Deborah Brandt (PT, DPT, CMA), retired Doctor of Physical Therapy, reached out to us in response to Blanaid Coveney’s wonderful post on panic buying, cognitive biases and availability heuristics. Deborah asked if we might be interested in sharing a piece she had written on her very personal experiences of pain, CRPS and PTSD, combined with her professional interest in the autonomic nervous system – here it is:
Twice I have experienced Post Traumatic Stress Disorder (PTSD) and chronic regional pain syndrome (CRPS) simultaneously. To understand my CRPS I took the Explain Pain course. While working to manage my PTSD I learned that CRPS and PTSD have much in common. Some of what follows comes directly from my study with NOI. This is an essay about the way childhood trauma set me up for PTSD and CRPS in my later life; what they have in common; and how addressing the autonomic nervous system (ANS) and can help the patient address PTSD and CRPS.
I offer my experience as an example of what a patient with chronic pain might bring to the treating physical therapist.
I discover myself running on an unfamiliar path in Central Park and watch my 6 month-old Golden Retriever, Lily, ears floating out like wings, enjoying running with me. Why am I running nowhere in Central Park on this beautiful fall day?
Slowly, I remember. I was with Lily when a tennis ball thrown for a dog hit me in the temple. I didn’t see it coming and was stunned. Screaming, I turned toward a woman who approached me from a distance, apologizing profusely. Putting my hands out to push her away, I screamed,
‘Don’t come near me, don’t touch me, how could you do such a thing?’
Then I discovered myself running.
I still have no memory of what happened between my screaming and my running on the path with Lily. My disembodied escape was not from the apologizing woman; I ran from my violent father whose danger my mother did not acknowledge. The shocking, unanticipated impact of the tennis ball had awakened my Post Traumatic Stress Disorder (PTSD).
Again with the dogs a few weeks later while still experiencing PTSD, I blanked out again and discovered myself lying on my side and face down with my foot planted in the mud, my ankle folded in half. I heard someone screaming and discovered that the voice belonged to me. Another woman approached me from a distance and apologized that her dog knocked me down.
In the emergency room I was told I was fine. The next day an orthopedist told me I had fractured my cuboid, (I had also fractured my second metatarsal) and then I slept for three days. When I awoke my pain did not feel like my previous fractures; it wasn’t local. I felt like I couldn’t move and had to give myself instructions on how to get out of bed.
I felt irritable, brain fogged, unable to make decisions, and uneasy about myself, but I didn’t know why. These puzzling sensations combined with the misinformation I received from the medical professionals I saw who used my cuboid fracture to explain away my pain, edema and the strange colors of my foot, adding to my confusion.
After four months a podiatrist finally suggested I see a pain doctor. I had discarded the leg that was causing me pain so I asked him why. He told me that something in the MRI might indicate I had CRPS.
With the help of the pain doctor, podiatrist, behavior therapist, and osteopath, my CRPS went into remission for 5 years. Because I couldn’t tolerate PT I did my own incomplete rehabilitation. The behavior therapist helped me re-inhabit my real leg using HeartMath. Four years later when talking with an osteopathic resident about my CRPS, I discovered that the pain-free, imaginary leg that I had created still felt attached at my hip. When I became conscious of that leg it disappeared.
In 2017 while experiencing another episode of PTSD I tripped and bruised my left knee. It recovered quickly. But, as though my body and brain remembered the previous foot injury from which I had never been completely rehabilitated, my CRPS returned along with an aggravation of the original foot injury. This time I had a different PT and was able to tolerate treatment.
Experience of danger and the Autonomic Nervous System
When treating an individual with CRPS it may be useful for the PT to be aware that sometimes it occurs with PTSD. In both instances the autonomic nervous system (ANS) is over-stimulated. Our ANS connects our central nervous system, (CNS), to our organ, respiratory, and cardiac systems. It is not under conscious control; however activities like meditation can have an effect on it. Its two components, the sympathetic nervous system (SNS), and the parasympathetic nervous system (PNS) keep our life-sustaining body systems in balance (homeostasis).
When we experience danger the SNS triggers increased heart and respiratory rates, raises blood pressure, and prepares us for fight or flight. The PNS responds when we have no hope for escape and we freeze. When we feel that the danger has passed, it returns to its usual function of reducing heart and respiratory rates and restoring balance to our systems. The ANS is designed to be resilient in response to external stimuli. But danger that continues over time can cause the SNS to remain in hyper-arousal which can cause CRPS, PTSD, and many other serious health problems.
