limited
symptoms, and somatization is distinct from fantasy life.
factitious disorder and malingering. There is Many individuals who do not satisfy strict
no ‘pathophysiological explanation’ to be diagnostic criteria for alexithymia nevertheless
found in the organ or region in which such a have an impoverished ability to express their
finding could be expected; however, comorbid emotions in words or by other adaptive
psychiatric symptoms may exist. The means. Important factors include intelligence,
misattribution of symptoms to disease may education and culture/sub-culture (e.g.
result in, or in cases of longer standing, arise ‘macho’ males). Somatization is more frequent
out of, the belief that disease is present. There in the lower socioeconomic classes, where
is ample opportunity for misattribution, as opportunities are limited (Gentry et al, 1974).
population-based surveys reveal that healthy Also important, once the patient has
adults experience more than one somatic presented, is the ability of the patient and the
symptom each week (Egan and Beaton, doctor to communicate effectively. Here,
1987). Medical attention is sought and sought much responsibility rests with the doctor, who
frequently; however, this may be insignificant must attend and work to understand the
in comparison to the attention sought from patient’s ‘physical’ language.
relatives, friends, pharmacist and alternative
therapists.
Somatization disorder
This is a descriptive account, free of
aetiological speculation. Others (Shapiro, Somatization disorder as defined in DSM-IV
1965; Schalling et al, 1973), using (APA, 1994) remains a controversial
neuropsychological testing, have shown that diagnosis. Somatization (the process) as
somatization is associated with information- described by Lipowski does occur in
processing deficits. A current review has somatization disorder; but the presence of the
confirmed that such patients manifest specific process is not sufficient to justify the
cognitive features (Rief and Nanke, 1999). diagnosis. For somatization disorder there
670_Chronic Pain.ch.08 19/02/2002 9 34 am Page 51
must be a lifetime history of pain in at least In the earlier diagnostic systems that did
four different parts of the body and at least allow hypochondriasis as a discrete entity,
one conversion or dissociative symptom. hypochondrical thoughts could be held with
In hysteria, an earlier designation for this delusional intensity. Using the DSM-IV
disorder, using neuropsychological testing, system, when delusions are present it is
information-processing deficits were necessary to make the diagnosis of delusional
demonstrated. These were characterized by disorder.
distractibility and difficulty in distinguishing
target stimuli (Ludwig, 1972; Flor-Henry et
Pain disorder
al, 1981).
Pain disorder associated with psychological
factors or with both psychological factors and
Hypochondriasis
a general medical condition is distinct from
Hypochondriasis (DSM-IV) involves somatization disorder in the DSM-IV system.
preoccupation with an unrealistic fear or belief However, some (Katon et al, 1984; Aigner
of having a serious disease, despite negative and Bach, 1999) regard chronic pain as the
investigation and assurance that no relevant most common form of somatization. The
pathophysiology is present. Fear or belief of diagnosis of pain disorder is particularly
having a serious disease, however, is common difficult when there has been physical disease
to all somatoform disorders. There are doubts or injury due to incompletely understood
as to whether hypochondriasis is a discrete phenomena, including sympathetically
disease entity (Rief et al, 1998). The diagnosis maintained pain (Walker and Cousins, 1997)
is frequently made in the primary care setting. and the painful joint stiffness and muscular
Management is notoriously difficult. weakness associated with disuse.
The DSM-IV can be criticized for giving a There is evidence that prior experience of
new definition to an old problem. Many older pain can influence the response to stimuli
textbooks (Curran and Partridge, 1969) did (Bayer et al, 1998). Learning appears to be
not list hypochondriasis as a discrete entity, aetiologically important in pain disorder, as
instead, indexing it ‘in endogenous depression, secondary gains reinforce pain-related
in GPI, in involutional melancholia, in behaviour; and prior social models, especially
schizophrenia, in senescence’. Kenyon (1976) sick and suffering parents, predispose to the
has strongly argued that hypochondriasis is development of the condition (Apley, 1975).
always a secondary part of another syndrome, The factors that sustain chronic pain
usually a depressive disorder. (particularly low back pain) probably include
670_Chronic Pain.ch.08 19/02/2002 9 34 am Page 52
fear of movement and pain, which can lead to about disease and discomfort, and is
the disuse syndrome and a self-perpetuating consequently culturally constructed (Wexler,
cycle (Vlaeyen and Linton, 2000). 1974). It may be construed as the patient’s
view of clinical reality (patient’s view). Some
Conceptual underpinning (Stimson, 1974) claim that medical doctors
treat illness poorly, while traditional and
Attribution theory alternative therapists, who listen and give
What individuals believe about their culturally relevant explanations, treat illness
symptoms greatly influences whom they well.
consult and how they manage those symptoms Disease may be defined as ‘abnormalities
(King, 1983). Individuals have enduring in the structure and function of body organs
attributional styles (Garcia-Campayo et al, and systems’. It may be construed at the
1997), such that when a symptom is medical view of clinical reality (medical view).
experienced, it is likely to be attributed to a One criticism of modern medicine is that it
physical, psychological or focuses on the treatment of disease and
environmental/normalizing explanation ignores the treatment of illness (Engel, 1977).
(Robins and Kirmayer, 1991). Not Common sense suggests a better outcome
surprisingly, general practice attenders with will be achieved if both illness and disease are
hypochondrical tendencies have more physical treated. Toward this end, the doctor should
attributions than those with anxiety disorders seek to understand the patient’s view fully, to
(MacLeod et al, 1998). Educational explain the medical view and to negotiate a
programmes designed to modify attribution shared view (Von Korff et al, 1997).
style are useful in the management of chronic
pain and somatization. Abnormal illness behaviour
Abnormal illness behaviour (AIB) provides an
Medical anthropology
intellectual framework for a comprehensive
Illness may be defined, anthropologically, as range of human behaviours (Pilowsky, 1969).
‘the human experience of sickness’. The It depends on two sociological concepts:
process begins with personal awareness of a illness behaviour and the sick role. Illness
change in body feeling and continues with the behaviour is defined as ‘the ways in which
labelling of the sufferer by self and family as individuals experience, perceive, evaluate and
‘ill’ (Kleinman et al, 1978). Illness is greatly respond to their own health status’
dependent on family and cultural beliefs (Mechanic, 1968). The sick role is
670_Chronic Pain.ch.08 19/02/2002 9 34 am Page 53
may be important in the maintenance of some respective belief systems and come to a
chronic pain. shared view of clinical reality. Others
Other support for the importance of have made similar observations. This
cognition in somatization and somatization approach is recommended.
disorder is available. Attributional theory is 2. The evidence for information-processing
not yet firmly established, but advances the deficits in these clinical presentations
reasonable proposition that ambiguous suggests that information should be
symptoms will be interpreted in accordance presented in an understandable form and
with personal beliefs and experience. Medical repeated frequently. The presence of
anthropology emphasizes the importance of information-processing deficits is one
the beliefs of the individual and the culture. reason why such patients may not
The sociological concepts mentioned here respond to the advice and information in
impact on classification rather than aetiology. the same manner as might other patients.
AIB forms an alternative envelope for certain This knowledge may reduce the burden
DSM-IV disorders, and does not obstruct the of their care.
proposal that cognitive factors are of 3. Present at all times as caring, confident,
aetiological importance. Whiplash disorder is firm and approachable (within agreed
an example of a chronic, painful, limits).
incapacitating syndrome that is secondary to 4. After appropriate investigation, inform
the cognitions of the patient, plus those of the the patient that no further investigations
society and culture in general, and the medical are indicated, at this time. Investigations
and legal professions in particular. (With are expensive, dangerous and usually
respect to chronic pain, fear of movement and unhelpful. Reassure that investigations
pain may serve to perpetuate this condition will be conducted, in the future, as
via the disuse syndrome.) indicated.
5. Limit the number of invasive treatments.
6. Limit the number of doctors the patient
Management
consults. The limitation of investigations
recommendations and invasive treatments is only possible
1. The anthropologists inform us that there when there is a limit on the number of
are at least two views of clinical reality doctors involved in the case. Continue to
(the patient’s and the medical view) and be involved on condition that the patient
that the best outcome is achieved when does not go outside the agreed team. An
the patient and doctor can discuss their interested general practitioner is
670_Chronic Pain.ch.08 19/02/2002 9 34 am Page 56
Pilowsky I. Abnormal Illness Behaviour. John Wiley Stimson G. Obeying the doctor’s orders: a view
& Sons Ltd, Chichester, 1997. from the other side. Social Science Medicine
1974, 8, 97–104.
Rief W, Nanke A. Somatization disorder from a
cognitive-psychobiological perspective. Current Trimble M. Post-traumatic Neurosis: From Railway
Opinion in Psychiatry 1999; 12: 733–8. Spine to the Whiplash. Wiley, Chichester, 1981.
Rief W, Hiller W, Margraf J. Cognitive aspects of Vlaeyen J, Linton S. Fear-avoidance and its
hypochondriasis and the somatization consequences in chronic musculoskeletal pain: a
syndrome. Journal of Abnormal Psychology 1998; state of the art. Pain 2000; 85: 317–32.
107: 587–95.
Von Korff M, Gruman J, Schaefer J, Curray S,
Robins J, Kirmayer L. Attributions of common Wagner E. Collaborative management of
somatic symptoms. Psychological Medicine 1991; chronic illness. Annals of Internal Medicine
21: 1029–45. 1997; 127: 1097–102.
Schalling D, Cronholm B, Asberg M, Espmark S. Walker S, Cousins M. Complex regional pain
Rating of psychiatric and somatic anxiety syndromes: including ‘reflex sympathetic
incidents – interrater reliability and relations to dystrophy’ and ‘causalgia’. Anaesthesia and
personality variables. Acta Psychiatrica Intensive Care 1997; 25: 113–25.
Scandinavica 1973; 49: 353–68.
Wexler N. Culture and mental illness: a social
Shapiro D. Neurotic Styles. Basic Books, New York, labelling perspective. Journal of Nervous and
1965. Mental Diseases 1974; 159: 379–95.
Sifneos P. Alexithymia: past and present. American
Journal of Psychiatry 1996; 153 (7 Suppl):
137–42.
670_Chronic Pain.ch.09 19/02/2002 9 34 am Page 59
related fear may be to impair the ability to Educational efforts can be focused on
accept that, in the chronic situation, pain does misunderstandings. Theoretically, correction
not mean further injury. of illogical thinking or catastrophizing could
prevent or reduce pain-related fear, avoidance
and disability.
Clinical implications
The term ‘cognitive behaviour therapy’ has
Many aspects of pain-related fear have been been applied to such patient–clinician
confirmed, and formal screening of patients interactions. This may discourage clinicians
may become routine clinical practice. who lack such training. However, clear
At present, screening may be achieved communication, accurate information and
using clinical skills. It is common for fearful encouragement are central, and are skills
patients to deny fear on initial, direct possessed by all experienced clinicians.
questioning. Matters become clearer if Graded physical activity may be the most
patients are asked to give an account of their effective method of preventing and
understanding of the nature of their problem rehabilitating pain-related fear and disability
and the consequences of movement. It is (Vlaeyen et al, 2001). A recent advance in the
important to know if patients anticipate management of acute back pain was the
immediate or delayed pain, or further injury. change from extended bed rest to early return
A number of questionnaires may be useful to normal activities.
in the identification process. Fear of pain has Graded physical activity makes particular
been measured using Pain And Impairment sense where there is a phobia about pain and
Relationship Scale (PAIRS: Riley et al, 1988) movement (McQuade et al, 1988). Also, there
and the Pain Anxiety Symptoms Scale (PASS: are people who are impervious to persuasion
McCracken et al, 1992). Fear of movement’s and who need to ‘see things with their own
causing further damage has been measured eyes’. Finally, after a period of inactivity, those
using the Survey Of Pain Attitudes (SOPA: with chronic pain are likely to experience
Jensen et al, 1987) and the Tampa Scale for increased pain during the recommencement of
Kinesiophobia (TSK: Kori et al, 1990). Fear activity. There may or may not be an eventual
of work-related activities has been measured diminution of pain. What will be achieved in
using the Fear Avoidance Beliefs the vast majority of cases, however, is a decrease
Questionnaire (FABQ: Waddell et al, 1993). in disability. This is a frightening, worrying
These may provide a screening role, but cut- time, and the presence of an informed clinician
off points indicating clinical significance have who acknowledges that the task is difficult, but
yet to be published. encourages perseverance, is a great advantage.
670_Chronic Pain.ch.09 19/02/2002 9 34 am Page 62
The best results can be expected when McCracken L, Zayfert C, Gross R. The pain anxiety
cognitive and physical approaches are symptom scale: development and validation of a
scale to measure the fear of pain. Pain 1992; 50:
combined in a supportive environment. 63–7.
McQuade K, Turner J, Buchner D. Physical fitness
References and chronic low back pain. Clinical
Orthopaedics Related Research 1988; 198–204.
Asmundson G, Norton P, Norton G. Beyond pain:
Riley J, Ahern D, Follick M. Chronic pain and
the role of fear and avoidance in chronicity.
functional impairment: assessing beliefs about
Clinical Psychology Review 1999; 19: 97–119.
their relationship. Archives of Physical Medicine
Crombez G, Vlaeyen J, Heuts P, Lysens R. Pain- and Rehabilitation 1988; 69: 579–82.
related fear is more disabling than pain itself.
Vlaeyen J, Linton S. Fear-avoidance and its
Evidence of the role of pain-related fear in
consequences in chronic musculoskeletal pain: a
chronic back pain disability. Pain 1999; 80:
state of the art. Pain 2000; 85: 317–32.
329–40.
Vlaeyen J, de Jong J, Geilen M, Heuts P, van
Jensen M, Karoly P, Huger R. The development
Breukelen G. Graded exposure in vivo in the
and preliminary validation of an instrument to
treatment of pain-related fear: a replicated
assess patients’ attitudes toward pain. Journal of
single-case experimental design in four patients
Psychosomatic Research 1987; 31: 393–400.
with chronic low back pain. Behavior Research
Kori S, Miller R, Todd D. Kinisophobia: a new Therapy 2001; 39: 151–66.
view of chronic pain behavior. Pain
Waddell G, Newton M, Henderson I, Somerville
Management 1990; Jan/Feb: 35–43.
