Fw: chronic pain syndrome

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Chronic pain syndrome (CPS) is a common problem that presents a major challenge to healthcare providers because of its complex natural history, unclear etiology, and poor response to therapy. CPS is a poorly defined condition. Most authors consider ongoing pain lasting longer than 6 months as diagnostic, and others have used 3 months as the minimum criterion. In chronic pain, the duration parameter is used arbitrarily. Some authors suggest that any pain that persists longer than the reasonable expected healing time for the involved tissues should be considered chronic pain. CPS is a constellation of syndromes that usually do not respond to the medical model of care. This condition is managed best with a multidisciplinary approach, requiring good integration and knowledge of multiple organ systems. Pathophysiology: The pathophysiology of CPS is multifactorial and complex and still is poorly understood. Some authors have suggested that CPS might be a learned behavioral syndrome that begins with a noxious stimulus that causes pain. This pain behavior then is rewarded externally or internally. Thus, this pain behavior is reinforced, and then it occurs without any noxious stimulus. Internal reinforcers are relief from personal factors associated with many emotions (eg, guilt, fear of work, sex, responsibilities). External reinforcers include such factors as attention from family members and friends, socialization with the physician, medications, compensation, and time off from work. Patients with several psychological syndromes (eg, major depression, somatization disorder, hypochondriasis, conversion disorder) are prone to developing CPS. Frequency: a.. In the US: Pain is the most common complaint that leads patients to seek medical care. Chronic pain is not uncommon. Approximately 35% of Americans have some element of chronic pain, and approximately 50 million Americans are disabled partially or totally due to chronic pain. Mortality/Morbidity: CPS can affect patients in various ways. Major effects in the patient's life are depressed mood, fatigue, reduced activity and libido, excessive use of drugs and alcohol, dependent behavior, and disability out of proportion to impairment. Race: No known predilection of CPS for any racial group has been described in the literature. Sex: Chronic pain is reported more commonly in women.History: Because of the complex etiology and the frequent presence of associated disorders, a general and open-minded approach to the assessment of the patient is needed. Obtaining the history of patients whose symptoms suggest CPS is important. A thorough history is necessary for the physician to direct further evaluation and appropriate consultations and avoid repeating invasive and expensive procedures. A detailed review of the musculoskeletal, reproductive, gastrointestinal, urologic, and neuropsychological systems must be obtained. As needed, specific questions should be asked of particular patients, depending on their associated disorders. a.. Focus the history on a characterization of the patient's pain. Obtaining the characteristics of the pain helps establish appropriate diagnostic and therapeutic plans. a.. Pain location: The location of pain is an important part of the history. Ask the patient to describe the type of pain and the location on a pain diagram (anterior/posterior and lateral view of human picture). a.. Precipitating factors: Ask questions about factors that provoke or intensify pain. This information may provide clues for possible etiologies or associated disorders. a.. Alleviating factors: Ask the patient if any factors help alleviate the pain. For example, rest may decrease pain of musculoskeletal origin. a.. Quality of pain: Ask the patient to describe the quality of pain. Various terms can be used to describe quality of pain, including throbbing, pounding, shooting, pricking, boring, stabbing, lancinating, sharp, cutting, lacerating, pressing, cramping, crushing, pulling, pinching, stinging, burning, splitting, penetrating, piercing, squeezing, and dull aching. a.. Radiation of pain: Ask the patient if the pain spreads or radiates. Spreading or radiating pain is a characteristic of neuropathic pain. a.. Severity or intensity of pain: Use some type of rating system to evaluate pain severity or intensity with a degree of objectivity and reproducibility. Different types of pain scales may be used. Numerical scales are more useful and reliable. The visual analog scale (VAS) is one of the commonly used numerical scales. a.. Obtain history specific to different systems and disorders. a.. Musculoskeletal a.. Neurologic