The hidden simplicity of diagnosing Complex Regional Pain Syndrome

CRPS, formerly known as Reflex Sympathetic Dystrophe (RSD) or Causalgia, sometimes called Sudeck’s Atrophy, and elsewhere called Neuroalgodystrophy (among other things), is confusing to label accurately because it’s not only complex, but it’s a disease of exceptions.

In many cases, pain is not sympathetically maintained; hence the deprecation of the name RSD. Atrophy doesn’t always happen; hence the deprecation of the name Sudeck’s Atrophy. And, most importantly, it is not a psychogenic disease[1], making the name neuroalgodystrophy, or the presumptive diagnoses of somatoform disorder or conversion disorder, irrelevant — not to mention prejudicial and counterproductive.

The earliest professional description in the historical record of a syndrome like CRPS occurs in the notes of Ambroise Pare’, groundbreaking surgeon and father of forensic pathology, as well as court physician of French king Charles IX in the late 1500′s[2]. Between North America and Europe, further descriptions and case studies appeared over the next few hundred years[1]. Consistent diagnostic characteristics were described by neurologist and American Civil War battle physician Silas Weir Mitchell in the mid-1860′s[3], who saw many hundreds of cases due to the peculiarities of the ballistics used in that war.

Thus, CRPS does not qualify as a “disease of modernity”, the cluster of diseases characterized by distributed pain, lethargy, memory/cognitive impact, and immune dysfunction. In fact, it predates the Industrial Revolution by a couple of centuries. CRPS has also been described in animals[4]. In short, there is no compelling evidence that CRPS is anything other than a disruptive companion of mammalian neurology, which has become more recognized as humans are living longer despite impairments, and describing illness better.

Various attempts have been made to create coherent diagnostic criteria. Sadly, they’ve been written and published by physicians, who rarely have the distinct skillset of information architecture — but who do have lots of practice using double negatives, complex constructions, and the passive voice. The inevitably garbled paragraphs which result from using this professional style to describe the diagnosis of Complex Regional Pain Syndrome come across, however unconsciously, as sloppy and ill-defined, regardless of the underlying information.

After much thought and research, this blogger’s view is that the most recent (2013) IASP diagnostic criteria[5] may not be perfect, but are currently the best we have for all-around clinical use. Therefore, in the interests of obviating (that is, doing an end-run around) the confusion, this blogger — who is an information architect — has turned the diagnostic criteria into a simple checklist.

Once completed for each patient, this checklist not only delivers a yes/no for CRPS diagnosis, but also highlights which features of that case are salient, and where treatment of that person should probably focus.

Full-sized PDF format is downloadable and available for free under Creative Commons Share-Alike Attribution International licensure. In other words, wherever you are in the world, you are free to use and alter this, copy it, pass it on, even charge for it — as long as it contains a link to this page (biowizardry.info) or its companion page, livinganyway.com, and you don’t try to claim or assert IP rights. It’s appropriate to pass it on as freely as it’s offered to you. Use it in good health — whenever possible.

REFERENCES

1. CRPS not psychogenic; also, history of CRPS:

Feliu, M., and Edwards, C.L. Psychologic Factors in the Development of Complex Regional Pain Syndrome: History, Myth, and Evidence. Clin J Pain, Volume 26, Number 3, March/April 2010.

2. King Charles IX, 1550-1574, had persistent burning pain, muscle wasting, and contractures following bloodletting with smallpox: Pare, A., 1634. Of the Cure of Wounds of the Nervous System.

The Collected Works of Ambroise Pare. Milford House, New York.

3. S. Weir Mitchell, Morehouse and Keen on causalgia:

Gunshot Wounds and Other Injuries of Nerves. Philadelphia: JB Lippincott Co., 1864.

«As to pain, I am almost ready to say that the physician who has not felt it is imperfectly educated.» S. Weir Mitchell.

4. CRPS in animals:

Bergadano, A., Moens, Y. and Schatzmann, U. (2006), Continuous extradural analgesia in a cow with complex regional pain syndrome. Veterinary Anaesthesia and Analgesia, 33: 189–192.

PMID: 16634945

5. Yet another link to the PDF of the Diagnostic Criteria checklist:

http://biowizardry.info/wp/wp-content/uploads/2014/12/CRPS_Diagnostic_CheckList.pdf

Creative Commons License
CRPS: Diagnostic Checklist by CRPS Publications is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

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Clarifying nutrition: focus on Source, Process, and Time

This table shows the antioxidant contents of 3,000 foods:

The Antioxidant Food Table

On first glance, I was annoyed, because there was so much redundancy in the foods examined: 11 entries for blackberries? Couldn’t they make up their minds?

