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Complex regional pain syndrome - 2: Physical therapy management
Abstract
Part I of this article reviewed the history, etiology and underlying mechanisms of CRPS I and II. The current article reviews the available research of physical therapy treatment interventions for patients with CRPS. As outlined in Part 1 of this article, there continues to be much uncertainty about the underlying mechanisms of CRPS. It remains challenging to develop evidence-based guidelines for physical therapy or for any other discipline. There is a paucity of prospective randomized clinical trials. The majority of published reports are case reports or consensus-based. Although the article is written primarily from a physical therapy perspective, the clinical guidelines are also of interest to other health care providers. Given the complexity and scope of CRPS, an interdisciplinary management approach is recommended.
... A unique therapeutic protocol has not been determined, even after two conferences of the International Association for the Study of Pain (IASP) dedicated to this disease (7,8). The primary aim of the treatment is to reduce pain and swelling, as well as to achieve full mobility and muscle strength, to improve function in the affected part of the extremity, and ultimately to achieve patient socialization (9). ...
... The choice of therapeutic procedures in the treatment of CRPS I is still an object of debate, since there is no unique therapeutic protocol (7,8,23,24). The multifactorial etiology of CRPS I and the complexity of the pathophysiological mechanisms influence the multidisciplinary therapeutic approach (25-30). ...
... They even suggest that the treatment of patients with a mild form of CRPS should include only physical therapy. The American Physical Therapy Association shows that physical procedures may improve function in 80% of patients with CRPS I (7,24). Particular emphasis is put on the application of physical procedures in the early stages in order to prevent disease progression. ...
Objective: The aim of this study is to estimate and compare the effects of low-level laser therapy and interferential current therapy in patients with complex regional pain syndrome type I. Material and Methods: Prospective randomized clinical research, including 45 patients with post-traumatic unilateral complex regional pain syndrome type I, treated at the Clinical Center Nis from December 2004 to January 2007. Low-level laser therapy and kinesitherapy were applied in group A (n=20), whereas group B (n=25) was treated with interferential current and kinesitherapy. For assessment of the therapeutic effect, the following parameters were tested: pain intensity was determined by visual analog scale, figure-of-eight measurement was used to determine the circumference of the affected part of the extremity, and range of motion of the affected joint was measured by a standard goniometer. Results: Statistically significant differences were obtained for all tested parameters in both groups, but the difference was greater in group A compared to group B (p<0.05). Conclusion: The results of this study show that both physical procedures are effective in the treatment of complex regional pain syndrome type I, but the efficiency of laser therapy is statistically significantly higher compared to interferential current therapy. © 2014 by Turkish Society of Physical Medicine and Rehabilitation.
... There is a general consensus that physical and occupational therapy is paramount in the treatment of CRPS, although high level data regarding the specifi c components and modalities (along with other medical and psychological intervention) that successfully restore normal function are currently not available. 68,121 Regardless of the lack of high-level investigations, protocols and practical guidelines for the treatment of CRPS have emerged from consensus conferences, metaanalyses, systematic literature reviews, and extensive clinical experience. In 2013, Harden and associates 121,310 described the necessity for specifi c treatments that included physical therapy, occupational therapy, vocational rehabilitation, medications, psychotherapy, and if required, interventions (nerve blocks, drug infusions, implantable pain treatment devices) to regain functional restoration . ...
... Occupational and physical therapy are considered essential in the treatment of CRPS. 21,53,68,202,220,244 In fact, many drug regimens are intended to relieve symptoms so patients can tolerate effective therapy measures. Several guiding principles 53 have been developed for therapy of CRPS patients ( Fig. 40-13 ), including: • Patient education • Graded exposure to activities, movements, light touch • Sensorimotor treatment: desensitization activities • Exercises: fl exibility, active range of motion, water therapy, stress loading • Graded motor imagery and mirror visual feedback • Pain management: coping/relaxation techniques, tissue massage A successful patient-therapist alliance with strong communication is paramount. ...
... Entretanto, o tratamento fisioterapêutico aqui apresentado, mostrou-se eficaz, contradizendo os achados desses autores. Contudo, precisa-se de estudos clínicos randomizados, cegos, para que um protocolo possa ser estabelecido 5 . Por enquanto, o melhor tratamento parece ser prevenir o desenvolvimento da SCDR I 1,3,4 . ...
... Physical therapy plays an important role in overcoming kinesophobia and facilitating active movement. Aggressive mobilizations and strengthening programs should be avoided as they may contribute to the development and maintenance of kinesiophobia 19 . ...
... Physiotherapy is advocated in CRPS clinical guidelines (Harden et al., 2006c;Stanton-Hicks et al., 2002), textbooks on pain (Giamberardino, 2002;Harden et al., 2001;Janig and Stanton-Hicks, 1996;Justins, 2005;McMahon and Koltzenburg, 2005;Wilson et al., 2005) and narrative CRPS reviews (Baron and Janig, 2004;Berthelot, 2006;Birklein, 2005;Dommerholt, 2004;Harden et al., 2006a;Quisel et al., 2005;Sharma et al., 2006;Wasner et al., 2003). Despite this advocacy, the role of physiotherapy in the describing physiotherapy were also numerous reflecting both the range of physiotherapy interventions and the terminology used to describe such interventions (Table 1). ...
To source and critically evaluate the evidence on the effectiveness of Physiotherapy to manage adult CRPS-1.
Systematic literature review.
Electronic databases, conference proceedings, clinical guidelines and text books were searched for quantitative studies on CRPS-1 in adults where Physiotherapy was a sole or significant component of the intervention. Data were extracted according to predefined criteria by two independent reviewers. Methodological quality was assessed using the Critical Review Form.
The search strategy identified 1320 potential articles. Of these, 14 articles, representing 11 studies, met inclusion criteria. There were five randomised controlled trials, one comparative study and five case series. Methodological quality was dependent on study type, with randomised controlled trials being higher in quality. Physiotherapy treatments varied between studies and were often provided in combination with medical management. This did not allow for the 'stand-alone' value of Physiotherapy to be determined. Heterogeneity across the studies, with respect to participants, interventions evaluated and outcome measures used, prevented meta-analysis. Narrative synthesis of the results, based on effect size, found there was good to very good quality level II evidence that graded motor imagery is effective in reducing pain in adults with CRPS-1, irrespective of the outcome measure used. No evidence was found to support treatments frequently recommended in clinical guidelines, such as stress loading.
Graded motor imagery should be used to reduce pain in adult CRPS-1 patients. Further, the results of this review should be used to update CRPS-1 clinical guidelines.
Study design:
Narrative review.
