Showing posts with label Kaiser Permanente Neurologists. Show all posts
Showing posts with label Kaiser Permanente Neurologists. Show all posts

Saturday, September 27, 2014

As the fog dissipates

I've been putting off blogging, though each day, lately, has proffered plenty of blog-fodder!  My head is not screwed on correctly, my memory is pretty faulty.  The people, animals, things, and activities that normally are my nominal saviors have fallen down on the job.  Or wised up!

Housekeeping:  The brave Ethan Hallmark died a few days ago.  You already know about the effervescent Brayden Martin.  His mom Maranda, brother Mason, grandmother Robin are blessed with the support of many friends, family, and memories.  Maranda's many off-the-cuff phone vids of a giggling Brayden, which, quite frankly, were starting to drive me crazy, now show themselves each as little jewels, shining, shining.  She did a great job raising that child and simply mowed down any circumstance that even hinted of getting in the way.

We were going to give Brayden one of my spare power chairs (that's right! my riches know no end!) and were even trying to make some adjustments and improvements, because he was a little boy, and, well, I am not.

Sven got out the Marlinspike Hall Treasury of Blowtorches and reconfigured the mind-boggling cloverleaf pattern on the underbelly of the chair.  Bianca Castafiore offered free picks of fabrics from her costuming collection that has clothed thousands of operatic divas over the years.  When she saw me with a glue gun and her precious Christian Lacroix courtisan costume (Hey! It was in the pile she said I could use!) -- she manhandled me.  Pins in her mouth, pinking shears, and microsurgical instruments strewn about, she cursed me, though I couldn't quite tell to what I was being condemned, or in what language. I heard some gutturals -- she may have gone Germanic on me.

Finally, spewing pins everywhere, she hollered -- and yes, Milanese operatic divas can and do "holler" -- "Retired Educator, you bilious brain fart! Brayden loves ORANGE and THIS is a wheelchair, hardly conducive to being covered in crinoline and skin-irritating brocades. What is wrong with you?  Go look in the mirror. You have "crétine" tattooed on your forehead..."

A courtisan costume designed by Christian Lacroix for the SF Opera's , "The Capulets and The Montagues,"
at the SF Opera's costume shop on Thursday, Aug. 23, 2012 in San Francisco, Calif.
Photo: Russell Yip, The Chronicle / SF




Well, in the end, it was beautiful and no one would ever notice our judicious use of duct tape.  I tried to ignore Captain Haddock's remark that it looked like a jeepney.

But something we'll cave in and call "circumstances" intervened, and our jeepney-opera inspired reinvention of a power chair ended up with a local woman who "needed me one of those," and we were glad it went to be of use for someone.

Brayden on wheels.  Laughing Brayden. That's mostly what Maranda showed us.  Well, there was courageous Brayden, miserable and steroid-cheeked, but still giving a thumbs-up, and laughing on command.  Such bravery in a kid gets its own reward, and so I am, guiltily, happy for him.

Ethan. I worried about Ethan, not in any specific Ethan-way, but in a general why-do-these-kids-have-to-be-so-god-damned-perfect way. Whenever he was presented in normalcy, and this young man had a lot of rugged, good other young men who visited daily, that's when I connected with Ethan.  As anti-hunting as I am, it was thrilling to see him "bag a buck" a little over a week before he died.

And I have no right to knock the ways in which people survive, and survive in horrid circumstances. My own circumstances lead me to find comfort in beauty, less and less in books, paintings, movies, and the quieter stories of derring-do, more and more in the actual eyes of actual people. Okay, okay, I'm also in awe of people who do the darnedest things.  I'm thinking of the Infectious Disease PA -- one funny and smart Ava Cooper -- who had a burning desire to see the underside of my Accursèd Right Foot.  Now, this could have been accomplished in several ways, most of which would have been painful, as the Accursèd Right Foot has taken on life in its own inimitable, separatist way.

Did I mention PA Cooper's outfit?  No?  Well, she reminded me of me, some mumblemumble years ago as I trekked about Berkeley and walked from UC-B to San Francisco, over the Golden Gate, and into Marin.  In other words, she was cute.  Black leggings and a striped tunic, happy to be alive. I think she had sparkles on her shoes, not sure.

So she lays down on the freaking floor of this exam room in the Infectious Disease Clinic, her left ear on the pristine floor, black hair cascading over the antiseptic tile, and peers at the butt ugly sole of mine foot.

I mean, doggone, woman, I'd be glad to prop this useless appendage on that green plastic chair over there... or you could lay down on top of god-knows-what bacterial Soup of the Day!

But it just confirmed my gut knowledge that ID specialists are unique and special, in other ways beyond their quirky, nerdy science.  Same goes for the guy we call "Sherlock," Dr. Phillip Brachman. The man cracks me up.  He does me the honor of taking whatever I say at its value.  Last time I saw him, I was sobbing, rocking, in misery.  I felt, however, that he needed to know I was listening and capable, even with snot running down my face and badly applied eye makeup smeared in avant garde fashion into a hairline fade.

"I only cry when I spike a fever or feel really rotten but it doesn't mean that I'm not HERE."

