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Canadian Rehabilitative Consultants
The Rehabilitation Specialists

SUCCESSFUL MANAGEMENT OF CHRONIC PAIN SYNDROME

JOHN C. CLIFFORD, MD, FRCPC
article first appeared in: Canadian Family Physician Volume 39, March 1993

SUMMARY

Managing patients with chronic pain syndrome can be frustrating and unrewarding. Much of the difficulty experienced when managing these pateients stems from an incomplete understanding of pain, especially the difference between acute and chronic pain. Pain theory and treatment of chronic pain syndrome are reviewed. An alternative management strategy for chronic pain syndrome is presented and the literature is reviewed.

For the family physician and, indeed, most specialists, the prospect of managing a patient with chronic pain syndrome does not usually evoke feelings of enthusiasm, competence, or success. More likely are feelings of inadequacy, cynicism, or outright hostility.

Chronic pain syndrome is a collection of symptoms, including chronic pain, reduced function, and reactive depression. A syndrome is a collection of signs and symptoms; as such, chronic pain syndrome describes a particular clinical presentation. Chronic pain syndrome is not synonymous with malingering.

It is possible to develop a successful mamangement strategy for patients with chronic pain syndrome provided one's interpretation of pain, style of management, and criteria for success are dramatically redefined.

The traditional medical view of pain is simply inadequate and inappropriate for the successful management of chronic pain syndrome. Indeed, if patients with chronic pain syndrome continue to receive traditional medical management, their pain symptoms often increase-along with feelings of anxiety, helplessness, social isolation, and depression.

Not surprisingly, such patients demonstrate a progressive loss of normal functioning, much to the confusion and frustration of the treating physician. However, before considering chronic pain syndrome management, an understanding of basic pain principles is essential.

Classification of pain

The International Association of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of tissue damage."1

Acute versus Chronic

Until recently, little attention was paid to the distinction between acute pain and chronic pain. However, it is critical that acute and chronic pain are considered as separate entities (Table 1).

Acute pain is a collection of experiences and responses produced by tissue damage or acute disease. Acute pain is a precise and well localized symptom, presumed to be an accurate indication of tissue damage.

Generally, acute pain resolves during the early stages of tissue healing. Alternatively, chronic pain is pain that persists beyond the usual course of an acute disease, or beyond a reasonable time for tissue damage to heal.

Organic versus Inorganic

It is also important to distinguish between chronic organic pain and chronic inorganic pain. Chronic organic pain occurs secondary to chronic tissue damage or dysfunction and can be established with diagnostic tests (ie, rheumatoid arthritis, peripheral vascular disease, radiculopathy) or can be assumed on the basis of clinical findings (ie, myofasical pain, fibromyalgia, tendonitis).

Chronic organic pain can also occur in the absence of peripheral tissue damage (ie, brainstem pain, thalamic pain, cortical pain) 2-4 when damage to the central nervous system appears to precipitate pain perception in the periphery.

Though chronic organic pain is generally considered a clear indication of tissue damage, it is important to remember that even chronic organic pain can be perceived at distant sites: cervical nerve root irritation with pain to the right shoulder, and lumbar nerve root irritation with pain to the calf or foot.

Furthermore, the perception of chronic organic pain can be modulated by central factors. Anxiety, depression, or vigilance can lower one's pain threshold, while distraction, relaxation, or increasing one's sense of control can raise the pain threshold.

Alternatively, chronic inorganic pain is the ongoing perception of pain in the absence of any obvious tissue disease (for example, phantom limb pain 5 and phantom tooth pain 6). While the initiation of such pain perception likely reflects some alteration in the periphery, the actual pain perception can occur on the basis of a cortical representation, 1-5,7,8 perhaps analogous to a visual or auditory memory.

As with other sensory memories, a memory of pain might be accessible to stimulation by central or peripheral factors. Thus, emotional factors, such as anxiety and hostility, can maintain or enhance the perception of phantom pain, while increased functional activity of the residual limb can decrease the perception of phantom pain. 5

Unfortunately, chronic organic pain can evolve into chronic inorganic pain, as for example, when severe peripheral vascular disease evolves into postamputation phantom limb pain. Once established as chronic inorganic pain, ongoing pain perception can become a diffuse and imprecise sensation, often inaccessible to standard analgesic therapy.

