Chronic Pain Syndrome
In both the Fourth and Fifth Editions of the Guides, a definition of chronic pain syndrome (CPS) was included that captured the major biopsychosocial characteristics of chronic pain. Indeed, the biopsychosocial approach to chronic pain and disability is currently viewed as the most heuristic perspective to the understanding, assessment, and treatment of chronic pain disorders, and has replaced the outdated biomedical reductionist perspective. This biopsychosocial approach views chronic pain as a complex and dynamic interaction among biological, psychosocial, and social factors that perpetuates, and may even worsen, the clinical presentation. Each person will experience a chronic pain condition uniquely, this accounting for the great individual difference in how pain is expressed. The complexity of a chronic pain disorder is especially evident when it persists over time, as a range of psychosocial and economic factors can interact with pathophysiology to modulate a patient’s report of discomfort and disability healing occurs, all patients experience some degree of physical deconditioning associated with stiffness and muscle atrophy in the injured area. Risk factors for profound deconditioning with the injured area becoming a “weak link” include extended periods of inactivity, inhibition of function due to pain, and fear avoidance. In striking contrast, the traditional and outdated biomedical approach assumes that all pain symptoms have specific physical causes, and attempts to eradicate the cause directly by identifying and rectifying the presumed pathophysiology. However, chronic pain can rarely be understood by the linear, nociceptive mechanism. As will be discussed later in this chapter, there is often an absence of a document-able relationship between pain and pathophysiology.
With the above biopsychosocial perspective in mind, CPS can be described as pain that continues beyond the normal healing time for the patient’s diagnosis and includes significant psychosocial dysfunction. It should be noted that this definition does not include any specific time frame to use in making the diagnosis of CPS. This omission is intentional and reflects clinical reality, in that some conditions would be expected to resolve in several days and others in several months or even years. The diagnosis of CPS should then be temporally connected to the point at which a given condition or conditions were expected to have resolved, rather than to any arbitrary time period for an injury or event. Regardless of when it occurs, CPS is a condition that ultimately adversely affects the patient’s well being, level of function, and quality of life. The major characteristics associated with CPS include the following with 3 or more required for a diagnosis:
Use of prescription drugs beyond the recommended duration and/or abuse of or dependence on prescription drugs or other substances.
Excessive dependence on health care providers, spouse, or family.
Secondary physical deconditioning due to disuse and/or fear-avoidance of physical activity due to pain.
Withdrawal from social milieu, including work, recreation, or other social contacts.
Failure to restore pre-injury function after a period of disability, such that the physical capacity is insufficient to pursue work, family, or recreational needs.
Development of psychosocial sequelae after that initial incident, including anxiety, fear-avoidance, depression, or nonorganic illness behaviors.