D, Main C. A Fear-Avoidance Beliefs
Kottke F. The effects of limitation of activity upon Questionnaire (FABQ) and the role of fear-
the human body. Journal of the American avoidance beliefs in chronic low back pain and
Medical Association 1996; 196: 117–22. disability. Pain 1993; 52: 157–68.
Lethem J, Slade P, Troup J, Bentley G. Outline of
fear-avoidance model of exaggerated pain
perceptions. Behavior Research Therapy 1983;
21: 401–8.
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 63
Overview of techniques
Relaxation is infrequently defined. It has been described as the
absence of tension, stress, discomfort, anxiety and distress. It
is a psychophysiological state (it has mental and physical
components). The key features include increased slow brain
wave activity, lowered respiration and heart rate, lowered
adrenal outflow, and a lowering of mental activity other than
effortless attention. A definition from scholars interested in
response to stimuli reads ‘A generalized psychophysiological,
wakeful state of minimal activity or preparation for response
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 64
to any demand placed upon the body and the risk of strong transference (Freud is said to
mind’ (Wentworth-Rohr, 1988). Both have been unexpectedly kissed by a patient
components, mental and physical, must be when she woke from a trance). There is also
targeted in the pursuit of the relaxed state. the risk of the hypnotist developing the
Hypnosis also lacks a straightforward ‘Messiah Complex’ (Scott, 1974).
definition. It is swathed in mystique. It is These difficulties represent no challenge
known as a method by which deep trance for the thoroughly trained hypnotherapist.
states can be induced and potent post- For those without such training, however,
hypnotic suggestions implanted. Importantly, they represent significant obstacles. The
to the present time, it lacks a physiological present account will borrow elements from
profile to distinguish it from relaxation. One hypnosis, but does not attempt a
definition of hypnosis is ‘a consent state of comprehensive coverage of that field.
physiological relaxation in which the critical Relaxation, hypnosis and meditation all
faculty of the conscious mind is by-passed to have the potential to narrow concentration,
some degree’ (Scott, 1974). This purported focus attention and increase receptivity to
distinguishing feature of hypnosis, the suggestion. The common denominator is the
potential for by-passing ‘the critical faculty of reduction of physiological arousal and the
the conscious mind’, may not be unique, removal of distressing thoughts.
however, as proponents of relaxation and
meditation also claim to achieve increased
Benefits persist
receptivity to suggestion (Meares, 1968).
The difficulties of hypnosis include the The relaxation, hypnosis and meditation
stigma of charlatanism (the legacy of stage treatments of anxiety and pain have not been
hypnotists) and the suspicion of malevolent extensively studied with the randomized,
mind control that pervade the public view. double blind, placebo-controlled trials that
There is the difficulty of deciding whether or characterize medication treatment research.
not a patient is a good hypnotic subject. Nevertheless, various relaxation procedures
There may be difficulty in inducing hypnosis; have earned a place as effective treatments of
even patients who appear to be good these conditions.
candidates and have received adequate When a patient is physically and mentally
preparation may resist induction. Patients may relaxed, there can be little anxiety and mental
claim that they were ‘not really’ hypnotized distress. Proponents of relaxation, hypnosis
and were ‘just pretending’, a situation that and meditation tell us that with daily practice
calls for time-consuming exploration. There is the benefits experienced during active
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 65
treatment sessions begin to persist after the indicates that appropriate processes have been
sessions have ceased. Over time these benefits initiated. With each initiation, ability
last for longer and longer periods, until they increases. In the maintenance stage (after the
remain throughout the entire day. first month) the technique should be practised
every day. Some would say twice a day, but
that may be unrealistic. A minimum of 20
General technical details
minutes per day (total) should be so
The therapist should learn by undergoing dedicated. With practice, ability to initiate
instruction or attending classes whenever relaxation increases and the total time
available. However, it is possible to learn necessary for good effect may be reduced.
sufficiently from books and personal In general, it is better for the patient to sit
experimentation to be able to offer patients on a dining-style chair without arms or head
some simple techniques. rest, with feet flat on the floor and hands
It is better to avoid the use of the term resting on the thighs. The relaxation sought is
‘hypnosis’, which generates fear in some not like that which precedes sleep, and
patients and may cause others to twist therapy patients do not fall off their chairs. There are
into a contest of wills. Do not hesitate to advantages to providing less than full body
involve a chaperon or friend/relative of the support; when sitting as described, it is
patient. Exercises for the body are an accepted necessary to work hard at achieving relaxation.
feature of modern society. Relaxation, Some authorities recommend a head rest; and
hypnosis and meditation are exercises for the it is possible to achieve relaxation in the
mind and should be conduced in a similar, supine position.
open (but confidential) matter-of-fact The patient usually sits with eyes lightly
manner. closed. This is not essential, as it is possible to
In the skill-acquisition stage (the first achieve relaxation with the eyes open. When
month) a technique should be practised as deep relaxation is achieved, the eyes may
often as possible. This may be five or six times partially open. In the early skill-acquisition
per day. The actual number of times this stage the patient may be troubled by
happens depends on enthusiasm and trembling eyelids, but this passes within a
opportunity. Each practice session can be week or so.
short: perhaps three to five minutes. It is The therapist should speak in a quiet flat
better to persist until a noticeable change voice, similar to that used to deliver a sermon.
occurs, such as a change in rate of pulse or Speaking slowly gives the patient time to
breathing or a sense of emotional peace. This perform the indicated tasks and the therapist
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 66
time to decide on the next instruction. The in motivation following the early honeymoon
therapist should repeat instructions for the phase. Brief periods of even a few seconds of
same reasons. heaviness of limbs or drifting free of everyday
Permissive phraseology should be thoughts during relaxation sessions are
employed. Use of commands (‘You must relax evidence that a favourable result can be
your legs’) will discourage co-operation and achieved. Patients should be informed that,
will usually result in failure of therapy. Some from this point, abilities and rewards rapidly
confident hypnotherapists use predictions become apparent.
(‘Your finger will lift’) to good effect. These Whether relaxation, hypnosis or
predictions may be relying on little-known meditation is achieved depends on the quality
normal human physiology – for example, of the instructions of the therapist and the
relaxed fingers do twitch from time to time – abilities of the patient. It is a given that
or on the power of suggestion, which may be treatment sessions are only attempted in safe,
facilitated by charisma, training and a good warm, suitably lit environments. The
sense of timing. The term ‘maybe’ lacks information made available by the therapist is
confidence and is unlikely to be successful. standard information. From the outset it must
The word ‘can’ (‘See if you can slow your be made clear that whether the desired
breathing still further’) places the task with endpoint is reached depends not on the
the patient. abilities of the therapist, but on the abilities of
Certain words, such as ‘calm’, ‘drift’, the patient to follow and apply that
‘peace’, ‘sink’, ‘ease’ and ‘heavy’, are favoured, information. This relieves the therapist of
as they not only impart information, but also responsibility, and leaves it with the patient.
strike a psychological cord that helps in In handing this responsibility to the
triggering the desired response. New therapists patient, the therapist should remember that a
develop their own lexicons and scripts with minority of people lack the ability to perform
which they have success. these activities and that these people must be
Patients should be informed of the need protected from a sense of failure. Thus from
for regular practice. Relaxation sessions will be the outset it is necessary to affirm that some
followed by periods of tranquillity, and the people are good at some things and other
length of these periods will increase with people are good at other things. Some people
practice. Sleep should also improve after a few are good at arithmetic, some are good at
days. Benefit during the day may be apparent dancing and others are good at relaxation in
at one week and will increase indefinitely. therapists’ offices. No one is good at
Patients need to be warned of the risk of a dip everything, and some people are not
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 67
particularly good at this form of relaxation. off the task and unbidden thoughts enter, they
These people may be able to find relief in are not pushed away, but they are not
activities such as swimming or playing attended and are allowed to pass through and
computer games. The point can be made that away. The patient maintains a passive mental
a mantra is (usually) a meaningless utterance attitude, the only mental activity being the
that is useful because it allows participants to effortless focusing and refocusing of attention
focus attention, and that a squash ball moving on the neutral task.
around on white walls, or a prompt blinking The mantra is a traditional Eastern
on a computer game screen can, at least in mechanism. It is usually a sound that is
part, perform the role of the mantra, allowing repeated aloud or experienced silently. It
freedom from intrusive concerns. becomes the focus of attention. These devices
Before concluding that the patient can are used as an aid in many popular forms of
gain nothing from office-based relaxation meditation. Mantras share some of the
techniques, however, it is obligatory for the features of counting sheep when sleep is
therapist to offer more than a single method. evasive.
To this end, some alternatives are described Focusing attention on breathing is a
below. neutral task that is used in most if not all
forms of relaxation, hypnosis and meditation.
Most commonly the patient is asked to slow
Methods of focusing
the breathing and to breathe with the
attention diaphragm rather than the ribs. (In
Central to these techniques is the exclusion diaphragmatic breathing, as the diaphragm
from the mind of worry and distressing descends, and air enters the lungs, the anterior
thoughts. This may be achieved by occupying abdominal wall, rather than the chest wall,
the mind with a task. It is possible to displace moves outward.) The patient may also be
distressing thoughts with happy thoughts; but asked to focus on the flow and feel of the air
in the initiation stage of relaxation, hypnosis as it enters the nose, trachea and lungs. In
and meditation, it is better to use a neutral some relaxation and hypnosis techniques
task. By focusing attention (concentrating) on attention to breathing is alternated with
the neutral task, awareness not only of worries attention to muscle relaxation. In some
and distress, but of the environment in meditation techniques attention to breathing
general, is reduced, and the mind becomes less (the counting to 10 breaths and then starting
critical and more open to imagery, suggestion again) is the only task (Wilson, 1995).
and autosuggestion. When the mind wanders Focusing attention on the muscles is a
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 68
neutral task that was pioneered by Jacobson Another perceptual exercise that is mainly
(1938). Like focusing on breathing, focusing used to deepen relaxation is creating the
on muscle relaxation achieves two ends experience of going down steps. Once some
simultaneously: it achieves one of the degree of relaxation is achieved the patient can
components of relaxation (decreased muscle be asked to see three steps leading down from
tension) and it provides a focus for attention, their present position. The patient can be
thereby assisting the avoidance of worry and asked to indicate when this task has been
the thoughts of everyday living. achieved. Patients are then asked to ‘feel’
themselves move down from the top to the
second step. As this occurs the patients are
Special technical details
asked to feel themselves ‘go deeper into
‘Visualization’ here means the formation of a relaxation’. The patient may be asked to
mental image as though objects were being seen indicate when this task has been achieved, and
through the eyes. This process can be used then to take the next step and go even deeper
either to initiate or to deepen the relaxed state into the relaxed state. The number of steps
or for both. The patient is asked to ‘see’ an can be altered to suit the therapist and the
image, often a serene water view. The patient patient.
must strongly focus to perform this task. The Ego-strengthening exercises have been
task can be made more exacting by asking the described in the hypnosis literature. Once
patient to ‘see’ things in greater detail. The hypnosis is induced the hypnotherapist makes
therapist may ask: ‘Try to see some small stones encouraging statements to the effect that the
over to one side.’ As a means of encouraging patient will become more confident, capable
continued participation the therapist may ask and contented. It is unlikely that this
the patient to indicate by lifting an index finger procedure modifies the ego as originally
when some particular object can be ‘seen’ intended. However, having relaxed patients
(details given below). Other perceptual relive events in which they were appreciated
modalities can be included. The patient may be and achieved positive results can serve as a
asked to try to ‘hear’ waves or lapping water. task on which to focus, and simultaneously as
The patient may be asked to ‘smell’ flowers. A a means of providing comfort and support. It
particularly useful task is to ask the patient to is necessary to discover in preliminary
‘feel’ the warmth of the sun on the face. discussion whether such an event can be
Patients may also be asked to ‘see’ themselves in identified. It is unhelpful to place this task
and ‘feel’ the rocking of a rowing boat while before deeply relaxed patients if they are
visualizing a beach scene. unable to identify events about which they
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 69
have positive memories and feelings. The but also to experience the associated feelings
Stein (1963) clenched fist technique may be and emotions. For example, as mentioned
useful. Relaxed patients are asked to re- above, the patient who is asked to slow the
experience an event associated with positive rate of breathing may also be asked to note the
thoughts and feelings; they are then asked to feeling of air going through the respiratory
make a fist and ‘keep hold’ of those feelings. passages. A more complex task is for the
The hand is kept closed until after completion patient who is asked to assume a peaceful
of the relaxation or hypnosis session. With attitude not simply to think of the concept of
practice, it is claimed that closing the hand peace, but also to achieve the feeling or
outside relaxation sessions may trigger the emotion of peace. These are more difficult
desired experience. tasks that require a greater degree of
It is possible to communicate with deeply concentration and provide a deeper level of
relaxed patients by asking them to indicate relaxation.
answers by the voluntary raising of the index Semantic and mystical issues arise. There is
finger of one hand. This does not cause no emotion called ‘peace’. It is possible to feel
disturbance of the relaxed state. (Experts in peaceful; but patients may be asked to go
hypnosis have described using the raising of a beyond ‘peaceful’. They may be asked to
finger as a means of communicating with the ‘become’ peace (for example), to allow their
unconscious; but that is a different matter.) body and mind, identity or essence to be
Questions can be phrased such that they transformed into or blend with nature, God,
require yes or no answers, one hand answering, the cosmos, or a universal serenity. At a more
yes, and the other, no. This feature should not secular level, patients may usefully be asked to
be overused, as it can have some temporary acquire or ‘get’ the feeling of drifting. It is
effect on the depth of relaxation. It can be used better for therapists to remain on the secular
to good effect as a means of indicating when a side of the border with mysticism. From the
task has been achieved, as in ‘When you have medical perspective and in medical parlance
been able to experience the feeling of inner such tasks foster a dissociative state.
peace, lift your index finger of your right hand.’ Dissociation is poorly defined, but includes
Such phraseology increases the chance of the separation of ordinarily integrated
success when the therapist is confident and behaviour, thought, feeling and consciousness.