On closer inspection, a deeper story emerged. Take a look at this and see what you find:

Product Label Procured in Antiox. (mmol/100g) Prep
Blackberries, cultivated USA 4.02 6
Blackberries, cultivated Solabaer, Sola, Norway Norway 4.13 3
Blackberries, cultivated Norway 6.14 3
Blackberries, cultivated Belgium Norway 3.84 3
Blackberries, cultivated, canned, drained S&W Fine Food, USA Norway 2.34 3
Blackberries, cultivated, frozen Local grocery USA 4.06 6
Blackberries, cultivated, frozen Wholesaler USA 3.89 6
Blackberries, cultivated, with sugar Findus, Norway Norway 4.76 3
Blackberries, Dessert Berries, without sugar, frozen Norske Dessertbaer, Norway (berries from Poland) Norway 5.98 3
Blackberries, dried, “Loch Ness” The Norwegian Crop Institute Norway 37.08 5
Blackberries, wild Norway Norway 6.13 4

Comments:

3 Purchased in grocery store, restaurant, cafe, bakery or marketplace.
4 Handpicked or received directly from supplier.
5 Previously published in Halvorsen et al. 2002 or Dragland et al. 2003
6 Previously published in Halvorsen et al. 2006.

Notice how much variation there is?

This table indicates what’s behind those eternally confusing reports about which food has the  most antioxidant activity.

With a spread of more than tenfold in the antioxidant activity in blackberries, you simply have to look at two more factors:

  • Source
  • Preparation
Understanding these two critical factors helps clarify a lot of red-herring driven confusion over which foods are most nutritious.

It’s a reminder of something we know, but tend to forget in the barrage of information and anxiety around food. 

  • Plants and animals need nutrients, water, sunshine and air to grow; the quality and quantity of these things affects what they produce.
    More species-appropriate and healthful growing environments produce more nutritious food than inappropriate or unhealthful environments.
    Different strains of the same species have different attributes, as someone who has tasted longhorn steak and kobe steak side-by-side could probably tell you.
  • Food nutrients are reactive, which means that heat and light are going to make them change over time.
    If they weren’t reactive, they wouldn’t be nutrients, because nutrients need to be amenable to digestion and assimilation — that is, physical and chemical reactions — before they can do us any good.
    Therefore, food nutrients are susceptible to heat, light and time.

Source matters

Cultivated blackberries from 3 different places had an antioxidant score that varied by roughly a third. That’s a significant variation!

There was only one sample of wild berries, which rated about the same as the best of the cultivated fresh berries from the same region. Wild strains of berries are generally more nutritious, so it should be said that this study does not specify if these berries were from a wild strain, or from a cultivated strain found growing in the wild. Not everyone realizes there’s a difference, but heredity matters (kobe/longhorn.)

Preparation matters

Processing makes a huge difference in the amount of nutrition available per, say, 100 grams.

Notice how the canned berries, which are subjected to considerable heat in the canning process, have the least antioxidants.

The frozen berries, which are meant to last awhile (thus being subject to time) have less bounce per ounce than some, but more than the canned berries.

The fresh Norwegian berries that travelled to Belgium are likewise impoverished, and the distinguishing factor between them and the Norwegian berries in Norway is the transit… time.

This may also be due to using a strain of blackberry that withstands transport better — a trait which, in produce, often goes with a lower nutritional profile.

If fruit is dried correctly (a big “if”), then it retains much of its nutritional value and has the considerable advantage of concentrating it into a smaller quantity. Thus, the 100gm of dried, possibly higher-quality berries turned out to have the biggest antioxidant kick — by a factor of roughly 10 over frozen berries.

Subjective matters

I’ve been thinking about this article since I read it a month ago.

Then, as I was struggling with brain fog this weekend, I got a pair of half-pints of organic raspberries from a large commercial producer which is famous for consistently mild, sweet-smelling berries that hold their shape despite being shipped all over. They were on sale.

I ate a whole package, hoping for that antioxidant kick that would chase some of the fog away. Not wanting too much sugar in my system (and hating to spend that much money in one sitting), I hesitated before starting on the second package, but no good. I might as well have been eating cardboard for all the good it did. I began to wonder if I should bother with raspberries at all, given how every bite I eat has to matter.

