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Management of musculoskeletal pain

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Chronic musculoskeletal pain is a major public health problem affecting about one third of the adult population. Pain is often present without any specific findings in the musculoskeletal system and a strictly biomedical approach could be inadequate. A biopsychosocial model could give a better understanding of symptoms and new targets for management. Identification of risk factors for chronicity is important for prevention and early intervention. The cornerstones in management of chronic non-specific, and often widespread, musculoskeletal pain are non-pharmacological. Physical exercise and cognitive behavioral therapy, ideally in combination, are first line treatments in e.g. chronic low back pain and fibromyalgia. Analgesics are useful when there is a specific nociceptive component, but are often of limited usefulness in non-specific or chronic widespread pain (including fibromyalgia). Antidepressants and anticonvulsants could be of value in some patients but there is a need for more knowledge in order to give general recommendations.

Introduction

Chronic musculoskeletal pain is a major health problem in most industrialised countries with a prevalence of around 35% in the general population.1, 2 It can be the consequence of a pathological process in the musculoskeletal system, but often presents as a clinical problem when pain persists beyond the expected time of healing and with no specific pathological findings in bones, joints or muscles. In the latter situation a traditional biomedical management approach is often inadequate. Failure in the understanding and treatment of the condition can lead to both frustration for the health care provider and mistrust from the patient.3 Also in cases with a well defined cause, such as osteoarthritis (OA) or rheumatoid arthritis (RA), pain can be more intense and generalised than expected from pathological findings or persist despite good management of the underlying disorder.4 A recent large population study, involving 15 European countries, pointed out that 40% of those suffering from chronic pain reported inadequate management of their pain problem.5 It is thus important to develop and implement management strategies for subjects with, or at risk for developing, chronic musculoskeletal pain.

The aim of this article is to give a biopsychosocial model of specific and non-specific musculoskeletal pain, review options for pharmacological and non-pharmacological treatment and, finally, suggest an evidence-based management strategy for prevention and treatment. The focus is on both pain with no obvious specific cause and pain with a specific cause where that pain persists beyond the expected time of healing or has a greater impact than expected.

Section snippets

Specific versus non-specific pain

Musculoskeletal pain is the most common feature in various musculoskeletal disorders, such as OA and RA, but also a common complaint in the absence of an obvious specific pathological process. There could be both specific and non-specific components of pain in the same individual and the balance and expression of these components of pain is highly individual. Also, pain without any tissue damage must be viewed as ‘real’ pain, otherwise the patient's experience is being denied.6

Although pain may

A biopsychosocial model for pain perception and the targets for pain management

Acute musculoskeletal pain is often nociceptive in its origin and the pain is aimed at protecting the individual, giving an early warning when there is a harmful or potentially harmful process in the body. Neuropathic pain, where there is an injury or dysfunction in the nervous system, is another common cause for pain perceived as coming from the musculoskeletal system. Pain is considered to be idiopathic when there is no specific or obvious known cause. This does not mean that the non-specific

Preventing chronicity – predictors and interventions

Predictors of chronicity can be related both to the clinical disorder and to the affected individual's personal lifestyle or psychosocial risk factors. Patients with factors indicating a risk for chronicity should be considered for an intervention equalling that for those with established chronic musculoskeletal pain. These factors are often referred to as ‘yellow flags’.

In the clinical situation special attention should be paid to previous pain episodes, pain reports from other locations,

Pharmacological methods of pain management

It is important to have adequate management of any underlying specific musculoskeletal disorders. Such management could include disease modifying drugs and pharmacological treatment of nociceptive and neuropathic pain. Pharmacological treatment is often of lower value than non-pharmacological intervention when pain is non-specific, chronic or widespread.

Non-pharmacological methods of pain management

Non-pharmacological treatment is often more important than pharmacological intervention. The cornerstones of non-pharmacological treatment are physical exercise and patient education with a cognitive approach, preferably given in combination within a multi-professional rehabilitation programme.59

Physical exercise includes various interventions such as walking, running, aerobic exercise, aerobic dancing, cycling and pool exercises. The variety of exercise modes together with the range of

A multimodal strategy for the management of chronic musculoskeletal pain

Intervention programmes often focus on only one or a few components in pain management and there is not one single scheme that can be said to give an evidence-based approach to every patient. In a multimodal approach it is important to note what condition to treat and who the individual is. A practical approach to chronic musculoskeletal pain based on the knowledge presented in this article is suggested below. Some of the points may apply to every patient with, or at risk for the development

Summary

Musculoskeletal disorders interact with the affected individual's lifestyle and psychosocial situation and the experienced pain is often non-specific with regard to findings in the musculoskeletal system. As well as specific treatment of peripheral pain generating disorders, non-pharmacological treatments are often the first line of treatment. The cornerstones are physical exercise and patient education with a cognitive approach. Management of chronic musculoskeletal pain calls for a

References (85)

  • N. Bogduk

    Regional musculoskeletal pain. The neck

    Baillière's Best Practice and Research. Clinical Rheumatology

    (1999)
  • L. Romundstad et al.

