BMJ 2014;348:g2631 doi: 10.1136/bmj.g2631 (Published 28 April 2014)
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
Complex regional pain syndrome medicalises limb pain Psychosocial factors may be more important than biomedical ones in type 1 disorder, writes Christopher Bass Christopher Bass consultant liaison psychiatrist, John Radcliffe Hospital, Oxford OX3 9DU, UK I am a psychiatrist who has worked in general hospitals and pain clinics since the 1970s and have assessed many patients given a diagnosis of type 1 complex regional pain syndrome (CRPS). The syndrome is often diagnosed by inexperienced junior doctors when confronted by patients with unexplained symptoms, especially pain in the hands and feet. CRPS was once called algodystrophy, then reflex sympathetic dystrophy, but by 1994 the sympathetic component was abandoned and the current term was introduced.1 CRPS is part of a larger problem in chronic pain and reflects our lack of knowledge of causal mechanisms.
and behaviour: the adoption of a label such as CRPS affords legitimacy but may be disempowering and encourage the adoption of the sick role.10 Although labelling can make sense of chronic and disabling symptoms, it may have adverse long term implications because the doctor may behave differently once the symptoms have been assigned a label. Some astute pain clinicians are aware of this capacity for iatrogenic harm11 and “abnormal treatment behaviour.”12
Several new diagnostic criteria have been proposed,3 but they are not sufficiently objective or reliable.4 For example, criteria such as “continuing pain that is disproportionate to the inciting event,” allodynia (pain to light touch), and weakness or tremor are common and non-specific. Any patient with these characteristics could attract a diagnosis of CRPS when “disproportionate pain” would be a more appropriate description.5 This term does not medicalise the symptoms with a “disease” label and has less potential for iatrogenic harm.
These psychosocial factors can and should be systematically measured using simple scales before a person is labelled as having CRPS and subjected to invasive procedures. Measures of “anxiety” and “depression” do not always detect these key antecedent factors.15
It has been my impression that increasing numbers of patients are being diagnosed with this disorder, and that incidence rates are increasing (estimates in 2007 of 50 000 new cases annually in USA).2 In my opinion excessive reliance on this so called biomedical diagnosis for these patients is misguided. How has this occurred?
Others have criticised the diagnosis of CRPS as “best construed as a reaction to injury, or to excessive, often iatrogenic, immobilisation after injury”6 and, more recently, as an “illness construction rather than an actual disease.”7
Not only is the diagnosis difficult to confirm but also it has been shown that brief immobilisation or prolonged casting of a limb can produce symptoms and signs that mimic CRPS.1 8
One of the unfortunate consequences of this diagnosis is that once established it has the potential to cause considerable disability, especially in vulnerable people.9 The “disease” label may also have a profound adverse effect on patients’ beliefs
As a consequence these patients often become excessively bodily focused and the suspicion of “disease” heightens bodily awareness and reinforces the belief that the patient is ill. Disability often ensues. Key psychosocial factors are ignored and neither acknowledged nor tackled by the interviewer. This is important, because considerable evidence now shows that catastrophic thinking and abnormal health beliefs and expectations are the main determinants of chronic pain after injury, as most of these cases are.13 14
Indeed, abundant evidence now shows that it is these aspects of the psychosocial environment and not biological factors that are associated with a higher likelihood of developing chronic painful disorders such as back pain,16 17 whiplash neck injury,18 19 and fibromyalgia or chronic widespread pain.20 It is invariably antecedent psychosocial factors, as well as beliefs or expectations about recovery after an injury, that are more likely to determine whether the pain becomes chronic, rather than the nature or severity of the injury. How can we rethink our approach to the management of these patients? Firstly, because these problems present in primary care,21 it is important for detection to occur at an earlier stage before it becomes a “chronic pain” problem. Primary care doctors routinely use the patient health questionnaire PHQ-9 to identify symptoms of anxiety and depression, so why can’t they be
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BMJ 2014;348:g2631 doi: 10.1136/bmj.g2631 (Published 28 April 2014)
Page 2 of 2
VIEWS & REVIEWS
encouraged to use an instrument that has the capacity to predict pain problems that are complicated, using so called yellow flags? Patients at risk of developing chronic pain can be identified on a simple rating scale and referred at an earlier stage for the appropriate intervention.22 In the community there have been recent initiatives from commissioners to link local Improved Access to Psychological Therapy (IAPT) services to pain services so that patients can access psychological treatment quicker.23 However, IAPT practitioners may lack the requisite skills to manage these complex patients.24 Secondly, there is a case for abandoning the term CRPS altogether because of its potential for iatrogenic harm. Terms such as “non-specific arm pain” have been advocated, and “good examples in the English language include headache and backache, why not armache or legache?”4
Finally, there needs to be appropriate education and training for clinicians working in pain clinics. The input of psychological services in pain clinics is patchy in the United Kingdom. Regrettably, few psychiatrists in the UK are interested or involved in chronic pain, and there is on average only one clinical psychologist with an experience in pain per three million of the population. Given the importance of psychosocial factors as drivers for chronic pain, this provision is grossly inadequate. We need adequate psychological services in pain clinics, especially because patients with chronic pain better accept psychological assessment and treatment if it is offered in a multidisciplinary pain context.25
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
23
Provenance and peer review: Not commissioned; not externally peer reviewed.