Introduction:
There are a variety of treatments with demonstrated effectiveness for the management of complex regional pain syndrome (CRPS). However given the variability in symptom presentation in this population, therapists may be unsure what treatments would be most effective for individual clients.
Purpose of the study:
To present a brief synthesis of the literature and propose a rehabilitation version of a mechanism-specific management algorithm to guide personalized treatment of CRPS.
Methods:
A systematic search of the literature was conducted to identify all randomized controlled trials, systematic reviews, and clinical practice guidelines addressing rehabilitation of CRPS. Results were reviewed independently by 2 reviewers and final selection of articles was reached by consensus, Data was extracted using standardized forms, and a single rater gave quality ratings. Both reviewers then used the extracted data to present a synthesis of the evidence categorized by the proposed mechanisms of effect.
Results:
A total of 111 articles were retrieved and reviewed for inclusion; 49 were selected for data extraction. A synthesis of the key recommendations was compiled into a rehabilitation-specific version of the mechanism-based management algorithm proposed by Gierthmühlen et al (2014).
Conclusions:
Consideration of mechanism-appropriate rehabilitation interventions may assist therapists to select the most appropriate and effective treatments from the body of evidence supporting rehabilitation of CRPS.
Complex regional pain syndrome is a neuropathic condition, characterized by pain that is out of proportion to the original injury along with features of allodynia, vasomotor and sudomotor changes, and decreased range of motion of the affected limb. It is a difficult to treat entity with a still unclear pathophysiology. It is important for physicians to recognize, understand, and learn what evidence-based options are available to treat and manage this unique pain condition.
JUSTIFICATIVA E OBJETIVOS: A síndrome dolorosa complexa regional (SDCR) é uma síndrome dolorosa debilitante, com prevalência elevada em serviços de tratamento de dor. Apresenta diversas opções terapêuticas, sendo o bloqueio regional simpático uma das mais efetivas. O objetivo deste estudo foi relatar a intercorrência incomum do bloqueio de gânglio estrelado em paciente portadora de SDCR no membro superior direito. RELATO DO CASO: Paciente do sexo feminino, 49 anos, estado físico ASA I, admitida para tratamento de dor no ombro superior direito de forte intensidade, em queimação, associada a mudanças tróficas, após oito meses de traumatismo local. Diagnosticada com SDCR, indicou-se bloqueio simpático em gânglio estrelado. Após monitorização realizou-se bloqueio com bupivacaína a 0,5% (8 mL), evoluindo, após injeção em topografia de gânglio estrelado por abordagem paratraqueal, com parestesia de membros distal, ansiedade e taquidispneia importante. Imediatamente a paciente foi sedada e realizada intubação orotraqueal, permanecendo em observação por 135 minutos. Recuperada, foi levada para a sala de recuperação pós-anestésica (SRPA). Após três dias do procedimento, relatou redução de dor na escala visual analógica, de 10 para 3 pontos. CONCLUSÃO: Bloqueios regionais já demonstraram eficácia elevada no tratamento de quadros dolorosos vários, incluindo a SDCR. Este caso demonstrou que, apesar de serem incomuns, efeitos indesejáveis podem ocorrer, e o anestesiologista deve estar preparado para o suporte adequado do paciente nessas situações. O conhecimento adequado da anatomia e da técnica anestésica reduz a ocorrência desses efeitos.
Complex Regional Pain Syndrome (CRPS) typically affects the hand following trauma. It is characterised by pain, altered sensation, motor disturbance, oedema, functional limitation and psychological disturbance. There is no definitive curative treatment for CRPS and controversy exists regarding the most effective combination of interventions for the treatment of this syndrome (Siddiqui et al 2001).
A study was commissioned in 2006 to explore the therapeutic interventions being implemented with patients with CRPS in the UK. Sixty therapists at the British Association of Hand Therapists annual conference consented to participate in focus group discussions. Categories were established to identify all therapeutic modalities currently used by participants. Therapists utilised the following therapeutic techniques: functional activity, exercise, education, support, sensory re-education, desensitisation, stress loading, pressure garments, mirror visual feedback, splints and psychological strategies, amongst others.
The identified interventions were then reviewed against evidence in the recent literature. There is insufficient evidence to support the use of a single set of multidisciplinary interventions (Stanton-Hicks et al 2002) to address the primary long-term goals of functional restoration and pain relief. This study has, however, highlighted that this is achieved through the treatment of individual symptoms, using multiple therapeutic interventions and algorithms in a multidisciplinary approach.
BACKGROUND/AIM; Complex regional pain syndrom type I (CRPS I) is characterised by continuous regional pain, disproportional according to duration and intensity and to the sort of trauma or other lesion it was caused by. The aim of the study was to evaluate and compare, by using thermovison, the effects of low level laser therapy and therapy with interferential current in treatment of CRPS I.
The prospective randomized controlled clinical study included 45 patients with unilateral CRPS 1, after a fracture of the distal end of the radius, of the tibia and/or the fibula, treated in the Clinical Centre in Nis from 2004 to 2007. The group A consisted of 20 patients treated by low level laser therapy and kinesy-therapy, while the patients in the group B (n = 25) were treated by interferential current and kinesy-therapy. The regions of interest were filmed by a thermovision camera on both sides, before and after the 20 therapeutic procedures had been applied. Afterwards, the quantitative analysis and the comparing of thermograms taken before and after the applied therapy were performed.
There was statistically significant decrease of the mean maximum temperature difference between the injured and the contralateral extremity after the therapy in comparison to the status before the therapy, with the patients of the group A (p < 0.001) as well as those of the group B (p < 0.001). The decrease was statistically significantly higher in the group A than in the group B (p < 0.05).
By the use of the infrared thermovision we showed that in the treatment of CRPS I both physical medicine methods were effective, but the effectiveness of laser therapy was statistically significantly higher compared to that of the interferential current therapy.
This experiment tested the hypothesis that perceived self-inefficacy in exercising control over cognitive stressors activates endogenous opioid systems. Subjects performed mathematical operations under conditions in which they could exercise full control over the cognitive task demands or in which the cognitive demands strained or exceeded their cognitive capabilities. Subjects with induced high perceived self-efficacy exhibited little stress, whereas those with induced low perceived self-efficacy experienced a high level of stress and autonomic arousal. Subjects were then administered either an inert saline solution or naloxone, an opiate antagonist that blocks the analgesic effects of endogenous opiates, whereupon their level of pain tolerance was measured. The self-efficacious nonstressed subjects gave no evidence of opioid activation. The self-inefficacious stressed subjects were able to withstand increasing amounts of pain stimulation under saline conditions. However, when endogenous opioid mechanisms that control pain were blocked by naloxone, the subjects were unable to bear much pain stimulation. This pattern of changes suggests that the stress-induced analgesia found under the saline condition was mediated by endogenous opioid mechanisms and counteracted by the opiate antagonist.
