**1. Introduction**

Complex Regional Pain Syndrome or CRPS, is a chronic pain syndrome. Pain in medical treatment is frequently an expected symptom, and a normal manifestation of tissue trauma. However, when it reaches levels of intensity and duration beyond the expected, it may present as CRPS: it is no longer a symptom but a separate disease entity capable of making the affected person's life insufferable. CRPS may be triggered by a preceding condition. However, key to its diagnosis is the lack of any obvious tissue-related causes of pain. Its relative uncommonness has resulted in widely divergent reports by medical professionals over the years. Often, it was simply pain which eluded understanding. This has led to a host of labels used to describe it across time and in different countries. Currently, the following conditions are roughly equivalent to what is understood as CRPS:


11.Migratory osteolysis


This multitude of labels confuses the diagnostic process and hampers appropriate reactions to the reported symptoms.

The earliest scholarly treatment of unaccountable pain dates from the 16th century. In the 1598 book "Les Oeuvres ď Ambroise Paré", the barber-surgeon to French kings describes Charles IX's suffering around the year 1570 who, after bloodletting to treat smallpox, complained of persistent burning pain coupled with muscle loss, contracture and inability to bend or straighten his arm [2]. We also have historic descriptions of chronic pain in wounded soldiers. Pain as separate from injury and treatment was described in Lessons on the Principles of Surgery, published in France in 1766 [3], where it was observed that pain may occur in areas not directly affected by earlier trauma, and affect joints and muscles without any visible skin lesion in the area affected.

In 1813, Alexander Denmark, a British surgeon who worked at the Royal Navy Hospital in Gosport, Hampshire, reported the case of a soldier who was wounded by a bullet that had passed through his upper arm. The wound itself healed quickly, however he noted in his report: "I always found him with the forearm bent and in supine position and supported by the firm grasp of the other hand. The pain was of a 'burning' nature, and so violent as to cause a continual perspiration from his face". Eventually, the arm was amputated [4], and this concluded the patient's suffering.

The American Civil War also reaped a harvest of experience in enigmatic chronic pain. Claude Bernard, Silas Weir Mitchell, George Morehouse and William Keen all described frequent intense pain in the aftermath of battle wounds in veterans and among them, reports on pain disorders from gunshot wounds and other nerve damage [5].

In the 1880s the French neurologist Jean-Martin Charcot observed dystonic movement disorders and related contractions, and hypothesized that the syndrome's genesis (described as "hysteria minor") was in unstructured changes in the nervous system which were probably biochemical or physiological in nature [6].

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hyperaccumulation;

following conditions [8]:

tionate to any inciting event.

sudomotor activity in the region of pain.

account for the degree of pain and dysfunction.

conditions.

*DOI: http://dx.doi.org/10.5772/intechopen.94146*

sympathetic nervous system in neuropathic pain.

At the 29th Congress of the German Society of Surgeons (Deutscher Chirurgen Kongress) in 1901, Paul Sudeck delivered a paper entitled "Acute inflammatory bone atrophy", in which he discussed changes observed in patients' X-ray images. His examples included chronic atrophies causing exceptional disability. His influence can be seen in the use of his name in several of the labels given to this set of

During World War 1 René Leriche, an army surgeon in Strasbourg, hypothesized that the sympathetic nervous system was central in the rise of signs and symptoms of the conditions described by Sudeck. In 1917, he described a patient's complaints of chronic pain in the arm and numbness in the armpit where he received a gunshot wound. Leriche coined the term "sympathetic neuritis" to illustrate the role of the

The term "reflex sympathetic dystrophy" (RSD) was introduced by James Evans around 1947 [7]. Evans described 57 patients with a syndrome characterized by intense pain and clinical symptoms which he described as "sympathetic stimulation". The condition appeared as a consequence of fractures (21%), sprains (21%), vascular complications (19%), amputations (9%), joint or bone inflammations (5%), minor wounds (2%) and other minor injuries such as contusions (9%) and posture defects (7%). In 1973, John Bonica proposed the following three clinical stages of RSD:

• Stage 1, acute - the first three months after injury - characterized by erythema, calor, edema, significant hyperhidrosis, pain distribution unrelated to root or nerve involvement, limited range of motion and reduced muscle strength with a negative X-ray examination, but a positive scintigraphy showing

• Stage 2, dystrophic - characterized by severe pain, skin edema, decreased hair growth, discoloration, cyanosis, persistent hyperhidrosis, muscle weakness

