Is there a unifying diagnosis for patients with multiple chronic pain diagnoses, including Chronic Pain Syndrome, Median Arcuate Ligament Syndrome (MALS), Irritable Bowel Syndrome (IBS), endometriosis, and Pelvic Congestive Syndrome?

From the Guidelines

There is no single unifying diagnosis that encompasses all patients with multiple chronic pain conditions, but central sensitization syndrome (CSS) is a key underlying mechanism that may connect these conditions, including chronic pain syndrome, MALS, IBS, endometriosis, and pelvic congestive syndrome. CSS involves changes in the central nervous system that amplify pain signals and lower pain thresholds, creating heightened sensitivity to both painful and non-painful stimuli, as seen in patients with irritable bowel syndrome who exhibit allodynia, an abnormal state in which innocuous intestinal stimuli are perceived as painful 1. This neurological phenomenon helps explain why many patients suffer from multiple pain conditions simultaneously, as the nervous system becomes increasingly reactive to various stimuli.

Management of these conditions typically requires a multimodal approach, including medications, physical therapy, cognitive behavioral therapy, and sometimes interventional procedures. For example, medications such as duloxetine 30-60mg daily, pregabalin 75-300mg twice daily, or low-dose amitriptyline 10-25mg at bedtime may be prescribed to address both the specific underlying conditions and the overall pain processing dysfunction 1. Additionally, self-management strategies, neuromodulation, and brain–gut behavior therapies, such as cognitive behavioral therapy programs, hypnotherapy, and instruction in breathing techniques, can be effective in managing chronic pain 1.

It is essential to address the maintaining factors of chronic pain, such as fear of pain or re-injury, and to involve a multidisciplinary care team, including a psychologist with experience assessing and treating patients with chronic abdominal pain, to provide the best and most effective assessment and treatment approach 1. Furthermore, understanding that these conditions may share neurobiological mechanisms, such as central sensitization, can help guide more effective treatment strategies rather than treating each diagnosis in isolation, as highlighted in the diagnosis and treatment of endometriosis, which requires a comprehensive approach, including medical therapies, surgical excision, and imaging studies, such as expanded protocol transvaginal ultrasound (TVUS) and MRI, to inform patient decision making and surgical planning 1.

Key considerations in the management of these conditions include:

• A multimodal approach to treatment, including medications, physical therapy, cognitive behavioral therapy, and interventional procedures
• Addressing the specific underlying conditions and the overall pain processing dysfunction
• Involving a multidisciplinary care team, including a psychologist with experience assessing and treating patients with chronic abdominal pain
• Using self-management strategies, neuromodulation, and brain–gut behavior therapies to manage chronic pain
• Understanding the neurobiological mechanisms that underlie these conditions, such as central sensitization, to guide more effective treatment strategies.

From the Research

Unifying Diagnosis for Multiple Chronic Pain Conditions

There is evidence to suggest that central sensitization (CS) may be a common underlying mechanism for various chronic pain conditions, including chronic pain syndrome, MALS, IBS, endometriosis, and pelvic congestive syndrome 2, 3, 4.

• Central sensitization refers to an amplified response of the central nervous system to peripheral input, which can contribute to the development and maintenance of chronic pain.
• Studies have shown that CS is involved in various chronic pain conditions, including fibromyalgia, irritable bowel syndrome, and chronic pelvic pain 3.
• The concept of central sensitivity syndromes (CSS) has been proposed to describe a group of conditions characterized by CS, including fibromyalgia, irritable bowel syndrome, and temporomandibular disorder 3.

Treatment Implications

The recognition of CS as a common underlying mechanism for multiple chronic pain conditions has implications for treatment:

• A multimodal treatment approach that targets CS, including pain neuroscience education, cognition-targeted exercise therapy, sleep management, stress management, and dietary intervention, may be effective in managing chronic pain 2.
• Pharmacological options, such as tricyclic compounds, serotonin-norepinephrine reuptake inhibitors, and α2δ ligands, may also be useful in targeting CS 2, 4.
• A personalized treatment approach that takes into account the individual's specific needs and circumstances is recommended 5.

Diagnostic Considerations

The use of the term "chronic pain" as an umbrella term for various clinical conditions may be misleading, as it does not capture the complexity of long-standing pain states 6.

• A more nuanced approach to diagnosis and treatment is needed, one that takes into account the biopsychosocial factors that contribute to chronic pain 6.
• Further research is needed to develop more effective diagnostic methods and to identify the most appropriate labels for complex long-standing pain states 6.