The challenges of chronic pain and fatigue, Eccles and Davies, 2021

[Andy]

In this review, we explore the challenges of chronic pain and fatigue in clinical practice. Both pain and fatigue are common, troubling and frequently overlapping symptoms, and we describe both the clinical burden and the ‘clinical problem’. We explore commonly associated symptoms and possible pathological associations, including variant connective tissue (joint hypermobility), small fibre neuropathy, mast cell activation, dysregulated inflammatory and interoceptive processes, which may inform treatment targets. We suggest a multidisciplinary management approach.

Open access, https://www.rcpjournals.org/content/clinmedicine/21/1/19

 

[ME/CFS Skeptic]

The authors suggest considering problems with connective tissue (joint hypermobility), small fibre neuropathy, mast cell activation in patients with pain and fatigue.

On the hand, they propose a multidisciplinary model based on the biopsychosocial approach and referral to a health psychologist. The ideal response in box 4 includes a graded exercise program by a physiotherapist. The authors also suggest considering 'interoceptive processing':

Recent work suggests fatigue may be related to disrupted interoceptive mechanisms, equally, pain is also linked to differences in interoception.54–57 Mismatch between such observed and expected sensory signals representing bodily states may be important in symptom generation and maintenance, and such models have been extended to fatigue.5

The authors also propose that their approach is more cost-effective because referral to specialist may lead to expensive and unnecessary investigations. they write:

His planned programme of investigations (largely unnecessary) will cost several thousands of pounds [...] she will continue in her ‘sick role’ as she undergoes more and more investigations

This looks like a weird combination of the biomedical and psychosomatic model of ME/CFS. What holds it together is that it is a collection of unsupported theories about people with fatigue and pain. They all give the impression that Eccles and Davies know more about pain and fatigue and what to do about it, than their colleagues - while they probably don't. It seems like the opposite of saying "we don't know yet".

I hope I'm not being too harsh but I'm not a fan of this approach. Interested in hearing what others think

 

[Peter T]

I hope I'm not being too harsh but I'm not a fan of this approach. Interested in hearing what others think

Why do we see in this area a rush to produce clinical interventions based on pet theories, without any adequate investigation as to whether there is any evidence for that pet theory or if it is pure fantasy?

Because something is a logical possibility does not mean it is a reasonably fancy.

 

[Jonathan Edwards]

This looks like a weird combination of the biomedical and psychosomatic model of ME/CFS. What holds it together is that it is a collection of unsupported theories about people with fatigue and pain. They all give the impression that Eccles and Davies know more about pain and fatigue and what to do about it, than their colleagues - while they probably don't. It seems like the opposite of saying "we don't know yet".

I hope I'm not being too harsh but I'm not a fan of this approach. Interested in hearing what others think

Absolutely agree, this is a most weird and internally contradictory approach. A sort of BPS pastiche.
Maybe rather than BPS it is BSP (bromsulphthalein if I remember rightly) or PBS (phosphate buffered saline) or SPB (a general term for societies for the protection of birds)??

Or maybe it is just a reincarnation of Eccles himself.
'How do you know it is half past eight , Eccles.' (Bluebottle voice.)
'I got it written down on a piece of paper.'

About the level.

 

[Sean]

Why do we see in this area a rush to produce clinical interventions based on pet theories, without any adequate investigation as to whether there is any evidence for that pet theory or if it is pure fantasy?

And even when there is good evidence against it, including from their own studies.

It is crystal clear they have no intention of playing fair. They are on a mission, and nothing is going to stop them. Not even reality.

 

[Sly Saint]

 

[Wonko]

So...if I am in pain, but they decide, on their prefered basis of no investigations/evidence, that I am not, that I am wrong, and that I obviously need reeducating until I say I am no longer in pain?

If only other things could be done this way.

'Multiple pile vehicle pile up, many injured and dead, send ambulances.'

'I don't think so, there is no evidence.'

'I've got video!!!'

'I've told you that there was no accident, and as a professional I would know if there was, yet you persist in your delusions, you're clearly suffering from a maladaptive obsession - we have CBT for that.'

Just think of the savings.

 

[Jonathan Edwards]

Oops, that doesn't do much for the reputation the Academy of Medical Sciences.

 

[Invisible Woman]

Both pain and fatigue are common, troubling and frequently overlapping symptoms,

Right......I wonder why that could be?

Not being able to fall asleep &, when you do, waking up frequently because of the pain, waking early etc. does tend to make people very tired.

Not just tired of being in pain tired but tired, tired.

Honestly, will this BS never end?

 

[Amw66]

And I thought I was good at creative writing at school......

 

[Dolphin]

Well at least they're better than this guy

Functional disorders and chronic pain
Richard Sawyer
https://www.rcpjournals.org/content/clinmedicine/21/2/e242.2

While I applaud the descriptions used by Eccles and Davies to describe various approaches to chronic pain patient management as embraced by different doctors (particularly that used by Dr B), it seems to me that they then proceed further along the biomedical route by exploring hypermobility syndromes, small fibre neuropathy, mast cell activation disorders and inflammatory reactivity. This approach, in my experience, further entrenches ‘illness behaviour’ and distress among patients with functional chronic pain conditions and fails to approach pain management through a biopsychosocial approach. This then becomes a ‘barrier to progress’.8

The impact of psychological illness on chronic pain symptom presentation is well recognised and a holistic approach to managing these patients through illness de-escalation and promoting improved self efficacy is, in my opinion, more appropriate.

Response
Jessica A Eccles and Kevin A Davies
https://www.rcpjournals.org/content/clinmedicine/21/2/e243.1

Many conditions present with impairment of both physical and mental health. We feel strongly that in all cases it will be the evolution of a deeper understanding of the biology and pathophysiology of these illnesses, including myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) and fibromyalgia, that will in time lead to the evolution of more rationally-based and effective treatment strategies. Moreover, we feel that is it all too frequently the case that labelling a condition as ‘biopsychosocial’ or ‘psychological’ leads to negative perceptions among healthcare professionals, and may unfortunately result in physicians abrogating their clinical responsibilities to affected patients, as in our exemplar, Dr A.