Dr. Yovanny Ferrer Lozano ¹, MCs Lic. Dunia Ferrer Lozano  2

Translation: Sabrina Gisella Cordone. Más información en http://www.portalesmedicos.com/traductores-medicina/cordone/
 

1 Second degree specialist Orthopedics and Traumatology. Matanzas FCM instructor professor. Matanzas University adjunct teacher. FCMM researcher assistant

2 Master in Medical Psychology. Bachelor in Psychology Central University of Las Villas Auxiliar Professor

Cardenas Teacher Territorial Surgical Clinic Hospital, Julio M. Aristegui Villamil. Las Villas Central University, Marta Abreu.

Abstract

A prospective study of opinatic inclusion is performed to 42 patients who were treated in the Orthopedics and Traumatology Service from the Cardenas Teacher Territorial Hospital, from January 1999 to January 2004. All of them were diagnosed with a Complex Regional Pain Syndrome, according to the criteria put forward by the International Association for Pain Study.

In the 90.4% of this sample, there is a group of psychological peculiarities that remain stable, among the most predominant are anxiety signs as a condition and feature that is stable between the medium and high level, problems in regulating emotions, low tolerance towards frustrations, few communicative skills, which affects the process of problem solving, damage in the sphere of interpersonal relationships due to the patient`s tendency to interpret their own pain inadequately, to deny the chronic state exposed by the specialist and, far from it, to reject the participation of the psyche in their experience.

Key words: Nervous system, sympathetic and nervous system, complex regional pain syndrome, neuropathic pain.

Introduction

In 1528, Galeno described a nervous trunk that flowed through the costal heads and communicates with the spinal cord. This way he established the concept of sympathy among the different parts of the human body. The first references in patients with armory injuries are written by Mitchell in 1877. Sudeck made his famous description in 1900.

The term Reflex Sympathetic Dystrophy (RSD) was proposed by Evans in 1946. The International Association for Study of Pain (IASP) creates in 1994 the Type I Complex Regional Pain Syndrome (SDRCI) in order to replace the term RSD. Furthermore, in this meeting, the replacement of the term causalgia or sympathetic hiper excitability by the term Type II Complex Regional Pain Syndrome (SDRC-II). (1)

The International Association for Study of Pain (IASP) defines the Complex Regional Painful Syndrome as the different painful conditions of regional localization, after an injury, that presents a distal preponderance of abnormal symthomps, surpassing the expected clinic course of the inicial incident in size and duration, and this frequently causes an important motor deterioration, with a variable progression in time (2).

Conceiving men as a biopsychosocial being, numerous therapeutic approaches have been structured for treating the Complex Regional Pain Syndrome (SDRC), which proves the need for an increasingly diversified multi-disciplinary attention in the presence of this neuropathic pain type (3). Although the rehab physical treatment has been chosen by many institutions as an alternative, once this syndrome is established from the point of view of Psychology, the attention to this kind of patient gains great importance, not only for the nervous damage it represents, but also for the subjective experiences that are undergone as part of the internal signs (4).

Methods

A prospective study of opinatic inclusion is performed to 42 patients who were treated in the Ortopedics and Traumatology Service from the Cardenas Teacher Territorial Hospital, from January 1999 to January 2004. All of them were diagnosed with a Complex Regional Pain Síndrome, according to the criteria put forward by the Internacional Association for Pain Study.

• It is a syndrome that develops after a dangerous cause episode.
• It appears as an spontaneous pain or allodynia/hyperalgesia, which is not restricted to the territorial distribution of a peripheric nerve, and not proportional to the causing episode.
• There is or has been evidence of edema, an anomaly in the cutaneous blood flow or abnormal sweating activity, in the painful region since the causing episode.

This diagnosis is disregarded because of the presence of other conditions that may explain the degree of pain and dysfunction. For obtaining the psychological diagnosis and therapy, the following techniques were performed in each case:

- Interview in different modalities: Aimed at exploring the general condition of the patient, present concerns, causes of depressive manifestations or referred disorders. This procedure, after the application of each of the remaining techniques, was useful for triangulating the obtained information.

- Test of phrases completion: (Rotter) Aimed at studying in depth the emotional-motivational sphere. The answers are evaluated according to Gonzalez Rey`s criteria (5).

- IDARE inventory: To evaluate the anxiety levels as a condition and as a feature.

- Essay called “What is essential for me”: To gain access to the conscious elaborations of the patient related to their motivational hierarchy and future projections.

We also include the family as a support group from the realization of their condition.

Results

Out of the total of people consulted because of alterations associated to the presence of Complex Regional Painful Syndrome in the last 5 years, we find a group of psychological peculiarities that remain stable in the 90.4% of the cases. The main difficulties concentrate on the acceptance of the disorder and its consequences, and in the regulation of anxiety physical status and depression, which are caused by the same symptoms and its limitations.

Next, we list these symptoms:

• Signs of anxiety as a condition and feature that is stable between the medium and high level.
• Problems in regulating emotions.
• Low tolerance to frustrations.
• Predominance of depressive distal condition, with loss of interest for common activities.
• Pessimistic beliefs related to health, centered on a negative image of its being, life and future.
• Presence of different cognitive distortions, with certain predominance of overgeneralization, opposed thinking, catastrophic vision and the “I should”.
• Styles of confronting situations through emotions.
• Intensity of symptoms as long as they are referred to is unproportionate compared to the harshness of the trauma, that can be absolutely minimal.
• Few communicative skills, which affects the ineffective process of problem solving.
• Damage in the sphere of interpersonal relationships, specially caused by the patient`s relationship with the health professionals that treat them, in most of the cases due to the patient`s tendency to interpret their own pain inadequately, to deny the chronic state exposed by the specialist and, far from it, to deny the participation of the psyche in their experience, which they state is physiological.

