Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo

Psychological processing in chronic pain: a neural systems approach

Our understanding of chronic pain involves complex brain circuits that include sensory, emotional, cognitive and interoceptive processing. The feed-forward interactions between physical (e.g., trauma) and emotional pain and the consequences of altered psychological status on the expression of pain have made the evaluation and treatment of chronic pain a challenge in the clinic. By understanding the neural circuits involved in psychological processes, a mechanistic approach to the implementation of psychology-based treatments may be better understood. In this review we evaluate some of the principle processes that may be altered as a consequence of chronic pain in the context of localized and integrated neural networks. These changes are ongoing, vary in their magnitude, and their hierarchical manifestations, and may be temporally and sequentially altered by treatments, and all contribute to an overall pain phenotype. Furthermore, we link altered psychological processes to specific evidence-based treatments to put forth a model of pain neuroscience psychology.

Mirror therapy for Complex Regional Pain Syndrome (CRPS)—A literature review and an illustrative case report

Background and purpose

This case of a 42 year old woman with lower extremity Complex Regional Pain Syndrome (CRPS) after a twisting injury of the ankle, effectively treated with the addition of mirror therapy to a rehabilitation programme, prompted a literature review of both CRPS and mirror therapy. Mirror therapy is a newer adjunct to other forms of pain control and functional restoration for treatment of CRPS as well as other difficult clinical problems. This was a required group project as part of a university based course in chronic pain for healthcare workers.

Materials and methods

The PubMed database up to September 26,2012 was reviewed using four search word groups: “CRPS mirror therapy”, “mirror CRPS”, “reflex sympathetic dystrophy OR Complex Regional Pain Syndrome AND mirror” and “reflex sympathetic dystrophy OR Complex Regional Pain Syndrome AND mirror + RCT”. Nine studies from PubMed met the criteria that this working group had chosen for inclusion in the analysis of mirror therapy as treatment. These references were supplemented by others on CRPS in order to generate an adequate review of both the syndrome CRPS and mirror therapy itself. Some references were specific for mirror therapy in the treatment of CRPS but others described mirror therapy for the treatment of phantom limb pain, brachial plexus avulsion pain, for physical rehabilitation of stroke related paresis and for rehabilitation after hand surgery.

Results

Criteria for the diagnosis of CRPS including the International Association for the Study of Pain criteria and the Budapest criteria are reviewed with an emphasis on the specificity and sensitivity of the various criteria for clinical and research purposes. The signs and symptoms of CRPS are a part of the criteria review.

The main treatment strategy for CRPS is physical rehabilitation for return of function and mirror therapy is one of many possible strategies to aid in this goal.

The patient in this case report had failed many of the adjunctive therapies and rehabilitation had been unsuccessful until the addition of mirror therapy. She then could progress with physical rehabilitation and return to a more normal life. Mirror therapy techniques are briefly described as part of a discussion of its success with relationship to signs and symptoms as well as to the duration of CRPS (and other syndromes). Some discussion of the theories of the central effects of both CRPS and phantom limb pain and how these are affected by mirror therapy is included.

An analysis of the 9 most relevant articles plus a critique of each is present in table form for review.

Conclusions

There appears to be a clear indication for the use of mirror therapy to be included in the multidisciplinary treatment of CRPS types 1 and 2 with a positive effect on both pain and motor function. There is also evidence that mirror therapy can be helpful in other painful conditions such as post stroke pain and phantom limb pain.

Implications

CRPS is often overlooked as an explanation for obscure pain problems. Prompt diagnosis is essential for effective treatment. Mirror therapy is a newer technique, easy to perform and can be a useful adjunct to aid physical rehabilitation and decrease pain in this population. Much further prospective research on mirror therapy in CRPS is ongoing and is needed to systematize the technique, to clarify the effects and to define the place of this therapy in the multidisciplinary management of CRPS.

