One of the worst forms of chronic pain is
Complex Regional Pain Syndromes.
Complex Regional Pain Syndromes are a very
confusing aspect of pain.
CRPS is probably
the commonest reason, other than headaches,
that people see pain physicians.
CRPS is divided into two subtypes.
Type 1, where there is no known underlying peripheral nerve injury,
and type 2 where there is an identifiable cause of peripheral nerve injury.
It occurs in a transitional to a chronic
form. And this is one of the conditions where,
if it's treated very aggressively in that what I call
transitional phase, can be treated and cured.
It could be initiated by very minor
insults, just soft tissue injuries, usually to the periphery,
more commonly on upper limbs than
lower limbs, but it can occur in either.
And it's caused by peripheral sensitization
resulting in what's called Allodynia and Hyperalgesia.
So allodynia is the condition in which
barely a breath of air causes
severe pain. And hyperalgesia
is pain that's much more extreme than
the injury seems to indicate. So Complex
Regional Pain Syndromes can be associated
with very minor injuries. And I'm
going to tell you a story from my own life, from the life
of my son, my younger son, who was driving
my car one day and was T-boned by a poor, confused
lady who went through a red light and smashed
into my son, my son who was driving.
He immediately had some
mild pain in his right, left arm and he
had some difficulty with his neck.
But beyond that, he really didn't have a lot of problems. We went
to the hospital, he was examined, there were no severe
injuries discovered. My son is a pianist.
He plays the piano. And at the time
this occurred, he was in university doing his degree
in Piano Performance. And he needed to practice
a piano anywhere from 4-8 hours a day.
He discovered very quickly after this
accident that he couldn't practice, that he
had pain in his left wrist that not only
interfered with his ability to practice the piano, but interfered
with his sleep, and was starting to cause
some changes in his personality that were
a concern both to him and to us. We had his wrist
absolutely thoroughly investigated.
It was x-rayed, he had
nerve studies done, he had an MRI,
he had a CT scan. He went
to see a hand and wrist specialist
and nothing showed any acute injury,
there was no fracture, there were no obvious damage,
but he continued to have pain and he was unable
to play the piano. We worked
very aggressively on using
nonprescription medications, he was not
given any narcotics. And physiotherapy.
And over a year. But it took a full year.
He finally recovered. That was
about 10 years ago. He now plays the piano
all the time. He has a very busy piano
studio where he teaches students,
and the pain is largely gone. It only occurs
occasionally. But I think that gives you
some indication of how devastating this
injury is, complex regional pain syndromes,
in the absence of any real damage that could
be determined. He was incapacitated, he wasn't
able to do what he was planning to do for the rest
of his life. I'm going to tell you
a second story about a young woman
I was involved in the treatment of,
who had a minor fracture in her wrist.
And she discovered, she developed a complex
regional pain syndrome that became increasingly
severe over a couple of months. And it affected
her to the point where her skin changed color,
it became pale, she developed
edema in her hand and wrist. She
develop this allodynia, you could not go near her
without the pain becoming very severe.
This was a very stable, capable woman.
She had a young family, she had
a full time job, and she was right arm
dominant. She went through a very
aggressive series of treatments, right up to
the point of having what's called a spinal
cord stimulator inserted, which is just about
the most invasive thing we can do
for pain management. None of them
worked. She chose to have an amputation
of her dominant arm to get rid
of that pain. She had a minor
injury, she ultimately, two years later,
ended up having her dominant arm
removed. And she was thankful for it.
So this gives you some idea of how
severe this problem can be and how
devastating it can be to an individual's
life. It's often associated with extreme sensitivity,
that's the allodynia I've mentioned
about. But changes to the central nervous system
resulting in brain adapting to the constant pain,
and what's known as neuroplasticity, where
the actual functioning of the brain changes
somewhat to modify its response
to the pain. And we simply don't know
what causes this. But it's a devastating condition
and it's very common.