The next day, I stopped at a roadside stand and picked up a single half-pint of organic raspberries from a farmstand, for slightly more than the brand-name berries cost on sale, but less than they cost otherwise. (Farmstands are generally worth the gas I spend on finding and mapping them.) They were much smaller, much darker, and some of them were squashed. They wound up spilling in the car, and I pulled over to scoop them up and keep them from messing up the rest of my shopping. I quickly gave up on extracting them neatly, and just shoved the spilled half into my mouth.

Quite apart from the flavor explosion — which was an eye-opener in itself — within a minute, the fog had lifted. My eyes were sharper and my head was clearer than it had been in awhile. THAT was the antioxidant kick. It lasted for hours, and I got another one when I ate the second half.

Summary and context

A lot of the fuss over what to eat can be resolved with a little common sense and remembering what you learned in grade school when you were sprouting beans in little cups.

How fresh your food is, probably matters more than exactly what it is.

How well it was grown, probably matters more than the packaging.

And, if you’re lucky enough to live near farm country, roadside stands are worth your time.

If not, build farmer’s markets into your schedule, because they bring the fresh food right to your neighborhood, with very little time between the soil and you.

I’ve found that each bite of more nutritious food is more rewarding in every sense, and I wind up needing less to meet my needs. It’s economical in the long run, although I remember it took a few months of eating good food voraciously to catch my impoverished system up. That cost a lot up front, but it paid off in the end: my system became more efficient and my tastes evolved for satiation, not overstimulation. I eat enough and am genuinely pleased; that eternal nervous quest for more-more-more is gone.

Grocery stores are for filling in after the farmer’s market and roadside stands, in my view. I have a limited budget and stringent nutritional needs, so I’ve come to that realization the hard way. This study just reinforces my discovery in a different way.

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Link between fast food and depression confirmed, not clarified

This article states that around 5% of non-depressed people go on to develop depression when they eat junk food of the baked-goods variety (like croissants, pecans spins and Twinkies) or fast food.

Link between fast food and depression confirmed

The authors assume the link is causal (fast/junk food causes depression), but I don’t see why. Many people only eat fast food and carb-rich junk food when they’re already depressed and want the temporary solace (and serotonin/insulin hit) of comfort food. It might be smarter to eat more trail mix, olives and avocados when we’re depressed, and leave out the Twinkies, but the fact is they cost more.

So, is the fast food/junk food self-medication for depression, contributor to depression, or both? It makes more sense to view it as a sign that something is amiss, rather than leaping to the conclusion that fast/junk food itself is the problem.

When people need to self-medicate, they’re going to find a way. And at least fast food is not going to cause as many accidents as alcohol, as much ruin as harder drugs, or as much disease as compulsive sex — all of which are popular forms of self-medication for depression.

Something to consider… We need not leap right to the blaming mentality. We can treat these changes in habits as useful clues instead.

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Gender & personality — the US isn’t everybody!

This ScienceDaily article reports on a study which states that the personality differences between men and women are simply enormous and have been substantially underreported for years:

http://www.sciencedaily.com/releases/2012/01/120104174812.htm

However, if you read the actual methodology used in the study, you’ll see that the entire population studied was from only one country, the US:

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0029265

“Personality measures were obtained from a large US sample (N = 10,261)”

This is culturally arrogant at best, but it’s now intellectually indefensible. It has recently been demonstrated that one of the most profound gender differences in the brain (math ability) is purely a cultural artifact, when you look at international populations:

http://www.sciencedaily.com/releases/2011/12/111212153123.htm

Therefore, what the original study says — that there are enormous personality differences between the genders — is deceptive. All it means is that, in the U.S., huge gender-based personality differences are tolerated, or even encouraged and trained.

As an international traveler all my life, I could have told you that for free!

In the math study, one researcher said, “People have looked at international data sets for many years. What has changed is that many more non-Western countries are now participating in these studies, enabling much better cross-cultural analysis.”

In short, there is no excuse for such sloppy social science as the “gender-based personality differences” researchers have perpetrated.

Believe it or not, the U.S. is not a good template for studying the entire human population. It’s only a good template for studying the U.S.

Since these scientists are working from Italy and Britain — both countries with famously self-satisfied national identities — you’d think that would be more apparent to them.

It’s disturbing to see such cultural subjugation in science. One expects a degree of cultural infatuation in other realms (like cinema and music, which depend on cultural blending for their development), but not in science. Science requires a bit more intellectual integrity, if not clearer thinking.

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News flash: Dementia is confusing & doctors should communicate

I can’t resist candidates for the Dept. of the Blith. Obv.: Many geriatric patients receive an incorrect dementia diagnosis. 