positive: it is not a question of whether, but Thus, in so far as relaxation aims at producing
when the task will be achieved. a state of profound physical inactivity,
A valuable tool is to ask patients not only avoidance of the present environment, and
to follow instructions on an intellectual level, uncritical thought processes, there are
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 70
similarities to a dissociative state. Relaxation established in this field. For example, the
of the type described here could be considered original progressive muscular relaxation
as controlled dissociation. technique (Jacobson, 1938) called for repeated
Complications of relaxation are very few. muscular contraction and relaxation of
There is some danger of uncontrolled individual muscles or muscle groups, with
dissociation following treatment sessions. whole sessions being spent on small
These are averted by discussion following anatomical areas and coverage of the whole
treatments. The therapist ensures that the body taking many weeks. Abbreviated versions
patient is orientated in time and place and were appropriated. More recent relaxation
restored to normal consciousness. Positive or techniques have dispensed with the forceful
negative experiences need to be reviewed, and contraction of muscles; instead, the attention
the patient should be able to respond to of patients is directed to individual muscle
potentially dangerous painful conditions in groups, with the instruction simply to relax
the appropriate manner. them during slow expiration. Different
Audiotapes may be made of relaxation authors have drawn attention to the
sessions for use by patients at other times. importance of relaxing different muscle
This gives the patients an accurate account of groups (face, neck, hands); this appears to be a
the session and the opportunity to practise the matter of personal preference.
tasks at their own pace. A potential Suggestion (defined for present purposes)
disadvantage is that patients may become is a primitive process by which ideas can be
dependent on the therapist rather than accepted into the mind without critical
developing their own initiative and self- evaluation. Autosuggestion occurs when the
administered relaxation sessions. Opinions subjects present ideas to themselves. These
differ from one therapist to another and one procedures were first described in hypnosis.
from one patient to another. However, as relaxation techniques also focus
attention and increase receptivity, self-
delivered ego-strengthening exercises, and
Developing a unique method
positive self-messages, which constitute
It is recommended that therapists should autosuggestion by other names, have been
borrow from different techniques and develop included in many relaxation protocols.
a unique relaxation method with which they The relaxation technique described by
are personally comfortable and that suits their Meares (1968) borrows from meditation
clinical circumstances. techniques. The patient repeats thoughts: ‘It is
Borrowing and modifying is well good to relax. Relaxing is natural. It is the
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 71
natural way to calm and ease.’ This is similar process (this would be called
reminiscent of the repetition of a mantra. autohypnosis, if the therapy were considered
There is a difference, however, as these to be hypnosis) for a total of not less than 20
thoughts contain messages describing the minutes per day. Patients are advised that
desired mental state, which is not the case there may be minor setbacks, but progress can
with most mantras. be anticipated. Patients are also advised of the
risk of loss of enthusiasm, particularly if
progress is slower than desired.
Relaxation treatment of
The following scripts are provided as a
anxiety guide to the types of relaxation sessions that
Anxiety is common in pain states, and anxiety can be developed. The therapist is encouraged
increases the suffering associated with pain. to explore and modify.
For these reasons it is appropriate to reduce
anxiety in pain states. Relaxation (Fisher and Script 1
Durham, 1999), hypnosis (Ashton et al, The following monologue gives an idea of a
1997) and meditation (Miller et al, 1995) relaxation session early in the
have all been shown to reduce anxiety. The treatment/education process. Some repetition
system described in this essay is a hybrid, is given here, but in reality in a session lasting
elements having been drawn from across this more than 10 minutes even more repetition
therapeutic spectrum. would occur. In the initial phase of this
Relaxation, hypnosis and meditation are session the focus is mainly on the
frequently practised by healthy individuals musculature. That is not mandatory. Then
whose motives are many, including pleasure, the imagery of going down steps is used to
self-development and self-awareness. No deepen the relaxation. The patient is asked to
specific anti-anxiety component needs to be communicate with the therapist using finger
added for these to be considered effective movements. Toward the end, encouraging
treatments of anxiety. Obviously, these statements are made and the patient is
techniques produce a physical and mental encouraged to remain in touch with positive
state that is the antithesis of anxiety, and this feelings on cessation of the session.
is presumably relevant to their therapeutic
action. Please close your eyes . . . and try to follow
Patients can be taught to relax using scripts my suggestions . . . I can tell you the things
similar to the one that follows. They are to aim for . . . but you are the one who has
encouraged to self-direct themselves through a to do the work . . . First try to
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 72
concentrate on slowing your breathing retain and explore this relaxed feeling for
down . . . Calm, slow breathing . . . Calm yourself.
and relaxed . . . That’s good . . . Now I OK, that’s fine . . . You have calmed
want you to think about the muscles of your breathing and relaxed . . . Well done
your forehead . . . Let the muscles of your . . . Now try to see three steps in front of
forehead relax . . . Calm, slow breathing you . . . Calm and relaxed . . . See yourself
. . . Calm and relaxed . . . As you breathe standing on the top step . . . with a path at
out say ‘Relax’, inside . . . Thinking of the the bottom . . . See the details of these
muscles of your forehead . . . as you three steps . . . Slow your breathing down
breathe out think, ‘Relax’ . . . Let the . . . Very slow now . . . When you can see
muscles of your forehead relax . . . Now three steps . . . slowly move the index
think of the muscles of your face . . . your finger of your right hand.
eyes . . . and your mouth . . . as you OK, that’s great . . . Now see if you can
breath out say, ‘Relax’ . . . and let the get the feeling of stepping down from the
muscles of your eyes . . . your face . . . and top step to the second step . . . Feeling
your mouth, relax . . . You are doing very good . . . Calm and relaxed . . . as you step
well . . . You have control of your down try to get the feeling of going deeper
breathing . . . Now think of the muscles of into relaxation . . . Try to get that feeling
your neck and shoulders . . . Relax your of stepping down . . . I will let you
neck and shoulders . . . feel them sag a concentrate on stepping down . . . Move
little . . . feel them sink . . . feel them heavy that finger when you have been able to get
and relaxed . . . Calm and relaxed . . . down.
Think of the muscles of your chest and Good . . . Now can you get down to
your abdomen . . . let them relax . . . the next step? . . . As you go down you
deeply relax . . . Now think of the muscles will become more relaxed . . . Calm and
of your legs . . . as you breathe out . . . let relaxed . . . You are doing very well . . .
your legs relax . . . Now think of your feet Move your index finger when you have
. . . Now think of your hands . . . as you stepped down.
breathe out . . . let your feet and hands That’s good . . . OK . . . Why don’t
relax . . . Calm and relaxed . . . Everything you try to step down on to the path? . . .
is heavy and relaxed . . . You are feeling You have done very well . . . We will only
good . . . You sink into the chair . . . You go as far at the path today . . . Try to step
have done very well . . . I am going to stop down on to the path . . . As you do . . . feel
talking for a minute . . . In the silence, yourself go even deeper into relaxation . . .
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 73
Heavy and sinking into the chair . . . Face of relaxation by focusing on breathing. In a
relaxed . . . Neck relaxed . . . Chest relaxed preliminary discussion it is necessary to
. . . Legs relaxed . . . See if you can step establish whether the patient is able to breathe
down on to the path . . . As you step down through the nose. If not, it is necessary to
you will get more relaxed than ever . . . modify the wording to detail breathing
Move that finger when you make it down through the mouth. In this discussion it will
to the path. also be necessary to determine whether the
Well done. You should feel very patient is capable of diaphragmatic breathing.
pleased with yourself . . . You have taken If not, a lesson will be necessary. Finally, it
control of your mind and your body . . . will be necessary to discover a happy event in
You are in control . . . Take a moment to the life of the patient. This is preferably an
explore the feeling of relaxation . . . take event in which the patient played an active
note that you have produced this state of part. The preferred event was marked by the
profound relaxation . . . Let me know patient’s feeling capable and appreciated. It is
when you have been able to get a good used as a visualization task and a means of
feeling about what you have achieved. making supportive statements.
OK, now we are going to start to come
back up . . . Slowly turn around . . . See the Please close your eyes and focus on your
steps in front of you . . . Keep hold of that breathing . . . breathe in through your nose
good feeling about yourself . . . First, step . . . Feel the air going into your nostrils . . .
back up one step . . . Feeling good . . . Calm Slow the flow down . . . Concentrate only
and relaxed . . . Now back to the next step on your breathing . . . Concentrate on your
. . . Holding on to that good feeling . . . nostrils . . . Feel the air cool and flowing
Now finally up to the top step . . . You have freely . . . Now let yourself relax . . . Think
done very well . . . You have taken control of the air going down your neck . . .
of your mind and body . . . Gradually let Flowing freely . . . Slow your breathing . . .
your eyes open . . . Hold on to that good Feel the air go into your chest . . . You can
feeling . . . Don’t move too fast . . . You relax . . . Feel your body heavy and relaxed
have been deeply relaxed . . . You have in the chair . . . As the air enters your body
been in control . . . You have done well. . . . Feel your tummy rise . . . Relax your
OK. How do you feel? chest . . . Let your chest be heavy . . .
When the air comes into your body . . . let
Script 2 your tummy rise . . . Your breathing is
This monologue demonstrates the initiation much slower now . . . Your tummy rises
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 74
very slowly . . . You can hardly feel it rise treatment of anxiety. Hypnosis is used in
. . . Relaxed all over . . . I will stop talking acute dentistry, burns and surgery. The term
for a minute and let you concentrate on hypnoanalgesia is mainly restricted to the pain
your slow relaxed breathing. insensitivity induced in such acute settings.
Great, you’re doing fine . . . You are in While the mainstay of chronic pain treatment
control . . . Check your body . . . If you is the same set of techniques that are used in
have tension anywhere . . . Let go . . . See if the treatment of anxiety, the specific
you can get the feeling of drifting . . . As if hypnoanalgesic techniques may be co-opted
you are floating . . . Drifting . . . Let go and from acute care. These specific techniques
drift. may provide some relief in problematic cases
Now get in touch with that time we and provide some refreshing variation in
were talking about . . . See yourself in that clinical practice.
situation . . . See the details . . . Let yourself The term hypnoanalgesia will be avoided
drift . . . Now get in touch with that here, as similar effects can be obtained in
feeling of success . . . Get that feeling of relaxed states other than hypnosis. An early
being pleased . . . Get that feeling of specific relaxation/hypnosis pain reduction
confidence . . . Things went well . . . Hold method commences with the creation of local
on to that feeling of success . . . Let numbness/analgesia in the hand. The relaxed
yourself drift . . . I am going to be quiet patient is asked to create the experience of
now for a minute and let you get those having a hand in a bucket of ice water and to
feelings flowing over you. produce a feeling of coldness progressing to
Good. Now, hold on to that feeling as numbness or deadness. The hand may then be
you come back . . . Gradually coming up moved to a particular site, and the patient is
. . . hold on to that feeling . . . Feeling calm asked to experience the numbness of the hand
. . . Feeling Good. passing to the second site. This method is
How do you feel now? complicated, involving a number of steps, any
of which may be a source of difficulty, and is
not recommended. It was perhaps popular
Relaxation treatment of pain
because the passing of analgesia from one
Relaxation (NIH, 1996), hypnosis (Lang et al, region to another was spectacular and held
2000) and meditation (Kaplan et al, 1993) some entertainment value. It is included here
have been shown to reduce pain. Reduction in because it has historical value and gives us an
chronic pain (Lewis, 1992) may be achieved idea of the possibilities.
using exactly the same techniques used in the An alternative method is to ask the patient
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 75
to create the experience of numbness as it The lessons of Ainslie Meares (1968) are
occurs with the injection of local anaesthetic. most useful in helping people with pain. He
To assist in the creation of the effect the patient pointed out that pain is a warning sign that the
can be asked first to experience the prick of a body is being harmed, but it is when the patient
needle and then a sting as if a bolus had been becomes emotionally distressed that pain
injected, and finally a slowly spreading becomes aversive and excessive. ‘Unless we react
numbness. This numbness can be produced at to it there is little or no hurt in the painful
any site, and the technique can be used to stimulus.’ He makes the point that when a child
supplement the pain relief of general relaxation. falls and is distressed, mother’s kisses on the
Another technique that has been used in the cheek markedly reduce the crying. Her kisses (to
management of acute pain (burns dressing, the cheek, not the knee) ease the emotional
surgery, dental work) is ‘projection of the body distress, not the nociceptive focus. Thus Meares
image’ to a distant location. The patient is points to the need for the patient to understand
asked to create the experience of the body part the nature of pain and to be confident that
(or even the whole body) floating away to a when emotional distress can be controlled (by
distant place. In preparatory discussion, the relaxation) there is no need to be, or possibility
therapist and patient agree that if a particular of being overwhelmed, by pain.
piece of anatomy is at a distant location, it Meares (1968) described a range of
cannot be ‘here’ and thus cannot be painful. reactions to pain, including depression and
Whether this mechanistic explanation is hostility. In keeping with his insight that the
necessary is doubtful; as has been mentioned, amount of hurt associated with pain is
any task that requires focused attention has the proportional to the associated emotional
ability to reduce the experience of pain. distress, he recommends that patients are
Visualizing a scene has been described helped to a philosophical response. ‘It can’t be
above as a means of inducing relaxation. It is helped, but I will get over it.’ Relaxation
also reported to be useful in acute pain exercises can assist in shaping this response.
situations, under the designation, ‘reduction Finally, Meares (1968) acknowledges the
of awareness by distraction’. We are not possibility of pain relief by the above-
usually aware of the touch of our clothes; mentioned methods, but favours the ‘feeling
thus, if we are distracted, we may not be fully of pain in its pure form’. He supplies us with
aware of nociceptive stimuli. The more able the knowledge that pain is a signal; and, in a
the patient is to focus and the greater detail state of relaxation, the patient is able to
that can be experienced, the better will be the experience pain as information rather than as
analgesic effect. an unbearable sensation.
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 76
you are moderately relaxed . . . Heavy in in control . . . You are calm and feeling
your chair . . . Slow your breathing . . . Get good . . . You are feeling fine . . . in spite of
ready and now down to four . . . Now you your pain . . . Calm and peaceful . . . You
are deeply relaxed . . . Calm and relaxed can accept your pain . . . You are doing
. . . Heavy and relaxed . . . Get ready and well . . . Stay feeling calm . . . Now
now come down to five . . . very deeply gradually come back up . . . and open your
relaxed . . . I will give you a minute to eyes.
make the last step down.
