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Complex regional pain syndrome medicalises limb pain

BMJ 2014; 348 doi: (Published 28 April 2014) Cite this as: BMJ 2014;348:g2631

Re: Complex regional pain syndrome medicalises limb pain

Prioritising psychosocial over biomedical factors at diagnosis of type 1 CRPS - and conflating CRPS with other causes of chronic pain by adopting yet another, even vaguer label - infers that CRPS is a psychosomatic condition, and would lead medical thinking away from finding the cause(s) of this very real condition.

To avoid confusion, diagnosis of CRPS really should be restricted to patients who have the clearly-described signs, including trophic and/or vascular/sudomotor/proprioceptive sympathetic regulatory changes in the affected limb.

The seemingly large increase in CRPS may suggest that it is becoming a fashionable diagnosis, which fulfils our need to diagnose, but which rests on criteria inadequately specific or too loosely applied to ensure the coherence of the CRPS diagnosis.

To infer that patients with CRPS who express wishes to have limbs amputated or to end their lives are driven by catastrophic thinking is itself evidence of iatrogenic harm by disbelief - the pain really is that bad and it may drive extreme responses in otherwise well-balanced individuals.

My own experience of discal neck injury at 28yoa, followed by progressive deterioration over twelve years with multi-level radiculopathies, was painful. But it bears no comparison to the *high-emotive descriptors* pain of CRPS I experienced for about a year 2002-3.

The ascribing, in my case, of the cause as being a distortion of the sympathetic trunk by jammed/subluxed upper rib heads, facilitated a cure by one (among many I tried) highly skilled mechanical medical osteopath.

There is a substantial cohort of patients who develop upper limb CRPS after shoulder injuries; it is my opinion that sympathetic trunk distortion by rib-heads (difficult to measure by nerve conduction studies) may underlie the explanation in some such cases. Physical and potentially curable.

It was this experience which led to my recovery and my subsequent training as a medical osteopath (my MRI still shows multilevel radicular compression and bulging disc osteophytes with cord impressions). Mechanical osteopathy has proved extremely useful to me in general practice, treating - and quite often curing - patients with many presentations of chronic spinal and limb pains, including a few with features of CRPS. Most have already done the rounds of medical and Pain Clinic specialities without benefit.

There are those who believe that back pain is a psychosocial construct and that osteopathy is witchcraft, despite strong evidence to the contrary. I know my narrative counts for little in evidence-based Medicine, but it is real.

A substantial proportion of chronic pain is musculoskeletal in origin and may potentially be remediable by use of a mechanical model for diagnosis and treatment. We lack such training as doctors. The demedicalisation of back pain hitherto has not led to any reduction in the consequent burden on patients, doctors, industry or the State.

Demedicalising CRPS and using homogeneous, over-arching terms risks distracting us from looking for proper answers on behalf of individuals with - if correctly identified - different presenting conditions.

Competing interests: No competing interests

02 June 2014
Nick Mann
GP and Osteopath
Well St Surgery
28 Shore Rd E9 7TA