3.9.1 Discuss cultural and social influences on the evolution and understanding of
the following pain conditions:
“Railway spine”
It was a 19th century diagnosis for post-traumatic symptoms of passengers involved in railroad accidents
People came forward stating they had ailments - however there was no obvious injury so these injuries were regarded as fake
Reference:
“Writers’ cramp” or Focal Hand dystonia
Description
Idiopathic movement disorder of adult onset characterised by abnormal posturing and movement of the hand and/or forearm during tasks requiring skilled hand use such as writing.
Epidemiology
Typical age onset 30-50yo
Presentation
Often a feeling of tension in the fingers and forearms that interferes with writing fluency
It can progress to significant muscle pain and cramping from minimal exertions such as turning pages of a book. Can cause other symptoms such as uncomfortable positioning similar to restless legs syndrome, trembling in the jaw, TMD, voice problems.
EMGs placed into the muscles effected can show nerve signals transmitted even when the limbs are at rest
Symptoms can vary significantly over time
Can see mirror effects - use of one hand causes worsening of symptoms in other limbs.
Stress, anxiety, lack of sleep, sustained use, and cold temps can worsen symptoms
Cause
Not known. Excessive fine motor activity likely plays a role
There may be a genetic component - up to 20% of patients have a family member with similar
Management
Quite difficult due to no understanding of underlying pathophysiology
Botox can be helpful in some cases
Behavioural retraining with writing devices, switching hands, occupational therapy, biofeedback, etc. None are effective in all cases.
Anticholinergics have been tried with some success
Reference:
Myofascial pain syndrome
Definition
Defined as pain from myofascial trigger points in skeletal muscle
Thought to be regional pain from hyper irritable spots in taut bands of skeletal muscle known as myofascial trigger points
Causes
Direct or indirect trauma
Spine pathology
Exposure to cumulative or repetitive strain
Postural dysfunction
Physical reconditioning
Diagnostic criteria
There is none. Some electrodiagnostic and morphologic findings have been seen but are not clinically practical
Basically - first 3 are essential:
Taut band in muscle
Exquisite tenderness at a point on the taut band
Reproduction of the patient's pain
Local twitch response
Referred pain
Weakness
Restrictive ROM
Autonomic changes
Presentation
Acute or chronic muscle pain
Dull, deep, aching and poorly localised pain
Stabbing is rare
Can have some somatic referred pain
DDx
Hypothyroidism
Iron deficiency
Vitamin D insufficiency
Vitamin B12 deficiency
Parasitic infection
Treatment
NSAIDs - No RCTs looking at NSAIDs in MPS (may consider use but risks+)
Tramadol - No studies
Opioids - No evidence - possible evidence of harm
Lidocaine patch - Few small RCTs showed some benefit over placebo
Benzodiazepines - No RCTs
Gabapentinoids - No RCTs
TCAs - None
SNRI - None
Botox - Double blind RCT suggested benefit at 4 weeks. Cochrane study with mixed benefit
Dry needling - Hart to do RCTs. Dry needling test was done in anaesthetised patients - superiority of dry needling versus placebo.
Reference:
Desai, M. J., Saini, V., & Saini, S. (2013). Myofascial pain syndrome: a treatment review. Pain and therapy, 2(1), 21–36. https://doi.org/10.1007/s40122-013-0006-y
Fibromyalgia syndrome
Definition
The most common cause of chronic widespread musculoskeletal pain
Often associated with fatigue, cognitive disturbance, psychiatric symptoms and multiple somatic symptoms
Epidemiology
Most common in women 20-55 yo
2-3 % prevalence and increases with age
Possibly more prevalent and varies with diagnostic criteria
Presentation
Generalised pain, fatigue, sleep disturbances - lasting for at least 3 months not explained by any other medical condition
Pain is now described as 'multisite pain' following a working group in 2018. Typically pain involves six different sites. Can be muscles and joints.
