Preventing chronic pain from escalating to chronic pain syndrome (CRPS)
Andrea's history, examination, and investigations
Andrea, a 35-year-old nurse, married with 3 children, came to the examination with a history of left arm pain triggered by a minor injury about 4 months earlier. She described the pain as constant and burning, involving her arm, wrist, and hand, and she rated her pain as 9 out of 10. She was unable to work, pick up her 3-year-old son, or carry out her household duties. Her sleep had also been disturbed. Painkillers were ineffective. She had gained 20 pounds since the injury due to inactivity and changes in eating habits.
On examination she was teary-eyed and protective of her left arm. Her left hand was mottled-blue in color and cold to touch with noticeable loss of hair on the arm. There was some muscle wasting in her left shoulder girdle muscles indicating decreased use of her arm due to pain and guarding.
Investigations, CT scan, MRI, X-rays, and blood work were normal. A bone scan was ordered and showed decreased bone density in her left arm.
Getting help
Eventually, Andrea went to a pain clinic, where she was diagnosed with complex regional pain syndrome with secondary frozen shoulder. She was started on low dose of antidepressants to help her sleep and to decrease her pain level.
Andrea was booked for an immediate consultation with an anesthetist, who performed three stellate ganglion nerve blocks. Following the first injections, the color and temperature of her hand returned to normal and her pain was greatly reduced.
Her rehabilitation program was composed of intensive physical modalities: physiotherapy, massage, chiropractic, occupational therapy, and kinesiology to reactivate her shoulder, upper back, neck, and left arm muscles. She consulted a nutritionist for advice on a healthy diet and had the kinesiologist work out a tailor-made fitness program specific to her needs and fitness level.
At the end of the 8-week program, Andrea regained a full range of motion in the left shoulder, her pain level dropped down to 1 out of 10, she was able to participate in all of her daily activities, and she started a graduated return-to- work program. Andrea lost 10 pounds and continued her exercise program at the community center 3 times per week with her family. Her sleep and energy gradually returned to normal.