With respect to treating Complex Regional Pain Syndrome, we have had to deal with almost strict empiricism; people just used what they thought worked and what they were comfortable with. Of course, being a researcher, I was always ‘we need better evidence and more data.’ One of the hurdles against that was the fact that we didn’t have good, clear objective diagnostic criteria. We fixed that to an extent. We have subjective and quasi-objective diagnostic criteria now, which is still not ideal, but it had another ramification besides being able to bring people into studies. Because we deliberately designed the criteria so that it would be clinically accessible, we made it so that any doctor, any clinic anywhere in the world, with no special equipment, no special training could make the diagnosis and that’s helped a lot clinically. We’re now seeing good evidence based, large scale pharmaceutical trials. We’re talking about 300 to 400 patient trials, which is critically important for generating a real true evidence base. We also have larger trials of physical therapy, mindfulness therapy, mirror therapy, progressive muscle relaxation. All of these things are useful for at least a subset of CRPS patients.
The critical message to the clinician is to embrace the parts of the disease that you can treat. I believe that all chronic pain is biopsychosocial and to ignore the psychologic and the sociologic is to fail. Depression and anxiety are ubiquitous in all chronic pain and especially CRPS, and we can treat them. For depression we’ve got such effective drugs that are cheap and have low side effects. Antidepressant, anxiolytic drugs sort of go hand in hand and there’s a bunch of them. Sociologic disease is more difficult to treat, more labor intensive. You need occupational therapists and vocational therapists, and work with insurance companies and Workers Comp carriers. But physicians can have a huge impact on sociologic disease, and thereby help patients get on with their lives. I’m a rehabilitationist, and we believe in function as something you can measure, something you can put your hands on as opposed to pain, which is completely subjective. In CRPS, there’s a vein of thinking that you have to reanimate the affected part. If sufferers have the dystonias and terrible pain with movement, what happens is they stop moving the part, which initiates bone loss and muscle loss and more pain and sympathetic abnormality. Patients get to the point where they never move the limb, which is called kinesiophobia amongst other things. So you must reanimate the part. You must get it moving again. I believe that so strongly that I’ll always say in a lecture “if you can’t get the patient to move the affected part, you’ll never succeed.” They won’t get better. They may not get worse, but they often do so you’ve got to break that fear of movement to succeed in treating CRPS.