Fatigue and sleep are core features of the diagnosis. Often stiff in the morning and feel unrefreshed. Often they say they sleep 'lightly' waking frequently during the early morning and difficulty getting back to sleep
'Fibro fog' is common. Difficulties with attention and doing tasks requiring rapid thought changes. Meta-analysis of 23 case-control studies found significant impairment in FM patients compared to controls - explained in part by pain and depression.
Psychiatric symptoms are common - 30-50% at diagnosis also have depression and/or anxiety. FM patients are three times more likely to also have depression than others. 1/4th of patients with FM had major depression and 1/2 had a history of depression.
Headaches are common in 50% of patients with FM including migraine and muscular tension types.
Paraesthesias - Are common but electrophysiologic testing is normal
Comorbid conditions are often found including abdominal, chest wall pain, IBS, pelvic pain etc.
Physical findings
Often marked tenderness on modest palpation in multiple soft tissue sites
Rarely there may also be signs of small-fibre neuropathy
Diagnosis
Chronic pain of at least 3 months duration without another cause. Widespread pain at multiple sites with moderate to severe problems with sleep or fatigue. Widespread tenderness in exam may be found and there is an absence of joint swelling or other evidence of inflammatory changes on physical examination
The American College of Rheumatology diagnostic criteria for 2010 and related documented sheets can be useful. Tender points that were a critical feature in the 1990 diagnostic criteria are no longer required.
2010 diagnostic criteria assess:
Widespread pain index > 7 and symptom severity scale >5
WPI 4-6 and SSS >9
Symptoms present for 3 months
No other disorder explains symptoms
2011 changes altered criteria slightly to allow for patients to self-administer the questions.
2016 multisite pain was suggested - pain in 4 of 5 regions
There is also an ACTTION-APS Pain taxonomy AAPT - which tried to define criteria more clearly in 2019. These criteria are:
MSP defined as six or more pain sites from a possible nine
Moderate to severe sleep problems or fatigue
Both must have been present for at least 3 months
Pathophysiology of Fibromyalgia
Temporal summation of pain
Decreased endogenous pain inhibition - endogenous opioid responsiveness changes
Neuropeptide changes - particularly with upregulation of pronociceptive peptides such as substance P.
Brain pain dysregulation - morphology, neurotransmitter, and resting-state connectivity changes
Loss of descending inhibition
Altered HPA axis changes
Genetic predisposition
Decreased grey matter volume
Differential diagnosis
Investigations
CBC + and ESR or CRP can be used. Further testing does not really help. ANA and RF are rarely helpful. CK or TSH also are options.
Treatment
Initial management
Patient education - 2019 Systematic review level 1A - suggested patient education reduced pain intensity, anxiety (as well as catastrophising) and should be the first step for fibromyalgia
Fibromyalgia is a real illness
Explain centralised pain
Lack of evidence of persistent infection or damage
Stress and mood disorders role
Sleep and sleep hygiene
Importance of exercise - address the muscle 'spasm' pain and 'deficient blood flow'
Prognosis - likely symptoms will wax and wane
Addressing comorbidities
Sleep
Mood disturbances
IBS
Exercise - Evidence from RCTs and Systematic reviews. 2017 Systematic review - exercise improves health-related quality of life and low-quality evidence that aerobic exercise decreases pain and improves physical function
Low-impact aerobic exercise for patients with fibromyalgia. Benefits for pain, function and may be benefits for sleep. Even modest exercise can help.
Preferences based on patient interest are key
Ideally 30 mins of aerobic exercise 3 times per week
CBT
Pharmacology
TCA at night time at 10 mg - 2015 review of systematic reviews and meta-analyses supported the view that low dose amitriptyline is first line.
SNRI (particularly if fatigue or depression is a major feature). 2013 systematic review and meta-analysis involving 6000+ patients showed duloxetine superior to placebo in pain reduction in FM
Gabapentinoids (particularly if sleep problems) - 2018 summary of clinical trials, open-label extensions, meta-analyses and post-hoc analyses for pregabalin in FM confirmed improved pain, sleep, and overall patient status in a wide range of demographics.