Transient and persistent pain induced connectivity alterations in pediatric complex regional pain syndrome

Evaluation of pain-induced changes in functional connectivity was performed in pediatric complex regional pain syndrome (CRPS) patients. High field functional magnetic resonance imaging was done in the symptomatic painful state and at follow up in the asymptomatic pain free/recovered state. Two types of connectivity alterations were defined: (1) Transient increases in functional connectivity that identified regions with increased cold-induced functional connectivity in the affected limb vs. unaffected limb in the CRPS state, but with normalized connectivity patterns in the recovered state; and (2) Persistent increases in functional connectivity that identified regions with increased cold-induced functional connectivity in the affected limb as compared to the unaffected limb that persisted also in the recovered state (recovered affected limb versus recovered unaffected limb). The data support the notion that even after symptomatic recovery, alterations in brain systems persist, particularly in amygdala and basal ganglia systems. Connectivity analysis may provide a measure of temporal normalization of different circuits/regions when evaluating therapeutic interventions for this condition. The results add emphasis to the importance of early recognition and management in improving outcome of pediatric CRPS.

Rehabilitation of complex regional pain syndrome: evidence based or trial and error?

SUMMARY Complex regional pain syndrome (CRPS), a relatively rare condition, is commonly diagnosed late and has no known cause or cure. There is a limited evidence base for therapeutic interventions and the majority of patients make a spontaneous recovery. The florid signs and symptoms of early CRPS are diminished and altered in the more persistent treatment-resistant form. New signs and symptoms, not listed in diagnostic criteria, begin to emerge that can confuse both the patient and clinician, and lead to questioning of the diagnosis. Trying to implement timely and evidence-based rehabilitation techniques within the above scenario is a significant challenge. This article will discuss those challenges and consider recent clinical and research advances that have sought to address some of these problems in CRPS type I.

Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition

OBJECTIVE

This is the fourth edition of diagnostic and treatment guidelines for complex regional pain syndrome (CRPS; aka reflex sympathetic dystrophy).

METHODS

Expert practitioners in each discipline traditionally utilized in the treatment of CRPS systematically reviewed the available and relevant literature; due to the paucity of levels 1 and 2 studies, less rigorous, preliminary research reports were included. The literature review was supplemented with knowledge gained from extensive empirical clinical experience, particularly in areas where high-quality evidence to guide therapy is lacking.

RESULTS

The research quality, clinical relevance, and "state of the art" of diagnostic criteria or treatment modalities are discussed, sometimes in considerable detail with an eye to the expert practitioner in each therapeutic area. Levels of evidence are mentioned when available, so that the practitioner can better assess and analyze the modality under discussion, and if desired, to personally consider the citations. Tables provide details on characteristics of studies in different subject domains described in the literature.

CONCLUSIONS

In the humanitarian spirit of making the most of all current thinking in the area, balanced by a careful case-by-case analysis of the risk/cost vs benefit analysis, the authors offer these "practical" guidelines.

Inflaming the brain: CRPS a model disease to understand neuroimmune interactions in chronic pain

We review current concepts in CRPS from a neuroimaging perspective and point out topics and potential mechanisms that are suitable to be investigated in the next step towards understanding the pathophysiology of CRPS. We have outlined functional aspects of the syndrome, from initiating lesion via inflammatory mechanisms to CNS change and associated sickness behavior, with current evidence for up-regulation of immunological factors in CRPS, neuroimaging of systemic inflammation, and neuroimaging findings in CRPS. The initiation, maintenances and CNS targets implicated in CRPS and in the neuro-inflammatory reflex are discussed in terms of CRPS symptoms and recent preclinical studies. Potential avenues for investigating CRPS with PET and fMRI are described, along with roles of inflammation, treatment and behavior in CRPS. It is our hope that this outline will provoke discussion and promote further empirical studies on the interactions between central and peripheral inflammatory pathways manifest in CRPS.