• Stage 3, atrophic - characterized by lesser but nonetheless disabling pain which subsides with rest and increases with passive motion. The skin may be atrophic, thin, dry, sometimes ulcerated, cold, mottled or cyanotic in toto; possible loss of joint range of motion and muscle strength with tendon atrophy, contractures, tremors and dystonia causing a significant motor impairment of the affected limb. At this stage, the radiographic examination shows

The name was changed to Complex Regional Pain Syndrome in 1994 and the Orlando Conference established that CRPS could be diagnosed in presence of the

1.The presence of an initiating noxious event or a cause of immobilization.

3.Evidence at some time of edema, changes in skin blood flow, or abnormal

2.Continuing pain, allodynia, or hyperalgesia with which the pain is dispropor-

4.This diagnosis is excluded by the existence of conditions that would otherwise

and limited range of motion of the affected joint or joints;

inhomogeneous regional osteoporosis (Sudeck's atrophy).

This typology is used in some countries to this day.

#### *Suffering as a Diagnostic Indicator DOI: http://dx.doi.org/10.5772/intechopen.94146*

*Pain Management - Practices, Novel Therapies and Bioactives*

8.Babinski-Froment sympathetic paralysis

12.Traumatic angiospasm; traumatic vasospasm

15.Complex Regional Pain Syndrome Type 1

16. Sudeck-Babinski-Leriche syndrome

17.Pourfour du Petit syndrome [1]

ate reactions to the reported symptoms.

visible skin lesion in the area affected.

9.Leriche's post-traumatic osteoporosis

6.Peripheral trophoneurosis

10.Postinfarction sclerodactyly

13.Hand–shoulder syndrome

11.Migratory osteolysis

14.Foot–hip syndrome

5.Causalgia (also known as CRPS Type 2 when accompanied by nerve damage)

This multitude of labels confuses the diagnostic process and hampers appropri-

The earliest scholarly treatment of unaccountable pain dates from the 16th century. In the 1598 book "Les Oeuvres ď Ambroise Paré", the barber-surgeon to French kings describes Charles IX's suffering around the year 1570 who, after bloodletting to treat smallpox, complained of persistent burning pain coupled with muscle loss, contracture and inability to bend or straighten his arm [2]. We also have historic descriptions of chronic pain in wounded soldiers. Pain as separate from injury and treatment was described in Lessons on the Principles of Surgery, published in France in 1766 [3], where it was observed that pain may occur in areas not directly affected by earlier trauma, and affect joints and muscles without any

In 1813, Alexander Denmark, a British surgeon who worked at the Royal Navy Hospital in Gosport, Hampshire, reported the case of a soldier who was wounded by a bullet that had passed through his upper arm. The wound itself healed quickly, however he noted in his report: "I always found him with the forearm bent and in supine position and supported by the firm grasp of the other hand. The pain was of a 'burning' nature, and so violent as to cause a continual perspiration from his face". Eventually, the arm was amputated [4], and this concluded the patient's suffering. The American Civil War also reaped a harvest of experience in enigmatic chronic pain. Claude Bernard, Silas Weir Mitchell, George Morehouse and William Keen all described frequent intense pain in the aftermath of battle wounds in veterans and among them, reports on pain disorders from gunshot wounds and other

In the 1880s the French neurologist Jean-Martin Charcot observed dystonic movement disorders and related contractions, and hypothesized that the syndrome's genesis (described as "hysteria minor") was in unstructured changes in the nervous

system which were probably biochemical or physiological in nature [6].

7.Reflex sympathetic dystrophy - commonly abbreviated as RSD

**114**

nerve damage [5].

At the 29th Congress of the German Society of Surgeons (Deutscher Chirurgen Kongress) in 1901, Paul Sudeck delivered a paper entitled "Acute inflammatory bone atrophy", in which he discussed changes observed in patients' X-ray images. His examples included chronic atrophies causing exceptional disability. His influence can be seen in the use of his name in several of the labels given to this set of conditions.

During World War 1 René Leriche, an army surgeon in Strasbourg, hypothesized that the sympathetic nervous system was central in the rise of signs and symptoms of the conditions described by Sudeck. In 1917, he described a patient's complaints of chronic pain in the arm and numbness in the armpit where he received a gunshot wound. Leriche coined the term "sympathetic neuritis" to illustrate the role of the sympathetic nervous system in neuropathic pain.

