Tag Archives: RSD

09Jun/11

Complex Regional Pain Syndrome – ‘it feels weird’

Complex Regional Pain Syndrome (CRPS) often presents with a number of signs and symptoms. The main complaints are usually pain, colour change (minute to minute sometimes), temperature change, swelling, sweating changes, skin/nail/hair changes (trophic) and an altered perception of the affected part. It is this last sense that I am going to focus upon in this blog.

I hear many different descriptions of the symptoms of CRPS and actually encourage the use of a wide range of words. This is so that I can develop a really good picture and insight into the individual’s experience which is exactly that, individual. One aspect that I am particularly interested in is the perception of the affected area. In the vast majority, if not all, cases there is an altered sense of the region. For example, in the case of the hand it can feel bigger (sausage fingers often a good description of the feel), swollen, distorted, out of place, detached, like it belongs to someone else, like it is not there unless looked at (visual input to confirm presence) or denial that it is there at all (denial – similar to those who suffer strokes).

This variety of descriptions paint the picture of a ‘stranger’ aspect of the condition, often claimed to be ‘weird feelings’ as they are so abstract and like nothing before. Clearly this can be worrying and sometimes I hear that when the descriptions are given to others there maybe disbelief. Any aspect of a problem that creates fear or anxiety can affect pain and must be addressed.

So what is going on? When we have an on-going painful problem and we are not moving normally, changes occur within the central nervous system to give us this different experience. In the brain we have maps, virtual maps, that the brain uses to work out where sensory information is coming from and control movement. These maps are well defined under normal circumstances with a genetic blueprint that is moulded by experiences. This precise definition relies on a constant stream of information coming in from the tissues. In the case that this flow is altered or stopped, the map changes. We know this from fMRI studies that demonstrate reorganisation of the brain in certain areas. Certain representations of body parts are found to be in different locations in pain states. In fact, many brain changes have been found in chronic pain, these changes underpinning our different experiences of the body. The good news is that with effective treatment of the pain, these changes are reversed. Effective treatment will be the subject of another blog, but this includes such therapies as graded motor imagery and others that seek to ‘redefine the maps’.

In summary, chronic pain states, including CRPS and back pain, we know that the cortical (brain) maps change and that this is the reason why the affected area can feel ‘weird’, out of place and just not right. The map is ‘smudged’. In a sense this is useful as it draws our attention to something that needs dealing with imminently. The focus of treatment for this is upon ‘redefining’ the maps, the same for a range of conditions. In fact, my view is that this is what modern rehabilitation is really about in essence, via normalisation of sensation, motor control and the congruence of these factors, alongside the traditional strength gains and tissue changes. Our understanding of smudging and cortical reorganisation has triggered a change in thinking for rehabilitation, targeting the brain, training the brain and offering science based solutions for chronic pain.

The pictures are from the book ‘Explain Pain

19Apr/11
Hands of God & Adam

Complex Regional Pain Syndrome (CRPS/RSD)

Complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy (RSD), is undoubtedly a nasty condition in many cases. It can be hugely disruptive in the desire to lead a normal and fulfilling life due the experience of sheer pain and the difficulty in doing day to day activities.

I hear a huge range of stories of how the problem began and how it has been treated. Sometimes there is a significant injury, but often it is the type of event that one would associate with recovery such as an ankle sprain, a knocked elbow or a fracture. Unfortunately in a number of cases this simply does not happen. The injury is sustained, the area usually hurts as you would expect but then it continues to hurt and gets worse. There are associated signs and symptoms such as colour change, temperature change, altered sensation (pins and needles, numbness), an altered sense of position, a feeling of ‘largeness’, ‘thickened’ skin, huge sensitivity to light touch (allodynia), changes in skin, hair and nails. Fortunately we understand much more about the underlying mechanisms and can explain what and why this is happening, giving the problem a meaning which is so important in a condition that is troubling and causing great suffering.

CRPS in the foot and leg causes great difficulty in walking and standing in many cases. If the tissues are stiffened and the control of movement is poor, the ability to walk normally can be severely limited. Add the pain to this scenario and it becomes incredibly disabling at times as the sufferer simply cannot undertake normal activities. In CRPS in the upper limb it is writing, computer use, dressing, holding tools and self-care that are challenged.

Similar to any painful state, determining the pain mechanism(s) is important in deciding where to focus the treatment. Often there can be co-existing mechanisms such as inflammatory pain and neuropathic pain underpinned by different processes and manifesting in different ways. Neuropathic pain is often sharp, lancing, shooting and accompanied by a loss of sensation in the same area that can be confounding until you understand how it works. Inflammatory pain can be provoked by movement and touch with the mechanism being excited sensory nerves (nociceptors) as a result of the release of inflammatory molecules. Nerves themselves can release such chemicals into the tissues (neurogenic inflammation) and thereby keep the process going. There are many other aspects to the pain and the drivers and influences.

As well as elucidating the pain mechanisms, identifying the influences is also very important. This can include stress, fatigue, emotional state, past experience, culture, beliefs in addition to lifestyle factors and general health. Personally I look for risk factors for chronicity with all new assessments so that these can be fealty with swiftly. When a condition has been in existence for a longer period, adapting this to understand behaviours, choices and other factors that could be prolonging the problem is important.

Modern treatment of pain including CRPS should be within a biopsychosocial framework. That means looking at the biological mechanisms, psychology and social factors that are all part of the pain experience and mould the individual perception. In many cases the sufferer needs input from physiotherapy, pain medicine and psychology. Initially educating the patient to develop understanding, reduce fear of the pain and movement and enable effective coping and self-care is key. Desensitising the body with a range of techniques that blend the physical with the cognitive through the application of various stimuli is useful. This could be a paint brush or cotton wool for example. Tactile discrimination and two point discrimination are normal sensory functions that can be altered and according to recent studies are likely to need training. The graded motor imagery programme is part of the treatment, targeting brain changes that can occur. The three stages are laterality, imagined movement and mirror therapy. This is a newer intervention and is demonstrating good results in CRPS and with other nasty pains. The self-care aspects are fundamental. Teaching the patient to manage their activities and to develop consistency through their day is key. Sometimes activities are overdone and there is a trade off. For example standing at a party, but you really want to go and afterwards you know it will hurt but accept that this will be the case. Good flare-up management skills can play a huge role during these times. A further group of interventions I call perceptual exercises. Due to the plastic changes in the sensory and motor cortices, the sense of self, body and movement can feel different in many ways. Working with this through the use of imagery, mindfulness, awareness and other strategies can really help to get back in touch with the body alongside the other techniques. Finally, motor control exercise to normalise movement is very important but to be done at the right time in the right way.

The context of the treatment can affect the success of the strategy. Timing, environment, understanding and belief must all be considered when designing a programme. Newer ideas and research about neuroimmune responses to exercise, movement and thoughts suggest that we need to be mindful of these factors. This is the modern way of looking at the individual, their pain and circumstances to offer practical and effective strategies in improving outcomes and quality of life.

Subsequent blogs will look at the other symptoms, why and how they manifest and the effects of stress upon the body.