Psychologists have made important contributions to the assessment and treatment of pain patients by operationalizing relevant psychological variables, namely, behavior, affect, and cognition. Few attempts, however, have been made to integrate the results of these comprehensive assessments, to identify a taxonomy of pain patients and, subsequently, to consider differential interventions based on patient characteristics. The primary purpose of this article was to develop and cross-validate an empirically derived classification system of chronic pain patients. The first study identified three unique subgroups of chronic pain patients, labelled dysfunctional, interpersonally distressed, and minimizers/adaptive copers. A second study served to cross-validate and confirm the uniqueness and accuracy of the taxonomy. The implications of this classification system for treatment planning are discussed.
There is growing evidence for the idea that in back pain patients, pain-related fear (fear of pain/physical activity/(re)injury) may be more disabling than pain itself. A number of questionnaires have been developed to quantify pain-related fears, including the Fear-Avoidance Beliefs Questionnaire (FABQ), the Tampa Scale for Kinesiophobia (TSK), and the Pain Anxiety Symptoms Scale (PASS). A total of 104 patients, presenting to a rehabilitation center or a comprehensive pain clinic with chronic low back pain were studied in three independent
studies aimed at (1) replicating that pain-related fear is more disabling than pain itself (2) investigating the association between pain-related fear and poor behavioral performance and (3) investigating whether pain-related fear measures are better predictors of disability and behavioral performance than measures of general negative affect or general negative pain beliefs (e.g. pain catastrophizing). All three studies showed similar results. Highest correlations were found among the pain-related fear measures and measures of self-reported disability and behavioral performance. Even when controlling for sociodemographics, multiple regression analyses revealed that the subscales of the FABQ and the TSK were superior in predicting self-reported disability and poor behavioral performance. The PASS appeared more strongly associated with pain catastrophizing and negative affect, and was less predictive of pain disability and behavioural performance. Implications for chronic back pain assessment, prevention and treatment are discussed.
Recent work in our research consortium has raised internal validity concerns regarding the current IASP criteria for Complex Regional Pain Syndrome (CRPS), suggesting problems with inadequate sensitivity and specificity. The current study explored the external validity of these IASP criteria for CRPS. A standardized evaluation of signs and symptoms of CRPS was conducted by study physicians in 117 patients meeting IASP criteria for CRPS, and 43 patients experiencing neuropathic pain with established non-CRPS etiology (e.g. diabetic neuropathy, post-herpetic neuralgia). Multiple discriminant function analyses were used to test the ability of the IASP diagnostic criteria and decision rules, as well as proposed research modifications of these criteria, to discriminate between CRPS patients and those experiencing non-CRPS neuropathic pain. Current IASP criteria and decision rules (e.g. signs or symptoms of edema, or color changes or sweating changes satisfy criterion 3) discriminated significantly between groups (P
Posttraumatische dystrofie (PD), ook sympathische re-flexdystrofie genoemd, is een syndroom dat wordt geka-rakteriseerd door de trias van sensorische, motorische en autonome stoornissen. 1 2 Internationaal wordt tegen-woordig veelal gesproken van 'complex regionaal pijn-syndroom type I'. 3 De geschatte incidentie van PD is in Nederland ongeveer 8000 per jaar. Vroege tekenen en symptomen zijn diffuse pijn, oedeem, temperatuur-en kleurveranderingen en verminderde beweeglijkheid. Deze tekenen en symptomen treden op in een gebied veel groter dan en mede distaal van dat van het primai-re letsel of van de operatie. 4-7 Ze nemen daarnaast in ernst toe door gebruik van de extremiteit, bijvoorbeeld bij dagelijkse activiteiten. 7-9 Na een ernstige PD is slechts 1 op de 5 patiënten in staat zijn of haar vroegere acti-viteiten en werkzaamheden volledig te hervatten. 10 PD is daardoor niet alleen fysiek, maar ook psychisch en so-ciaal invaliderend. Een variëteit aan behandelingen van PD is beschre-ven; onder deze worden fysiotherapie en in mindere mate ergotherapie genoemd, adjuvant aan de medische behandeling. 11-16 Er zijn echter geen adequate gecontro-leerde studies die de meerwaarde van deze behandel-methoden bij PD bevestigen. 14 Studies op grond waar-van gemeld wordt dat bijvoorbeeld fysiotherapie zinvol is bij patiënten met PD missen een controlegroep. 12 15 16 Wij onderzochten de volgende vragen: (a) wat is de invloed van fysiotherapie en ergotherapie op het ver-loop van de stoornissen in functies en beperkingen in activiteiten die ontstaan ten gevolge van PD? (b) in hoeverre verminderen beide interventies de ernst van Ned Tijdschr Geneeskd 2002 11 mei;146(19) 895
In this experiment, we tested for opioid and nonopioid mechanisms of pain control through cognitive means and the relation of opioid involvement to perceived coping efficacy. Subjects were taught cognitive methods of pain control, were administered a placebo, or received no intervention. Their pain tolerance was then measured at periodic intervals after they were administered either a saline solution or naloxone, an opiate antagonist that blocks the effects of endogenous opiates. Training in cognitive control strengthened perceived self-efficacy both to withstand and to reduce pain; placebo medication enhanced perceived efficacy to withstand pain but not reductive efficacy; and neither form of perceived self-efficacy changed without any intervention. Regardless of condition, the stronger the perceived self-efficacy to withstand pain, the longer subjects endured mounting pain stimulation. The findings provide evidence that attenuation of the impact of pain stimulation through cognitive control is mediated by both opioid and nonopioid mechanisms. Cognitive copers administered naloxone were less able to tolerate pain stimulation than were their saline counterparts. The stronger the perceived self-efficacy to reduce pain, the greater was the opioid activation. Cognitive copers were also able to achieve some increase in pain tolerance even when opioid mechanisms were blocked by naloxone, which is in keeping with a nonopioid component in cognitive pain control. We found suggestive evidence that placebo medication may also activate some opioid involvement. Because placebos do not impart pain reduction skills, it was perceived self-efficacy to endure pain that predicted degree of opioid activation.