The term "reflex sympathetic dystrophy" (RSD) was introduced by James Evans around 1947 [7]. Evans described 57 patients with a syndrome characterized by intense pain and clinical symptoms which he described as "sympathetic stimulation". The condition appeared as a consequence of fractures (21%), sprains (21%), vascular complications (19%), amputations (9%), joint or bone inflammations (5%), minor wounds (2%) and other minor injuries such as contusions (9%) and posture defects (7%). In 1973, John Bonica proposed the following three clinical stages of RSD:


This typology is used in some countries to this day.

The name was changed to Complex Regional Pain Syndrome in 1994 and the Orlando Conference established that CRPS could be diagnosed in presence of the following conditions [8]:


Bonica's typology is currently under review. Some experts suggest a fourth stage [9], in which changes become irreversible and amputation appears the only effective method of alleviating pain in the affected limb [10]. This prospect highlights the importance of diagnosing CRPS as early as possible. Only timely treatment may save the patient. It is imperative to define the process of differentiation between pain as part of the healing process, and neuropathic pain which may lead to CRPS.

Pain is considered mainly as the subjective sensation [11] of the individual patient. This definition stipulates that the sensation is unpleasant and results from the real or hypothetical possibility of body tissue damage. The definition ignores experiences which might be perceived as positive [12]. It may seem incredible, but some people perceive pain as positive and have no negative associations with it. Although we tend to ignore this, such an attitude has firm foundations in the sphere of Western European culture: consider known martyrs and ascetics who used pain for self-improvement. In some religious practices pain is an important means towards redemption, with no negative connotations at all. Whether as "punishment" or "challenge", it may come with positive implications. Aside from spiritual overtones, medical patients often report a positive attitude towards pain when their pain is lesser than expected or when they consider alternatives worse than enduring pain.

It may therefore be accepted that people respond to pain differently and this should lead us to consider pain's applicability as a diagnostic. Patients, especially those suffering from algodystonia, motor neuron dystrophy, or CRPS [13], report pain inaccurately or too late for positive prognosis. This paper summarizes information from interviews with chronic pain sufferers in order to identify actions by medical practitioners which may have led to misunderstanding the nature of the patients' conditions.

#### **2. Experiencing painful sensations**

The effect of chronic pain on the patient is, chiefly, an altered consciousness. In chronic pain, the body is in a constant state of agitation, which is an imbalance between chemical mediators responsible for conducting and attenuating pain stimuli. As a result of chemical imbalance, patients may experience symptoms such as mood disorders, anxiety or panic attacks, or even sensory processing and memory disorders [14].

For people who have not experienced such states, the nature of the suffering may be incomprehensible. Conversely, chronic sufferers may be unaware of reporting incorrectly on their experiences.

A common practice among doctors dealing with chronic pain sufferers is to use numeric rating scales, or pain scales: patients are asked to self-assess their pain on a scale from 0 (no pain) to 10. The goal of pain scales is to give the doctor an idea of pain's intensity, but their usefulness is limited by education and experience of both the doctor and the patient. The following example will illustrate the problem: a girl aged 17 with diagnosed CRPS in the leg and clubfoot, suffering pain for a year and treated symptomatically, was admitted to hospital with abdominal pain. The patient indicated that the pain was intense and assigned it the value of 5 on the pain scale. As a result, she was classified as not requiring immediate attention and asked to wait in line. Her state rapidly deteriorated. Further investigation revealed acute appendicitis and secondary peritonitis. Had she not been a chronic pain sufferer, she would have assigned her pain the value of 9 or 10.

It is important to be aware that pain scales are relative and therefore should have limited applicability. The bottom end of the scale - "zero" - signifies no pain, however there is no equally clear definition for "ten". It could signify pain leading to unconsciousness, or pain which causes the sufferer suicidal thoughts, or is greater

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*DOI: http://dx.doi.org/10.5772/intechopen.94146*

resulted in the CRPS diagnosis [15].

inaccurate diagnoses.

non-sufferers, useless.

than ever experienced. For some, the worst possible pain could be a toothache, for others a laceration. This lack of clear qualitative definition of pain on a pain scale leads to misinterpretations and "strategic assessments" both by diagnosticians and sufferers: patients often overestimate their pain in hope of receiving more urgent help; while medical professionals interpret patients' estimations as exaggerated. The

