From acute musculoskeletal pain to chronic widespread pain and fibromyalgia: rehabilitation addressing cognitive emotional sensitisation and beyond

Introduction: During the past decade, scientific research has providednew insight into the development from an acute, localized
musculoskeletal disorder (e.g. a whiplash trauma) towards chronic
widespread pain and fibromyalgia (FM). Aim: By applying science to
practice, it is explained that rehabilitation should be able to influence
the process of chronicity in 3 different ways. Patients and Methods:
An in-depth review of basic and clinical research resulted in a clear
understanding of the processes involved in the development from
an acute, localized musculoskeletal pain problem towards chronic
widespread pain and FM. Both peripheral and central causes of
ongoing pain complaints have been identified, and provide a solid
base for designing a theoretical framework for rehabilitation in
these patients. Finally, the theoretical framework was confronted
with evidence from randomized controlled clinical trials. Results:
Chronic widespread pain and FM are characterised by sensitisation
of central pain pathways. Inappropriate cognitions and personality
traits have a negative impact on the descending pain-inhibitory
mechanisms (cognitive emotional sensitisation). In order to prevent
chronicity in acute or subacute musculoskeletal disorders, it seems
crucial to limit the time course of afferent stimulation of peripheral
nociceptors. In case of chronic widespread pain and established
sensitisation of central pain pathways, relatively minor injuries/
trauma at any location are likely to sustain the process of central
sensitisation and should be treated appropriately with rehabilitation
accounting for the decreased sensory threshold. In addition, the role
of rehabilitation in such patients encompasses improving pain beliefs
(e.g. pain neurophysiology education) and exercise interventions,
which should account for the process of central sensitisation by
using low to moderate intensity, aerobic exercises using multiple
recovery periods and if available hydrotherapy in warm water.
However, rehabilitation specialists unaware of, or ignoring the
processes involved in the development and sustaining of chronic
widespread pain and FM, may cause more harm then benefit to the
patient by triggering or sustaining central sensitisation. Conclusion:
Rehabilitation, when applied successfully to acute musculoskeletal
disorders, might has the capacity to prevent chronicity. Rehabilitation
has its place in the comprehensive management of those with
chronic widespread pain and FM.