The specific functional losses in the patient's life need to be identified as to kind and degree. Whether the patient's orientation is toward function or toward pain should be clarified promptly; if the orientation is not toward function, the therapy team should explore why it is not. Most patients are function oriented and want nothing more than to obtain enough understanding to control their pain so that they can return to a normal life-style. Patients with poor coping skills learn to depend on pain to survive in life and need counseling to deal with this additional suffering. Often, patients' involvement in litigation regarding their pain is based either on their conviction that the medical community has nothing more to offer them by way of pain relief and improved function, or on the hope of receiving payment for accumulated medical bills.

To help a patient with chronic enigmatic pain, the examiner must find sources of pain that have been overlooked, and that means conducting examinations that were not previously performed. After the history, the first order of business is to conduct a time-consuming, detailed, complete physical examination looking for well-known causes of pain that were missed. Such an examination is rarely performed when the examiner expects to find that the patient's pain is "all in the head."

The patient with chronic pain is one of the most difficult problems the clinician must deal with. Once pain becomes chronic, a number of self-perpetuating factors encourage its persistence, including sleep loss, muscle weakness, loss of control, feelings of depression and hopelessness, anger, narcotics addiction, and often secondary gain. Narcotics are much less effective in chronic than in acute pain. Their use is accompanied by tolerance and often by addiction or dependence, depression, sleep disorders, constipation, and depressed mentation.
In treating patients with chronic pain, the following approaches are important:

1. The physician must acknowledge that the patient is suffering with " real pain "; chronic pain is rarely fictitious.
2. Diagnostic workups should be circumscribed and avoid redundancy.
3. Patients should be directed to the goals of improved function and control rather than cure. Thus, increased activity and stress reduction are important.
   

Common syndromes

Myofascial pain

Recent studies indicate that myofascial pain is the most common single source of musculoskeletal pain.

Myofascial pain due to active Trigger points can present as acute, recurrent, or chronic. The patient with an acute-onset myofascial pain syndrome usually associates the onset of pain with a specific overload of the muscles and, therefore, expects it to be self-limiting, like postexercise soreness. In the absence of mechanical or systemic perpetuating factors, a newly activated Trigger point sometimes spontaneously regresses to a latent Trigger point, if the muscle remains moderately active but is not overloaded. This residual myofascial syndrome due to latent Trigger points continues to cause some degree of dysfunction, but no pain.

Active Trigger points that spontaneously regress to the latent stage are readily susceptible to reactivation, and the patient may experience recurrent episodes of the same pain problem. Again, the individual expects each episode to be limited in duration and, therefore, tolerates it until relief becomes overdue.

However, in the presence of sufficiently severe perpetuating factors, the active Trigger points persist and may propagate as secondary and satellite Trigger points , leading to a progressively severe and widespread chronic myofascial pain syndrome. When undiagnosed, interminable pain has, psychologically, a totally different impact than pain of limited duration.

Since secondary and satellite Trigger points usually develop in functionally related muscles of the same region of the body as the primary Trigger point, the term chronic regional myofascial pain syndrome may help distinguish the regional distribution of the chronic myofascial pain syndrome from the total-body painfulness of fibromyalgia. Because mechanical and systemic perpetuating factors also increase the susceptibility of the muscles to the activation of primary Trigger points, patients with severe perpetuating factors are likely to develop clusters of myofascial syndromes in several regions of the body.

Fibromyalgia, previously called fibrositis, is officially defined as causing WIDESPREAD pain for at least 3 months. Digital palpation of the patient must elicit pain at large number of tender point sites. An older term, fibrositis, has been used in many ways, the published descriptions of fibrositis had a closer resemblance to myofascial pain syndromes than to what is now known as fibromyalgia.

Many authors, consider myofascial pain syndrome and fibromyalgia as two separate conditions that need to be distinguished clinically. Others believe that a myofascial pain syndrome and fibromyalgia are different aspects of basically the same condition, with each diagnosis representing the ends of a spectrum of signs and symptoms. 

An acute single-muscle myofascial pain syndrome is easily distinguished from fibromyalgia. However, it can be difficult to distinguish chronic myofascial pain syndromes from fibromyalgia. The distinctions are particularly blurred if the patient has both fibromyalgia and chronic widespread myofascial pain that involves multiple regions.

The term " myofascial pain modulation disorder ", identifies a relatively small group of myofascial pain patients who show a remarkable distortion of their pain referral patterns. Instead of each active Trigger point projecting pain to its expected location (reference zone), the referred pain and tenderness from all Trigger points in a region converge on one common location. This location may not be the expected zone of pain reference for any of the involved muscles. Characteristically, the convergent focus is the site of previous trauma or intense pain prior to onset of the pain modulation disorder.