The final diagnosis was determined by postmortem autopsies examining structures and changes in the brain, which are pretty definitive.

Most dementias are currently incurable, and only some can even be managed. So why does this matter?
Two reasons: the clinical and the academic — which is ultimately clinical, too. 
Firstly — and I’m speaking as someone who has skirted dementia myself — if anything can be done to mitigate this hideous state, it should be done. Correct diagnosis improves your chances of getting appropriate care. 
Secondly, incorrect diagnoses screw up the data. How can we evolve our understanding, improve diagnostic criteria, develop more effective treatment, and work on actual cures, if we aren’t clear about what we’re working with and how it plays out?
What’s lovely and touching about this is, the researchers truly believed that correct diagnoses were much more common, and that the communications between the neurology department and the geriatric psychiatry clinic were better than they were … and that they changed their stance dramatically in response to their findings. 
Knowing how cautiously physician researchers normally phrase recommendations, and how neutral and respectful Swedes prefer to be, the researcher’s closing remarks sound like a passionate cry from the heart. It’s really moving. 
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The key to growing old gracefully

Another candidate for the overpopular Department of the Blitheringly Obvious:

“Social life and mobility are keys to quality of life in old age”
http://www.sciencedaily.com/releases/2011/05/110528191542.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Fmind_brain+%28ScienceDaily%3A+Mind+%26+Brain+News%29

The article goes on to say that old people go to great lengths to stay active and connected, and use their well-seasoned brains to problem-solve issues of daily living at a rate that makes most younger people look like pikers.

In this article, they actually used the term “extreme lengths” — obviously they haven’t considered what it’s like to be old. You simply have to cope, in order to have a life worth living, and your friends help you figure it out. Doesn’t that seem pretty self-explanatory?

Nurses could have told them all that, plus a bunch of gruesome stuff about skin care, but study scientists pay even less attention to nurses than they do to patients. I’m just glad someone FINALLY thought of asking the only people whose opinion on “quality of life for the elderly” really counts.

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Re-Learning Aids

I originally created this blog as a place to digest articles on medicine and biomedicine — especially as they relate to real, live human beings of the kind who need to use medicine and biomedicine. After all, needing it means our systems are not quite normal.

I have a condition that punches holes in my memory and cognition. This means that, even though this biomedical stuff is meat and drink to me, I have to look up things that — with my old brain — I used to know like the back of my hand. (That is, the hand where the CRPS started, naturally.)

Really basic things, like the names of our handful of neurotransmitters, each with its many jobs; or the role of the pituitary gland and its intense relationship with … well, with every other regulatory part of the body.

So I’ll post a couple of tutorials on these subjects here, for both you and me to refer to at need. If I’m really clever, I’ll post them as pages which you can access easily; for now, I’ll be happy to get them up at all.

Soooo …. [drumroll, please]

Coming soon:
- A quick rundown on neurotransmitters, with interesting dietary notes.
- Tutorial on the Limbic-Hypothalamic-Pituitary-Adrenal axis.

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Spinal cord changes in longstanding CRPS

This is brilliant:

Spinal cord histopathological alterations in a patient with longstanding complex regional pain syndrome

The authors did an autopsy on one person with longstanding CRPS and did comparative autopsies on 4 people who did not have CRPS. They checked samples from the neck, thorax, and low-back for microglia and astrocytes. These are the kinds of cells that not only are part of the nervous system’s immune response, but also increase the transmission of pain signals. That means, inflammation plus more pain! They found plenty in the CRPS patient’s spine.

They also found that the normal cells in the dorsal horn of the spine – the ones that carry sensations of light touch, vibration, and proprioception (the sense of the body in space) – are significantly fewer in the CRPS patient. This makes sense of the fact that allodynia (light touch) gets worse, vibration is so agonizing (making both riding public transit and holding a steering wheel pretty horrible), and we get clumsy over time because we can’t quite feel where our bodies are in space.

These strange cellular changes were found “most prominently at the level of the original injury, but extending throughout the entire length of the spinal cord.” That means that the allodynia, diminished balance, etc. physically spread from the original dorsal root, all the way up and down the spine, affecting the whole physical self.

So, with more cells for pain and immune attack, and fewer cells to transport normal messages of light touch, vibration, and proprioception, we have some stunningly clear evidence that the spreading allodynia, clumsiness, and intolerance to vibration is NOT IMAGINARY.

Given how many people get told that it’s all in their heads, they’re hurting because they’re thinking wrong or because they were abused as children, etc., this is an important thing to keep in mind. Let’s keep the cart behind the horse.

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