For example, the average ‘number needed to treat’ for achieving a 50% reduction in pain in one patient is 4 for amitriptylin, 8 for duloxetine and 14 for pregabalin (Lunn, Hughes, & Wiffen, 2014; Moore, Derry, Aldington, Cole, & Wiffen, 2015; Wiffen et al., 2013)
In real world use, most patients do not use appropriate dose or for appropriate duration
Prognosis
Most have long term pain and fatigue sadly
Meta-analysis in 2012 suggested few patients gain signfiicant benefit from pharmacological therapies
There may be an increased risk of suicide in the cohort
Reference:
UpToDate Accessed July 2021
Whiplash
Definition
Characterised by sudden acceleration-deceleration movements of the head with flexion and extension of the neck - causing injury to the cervical spine
Epidemiology
300-600 per 100,000 in North America and Western Europe
79% of whiplash patients reported residual pain 12 months after their accident
40-50% often have chronic symptoms
Diagnosis and classification
Quebec Task Force Classification of Grades of Whiplash Associated Disorders
Presentation
Important to make sure she is medically cleared (e.g. imaging as appropriate via the Canadian C-spine criteria.
Once stable, a full history of the event including possible risks for PTSD (the impact of events scale) and catastrophisation should be assessed. If found, psychological factors should be addressed early
Neck disability index - https://www.worksafe.qld.gov.au/__data/assets/pdf_file/0018/17532/neck-disability-index1.pdf
Prognostication
Baseline neck pain intensity and disability are strongly correlated with outcome
Post-injury anxiety
Catastrophising
Compensation and legal factors
Early use of healthcare
Initial neck ROM and cold hyperalgesia are predictive of ongoing disability
Trauma-related parameters have NO effect on outcome
MRI findings had no bearing on outcome
Collision factors also had no bearing
Age, gender, marital status and education are NOT predictive of ongoing disability
Previous physical health is NOT predictive of ongoing pain/disability
COMPENSATION factors are inconclusive
Management
Advise patients to stay active
Reassure that they should do normal activites
Exercise is beneficial including neck exercises
Acute pain medications include:
Paracetamol,
NSAIDs (if paracetamol is ineffective),
Opioid analgesics ONLY in very short use if at all (WAD grades > 2-3 only)
Acupuncture is ineffective
Kinesio taping, manual therapy and manipulation, trigger point needling, surgery, have minimal evidence or role
There may be roles for repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (TDCS). Meta-analysis in 2016 showed positive results in fibromyalgia.
Reference:
Al-Khazali, Haidar Muhsena; Ashina, Håkana; Iljazi, Afrima; Lipton, Richard B.b; Ashina, Messouda; Ashina, Saitc; Schytz, Henrik W.a,* Neck pain and headache after whiplash injury: a systematic review and meta-analysis, PAIN: May 2020 - Volume 161 - Issue 5 - p 880-888
doi: 10.1097/j.pain.0000000000001805
Hou, W. H., Wang, T. Y., & Kang, J. H. (2016). The effects of add-on non-invasive brain stimulation in fibromyalgia: a meta-analysis and meta-regression of randomized controlled trials. Rheumatology (Oxford, England), 55(8), 1507–1517. https://doi.org/10.1093/rheumatology/kew205
FND
Somatic Symptom Disorder
(SEE BELOW)
3.9.2 Understand the differences between symptom cluster, syndrome and metasyndrome, with particular reference to chronic widespread pain.
Symptom Cluster: 2 or more symptoms that are related to each other and that occur together. Symptom clusters are composed of stable groups of symptoms, are relatively independent of other clusters, and may reveal underlying dimensions of symptoms
Syndrome: a group of symptoms that consistently occur together, or a condition characterized by a set of associated symptoms.
Metasyndrome: - Cannot find this definition within Google (somatoform behaviours etc.)
3.9.3 Outline the heterogeneity of the clinical phenotype of “chronic widespread
pain”.
Diagnostic clarification of chronic widespread pain has been historically difficult. For example, in ICD-10 pain is attributable exclusively to an underlying pathophysiological mechanism. If that mechanism has not been clearly elucidated, then the only options for diagnosis are somatoform pain disorders.
