Page 382 Guide to Pain Management in Low-Resource Settings

370 Andreas Kopf

Refl ex sympathetic dystrophy (complex regional dermatomes. Therefore, other pain etiologies than
pain syndrome type I) radicular compression have to be taken into account,

Pain, usually burning pain, that is associated with “au- such as facet-joint pain, sacroiliacal joint irritation,
tonomic changes”—changes in the color of the skin, or myofascial pain.
changes in temperature, changes in sweating, and swell-
Somatoform disorders
ing. Refl ex sympathetic dystrophy is caused by an injury
Th e somatoform disorders are a group of psychiat-
to the bone, joint, or soft tissues without nerve damage.
ric disorders that cause unexplained physical symp-
Th e most frequent cause is a radius fracture. Apart from
toms (somatoform disorder, hypochondriasis, pain
nerve damage, CRPS type I is not distinctive from CRPS
disorder,and conversion disorder). Th e pathophysiol-
type II. An older term is Sudeck disease, which should
ogy of these complaints still remains unclear. A com-
not be used, because sympathetic dysfunction may be
mon main symptom of these disorders is that physical
part of CRPS, but is no prerequisite for diagnosis. Diag-
symptoms cannot be completely explained by means
nosis and treatment are diffi cult and should be left to a
of a physiological process. Somatic disorders can be
specialist. Advanced CRPS may leave the patient with a
accompanied by defi ned physical illnesses, but they
permanently unusable extremity.
may not be adequately explained by these illnesses.
Rheumatoid arthritis Patients who suff er pain without an organic cause
An autoimmune disease that causes chronic infl amma- are often unable to cope with emotional stress; this is
tion of the joints and the tissue around the joints, as converted into physical stress factors. Th ese diff use
well as other organs in the body. Autoimmune diseases stress factors can no longer be understood as a physi-
occur when the body tissues are mistakenly attacked by cal expression of an intrapsychic confl ict, but are non-
the body’s own immune system. Th e immune system is specifi c, vegetative stress factors (e.g., with agitation,
a complex organization of cells and antibodies designed shaking, and pain) as a result of emotional pressure
to “seek and destroy” invaders of the body, particularly experienced primarily physically. Various physical dis-
infections. Patients with autoimmune diseases have an- orders can result. Th e standard medical treatment is
tibodies in their blood that target their own body tis- often limited. Th ese disorders should be considered
sues, where they can be associated with infl ammation. early on in the evaluation of patients with unexplained
Because it can aff ect multiple other organs of the body, symptoms to prevent unnecessary interventions and
rheumatoid arthritis is referred to as a systemic illness testing. Th e identifi cation of a life event that is impor-
and is sometimes called rheumatoid disease. While tant enough to be taken as a cause of this disorder may
rheumatoid arthritis is a chronic illness (meaning it can prove helpful to “solve” the stress of this life event with
last for years), patients may experience long periods behavioral interventions. Consequently, the somato-
without symptoms. Pain management includes NSAIDs form pain may diminish over time.
and opioids. Pain control should not be attempted with-
Spinal stenosis
out controlling the infl ammation, otherwise joint de-
Narrowing of the spaces in the spine, resulting in com-
struction will continue.
pression of the nerve roots or spinal cord by bony spurs
Sciatica or soft tissues, such as disks, in the spinal canal. Stenosis
Pain resulting from irritation of the sciatic nerve, occurs most often in the lumbar spine (in the low back)
typically felt from the low back to behind the thigh in patients older than 60 years, but it also occurs in the
and radiating down below the knee. While sciatica cervical spine (in the neck) and less often in the thoracic
can result from a herniated disk directly pressing on spine (in the upper back). Th e typical symptoms to ask
the nerve, any cause of irritation or inflammation of when suspecting spinal stenosis are claudication (pain
this nerve can reproduce the painful symptoms of increases after a certain time of exercise without evi-
sciatica. Diagnosis is by observation of symptoms, dence of peripheral artery disease) and pain relief with
physical and nerve testing, and sometimes by X-ray bending forward. If surgery is not possible, a few thera-
or MRI if a herniated disk is suspected. Very often, peutic options are left for analgesia, including epidural
physical examination and careful taking of the history steroids, physiotherapy, opioids and NSAIDs, and fl ex-
will reveal that the pain is not radiating along typical ion-orthostasis.