Emotional pain and physical pain are processed similarly.[i] CRPS and PTSD manifest on a continuum similar to blood pressure which can go up with stress, but can also go down with meditation, or when the stress is relieved. The nature of life is change, so the more appropriately the ANS ebbs and flows in relation to the environment, the more coincident body systems are with real-world reality. A defining factor of CRPS is pain greater than would be expected. PTSD is a complex state that includes fear and the experience of danger greater than the present reality. For both, the exaggerated experience of danger may be triggered by a precipitating event.
Common treatment modalities for CRPS include medication, spinal cord or dorsal root ganglion stimulation, biofeedback, and physical therapy. Useful for treating PTSD is EMDR (eye movement desensitization and reprocessing), hypnosis, medication, and cognitive – behavior therapies.
In his book, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, Bessel van der Kolk writes about ways people recover from trauma and PTSD. He explains that traumatic memories are stored in the limbic (emotional) system of our brains, separate from non-traumatic memories and away from the language center of our brain. Therefore, he writes, talk therapies, while they can be very helpful, often can’t reach the non-verbal, lived experience of PTSD.
However, he says, the experience may be accessed through metaphor and imagery in one of the many ways that allow us to externalize internal feelings non-verbally. Journaling and the creative arts therapies are some of the ways this may be done. Cognitive processes can be employed to facilitate understanding and integration once these feelings are expressed.
Chronic pain is also a wordless experience that can be expressed through metaphor and imagery. CRPS and PTSD are both psychophysical states in which the SNS remains inappropriately hyper-aroused. PTs can explore techniques to help the patient access the embodied self and balance the ANS and guide them to adjunctive treatments. There are active modes for affecting the ANS: Yoga, and other movement meditation disciplines; receptive modes – massage and energetic and manual therapies; and participatory modes – body and movement therapies many of which employ active and receptive components. Breathing exercises which focus on the out-breath are included in many of these activities because that phase activates the restorative PNS.
PT treatment for CRPS employs the three pronged biopsychosocial approach for treating chronic pain. 1) Education that pain is processed in the brain not in the body tissues that hurt, and addressing the patient’s beliefs about pain; 2) desensitizing the patient to perceived pain through graded sensory experiences. The senses involved are primarily vision, touch, proprioception (sense of body position in space) and kinesthesia (sense of movement).
3) Graded motor imagery (GMI) leading to active movement: the patient visualizes movements that may be too painful to produce. Merely visualizing movement may cause some people pain. GMI includes practicing left right discrimination, and the use of a mirror box. As movement becomes tolerable, visual imagery is embodied through body movement in space. [ii] [iii] If the CRPS was triggered by an injury that is still acute, the injury and the CRPS would be treated simultaneously.
To help your patients achieve a better balanced ANS and to maximize their rehabilitation you can recommend and facilitate the following:
- We experience a reality that is outside of our own through the mediation of other persons whose reality we trust. The treatment team should include: doctor to help control pain; movement professional (PT) to guide safe active movement and if necessary, treat acute pain; psycho-therapist who can help process and integrate feelings.
- Differentiate pain: after an injury, acute pain and chronic CRPS pain may occur simultaneously, and may be accompanied by neuropathic pain. Treatment should acknowledge all sources of pain.
- Address fears and thoughts about pain and movement.
- Learn, or relearn, to move breath and body appropriately so that muscle tension is decreased and cleansing blood flow is increased.
- Access and express the wordless memory of trauma through: EMDR; hypnosis; metaphor; techniques using symbolic representation of feelings.
- Include stress reduction techniques to decrease the hyper-arousal of the SNS and increase the PNS restorative function.
- Identify and implement a healthy lifestyle that addresses anti-inflammatory nutrition, exercise, sleep, self-reflection, and interpersonal experiences.
- Process thoughts and feelings with helping professionals to consolidate a re-integration of a healthy self.
Deborah R. Brandt, PT, DPT, CMA is a retired Doctor of Physical Therapy, Certified Movement Analyst, and dancer who has lived with both CRPS and PTSD. She has studied pain and embodied expression of feelings throughout her professional life. To contact her, email <firstname.lastname@example.org> and put CRPS in the subject line.
[i] Eisenberger NI. The neural bases of social pain: Evidence for shared representations with physical pain. Published online 2012 Jan 27. Accessed 11/12/17.
[ii] Physical Therapist’s Guide to Chronic Regional Pain Syndrome: http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=31c5d12d-2fd4-4723-949d-ad741d4c71d7 accessed 10/18/17.
Physical Therapist’s Guide to Chronic Pain Syndromes: http://www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=dd79c11d-9ac3-42cc-bcc2-2edd5079a57a Accessed 10/18/17.
Physical Therapist’s Guide to Pain
[iii] Butler DS, Moseley GL. Explain Pain. 2nd ed. Adelaide, South Australia: Noigroup Publications; 2013