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with depression. However, they found that when they controlled
for interference and ‘self-control,’ pain was no longer
associated with depression.
This was an epiphany for me because in years of working in
a chronic pain rehabilitation program, I had often been surprised
that some of the most grateful patients were ones who
had little or no pain relief. When I’d seek an explanation for
why they were satisfied with a treatment that seemed to have
failed, they’d reply with such statements as, ‘Yes, but now I have
my life back!’
What this tell us is that if we can help people with pain to
regain the things in life that bring them joy, and can help them
regain a sense of empowerment and control over their lives,
then it may be possible for them to have a good quality of
life—a life with pleasure and freedom from depression, despite
persistent pain. This is an especially critical issue because of the
fact that chronic pain, while often helped, is rarely cured.
Q. If a person with CRPS is extremely upset, can that
affect the disease?
DR. COVINGTON It is clear that psychic factors can modulate
the disease. There are several studies that show that people had
marked stress at the time they developed CRPS. And we know
that autonomic arousal stimulates catecholamine release, so if a
person with CRPS becomes frightened, angry, has an orgasm—
anything that causes emotional arousal—it can cause a pain
discharge at the same time.
Q. What is the relationship between pain and activity
in people with CRPS?
DR. COVINGTON In a 1969 study, a researcher found that many
of the trophic sequelae (i.e., claw hand, ridge fingers, and skin
changes) were due to prolonged disuse occasioned by pain.
He claimed that these changes developed in people who were
poorly motivated to get well—who were unwilling to overcome
the stiffness that follows immobilization after trauma. So basically,
he said that people get CRPS because they’re not exercising
enough—that getting the disease was their own fault.
While I dispute the idea that getting the disease was their
fault, we do know that responses to pain range from normal
function to invalidism. And we do know from a number of
studies that simple disuse, overprotection, and immobilization
will create many characteristics that resemble CRPS (including
bony demineralization, vasomotor changes, and swelling). A
very old study of 142 patients found that exercise alone caused
reversal of edema, trophic changes, and vasomotor signs (3).
This was a study of young people, and young people do get
well much more often than adults do.
So the fact that disuse and immobilization produce signs
similar to CRPS, together with the fact that use and exercise
can eliminate some of the signs of CRPS, suggests that behaviors
are likely to play a major role in the extent to which this
We don’t have a good
understanding of exactly
what CRPS is and why
some people get it
and others don’t.
disease progresses or improves. I doubt that it’s the only factor,
but it strongly suggests that what patients do in response to the
disease may strongly impact outcome.
COGNITION
Q. Wh at affect does cognition (what a person thinks)
have on the disease?
DR. COVINGTON What patients think can disable them. Misunderstandings
and misinformation can lead to inactivity. A person
may fear spinal range of motion because the associated pain
could presage paraplegia or incontinence. The cognition thus
leads to inactivity which leads to deconditioning. A cycle of
escalating pain and disability ensues. Fitness and education can
be curative. And with CRPS, you often see people who seem to
be more disabled than they ought to be. This disability may
appear psychiatric when actually it’s a lack of information or
misinformation—a knowledge deficit. When people are
informed about what they can do safely, they will sometimes
get well, at times with no help from health care providers.
Q. What are some beliefs that can make a person sick?
DR. COVINGTON Several studies have shown that a belief that
pain is mysterious and unexplained, or that it connotes body
damage will increase suffering and dysfunction, even when the
beliefs are false. If a person sees himself as helpless and fragile, of
if he sees the world as indifferent, hostile, and without opportunity—such
beliefs can increase the person’s level of disability.
The concept of ‘locus of control’ is an important focus of
work with people in pain. An internal locus of control is characteristic
of those who see themselves as ‘the captains of their
ships.’ They tend to be ‘take charge’ or executive types. A
patient with this attitude is much more likely to do well than
one who attributes events to fate or to powerful other people.
Those with an external locus of control are likely to take a
passive (and therefore ineffective) approach to dealing with
pain, since they think their efforts are futile. In our rehabilitation
program we even go to the point of encouraging certain
patients to wear sweatshirts that say ‘CEO’ to remind them that
they are the CEOs of their lives as they learn to manage pain.
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