This report aims to present an orderly approach to the treatment of Chronic Regional Pain Syndrome (CRPS) types I and II through an algorithm. The central theme is functional restoration: a coordinated but progressive approach that introduces each of the treatment modalities needed to achieve both remission and rehabilitation. Reaching objective and measurable rehabilitation goals is an essential element. Specific exercise therapy to reestablish function after musculoskeletal injury is central to this functional restoration. Its application to CRPS is more contingent on varying rates of progress that characterize the restoration of function in patients with CRPS. Also, the various modalities that may be used, including analgesia by pharmacologic means or regional anesthesia or the use of neuromodulation, behavioral management, and the qualitatively different approaches that are unique to the management of children with CRPS, are provided only to facilitate functional improvement in a stepwise but methodical manner. Patients with CRPS need an individual approach that requires extreme flexibility. This distinguishes the management of these conditions from other well-described medical conditions having a known pathophysiology. In particular, the special biopsychosocial factors that are critical to achieving a successful outcome are emphasized. This algorithm is a departure from the contemporary heterogeneous approach to treatment of patients with CRPS. The underlying principles are motivation, mobilization, and desensitization facilitated by the relief of pain and the use of pharmacologic and interventional procedures to treat specific signs and symptoms. Self-management techniques are emphasized, and functional rehabilitation is the key to the success of this algorithm.
One hundred twelve patients with posttraumatic reflex sympathetic dystrophy were treated using 4 methods: regional intravenous blocks with lignocaine and methylprednisolone, mannitol i.v. (free-radical scavenger), calcitonin i.m. and physical therapy (program of exercises). Good results occurred in 73 cases (65%), moderate in 27 (24%) and poor results (persistence of spontaneous pain and/or malfunction of the hand) in 12 (11%). The method of treatment had no significant influence on the frequency of poor results. The following factors were analyzed in order to assess their influence on the results of the treatment: age, sex, psychological status, type and severity of the initial injury, duration and stage of the disease, initial deficiency of finger flexion, presence of changes on x ray and bone scans; the results were subjected to statistical analysis ("z" test comparing frequency for two independent trials). The incidence of poor results was significantly higher in patients with duration of reflex sympathetic dystrophy longer than 12 months, in the second and third stages of disease, and in cases with coexisting nerve injuries or compression as a consequence of initial trauma. The other factors analyzed had no significant influence on the unfavourable result of the treatment of reflex sympathetic dystrophy.
Sympathetic blockage and physiotherapy are among the most effective treatment approaches for the complex regional pain syndrome (CRPS). It is important to institute the treatment as early as possible in order to avoid major functional limitations of the affected limb. Unfortunately, there is a paucity of vigorously applied randomised or placebo-controlled trials for these therapeutic approaches. A prospective randomised study of 35 outpatient clinic patients with type I complex regional pain syndrome of the lower extremities lasting less than 6 months is described. One of two treatments, exercise alone or exercise in combination with manual lymph drainage, was applied for six weeks, three times a week, to the affected limb. Clinical and subjective parameters for pain, swelling, temperature, and range of motion were evaluated. Manual lymph drainage was chosen as adequate therapy for oedema reduction, whereas exercise was applied as standard therapy for contracture prophylaxis in reflex sympathetic dystrophy. Both groups were asked not to use analgesics but received extensive instructions for avoiding pain. Significant improvements in clinical parameters were observed in both groups, but no significant effect between treatment groups was found. Pain measurement alone with a verbal rating scale showed a tendency towards greater pain reduction in the group receiving lymph drainage. The results indicate that, during the first 6 months of complex regional pain syndrome type I, manual lymph drainage provides no additional benefit when applied in conjunction with an intensive exercise program.
Objective. To investigate the effectiveness and cost of adjuvant physical therapy (PT) and occupational therapy (OT) in patients with reflex sympathetic dystrophy (RSD) as well as the influence of these in reducing the percentage of impairment. Design. Prospective randomised controlled trial, with one-year follow-up. Method. At the university hospitals of Nijmegen and Amsterdam (Free University), the Netherlands, 135 patients who had been suffering from RSD of one upper limb for less than one year were randomised to receive PT, OT, or a control treatment (CT; social work) on a per protocol basis. They also received medical treatment on a per protocol basis. Improvement in the 'Impairment level sumscore' (ISS) was assessed both during and after one year. A difference of 5 ISS points between the groups was defined as clinically relevant. Furthermore, the severity of disability and the percentage of impairment were measured and tested on an exploratory basis, one year after the patient's inclusion in the study. The cost-effectiveness of the adjuvant interventions was also calculated. Results. PT and to a lesser extent OT resulted in a significant and also more rapid improvement in the ISS compared to CT (for intention-to-treat analysis and per-protocol analysis the respective improvement in scores were: PT 5 and 7 points, OT 3.5 and 5 points, one year after inclusion). On a disability level, a positive trend was found in favour of OT. The percentage of impairment did not significantly differ between the three groups. PT was more favourable than OT with respect to the incremental cost-effectiveness ratio. Conclusion. Both PT and OT contributed to the recovery from RSD of the upper limb. At the disorder level PT had the greatest and most rapid effect and was also the most cost-effective. The added value of PT and OT was not reflected in better outcomes on percentage of impairment compared with the control treatment one year after inclusion.
The treatment of persons with myofascial pain syndrome (MPS) follows the general principles that apply to all medical disorders. The nature of the pain problem first must be understood through developing an appropriate differential diagnosis and evaluating the contributions of coexisting disorders, until a single working diagnosis emerges. Following the initial assessment and formulation of diagnostic hypotheses, new data are collected. A regular review at each encounter and modification of the hypotheses facilitate a more efficient and effective management of patients with MPS and dictate the actual program components (Higgs & Jones, 1995; Jones, 1994). After addressing the issue of diagnosis, the practitioner must determine the structural or biomechanical functioning of the patient and the contribution that any dysfunction may have to the individual’s pain. Medical and psychological disorders that may alter the presentation of MPS or that may predispose to its becoming chronic are assessed. Treatment of persons with MPS addresses each of these issues specifically (Figure 21.1). There must be relief of pain by the direct inactivation of the myofascial trigger point (MTrP) itself. The mechanical and structural factors that affect or overload the muscle and aggravate the pain must be resolved or alleviated. The medical and psychological problems that affect muscle function, including those that alter and impair intracellular metabolism, must be identified and corrected where possible. Inactivation of the MTrP may occur with direct intervention at the MTrP itself, through correction of the mechanical factors that produced it or through improvement in the underlying medical disorders that predispose to the development or maintenance of the MTrP.
