How Deep Is Your Pain?

pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. or described in terms of such damage. Pain helps us to withdraw from the actual injury and is usually a protective measure. It also helps us seek appropriate action and prevent potential harm that we might do to ourselves. But sometimes, the pain continues to bother people even after the actual stimulus has been taken care of, continuing to impact an individual’s life.

Debilitating Pain Syndromes

Complex Regional Pain Syndrome (CRPS)
Phantom Pain
Fibromyalgia

Here is an example of a case where a patient with severe pain was treated:
A 49-year-old male was involved in a motor bike accident and sustained a trimalleolar fracture. He underwent an operation and the recovery was as expected and he went home, but he was walking with crutches when discharged. He continued to suffer from pain though the wound had healed and had to be readmitted to the hospital again to remove the surgical plates placed in his ankle. There was some improvement in the pain but it started again after six months.

The pain increased in intensity and started affecting his day-to-day life. So, he avoided meeting his friends and family and became quite withdrawn. He even quit his job as a carpenter and always stayed at home due to the pain. Finally, an orthopaedic team met him and even a number of tests could not detect the cause of the pain. He was then referred to a neurologist to manage the pain. He reported throbbing pain in his right ankle ranging in intensity between seven to nine out of 10 on a pain scoring system. He also reported of a freezing sensation over his foot as well as a change of colour in his toot and ankle with it turning pink/ mottled and swelling during a flare up.

A neurologist reviewed his case and noted that he has less hair on his right leg. has smooth skin with mottled appearance, dystrophic nails, cold to touch and sweaty on comparison to the normal side. The man was diagnosed with CRPS and referred to chronic pain service. He was put on multiple medications with limited benefits. He was also given some low dose antidepressants, which made no significant difference.

He then had to undergo intensive therapy under the rehabilitation department and inputs from the pain team at the same time. He was started on peripheral nerve block with a local anaesthetic and was seen by a rehabilitation physician, physiotherapist, occupational therapist, psychologist and a social worker for a multidisciplinary approach.

Budapest Diagnostic Criteria For CRPS

The man had temperature changes. colour changes, swelling, sensitivity changes, shiny skin and dystrophic nails.

The Budapest Criteria

Sensory
Allodynia (aka pain normally not painful situations such as touch, temperature, or movement), Hyperalgesia (heightened pain intensity)

Vasomotor
Differences in skin temperature (greater than 1°C)

Differences in skin colouration between different sides of the body

Sudomotor/oedema
Changes or asymmetry in swelling

Changes or asymmetry in sweating

Motor/trophic Decreased movement
Motor symptoms (weakness, tremors etc)

Changes in hair/skinfriails

Left/Right Discrimination

The man was challenged with various approaches and his responses and accuracies were timed. Research shows that people with debilitating pain lose left/right discrimination and retraining, helps them to progress to the next stages of GMI.

He then underwent motor imagery where he had to imagine doing some movements and initially he had pain issues just by imagining the movements, but he made progress with time. His third step in GMI (Graded Motor Imagery) was mirror therapy.

Invented by Dr Vilayanur S Ramachandran, mirror therapy was initially designed for relieving phantom pain and is now being used for other conditions like complex pain syndromes and stroke recovery as well.