As shown above, applying a simple pain scale may lead to incorrect diagnoses if the patient's situation is incorrectly assessed. Orthopedic and neurologic patients suffering from CRPS as the result of medical interventions often communicate pain in the affected limb, which is interpreted by the specialists as an indicator of appropriateness of treatment and ignored. In consequence, no treatment is offered. In another example, a patient aged 16, experiencing difficulty walking, underwent a hallux valgus (bunion) operation. First her left foot was operated and after six months, in December 2018, the right foot. The post-operative wound did not heal well and in January 2019 the patient was admitted to hospital and given a course of antibiotics. Shortly afterwards she suffered an incident at school: the operated foot was struck with a door and its bones repositioned. This resulted in a further operation to reposition the bones and stabilize the foot. The patient began reporting increased pain; however, her frequent complaints became increasingly ignored by the medical staff. Both doctors and other professionals began treating the patient as hysterical and explained the pain away as natural and necessary after the operation. After several months of ineffective physiotherapy, clubfoot developed and this

This, and other similar incidents, suggests that sufferers may not realize that when they report pain, their reports may be interpreted as imprecise and lead to

Tissue damage or loss of continuity often lead to deep but reversible changes in both the peripheral and central nervous system, typically presenting as hypersensitivity and chronic pain as the body's response to inflammation of tissue surrounding affected nerve structures. These changes accompany tissue repair processes, treatments of injuries and other conditions up until full recovery of the tissue [16]. If, however, pain exceeds the normally expected healing time, the situation changes diametrically. Pain conditions lasting more than three months necessitate the modification of the treatment process to account for chronic pain conditions [17]. Chronic pain conditions render the common pain assessment methods, used with

The sensation of pain in general is not as good a diagnostic as its particular form which, to differentiate it from pain, may be called suffering, and be understood as the negative sensation caused by lesions or other tissue interference, felt to be unacceptable and greater than expected. Such perceptions should be a cue for medical practitioners to suspect that the pain is not "normal" for the situation and to search for alternative or expanded diagnoses and treatments. Interviews with 35 CRPS sufferers, aged 15–45, reveal the prevalent experience of insufficient reaction by medical staff to, or disregard for, reported suffering. Since CRPS develops subsequently to a pre-existing condition, the sufferers have a unique experience of pain: they are able to compare their current sensations compounded by CRPS with past, pre-syndrome experience. Their observations have been juxtaposed in the table below. CRPS-related pain experiences are categorized as "suffering"; i.e. chronic and unacceptable in intensity. Reports of such sensations should automatically trigger a reassessment of the current diagnosis and treatment plan (**Table 1**).

The genesis of CRPS development is unidentified and the condition can only be recognized when already present. Paying attention to the above-listed symptoms may help diagnose the syndrome early enough to implement prophylactic treatment.

only incontestable feedback from using pain scales is the existence of pain.

#### *Suffering as a Diagnostic Indicator DOI: http://dx.doi.org/10.5772/intechopen.94146*

*Pain Management - Practices, Novel Therapies and Bioactives*

**2. Experiencing painful sensations**

memory disorders [14].

incorrectly on their experiences.

she would have assigned her pain the value of 9 or 10.

Bonica's typology is currently under review. Some experts suggest a fourth stage [9], in which changes become irreversible and amputation appears the only effective method of alleviating pain in the affected limb [10]. This prospect highlights the importance of diagnosing CRPS as early as possible. Only timely treatment may save the patient. It is imperative to define the process of differentiation between pain as part of the healing process, and neuropathic pain which may lead to CRPS. Pain is considered mainly as the subjective sensation [11] of the individual patient. This definition stipulates that the sensation is unpleasant and results from the real or hypothetical possibility of body tissue damage. The definition ignores experiences which might be perceived as positive [12]. It may seem incredible, but some people perceive pain as positive and have no negative associations with it. Although we tend to ignore this, such an attitude has firm foundations in the sphere of Western European culture: consider known martyrs and ascetics who used pain for self-improvement. In some religious practices pain is an important means towards redemption, with no negative connotations at all. Whether as "punishment" or "challenge", it may come with positive implications. Aside from spiritual overtones, medical patients often report a positive attitude towards pain when their pain is lesser

than expected or when they consider alternatives worse than enduring pain. It may therefore be accepted that people respond to pain differently and this should lead us to consider pain's applicability as a diagnostic. Patients, especially those suffering from algodystonia, motor neuron dystrophy, or CRPS [13], report pain inaccurately or too late for positive prognosis. This paper summarizes information from interviews with chronic pain sufferers in order to identify actions by medical practitioners which may have led to misunderstanding the nature of the patients' conditions.