a.. Gynecologic and obstetric a.. Urologic a.. Gastrointestinal a.. Psychological: A good psychosocial or psychosexual history is needed when organic diseases are excluded or coexisting psychiatric disorders are suggested. Obtain sufficient history to evaluate depression; anxiety disorder; somatization; physical or sexual abuse; drug abuse/dependence; and family, marital, or sexual problems. Somatization is a common associated psychologic disorder in women with chronic pain. Somatization scales can be used for evaluation. a.. Sternbach's 6 D's of CPS are as follows: 1.. Dramatization of complaints 2.. Drug misuse 3.. Dysfunction/disuse 4.. Dependency 5.. Depression 6.. DisabilityPhysical: Good rapport, tolerance, and an open-minded approach are important when evaluating any patient with chronic pain. A good thorough systematic examination usually leads to an appropriate diagnosis and therapy. Patients often have Waddell signs. The disability is usually out of proportion to the impairment and the objective findings. Detailed examination of the musculoskeletal system is important. Examination of various other systems (eg, gastrointestinal, urologic, neurologic) also should be performed. Causes: Various neuromuscular, reproductive, gastrointestinal, and urologic disorders may cause or contribute to chronic pain. Sometimes multiple contributing factors may be present in a single patient. a.. Musculoskeletal disorders a.. Osteoarthritis/degenerative joint disease (DJD)/spondylosis b.. Rheumatoid arthritis c.. Lyme disease d.. Reiter syndrome e.. Disk herniation/facet osteoarthropathy f.. Fractures/compression fracture of lumbar vertebrae g.. Faulty or poor posture h.. Fibromyalgia i.. Polymyalgia rheumatica j.. Mechanical low back pain k.. Chronic coccygeal pain l.. Muscular strains and sprains m.. Pelvic floor myalgia (levator ani spasm) n.. Piriformis syndrome o.. Rectus tendon strain p.. Hernias (eg, obturator, sciatic, inguinal, femoral, spigelian, perineal, umbilical) q.. Abdominal wall myofascial pain (trigger points) r.. Chronic overuse syndromes (eg, tendinitis, bursitis) a.. Neurological disorders a.. Brachial plexus traction injury b.. Cervical radiculopathy c.. Thoracic outlet syndrome d.. Spinal stenosis e.. Arachnoiditis f.. Metabolic deficiency myalgias g.. Polymyositis h.. Neoplasia of spinal cord or sacral nerve i.. Cutaneous nerve entrapment in surgical scar j.. Postherpetic neuralgia (shingles) k.. Neuralgia (eg, iliohypogastric, ilioinguinal, or genitofemoral nerves) l.. Polyneuropathies m.. Polyradiculoneuropathies n.. Mononeuritis multiplex o.. Chronic daily headaches p.. Muscle tension headaches q.. Migraine headaches r.. Temporomandibular joint (TMJ) dysfunction s.. Temporalis tendonitis t.. Sinusitis u.. Atypical facial pain v.. Trigeminal neuralgia w.. Glossopharyngeal neuralgia x.. Nervus intermedius neuralgia y.. Sphenopalatine neuralgia z.. Referred dental or TMJ pain aa.. Abdominal epilepsy ab.. Abdominal migraine a.. Urologic disorders a.. Bladder neoplasm b.. Chronic urinary tract infection c.. Interstitial cystitis d.. Radiation cystitis e.. Recurrent cystitis f.. Recurrent urethritis g.. Urolithiasis h.. Uninhibited bladder contractions (detrusor-sphincter dyssynergia) i.. Urethral diverticulum j.. Chronic urethral syndrome k.. Urethral carbuncle l.. Prostatitis m.. Urethral stricture n.. Testicular torsion o.. Peyronie disease a.. Gastrointestinal disorders a.. Chronic visceral pain syndrome b.. Gastroesophageal reflux c.. Peptic ulcer disease d.. Pancreatitis e.. Chronic intermittent bowel obstruction f.. Colitis g.. Chronic constipation h.. Diverticular disease i.. Inflammatory bowel disease j.. Irritable bowel syndrome a.. Reproductive disorders (extrauterine) a.. Endometriosis b.. Adhesions c.. Adnexal cysts d.. Chronic ectopic pregnancy e.. Chlamydial endometritis or salpingitis f.. Endosalpingiosis g.. Ovarian retention syndrome (residual ovary syndrome) h.. Ovarian remnant syndrome i.. Ovarian dystrophy or ovulatory pain j.. Pelvic congestion syndrome k.. Postoperative peritoneal cysts l.. Residual accessory ovary m.. Subacute salpingo-oophoritis n.. Tuberculous salpingitis a.. Reproductive disorders (uterine) a.. Adenomyosis b.. Chronic endometritis c.. Atypical dysmenorrhea or ovulatory pain d.. Cervical stenosis e.. Endometrial or cervical polyps f.. Leiomyomata g.. Symptomatic pelvic relaxation (genital prolapse) h.. Intrauterine contraceptive device a.. Psychological disorders a.. Bipolar personality disorders b.. Depression c.. Porphyria d.. Sleep disturbances a.. Other a.. Cardiovascular disease (eg, angina) b.. Peripheral vascular disease c.. Chemotherapeutic, radiation, or surgical complications