Only a good doctor would address that with a slight nod and continue his Sherlockian machinations with computer and pharmacists online and on the phone.  He does not remember the day that I decided he was the cat's meow.  It was way back at the beginning of the Lose-A-Shoulder-To-A-Biofilm-Infection saga.  Maybe 2007 or 2008.  I was in the hospital and for some reason, in isolation (musta been one of those MRSA scares), and had the deep need to exit my bed and get into my wheelchair.

Isolation rooms are often neglected rooms.  Things are brought in that can't then just be taken out, without a hullaballou of cleaning.  So my bed was surrounded by every bit of equipment imaginable, from IVACs to bedside commodes (3 for some reason that I don't even want to know...) and extra bedside tables.  It was a sea of redundant medical schtuff.

I managed to climb over the rails, not pull out any i.v.s or detach monitoring devices, keep the foley catheter intact (though I forgot to nab the drainage bag, still hooked on the bedrail) and shove a path to the wheelchair.  It's *possible* that I was febrile and hallucinating.

Once ensconced in my chair, I surveyed the room and burst into... you guessed it... tears!  There was no where to go, no direction to point my joy stick, that was not blocked by redundant medical schtuff. And look!  My foley bag is over there, and I am over here!

The door to my isolation room pops open, and Dr. Brachman's head pivots about, figuring I must be in there somewhere.

He sees me trapped in the corner, surrounded by beeping machines, poop contraptions, and mobile tables with immovable wheels.  Dr. Brachman (formerly "Infectious Disease Dood") never wore protective gear.  No bright yellow paper suits for that guy, and rarely even any gloves.  :Lots of handwashing, though.

Anyway, even at that point in my experiences -- I was almost medically virginal -- I already knew that doctors don't "do" stuff.  They leave that for "someone." Someone in Internal Medicine. Someone in Radiology. Someone in Ortho, in Pain Management.  In this case, I would expect an even less elucidated "someone," like a lowly nurse, or the even more lowly patient care technician. But Dr. Brachman crowed something like, "Let's get you out of there."

In super hero fashion, he tossed equipment to the left, to the right, out the window, shoved stuff into the bathroom, and soon cleared a path...

So that I could humbly go back to bed.

The story doesn't tell well.  But it does mark the moment when I knew this guy was kind, smart, and funny as hell.

I don't want to lose you in this swirl of time traveling tale-telling.  Fast forward to... September 10, 2014.  I THINK that was the day.  It was referenced above as the weepy, snotty-nosed visit to Dr. B, after lo, these many years.  I saw him, was in unbelievable pain, so unbelievable that I'm not even going to throw adjectives at it.  He wanted several things.  A biopsy.  He actually went and dragged a dermatologist into the room ("She was wandering around the halls.").  He had, with a straight face, assured me that I did not want him wielding a knife or any pointy instruments. The dermatologist laughed at the both of us and did the standard, "I wouldn't touch that with a 10-foot pole" routine, and made dire threats about what would happen if the skin broke or were breached -- "It will never heal."

Pshaw!

Next he wanted to use a new antibiotic, administered intravenously, but only once a week.  It was the new gorillacillen: Dalvance (dalbavancin).  No matter that it wasn't in my insurance carrier's formulary and that getting it to the nearest infusion center would require calling out the National Guard. Oblivious to the fact that while he was an established Super Hero, the rest of the organization was peopled by mere hard-working humans.  "We'll work out the details.  I am trying to make things as easy as possible on you." Be still my heart!

Finally, he wanted an MRI. I tried to squash that idea, knowing how much orthopedic hardware is buried in my corrupt flesh, but he muttered something about "the radiologists will figure something out." This after everyone and their brother (and their sister) had wanted MRIs for the past 5 years but were denied, every time!

And Lo! (the Angel of the Lord), if his nurse didn't come sprinting out to the very carpeted waiting room, where I was gently waking a dangerously tired and grumpy Fred. "Your MRI is this afternoon!"

She handed us the order as well as the address of the place (far, far away), complete with a map. I don't know if I blogged about the rest of the day -- it had the makings of concretizing any loose PTSD symptoms Fred and I had managed to scrape off our souls.  The directions turned out to be to a Dental Urgent Care facility, located in the boondocks of a half-occupied strip mall.  A missed photographic opportunity, for sure, was the look on the ultra-plucked, hyper-blushed "fresh" country face of the 19 year old dental receptionist's face.

Me, red-eyed and sweaty, with a leg that looked like Mt. Vesuvius about to make history:  I'm guessing that you guys don't do MRIs here.

Bug-eyed receptionist:  No, ma'am.

There followed the saga of how phones don't help ya much when your call swirls at 28 mph in the perpetual vortex of "Customer Service Representatives are busy helping other customers.  Please continue to hold. Your call is very important to us.  For faster service, try logging on to KP.org!"

Have I been less than kind lately when speaking of Dear Fred?  Yes, I have, even if only in my very cranky, confused brain.  The man told me, not terribly politely, to "shut up, just shut up," and grabbed the sheath of helpful paperwork out of my right claw.  We were, of course, late now for the bleeping MRI.