    Adding propacetamol to ketorolac increases the tolerance to painful pressure

    European Journal of Pain

    (2006)
  • W.W. Woo et al.

    Randomized double-blind trial comparing oral paracetamol and oral nonsteroidal antiinflammatory drugs for treating pain after musculoskeletal injury

    Annals of Emergency Medicine

    (2005)
  • J. Mao

    Opioid-induced abnormal pain sensitivity: implications in clinical opioid therapy

    Pain

    (2002)
  • L.M. Arnold et al.

    A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder

    Pain

    (2005)
  • K. Mannerkorpi et al.

    Physical exercise in fibromyalgia and related syndromes

    Best Practice and Research. Clinical Rheumatology

    (2003)
  • C. Witt et al.

    Acupuncture in patients with osteoarthritis of the knee: a randomised trial

    Lancet

    (2005)
  • S.J. Linton et al.

    A cognitive-behavioral group intervention as prevention for persistent neck and back pain in a non-patient population: a randomized controlled trial

    Pain

    (2001)
  • D.A. Williams

    Psychological and behavioural therapies in fibromyalgia and related syndromes

    Best Practice and Research. Clinical Rheumatology

    (2003)
  • F.J. Keefe et al.

    Cognitive behavioral control of arthritis pain

    The Medical Clinics of North America

    (1997)
  • P.W. Buckle et al.

    The nature of work-related neck and upper limb musculoskeletal disorders

    Applied Ergonomics

    (2002)
  • S. Bergman et al.

    Chronic musculoskeletal pain, prevalence rates, and sociodemographic associations in a Swedish population study

    The Journal of Rheumatology

    (2001)
  • P. Croft et al.

    The prevalence of chronic widespread pain in the general population

    The Journal of Rheumatology

    (1993)
  • H. Merskey

    Logic, truth and language in concepts of pain

    Quality of Life Research

    (1994)
  • C.J. Woolf

    Pain: moving from symptom control toward mechanism-specific pharmacologic management

    Annals of Internal Medicine

    (2004)
  • S. Stahl et al.

    Understanding pain in depression

    Human Psychopharmacology

    (2004)
  • F. Birrell et al.

    Health impact of pain in the hip region with and without radiographic evidence of osteoarthritis: a study of new attenders to primary care. The PCR Hip Study Group

    Annals of the Rheumatic Diseases

    (2000)
  • A.K. Nilsdotter et al.

    Predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study

    Annals of the Rheumatic Diseases

    (2003)
  • J. Scholz et al.

    Can we conquer pain?

    Nature Neuroscience

    (2002)
  • L.R. Watkins et al.

    Glial proinflammatory cytokines mediate exaggerated pain states: implications for clinical pain

    Advances in Experimental Medicine and Biology

    (2003)
  • R. Melzack et al.

    Pain mechanisms: a new theory

    Science

    (1965)
  • T. Theorell et al.

    Psychosocial job factors and symptoms from the locomotor system – a multicausal analysis

    Scandinavian Journal of Rehabilitation Medicine

    (1991)
  • J. McBeth et al.

    Risk factors for persistent chronic widespread pain: a community-based study

    Rheumatology (Oxford)

    (2001)
  • S. Bergman et al.

    Chronic widespread pain: a three year follow-up of pain distribution and risk factors

    The Journal of Rheumatology

    (2002)
  • J.M. van der Waal et al.

    Course and prognosis of knee complaints in general practice

    Arthritis and Rheumatism

    (2005)
  • T.R. Allison et al.

    Musculoskeletal pain is more generalised among people from ethnic minorities than among white people in Greater Manchester

    Annals of the Rheumatic Diseases

    (2002)
  • M.S. Goldberg et al.

    A review of the association between cigarette smoking and the development of nonspecific back pain and related outcomes

    Spine

    (2000)
  • R. Webb et al.

    Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population

    Spine

    (2003)
  • K. Walker-Bone et al.

    Hard work never hurt anyone: or did it? A review of occupational associations with soft tissue musculoskeletal disorders of the neck and upper limb

    Annals of the Rheumatic Diseases

    (2005)
  • K.B. Hagen et al.

    The updated Cochrane review of bed rest for low back pain and sciatica

    Spine

    (2005)
  • D. Kendrick et al.

    Radiography of the lumbar spine in primary care patients with low back pain: randomised controlled trial

    British Medical Journal

    (2001)
  • K.D. Muirden

    Community oriented program for the control of rheumatic diseases: studies of rheumatic diseases in the developing world

    Current Opinion in Rheumatology

    (2005)
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