That’s good . . . You are able to control
The problem of non-
your mind and body . . . Now try to
imagine sitting or lying at the beach . . .
compliance
Calm and relaxed . . . take your time and Most patients are able to obtain some relief
see the blue of the water and the sky . . . from anxiety and chronic pain through
Calm and relaxed . . . waiting to be able to relaxation, hypnosis or meditation. However,
see the water and the sky . . . Are there any many do not persist with these techniques.
clouds in the sky? . . . If there are some This is surprising, given that the pain is ever
clouds . . . move the index finger of your present and other treatment options are
left hand . . . If there are no clouds, move problematic and offer little relief. While these
the index finger of your right hand. techniques may have a modest temporary
OK, there are some clouds . . . Now effect, they are endlessly repeatable.
see the sand . . . focus on the sand . . . Try The reasons why they are abandoned, why
to see some seaweed on the sand . . . You patients cease claiming these analgesic
are doing well . . . Deeply relaxed . . . Now benefits, include the facts that the techniques
try to feel the sun on your face . . . try to are time-consuming, require effort and
feel the warmth on your face . . . provide only partial relief. Further, chronic
concentrate on the feeling of the sun on pain is distressing and exhausting, making
your face. effort more difficult. Finally, these techniques
Now, think about your pain . . . Stay can be boring.
calm and relaxed . . . Your pain is a There is little awareness that patients with
message . . . Your pain is a message you chronic pain often discontinue these
don’t need . . . Stay calm and relaxed . . . techniques. Patients often do not offer this
Accept your pain as a nuisance . . . information because they have been ‘sold’ the
Something you don’t need . . . But techniques as solutions to the pain, and they
something you can live with . . . You are therefore feel ungrateful and embarrassed
670_Chronic Pain.ch.10 19/02/2002 9 34 am Page 78
attitudes, expectations and means of relating Where pain is due to psychological factors,
that were learnt in earlier relationships, it can be conceptualized as arising from
particularly those of the first few years of life. unconscious conflicts. For example, pain may
During the process of psychoanalysis the be a means of keeping a conflict from the
patient attributes to the analyst the conscious mind, or a manner of dealing with
characteristics of one or more important the guilt attached to a particular conflict. In
persons from the past, and eventually begins such circumstances, treatment using
to respond to him or her using unconscious psychoanalytic techniques could be applied.
attitudes and expectations from the past. Where pain has some physical basis but
Whenever evidence of transference emerges psychological difficulties are hampering
the analyst interprets or points out the recovery, psychoanalysis may be employed to
presumed origin of this material. There are reduce anxiety or depression and to improve
usually unconscious mechanisms within the interpersonal functioning. In such cases
patient that function to keep such conflicts improvement in pain and adjustment to
and attitudes from consciousness. These serve residual pain are features of a general
a defensive, homeostatic role. Commonly the improvement in self-understanding, the sense
interpretation is rejected; in psychoanalytic of self-worth and coping skills.
terminology, the interpretation is met with Psychoanalytic theory may be useful in
resistance. The resistance may then be understanding patients in a range of
interpreted, or exposed, by the analyst. When circumstances. For example, we may be able
the patient is able to accept an interpretation to detect the conflict underlying pain of
he or she is said to gain insight. Through psychological origin, or to recognize
serial insights the patient gains deep self- transference issues, when a patient responds to
understanding and is able to develop new helpful clinicians in an inappropriately
attitudes, expectations and means of relating. aggressive manner, which appears to have
origins in early life. Such understanding does
not lead automatically to psychoanalytic
Psychoanalysis in chronic pain
treatment, owing to practical issues such as
For a range of reasons, including the length cost or the unsuitability of many patients (for
and expense of training in psychoanalysis and example, patients need to have at least some
the length and expense of this treatment for ability to sustain effort and relationships).
individual patients, this form of treatment is Nevertheless, such understanding better
generally less available now than it was in the equips us to help such patients using
early to middle twentieth century. alternative methods.
670_Chronic Pain.ch.11 19/02/2002 9 35 am Page 84
Cognitive therapy (CT) and than the other way around (which may also be
cognitive behaviour therapy the case in certain circumstances). CT aims to
(CBT) correct errors in information processing as a
means of relieving emotional distress.
CT is usually a short-term treatment of 10 to Therapists explore the thinking style and
20 sessions, which are conducted once or, at habits of patients and offer and encourage the
most, twice per week. It is a system of use of logical perspectives and more adaptive
psychotherapy that aims at symptom removal responses. Where social withdrawal and other
rather than resolution of underlying conflicts, self-defeating behaviours have developed,
as in psychoanalysis and the related behavioural modification is also encouraged:
psychotherapies. CT is based on the theory examples include relaxation exercises and
that characteristic ‘errors in information assertiveness training.
processing’ occur in depression, anxiety, CT does not claim that errors of
personality disorder and other states of information processing are the sole or even the
emotional distress (Wright and Beck, 1996). initial causative feature of the syndromes of
These errors in information processing interest. The authors acknowledge the
have also been called ‘pathological importance of genetics, early life experiences,
information processing’, ‘cognitive distortions’ interpersonal conflict and other factors known
and ‘crooked thinking’ (Ellis, 1962). They do to have aetiological importance in mental
not arise from organic pathology, as do the disorders. Instead, CT is construed as a means
information processing or cognitive difficulties of treatment of certain symptoms, and as a
of dementia. Instead, these errors of helpful technique that can be used in
information processing relevant to CT are combination with medication (Simons et al,
more a matter of thinking style or habit. They 1984).
occur in response to environmental stimuli. CT is an expanding catalogue of
For example, if a person prone to depression techniques. Albert Ellis (1962), a pioneer in
makes a mistake at work, he or she might the field who coined the term ‘rational
think, ‘That just proves how dumb I am.’ The emotive therapy’ (RET), restricted his
person prone to anxiety, however, may avoid activities to disclosing ‘crooked thinking’ and
taking action, thinking, ‘If I make a mistake teaching logical thinking. Later workers added
they’ll think I’m absolutely stupid.’ behavioural techniques. Specific CT
Central to CT theory is that errors in approaches have been developed for the
information processing result in emotional treatment of depression (Beck et al, 1979),
distress and maladaptive behaviour, rather anxiety disorders (Beck et al, 1985),
670_Chronic Pain.ch.11 19/02/2002 9 35 am Page 87
personality disorders (Beck et al, 1990) and of how this may apply in chronic pain is taken
other conditions. from Turner and Romano (1990): a patient
Which particular techniques are included who thinks ‘I can’t take this any more’ is
under the CT umbrella is largely a matter of encouraged to more adaptive thinking, such as
personal opinion. With the addition of ‘Is it really true that I can’t deal with this? No.
behavioural components, some have used the It may be difficult, but I’ve done it before and
designation ‘cognitive behaviour therapy’ can again.’
(CBT) for this form of psychotherapy. There Coping skills is a range of techniques
is argument about the appropriateness of including relaxation, hypnosis and
subsuming age-old techniques such as meditation. ‘Coping self-statements’ may be
hypnosis and relaxation under the CT placed under the general heading of coping
heading, as this could be taken incorrectly to skills, or enjoy a separate heading. Examples
suggest that the clinician needs special CT from Turner and Romano (1990) include:
training to be qualified to deliver these ‘Relax’, ‘I can cope’ and ‘Focus on what you
services. have to do.’
CT has much to offer in the management
of the negative self-concepts and moods that
Cognitive therapy in chronic pain
may be associated with chronic pain and
All clinicians involved in the treatment of disability. CT and educational activities in
chronic pain provide accurate information to general help patients make the best possible
patients about the nature of chronic pain and adjustments to their situations.
encourage them to think logically and
constructively about their situation. A
Summary
particular example occurs when managing a
person with pain-related fear who is inactive Psychotherapy is a vast theoretical and service
and becoming disabled because of the landscape. Three points that represent
erroneous belief that pain indicates further different approaches have been described. All
structural damage. Appropriate interventions aim to reduce emotional distress.
are consistent with the CT approach. Psychoanalysis is a lengthy process that works
Current CT activities can be grouped to develop insight and resolution of
under two main headings: cognitive unconscious conflicts, thereby reducing
restructuring and coping skills. symptoms and encouraging growth of the
Cognitive restructuring is the correcting of personality. Supportive psychotherapy
errors in information processing. An example predominantly supports and encourages and
670_Chronic Pain.ch.11 19/02/2002 9 35 am Page 88
general emotional well-being of chronic pain Bloch S, Singh B. Understanding Troubled Minds.
Melbourne University Press, Melbourne, 1997;
patients and favourably influence the
296.
experience of pain to some extent, depending
Ellis A. Reason and Emotion in Psychotherapy. Lyle
on the personality and life circumstances of
Stuart, New York, 1962.
the individual and the nature of the pain.
Frank J. Persuasion and Healing. Williams and
Psychotherapy alone is rarely a satisfactory Wilkins, Baltimore, MD, 1961.
treatment of chronic pain (Pilowsky and
Ornstein A. Supportive psychotherapy: a
Barrow, 1990), and this chapter does not contemporary view. Clinical Social Work Journal
pretend to teach psychotherapy. However, 1986; 14: 14–30.
psychotherapy provides useful advice about Pilowsky I, Barrow C. A controlled study of
the productive patient–clinician relationship psychotherapy and amitriptyline used
individually and in combination in the
and central elements of therapy. The
treatment of chronic intractable, ‘psychogenic’
psychotherapeutic relationship is confiding pain. Pain 1990; 40: 3–19.
and empathetic. The patient and clinician
Shapiro D, Shapiro D. Meta-analysis of
agree on the therapeutic approach, exchange comparative therapy outcome studies: a
information and ensure that each understands replication and refinement. Psychological Bulletin
1982; 92: 581–604.
the other. Hope and the trial of new or
regained skills are encouraged, attempts are Sifneos P. Alexithymia: past and present. American
Journal of Psychiatry 1996; 153 (7 Suppl):
acknowledged. The therapist is a model and
137–42.
the therapist’s attitudes, beliefs and behaviour
Simons A, Garfield S, Murphy G. The process of
are learned by the patient. change in cognitive therapy and
psychopharmacology for depression: sustained
improvement over one year. Archives of General
Psychiatry 1984; 41: 45–51.
670_Chronic Pain.ch.11 19/02/2002 9 35 am Page 89
Fibromyalgia
Introduction
Fibromyalgia (FM) is at the severe end of the spectrum of
widespread pain. With broad diagnostic criteria, widespread
pain was observed in 11.2% of a section of the British
population (Croft et al, 1993). Fibromyalgia has been
observed in 2% of a section of the North American
population (Wolfe et al, 1995; Lawrence et al, 1998).
FM (and its forerunner, fibrositis) has been a contentious
condition. Some authorities view the condition as a variant of
anxiety, and point out that panic disorder was, for many
decades, considered to be a heart condition (Skerritt, 1983).
However, The American College of Rheumatology adopted
diagnostic criteria in 1990 (Wolfe et al, 1990). These include
widespread pain (defined as pain in the left and right sides of
the body as well as above and below the waist), for at least 3
months. Axial pain (defined as pain in the cervical spine,
670_Chronic Pain.ch.12 19/02/2002 9 35 am Page 92
anterior chest, thoracic spine or low back) early life and in the previous year (Anderberg
must be present. In addition, the patient must et al, 2000a); this does not, however, resolve
report pain in at least 11 of 18 designated sites questions of cause and effect.
on digital palpation. While there may be The prognosis is poor. At 3-year follow-
problems with these criteria in so far as they up, only 3% of patients were found to be free
are restrictive, they have allowed of all pain (Felson and Goldenberg, 1986).
standardization of research. Current treatment is far from satisfactory.
Additional, commonly occurring FM is commonly associated with
symptoms/conditions, which are however not psychiatric disorders. Macfarlane et al (1999)
diagnostic criteria, include fatigue and non- found that over 25% of those with generalized
restorative sleep, irritable bowel syndrome pain (not precisely FM) had some
(IBS), Raynaud’s syndrome-like symptoms, concomitant mental disorder, most commonly
headache, subjective swelling, paraesthesia, depression. Anderberg et al (1999) found
palpitations, significant functional disability, higher figures for FM: 37% suffering
psychological distress (including depression or depression and 16% suffering anxiety.
anxiety) and cognitive complaints (particularly Depression in FM is independent of the
memory problems and inability to cardinal features of pain severity and
concentrate). hypersensitivity to pressure pain (Okifuji et al,
The aetiology of FM is unknown. Several 2000); however, it may contribute to the
mechanisms may be involved. A high inability fully to perform the activities of daily
prevalence in the female relatives of FM life.
patients suggests a genetic vulnerability FM patients tend to feature high levels of
(Buskila & Neumann, 1997). In the related harm avoidance (Anderberg et al, 1999) and a
condition of somatization, genetic factors strong tendency to catastrophizing (Hassett et
accounted for 25–50% of the total variance in al, 2000). There is evidence that unexplained
reports of symptoms, whereas familial and physical symptoms (which include FM) are
environmental effects accounted for virtually associated with abnormal attachment style
no variance (Kendler et al, 1995). Onset often (Taylor et al, 2000). This suggests that
appears to follow physical or psychological patients with poorer relationships will have
stress. The majority (70%) of patients identify poorer social and emotional supports and are
both physical and psychosocial factors more likely to present with such symptoms to
(Neerinckx et al, 2000). Compared to healthy the doctor.
individuals, there is evidence that those with
FM have suffered more stressful events in
670_Chronic Pain.ch.12 19/02/2002 9 35 am Page 93
Fibromyalgia 93
Overlap Pathophysiology
There is discussion about symptom overlap While the aetiology of FM remains uncertain,
between FM and chronic fatigue syndrome a range of pathophysiological phenomena
(CFS), temporo-mandibular joint disorder have been reported. Which (if any) are
(TMD), somatoform disorder and other primary and which are epiphenomena remains
medically unexplained syndromes. to be determined.