Fred managed to do the following:  figure out where the nurse had intended to send us; close his eyes and retrace our meandering path to the strip mall, and (after opening those beautiful eyes again) drove us to a neutral point on the map now in his head.  And then, gasp!  He stopped and asked one of the indigenous  population where "X bleeping road might be." He was given landmarks, the only one which either of us remembered being a "Waffle House."

Yes, of course, we got there.  I forked over a $350 co-pay, and the lady said I was lucky because some poor soul had coded in the MRI suite and "they're still working on him, so they're behind anyway!" Hooray!

Anyway, we got it done, but the rest of the week was difficult due to my leg not appreciating hours on the road, and so on, and such froth.  The new antibiotic was all set up for Friday, then cancelled Friday morning.  I ended up in the ER/ED again, admitted again, and Plan C, D, or E was implemented.  Got a PICC line inserted and was started on Daptomycin.  Home nursing was set up.

Doctor Brachman went on vacation that Thursday, bless his bones.  Several nurses suggested that he might be autistic.  At my protestations, they'd say, "O! You like him.  Well, he's very talented at what he does.  People say he's a genius." Wily, crafty nurses.

Things began to go swimmingly.  The next four days saw slow improvement, and Fred easily fell back into the PICC line routine, and with good humor.  I was able to briefly stop observing my own navel lint, and consider the lives of people I love.  Somewhere in the middle of all that, Brayden died, Ethan was suddenly on hospice, Kate McRae suffered her third brain cancer relapse, my Lumpy Brother began radiation (complete with his own stories of clusterf*cks), my Amazing Stepsister continued to amaze in her care of our declining stepmom.  Even the stepmom amazed, as she unveiled the "dark side" of her personality, yelling at sweet Lumpkins, "Why aren't you here helping me?" That must have felt like (yet another) punch in the stomach for sweet Grader Boob. Anyway, I caught up on almost everyone's misery, finding strength in these beautiful people suffering so much more that I ever had or will.  They were still laughing through the tears, and I was tired of being snot-faced, so I did some cosmic chuckling.

Then we hit the next Wednesday.  You probably won't believe this.  We had an 8 am appointment with the Pain Management folks, a good thing as I had pain in need of management!  We also had found -- on the revered KP.org website -- and printed out the directions to this fifth new facility. Fred read them over, I double checked addresses, it looked easy as a deep dish cherry pie.

They were woefully wrong. Particularly the direction which had us turn left off the interstate exit, when the facility was about a half mile... to the right.  Easily a dozen roads bore the same moniker but swapped designations -- road, street, circle, parkway, lane, path-to-hell.  Fred didn't yell or snap quite so much, having witnessed my careful preparations up in the Computer Turret -- and getting up to the Turret in my condition was no easy feet.  Feat.

Again, the indigenous peoples of Jonesboro rose to the occasion, and our sanity-saving landmark this time was a "Steak and Ale."

I know!  I did not think there were any Steak and Ales left in existence, not that I'd ever frequented one.  Before Fred, and even ten years into Fred Time, I was a vegetarian.  If I had more red blood cells, I'd be going back to it.

So we got there... my leg now throbbing and growing, CRPS going nuts from more car stress.  Ruby the Honda CRV is a true babe, but when Fred is in NASCAR mode, she's not the smoothest babe on the road.

They refused to see me.  I begged, finally, waving about the KP.org directions, squealing nonsense about how "It wasn't our fault... y'all fucked us again!"  That got me a short visit with the local Nurse Ratchet.  She actually looked at the directions, shook her head, disappeared for 10 minutes, during which time a humming, blank-faced Fred went in search of coffee but only found grape-flavored vitamin water -- and then she returned and said, gruffly:  "Okay, she'll see you."

There's more, but I want to get to the following Monday, somehow.  The rest of Wednesday the 17th we shall cover with the gauzy curtain of faulty memory.  Thursday, Friday, and most of Saturday were lost to me -- big ass fatigue and a CRPS tantrum, fever, the right hand a lost claw. The last half of Saturday, I perked up.  For some reason, the infection in my leg seemed to be localizing again, kind of going back to its original look of a lone volcano in the middle of the top of my red and purple foot.  By Monday morning, I was pretty sure the thang was gonna blow.  "Good thing," thought I, "that Super Home Health Nurse Cindy is scheduled to come change my PICC dressing and draw labs. She can tell me if it's gonna blow -- and what the heck to do if it does!"

Poor Fred had been up all night, hitting the hay at sunrise.  So I decided to get up and toodle around the Manor, doing very small tasks and tending to very small animals (the Captain's husbandry interests in miniature species shows no sign of flagging... and then, of course, there are the three cats).  I let up whenever the volcano rumbled, but needed to be up to let down the drawbridge and pry open the mock and heavy Florence Baptistery doors to let the good nurse in.

Cindy is the first health care worker I've ever felt comfortable with in my home (Hey, we may be squatters, but we love Tête de Hergé and the Haddock ancestral testament to wild imperial-and-material-ism!).

And she was about to put on a show of ingenuity.

As I finally sidled up to the fanschy-panschy hospital bed in my Road Warrior wheelchair, and finally maneuvered mine arse onto its thin mattress, my piece o'shit right leg gently knocked the laptop precariously perched on the leg of the bedside table.  I watched, in what seemed like slomo, as it tipped gently onto the top of that piece o'shit foot, the high point of which, Mount Vesuvius, appeared to be its desired end point.