24
1 2 3 4
Schott GD. Complex? Regional? Pain? Syndrome? Pract Neurol 2007;7:145-57. Breuhl S, Chung OY. How common is complex regional pain syndrome-Type 1? Pain 2007;129:1-2. Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med 2007;8:326-31. Ring D, Barth R, Barsky A. Evidence-based medicine: disproportionate pain and disability. J Hand Surg Am 2010;35:1345-7.
For personal use only: See rights and reprints http://www.bmj.com/permissions
25
Vranceanu AM, Barsky A, Ring D. Less specific arm illnesses. J Hand Ther 2011;24:118-23. Pearce JM. Chronic regional pain and chronic pain syndromes. Spinal Cord 2005;43:263-8. de Asla RJ. Complex regional pain syndrome Type 1: disease or illness construction? J Bone Joint Surg Am 2011;93:e116. Singh HP, Davis TR. The effects of short-term dependency and immobility on skin temperature and colour in the hand. J Hand Surg Br 2006;31:611-5. Gupta A, Silman AJ, Ray D, Morriss R, Dickens C, MacFarlane GJ, et al. The role of psychosocial factors in predicting the onset of chronic widespread pain: results from a prospective population-based study. Rheumatology (Oxford) 2007;46:666-71. Page LA, Wessely S. Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter. J Roy Soc Med 2003;96:223-37. Munglani R. Does a diagnosis in pain medicine promote disability? Pain News 2012;10: 16-8. Kouyanou K, Pither CE, Wessely S. Iatrogenic factors and chronic pain. Psychosom Med 1997;59:597-604 . Creed F. Should general psychiatry ignore somatization and hypochondriasis? World Psychiatry 2006;5:146-50. Blyth FM, Macfarlane GJ, Nicholas MK. The contribution of psychosocial factors to the development of chronic pain: the key to better outcomes for patients? Pain 2007;129:8-11. Beerthuizen A, Stronks DL, Huygen FJ, Passchier J, Klein J, Spijker AV. The association between psychological factors and the development of complex regional pain syndrome type 1 (CRPS1)—a prospective multicentre study. Eur J Pain 2011;15:971-5. Nicholas MK, Linton SJ, Watson PJ, Main CJ. Early identification and management of psychosocial risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Phys Ther 2011;91:737-53. Main CJ, Sowden G, Hill JC, Watson PJ, Hey EM. Integrating physical and psychological approaches to treatment in low back pain: the development and content of the STarT Back trial’s “high risk” intervention. Physiotherapy 2012;98:110-6. Holm LW, Carroll LJ, Cassidy JD, Skillgate E, Ahlbom A. Expectations for recovery important in the prognosis of whiplash injuries. PloS Med 2008;5:e105. Atherton K, Wiles NJ, Lecky FE, Hawes SJ, Silman AJ, Macfarlane GJ, et al. Predictors of persistent neck pain after whiplash injury. Emerg Med J 2006;23:195-201. Haviland MG, Morton KR, Oda K, Fraser GE. Traumatic experiences, major life stressors, and self-reporting a physician-given fibromyalgia diagnosis. Psychiatry Res 2010;177:335-41. Croft P, Blyth FM, van der Vindt D, eds. Chronic pain as a topic for epidemiology and public health. In: Chronic pain epidemiology; from aetiology to public health. Oxford University Press, 2010. Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;378:1560-71. Department of Health, Improving access to psychological therapies (IAPT). Long-term conditions positive practice guide. October 2008. www.iapt.nhs.uk/silo/files/longtermconditions-positive-practice-guide.pdf. Williams AC, Johnson M. Persistent pain: not a medically unexplained symptom. Br J Gen Pract 2011;61:638-9. Roditi D, Robinson ME. The role of psychological interventions in the management of patients with chronic pain. Psychol Res Behav Manag 2011;4:41-9.