Chronic inorganic pain can persist indefinitely or can increase in distribution or intensity. In addition, emotional factors, such as anxiety, depression, or anger, can intensify the ongoing perception of pain.

Finally, factors that stimulate or reinforce the memory of a particular pain (for example, prolonged medical management directed to the affected region) can inadvertently contribute to this ongoing or increasing pain perception.

Thus, with chronic inorganic pain, as with other sensory perceptions, the relationship between what is taking place peripherally and what is perceived centrally is not always direct, particularly as the chronicity of the pain increases or the tissue disease becomes less distinct.

Consequently, arguments about whether or not the pain is "real" are irrelevant. furthermore, it is inappropriate to respond to ongoing or increasing expressions of pain with a litany of assumed peripheral tissue diagnoses in an attempt to explain the pain. Instead, one should ask two key question: does the ongoing perception of pain represent tissue disease that is treatable? and does the ongoing perception of pain preclude a safe increase in function on a graduated basis?

Finally, it must be emphasized that chronic inorganic pain is a diagnosis of exclusion, made reluctantly after a battery of appropriate investigations and treatments has yielded no significant results.

Ongoing research into presumed examples of chronic inorganic pain is essential to ensure that diagnosable or treatable pathophysiology is not overlooked. For example, a recent review article 9 suggests that decreased blook flow in the residual limb can be related to postamputation phantom pain.

Appropriate treatments could then be developed, such as peripheral vasodilators, muscle relaxants, or biofeedback. Of course, in clinical cases where such specific treatments are not apparent, it remains necessary to consider a range of treatment options. However, if ongoing pain perception persists, it is appropriate and indeed essential that management ultimately focus on establishing the parameters of safe function, whether chronic organic or chronic inorganic pain.

Impairment, Disability, and Handicap

The World Health Organization 10 has defined the following:

Impairment: Impairment is any loss or abnormality of psychological, physiological, or anatomical structure or function. Examples of impairment include diagnosable tissue damage, depression, diabetes mellitus, or chronic pain.

Disability: Disability is any restriction or inability to perform an activity of personal care. Examples of disability include an inability to void, dress, walk, or cope around the house.

Handicap: Handicap is any restriction or inability to fulfil a role that would be normal for that individual. Examples of hanicap would include an inability to work, to move freely in one's environment, or to maintain customary social relationships.

Impairment, disability and handicap are not synonymous (Figure 1);

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The same impairment can lead to different levels of dysfunction depending on the individual and his or her environment. For example, an amputation of the fifth digit (ie, impairment) will have far greater vocational implications (ie, handicap) for a secretary or musician than for a teacher or psychiatrist.

Furthermore, an individual's ultimate level of function (ie, disability or handicap) is influenced by many factors beyond the original tissue damage (Figure 2). It is important totake these points into consideration when assessing an individual's domestic or vocational potential.

A functional assessment should reflect the many intrinsic and extrinsic factors that can influence an individual's level of function. A valid functional assessment can be made only when as many of these factors as possible have been addressed.

Figure 2 is a statement of potential, identifying a variety of ways to assist an individual in achieving maximum functional restoration.

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Tissue damage, Pain, and Lost Function

Immediately following an injury, the concepts of tissue damage, acute pain, and lost function are synonymous (Figure 3).Usually, tissue damage heals, pain resolves, and function is restored.

Sometimes, however, patients continue to perceive pain well beyond the normal time of healing, often without objective evidence of injury or disease. In such cases, the assumption is sometimes made that tissue damage still persists. Additional diagnoses are soon applied, and the individual remains dysfunctional for fear of doing more damage.

Notwithstanding ongoing pain perception, the concepts of tissue damage, chronic pain, and lost function must be understood and managed as separate entities 11 (Figure 3). Chronic pain perception can exist in the absence of significant ongoing tissue damage. 1

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Once significant tissue damage has been ruled out, it is safe to begin increasing the patient's level of function in a carefully controlled setting. Patients with chronic pain syndrome can underestimate their funcitonal capacity. 12 When patients with chronic pain syndrome are observed, their functional level often is not significantly different from the level before injury.