Yelling, yelling, whining, etcetera. Nurse Cindy rescues foot, only to find red thick and very pussy lava flowing underneath the electronics.  As if of one mind, we both said:

"We need to get a culture sample of that!"

Nurse Cindy became Nurse MacGyver.  She helped me haul the rest of me into bed, then sprinted to her car, and around the vast Marlinspike Hall in search of sterile implements.  In the end, with sterile gauze, she sucked up some of the "sample," placed it in a sterile vacutainer, and wrapped the whole kit-and-caboodle inside a sterile glove, then raced off to deliver it to a lab.

(The lab refused it.)
(But Nurse Cindy of Coram showed her worth that day!)

She also showed us how Fred now needed to, in as highly "clean," if not "sterile" conditions, change the bandage on the still-leaking foot, 3 times a day.  The first time he did it, I tried not to scream at Poor Fred as he donned gloves, removed the nasty, bloody wrappings, then SCRATCHED HIS NOSE.  In a well-modulated voice, I reiterated the instructions about what his hands were supposed to touch, and not touch, mostly for his sweet protection.  All I got was a "Did I really scratch my nose? I don't think so." Then he scratched his ear.

Fast forward to Wednesday, fast becoming my day of woe. September 24, 2014.  The day that went off without a hitch!  We knew where our appointment was, there was little traffic, we were even early!  And then I met the funny and smart PA Ava Cooper, the woman who plopped on the floor just to gaze at the sole of my foot.

I failed to mention that, thanks to Nurse Cindy MacGyver's instructions on wet bandaging, we had kept the volcano flowing... so that PA Ava Cooper could take a culture sample using the boring old typical tools of her trade! She acknowledged that the foot and lower leg were once again crappy looking (I forget the medical terms).  Another week of intravenous Dapto was ordered.  And we were back at the drawbridge a mere hour-and-a-half after departure.

The other thing I failed to mention was that late yesterday, a message came to me that there was a test result.  We weren't exactly expecting anything to grow, given the Dapto and all, but damned if something did not show itself:  serratia marcescens, or as I like to call it, "S. Macarena." It's been labelled a "secondary" infection, and so, in secondary fashion, a second antibiotic has been added. Blame is assigned to immunosuppression.

The new antibiotic makes me fart.

There are worse things, and these productions are near odorless, although annoying.  Dobby, for one, is not amused. Buddy and Marmy look alarmed, gaze about, sniff, and then go back to sleep.

I'm very vague now, depressed over my hand, though I snagged an appointment for October 7 for an OT "treat and evaluate, make new splint" session.  I also gave up on the arseholes in Neurology, the Doctors Huddleston and Wilensky, and am going to give Dr. Cole a shot at not hurting, and possibly, helping me.  Though I think it's too late for this hand.  But maybe she can take on the new neck jerks, head jerks, visual anomalies, and the everlovin' leg conniption fits from CRPS.  Pain is, as the kids say, ridiculous.

There's also so much going on in our world, on this Earth, that has me fascinated, terrified, and full of crazed opinions.  I want to blog about Syria, Saudi Arabia, Iran, Iraq, Israel, Algeria, France, the U.K. (and Scotland!), not to mention all the home grown idiocy this republic is producing, the degradation of politics, the apparent impossibility of holding office and holding on to one's ethics at the same time... I also want to make some kickass cat videos.

And I want to comfort Maranda, but cannot, don't know her well enough, don't speak the same language, no way I could!

But I can leave you with this recent photo of Ethan Hallmark, a remarkable cancer patient, and its young victim, but also a cool and ordinary kid.  As the fog dissipates, smiles and damp eyes gather in the wake.  You can read Ethan's story, as faithfully recorded by his Mom, at CaringBridge, HERE




************************************************************************



Maranda loving on Brayden... and vice-versa!




© 2013 L. Ryan

Wednesday, June 4, 2014

CRPS Ideology: A Timely Thread

An interesting, and timely, series of exchanges engendered by a "Personal View" statement entitled "Complex regional pain syndrome medicalises limb pain" submitted by Christoper Bass, a British psychiatrist. [BMJ 2014;348:g2631].

If you're a Faithful Reader, perhaps you'll recall two recent rants from this very blog as you read.
Good on ya!  For the Uninitiated, these two posts offer the reality that can result when entrenched ideology collides with actual patients:
Dr. Huddleston: A Presumption, I Presume?
Jose Ochoa, Famed Medical Turd, Has Doppelgänger in Metro Atlanta



Rembrandt's The Anatomy Lesson of Dr. Nicolaes Tulp



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.
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?
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 … [continued HERE]
______________________________________________________________________________________________________________________
Here are a few of the responses to Dr. Bass. To keep an eye on the growing thread, check back through THIS LINK:

Richard Haigh, Consultant Rheumatologist & Hon Senior Lecturer
Prof Candy McCabe, Royal National Hospital for Rheumatic Diseases;
Dr Nick Shenker, Addenbrookes Hospital, Cambridge.
Royal Devon & Exeter Hospital, Exeter EX2 5DW
With colleagues, we have set up CRPS Network UK to improve clinical care and promote research into this condition. Our members have been involved in developing recent evidence based national guidelines. We are disappointed that Bass writes a provocative but poorly argued case that CRPS is over diagnosed and has psychological stress as the main trigger and thus is a ‘medicalised’ phenomena[i]. We would argue that the evidence points in the other direction, and it is sad that Bass has ignored much of the peer reviewed literature that supports the construct as a distinct clinical phenomena and fails to recognise significant scientific and clinical advances.
Firstly he claims, without evidence, that junior doctors are diagnosing this condition without support of senior doctors. A brief survey of Pain Clinic services in the South West region reveals they are wholly consultant led and readily accept urgent referrals of suspected CRPS. In our clinical experience and supported by data from the CRPS UK Register, it is far more likely that CRPS is under diagnosed, under treated and clinicians advise inappropriate coping strategies (i.e. immobilisation) due lack of knowledge of the condition throughout all levels of the health service[ii][iii].
Whilst the exact sequence of events determining the aetiology is unclear there is a huge amount known about the aberrant systems in CRPS Type 1 - cytokines, oxidative stress, vascular flow, neurogenic inflammation, markers of bone metabolism and significant peripheral and central nervous system abnormalities, none of which have been shown to be related to psychological distress - despite many researchers confident they would find a link.  Much of this work has demonstrated differences between CRPS and injury / fracture, refuting the notion that the construct is just a little more than reaction to injury[iv] [v]. Animal models demonstrate similar pathological patterns to human CRPS - again differentiating CRPS from a ‘normal’ response to injury[vi] [vii] and CRPS serum-IgG, when transferred to mice elicits abnormal behaviour consistent with that seen in animal models of CRPS[viii]. Some - but importantly not all - of the signs and symptoms of CRPS such as swelling and sensory phenomena can be seen following immobilisation. This is not evidence that the condition is merely due to immobilisation, but provides insight into some of the neurological mechanisms. It also confirms clinicians' observations that an active rehabilitation approach discourages the development of the syndrome, but even with this some people continue to have rapidly progressing CRPS.
The diagnostic criteria have been developed and modified until we have an internationally agreed set, combining both symptoms and signs. The ‘Budapest Criteria’ have excellent sensitivity (0.99), and greatly improved specificity (0.68).  The use of these criteria will reduce the possibility of false diagnosis[ix].
Bass cites evidence of psychosocial factors influencing outcome in chronic painful conditions such as CRPS. We do not doubt this and would expand this hypothesis that the outcome in more tangible conditions such as rheumatoid arthritis, stroke and malignancy are modified by such factors. He also claims “key psychological factors are ignored”. However, studies in both primary and secondary care have not found evidence that CRPS is associated with psychological distress[x] [xi]. A well controlled primary care study that examined 4 control cases for every CRPS case could not demonstrate an association with other pain syndromes or a pre-morbid psychological state before the development of CRPS[xii].
Bass then argues that the issue is that the diagnostic label is causing considerable disability. We can find no evidence for this. Our experience is that the diagnosis allows patients to make sense of distressing and often bizarre symptoms[xiii] and helps clinicians to develop active treatment programmes promoting functional restoration. Conversely, exactly the type of scepticism purported by Bass around the validity of their condition, greatly increases patients’ distress and leads to delayed diagnosis and access to appropriate rehabilitation. The invaluable multi-collegiate national guidelines published by the Royal College of Physicians in 2012 advocate active rehabilitation and do not recommend adoption of the sick role and disempowerment as claimed by Bass - they call for quite the opposite[xiv].
We agree that there is indeed a lack of psychological and psychiatric services for patients with severe chronic pain in the UK, but such deficiencies need addressing without dreaming up an alternative model for the aetiology, diagnosis and treatment of CRPS - without the evidence to support it! The huge amount of evidence and fascinating science supporting the existence of this syndrome has encouraged its recognition and early appropriate management - we don't need a step back towards attributing symptoms and signs of this condition to psychosocial factors as advocated by Bass.