The effect of chronic pain on the patient is, chiefly, an altered consciousness. In chronic pain, the body is in a constant state of agitation, which is an imbalance between chemical mediators responsible for conducting and attenuating pain stimuli. As a result of chemical imbalance, patients may experience symptoms such as mood disorders, anxiety or panic attacks, or even sensory processing and

For people who have not experienced such states, the nature of the suffering may be incomprehensible. Conversely, chronic sufferers may be unaware of reporting

A common practice among doctors dealing with chronic pain sufferers is to use numeric rating scales, or pain scales: patients are asked to self-assess their pain on a scale from 0 (no pain) to 10. The goal of pain scales is to give the doctor an idea of pain's intensity, but their usefulness is limited by education and experience of both the doctor and the patient. The following example will illustrate the problem: a girl aged 17 with diagnosed CRPS in the leg and clubfoot, suffering pain for a year and treated symptomatically, was admitted to hospital with abdominal pain. The patient indicated that the pain was intense and assigned it the value of 5 on the pain scale. As a result, she was classified as not requiring immediate attention and asked to wait in line. Her state rapidly deteriorated. Further investigation revealed acute appendicitis and secondary peritonitis. Had she not been a chronic pain sufferer,

It is important to be aware that pain scales are relative and therefore should have limited applicability. The bottom end of the scale - "zero" - signifies no pain, however there is no equally clear definition for "ten". It could signify pain leading to unconsciousness, or pain which causes the sufferer suicidal thoughts, or is greater

**116**

than ever experienced. For some, the worst possible pain could be a toothache, for others a laceration. This lack of clear qualitative definition of pain on a pain scale leads to misinterpretations and "strategic assessments" both by diagnosticians and sufferers: patients often overestimate their pain in hope of receiving more urgent help; while medical professionals interpret patients' estimations as exaggerated. The only incontestable feedback from using pain scales is the existence of pain.

As shown above, applying a simple pain scale may lead to incorrect diagnoses if the patient's situation is incorrectly assessed. Orthopedic and neurologic patients suffering from CRPS as the result of medical interventions often communicate pain in the affected limb, which is interpreted by the specialists as an indicator of appropriateness of treatment and ignored. In consequence, no treatment is offered. In another example, a patient aged 16, experiencing difficulty walking, underwent a hallux valgus (bunion) operation. First her left foot was operated and after six months, in December 2018, the right foot. The post-operative wound did not heal well and in January 2019 the patient was admitted to hospital and given a course of antibiotics. Shortly afterwards she suffered an incident at school: the operated foot was struck with a door and its bones repositioned. This resulted in a further operation to reposition the bones and stabilize the foot. The patient began reporting increased pain; however, her frequent complaints became increasingly ignored by the medical staff. Both doctors and other professionals began treating the patient as hysterical and explained the pain away as natural and necessary after the operation. After several months of ineffective physiotherapy, clubfoot developed and this resulted in the CRPS diagnosis [15].

This, and other similar incidents, suggests that sufferers may not realize that when they report pain, their reports may be interpreted as imprecise and lead to inaccurate diagnoses.

Tissue damage or loss of continuity often lead to deep but reversible changes in both the peripheral and central nervous system, typically presenting as hypersensitivity and chronic pain as the body's response to inflammation of tissue surrounding affected nerve structures. These changes accompany tissue repair processes, treatments of injuries and other conditions up until full recovery of the tissue [16]. If, however, pain exceeds the normally expected healing time, the situation changes diametrically. Pain conditions lasting more than three months necessitate the modification of the treatment process to account for chronic pain conditions [17]. Chronic pain conditions render the common pain assessment methods, used with non-sufferers, useless.

