Chronic Pain

Chronic overlapping pain conditions affect a large portion, at least 20%, of both the pediatric and adult populations. The pathophysiology is unknown. Current thinking favors a central nervous system etiology, perhaps related to threat mechanisms, accounting for the frequent co-occurrence of disorders in such disparate parts of the body. The list includes fibromyalgia, migraine headache, temporomandibular joint disorder, chronic fatigue syndrome, irritable bowel syndrome and other functional gastrointestinal disorders, vulvodynia painful bladder syndrome, chronic lower back syndrome and painful endometriosis, and many others. Diagnosis may not be difficult in the patient presenting with multiple syndromes but may require more evaluation to exclude a different cause when the syndrome is isolated. The most effective treatment strategy employs a biobehavioral approach that begins with strong validation of the complaints, an explanation of their probable source, a physical conditioning program, physical therapy (PT) directed at the involved body part (e.g., pelvic floor PT for bladder pain), and cognitive-behavioral therapy to address activity fear/avoidance, catastrophizing, and other unhealthy learned coping strategies that maintain and enhance the syndrome. Frequent comorbid psychiatric issues such as sleep disturbance, depression, and anxiety should also be addressed with a biobehavioral approach. Adjunctive medications such as serotonin reuptake inhibitors, tricyclic antidepressants, and anticonvulsants are most useful when applied in the biobehavioral context. Opioids and benzodiazepines should never be employed.