[i]BMJ 2014;348:g2631
[ii] Allen GGaler BSSchwartz L. Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain. 1999;80(3):539-44.
[iii] Shenker NG, Goebel A, Rockett M, Batchelor J, Jones G, Parker RA, Williams ACdeC, McCabe CThe prognosis for patients with chronic Complex Regional Pain Syndrome: the value of the CRPS-UK Registry. British Journal of Pain In Press
[iv] Parkitny L, McAuley JH, Di Pietro F, Stanton TR, O’Connell NE, Marinus J, van Hilten JJ Moseley GL. Neurology. Jan 1, 2013; 80(1): 106–117. Inflammation in complex regional pain syndrome. A systematic review and meta-analysis.
[v]Marinus J1, Moseley GLBirklein FBaron RMaihöfner CKingery WSvan Hilten JJ. Clinical features and pathophysiology of complex regional pain syndrome.Lancet Neurol. 2011 Jul;10(7):637-48.
[vi] Bennett GJ. A hypothesis for the cause of complex regional pain syndrome-type I (reflex sympathetic dystrophy): pain due to deep-tissue microvascular pathology.Pain Med. 2010 Aug;11(8):1224-38.
[vii] TZ, Offley SC, Boyd EA, Jacobs CR, Kingery WS. Substance P signaling contributes to the vascular and nociceptive abnormalities observed in a tibial fracturerat model of complex regional pain syndrome type I. Pain. 2004;108(1-2):95-107.
[viii]Goebel A1, Leite MIYang LDeacon RCendan CMFox-Lewis AVincent A. The passive transfer of immunoglobulin G serum antibodies from patients with longstanding Complex Regional Pain Syndrome. Eur J Pain. 2011 May;15(5):504.
[ix]Harden RN1, Bruehl SPerez RSBirklein FMarinus JMaihofner CLubenow T,Buvanendran AMackey SGraciosa JMogilevski MRamsden CChont MVatine JJ. Validation of proposed diagnostic criteria (the "Budapest Criteria") for Complex Regional Pain Syndrome. 2010;150(2):268-74.
[x]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 Pain2011;15:971-5.
[xi]Beerthuizen Avan 't Spijker AHuygen FJKlein Jde Wit R. Is there an association between psychological factors and the Complex Regional Pain Syndrome type 1 (CRPS1) in adults? A systematic review. Pain. 2009 Sep;145(1-2):52-9.
[xii]de Mos M1, Huygen FJDieleman JPKoopman JSStricker BHSturkenboom MC. Medical history and the onset of complex regional pain syndrome (CRPS). Pain.2008 Oct 15;139(2):458-66.
[xiii]Lewis JSKersten PMcCabe CSMcPherson KMBlake DR. Body perception disturbance: a contribution to pain in complex regional pain syndrome (CRPS). Pain.2007;133(1-3):111-9.
[xiv] Goebel A, Barker CH, Turner-Stokes L et al . Complex regional pain syndrome in adults: UK guidelines for diagnosis, referral and management in primary and secondary care. London: RCP, 2012.


Psychological factors in Complex Regional Pain Syndrome  4 June 2014

Dr Michael D Spencer
Honorary Consultant Psychiatrist, Department of Pain Medicine, West Suffolk Hospital, Bury St Edmunds IP33 2QZ, UK.

Mr Stuart McKechnie
Barrister, 9 Gough Square, London EC4A 3DG.

Dr Rajesh Munglani
Honorary Consultant in Pain Medicine, Department of Pain Medicine, West Suffolk Hospital, Bury St Edmunds IP33 2QZ, UK.

Sir,

This letter is in response to the personal viewpoint article “Complex regional pain syndrome medicalises limb pain1.

Whilst it is to be welcomed that Bass highlights the need for greater psychological input to NHS pain clinics, and the frequent role of psychological factors in the maintenance of chronic pain conditions such as complex regional pain syndrome (CRPS), we are concerned that the article appears to suggest that i) the causation of CRPS is largely within the psychological domain; and moreover that ii) somehow the condition could be minimised or averted if only it could be re-framed in a manner that demedicalised the problem – Bass states “there is a case for abandoning the term CRPS altogether because of its potential for iatrogenic harm” – and indeed he suggests we consider alternative descriptive terms such as “armache or legache”.

There is now abundant evidence to implicate autoimmune and oxidative stress processes within the causation of a significant number of CRPS cases2-4 and although not fully understood, it now looks very likely that any consideration of the aetiology of CRPS must largely focus upon neurophysiological and neurochemical pain processing pathways within a complex multifactorial context that also includes genetic and environmental factors. Furthermore, magnetic resonance imaging demonstrates structural abnormalities of connectivity between brain structures in CRPS – measures that are separable5 from those in other chronic pain conditions such as chronic back pain and fibromyalgia.  Clearly the position that CRPS arises because of pre-accident psychological factors or post-accident factors such as the pursuit of litigation are not in concordance with a growing body of evidence relating to the neuropathological aetiology of the condition.  As the UK guidelines on CRPS puts it lucidly, “It is also now clear that CRPS is not associated with a history of pain-preceding psychological problems, or with somatisation or malingering”6. Prospective studies also dismiss any such psychological factors in the genesis of CRPS7.

Nonetheless, psychological factors are of considerable importance in the management of CRPS, as with other chronic pain conditions, and the development of distress, helplessness and depression, in addition to dysfunctional pain beliefs and behaviours (for example the belief that the pain is harmful and that avoiding activity will help the recovery, and behaviours of guarding and avoidance of movement) are “Yellow Flags” associated with chronicity in acute back pain8 and which are equally applicable to outcome in CRPS6.  Authors of this letter include a psychiatrist and pain medicine clinician practicing within an NHS pain clinic, in cases where we encounter patients with CRPS in whom significant levels of disability have developed, psychiatric enquiry often reveals the onset of enhanced levels of disability to be chronologically associated with the onset or worsening ofdepression or some other form of psychological distress such as symptoms of post-traumatic stress disorder (PTSD).  In such cases, appropriate treatment of these psychological exacerbating and maintaining factors is hugely important as part of a multi-disciplinary approach to treating the CRPS9.