Objective. To assess the clinical efficacy and possible adverse effects of spinal cord stimulation for the treatment of patients with chronic reflex sympathetic dystrophy. Design. Retrospective. Method. All 23 patients who suffered severe pain due to chronic reflex sympathetic dystrophy and who were treated in 1991-1996 were included in the study. The spinal cord stimulation system was implanted only after a positive 1-week test period. The visual analogue scale score for pain was obtained in all patients prior to treatment, 1 month after implantation, and at last follow-up. At final follow-up examination, patients were asked to rate the effect of their treatment on a 7-point discrete global perceived effect scale. Results. Eighteen (78%) of the 23 patients reported improvement during the test period. Permanent implantation of a stimulation system was not performed in the other five patients. Complications after implantation occurred in nine (50%) of 18 patients. The system was removed in three patients after implantation (17%). At the end of follow-up (mean: 32 months; range: 6-79) 15 patients still had an implanted system. The mean pain score had decreased from 7-9 to 5.4 (P < 0.001). In the other eight patients the pain score had not changed significantly. In 13 patients (57%) in whom the system was implanted, clinical status had much improved or improved; in these patients the treatment was considered successful. Conclusion. In this retrospective investigation, the majority of patients with chronic reflex sympathetic dystrophy reported an improvement after implantation of a spinal cord stimulation system.
Myofascial pain syndrome (MPS) is associated with several pain conditions. The occurrence of MPS in 47 patients with complex regional pain syndrome 1 (CRPS 1) and in 17 patients with CRPS II was evaluated. The dominant hand was affected in 64.4% of patients with CRPS 1 and in 60% of patients with CRPS II. The majority of the patients used the affected limb in less than 75%, of their daily activities. Myofascial pain syndrome was diagnosed in 79.7% of CRPS I patients, and 68% of those with CRPS II. In 87.2% of the CRPS I patients, and in 76.4% of the CRPS II patients, the treatment of MPS aided the control of pain and the associated disability. The treatment of myofascial pain syndrome is essential to the success of treating complex regional pain syndrome.
A blinded meta analysis was performed on randomized clinical trials (RCT) on the medicinal treatment of reflex sympathetic dystrophy (complex regional pain syndrome type I) to assess the methodological quality and quantify the analgesic effect of treatments by calculating individual and summary effect sizes. The internal validity of 21 RCTs was investigated and the quality weighted summary effect size was calculated using a fixed effect model (Glass Δ). The methodological quality ranged from moderate to good (average 46%). Differences were found between the trials in inclusion/exclusion criteria, treatment methods, duration of treatments and trials, and measurement instruments. Statistical analysis was possible for four subgroups; one evaluating the analgesic effects of sympathetic suppressors in general (n = 12), one subgroup concerning the analgesic effects of guanethidine (n = 6), one investigating the analgesic effect of intravenous regional sympathetic blocks (n = 9), and one subgroup (n = 5) evaluating the analgesic effect of calcitonin. Except for the calcitonin subgroup (P = 0.002), the quality-weighted summary effect size of these subgroups were not significant. No significant analgesic effect by sympathetic suppressing agents could be established. Calcitonin seems to provide effective pain relief in reflex sympathetic dystrophy patients. The results of the present study show that weighting methodological quality influences the magnitude of the effect sizes of specific treatment methods. Future studies should control for methodological quality.
Abnormal movements may be a clinical feature in complex regional pain syndrome (CRPS), but their basic nature is unclear. Between August 1989 and September 1998, patients fulfilling diagnostic criteria for CRPS (I or II) and displaying abnormal movements were entered into a prospective study. Fifty-eight patients, 39 women and 19 men, met entry criteria; 47 had sustained a minor physical injury at work. The patients exhibited various combinations of dystonic spasms, coarse postural or action tremor, irregular jerks, and, in one case, choreiform movements. Patients underwent rigorous clinical and laboratory evaluation aimed at characterizing their neurological disturbance. Surprisingly, no case of CRPS II but only cases of CRPS type I displayed abnormal movements. In addition to an absence of evidence of structural nerve, spinal cord, or intracranial damage, all CRPS I patients with abnormal movements typically exhibited pseudoneurological (nonorganic) signs. In some cases, malingering was documented by secret surveillance. This study highlights abnormal movements in CRPS as constituting a key clinical feature that differentiates CRPS I from CRPS II. They are consistently of somatoform or malingered origin, signaling an underlying psychoneurological disorder responsible for the entire CRPS profile. © 2000 John Wiley & Sons, Inc. Muscle Nerve 23: 198–205, 2000.
Complex regional pain syndrome-reflex sympathetic dystrophy (CRPS/RSD) is complex pain-dysfunction syndrome of unknown cause that typically affects a single extremity. Changes are usually more marked peripherally. There are no generally accepted clinical diagnostic criteria or laboratory studies for CRPS/ RSD; our current state of knowledge allows the diagnosis to be made only on clinical grounds. Clinical suspicion should be raised if pain and disability are greater than would usually be expected as a result of the original incident, if recovery is slower than expected, and if autonomic changes are prominent in the affected extremity. The pain associated with the condition may be sympathetically maintained, sympathetically independent, or both.
No evidence-based treatment regimens for CRPS/RSD are available. Treatment of the individual patient is empiric and uses symptomatic techniques that seem logical o r that have been proven to be effective in other conditions. The sympathetic nervous system makes an unknown contribution to CRPS/RSD, but it is not known whether this is a cause or an effect of the pain. Psychological and psychiatric changes are probably secondary rather than etiologic.
Treatment should be immediate, aggressive, and directed toward restoration of full function of the extremity. Various analgesic techniques may be necessary to permit the patient to comply with the rehabilitation program. This program is best carried out in a comprehensive interdisciplinary setting, with a primary emphasis on functional restoration.
Stress perceived by the patient during the application of a manual therapy treatment technique may account for the reported findings of sympathoexcitation and hypoalgesia immediately after its application. This study investigated whether there was a difference in the level of perceived stress and pain before, during and after the application of a treatment condition (treatment, placebo or control technique), or whether the difference related to the time course of subject involvement in the study.
Twenty‐four asymptomatic subjects participated in a double‐blind, placebo‐controlled, within‐subjects study in which stress was measured with a stress rating scale and a stress visual analogue scale. Pain experienced by the subject during the application of the treatment technique was measured with a visual analogue scale and modified McGill pain questionnaire. There was no effect of the treatment condition on perceived stress, but there was a reduction in stress levels over the time course of involvement in the experiment, as demonstrated by pre‐application levels of stress. Pain was not produced by the treatment technique.
This study demonstrated that stress and pain were not features of the lateral glide manipulation of the cervical spine in asymptomatic subjects. If the dorsal periaqueductal grey region is responsible for the initial effects of manual therapy, as has been previously suggested, then stress and pain do not appear to play a role in activating this system during the application of a manual therapy treatment technique in asymptomatic subjects.