However, there are clearly disorders for which there is pathophysiological factors ongoing with contributing biological, social, and psychological factors, contribute - which currently do not have a diagnostic basis.
Chronic primary pain overcomes these limitations by providing a clear definition without inappropriate classification into psychiatric disorders and allows for subtypes.
Arguably, simply defining chronic pain into 'somatic' or 'psychogenic' has become obsolete
Terms like 'functional' never made clear sense in regards to its dichotomous understanding of either it's 'all in the head' or are we talking about a persons level of function?!
Chronic primary pain definition:
- Persists for longer than 3 months
- Is associated with significant emotional distress (e.g. anxiety, anger, frustration) and/or significant functional disability (interference in ADLs and social roles)
- Symptoms are not better accounted for by another diagnosis
Chronic primary pain can occur in any body system, and in anybody site including a combination of sites.
Chronic widespread pain is diffuse musculoskeletal pain in at least 4 of 5 body regions and in at least 3 or more body quadrants (upper-lower/left-right) and axial skeleton
It is associated with significant distress and/or functional disability
The diagnosis is appropriate if pain is NOT directly attributable to nociceptive pain in these areas and if there are features consistent with nociplastic pain such as spontaneous or evoked pain in the region with allodynia and/or hyperalgesia with psychological and social contributors.
Fibromyalgia syndrome - is itself a FORM of CWP - in at least 4 of 5 body regions and is associated with sleep disorders, cognitive dysfunction, and somatic symptoms. Symptoms need to be present for 3 months and not explained by something else.
Reference: IASP - Chronic primary pain discussion paper (2018)
3.9.4 Compare and contrast neurobiological and psychobiological understandings
of chronic widespread pain, including but not limited to:
Central sensitisation of nociception
Central sensitisation is a neuronal signal amplification process leading to a greater perception of pain
Fibromyalgia, and related conditions, are thought to be related to a pain-processing problem within the brain leading to hypersensitivity to painful stimuli.
Mono-aminergic neurotransmission is disrupted with elevated excitatory neurotransmitters (glutamate and substance P) and fewer neurotransmitters such as serotonin and norepinephrine involved in descending anti-nociceptive pathways.
Dopamine dysregulation and endogenous opioid alterations likely explain the central pathophysiology of FM
Psychological factors can exacerbate sensitisation - for example 'cognitive-emotional sensitisation' describes where a patient pays more attention to their pain, it can increase their perception of pain
Bidirectional relationship with neurotransmitter changes
Evidence for these changes has been noted in fMRI studies where the same amount of pressure leads to greater neuronal activation of pain-processing areas of the brain in patients with FM compared with controls.
Reference:
Siracusa, R., Paola, R. D., Cuzzocrea, S., & Impellizzeri, D. (2021). Fibromyalgia: Pathogenesis, Mechanisms, Diagnosis and Treatment Options Update. International Journal of Molecular Sciences, 22(8), 3891.
Affective spectrum disorders
These are the large array of different mood disorders.
There is an increasing suggestion of genetic and environmental factors predisposing a patient to affective disorders - in a similar way to pain disorders
These are often also disorders of neurotransmitter regulation and these are similar processes as in pain conditions
It is likely the acute stress response - with its associated HPA system alterations play a role in disrupting normal neurotransmitter use
3.9.5 Critically discuss “fibromyalgia syndrome” as an example of:
(a) chronic primary pain (as a taxonomic entity)
See above in detail
(b) Nociplastic pain (as an example of this descriptor of mechanism)
Nociplastic pain is pain that results from dysfunction of the somatosensory nervous system despite mostly intact neural and non-neural structures
Both chronic primary pain and functional pain disorders are dominated by 'nociplastic pain'.
'Functional' implies multifactorial etiologies
'Primary' suggests unknown or absent contributors and can imply fewer preventative and treatment options
Reference:
Popkirov, S., Enax-Krumova, E. K., Mainka, T., Hoheisel, M., & Hausteiner-Wiehle, C. (2020). Functional pain disorders - more than nociplastic pain. NeuroRehabilitation (Reading, Mass.), 47(3), 343–.