However, recognition of the underlying CRPS is vital and informs the provision of specialist treatments by Pain Medicine colleagues (in the form of specialist rehabilitation programmes and pharmacological and neuromodulatory interventions where appropriate).  To replace the CRPS diagnosis with a descriptive term such as “disproportionate pain” or “armache” would be a retrograde step, obfuscating that which has been clearly demarcated and elucidated through clinical and basic research.

Equally, one cannot ignore the serious impact that Bass’ proposed changes could have upon the assessment of chronic pain conditions in the courts.  Over the years, great strides have been made by the legal profession in recognising the validity of diagnoses in Pain Medicine. This has been reflected by the introduction of a separate section relating to Chronic Pain Disorders, including CRPS, within the 11th and 12th edition Judicial College Guidelines for the Assessment of General Damages in Personal Injury Cases. Judicial findings of CRPS are now commonplace, based on tested expert medical opinion, leading to financial awards that are commensurate with what is often a significant level of disability. Declassifying CRPS would have the potential to undermine the now generally accepted proposition that pain disorders should not be viewed through a prism of psychiatric injury or damage alone and therefore deny those suffering from CRPS a fair level of compensation. This would be a matter of some concern amongst those representing injured parties.

Finally, whilst psychological treatments are an essential part of the toolkit in treating CRPS and psychological processes are often key to understanding the perpetuation of chronic presentations, neuropathology and pain mechanisms not psychology are at the heart of causation of CRPS and psychological treatments cannot replace the specialist Pain Medicine rehabilitative, pharmacological and interventional treatments that CRPS patients often require.  To put it another way – just because one of the tools we need is a hammer, doesn't mean that the problem must be a nail.


References:

1. Bass C. Complex regional pain syndrome medicalises limb pain. BMJ 2014;348:g2631.
2. Goebel A, Blaes F. Complex regional pain syndrome, prototype of a novel kind of autoimmune disease. Autoimmunity reviews 2013;12(6):682-6.
3. Tekus V, Hajna Z, Borbely E, et al. A CRPS-IgG-transfer-trauma model reproducing inflammatory and positive sensory signs associated with complex regional pain syndrome. Pain 2014;155(2):299-308.
4. Taha R, Blaise GA. Update on the pathogenesis of complex regional pain syndrome: role of oxidative stress. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2012;59(9):875-81.
5. Geha PY, Baliki MN, Harden RN, et al. The brain in chronic CRPS pain: abnormal gray-white matter interactions in emotional and autonomic regions. Neuron 2008;60(4):570-81.
6. Royal College of Physicians. Complex regional pain syndrome in adults: UK guidelines for diagnosis, referral and management in primary and secondary care. Royal College of Physicians: London, 2012.
7. Beerthuizen A, Stronks DL, Huygen FJ, et al. The association between psychological factors and the development of complex regional pain syndrome type 1 (CRPS1)--a prospective multicenter study. Eur J Pain 2011;15(9):971-5.
8. Main CJ, Williams ACC. Musculoskeletal pain. In: Mayou R, Sharpe M, Carson A, eds. ABC of Psychological Medicine. London: BMJ Publishing Group, 2003:37-40.
9. Harden RN. Complex regional pain syndrome. British Journal of Anaesthesia 2001;87(1):99-106.





Andreas Goebel, Consultant and Senior Lecturer in Pain Medicine
William Campbell, Beverly Collett, Martin Johnson, Kate Grady

The Walton Centre NHS Foundation Trust and University of Liverpool, Liverpool L9 7LJ