Some special interest groups want CFS to Naturally, the early studies focused on the
be accepted as separate condition. The structure of muscle. Fibres were sometimes
evidence to decide this point is still being described as ‘moth-eaten’ or in similar terms.
accumulated. However, such changes have not been
Clauw and Chrousos (1997) point out observed in controlled studies, and FM is no
that CFS has severe chronic fatigue as a longer considered to be a muscular disorder
necessary diagnostic feature, which must occur (Sims, 1998).
in the presence of four of eight symptoms The pain threshold of peripheral structures
(myalgia, arthralgia, sore throat, tender nodes, and viscera is globally diminished. Parallel
cognitive difficulty, headache, post-exertional phenomena have been demonstrated for
malaise, sleep disturbance), and that five of pressure, heat, cold and electrical stimulation
these are pain-based. FM, however, has pain (Dessein et al, 2000). These observations, in
as the single necessary and sufficient feature the absence of detectable peripheral
(albeit with particular conditions), and is pathology, have moved attention to the
frequently accompanied by fatigue, sleep central nervous system.
disorder, cognitive difficulties, headache, post- Somatosensory-induced
exertional malaise and sleep disturbance. electroencephalographic potentials in FM are
In a recent study 58% of females and 80% significantly different from those of normal
of males with fibromyalgia met the full criteria individuals, and objectify the subjective
for CFS (White et al, 2000). Thus significant reports of patients, indicating a lower pain
overlap between FM and CFS would seem to threshold. There is a significant amplitude
be beyond question. enhancement of cerebral potentials in
Also, FM and CFS have similar comorbid response to painful CO2-laser stimulation
illnesses/conditions, including IBS, interstitial (Gibson et al, 1994; Lorenz et al, 1996).
cystitis and generalized pain sensitivity. The Transcranial magnetic stimulation (TMS)
lifetime rates of IBS are 77% in FM and 92% was applied to the motor cortex of FM
in CFS (Aaron et al, 2000). patients in various conditions (e.g. single
670_Chronic Pain.ch.12 19/02/2002 9 35 am Page 94
pulse, paired pulse, relaxed and contracted in blunted secretion of thyrotropin and
muscles) (Salerno et al, 2000). Responses were thyroid hormone release in response to
captured from different sites and a range of thyroid-releasing hormone (TRH) (Clauw
calculations were performed. Motor cortical and Chrousos, 1997).
dysfunction was demonstrated in both On examining the HPA axis, the 24-hour
excitatory and inhibitory mechanisms. levels of free cortisol in urine are low and
However, similar findings were obtained from there is a blunted cortisol response to
rheumatoid arthritis patients, and they may be exogenous CRH (Crofford et al, 1994). It
a universal feature of chronic pain disorders. may be relevant that 24-hour levels of free
The autonomic system is impaired. The cortisol in urine are also significantly lower in
sympathetic system may manifest diminished CFS than in normal controls (Cleare et al,
baseline tone, lability and a reduced 2001). Returning to fibromyalgia, insulin-
responsiveness to stressors. Raj et al (2000) induced hypoglycaemia has been reported to
studied the heart rate over 24-hour periods both increase (Griep et al, 1993) and decrease
and during tilt-table experiments. Qiao et al (Alder et al, 1999) adrenocorticotropic
(1991) studied the conductance and blood hormone (ACTH) release. Very low levels of
flow of palmar skin during acoustic IGF-1 occur in one-third of FM patients, and
stimulation and cold pressor tests. The results may be specific to FM (Bennett et al, 1992).
of these studies suggest increased activity of The immune responses are frequently
cholinergic and decreased activity of abnormal. Low natural killer cell numbers and
adrenergic components of the peripheral function have been reported (Caro et al,
sympathetic nervous system. 1993). However, the enhanced humoral
Non-restorative sleep is reported by 75% immune responses that have been
of FM patients (Wolfe, 1989). There is a well- demonstrated in CFS do not appear to be a
established alpha wave intrusion during the feature of FM.
non-REM sleep stages 3 and 4 (Moldofsky et Alterations in neurotransmitters and
al, 1975). receptors are reported. The cerebrospinal fluid
Endocrine abnormalities have been (CSF) has a threefold increase in substance P
detected in hypothalamic–pituitary–adrenal (SP: Vaeroy et al, 1988) and decrease in
axis (HPA) function, in low levels of growth norepinephrine (NE: Russell et al, 1992a).
hormone (GH) and insulin-like growth Serum serotonin and tryptophan are decreased
factor-1 (IGF-1 which is produced in response and the density of serotonin receptors on
to GH and has many biological activities), in circulating platelets is increased (Russell et al,
varying degrees of gonadal hypofunction, and 1992b).
670_Chronic Pain.ch.12 19/02/2002 9 35 am Page 95
Fibromyalgia 95
There is evidence of decreased regional have been found to improve the sleep disorder
cerebral blood flow in women with without concomitant improvement in pain or
fibromyalgia. Comparing FM with healthy fatigue.
women, Montz et al (1995) found that those Sleep has not been extensively studied in
with FM demonstrated significantly lower FM, and it remains unclear whether sleep
regional cerebral blood flow (rCBF) of the disorder is a cause or consequence of the
cortex and thalamic and caudate nuclei. While condition. However, important pieces of the
this was a small study and replication is puzzle include the facts that (1) low ILGF-1
awaited, it points toward central changes in levels may be related to sleep pathology, as
FM. GH secretion occurs during stage 4 sleep
(Clauw and Chrousos, 1997), and (2)
serotonin modulates stage 4 sleep (Moldofsky,
Speculation
1982).
As has been mentioned, which (if any) of the
pathophysiological findings listed above are
primary and which are epiphenomena remains
FM as a consequence of CNS
sensitization
to be determined. Nor is it always clear in
which direction the biological events are The pain threshold of a range of modalities is
occurring. Nevertheless, attempts have been lower in FM than in normal controls. This
made to organize the existing information. has been objectified using evoked potentials.
This leads, as no abnormality with muscle has
been detected, to speculation regarding altered
FM as a sleep disorder
CNS sensory information processing. The
The hypothesis that FM is the result of sleep term ‘sensitization’ is used in such
disorder is suggested by the frequent clinical circumstances, and is defined as an increased
finding of disturbed and non-restorative sleep, excitability of spinal and supraspinal neural
and fatigue. It is supported by the findings of circuits.
alpha wave intrusion during the non-REM Sensitization develops consequent to
sleep stages 3 and 4 (Moldofsky et al, 1975) ongoing nociceptive input. Various forms
and the observation that disrupting the non- have been identified. One involves wide
REM sleep of normal subjects leads to dynamic range (WDR) neurones; these are
muscular aching and generalized tender points second-order dorsal horn neurones that
(Moldofsky and Scarisbrick, 1976). However, respond to either non-nociceptive or
temazepam, melatonin and other hypnotics nociceptive input. When WDR neurones
670_Chronic Pain.ch.12 19/02/2002 9 35 am Page 96
become sensitized, consequent upon ongoing systems in FM. A large number of reviews
nociceptive input, they respond to all input, support the stress response dysregulation
including non-nociceptive, as though it is hypothesis (Clauw and Chrousos, 1997;
nociceptive. Thus light touch or movement Dessein et al, 2000; Heim et al, 2000; Neek,
may cause pain (Gracely et al, 1992). 2000; Neek and Croford, 2000; Torpy et al,
Once central sensitization has occurred, 2000).
this mechanism could sustain painful muscles. Corticotropin-releasing hormone (CRH) is
It is possible that associated painful organ- a principal modulator in the stress response.
specific syndromes such as IBS have a similar The CRH neurones, which are mainly localized
basis. As to the initiating event, FM is often in the paraventricular nucleus of the
consequent upon insults such as rheumatoid hypothalamus, are widely distributed
arthritis and osteoarthritis and physical throughout the CNS. CRH has a profound
trauma (it may also have roots in effect on the function of the endocrine system.
psychological trauma). It also mediates arousal and stress-induced
As has already been noted, in FM, the CSF analgesia via beta-endorphin and excitatory
SP may be three times the normal. This is amino acid-secreting neurones that project
important, as SP is believed to be a major from the hypothalamus to the brain stem and
factor in the process of central sensitization spinal cord. It has input to the sympathetic
(Watkins et al, 1994). system, which exerts antinociception via the
spinal descending inhibitory pathways with the
release of noradrenaline, serotonin and
FM as dysregulation of the stress
neuropeptide Y at the dorsal horn.
response
Thus the biological consequences of low
This model posits that FM is a consequence of CRH state are the opposite of that seen in
dysregulation of the human stress response, acute stress and are similar to those noted in
which is mediated predominantly by the fibromyalgia and fatigue states: hypoarousal or
endocrine and sympathetic systems. It has fatigue and diffusely increased peripheral and
been argued that while the stress response was visceral nociception (generalized pain). Also,
adaptive during human evolution, it is along with the dysregulation of the autonomic
generally maladaptive for man in modern system may come dysregulation of smooth
society, who rarely faces threats to survival muscle and cardiovascular function, which
(Meaney et al, 1993). underpin at least some of the organ-specific
Mention has been made of reported syndromes (IBS, palpitations, Raynaud) that
impairments of the autonomic and endocrine occur in this spectrum of disorders.
670_Chronic Pain.ch.12 19/02/2002 9 35 am Page 97
Fibromyalgia 97
response dysregulation and the sleep restructuring, aerobic exercise and stretching,
disturbance, and may serve to integrate these activity pacing and patient and family
hypotheses. education. It is difficult for the clinician to
Serotonin in serum and SP in CSF may determine which of these elements is or are
both be abnormal in FM. Both of these agents responsible for any improvement.
can influence the endocrine system function Exercise programmes have produced
and play a role in CNS sensitization. Thus a significant reductions in pain and tender point
neurotransmitter hypothesis may warrant count (Martin et al, 1996). Sleep and level of
consideration in the future. fatigue are unaffected. Long-term benefits,
however, have not been demonstrated. In
spite of the initial improvement, patients have
Treatment
ceased to exercise (Wigers et al, 1996).
The response to treatment is poor. Most Courses of cognitive behaviour therapy
patients have used over-the-counter analgesics that aim to reduce the use of unhelpful
and a range of alternative treatments, such as behaviours such as excessive rest and over-
vitamins and prayer. Many have also used monitoring of bodily symptoms and
acupuncture (which is now being unhelpful attributions, and to increase
incorporated into mainstream medicine) with confidence in the ability to manage
some benefit (Berman et al, 1999). symptoms, and that teach relaxation
In this setting of relative therapeutic techniques, have produced promising results
impotence, it is especially important to attend (Goldenberg et al, 1992). Unfortunately,
to any concomitant psychiatric disorders. These long-term benefits have not been proved
can be anticipated in at least one-quarter of FM (Richards and Cleare, 2000).
patients, and respond to standard treatments. Goossens et al (1996) compared the
outcome of three treatment streams: (1)
educational; (2) education plus cognitive
Exercise, education and CBT
therapy; and (3) the waiting list. Both
Exercise, education and CBT have the treatment groups provided benefits. However,
advantage of being relatively free of side- there was no significant difference in
effects and involving the patients in the outcomes between the treatment groups. The
treatment process. There is some evidence of addition of a cognitive component to the
efficacy, but less of prolonged benefit. Many educational intervention led to significantly
treatment programmes include combinations higher health-care costs, but no additional
of relaxation, meditation, cognitive clinical benefit.
670_Chronic Pain.ch.12 19/02/2002 9 35 am Page 99
Fibromyalgia 99
Fibromyalgia 101
Griep E, Boersma J, de Kloet E. Altered reactivity of Martin L, Nutting A, Macintosh B, et al. An exercise
the hypothalamic–pituitary–adrenal axis in the program in the treatment of fibromyalgia. Journal
primary fibromyalgia syndrome. Journal of of Rheumatology 1996; 23: 1050–3.
Rheumatology 1993; 20: 469–74.
Meaney M, Bhatnagar S, Larocque S, McCormick
Hassett A, Cone J, Patella S, Sigal L. The role of C, et al. Individual differences in the
catastrophizing in the pain and depression of hypothalamic–pituitary–adrenal stress response
women with fibromyalgia syndrome. Arthritis and the hypothalamic CRH system. Annals of
and Rheumatism 2000; 43: 2493–500. the New York Academy of Sciences 1993; 697:
70–85.
Heim C, Ehlert U, Hellhammer D. The potential
role of hypocortisolism in the pathophysiology Millea P, Holloway R. Treating fibromyalgia.
of stress related bodily disorders. American Family Physician 2000; 62: 1575–82,
Psychoneuroendrocrinology 2000; 25: 1–35. 1587.
Hrycaj P, Stratz T, Mennet P, Muller W. Moldofsky H. Rheumatic pain modulation
Pathogenic aspects of responsiveness to syndrome: the interrelationships between sleep,
ondansetron (5HT type 3 receptor antagonist) central nervous system serotonin, and pain.
in patients with primary fibromyalgia syndrome Advances in Neurology 1982; 33: 51–7.
– a preliminary study. Journal of Rheumatology
Moldofsky H, Scarisbrick P. Induction of
1996; 23: 1418–23.
neurasthenic musculoskeletal pain syndrome by
Kendler K, Walters E, Truett K, Heath A, Neale M, selective sleep stage deprivation. Psychosomatic
Martin N. A twin-family study of self-report Medicine 1976; 38: 35–44.
symptoms of panic-phobia and somatization.
Moldofsky H, Scarisbrick P, England R, Smythe H.
Behavior and Genetics 1995; 25: 499–515.
Musculoskeletal symptoms and non-REM sleep
Lawrence R, Helmick C, Arnett F, et al. Estimated disturbance in patients with ‘fibrositis
prevalence of arthritis and selected syndrome’ and healthy subjects. Psychosomatic
musculoskeletal disorders in the United States. Medicine 1975; 37: 341–51.
Arthritis and Rheumatism 1998; 41: 778–99.
Montz J, Bradley L, Modell J, Alexander R, Trian-
Leventhal L. Management of fibromyalgia. Annals of Alexander M, Aaron L, et al. Fibromyalgia in
Internal Medicine 1999; 131: 850–8. women. Abnormalities of regional cerebral
blood flow in the caudate nucleus are associated
Lorenz J, Grasedyck K, Bromm B. Middle and long
with low pain threshold levels. Arthritis and
latent somatosensory evoked potentials after
Rheumatism 1995; 38: 926–38.
painful laser stimulation in patients with
fibromyalgia syndrome. Electroencephalography Neek G. Neuroendocrine and hormonal
and Clinical Neurophysiology 1996; 1000: perturbations and relations to the serotonergic
165–8. system in fibromyalgia patients. Scandinavian
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Macfarlane G, Morris S, Hunt I, Benjamin S et al.
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fibromyalgia. A 4.5 year prospective study. The American College of Rheumatology 1990
Scandinavian Journal of Rheumatology 1996; 25: criteria for the classification of fibromyalgia.
77–86. Arthritis and Rheumatism 1990; 33: 160–72.
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Rheumatic Diseases Clinics of North America The prevalence and characteristics of
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and Rheumatism 1995; 38: 19–28.