Fear of pain in the context of intensive pain rehabilitation among children and adolescents with neuropathic pain: associations with treatment response

Recent research has implicated pain-related fear in relation to functional outcomes in children with chronic pain. The current study examined fear of pain, disability, and depression within the context of an intensive pain rehabilitation program. One hundred forty-five children and adolescents who participated in an intensive interdisciplinary pediatric pain rehabilitation day program were assessed in this study. Patients completed measures of pain intensity, pain-related fears, functional disability, and depressive symptoms at admission, discharge, and on average, 2 months postdischarge. After controlling for pain intensity, pain-related fear was significantly related to disability and depressive symptoms at all time points. As predicted, a decline in pain-related fear was significantly associated with a decrease in disability and depressive symptoms. Interestingly, high levels of pain-related fears at admission predicted less reduction in functional disability and depression at discharge, suggesting that high levels of pain-related fear may be a risk factor in relation to treatment outcomes. Overall, results indicate that the relationship between fear of pain and changes in disability and depressive symptoms are closely linked, with fear of pain playing an important role in treatment.

PERSPECTIVE

This paper presents results underscoring the importance of pain-related fear in relation to treatment response for children and adolescents with chronic pain. These findings support the need to develop and implement interventions that target reductions in pain-related fear.

Complex [corrected] regional pain syndrome: what specialized rehabilitation services do patients require?

Complex [corrected] regional pain syndrome (CRPS) is a complex disorder, the optimal treatment of which requires an interdisciplinary approach encompassing medical, interventional, psychological, and rehabilitation services that emphasize the role of physical and occupational therapies. The central focus of treatment is the restoration of function, utilizing a systematic, coordinated, and progressive set of therapeutic strategies. The poorly delineated pathophysiology and variable course of CRPS suggest that individualized strategies are required for optimal management, but also mean that carefully controlled trials of physiotherapy are difficult to conduct. This article presents a brief review of the nature and pathophysiology of CRPS, the medical and psychological approaches that have been found to be effective, and a review of the current trends in rehabilitation.

Is physiotherapy effective for children with complex regional pain syndrome type 1?

OBJECTIVES

This study synthesized current research evidence on the effectiveness of physiotherapy for the management of children diagnosed with complex regional pain syndrome type 1 (CRPS-1), to provide up-to-date physiotherapy treatment recommendations, and to identify areas that require further investigation.

METHODS

Nine electronic databases were searched for quantitative studies that evaluated the effect of physiotherapy on children with CRPS-1. The methodological quality of the studies was evaluated using the Critical Review Form. Data were extracted regarding the study design, participant characteristics, types of outcome measures used, and physiotherapy technique used and its effectiveness.

RESULTS

The search strategy identified 303 potential studies, of which 12 met the inclusion criteria (1 randomized controlled trial, 1 comparative study, 10 case series). The methodological quality of all studies was rated as poor to fair. The "stand-alone" value of physiotherapy could not be determined as physiotherapy was prescribed in conjunction with psychological and medical interventions. There is low volume and poor-to-fair quality evidence which suggests that physiotherapy prescribed with other interventions may lead to short-term improvement in the signs and symptoms of CRPS-1 or functional ability in children with CRPS-1, and the relapse rate may be moderately high.

DISCUSSION

High-quality studies are required in this area. These studies should evaluate a package of care (which includes physiotherapy); they should investigate the effects of physiotherapy treatments that have proven effectiveness in adults with CRPS-1; they should use psychometrically sound measures to evaluate outcome; and the nature of physiotherapy should be detailed in future publications to enable replication in the clinical setting.

Factors that affect decisions about physical activity and exercise in survivors of breast cancer: a qualitative study

BACKGROUND

Exercise has many benefits for survivors of breast cancer, yet only half of this population regularly exercise. Fear has been identified as a barrier to exercise for people with neuromusculoskeletal conditions but has been minimally explored in women with breast cancer.

OBJECTIVES

The purposes of this study were: (1) to investigate factors that affected decisions about physical activity and exercise in survivors of breast cancer and (2) to determine whether fear was a factor.

DESIGN

This investigation was a grounded-theory qualitative study. Qualitative data were triangulated with data from 2 quantitative scales that measured participants' beliefs about exercise and their activity levels.

METHODS

Thirty-four survivors of breast cancer in 8 focus groups participated in semistructured interviews that were recorded, transcribed, and coded. Concept maps created for each group were merged to develop themes. Beliefs about physical activity and exercise were assessed with the Decisional Balance Scale. The Rapid Assessment of Physical Activity was used to assess behaviors regarding physical activity and exercise before and after the breast cancer diagnosis.

