Nature reviews. Rheumatology
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The aim of this Review is to give a short presentation of the manifestations, assessment methods, and mechanisms underlying localized and widespread musculoskeletal pain, deep somatic tissue hyperalgesia and chronification. Hyperalgesia can be explained by increased pain sensitivity of nociceptors located in deep tissue (peripheral sensitization) or by increased responses from dorsal horn neurons (central sensitization). The spreading of pain and sensitization is related to increased synaptic activity in central neurons and to changes in descending control from supraspinal centers. ⋯ The transition of acute localized musculoskeletal pain into chronic widespread pain is related to the progression of peripheral and central sensitization. This sensitization for the chronification of pain should be assessed by adequate pain biomarkers. Furthermore, pain prevention should target early intervention strategies and new anti-hyperalgesic compounds should be developed.
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Arthritis pain has traditionally been evaluated from a biomedical perspective, but there is increasing evidence that psychological factors have an important role in patients' adjustment to arthritis pain. The evolution of pain theories has led to the development of models, such as the cognitive-behavioral model, which recognize the potential involvement of psychological factors in pain. Emotional, cognitive, behavioral and social context variables are useful in understanding pain in patients with arthritis, and have led to the development of psychological approaches for treating arthritis pain. These include pain coping skills training, interventions that include patients' partners, and emotional disclosure strategies.
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The use of opioids for the treatment of chronic pain has increased dramatically over the past decade. Whether these drugs provide considerable benefits in terms of pain reduction and improved function to balance the risks associated with their use, however, is unclear. Of particular importance to clinicians treating chronic musculoskeletal pain is opioid-induced hyperalgesia, the activation of pronociceptive pathways by exogenous opioids that results in central sensitization to pain. ⋯ Opioids also have powerful positive effects on the reward and reinforcing circuits of the brain that might lead to continued drug use, even if there is no abuse or misuse. The societal risk of increased opioid prescription is associated with increased nonmedical use, serious adverse events and death. Patients with chronic musculoskeletal pain should avoid the long-term use of opioids unless the benefits are determined to outweigh risks, in which case, the use of chronic opioids should be regularly re-evaluated.
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Chronic low back pain and osteoarthritis are two musculoskeletal problems that are highly prevalent in the general population, are frequently episodic and persistent, and are associated with high costs to society, both direct and indirect. This epidemiological picture provides the background that justifies the use of self-management strategies in managing these problems. For this Review, relevant systematic reviews were included that related to effectiveness; other study designs were included that addressed other aspects of the topic. ⋯ Educational programs for patients with back pain are effective in an occupational setting and if combined with an exercise program. Exercise is an effective strategy in the management of both chronic low back pain and osteoarthritis, although it is unclear what the optimum exercise is. Exercise, supported by advice and education, should be at the core of self-management strategies for chronic low back pain and osteoarthritis.