Popkirov, Stoyan et al. ‘Functional Pain Disorders – More Than Nociplastic Pain’. 1 Jan. 2020 : 343 – 353.
(c) central sensitisation of nociception (as an example of a pathophysiological process)
Discussed above
Pain processing is from structures (nociceptors over spinal wide dynamic range neurons to a mesolimbic network), functions (extinction, inhibition, habituation to conditioning, amplification and sensitisation) to directions (bottom-up, top-down, immune and endocrine systems, organisms and their external environments)
(d) an affective symptom disorder (as a psychological construct)
Discussed above
(e) a syndrome (as a clinical entity)
3.9.6 Discuss the evolution of the concept of somatic symptom disorder
SSD is a single diagnostic entity that replaces 3 of the DSM4 somatoform disorders (somatisation disorder, pain disorder, and undifferentiated somatoform disorder (and in some cases, hypochondriasis))
Diagnosis of SSD requires:
1 or more physical symptoms lasting 6 months or longer associated with excessive thoughts, feelings or behaviours
It is described in terms of: Nature (e.g. pain), duration (persist and severity)
Described in words - Disproportionate emotional distress and excessive, unsatisfactory, and maladaptive illness and sick-role behaviours. The ultimate source of the somatic symptoms is less important than the patient's reaction to the symptoms.
SSD is the evolution from DSM 4 where diagnoses like 'pain disorder' were criticised.
The questionable importance of medically unexplained pain in pain disorder associated with psychological factors
Lack of a definition of psychological factors or a description of when they are of sufficient importance or magnitude to play a role in the pain experienced in the presence of a general medical condition - made it a diagnosis of exclusion
Criticisms of DSM5 SSD include:
Diagnostic inflation with fear of misdiagnosing a medical illness (false positive rate is likely also to be high and 15% of cancer patients, 15% of heart disease patients and 25% of IBS would qualify for a diagnosis of SSD) - However, seems somatic symptom disorder may be more restrictive than previous 'somatisation' diagnosis
Inadequate field testing
Risks with new SSD category include:
Stigma
Overlooked diagnoses with a failure to investigate new or worsening symptoms
Increased risk of inappropriate psychotropic medications
Gender trap - women present with physical symptoms more commonly than men
Working group suggested benefits:
Construct (appropriateness of the inferences made from), descriptive (accuracy and objectivity of information gathered) and predictive (Extent to which a score or test predicts scores on some criterion measure or future outcome) validity were improved
Inter-rater reliability
Test-retest reliability are good to very good
May actually reduce overdiagnosis - they require more functional difficulties such as emotional, thoughts or behaviours, than the previous 'somatoform disorders'
Removing 'medically unexplained' symptoms is important as it was very unreliable. It is difficult to prove that a symptom is 'negative' based upon investigations and clinical acumen.
3.9.7 Discuss the DSM-5 diagnostic category of somatic symptom and related
disorders, including but not limited to:
Somatic symptom disorder
Cochrane review in 2015 looking at 26 RCTs suggested evidence for pharmacological therapy for somatoform disorders is poor with the efficacy of many however these were small sample sizes with a high risk of bias and lack of clear follow-up
Cochrane review in 2014 looked at non-pharmacological therapies for somatisation and CBT, mindfulness, psychodynamic and integrative therapy were superior to usual care or waiting list in reduction of symptom severity. But again these were limited studies.
Epidemiology
General population 4-6%
Primary care patient - 17%
Likely higher in those with other functional disorders such as fibromyalgia (25-60%)
Health care utilisation is higher in SSD patients
Risk factors
Female sex
Fewer years of education
Lower socioeconomic status
History of childhood chronic illness
History of sexual abuse or other childhood or adult trauma
Concurrent general medical disorders (especially in older patients)
Health anxiety
Concurrent psychiatric disorder (especially depression or anxiety disorders)
Family history of chronic illness
Underlying factors explained
Developmental factors - poor emotion and high negative emotions lead to symptoms in childhood and these often pervade into adulthood. Particularly if another family member was unwell. Negative parenting and poor attachment may lead to care-seeking behaviours
Physical/sexual abuse - Meta-analysis of 23 studies (4600 patients) examined the association between history of abuse or rape and lifetime diagnosis of somatic syndromes - Somatic symptoms were three times more common in those who had experienced trauma
Cognitive and perceptual distortions and behavioural abnormalities - Some people relate benign sensations to threatening pain and misattribute these to serious disease
Difficulties with self-expression - Physical symptoms can be used to express distress in patients who have difficulty explaining emotions in words (alexithymia).