The sensation of pain in general is not as good a diagnostic as its particular form which, to differentiate it from pain, may be called suffering, and be understood as the negative sensation caused by lesions or other tissue interference, felt to be unacceptable and greater than expected. Such perceptions should be a cue for medical practitioners to suspect that the pain is not "normal" for the situation and to search for alternative or expanded diagnoses and treatments. Interviews with 35 CRPS sufferers, aged 15–45, reveal the prevalent experience of insufficient reaction by medical staff to, or disregard for, reported suffering. Since CRPS develops subsequently to a pre-existing condition, the sufferers have a unique experience of pain: they are able to compare their current sensations compounded by CRPS with past, pre-syndrome experience. Their observations have been juxtaposed in the table below. CRPS-related pain experiences are categorized as "suffering"; i.e. chronic and unacceptable in intensity. Reports of such sensations should automatically trigger a reassessment of the current diagnosis and treatment plan (**Table 1**).

The genesis of CRPS development is unidentified and the condition can only be recognized when already present. Paying attention to the above-listed symptoms may help diagnose the syndrome early enough to implement prophylactic treatment.


#### **Table 1.**

*Sufferers' reported experiences before and after developing CRPS.*

Countless cases justify the necessity to identify changes in suffering and to adjust treatment appropriately. The cases listed below are all from the last two years and are representative of many other such cases.

#### **2.1 Case: symptoms non-specific to the treated condition**

Girl, 17, diagnosed with CRPS after two years of symptoms. At 15, she developed intervertebral hernia as a result of a sports injury. An orthosis was fitted and the patient was prescribed physical rehabilitation. The patient reported severe pain, which did not subside after the removal of the orthosis. Further treatment included electrostimulation, acupuncture and symptomatic treatment. At 16, the patient began reporting severe stomach symptoms. Six months later, changes characteristic of CRPS began appearing on her left leg: the leg changed coloring, hair growth increased. Bone loss occurred [18–21]. CRPS spreading to organs such as the stomach is not typical. Frequently children suffer from severe musculoskeletal pain (Amplified Musculoskeletal Pain Syndrome - AMPS), which can be interpreted as Complex Regional Pain Syndrome, Reflex Sympathetic Dystrophy, Reflex Neurovascular Dystrophy, or extensive pain, such as in fibromyalgia. CRPS was eventually diagnosed and specialist treatment commenced c. 19 months after the initial appearance of CRPS symptoms. The patient's left leg and stomach remain affected by CRPS. She is fed by a gastric (nasoduodenal - ND) tube. Leg pain causes her to periodically use crutches.

#### **2.2 Case: identification hindered by comorbidities**

Girl, 12, treated for tumor. She broke her leg in an accident at school. A typical treatment followed: the bone was set and a plaster cast was used to immobilize the

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*DOI: http://dx.doi.org/10.5772/intechopen.94146*

**2.3 Case: incorrect fracture fixation**

began after the hand swelled and deformed.

medical practitioners exposed to improvisation.

patient's comfort and returned relative independence to her.

**2.4 Case: perioperative injuries**

radiographic imaging.

commenced over a year after the symptoms first appeared.

leg. From the very start, the patient reported increased pain which was interpreted as symptomatic of the tumor. After the removal of the plaster cast the limb was swollen and hypersensitive to touch. Symptomatic treatment and physical rehabilitation brought no results: the child continued to be in constant pain. After changes in the bone were discovered, CRPS was diagnosed. CRPS-specific treatment

Man, 43, broke the scaphoid bone in his right hand in a motorcycle collision. The hand was immobilized with a plaster cast. The patient had a history of alcohol abuse. He did not report any discomfort resulting from an overtight cast: he ignored the growing pain and anesthetized himself with alcohol. After the removal of the cast, the pain did not subside and within three months symptoms characteristic of CRPS, such as swelling, color change and hypersensitivity, appeared. Because of his alcohol abuse, his reports of increasing persistent pain were ignored. Treatment

Appearance of additional pain signals during treatment for other conditions mainly orthopedic operations - can be illustrated by five cases: two affected lower limbs, two affected upper limbs, and one affected a shoulder. The patients all reported severe pain and difficulty moving the affected limbs. In all cases their reports of abnormal pain were interpreted as normal pain. The patients were prescribed physical rehabilitation which brought no positive results. CRPS was not recognized until limb deformation was visible or bone loss was detected with

All this evidence suggests that there are major blind spots in diagnostic procedures where chronic pain is a factor, often preventing new disease entities from being discovered and treated. To rectify this situation, new procedures are required to complement existing procedures in situations which, currently, leave