As patients with chronic pain syndrome become more active, their ongoing pain perception can actually decrease. 13 Therefore, continuing to equate chronic pain with a significant loss in function is often unnecessary and inappropriate.

Chronic organic pain alone is rarely an indication of total and permanent disability or hanicap. Chronic inorganic pain alone is never an indication of total and permanent disability or handicap.

Models of Management

Medical Management. Medical management is based on actual or presumed tissue disease. Traditional medical management includes investigations, diagnosis, and treatment. The goal is to cure (ie, to alleviate pain).

Convalescence. Convalescence is a period of rest and relaxation following the subsidence of a disease process. The goal is gradual recovery of health and strength.

Functional management. Functional management includes physical, psychological, and vocational rehabilitation. The goal is increased function, not alleviation of pain.

Rehabilitation. Rehabilitation is a progressive, dynamic, goal-oriented, and often time-limited process that enables an individual with an impairment to identify and reach an optimal mental, physcial, cognitive, and social functional level. Rehabilitation provides opportunities for the individual, the family, and the community to accomodate a limitation or loss of function and encourages social integration and independence.

What usually happens

An informal review of several thousand cases of chronic pain syndrome over the past 10 years reveals a surprisingly similar pattern of care of patients suffering initial soft tissue injuries.

Prolonged medical management. X-ray examinations usually result in non-specific findings. A regional musculoskeletal diagnosis is applied; return to function is predicted between 1 and 3 months later. A variety of treatments is attempted including medication (ie, analgesics, anti-inflammatory agents, muscle relaxants, and antidepressants), physiotherapy (eg, manual therapy, exercise), injections (eg, soft tissue, epidurals, nerve blocks), counterirritants (transcutaneous electrical nerve stimulator [TENS], acupuncture), referral to a chiropractor, and massage.

If symptoms do not resolve, diagnoses are added or intensified and the estimated date of funcitonal recovery is delayed. Referrals are then arranged (usually with orthopedic surgeons but sometimes with neurologists, rheumatologists, physiatrists, or psychiatrists).

Occasionally, a missed diagnosis is identified and symptoms of chronic pain resolve with appropriate treatment. If the pain persists or increases, the treating physician can then resort to recycling or intensive treatment.

Recycling: The patient is recycled back through medical management with repeat or additional investigations, repeat treatments, or multiple referrals - often with little or no useful information gleaned.

Intensive Treatment: The patient is subject to prolonged trial of medication, physiotherapy, injections, or chiropathy - often with the patient reporting only short-term relief of symptoms.

Of significant concern is that, while the patient continues to receive medical treatment, ongoing pain perception, illness behaviour, and passivity are reinforced. 14 At the conclusion of such ineffective management, the patient's perception of pain often continues:

and the result is a tendency to see pain as essentiakky a passive happening inflicted on helpless vuctuns because the toolbox of the medical corporation is not being used in their favour. In this context, it now seem rational to flee pain rather than to face it, even at the cost of giving up intense aliveness. It seems reasonable to eliminate pain, even at the cost of losing independence. 15

Convalescence: Instead of medical management, patients can be allowed to cavalesce - generally, a passive process where patients themselvdes determine their level of ability. During this stage, the family and treatment team can inadvertently support the process of self-limitation, with well-meaning but ill advised advice to "cope". "pace", or "adjust" to the patient's new level of dysfuction. Such recommendations are usually based on subjective complaints of chronic pain.

Inadequate resolution: As the perception of pain continues, the patient and family can experience increasing uncertainty, anxiety, and confusion. Patients may fear that ongoing pain perception represents tissue damage and can be reluctant to increase activity for fear that such activity will increase tissue damage.

Patients are usually unaware that ongoing pain perception can exist in the absence of significant tissue damage and that, in the absence of significant tissue damage, it is not only safe but advantageous to increase physical activity.