Chinese hamster ovary cells grown under conditions which are optimal for the production of a genetically engineered protein in batch culture, lose significant viability shortly after entering the stationary phase. This cell death was investigated morphologically and was found to be almost exclusively via apoptosi. Furthermore, cells were analyzed by flow cytometry using a fluorescent DNA end-labeling assay to label apoptotic cells, in conjunction with cell cycle analysis using propidium iodide. Apoptotic cells could be detected by this method, and by the radioactive end-labeling of extracted DNA, on all days of culture from day 1 to day 7; however, the degree of apoptotic cell death increased dramatically when the cells entered the stationary phase, rising to 50-60% of the total cell number at the termination of the culture. Flow cytometric analysis showed that the majority of cells underwent apoptosis whilst in G(1)/G(0) and formed an apoptotic population with high DNA FITC end-labeling and hypodiploid propidium iodide binding. Additionally, the ability or inability to secrete specific protein products did not appear to interfere with the development of the apoptotic population with time.
To assess the ability of the International Association for the Study of Pain Complex Regional Pain Syndrome (CRPS) diagnostic criteria and associated features to discriminate between CRPS patients and patients with painful diabetic neuropathy.
Prospective assessment of signs and symptoms in a series of CRPS and diabetic neuropathy patients.
University of Washington Multidisciplinary Pain Center.
A consecutive series of 18 CRPS patients and 30 diabetic neuropathy patients.
Patients completed a 10-item patient history questionnaire assessing symptoms of CRPS prior to medical evaluation. The evaluating physician completed a 10-item patient examination questionnaire assessing objective signs of CRPS.
The analyses conducted were designed to test the ability of CRPS signs and symptoms and associated features to discriminate between CRPS patients and diabetic neuropathy patients.
Data analysis suggested that CRPS decision rules may lead to overdiagnosis of the disorder. Diagnosis based on self-reported symptoms can be diagnostically useful in some circumstances. The addition of trophic tissue changes, range of motion changes, and "burning" quality of pain did not improve diagnostic accuracy, but the addition of motor neglect signs did. Test of a CRPS scoring system resulted in improved accuracy relative to current criteria and decision rules.
Poorly understood disorders lacking prototypical signs/symptoms and diagnostic laboratory testing must rely on the development of reliable diagnostic guidelines. The results of this study should assist in the further refinement of the CRPS diagnostic criteria.
Case histories of 125 patients with reflex sympathetic dystrophy syndrome of the upper extremity seen from July 1973 to March 1976 were reviewed. There was a 2.9:1 female preponderance. Twenty-four patients had documented litigation pending; however, it did not alter the final outcome significantly. On medical records, progress was noted for 86 patients with 16% having excellent results, 35% good, 26% satisfactory, 6% fair and 17% poor (all subjective evaluations by treating physicians). Median duration of follow-up prior to this study was approximately 2.5 months. Median duration between last clinic visit and follow-up study was 14.5 months. Follow-up letters sent to 123 patients who were believed to be alive showed that 4 patients had died; 77 (63%) replied. The majority of patients (53/77) reported that they still had pain in the shoulder/or hand, but 68% were taking no medications and only 15.3% (12) were taking narcotics. Twenty-eight patients (36%) claimed they were continuing physical therapy at home. Twenty-four (31%) retired or did not go back to the same work. Thirty-five percent were officially disabled, 30% were back at their same jobs and 29/59 female patients (49%) were able to do all the housework. Eighteen patients (23%) were able to return to 100% daily activity, 23 patients (30%) to 75% activity. Eleven patients (14%) had modified their activities considerably and were not able to do well.
We report on the experience with our first seventy patients who had reflex sympathetic dystrophy and were less than eighteen years old (average age, 12.5 years). In our series, the patients were predominantly girls (male to female ratio, 11:59) and the lower extremity was involved most often (sixty-one of the seventy patients). The average time from the initial injury to the diagnosis was one year, which indicates that the syndrome remains under-recognized in patients in this age-group. Conservative treatment with physical therapy, transcutaneous electrical nerve stimulation, psychological therapies including cognitive-behavioral management and relaxation training, and tricyclic anti-depressants was effective in improving the average scores for pain and function for forty patients. Sympathetic blocks were helpful for twenty-eight of thirty-seven patients. Thirty-eight of the seventy patients in the series continued to have some degree of residual pain and dysfunction. Reflex sympathetic dystrophy in children differs in presentation and clinical course from the syndrome in adults. It is best treated in a multidisciplinary fashion.
We present 43 patients with reflex sympathetic dystrophy (RSD) who manifested abnormalities of movement. The patients have focal dystonia, weakness, spasms, tremor, difficulty initiating movement, and increased tone and reflexes. These motor signs and symptoms may precede other manifestations of the illness by weeks or months. They most frequently, but not invariably, occur concomitantly with sudomotor or vasomotor changes and pain. Lioresal is effective in reducing spasms. Early in the course of RSD, the motor manifestation may be alleviated by intense sympathetic blockade or sympathectomy. In many patients, the movement disorder becomes independent of sympathetic innervation.
Reflex sympathetic dystrophy (RSD) is a complex syndrome of pain, trophic changes, and vasomotor instability secondary to an abnormal hyperactive state of the sympathetic nervous system following injury to an extremity. Numerous theories have been proposed to explain the pathophysiology. None is universally accepted. The diagnosis of RSD is complicated because some patients improve without treatment, whereas others develop intractable symptoms even after the injury has healed. A delay in diagnosis and/or treatment for this syndrome can result in severe physical and psychological problems. Early recognition and prompt treatment, i.e., sympathetic blockade and physical therapy, provide the greatest opportunity for a successful outcome.
This experiment tested the hypothesis that perceived self-inefficacy in exercising control over cognitive stressors activates endogenous opioid systems. Subjects performed mathematical operations under conditions in which they could exercise full control over the cognitive task demands or in which the cognitive demands strained or exceeded their cognitive capabilities. Subjects with induced high perceived self-efficacy exhibited little stress, whereas those with induced low perceived self-efficacy experienced a high level of stress and autonomic arousal. Subjects were then administered either an inert saline solution or naloxone, an opiate antagonist that blocks the analgesic effects of endogenous opiates, whereupon their level of pain tolerance was measured. The self-efficacious nonstressed subjects gave no evidence of opioid activation. The self-inefficacious stressed subjects were able to withstand increasing amounts of pain stimulation under saline conditions. However, when endogenous opioid mechanisms that control pain were blocked by naloxone, the subjects were unable to bear much pain stimulation. This pattern of changes suggests that the stress-induced analgesia found under the saline condition was mediated by endogenous opioid mechanisms and counteracted by the opiate antagonist.
