10Management of musculoskeletal pain
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
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2018, Musculoskeletal Science and PracticeCitation Excerpt :Musculoskeletal pain, both short- and long-term, can be a major reason for seeking treatment. In many cases musculoskeletal pain lacks physiological or morphological findings of changes that may explain the pain (Jutel, 2010), and especially in chronic unexplained pain conditions limited effects are seen from pharmacological interventions (Bergman, 2007). Thus, several of these patients are offered non-pharmacological therapies, e.g. patient education, exercise and cognitive behavioral therapies (Bergman, 2007).