Wolfe F, Smythe H, Yunus M, Bennett R, et al.
670_Chronic Pain.ch.13 19/02/2002 9 36 am Page 105
Headache
Headache 107
Also there is the danger of drug dependence, the migraine is of mild or moderate severity.
particularly where control is difficult. Finally, Like all migraine regimens, it is most effective
there is evidence that these drugs, taken over when commenced early.
time, may actually cause headache.
Pethidine, which is frequently sought and Aspirin (900 mg) or paracetamol
provided, has the additional disadvantage of (1000 mg) plus
having a metabolite (norpethidine) that is metoclopramide (10 mg) or
neurotoxic and a strong convulsant (Hassan et prochlorperazine (5 mg).
al, 2000).
The analgesic can be repeated every 4 hours.
Headache 109
there is insufficient response, by diazepam repeated only once, after one hour, if there
5 mg by mouth. has been no improvement.
e. Naproxen (500 mg) is available as a
2. Regimen Two: NSAID or 5-HT1D agonist suppository.
plus antiemetic
This regimen is appropriate as the routine 3. Regimen Three: Antiemetic plus dopamine
treatment where the patient has, in the past, blockade
failed to achieve satisfactory results with This is appropriate treatment where Regimen
Regimen One. It can also be implemented as a One has failed and the doctor is able to
second-wave treatment if there is no sign of provide a home visit.
improvement with the application of Regimen
One. Metoclopramide 10 mg imi plus
chlorpromazine 50 mg orally or imi.
Naproxen (1000 mg, oral) or sumatriptan
(50–100 mg, oral) plus an antiemetic, as Points to remember:
above. a. In pregnancy, metoclopramide may be
used only in the last trimester.
Naproxen can be repeated once, after 4 hours. b. Chlorpromazine can be used throughout
Sumatriptan (50 mg) can be repeated after pregnancy and can be used alone in the
one hour; administration above 100 mg offers first two trimesters. There is little point
no additional benefit. substituting prochlorperazine for
metoclopramide in the first two trimesters,
Points to remember: as prochlorperazine and chlorpromazine
a. Sumatriptan is contraindicated in are from the same drug family
pregnancy and where there are risk factors (phenothiazines).
for cardiovascular or cerebrovascular c. Metoclopramide is given by imi at this
accident. stage of the episode irrespective of
b. Naproxen is contraindicated where there vomiting. It reverses gastroparesis and
are enteric ulcers or bleeding disorders. reduces nausea.
c. Sumatriptan is commenced with the onset d. Chlorpromazine given by imi is
of pain, not during the aura. uncomfortable and may (rarely) lead to a
d. Sumatriptan (6 mg) is also available as a sterile abscess. These are relatively low-
patient- or professional-administered priority issues at this stage of severe
subcutaneous injection. This can be migraine. If vomiting is not a major
670_Chronic Pain.ch.13 19/02/2002 9 36 am Page 110
Headache 111
Points to remember:
Tension-type headache
a. Contraindications: peptic ulceration, liver
or kidney disease and coagulation Tension headache is the most common form
disorder/treatment. of headache. It is more common in females,
b. Side-effects: erosive gastritis, diarrhoea, and onset may be in middle life. Chronic
fluid retention, haematological anxiety or depression is frequently present.
complications. Tension headache is usually bilateral, but
d. For migraine associated with may occur on one side. It does not always
menstruation: naproxen for one week occur in the same location. In order of
before through to one week after frequency it occurs in occipital, parietal,
menstruation. temporal and frontal regions. It is described as
e. Where erosive gastritis complicates dull, aching, full or tight; often as if the head
successful prophylaxis, consider combining were encircled by a tight band. There may be
naproxen with a proton pump inhibitor throbbing. Sleep is usually not disturbed, but
such as omeprazole 20 mg daily. the headache may be noticed soon after
waking. There may be grinding of the teeth
and tenderness around the head.
The patient and the doctor A thorough history and physical (including
In the management of migraine, the patient neurological) examination is mandatory. The
and the doctor must work as a team. There aim is not only to exclude other diagnoses, but
may also be other team players, including to confirm the diagnosis of tension-type
family members, a psychologist, employers headache. In the physical examination a
and doctors from various fields. manual examination of pericranial muscles
The patient should keep a headache diary may identify tender points (manual pressure
670_Chronic Pain.ch.13 19/02/2002 9 36 am Page 113
Headache 113
Headache 115
Headache 117
texture, tone, or response to active and with paracetamol, NSAIDs or tramadol (up to
passive stretching and contraction. 400 mg/day). Tramadol may cause
• Abnormal tenderness of neck muscles. gastrointestinal side-effects and sweating, and
D. Radiological examination reveals at least should be used with caution in combination
one of : with serotonin-enhancing antidepressants,
• Movement abnormalities in flexion and because of the potential for the serotonin
extension syndrome (characterized by restlessness,
• Abnormal posture myoclonus, diaphoresis, tremor and mental
• Fractures, congenital abnormalities, status changes, such as confusion).
tumours, RA, or other distinct Continuous use of analgesics should be
pathology (not spondylosis or avoided, owing to the danger of worsening the
osteochondrosis). headache. Opioid substances are best avoided.
A trial of TCAs (amitriptyline 25–50 mg/day)
is worthy of consideration (adverse effects are
Management
mentioned above).
Causes should be identified and treated.
Symptomatic pharmacological, surgical and
chiropractic treatments do not produce lasting References
relief. Physiotherapy, muscle relaxation and Adams R, Victor M, Ropper A. Principles of
psychotherapy may provide temporary relief. Neurology, 6th edn. McGraw-Hill, New York,
1997.
It has been claimed that ipsilateral
Anderson C, Frank R. Migraine and tension
blockades of the C2 root of the occipital nerve
headache: Is there a physiological difference?
may allow differentiation between headache Headache 1981; 21: 63–GGG.
due to irritation of the C2 nerve root and
Bonica J. The Management of Pain, 2nd edn. Lea &
primary headache, such as migraine and Febiger, Philadelphia, 1990.
tension-type headache. However, the effect is Gobel H, Edmeads J. Disorders of the skull and
short-lived and the differentiation can be cervical spine. In: Olesen J, Tfelt-Hansen P,
achieved on history (Gobel and Edmeads, Welch K (eds) The Headaches. Lippincott
Williams and Wilkins, Philadelphia, 2000;
2000).
891–8.
Craniocervical dystonia is a disorder that
Hassan H, Bastani B, Gellens M. Successful
calls for special skills and experience, treatment of normeperidine neurotoxicity by
including the use of intramuscular injection of hemodialysis. American Journal of Kidney Disease
botulinum, thalamotomy and nerve resection. 2000; 35: 146–9.
Symptomatic treatment may be achieved IHS (Headache Classification Committee of the
670_Chronic Pain.ch.13 19/02/2002 9 36 am Page 118
brain changes, and raise the possibility that pain still have symptoms at three months
sensitization may occur. (Frymoyer et al, 1983), at least 10% report
The presence or absence of neurological persistent symptoms at one year, and 25–50%
symptoms is a straightforward and useful report relapse within one year (Croft et al,
distinction. Sciatica may compound back pain 1998). This relatively small group of patients
and is usually associated with disc herniation, with chronic pain accounts for the greater part
but may also accompany other pathology, of disability, compensation and public costs in
including spinal stenosis and degenerative general.
bony conditions (Atlas and Deyo, 2001).
The non-mechanical conditions can be
The diagnostic process
divided into those that directly involve the
spine, such as neoplasia, infection and The assessment of back pain is daunting, as
inflammatory arthritis, and those that involve the differential diagnosis is extensive and
other systems, such as vascular disease and includes serious progressive conditions.
diseases of pelvic, renal and gastrointestinal Guidelines have been developed that protect
organs. These are all uncommon (Deyo et al, both the patient and the doctor (Bigos et al,
1992). 1994). The first task is to identify the serious
progressive conditions and investigate and
refer as appropriate. A thorough history and
Clinical course of benign back physical examination, taking account of a
pain and sciatica short list of symptoms, ‘red flags’, will achieve
The clinical course of the serious progressive this end with reasonable sensitivity and
conditions will depend on the nature of the certainty (Deyo et al, 1992).
specific condition. Mechanical problems are
by far the most common causes of back pain, Red flags
and the majority are non-specific and self- 1. Recent severe trauma
limiting (Atlas and Deyo, 2001). Seventy-five 2. Weight loss, night sweats, fever
to 90% of such cases improve in one month 3. Past history of carcinoma, steroids, IV
(Croft et al, 1998) and more than 50% of drug use
sciatica cases improve in six weeks (Andersson 4. Severe night pain
et al, 1983). 5. Structural deformity
The above figures are encouraging, and 6. Progressive neurological deficits
support the conservative approach. 7. Inflammatory character pain
Nevertheless, at least 5% of those with back 8. Features of cauda equina syndrome
670_Chronic Pain.ch.14 19/02/2002 9 36 am Page 122
(urinary retention, saddle anaesthesia, range of circumstances, but this can usually be
bilateral neurological symptoms and signs) discussed with, and performed on the way to,
the specialist. When a red flag condition is
Not considered a red flag, but worth suspected, it is reasonable to schedule further
remembering is the fact that complaints of visits and keep the case under close review
back pain in the presence of normal (Bogduk, 1999).
movements and the absence of tenderness
suggest a visceral or vascular source of pain. In
Special investigations
practice, most of the red flags noted by
clinicians prove to be false positives; but It is important to order special investigations
caution is recommended. only when the results will influence treatment.
The physical examination should Imaging studies may not be helpful, as
commence with the patient standing and findings are poorly associated with symptoms.
unclothed. The important features are The most common causes of nerve root
posture, flexibility and tenderness. Straight-leg irritation, herniated disc and spinal stenosis
raising in lying is a good screening test for cannot be demonstrated with plain
nerve-root complications. A history of sciatica radiographs.
or straight-leg raising limited by pain to less CT and MRI studies should be ordered
than 60 degrees calls for a more detailed when the history and examination strongly
neurological examination of the lower limb. suggest a serious progressive disorder such as
Full details are available in texts on physical cauda equina syndrome, infection or tumour.
examination and neurology. In 98% of cases, When sciatica is probably due to a herniated
disc herniation involves the L5 and S1 nerves disc or spinal stenosis, and neurological signs
(Spangfort, 1972). Screening for L5 pathology are slight, early imaging is unnecessary, as
includes extension of the great toe and patients can be expected to recover with
walking on the heels, and loss of sensation on conservative management (Atlas and Deyo,
the dorsum of the foot. Screening for S1 2001). If improvement is slow with
pathology includes walking on the toes, conservative treatment, imaging studies
decreased sensation on the lateral aspect of the should be conducted. However, in chronic
sole, and reduced ankle reflex. back pain, extensive evaluations usually show
When there is strong evidence of a serious no surgically correctable lesions (Frymoyer,
progressive condition, immediate referral to a 1988).
specialist is appropriate. Whether special The patient may have expectations that
investigations are conducted will depend on a imaging will be performed. When
670_Chronic Pain.ch.14 19/02/2002 9 36 am Page 123
appropriate, it will be possible to reassure the al, 1995) and sciatica (Vroomen et al, 1999),
patient, and not ordering special return to usual activities has produced better
investigations may reassure that this is a outcomes than formal bed rest. It is
benign condition, familiar to the doctor. recommended that bed rest should be
Alternatively, it may not be possible to retain available as necessary and that activities that
the confidence of the patient without promote pain should be avoided.
performing some screening tests. It is not In the acute situation, the patient is in
uncommon to encounter patents who have pain and movement makes it worse. This is a
had repeated imaging studies only months or most distressing situation. The patient fears
even weeks apart, sometimes ordered by the the pain and fears that it will not be relieved
same doctor. Unless there are excellent and may even get worse, and further, that an
indications that change has occurred, repeat inability to perform the usual duties will have
studies cannot be justified. dire financial and social consequences for the
Routine laboratory tests are not needed. individual and the family. Fear of pain and
When other than benign mechanical movement is a major cause of chronicity
conditions are considered, erythrocyte (Croft et al, 1995), and has been discussed at
sedimentation rate (ESR), full blood count length in an earlier chapter. Thus the
and urinalysis are useful and relatively importance of early reassurance, an
inexpensive screening tests. Testing for the explanation of the nature of the condition and
HLA-B27 antigen has been useful in an exposition of the rationale of treatment
suspected ankylosing spondylitis. cannot be overemphasized.
Nuclear medicine and clinical Psychosocial factors frequently play a role
neurophysiology studies are better conducted in the persistence of back pain and disability.
in collaboration with a specialist. Accordingly, experts recommend identifying,
early in the acute stage, those patients with
psychosocial risk factors, in the hope that
Management in the acute
appropriate management will prevent the
stage
chronic condition. While this approach makes
The conservative approach emphasizes the sense and guides modern management, the
need for reassurance, and education of the study has not yet been performed that
patient regarding the nature of the condition substantiates the approach. It is relevant,
and its probable prognosis, and the however, that studies of rapid return to usual
opportunity for recovery. Extended bed rest is activities have had favourable outcomes. This
unhelpful. In both back pain (Malmivaara et process protects income, status and self-
670_Chronic Pain.ch.14 19/02/2002 9 36 am Page 124
esteem. It also helps to avoid conflict between unacceptably slow and psychosocial factors
patient, employer and insurer, and can be excluded as influential factors. While
resentment, anger and protracted legal battles. going to surgery too soon should be avoided,
Further, early return to work is associated delaying herniated disc surgery beyond 12
with less use of problematic medication, and weeks has been found to compromise
consequently, less risk of drug-use outcome (Weber, 1978). However, no more
complications. than 5 to 10 per cent of patients with
Other risk factors for persistent symptoms unremitting sciatica require operation
include a history of painful disorders, (Frymoyer, 1988). One study found that
depression, personality disorder, substance surgical treatment of lumbar disc herniation
abuse and current litigation and dissatisfaction produced a better functional ability and fewer
with work (Andersson et al, 1983; Deyo and symptoms than non-surgical management at
Diehl, 1988). Psychiatric, social work and one and two years, but that this was no longer
occupational therapy assessments should be evident at four and ten years (Weber, 1978).
conducted as appropriate. Psychiatric Physical treatments such as spinal
disorder, such as depression, should be manipulation, facet joint injection, epidural
vigorously treated. For the patient who finds steroid injection and ligamentous injection
work unrewarding, it may be possible for the and acupuncture are said to be of value, but
employer to provide alternative, more others claim efficacy has yet to be proved
satisfying duties. The occupational therapist (Atlas and Deyo, 2001).
may choose to take part in such negotiations.