Dealings with health insurance agencies and a lengthy litigation process, for example, can cause the patient continuous frustration, anxiety, anger, and increased pain perception and dysfunction. 16-19

What should happen

Before considering appropriate management strategies, it is necessary to emphasize several important principles in treating soft tissue injuries.

• Most soft tissue injuries can be expected to heal within 3 to 6 months. 20
• Soft tissue healing is facilitated by movement. 21
• Early activity encourages functional recovery in acute neck pain 22 and acute low back pain. 23
• Ongoing pain perception can exist in the absence of tissue damage. 7,24,25
• Ongoing pain perception need not be synonymous with loss of function. 11,13
• A structured exercise program encourages functional recovery in chronic pain. 26,27
• Ongoing pain perception can diminish with increasing physical activity. 28

Medical management

Within the context of these principles, we can now turn to an appropriate management strategy for patients with chronic pain syndrome (Figure 4).

Such an approach is imperative, especially for patients with pre-existing chronic pain, when vigilance must be especially acute.

The inital clinical assessment must include a thorough history (including a functional assessment), as well as a complete physical examination (including neurological, musculoskeletal, and soft tissue evaluations). Suspected tissue damage should be explored with appropriate investigations.

Commence symptom-directed therapy as appropriate, incluidng medication, manual therapy, injections, or analgesic modalities. Prolonged inactivity must be avoided. Instead, introduce early mobilization of the injured tissues on a graduated basis.

If diagnosis or analgesia remains elusive after 6 to 7 weeks, refer the patient to an appropriate specialist. 29 If impending chronic pain syndrome is suspected, the referring physician should contact the specialist to explain the concern and attempt to obtain an early referral. The development of chronic pain syndrome can have disastrous implications, and all efforts must be made to interrupt this process as early as possible.

Even after a thorough course of appropriate medical management, however, a patient can still experience ongoing pain perception. The most honest and helpful information that should be given to such patients is as follows.

• The ongoing perception of pain is real.
• The pain is unlikely to be cured.
• While the exact cause cannot be determined, significant diagnosable tissue damage can be (and has been) excluded.
• It is safe to begin increasing activity.
• Exacerbations of pain will accompany even a graded exercise program.
• The long term benefits of increasing function are substantial.

The treating physician should avoid offering creative interpretations of the ongoing pain perception or suggesting expected deadlines for the relief of pain. Instead, the physician should emphasize the natural healing of soft tissue injuries, as well as the possibility that benign chronic pain can last well beyond the point of the soft tissue's healing.

Also, the physician should avoid recycling, intensive treatment, or convalescene. Finally, the physician must recognize that prolonged, unsuccessful medical management beyond 3 months can

unleash previously controlled psychologic conflicts and interject the threat of loss of socio-economic order in the patient's life. The emotional reactions that emerge then play directly into the perpetuation of pain. Further, the physical inactivity dictated by the pain leads to a bodily deconditioning that aggravates the organic foundation of the problem. 29

As suggested earlier, it is important to determine whether the ongoing perception of pain represents acute tussue injury that is treatable and whether the ongoing pain perception precludes the safe increase in function on a graduated basis. Usually, neither is the case. Thus it becomes imperative to discontinue prolonged ineffective medical management and to begin an early program of therapeutic exercise designed to enhance musculoskeletal and cardiovascular conditioning.

Functional management.

When symptoms of chronic pain persist after aggresive medical management and early reactivation, it is essential for patients to move on to a coordinated functional restoration program. This management transition must occur between 3 to 6 months following injury. 29

The goal of such management is increased function, not pain relief. If the patient (or family physician) continues to expect significant short-term pain relief, then such a transition in management will achieve little. The prerequisites for transition are: both the patient and physician are prepared to leave behind the concepts of diagnosis and cure, and the patient is prepared to increase function in spite of ongoing pain perception.

