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Complex regional pain syndrome medicalises limb pain

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2631 (Published 28 April 2014) Cite this as: BMJ 2014;348:g2631

Re: Complex regional pain syndrome medicalises limb pain

Dr. Christopher Bass describes the use of the name Complex Regional Pain Syndrome (CRPS) as a medicalisation of limb pain and by this description and the rest of the article he infers that CRPS is not a disease. 1 Dr. Bass may be right, but if we accept his argument we may demedicalise many more psychiatric and neurological conditions such as depression, schizophrenia, autism, migraine and many more that share with CRPS the fact that their diagnoses depend on clinical criteria. This response to Dr. Bass is not meant to defend CRPS’s right to be recognised as a disease, but to consider the right of patients to have an explanation for their symptoms, which are agonising, painful and often dismissed as a non-entity.

Dr. Bass argues that if CRPS label is given, it legitimises sick role. Although, some patients may behave that way, it is also recognised that many more patients and their relatives take the opposite attitude of “if that is the disease, what is the treatment?” and start looking for a solution rather than blaming all their ills on the label.

CRPS is a clinical disorder characterised by objective autonomic and sometimes neurologic signs as well as a subjective reporting of pain. The fact that the autonomic features can be reproduced in a laboratory environment by immobilisation after injury does not necessarily discredit CRPS from its independent characteristics. Immobilisation after injury is likely to be merely a risk factor that triggers the “disease” in predisposed individuals in the same way that exposure to pollens trigger asthma in an individual predisposed to asthma and photic stimulation triggers a seizure in people with photosensitive epilepsy. In considering the above, it is reasonable to ask: why do some patients have continuing pain “disproportionate” to the inciting event while others don’t? The answer is likely to be because most of us are not genetically predisposed or otherwise to CRPS in the same way as the majority of us are not predisposed to asthma or epilepsy.
Dr. Bass accepts that some patients are at risk of developing chronic pain including CRPS and calls for primary care doctors “to use an instrument that has the capacity to predict pain problems that are complicated, using so called yellow flags”. In this statement Dr. Bass agrees that some patients have higher predisposition to chronic pain or CRPS than others, but does not seem to accept that this predisposition could be biologic in origin with the biopsychosocial model in its manifestation.

Dr. Bass also misses the point that changing the name of a condition does not change its clinical presence. His suggestion of renaming CRPS (previously known as reflex sympathetic dystrophy) as “legache” or “armache” may be attractive to some, but is unlikely to make the pain “proportionate” to the inciting event or change the treatment options offered by doctors. History shows that changing the name of myalgic encephalomyelitis (ME) to chronic fatigue syndrome did not reduce the incidence of the condition or its impact on patients’ quality of life, but may have changed our uderstanding of its biologic origin or lack of it.

We agree with Dr. Bass in his final comment that clinical psychologists play an important role in the biopsychosocial model of CRPS management and more psychologists with expertise in managing pain are needed.

References:
1. Bass C, Complex regional pain syndrome medicalises limb pain, BMJ, 2014;384:g2631

Competing interests: No competing interests

02 June 2014
Ishaq Abu-Arafeh
Consultant Paediatrician
Hashem Abu-Arafeh, Research Assistant
Forth Valley Royal Hospital
Stirling Road, Larbert, FK5 4WR