Clinical presentation
One or more current somatic symptoms that are long-standing and cause distress or psychological impairment. Multiple symptoms can be present but only one is required to make the diagnosis.
Excessive thoughts, worrying, or behaviours related to the somatic symptoms or to health concerns
Can be mild to severe.
The most common symptom is pain
The amount of symptoms is not a factor in making the diagnosis - but the more symptoms the more likely the diagnosis is correct and the more pervasive the condition
REMEMBER this can occur whether the person has a disease or not. The important question is are the persons responses to these somatic symptoms the same or greater than others with the same symptoms?
Prognosis
Sadly most patients become frustrated with their care and care providers.
Clinicians may also experience negative feelings due to their efforts seeming futile
Symptoms fluctuate over time. Improvement can be seen in up to 50% of patients.
Children
Kids can also get this condition. Most common symptoms are abdominal pain, back pain, blurry vision, fatigue, headache, and nausea
Culture
Does not seem to impact prevalence though may influence many other aspects of care
Illness anxiety disorder
Physical complaints are mild or non-existent but lead to excessive worry
Conversion disorder (changed to functional neurological symptom disorder)
DSM5 involves:
One or more symptoms of altered voluntary motor or sensory function
Clinical findings suggesting incompatibility between the symptoms and recognised medical and neurological conditions
These symptoms or signs are not better explained by another medical or mental health disorder
The symptoms cause clinically significant distress in social, occupational, or other areas of functioning that warrant attention
NB: Symptoms are not consciously designed to fill others such as in factious disorder or malingering - but rather are emotional distress not under conscious awareness or control
Epidemiology is not known
History taking
IMportant to ask about symptoms in all facets - Pain, fatigue, sleep, memory and concentration
A history of depression and anxiety is common in these groups
Functional conditions such as irritable bowel syndrome, fibromyalgia, chronic pelvic pain and multiple chemical sensitivity also have strong associations with CD
Examination findings may include Hoover's sign, vibratory sense on the sternum and forehead, and elbow flex-ex test (asked to flex or extend the normal side while the other side is examined at the same time
Investigations can be performed as prudent for risk factors, age etc.
PHQ 15 can be used as a questionnaire - Patient Health Questionnaire
Treatment
Comprehensive and multidisciplinary is the best way
Inpatient therapy has greater evidence than outpatient
CBT has some support and hypnosis has mixed outcomes
Transmagnetic stimulation may have some increasing evidence of benefit - though small studies
Reference:
Tsui, P., Deptula, A., & Yuan, D. Y. (2017). Conversion disorder, functional neurological symptom disorder, and chronic pain: comorbidity, assessment, and treatment. Current pain and headache reports, 21(6), 1-10.
Psychological factors affecting other medical conditions
Factitious disorder
the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives’.
Although rare, in areas of litigation and disability evaluation malingering may be as high as 30%.
3.9.8 Demonstrate application of formulation required in patients with chronic
widespread pain.
Formulation is similar to other chronic pain syndromes. No specific evidence or suggestion found in this setting
3.9.9 Discuss the unique role of the SPMP in understanding, explaining and
managing chronic widespread pain to patients, their families and colleagues
Provision of chronic pain education, particularly in the setting of CWP, has been shown to lead to lower perceived pain and higher expectations of recovery. These findings are particularly in patients who reported a shift in their pain cognition or self-management strategies.
Younger people have higher expectation of recovery than older. Up to 40% of patients who experience pain education in one study reported no change in their pain cognition nor self-management strategies.
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