Debate

The number of patients suffering from Complex Regional Pain Syndrome (SDRC) in the last years has had a slight increase. Two hypotheses have been formulated as regards this phenomenon: either the knowledge about medical sciences has moved forward with such a speed that this disorder can be better diagnosed, and thus, this is the cause of the slight increase in the number of cases arising, or the continuous demands of daily life and the styles of confronting used to respond to life, in a great percentage of the population, is proving to be inadequate and act as predisponent for the appearance of such alterations (6).

The clinic experience proves that the Sympathetic Nervous System is responsible to maintain and perpetuate certain chronic painful syndromes (7). The following efferent actions of this component from the Autonomous Nervous System are involved in the production and maintenance from the Complex Regional Pain Syndrome (SDRC);

• The sympathetic function in the affected area is abnormal; edema, sweating and dystrophia in the skin (sweating disorder) and alterations in the blood flood with changes in temperature (vasomotor disorder).
• Prompt ease of pain after a sympatheticolitic therapy, in those cases of pain mediated through the sympathetic.
• Activation of the sympathetic nervous system by intense noises, iontophoretic application or intradermic application of adrenergyc agents, that exacerbate pain.

However, it was also proved that pain in this pathology not is not always generated, maintained and perpetuated by said system, although it can be regarded that there are normally sympathetic-sensible interactions in the human healthy tissues, proving that its activity and the catecholamines can primarily stimulate the afferent nociceptor. Hence, so much therapeutic failure is reported only with sypatheticolitics in cases of Type I Complex Regional Painful Syndrome (8). Pain is a complex and multidetermined phenomenon. It encloses a “system of alarms” that involve all the organism and in which the following systems intervene: perihperic and central nervous systems, vegetative nervous system, endocrine system, pschological factors laid to the personality of the subject experiencing the pain, historical factors (previous experience), environmental factors (family and social circle) and circumstantial factors (conditions in which pain is experienced). That is why each patient`s pain is specific and different. There are no exclusion groups.

The personality features act as a mediator between the acceptance and confrontation of the syndrome; therefore, an human being can develop this condition provided that biological and personality aspects condition so. That is why it is impossible to offer closed protocols from the therapeutic point of view and tackle this issue only from the patient, without taking into account their environment.

As regards psychology, the main difficulties are focused on the acceptance of the disorder and its consequences, that can come to extremities amputation in the harshest stages, and in the regulation of anxiety physical status and depression, which are caused by the same symptoms and its limitations (9). Pain gains great importance, not only for the nervous damage it represents, but also for the subjective experiences that are undergone as part of the internal signs and that guarantee the presence of a mental disorder. It is important to combine cognitive techniques that be aimed at wrong beliefs constructed around this disease, behavioral techniques focused on the comprehension and modification of human behavior through training, taking as a reference the contextual analysis and the causes of such manifestations and relaxation techniques that allow a better frame of mind of the patient facing their new reality (10).

It is necessary to teach the patient to face the pain, to coexist with limitations the syndrome itself imposes, as well as guide their relatives for them to become an active network of social support. The first sign of physical and psychological rehab is that the patient stops focusing their lives in the disease. A good end result is not obtained if the physical and not the psychological disability is overcome. The latter cause could leave a lifelong mark in the patient. Any time is essential in order to begin the treatment. A late diagnosis should not be a cause to abandon the therapy. A future prognosis depends to a great extent to it.

References:

1.     Greipp ME. Complex regional pain syndrome type I: research relevance, practice realities. J Neurosci Nurs. 2003; 35(1): 16-20.

2.     Forouzanfar T, Koke AJ, van Kleef M, Weber WE. Treatment of complex regional pain síndrome type I. Eur J Pain. 2002; 6(2): 105-122.

3.     Price DD. Psycological and neural mechanisms of the affective dimension of pain. Science, 2000; 288:1759-1772.

4.     Ferrer, D; Rodríguez, L; Ferrer, Y: La configuración del sentido de la vida en pacientes con amputaciones traumáticas de las extremidades. Cuaderno de Investigaciones Corporación Universitaria Ibagué, Colombia, 2003; 5: 34-53. ISN: 1657-401X

5.     González, F. La Personalidad: su educación y desarrollo. Ed. Pueblo y Educación, La Habana 1989

6.     David J, Basbaum AI. Molecular mechanisms of nociception. Nature, 2001; 423:203-10.

7.     Ribbers GM, Geurts AC, Stam HJ, Mulder T. Pharmacologic treatment of complex regional pain syndrome I: a conceptual framework. Arch Phys Med Rehabil. 2003; 84(1): 141-146

8.     Hubbard PHD. Reflex dystrophy syndrome. J Infus Nurs. 2002; 25(2): 121-126.

9.     Karakurum G, Pirbudak L, Oner U. Sympathetic blockade and amitriptyline in the treatment of reflex sympathetic dystrophy. Int J Clin Pract. 2003; 57(7): 585-7.

10.   Serra J. Tratamiento del dolor neuropático. Es necesario un paso adelante. Rev. Soc. Esp. Dolor. 2002; 9: 59-60.

11.   Pérez RS. The treatment of complex regional pain syndrome type I with free radical scavengers: a randomized controlled study. Pain. 2003; 102(3): 297-307

Translation: Sabrina Gisella Cordone. Más información en http://www.portalesmedicos.com/traductores-medicina/cordone/