Sir,
We have read with interest the recent Personal View by Dr. Chris Bass on Complex Regional Pain Syndrome1.
For clarification, Complex Regional Pain Syndrome (CRPS) is an uncommon disorder affecting limbs, which in over 90% of cases arises after trauma. Comprehensive reviews on CRPS have been published 2 3, and the UK Royal College of Physicians has supported the development of the UK Guidance, which was recently published with the support of over 20 UK professional organisations and Royal Colleges, including the British Psychological Society4 5. A guidance chapter for the diagnosis and management of CRPS in psychiatric practice is currently being written by a multidisciplinary group, which includes representation from the Royal College of Psychiatrists; this will be available with the first revision of the UK CRPS Guidance in 2015. Dutch and US guidance is also available.
Dr. Bass makes four propositions (a-d), which need to be refuted, and additional suggestions (e-f), which should be addressed:
a) Dr. Bass asserts that CRPS can be diagnosed on the basis of sensory and motor signs. This is incorrect – the Budapest diagnostic criteria require the presence of additional symptoms. A synopsis of the CRPS diagnostic criteria can be found in appendix 4 of the referenced ‘long’ UK Guidance.
b) Dr. Bass indicates that CRPS, when diagnosed in GP practice should best be managed first by identifying possible yellow flags, then arranging referral for an (unspecified) ‘appropriate intervention’. This proposed management strategy conflicts with the Royal College of Physicians guidance for the management of CRPS in GP practice, which has been supported by the RCGP. The latter guidance proposes that GPs refer patients to Pain Medicine Specialists or (for complex multiple disabilities) to Rehabilitation Specialists (except in mild cases). Specific treatments and expertise are then available through these services.
c) ‘..abundant evidence shows that it is psychosocial, not biological factors, that are associated with a higher likelihood of developing chronic painful disorders…’ Here Dr. Bass abandons the discussion on CRPS altogether for a more general discussion on chronic pain. In CRPS research, the pre-existence of major psychological factors has now been soundly refuted6. Dr. Bass would do well do acknowledge such population-based research. In these same studies CRPS was associated with ACE inhibitor intake (but not with intake of other anti-hypertensives) 7, and asthma (but not COPD) 6, highlighting a likely contribution from neurogenic inflammation, which had earlier already been suggested in microdialysis studies 8. The prospective (but not population-based) study of patients after limb fracture by Berthuitzen et al., which Dr. Bass cites, again found no correlation between psychological factors and the development of CRPS; in contrast biological factors such as intra-articular fractures and fracture dislocations were correlated 9. Further research is indeed called for to assess the impact of psychological factors on variability after trauma, but until the results of such research are available, they should not be pre-empted.
d) Dr. Bass calls for appropriate education and training for clinicians working in pain clinics. We could not agree more. Dr. Bass should feel reassured by the rigorous training and examination programme which Pain Medicine Consultants now undertake to achieve the professional qualification of Fellowship of the Faculty of Pain Medicine of the Royal College of Anaesthetists (FFPMRCA). It is disappointing that this has not been acknowledged.
e) Dr. Bass calls for adequate psychological services in pain clinics. Such a call is in keeping with a modern understanding of Pain Medicine, and should be applauded (see http://www.britishpainsociety.org for details on UK initiatives to secure multidisciplinary provision of pain services). The primary goal is to treat patients in their biopsychosocial contexts. It is not to elucidate psychological causative factors (with selected exceptions where the input of psychiatrists is indeed important). The idea, that we should generally look for non-biological causative factors for CRPS in order to then help the patient by treating their psychology has been largely discredited 9-11, and has the potential to cause harm by suggesting their condition is psychological/psychiatric, when this is not the case.
f) We believe that Dr. Bass is right to point out the potential for causing iatrogenic damage by making an inappropriate diagnosis, which he says he has many times witnessed. We too have seen inappropriate diagnoses of CRPS, although these are normally relatively easily recognised and refuted by appropriately trained professionals. Of note, in medico-legal practice, the diagnosis of CRPS poses particular challenges, but a discussion around the judicial system is beyond the scope of this letter.
In summary, whilst we are mindful that this is a ‘personal view’, the viewpoint of Dr Bass leaves us somewhat underwhelmed as it lacks medical and diagnostic accuracy and makes only partial reference to the available literature. We are concerned that BMJ readers may have been misinformed or misguided. Full information and guidance on the management of CRPS are detailed in the UK CRPS Guidelines [6].
Dr. Andreas Goebel, Chair UK CRPS Guideline Group
Dr. William Campbell, President British Pain Society
Dr. Beverly Collett, Chair Chronic Pain Policy Commission
Dr. Martin Johnson, RCGP Lead for Chronic Pain
Dr. Kate Grady, Dean Faculty of Pain Medicine Royal College of Anaesthetists
Bibliography
1. Bass C. Complex regional pain syndrome medicalises limb pain. BMJ 2014;348:g2631.
2. Marinus J, Moseley GL, Birklein F, Baron R, Maihofner C, Kingery WS, et al. Clinical features and pathophysiology of complex regional pain syndrome. Lancet Neurol. 2011/7;10(7):637-48.
3. Goebel A. Complex regional pain syndrome in adults. Rheumatology (Oxford) 2011/10;50(10):1739-50.
4. Turner-Stokes L, Goebel A. Complex regional pain syndrome in adults: concise guidance. Clin Med 2011;11(6):596-600.
5. Goebel AB, Ch; Turner-Stokes, L; et al. Complex Regional Pain Syndrome in Adults. UK guidelines for diagnosis, referral and management in primary and secondary care. London: Royal College of Physicians, 2012.
6. de Mos M, Huygen FJ, Dieleman JP, Koopman JS, Stricker BH, Sturkenboom MC. Medical history and the onset of complex regional pain syndrome (CRPS). Pain 2008;139(2):458-66.
7. de MM, Huygen FJ, Stricker BH, Dieleman JP, Sturkenboom MC. The association between ACE inhibitors and the complex regional pain syndrome: Suggestions for a neuro-inflammatory pathogenesis of CRPS. Pain 2009/4;142(3):218-24.
8. Birklein F, Schmelz M, Schifter S, Weber M. The important role of neuropeptides in complex regional pain syndrome. Neurology 2001/12/26;57(12):2179-84.
9. Beerthuizen A, van 't SA, Huygen FJ, Klein J, de WR. Is there an association between psychological factors and the Complex Regional Pain Syndrome type 1 (CRPS1) in adults? A systematic review. Pain 2009/9;145(1-2):52-59.
10. Lohnberg JA, Altmaier EM. A review of psychosocial factors in complex regional pain syndrome. Journal of clinical psychology in medical settings 2013;20(2):247-54.
11. Feliu MH, Edwards CL. Psychologic factors in the development of complex regional pain syndrome: history, myth, and evidence. Clin J Pain 2010;26(3):258-63.