Cite this as: BMJ 2014;348:g2631 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
Complex regional pain syndrome medicalises limb pain Psychosocial factors may be more important than biomedical ones in type 1 disorder, writes Christopher Bass Christopher Bass consultant liaison psychiatrist, John Radcliffe Hospital, Oxford OX3 9DU, UK I am a psychiatrist who has worked in general hospitals and pain clinics since the 1970s and have assessed many patients given a diagnosis of type 1 complex regional pain syndrome (CRPS). The syndrome is often diagnosed by inexperienced junior doctors when confronted by patients with unexplained symptoms, especially pain in the hands and feet. CRPS was once called algodystrophy, then reflex sympathetic dystrophy, but by 1994 the sympathetic component was abandoned and the current term was introduced.1 CRPS is part of a larger problem in chronic pain and reflects our lack of knowledge of causal mechanisms.
and behaviour: the adoption of a label such as CRPS affords legitimacy but may be disempowering and encourage the adoption of the sick role.10 Although labelling can make sense of chronic and disabling symptoms, it may have adverse long term implications because the doctor may behave differently once the symptoms have been assigned a label. Some astute pain clinicians are aware of this capacity for iatrogenic harm11 and “abnormal treatment behaviour.”12
Several new diagnostic criteria have been proposed,3 but they are not sufficiently objective or reliable.4 For example, criteria such as “continuing pain that is disproportionate to the inciting event,” allodynia (pain to light touch), and weakness or tremor are common and non-specific. Any patient with these characteristics could attract a diagnosis of CRPS when “disproportionate pain” would be a more appropriate description.5 This term does not medicalise the symptoms with a “disease” label and has less potential for iatrogenic harm.
These psychosocial factors can and should be systematically measured using simple scales before a person is labelled as having CRPS and subjected to invasive procedures. Measures of “anxiety” and “depression” do not always detect these key antecedent factors.15
It has been my impression that increasing numbers of patients are being diagnosed with this disorder, and that incidence rates are increasing (estimates in 2007 of 50 000 new cases annually in USA).2 In my opinion excessive reliance on this so called biomedical diagnosis for these patients is misguided. How has this occurred?
Others have criticised the diagnosis of CRPS as “best construed as a reaction to injury, or to excessive, often iatrogenic, immobilisation after injury”6 and, more recently, as an “illness construction rather than an actual disease.”7
Not only is the diagnosis difficult to confirm but also it has been shown that brief immobilisation or prolonged casting of a limb can produce symptoms and signs that mimic CRPS.1 8
One of the unfortunate consequences of this diagnosis is that once established it has the potential to cause considerable disability, especially in vulnerable people.9 The “disease” label may also have a profound adverse effect on patients’ beliefs
As a consequence these patients often become excessively bodily focused and the suspicion of “disease” heightens bodily awareness and reinforces the belief that the patient is ill. Disability often ensues. Key psychosocial factors are ignored and neither acknowledged nor tackled by the interviewer. This is important, because considerable evidence now shows that catastrophic thinking and abnormal health beliefs and expectations are the main determinants of chronic pain after injury, as most of these cases are.13 14
Indeed, abundant evidence now shows that it is these aspects of the psychosocial environment and not biological factors that are associated with a higher likelihood of developing chronic painful disorders such as back pain,16 17 whiplash neck injury,18 19 and fibromyalgia or chronic widespread pain.20 It is invariably antecedent psychosocial factors, as well as beliefs or expectations about recovery after an injury, that are more likely to determine whether the pain becomes chronic, rather than the nature or severity of the injury. How can we rethink our approach to the management of these patients? Firstly, because these problems present in primary care,21 it is important for detection to occur at an earlier stage before it becomes a “chronic pain” problem. Primary care doctors routinely use the patient health questionnaire PHQ-9 to identify symptoms of anxiety and depression, so why can’t they be
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2631 doi: 10.1136/bmj.g2631 (Published 28 April 2014)
Page 2 of 2
VIEWS & REVIEWS
encouraged to use an instrument that has the capacity to predict pain problems that are complicated, using so called yellow flags? Patients at risk of developing chronic pain can be identified on a simple rating scale and referred at an earlier stage for the appropriate intervention.22 In the community there have been recent initiatives from commissioners to link local Improved Access to Psychological Therapy (IAPT) services to pain services so that patients can access psychological treatment quicker.23 However, IAPT practitioners may lack the requisite skills to manage these complex patients.24 Secondly, there is a case for abandoning the term CRPS altogether because of its potential for iatrogenic harm. Terms such as “non-specific arm pain” have been advocated, and “good examples in the English language include headache and backache, why not armache or legache?”4
Finally, there needs to be appropriate education and training for clinicians working in pain clinics. The input of psychological services in pain clinics is patchy in the United Kingdom. Regrettably, few psychiatrists in the UK are interested or involved in chronic pain, and there is on average only one clinical psychologist with an experience in pain per three million of the population. Given the importance of psychosocial factors as drivers for chronic pain, this provision is grossly inadequate. We need adequate psychological services in pain clinics, especially because patients with chronic pain better accept psychological assessment and treatment if it is offered in a multidisciplinary pain context.25
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
23
Provenance and peer review: Not commissioned; not externally peer reviewed.
