A biopsychosocial model
The development of chronic pain is a dynamic process involving neurophysiological pain regulation mechanisms and learning, as well as cognitive, emotional and behavioural aspects (17). The condition therefore needs to be understood in a biopsychosocial context where biological and psychosocial factors play equal roles. Relevant biological elements may be myofascial pain, a sensitized nervous system and physical de-conditioning. But disturbed sleep, and cognitive and emotional elements such as strong concentration on negative thoughts and feelings (catastrophization), too much attention to bodily sensations (hypervigilance) and severe chronic distress, may also contribute to the sensitizing process. Moreover, all of these elements may sustain and strengthen each other in a series of vicious circles thus adding to further chronicization (6). Logically, this model of understanding would call for multidimensional rehabilitation aimed at each of the contributing elements. Such an approach has indeed been documented to have positive effects on fibromyalgia and chronic low back pain (7, 18).
In 2004 the American Pain Society set up a panel of experts to find evidence-based guidelines for treating fibromyalgia. After assessing 505 treatment studies, the panel concluded on the following effective measures: A definite diagnosis, information/education, cognitive behavioural therapy, aerobic fitness training, a low dose of a tricyclic antidepressant (administered in the evening), and multidimensional rehabilitation that combined information and/or cognitive therapy with physical exercise training. Multidimensional rehabilitation was the only treatment that consistently showed lasting positive effects in the follow-up period. The authors also pointed out that there was little or no evidence for using opiates, antiflogistics, steroids, benzodiazepines, chiropractice, manual therapy, massage, electrotherapy or ultrasound. However, these treatment options are much used for fibromyalgia in Norway. No studies are so far available on myofascial pain treatment in fibromyalgia (18).
In the evidence-based European guidelines for the management of chronic low back pain, diagnostic clarification is recommended to eliminate pathology in the spinal canal, nerve root affection and structural deformities. Prognostic factors should be mapped; i.e. work situation, psychological strain and depression, severity of pain and to what extent this hampers functional level, previous episodes of low back pain, exaggerated reporting of symptoms and the patient’s own expectations. Recommended therapeutic interventions comprise information, cognitive behavioural therapy, guided physical training, short-course treatment with antiflogistics or weak opiates, and multidimensional rehabilitation (7).
After medical examination, patients with chronic myofascial-based musculoskeletal pain should be offered multidimensional rehabilitation. The minimum requirement is obligatory physical exercise with information and/or cognitive therapy (18). But several of the following components may be combined to advantage:
Extensive information on the cause and nature of the pain to give the patient confidence and understanding of factors that can aggravate, perpetuate or alleviate the pain. This forms the basis for mutual understanding between patient and therapist, which is the prerequisite for success. One should rouse hope and motivation in the patient, who should be given a true possibility of active self-management.
Cognitive behavioural therapy that emphasizes how negative thoughts can promote emotional reactions and hypervigilance, which in turn may lead to dysfunctional behaviour and long-lasting or increased, pain (19). Awareness of one’s own patterns of thought and notions, and how emotions, pain and behaviour may change as the result of choosing an alternative model for understanding, contribute to a secure, actively coping and well-functioning patient.
Aerobic exercise training, which has a documented positive effect on work capacity, sense of well-being, surplus energy, pain and sleep (18, 20, 21).
If necessary, medication taken at need for pain relief and sleep improvement.
Depending on the situation of the individual patient, these services may be given ambulant through their regular GP or an outpatient clinic, or intensively through hospitalization.
The Jeløy Kurbad Rehabilitation Centre has offered multidimensional rehabilitation to hospitalized patients with chronic myofascial pain/fibromyalgia since March 2001. The programme is intensive and has many components. It is unique, because in addition to the components mentioned above, it also includes diagnostics and treatment of the patients’ myofascial pain. As an example of how multidimensional rehabilitation may be done, this programme is presented with results at discharge and 6- and 12-month follow-up.