Strategies to Avoid Pain Chronification in PRM Programs

Purpose: Epidemiologic studies show that chronic generalized pain syndromes are found in western societies in more than 10 percent. Chronic generalized pain has high impact on functioning and quality of life and is related to high economic burden to health system and society. Studies show that pain chronification is related to changes in brain functions and alterations in pain regulation mechanisms e.g. extended representation of pain area in brain, reduced reciprocal pain inhibition at brain stem level and alterations in mediator levels, such as Anandamide, Brain-derived Neurotropin Factor and Serotonin. Risk factors for pain chronification are among others psychosocial conflicts in private or professional live, beliefs that activities are harmful for the body, katastrophizing beliefs, depression, anxiety and resignation. Health professionals and treatment strategies can contribute to pain chronfication too, e.g. by contradictory diagnosis, support of passive behavior, support of katastrophizing beliefs, insufficient pain relief and others. In the Department for rehabilitation Medicine of Hannover Medicals School based on knowledge about pain chronification mechanisms a program to avoid pain chronification has been developed and implemented.

Method: Pain chronification mechanisms have been analyzed from literature and consequences for management of patients with high risk of pain chronification have been derived.

Results: The resulting anti-chronification strategy aims at sufficient analgesia, treatment of functional deviations in musculoskeletal system, normalizing of pain threshold and behavioral modifications. Actions are taken to diagnose underlying health condition as quickly as possible, full assessment of deviations in locomotor function, sufficient analgesic medication, assessment of pain chronification risk factors, setting-up and negotiating with the patient a detailed rehabilitation plan (including time table), patient education program including cognitive behavioral treatment, and coordinated activities within the rehabilitation team. Although the put into practice of the program is not yet accomplished a significant decrease of length of treatment has been observed.

Discussion: Pain chonification is a process of neuroplasticity leading to changes in cortical pain representation and changes in pain regulation mechanisms. Main risk factors are long lasting pain, personal risk factors and some contextual factors. It is of great importance to prevent pain chronification consequently especially in patients with risk factors. The pain anti-chronification strategy in the department of Rehabilitation Medicine at Hanover medical School seems to be successful in decreasing length of treatment phases, however, the efficacy has to be evaluated in future studies.