24
1 2 3 4
Schott GD. Complex? Regional? Pain? Syndrome? Pract Neurol 2007;7:145-57. Breuhl S, Chung OY. How common is complex regional pain syndrome-Type 1? Pain 2007;129:1-2. Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med 2007;8:326-31. Ring D, Barth R, Barsky A. Evidence-based medicine: disproportionate pain and disability. J Hand Surg Am 2010;35:1345-7.
For personal use only: See rights and reprints http://www.bmj.com/permissions
25
Vranceanu AM, Barsky A, Ring D. Less specific arm illnesses. J Hand Ther 2011;24:118-23. Pearce JM. Chronic regional pain and chronic pain syndromes. Spinal Cord 2005;43:263-8. de Asla RJ. Complex regional pain syndrome Type 1: disease or illness construction? J Bone Joint Surg Am 2011;93:e116. Singh HP, Davis TR. The effects of short-term dependency and immobility on skin temperature and colour in the hand. J Hand Surg Br 2006;31:611-5. Gupta A, Silman AJ, Ray D, Morriss R, Dickens C, MacFarlane GJ, et al. The role of psychosocial factors in predicting the onset of chronic widespread pain: results from a prospective population-based study. Rheumatology (Oxford) 2007;46:666-71. Page LA, Wessely S. Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter. J Roy Soc Med 2003;96:223-37. Munglani R. Does a diagnosis in pain medicine promote disability? Pain News 2012;10: 16-8. Kouyanou K, Pither CE, Wessely S. Iatrogenic factors and chronic pain. Psychosom Med 1997;59:597-604 . Creed F. Should general psychiatry ignore somatization and hypochondriasis? World Psychiatry 2006;5:146-50. Blyth FM, Macfarlane GJ, Nicholas MK. The contribution of psychosocial factors to the development of chronic pain: the key to better outcomes for patients? Pain 2007;129:8-11. Beerthuizen A, Stronks DL, Huygen FJ, Passchier J, Klein J, Spijker AV. The association between psychological factors and the development of complex regional pain syndrome type 1 (CRPS1)—a prospective multicentre study. Eur J Pain 2011;15:971-5. Nicholas MK, Linton SJ, Watson PJ, Main CJ. Early identification and management of psychosocial risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Phys Ther 2011;91:737-53. Main CJ, Sowden G, Hill JC, Watson PJ, Hey EM. Integrating physical and psychological approaches to treatment in low back pain: the development and content of the STarT Back trial’s “high risk” intervention. Physiotherapy 2012;98:110-6. Holm LW, Carroll LJ, Cassidy JD, Skillgate E, Ahlbom A. Expectations for recovery important in the prognosis of whiplash injuries. PloS Med 2008;5:e105. Atherton K, Wiles NJ, Lecky FE, Hawes SJ, Silman AJ, Macfarlane GJ, et al. Predictors of persistent neck pain after whiplash injury. Emerg Med J 2006;23:195-201. Haviland MG, Morton KR, Oda K, Fraser GE. Traumatic experiences, major life stressors, and self-reporting a physician-given fibromyalgia diagnosis. Psychiatry Res 2010;177:335-41. Croft P, Blyth FM, van der Vindt D, eds. Chronic pain as a topic for epidemiology and public health. In: Chronic pain epidemiology; from aetiology to public health. Oxford University Press, 2010. Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 2011;378:1560-71. Department of Health, Improving access to psychological therapies (IAPT). Long-term conditions positive practice guide. October 2008. www.iapt.nhs.uk/silo/files/longtermconditions-positive-practice-guide.pdf. Williams AC, Johnson M. Persistent pain: not a medically unexplained symptom. Br J Gen Pract 2011;61:638-9. Roditi D, Robinson ME. The role of psychological interventions in the management of patients with chronic pain. Psychol Res Behav Manag 2011;4:41-9.
Cite this as: BMJ 2014;348:g2631 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