The important elements of the functional restoration program have been described in detail by Mayer and colleagues 26 and Hazard and associates. 27 Such programs are developed around an active exercise program in which the physical expectations increase in small, controlled, measurable steps to maximize the likelihood of success and minimize the likelihood of tissue damage. It must be emphasized to the patient that the purpose of the exercise is to increase function, 30 not to reduce pain. As the patient exercises, pain might increase; however, pain need not interfere with rehabilitation. 31,32

In functional restoration programs, it is necessary to include components of vocational rehabilitation as well as psychological and emotional support 33 for both the individual and the individual's family. The program should integrate the physical, psychological, and vocational aspects of chronic pain syndrome simultaneously. Occasionally, appropriate clinicians might already work together in a coordinated treatment program.

More often, however, appropriate clinicians will have to be brought together from the community. It is then critical that all involved clinicians work with the same management philosophy and give the same message to the patient.

To ensure consistent management, it is often necessary to convene team meetings. These meetings should include both patient and spouse, all clinicians involved in the functional management, a representative from the funding agency ( if applicable), and the patient's lawyer (if legal action is being pursued).

Ideally, team meetings should occur in the family physician's office at the end of the day, when theprocess can evolve in an unhurried environment. In my experience, team meetings are extremely valuable in ensuring coordinated care and patient cooperation, as well as in securing necessary funding for management.

For patients with chronic pain syndrome, the role of the family physician must be to salvage, preserve, and enhance function wherever possible. Considerable evidence indicates that an early return to the workplace is advantageous to patients, both physically and emotionally. 13,23,34,35

Returning an individual with chronic pain syndrome to the workplace, therefore, should be a primary goal of any rehabilitation program. Individuals with chronic pain syndrome who are struggling to remain at work should stay if at all possible, using appropriate vocational restrictions where required.

In my experience, hasty decisions to advise the patient to leave the workplace because of pain can have devastating vocational consequences.

Successfully returning a patient with chronic pain syndrome to the workplace is rarely easy. It often represents a tenuous agreement among the employer, who must accept a worker who is not "100%" into a sometimes modified work setting; the emoployee with chronic pain syndrome, who must be prepared to remain at work in spite of ongoing pain perception; and the family physician, who must be prepared to see the individual at regular intervals to allay fears that each exacerbation of pain represents new tissue damage.

In addition to the three basic components of a functional restoration program (ie, active exercise, vocational rehabilitation, and psychological support), several operational issued must be addressed to increase the chances of successful rehabilitation: behavioural and vocational objectives, schedule, case management, and medical reassessment.

Behavioural and vocational objectives:

It is important to define appropriate objectives at the toutset of the rehabilitation program, rather than making frequent modifications during the program in response to pain. Objectives should reflect any pre-determined vocational restriction.

Schedule:

It is important to define a realistic schedule before commencing the rehabilitation program. The scheule should define variables such as starting dates, duration of the progra, expected dates of acheiving objectives, and termination dates. The schedule must balance realistic objectives with individual variability and his or her need and right to exert control. Once established, the schedule should not be continually readjusted in response to exacerbations of pain in the absence of tissue damage.

Case Management:

A case manager is invaluable to the development of objectives and scheduling. The vocational rehabilitation counsellor is often ideally suited for this role. By regularly communicating with the individual, the vocational rehabilitation counselor can encourage the individual to attain objectives within the specified time. The vocational rehabilitation counselor also can coordinate and chair team meetings.

Medical reassessment:

Moving beyond medical management often causes anxiety for both the patient and the physician. To provide assurances that any subsequent diagnoses are not missed, it is appropriate to reassess the individual at fixed, predetermined intervals rather than in response to variations in pain perception.

Once the functional model is operational, one should assume that exacerbations of pain will occur as activity levels are increased. Managing such flare-ups appropriately is critical to successful rehabilitation. Invariably, there is pressure to diagnose new tissue damage, move the individual back into medical management, then recommend a reduction in the level of activity.

However, there is no evidence that substantial inactivity or a return to medical management either reduces pain perception or increases function in the long-term. Conversely, it is now recognized that prologned inactivity and recurrent inappropriate medical management can increase pain perception and reinforce dysfunction. 29

It must be emphasized that the issue is not whether to use medical management or functional management, but to ensure thorough medical management followed by comprehensive functional management. Clearly, the timing and maintenance of this management transition are critical. Patients must understand these unfamiliar concepts. Several excellent handbooks are available to assist patients in understanding chronic pain and its functional management. 36,37

Case resolution.