Psychologists have made important contributions to the assessment and treatment of pain patients by operationalizing relevant psychological variables, namely, behavior, affect, and cognition. Few attempts, however, have been made to integrate the results of these comprehensive assessments, to identify a taxonomy of pain patients and, subsequently, to consider differential interventions based on patient characteristics. The primary purpose of this article was to develop and cross-validate an empirically derived classification system of chronic pain patients. The first study identified three unique subgroups of chronic pain patients, labelled dysfunctional, interpersonally distressed, and minimizers/adaptive copers. A second study served to cross-validate and confirm the uniqueness and accuracy of the taxonomy. The implications of this classification system for treatment planning are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The pathogenesis of reflex sympathetic dystrophy--variously known as Sudeck's atrophy, causalgia, algodystrophy, and peripheral trophoneurosis--is not yet understood, and diagnosing and treating patients is difficult. We have prospectively studied 829 patients, paying particular attention to early signs and symptoms. In its early phase, reflex sympathetic dystrophy is characterised by regional inflammation, which increases after muscular exercise. Pain was present in 93% of patients, and hypoaesthesia and hyperpathy were present in 69% and 75% respectively. With time, tissue atrophy may occur as well as involuntary movements, muscle spasms, or pseudoparalysis. Tremor was found in 49% and muscular incoordination in 54% of patients. Sympathetic signs such as hyperhidrosis are infrequent and therefore have no diagnostic value. We found no evidence consistent with the presence of three consecutive phases of the disease. Early symptoms are those of an inflammatory reaction and not of a disturbance of the sympathetic nervous system. These data support the concept of an exaggerated regional inflammatory response to injury or operation in reflex sympathetic dystrophy.
Therapists throughout the world find it challenging to treat and rehabilitate patients with reflex sympathetic dystrophy. An insufficient understanding of the disease process often hinders the diagnosis, causing the patient unnecessary pain and distress. This paper presents effective diagnostic and treatment methods that emphasize patient trust as well as relaxation and range-of-motion exercises. The paper describes the cases of 120 women, aged 35 to 75 years, and 30 men, aged 30 to 60 years. The condition was diagnosed in these patients three months after the onset of primary symptoms and was successfully treated.
Patients with reflex sympathetic dystrophy (RSD) often present with pain and disability that cannot be explained on the basis of objective physical findings. This has led some to speculate that RSD may be caused or mediated by non-organic factors. Unfortunately, there have been few studies using standardized measures of mood and illness behavior that have compared patients with RSD to patients with other chronic pain disorders. The goal of the present study, therefore, was to compare the pattern of psychological dysfunction in patients with RSD to the pattern of dysfunction in patients with chronic back pain and local neuropathic pain. Patients with back pain resemble those with RSD in that both may report symptoms that cannot be reconciled with objective physical findings. Patients with local neuropathy, by contrast, report pain that is both circumscribed and consistent with a known organic cause. The records of 253 patients attending a tertiary pain service were retrospectively reviewed and three distinct (non-overlapping) diagnostic groups were formed: 25 were assigned to the RSD group; 44 to the back pain group; and 21 to the local neuropathy group. Using a set of stringent criteria to diagnose RSD and an analysis of covariance to control for differences in symptom duration and age, the present study found no evidence to suggest that patients with RSD were psychologically unique. Instead, RSD patients were remarkably similar to those with local neuropathy in terms of their symptom reporting, illness behavior, and psychological distress. The only exception was that RSD patients had more disability days during the preceding 6 months than those with local neuropathy (P < 0.05). The back pain group, on the other hand, presented with more diffuse pain complaints (P < 0.05) and had a greater number of non-specific medical symptoms (P < 0.05) compared to either the RSD or local neuropathy group. In contrast to previous research using less stringent diagnostic criteria, there was no evidence of higher pain scores or lower levels of psychological distress among patients with RSD. In addition, a validated survey of childhood trauma found that sexual abuse, physical abuse, emotional abuse, and cumulative trauma were evenly distributed among all three diagnostic groups. The burden of proof would appear to be upon those who advocate the non-organic hypothesis to provide credible evidence of psychological involvement in the etiology of RSD.
RSD is a symptom complex, representing an exaggerated response to injury or tissue damage. The amplification of the normal responses probably occurs both in the periphery and in the central nervous system. Diagnostic criteria are still under discussion, and treatment modalities are still directed toward the symptoms because the pathophysiology is not known. The pain of the condition may be sympathetically maintained of sympathetically independent (or both), and sympathetic blockade is useful in the former category. Treatment modalities must be directed toward optimizing both comfort and function of the affected extremity. Such treatment programs might occur in a multidisciplinary setting.
In a 4-year period, 17 consecutive patients with posttraumatic chronic regional pain syndrome were treated with a new technique, Movelat manipulation therapy. At average follow-up of 8 months, satisfactory results were achieved in 15 patients (88%), but 2 patients, 1 with digital nerve injury and 1 with ulnar nerve injury, did not respond to the therapy. Factors associated with good clinical response include chronic regional pain syndrome type I, i.e., dystrophy produced by a trauma to the hand but not involving a specific nerve injury, early-stage disease (within 3 months after trauma), and involvement of the upper limbs. Complications were rare and mild (pain over the tourniquet site in 3%, temporary dizziness in 1%). This therapy is simple and safe and recommended for early treatment of chronic regional pain syndrome.
Despite the growing popularity of qigong in the West, few well-controlled studies using a sham master to assess the clinical efficacy of qigong have been conducted.
To study the effect of qigong on treatment-resistant patients with late-stage complex regional pain syndrome type I.
Block-random placebo-controlled clinical trial.
Pain Management Center at New Jersey Medical School.
26 adult patients (aged 18 to 65 years) with complex regional pain syndrome type I.
The experimental group received qi emission and qigong instruction (including home exercise) by a qigong master. The control group received a similar set of instructions by a sham master. The experimental protocol included 6 forty-minute qigong sessions over 3 weeks, with reevaluation at 6 and 10 weeks. Assessment included comprehensive medical history, physical exam, psychological evaluation, necessary diagnostic testing. Symptom Check List 90, and the Carleton University Responsiveness to Suggestion Scale.
Thermography, swelling, discoloration, muscle wasting, range of motion, pain intensity rating, medication usage, behavior assessment (activity level and domestic disability), frequency of pain awakening, mood assessment, and anxiety assessment.
22 subjects completed the protocol. Among the genuine qigong group, 82% reported less pain by the end of the first training session compared to 45% of control patients. By the last training session, 91% of qigong patients reported analgesia compared to 36% of control patients. Anxiety was reduced in both groups over time, but the reduction was significantly greater in the experimental group than in the control group.
Using a credible placebo to control for nonspecific treatment effects, qigong training was found to result in transient pain reduction and long-term anxiety reduction. The positive findings were not related to preexperimental differences between groups in hypnotizability. Future studies of qigong should control for possible confounding influences and perhaps use clinical disorders more responsive to psychological intervention.