Medication in the acute stage should be
Management of the chronic
limited, whenever possible, to non-steroidal
stage
anti-inflammatory drugs (NSAIDs), mild
analgesics such as paracetamol, and tricyclic Typically, patients with chronic back pain
antidepressants. When stronger analgesics are have suffered a benign mechanical problem.
necessary, non-addictive tramadol may have a Some have received back surgery but have
place. Avoidance of potent opioids and continued to suffer pain and disability. It is
benzodiazepines, whenever possible, will help important to treat existing mechanical
to prevent addiction and iatrogenic problems, but it is unwise to pursue a physical
complications. lesion relentlessly.
Referral for specialist consultation is As emphasized above, it is important to try
appropriate when there is good evidence of to identify those cases at risk of developing
serious progressive disorder or recovery is chronic problems and to take preventive
670_Chronic Pain.ch.14 19/02/2002 9 36 am Page 125
action. This is the theoretical ideal, which can education in the short term, and may be
be difficult to achieve in practice. Psychiatric superior to acupuncture at one-year follow-up
consultation is indicated, and existing (Cherkin et al, 2001).
psychiatric disorders should be treated. Chronic pain may be helped by
In the chronic stage, efforts to reassure and medication. The patient needs to understand
educate the patient regarding the role of fear and accept that medication can usually
of pain and movement in perpetuating the provide moderate symptomatic relief, but that
condition should be redoubled. Patients often complete eradication of pain is unlikely. Side-
believe that pain is an indication that their effects frequently cause problems; some
body is undergoing further damage, and this information on reducing side-effects can be
discourages them from any activity. found in the final chapter on
Consequently, they lose muscle strength, joint Pharmacotherapy. It is better, when possible,
flexibility and aerobic fitness, which further to avoid opioid use because of the problems of
increases the likelihood of experiencing pain. tolerance and addiction.
Patients need to learn that while acute pain Symptoms accompanying chronic pain
indicates damage and serves to immobilize the include fear (anxiety), depression, insomnia
injured part, chronic pain does not indicate and irritability. It is often very difficult, in
new damage – it serves no useful purpose, and particular cases, to disentangle and make
is, in fact, maladaptive, as it discourages return definitive statements about these symptoms.
to normal function. Patients are encouraged The most parsimonious approach is to regard
gradually to increase their daily activity. them as components of a depressive
However, they are also taught to pace syndrome, such as major depressive disorder,
themselves, meaning that they are taught to which might be expected to develop secondary
avoid exerting themselves to the degree that to unrelenting pain. However, clinical
will cause a flare-up of symptoms. Thus, experience is that some of these symptoms can
‘pacing’ means dividing tasks into manageable present alone, or in combination, without
quantities that extend the patient, perhaps on being part of a depressive syndrome. This
subsequent days, without causing setbacks. issue has not been fully researched, but clearly,
Psychological techniques including relaxation insomnia and irritability may present alone or
and cognitive restructuring may have a place in combination, in the absence of a full
in reducing anxiety and chronic pain. depressive syndrome. Again, it is reasonable to
Multidisciplinary programmes offer expect these symptoms as a consequence of
advantages (Nicholas et al, 2000). Massage unrelenting pain. In practice, patients often
may be superior to acupuncture and self-care complain most about their irritability. This is
670_Chronic Pain.ch.14 19/02/2002 9 36 am Page 126
because of angry outbursts toward family (Fishbain, 2000). Thus, the TCAs may have
members, who have been loving and multiple benefits in the management of this
supportive, which leave the patient feeling condition.
regretful and self-critical. The anticonvulsants have traditionally
The above paragraph is, to some extent, an been recommended in the treatment of
academic exercise, as the antidepressants are neuropathic pain. However, in practice they
useful and recommended for the management are also used in the management of chronic
of anxiety, depression, insomnia and back pain, irrespective of the possibility of a
irritability, whether as separate symptoms or neuropathic contribution. In view of the wide
as part of a depressive syndrome. When the range of actions of these drugs, Caraceni et al
full depressive syndrome is present, the (2000) speculate that the anticonvulsants may
normal antidepressant dose is usually required. prove to have a wide range of applications in
However, symptomatic relief from anxiety, pain. In chronic back pain, as with the TCAs,
insomnia and irritability is usually achieved at the anticonvulsants have the advantage of
smaller doses. The choice of antidepressant is beneficial effects in anxiety and depression.
important. While the newer antidepressants, Carbamazepine and sodium valproate are well
venlafaxine and the selective serotonin established in the treatment of chronic pain;
reuptake inhibitors (SSRIs) such as fluoxetine, however, gabapentin is now being used, and
may be useful in full doses in the treatment of appears to be as effective, but with less
the depressive syndrome, they are less useful troublesome side-effects.
in the symptomatic treatment of anxiety, The NSAIDs have a place in chronic back
insomnia and irritability. In symptomatic pain, particularly where degenerative
treatment, the older, tricyclic antidepressants conditions contribute. They have troublesome
(TCAs), are more useful. The TCAs cause dry gastrointestinal effects, but the
mouth and other anticholinergic side-effects; cyclooxygenase-2 inhibitors, such as celecoxib,
but this may be minimized by using smaller have relatively fewer.
doses of the more tolerable agents, such as When opioids are being contemplated,
nortriptyline. Twenty-five or 50 mg of tramadol deserves consideration. It displays
amitriptyline or nortriptyline will greatly assist both weak opioid and monaminergic actions.
pain-related insomnia, and 10 or 25 mg once It is thought to be free of euphoria,
or twice per day will assist anxiety and withdrawal and addiction problems. There is
irritability. minimal respiratory depression, but nausea
The TCAs also have an important, first- and somnolence are common side-effects. In
line role in the analgesia of back pain at least one study benefit has been
670_Chronic Pain.ch.14 19/02/2002 9 36 am Page 127
demonstrated in chronic low back pain Atlas S, Deyo R. Evaluating and managing acute
(Schnitzer et al, 2000). low back pain in the primary care setting.
Journal of General Internal Medicine 2001; 16:
The use of opioids for non-cancer pain 120–31.
remains controversial, but there is good
Bigos S, Bowyer O, Braen G. Acute low back
evidence that they relieve chronic back pain problems in adults. Clinical Practice Guidelines
(Jamison et al, 1998). In comparisons of no. 14. Rockville, MD, Department of Health
populations who receive and do not receive and Human Services, 1994. (AHCPR
publication no. 95–0642.)
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Bogduk N. Management of low back pain. In:
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Update in the Management of Musculoskeletal
not the quantity of pain suffered, but the Pain. Alpha Biomedical Communications,
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(ed) Pain: What Psychiatrists Need to Know.
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Cherkin D, Eisenberg D, Sherman K, Barlow W,
long-acting medication taken regularly (daily
Kaptchuk T, Street J, Deyo R. Randomized trial
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Croft P, Papageorgiou A, Ferry S, Thomas E,
When oral opioids are deemed to have
Jayson M, Silman A. Psychological distress and
failed, in highly specialized centres devices low back pain: evidence from a prospective
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Pharmacotherapy
aware of the potential adverse effects of each frequently with gradual introduction. For
medication and monitor patient progress. example, carbamazepine and lamotrigene are
One current view, supported by the patients’ much less likely to cause characteristic skin
rights movements and legal systems, is that reactions if they are introduced slowly.
the patient must be informed about every When a patient is troubled by a particular
known adverse effect of every medication. adverse effect, it may be possible to change to
Another view is that patients are ill prepared another medication in the same family that is
to weigh the risks and benefits of specific less troublesome. For example, when a first-
medications. Exhaustive information may generation tricyclic antidepressant (TCA; e.g.
increase patient apprehension and the rate of amitriptyline) produces an unacceptably dry
detection/reporting of adverse effects, for no mouth, a second-generation TCA (e.g.
clinical gain. Thus some recommend giving desipramine), which has less anticholinergic
only a brief account of possible adverse effects, action, may be an answer.
encouraging contact at the first sign of Adverse effects may also be diminished by
problems, and arranging a follow-up visit for altering the time of administration. When
the near future. At follow-up, the clinician possible, give the majority of the sedating
asks non-leading questions about the body drugs of the regimen at night. This depends
systems that may be affected. It is legally safer on the purpose and half-life of the
for the clinician to take the comprehensive medication. Amitriptyline (half life 21 hours)
warning approach, which is often less given for depression, can be given all at night,
beneficial for the patient. while codeine (half life 2.9 hours) given for
It is sometimes possible to reduce the pain, is better given throughout the day.
impact of adverse effects. Always use the Likewise, activating agents such as stimulants
minimal effective dose. Commencing at full should be given in the morning. Different
dose produces the strongest adverse effects. patients may report different sedating or
This frightens and discourages and carries the alerting effects from the same medication. A
strongest likelihood of rejection of both this careful history will reveal the problem and the
medication in particular and all other necessary accommodation can be made.
medications. As a general rule, start with low The use of multiple pharmacological
doses and gradually increase. This allows the agents for the same or concurrent illnesses
patients gradually to become aware of and increases the likelihood of adverse effects.
gradually to accept adverse effects, and for Clinicians need to be informed regarding
physiological adjustments that will minimize interactions that cause adverse effects or
them. Some adverse effects occur much less reduce the efficacy of specific agents. For
670_Chronic Pain.ch.15 19/02/2002 9 37 am Page 131
Pharmacotherapy 131
Helpful agents include the following: Bethanechol has been suggested for
anticholinergic constipation. This choline ester
Eat more fruit and drink larger amounts of has been associated with adverse effects of
water. asthma, hyperthyroidism, coronary insufficiency
Fibre supplements (ispaghula, Fybogel; and peptic ulcer. Regular use for drug-induced
methylcellulose, Cellulone) constipation is not recommended; it is not
Faecal softener by mouth (docusate, Coloxyl). particularly effective, and is therefore not worth
Faecal softeners stimulate intestinal secretions, the risk of further adverse effects.
which enter and soften the stool. Thus oral Use of laxatives may be necessary where
administration may not be effective for two or high-dose opioid use is unavoidable. In many
three days. cases it is possible to reduce or change the
Peristaltic stimulant (sennosides a and b, offending medication, and increased intake of
Senokot) fruit, water and some fibre supplement will be
Combinations of faecal softener and peristaltic sufficient.
stimulant are available.
Suppositories (glycerol; Glycerine
3. Pruritus
Suppositories; docusate, Coloxyl
Suppositories) Pruritus results from spinal cord mu receptors.
Enema (docusate; Coloxyl Enema) It is relieved by diphenhydramine 25 mg (up
to 4 times daily).
Laxatives should be used with caution.
They are contraindicated in suspected
obstruction and certain other medical
4. Orthostatic hypotension
conditions. They may increase the absorption Orthostatic hypotension may result from
and hepatic uptake of other drugs. blockade of alpha 1-adrenergic receptors.
Continuous high-dose use may lead to Affected patients should be advised to change
dependence and should be avoided. However, posture slowly and to sit down immediately
regular intake of fibre supplement with faecal upon experiencing dizziness. Supportive
softener as required should be safe in the stockings to prevent venous pooling are
otherwise healthy individual. recommended by some authors, but are rarely
Some tolerance develops to the effects of used in clinical practice. Other measures may
opioids on gastrointestinal motility; however, include adding salt to the diet, and the use of
patients who take opioids chronically remain fludrocortisone. This adverse effect usually
constipated. subsides over time.
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Pharmacotherapy 133
Orthostatic hypotension may also result is the most widely used TCA in pain
from opioid use. There is peripheral arteriolar management, but is the most sedating.
and venous dilation, produced by several Nortriptyline is a metabolite of amitriptyline.
mechanisms, including provoked histamine It is less sedating but retains analgesic effects,
release. There is also blunting of reflex and can be used to replace the parent drug.
vasoconstriction in response to plasma CO2. Desipramine is a TCA that is stimulating in
There is no specific treatment; reduce the dose some individuals. It is not used extensively in
and consider an alternative analgesic agent. pain management, where a degree of sedation
is often valuable.
Where the antidepressant is being used
5. Sedation
exclusively in the treatment of depression, an
Sedation may result from stimulation of mu SSRI will provide a non-sedating alternative.
and kappa receptors by opioid drugs and
stimulation of histamine receptors by
6. Urinary retention
antidepressant drugs.