The following case illustrates issues caused by insufficient diagnostic procedures: girl, 15, was diagnosed with antero-inferior subluxation of the glenohumeral (shoulder) joint with muscle weakness of the shoulder girdle. The various treatments prescribed, such as Kirschner wire fixation, all followed existing procedures but, irrespective of the method used, the shoulder always slipped. In effect, the patient was discharged from several hospitals without positive prognosis. Doctors failed to act on the patient's reports of pain, treating it as natural and necessary under the circumstances. Over the next 120 days, the patient underwent various attempts to set the shoulder, leading to brachial plexus paralysis and gradual loss of functionality in the arm and the hand. The arm became hypersensitive and changed color. CRPS wasn't diagnosed until the detection of bone loss. Symptomatic treatment at a pain management clinic and arthrodesis improved the

Although medicine, as a study of humans and nature, appears to be closer to the humanities, its history shows it has more in common with the sciences. Physicians frequently see the human body as a mechanism. A rather complicated mechanism, but nevertheless one which allows us to specify procedures for pairing symptoms with treatments. The body is so complex that it could work if 99% of its components malfunction and, conversely, die with just 1% damage. Cause-and-effect medicine appears increasingly helpless when our cognitive apparatus identifies

#### *Suffering as a Diagnostic Indicator DOI: http://dx.doi.org/10.5772/intechopen.94146*

*Pain Management - Practices, Novel Therapies and Bioactives*

Genesis Understood, justified or even

Control Can be controlled (e.g. through

Duration Usually lasts 4–6 weeks

Treatment methods

Outcomes if unaddressed

**Table 1.**

**Interpretation of Pre-CRPS pain experiences Pain experiences with CRPS**

Intensity Changing intensity Persistent. No pain-free periods

Outside the patient's experience range

no relief)

suicide

practitioners

Hyperalgesia and allodynia

or area affected

Uncontrollable (standard doses of drugs bring

Constant, with occasional periods of lesser intensity (but never entirely pain-free), lasting more than 4–6 weeks. May increase in intensity

Certain standard treatments (such as physical medicine and rehabilitation) may lead to worsening of the patient's state, increase pain and bring no desired rehabilitation results

May lead to depression, including thoughts of

May lead to despondency and lack of cooperation with medical professionals after experiencing increased pain following treatment Distrust of medical and rehabilitation

desirable, e.g. as the result of operation or treatment

standard doses of drugs)

(depending on type of treatment); changes in type, intensity, or frequency over time

Standard procedures - even if disliked by the patient - bring about the desired improvement

Countless cases justify the necessity to identify changes in suffering and to adjust treatment appropriately. The cases listed below are all from the last two years

Girl, 17, diagnosed with CRPS after two years of symptoms. At 15, she developed intervertebral hernia as a result of a sports injury. An orthosis was fitted and the patient was prescribed physical rehabilitation. The patient reported severe pain, which did not subside after the removal of the orthosis. Further treatment included electrostimulation, acupuncture and symptomatic treatment. At 16, the patient began reporting severe stomach symptoms. Six months later, changes characteristic of CRPS began appearing on her left leg: the leg changed coloring, hair growth increased. Bone loss occurred [18–21]. CRPS spreading to organs such as the stomach is not typical. Frequently children suffer from severe musculoskeletal pain (Amplified Musculoskeletal Pain Syndrome - AMPS), which can be interpreted as Complex Regional Pain Syndrome, Reflex Sympathetic Dystrophy, Reflex Neurovascular Dystrophy, or extensive pain, such as in fibromyalgia. CRPS was eventually diagnosed and specialist treatment commenced c. 19 months after the initial appearance of CRPS symptoms. The patient's left leg and stomach remain affected by CRPS. She is fed by a gastric (nasoduodenal - ND) tube. Leg pain causes her to periodically use crutches.

Girl, 12, treated for tumor. She broke her leg in an accident at school. A typical treatment followed: the bone was set and a plaster cast was used to immobilize the

and are representative of many other such cases.

*Sufferers' reported experiences before and after developing CRPS.*

**2.2 Case: identification hindered by comorbidities**

**2.1 Case: symptoms non-specific to the treated condition**

**118**

leg. From the very start, the patient reported increased pain which was interpreted as symptomatic of the tumor. After the removal of the plaster cast the limb was swollen and hypersensitive to touch. Symptomatic treatment and physical rehabilitation brought no results: the child continued to be in constant pain. After changes in the bone were discovered, CRPS was diagnosed. CRPS-specific treatment commenced over a year after the symptoms first appeared.