There is growing evidence for the idea that in back pain patients, pain-related fear (fear of pain/physical activity/(re)injury) may be more disabling than pain itself. A number of questionnaires have been developed to quantify pain-related fears, including the Fear-Avoidance Beliefs Questionnaire (FABQ), the Tampa Scale for Kinesiophobia (TSK), and the Pain Anxiety Symptoms Scale (PASS). A total of 104 patients, presenting to a rehabilitation center or a comprehensive pain clinic with chronic low back pain were studied in three independent studies aimed at (1) replicating that pain-related fear is more disabling than pain itself (2) investigating the association between pain-related fear and poor behavioral performance and (3) investigating whether pain-related fear measures are better predictors of disability and behavioral performance than measures of general negative affect or general negative pain beliefs (e.g. pain catastrophizing). All three studies showed similar results. Highest correlations were found among the pain-related fear measures and measures of self-reported disability and behavioral performance. Even when controlling for sociodemographics, multiple regression analyses revealed that the subscales of the FABQ and the TSK were superior in predicting self-reported disability and poor behavioral performance. The PASS appeared more strongly associated with pain catastrophizing and negative affect, and was less predictive of pain disability and behavioral performance. Implications for chronic back pain assessment, prevention and treatment are discussed.
Complex regional pain syndrome (CRPS) remains a poorly understood chronic pain disorder. Little data has been published assessing the epidemiology of CRPS (and reflex sympathetic dystrophy, RSD). This study assessed epidemiological variables in 134 CRPS patients evaluated at a tertiary chronic pain clinic in the US, including demographic, health care utilization and legal/workman's compensation measures. In addition, the frequency of physician-imposed immobilization of the CRPS limb was assessed, as was physical examination evidence of myofascial dysfunction. This study found that these patients had seen on average 4.8 different physicians before referral to the pain center and had received an average of five different kinds of treatments both prior to and during pain clinic treatment. The mean duration of CRPS symptoms prior to pain center evaluation was 30 months. Seventeen percent had a lawsuit and 54% had a worker compensation claim related to the CRPS. Fifty-one patients received a bone scan, but only 53% of which were interpreted as consistent with the diagnosis of RSD/CRPS. Forty-seven percent had a history of physician-imposed immobilization, and 56% had a myofascial component present at evaluation. The duration of CRPS symptoms and the involvement of the upper extremity was significantly associated with the presence of myofascial dysfunction. Thus, this study found that most CRPS patients are referred to a pain specialty clinic after several years of symptoms and many failed therapies. The data also suggest the lack of utility of a diagnostic bone scan and highlight the prominence of myofascial dysfunction in a majority of CRPS patients.
A common assumption about pain is that it always results from the presence of underlying organic pathology. In the absence of objective pathology, an individual's report of pain may be ascribed to psychological causes. There is a wide variation in patient's experience of pain and organic factors alone cannot explain individual differences in patients' reports. Assessment of patients who report pain requires attention to psychosocial, behavioural, and organic factors. We describe a comprehensive approach to the assessment of psychological and behavioural variables that affect patients' reports of pain. We counter the duality of the somatogenic versus psychogenic perspective and suggest a more integrated assessment that encompasses not only the severity of pain and related physical pathology but also the person who is reporting the presence of pain.
Recent work in our research consortium has raised internal validity concerns regarding the current IASP criteria for Complex Regional Pain Syndrome (CRPS), suggesting problems with inadequate sensitivity and specificity. The current study explored the external validity of these IASP criteria for CRPS. A standardized evaluation of signs and symptoms of CRPS was conducted by study physicians in 117 patients meeting IASP criteria for CRPS, and 43 patients experiencing neuropathic pain with established non-CRPS etiology (e.g. diabetic neuropathy, post-herpetic neuralgia). Multiple discriminant function analyses were used to test the ability of the IASP diagnostic criteria and decision rules, as well as proposed research modifications of these criteria, to discriminate between CRPS patients and those experiencing non-CRPS neuropathic pain. Current IASP criteria and decision rules (e.g. signs or symptoms of edema, or color changes or sweating changes satisfy criterion 3) discriminated significantly between groups (P < 0.001). However, although sensitivity was quite high (0.98), specificity was poor (0.36), and a positive diagnosis of CRPS was likely to be correct in as few as 40% of cases. Empirically-based research modifications to the criteria, which are more comprehensive and require presence of signs and symptoms, were also tested. These modified criteria were also able to discriminate significantly, between the CRPS and non-CRPS groups (P < 0.001). A decision rule, requiring at least two sign categories and four symptom categories to be positive optimized diagnostic efficiency, with a diagnosis of CRPS likely to be accurate in up to 84% of cases, and a diagnosis of non-CRPS neuropathic pain likely to be accurate in up to 88% of cases. These results indicate that the current IASP criteria for CRPS have inadequate specificity and are likely to lead to overdiagnosis. Proposed modifications to these criteria substantially improve their external validity and merit further evaluation.
According to the cognitive-behavioral model of chronic pain, patient beliefs about their chronic pain influence their behavioral and psychological functioning. Previous correlational and longitudinal studies have supported this hypothesis. However, since previous research has relied almost exclusively on patient self-report to assess both beliefs and functioning, shared method variance may explain some of the relationships found. The aim of the current study was to replicate and extend previous research on the relationship between pain beliefs and patient functioning and behavior by assessing the latter based on three sources of information: patient report, spouse report and direct observation. A total of 121 patients with chronic pain completed self-report measures of beliefs and function. Their spouses completed a measure of patient pain behavior, and both participated in a protocol, from which patient pain behaviors were coded by trained observers. Previously reported relationships between patient beliefs about pain and patient-reported functioning were replicated. Measures of patient beliefs were more strongly associated with self-report measures of pain behaviors and functioning than with spouse and observer ratings of patient pain behaviors. However, significant associations between patient beliefs and both spouse- and observer-reported frequency of patient pain behaviors were found. These findings argue for the generalizability of the relationship found between patient beliefs and patient behaviors across assessment domains, and for the continued application of the cognitive-behavioral model to the understanding of patient adjustment to chronic pain.
To assess the prevalence of clinically evident myofascial dysfunction (MD) and its relationship to motor neglect (MN) in Complex Regional Pain Syndrome (CRPS).
Retrospective chart review.
Forty-one consecutively evaluated CRPS patients.
(a) Prevalence of trigger points in the proximal musculature of the CRPS limb. (b) Prevalence of MN in a subset (n = 34).
MD was detected in 61 % of CRPS patients. It was more prevalent in the upper limb (70%) than in the lower limb (47%). MN was more common in those who also had MD.
MD is common in CRPS patients, especially in the upper limb and in those patients with MN. Prospective trials are needed to confirm these intriguing findings, which may have important implications regarding CRPS pathophysiology and treatment.