Psychological resolution is essential following any trauma. Unfortunately, resolution is rately synonymous with cure, as in the case o f stroke or divorce. Though well-intentioned, ongoing attempts to cure chronic pain syndrome merely postpone resolution, denying the patient an essential component of healing.

Indeed, resolution can become impossible if excessively delayed. Premature convalescence is equally debilitating, underscoring once again the critical importance of timing in the management of patients with chronic pain syndrome.

Ideally, court settlements are awarded prompty and litigation is resolved successfully within a short period. Indeed, successful resolution of litigation can be an excellent form of case resolution. However, litigation can become prolonged, 38 often increasing expectations to return to medical management or to assign a lablel of "total disability".

Once again, intense pressure can be focused on all treating physicians, especially the family physician, whose role as the patient's advocate can be seriously challenged. Creative strategies may be necessary to encourage case resolution, including frequent reassurances to the individual and maintaining open communication with all parties involved.

Successful case resolution can be elusive. If achieved, a patient can resume normal activities with confidence. If not, the patient could remain dissatisfied, bitter, dysfunctional, and angry.

Pitfalls
Succesful progression of an individual beyond medical management, into functional management, and on to successful case resolution can be particularly difficult. In my experience, important warning signs of possible difficulties in management include:

• active adversarial confrontation (eg, Workers' Compensation Board, litigation, disability carrier);
• extended work history with job dissatisfaction;
• narcotic use;
• overly dramatic verbal expressions of pain;
• overly passive interpretation of events during care (eg, the patient says, "they made me...then sent me...they hurt me...");
• bizarre reations to medications or injections;
• steady deterioration of symptoms, without a single pain-free period;
• symptoms made worse with treatment;
• hostility;
• symptoms of pain involving the entire spine or half the body;
• excessive displays of pain behaviour (eg, buckling knees following light palpation of skin);
• multiple orthoses (collar, corset, canes, transcutaneous electrical nerve stimulation, crutches, wheel chairs);
• a caregiver available to assist the patient with dressing; and
• frequent emergency room attendance.

It is important to stress that, whole these warnings are not synonymous with malingering, they do suggest that complex psychosocial factors may be contributing to the ongoing perception of pain. While these factors must be addressed (though not necessarily solved), it is important to remember that they can be addressed either within medical management (where the primary goal is cure) or within functional management (where the primary goal is enhanced function).

In my experience, pursuing medical management for symptoms that are generally incurable is a prescription for failure. Ultimately, an individual must remain free to choose not to progress into functional management.

However, the family physician must then resist the pressure or temptation to recycle the patient back into medical management. Furthermore, the family physician must be preparte to identify all factors contributing to the resultant disability or handicap, including those of personal choice.

Much has been written about the early identification of patients prone to developing a chronic pain syndrome. From a pratical standpoint, however, it is probably advisable to treat every patient who develops acute pain of presumed soft tissue origin as though a chronic pain syndrome will develop.

This will ensure not only appropriate management for the initial injury, but also fewer individuals who actually develop a chronic pain syndrome.

Appropriate management of chronic pain syndrome can successfully restore lost function, if not an eventual reduction in pain perception. Such an outcome, however, is not easily achieved. Indeed, such an outcome will rarely occur unless the family physician clearly understands the different types of pain, appreciates the multiple factors affecting function, can operate within both medical and functional management programs, and can successfully move from medical to funcitonal management. Beyond that, the family physician requires resilience to withstand significant pressures to alter diagnosis, management, or prognosis.

The successful resumption of normal function is complex, involving many intrinsic and extrinsic factors (Figure 2). In my experience, successful long-term management of chronic pain syndrome depends on the knowledge, clinical skills, and resilience of the family physician, more than any other clinician on the management team.

Requests for reprints to: Dr. John Clifford, 1135 Adelaide St.N, Suite 201, London, ON N5Y 5K7

References

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