The term " post-traumatic hyperirritability syndrome " was introduced to identify a limited number of patients with myofascial pain who exhibit marked hyperirritability of the sensory nervous system and of existing TrPs. 

Similar phenomena have been described as the cumulative trauma disorder, the stress neuromyelopathic pain syndrome, and as The jolt syndrome.

Articular pain

 The term somatic dysfunction is now commonly used and includes skeletal dysfunctions that are often treated by mobilization and manipulation, as well as myofascial dysfunctions that are frequently treated with myofascial release techniques.

An understanding of the interface between myofascial pain syndrome and articular dysfunction and pain is one of the great voids in our current knowledge of manual medicine. 

Internal organs pain

Reflected pain and tenderness from disordered internal organs

Peripheral nervous system pain

Nerves may be injured along its course, or compressed,  or stretched by neighboring anatomic structures, especially at a point where it passes through a narrow space (entrapment neuropathy). They lead to a sensory, motor, or mixed deficit that is restricted to the territory of the affected nerve.  With involvement of a sensory or mixed nerve, pain is commonly felt distal to the lesion. The precise neurologic deficit depends on the nerve involved. Percussion of the nerve at the site of the lesion may lead to paresthesias in its distal distribution.

Backbone pain

Spinal disease may lead to local pain, root pain, or both. It may also lead to pain that is referred to other parts of the involved dermatomes. Local pain may lead to protective reflex muscle spasm, which in turn causes further pain and may result in abnormal posture and limitation of movement. Radicular pain arises from compression, stretch, or irritation of nerve roots and usually radiates from the back to the territory of the affected root. being exacerbated by coughing. straining, or stretching of the nerve fibers, eg. by straight leg raising. Root disturbances may also lead to paresthesias and numbness in dermatom at distribution and to weakness in segmental distribution; reflex changes may accompany involvement of motor or sensory fibers.

Atherosclerosis causes most degenerative arterial disease. Its incidence increases with age; although manifestations of the disease may appear in the fourth decade, people over 40 (particularly men) are most commonly affected. Risk factors include hypercholesterolemia, diabetes mellitus, smoking, and hypertension. Atherosclerosis tends to be a generalized disease, with some degree of involvement of all major arteries, but it produces its clinical manifestations by critical involvement of a limited number of arteries. Narrowing and occlusion of the artery are the most common manifestations of the disease, but weakening of the arterial wall, with aneurysmal dilatation of the arterial segment, also occurs, and both may be present in the same individual. Less common arterial diseases that must be considered are arteritis (of both large and small arteries), thromboangiitis obliterans (Buerger's disease), fibrodysplasia of visceral arteries, syphilitic aortitis, and radiation arteritis.

Systemic Perpetuating Factors

Systemic perpetuating factors should be corrected as they are identified when laboratory test results become available. Systemic factors are commonly overlooked, can be difficult to manage, and often make the difference between a successful and unsuccessful therapeutic outcome for the patient.

Vitamin inadequacy is probably the most common systemic perpetuating factor, and it has been experimentally demonstrated as important in patients with chronic pain.

Another frequently overlooked systemic factor is marginal or subclinical hypothyroidism. Like vitamin inadequacies, it is correctable.

Psychological Aspects

If the patient is function oriented and has developed few pain behaviors, the program described previously can be successful. If the patient has lost self-esteem, is pain oriented, and has developed pain behaviors, the clinician is faced with a complex web of problems that often requires an interdisciplinary team that includes a professional counselor in order to restore the patient to function. Elimination of the original myofascial TrP cause of the patient's pain is an essential part of the program. However, the pain is often perpetuated by poor sleep, inactivity, and hesitancy to undertake the necessary home-stretching program. Teaching the patient improved coping skills may be a necessary first step to eliminate reinforcement of pain behaviors by well-meaning, but over-protective, significant others. 

If patients with chronic pain are depressed, it is necessary to relieve their depression. Inactivity aggravates it and activity that gives them a sense of accomplishment improves it. A regular exercise program is very important. Antidepressant medication may be necessary, especially if sleep is impaired. Treatments that are done to the patient should be minimized, and effort should be concentrated on teaching what can be done by the patient.

Associated Conditions

Articular dysfunction and TrP tension  in related muscles etc. can perpetuate each other; in which case, both conditions must be corrected to obtain lasting benefit.

For example, addressing the myofascial pain syndrome in patients who also have fibromyalgia can significantly improve their condition; they will still have fibromyalgia and should receive therapy for it, too. The extent to which these two conditions adversely affect each other is not yet clearly established.

Treatment

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