Sedation due to opioid drugs in the Urinary retention may result from the use of
terminally ill may be managed with a anticholinergic drugs. It is rare that active
stimulant such as methylphenidate 5 mg (up treatment is needed. Bethanechol has a good
to 3 times daily). For non-cancer chronic pain effect, and can be use in oral or in
patients, however, the currently available subcutaneous form in acute situations.
stimulants, which are addictive and have other Urinary retention may occur when
adverse effects, are not recommended. For stimulation of the mu and delta opioid
these patients, dose reduction or changing to receptors inhibits the voiding reflex.
another opioid may be beneficial. Catheterization may be necessary in acute
The tricyclic antidepressants (TCAs) are situations. Tolerance develops to the effect of
the most frequently used antidepressants for opioids on the bladder.
chronic pain patients, because they have an
analgesic effect. This has not been
7. Dry mouth
satisfactorily demonstrated in the selective
serotonin reuptake inhibitors (SSRIs). The Dry mouth may be caused by anticholinergic
SSRIs have insignificant sedative effects. If a drugs. Oral bethanechol has been suggested,
TCA is being used for analgesic effects, and but may cause other adverse effects. Some
sedation is a problem, replacement with an relief may be obtained from chewing sugarless
SSRI cannot be recommended. Amitriptyline gum or sweets. It is important to use sugarless
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Pharmacotherapy 135
Most currently used NSAIDs are non- Among the antipsychotic drugs,
specific inhibitors of both isoforms of COX. olanzapine causes marked weight gain, while
When using these, when symptoms or risk quetiapine causes almost none. The
factors (past history, heavy alcohol use, older antihistamines are notorious for weight gain,
age) cause concern, gastroprotective therapy is and should be avoided as regular treatment
indicated. Misoprostol (800 micrograms in where overweight is a problem.
divided doses), a prostaglandin analogue, reduces Patients should attempt to restrict fats and
the incidence of ulcers. This treatment may lead carbohydrates. Where dry mouth is a
to abdominal pain and diarrhoea. A proton problem, pilocarpine mouthwash may be
pump inhibitor such as omeprazole (20 mg useful, but most important is to alert the
daily) or a histamine H2 receptor antagonist such patient to the calorie content of drinks and
as cimetidine (400 mg in divided doses) may encourage the drinking of plain water or other
also be effective. Both are associated with a range calorie-free beverages. The involvement of a
of generally mild adverse effects. dietician may be helpful. Exercise is
With regard to gastric irritation and ulcer, encouraged. When weight gain has been
the selective COX-2 inhibitors such as unavoidable, discussions may help the patient
celecoxib have advantages. Where they can be accept this altered condition.
afforded, such drugs are recommended.
in the periaqueductal grey matter. Stimulation Tolerance also develops to drugs other than
activates dorsal column noradrenaline and the opioids. For example, carbamazepine
serotonin-transmitting neurones that inhibit doses have to be increased subsequent to the
afferent input in the dorsal horns. Spinal induction of metabolizing enzymes.
opiate receptors are mainly located in the In humans tolerance to constipation does
dorsal horns. Their stimulation has a direct not develop. This means that the starting
inhibitory effect on afferent transmission. dose, or relatively small doses, continue to
cause this problem. Fortunately, tolerance to
respiratory depression and sedation develops
Tolerance, dependency and
over a few weeks, so that the starting dose, or
addiction
another particular dose, will cease to cause
These conditions are poorly understood, a these problems. However, at very high doses,
situation that creates difficulties for people tolerance finally ceases and the persistence of
with chronic pain and doctors alike. The adverse effects prevents further dose
principles are simple. They should be clearly escalation.
communicated and understood, and returned Tolerance to the euphoric effect develops
to, should clinical practice become in days to weeks. This is at the root of the
problematic. psychological dependency of addiction, which
will be discussed below. Where the euphoric
effect is a primary goal, or becomes an
Tolerance
important goal, tolerance will result in the
Tolerance is the condition that a certain dose seeking of higher doses.
of medication produces a decreased effect Tolerance also, unfortunately, develops to
following repeated administration. the analgesic effects. However, clinically, this
Consequently, a greater dose is thereafter is usually a gradual process, and it is common
required to achieve the desired effect. for patients to remain on a stable dose for
Tolerance is a normal, adaptive response to years (Brescia et al, 1992). There are a number
drugs, and is demonstrated in a wide range of of confounding factors. Rapid escalation of
animals. Various bodily changes may dose by the doctor encourages tolerance. On
contribute to tolerance, including the the other hand, requests from the patient for
induction of metabolizing enzymes, rapid escalation call for physical and mental
moderation via negative feedback of endocrine re-evaluation. However, there is no ceiling
gland activity, and the alteration of receptor effect, and as long as the adverse effects are
density in the ‘plastic’ nervous system. tolerable, increasing the dose will restore the
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Pharmacotherapy 137
analgesic effect. When approaching very high physiology. This is clearly the case where
doses, the clinician should involve colleagues tolerance has developed. Opioids suppress the
in the decision to increase. production of endogenous endorphins, and
Tolerance is soon lost. This means that if on cessation of medication the body is left
opioids can be tapered and ceased for three or with less than normal levels of a physiological
four weeks, the analgesic effects of lower doses agent.
will be restored (at least for a time). Withdrawal effects, albeit less dramatic,
are associated with the withdrawal of the
antiepileptics, venlafaxine, clonidine and
Dependence
many others.
There are two types of dependence: physical Withdrawal effects can be avoided by
and psychological dependence. There is much tapering rather than suddenly ceasing
to recommend replacing physical dependence medication.
with the term ‘neuroadaptation’ (Edwards,
cited in Jaffe, 1990); but this has not
Addiction (psychological
happened. For discussions with patients it is
dependence)
better to refer to psychological dependence as
‘addiction’. This topic will be dealt with Addiction or psychological dependence refers to
separately. compulsive drug use, an overwhelming interest
Physical dependence develops with the in securing a supply and the return to drug use
opioids and various other drugs. Physical after detoxification despite advice to the
dependence has developed when, if contrary. The term ‘compulsive’ is used here as it
administration is suddenly ceased, the patient relates to ‘compelled’, which means to be forced
demonstrates an abstinence syndrome, or or driven. Such behaviour causes the individual
physical withdrawal. The common picture in physical, psychological, or social harm.
opioid withdrawal includes muscle spasms, Addiction is observed with drugs that have
diarrhoea, and autonomic effects including euphoric or other comforting psychological
tachycardia and piloerection (the source of the effects.
term, ‘cold turkey’). These events can be both Addiction is suggested by aberrant drug-
painful (not to mention the re-emergence of related behaviour, which includes increasing
the pain that was the focus of treatment) and the amount of drug taken without medical
frightening. direction, hoarding drugs ‘in case’ they are
Withdrawal effects are an expected needed, obtaining drugs from different
response when drug use has altered doctors and buying drugs illegally.
670_Chronic Pain.ch.15 19/02/2002 9 37 am Page 138
Many patients are reluctant to accept and their management has been detailed
opioids because they fear addiction. Iatrogenic above.
addiction can occur; however, the risk is low
in the majority of patients, especially if
Management principles
clinicians are cautious and watch for aberrant
drug-related behaviour. The risks are higher Opioids are not a panacea for chronic pain,
for those who are excessively impulsive or and they all carry significant risks. Use in non-
dependent. Where there is a history of drug cancer pain is controversial by some accounts
abuse, treatment should proceed according to (Ward et al, 1993). However, Bouckoms et al
clear guidelines, preferably in collaboration (1992) reported the long-term treatment of
with a clinician with special experience in large series of patients with non-cancer
addiction. chronic pain in which 2/3 achieved effective
Many pain centres provide written pain relief. One-third demonstrated tolerance,
information and require all patients to sign physical dependency or drug abuse over a
opioid treatment contracts (Bouckoms, 1996; three-year period. Bennett (1999) recently
Irving and Wallace, 1997). Information is stated that opiates are the most effective
provided regarding tolerance, dependence and currently available treatment for most chronic
addiction. Before receiving the patient must pain states.
agree to adhere to directions, not to consult Opioids are considered to be more
other doctors, hoard medication, or buy/sell effective in non-neuropathic pain (Dellemijn,
drugs illegally, and not to use illegal drugs. 1999). Nevertheless, beneficial effects are
Most contracts state that contravention of reported with neuropathic pain (Watson and
these conditions will result in discontinuation Babul, 1998).
of the prescription of opioids. Opioids should only be considered when
all other avenues for relief (non-opioid and
co-analgesics) have been exhausted.
Adverse effects
It is not possible to predict whether an
There is no organ toxicity, and thus no fatal opioid will be helpful in a particular case. This
adverse effects, when opioids are used can only be determined through a clinical trial
according to directions. Respiratory arrest may in which the dose is gradually escalated till
occur in overdose. pain relief occurs or intolerable adverse effects
Nausea and vomiting, constipation, are experienced. Opioids differ from each
sedation, pruritus, urinary retention, and other; so that if one fails to provide relief, it is
sexual dysfunction are possible adverse effects, worth trying others.
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Pharmacotherapy 139
Brose and Spiegel (1992) caution against of long-acting drug taken twice daily (once
using inadequate doses. They advise that there daily if this provides sufficient relief), with a
is great individual variability, and that, for a limited supply of short-acting opioids to be
particular drug, one patient may need five or taken for breakthrough pain. This
six times the dose of another. However, arrangement provides a monitoring system. If
Caraceni et al (2000) caution that failure to the patient is needing an increased amount of
achieve at least partial analgesia with relatively short-acting opioid, and after consideration
low doses in the non-tolerant individual must there is no evidence of aberrant drug
raise doubts about the potential for opioid behaviour, it is time to increase the dose of the
treatment. load-bearing long-acting medication.
Long-acting opioids taken twice daily As was mentioned above, patients must be
(once daily if possible, depending on the case made aware of the potential risks and benefits.
and the available preparations) are a Many pain centres require the signature of an
fundamental of good opioid use in chronic opioid management contract.
pain. They allow the serum levels to be kept Improved physical and social functioning
relatively constant. Fluctuations in serum should be stressed. Pain relief should enable
levels lead to the frequent return of pain. The the patient to engage more actively with the
return of pain is frightening. Attempts to gain world. Such changes in behaviour bring
relief in these circumstances lead to excessive additional benefits.
opioid use. With short-acting opioids Only one practitioner should prescribe the
fluctuations in serum levels are unavoidable. opioid for a particular patient. However, other
Thus short-acting opioids should not be used clinicians should be involved in decisions to
as the basis of chronic pain management. use very high doses, and when the treatment
Further supporting this position is the fact of patients with a history of drug abuse is
that frequent ingestion of drugs followed by being considered.
immediate relief and then the return of At each appointment the doctor should
symptoms carries a greater risk of engendering enquire into and record the degree of
addiction. analgesia, adverse effects, physical and social
Even with stable serum opioid levels, activity and aberrant drug behaviour
patients may experience severe ‘breakthrough’ (preoccupation with drugs, hoarding, dose
pain, sometimes for explicable reasons, such as escalation, obtaining drugs from other
increased activity, but often for no apparent sources).
reason.
The recommended regimen is a fixed dose
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Pharmacotherapy 143
Pharmacotherapy 145
Pharmacotherapy 147
Pharmacotherapy 149
Pharmacotherapy 151
theoretical basis for specific use of alpha-1 profiles, and, with their modest efficacy, they
antagonists and alpha-2 agonists. The picture are generally thought to be drugs of second
is not yet clear, however, and some (Caraceni choice.
et al, 2000) consider the alpha-2 agonists to Some evidence suggests clonidine may be
be non-specific analgesics. combined with opioids, when tolerance to
Peripheral nerve terminals support alpha-1 opioids has developed (Bouckoms, 1996).
receptors. Stimulation of these receptors on Clonidine has been used in combination with
damaged nerves by ephedrine from other analgesics administered by intraspinal
sympathetic nerve terminals may be a cause of injection.
pain. Preganglionic nerves have pre-synaptic Doctors with special experience use
alpha-2 receptors. Stimulation of these phentolamine, an alpha-1 and alpha-2
receptors reduces the release of ephedrine into blocker, to determine whether oral treatment
the ganglionic synapse and, thereby, activity is likely to provide relief. Phentolamine,
in the post-ganglionic cell and release of 0.5–1.0 mg/kg, is infused intravenously over
ephedrine on to the peripheral nerve terminal. 30 minutes. Pain relief with this procedure
Thus a chemical sympathectomy can be supports a trial of oral medication. This test is
achieved by alpha-2 agonistic activity on the not universally employed, however, and a trial
preganglionic cell and alpha-1 antagonism of of oral medication will reveal whether it offers
target receptors. benefits.
Both types of drugs have neurological
effects; thus any analgesic effect may be
Adverse effects
mediated partially or wholly by central
actions. The adverse effects of these drugs can be
While the theory is attractive, oral and minimized by starting with low doses and
transdermal alpha-1 antagonists and alpha-2 increasing gradually, and many subside over
agonists have not achieved clinical two to three weeks. Both types of drug may
prominence. The alpha-1 antagonist, cause hypotension, drowsiness, nausea and
phenoxybenzamine, has been used with some vomiting.
success in CRPS (Ghostine et al, 1984; Clonidine may cause sinus bradycardia
Muizelaar et al, 1997). The alpha-2 agonist, and atrioventricular block; phenoxybenzamine
clonidine, administered transdermally has may cause tachycardia.
been useful for a small proportion of patients These drugs are also associated with a wide
with postherpetic neuralgia (Byas-Smith et al, range of less common effects, including nasal
1995). They have significant adverse effects congestion, dry mouth, hair loss, blurred
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Pharmacotherapy 153
As was pointed out above, some of the group of drugs; therefore they have different
analgesic effects of the anticonvulsants may constellations of adverse effects. Mention has
derive from NMDA blockade. A collection of been made of the adverse effects of the
other blockers is being researched as analgesics anticonvulsants.
(ketamine, dextromethorphan, amantadine), Ketamine has a wide range of adverse
but none have become routine treatment. effects. Heart rate and blood pressure have
The effects of oral ketamine on chronic been both raised and lowered. Arrhythmia has
neuropathic pain were retrospectively occurred. Respiration is frequently stimulated;
examined in 21 patients (Enarson et al, 1999). however, respiratory depression, laryngospasm
Only three obtained substantial benefits. and obstruction may occur. Diplopia and
Better results may be possible using the nystagmus have been noted. Hallucinations
intravenous route (Galer et al, 1993). A review and delirium occur. (These have been thought
(Weinbroun et al, 2000) of the clinical to occur only at anaesthetic doses. However,
benefits of dextromethorphan in chronic pain Mercadante et al (2000) report them at sub-
found unsatisfactory pain relief. The authors anaesthetic doses.) Tonic and clonic
also examined the evidence for movements, anorexia, nausea, vomiting and
dextromethorphan in acute pain, and found morbiliform rash have been reported.
an attenuation of pain, with tolerable adverse
effects. Intravenous amantadine has been
Selection of NMDA blocking drugs
shown to be effective in surgical neuropathic
pain (Pud et al, 1998), but not in sciatica Ketamine is the only NMDA blocking drug
(Medrik-Goldberg et al, 1999). (apart from the anticonvulsants) that is
Exciting evidence suggests that ketamine commercially available in a form that might
(Mercadante et al, 2000) and dextromethorphan be useful in chronic pain management.
(Price et al, 2000) increase the analgesic effects of Dextromethorphan is available as an
morphine. These studies suggest a capacity to antitussive syrup and amantadine is available
reduce tolerance to morphine that is considered as a capsule (and is used as an antiviral and
probable. Such a capacity would have wide antiparkinsonian agent).
application within pain management and
potentially in addiction medicine. Ketamine
Available as ampoules and vials, 200 mg
(base)/2 ml
Adverse effects
Oral administration: Enarson et al (1999)
The NMDA receptor blockers are a disparate started at 100 mg daily in divided doses and
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Pharmacotherapy 155
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Index
160 Index
Index 161
162 Index
Index 163
164 Index
Index 165
166 Index
Index 167
168 Index
Index 169
170 Index