RESULTS

Participants generally believed that exercise was beneficial (Decisional Balance Scale score: X=28.1 [of a maximum score of 44], SD=7.6, range=10-43). Participants decreased the amount of physical activity or exercise during treatment but increased the amount of exercise beyond prediagnosis levels after treatment (Rapid Assessment of Physical Activity score: median=6, range=2-7). Three prominent themes described participants' behaviors regarding physical activity or exercise: values and beliefs about exercise, facilitators and barriers that were both similar to those affecting the general population and cancer specific, and lack of or inaccurate information about safe exercise.

CONCLUSIONS

Survivors who were active were not afraid to exercise. However, concern about lymphedema and knowledge about safe and effective exercise programs influenced choices regarding physical activity and exercise.

Brief Fear of Movement Scale for osteoarthritis

OBJECTIVE

Fear of movement has important clinical implications for individuals with osteoarthritis (OA). This study aimed to establish a brief fear of movement scale for use in OA. Items from the Tampa Scale for Kinesiophobia (TSK) were examined.

METHODS

The English version of the TSK was examined in a community-based sample (n = 1,136) of individuals with OA of the hip or knee. Exploratory and confirmatory factor analyses were used to determine the number and content of the dimensions of fear of movement. Factorial invariance was tested across subgroups of sex, race, education, and OA severity. Convergent validity with measures of pain, physical functioning, and psychological functioning was examined.

RESULTS

Factor analyses identified a single-factor 6-item scale that measures activity avoidance due to pain-related fear of movement (confirmatory factor analysis indices of model fit: root mean square error of approximation = 0.04, standardized root mean square residual = 0.01, comparative fit index = 0.99, and Tucker-Lewis Index = 0.99). The 6-item scale demonstrated factorial invariance across sex, race, levels of education, and OA severity, suggesting that this scale performs consistently across diverse groups of individuals with OA. Convergent validity with measures of pain (β = 0.30-0.41), physical functioning (β = 0.44-0.48), and psychological functioning (β = 0.36-0.37) was also demonstrated.

CONCLUSION

The Brief Fear of Movement Scale identified in this study provides a promising and valid approach for assessing fear of movement in individuals with OA. This brief scale demonstrated several important strengths, including a small number of items, sound psychometric properties, and consistent performance across diverse groups of individuals with OA.

Using graded motor imagery for complex regional pain syndrome in clinical practice: failure to improve pain

BACKGROUND

There is good evidence from studies conducted in a single-centre research setting for the efficacy of graded motor imagery (GMI) treatment, a complex physiotherapy intervention, to reduce pain in long-standing complex regional pain syndrome (CRPS). However, whether GMI is effective in clinical practice is not established.

AIM

To establish whether GMI is effective in clinical practice.

METHODS

We undertook a prospective audit of GMI treatment at two UK centres with a special interest in the management of patients with CRPS. All patients received GMI, in conjunction with a range of other 'best practice' physical and psychological interventions.

RESULTS

The patients' average pain intensities did not improve with treatment [centre 1: n = 20, pre-post numeric rating scale (NRS) difference 0.6 [confidence interval (CI) -0.3 to 1.5]; centre 2: n = 12, pre-post NRS difference 0.2 (CI: -0.9 to 1.2)]. Patients at centre 1 reported significant functional improvement. Improved performance on left/right judgement replicated in both centres seen in the clinical trials.

CONCLUSIONS

The failure of our real-world implementation of GMI suggests that better understanding of both the GMI methodology and its interaction with other treatment methods is required to ensure that GMI research results can be translated into clinical practice. Our results highlight challenges with the translation of complex interventions for chronic pain conditions into clinical practice.

Pain-related fear: a critical review of the related measures

Objectives: In regards to pain-related fear, this study aimed to: (1) identify existing measures and review their measurement properties, and (2) identify the optimum measure for specific constructs of fear-avoidance, pain-related fear, fear of movement, and kinesiophobia. Design: Systematic literature search for instruments designed to measure fear of pain in patients with persistent musculoskeletal pain. Psychometric properties were evaluated by adjusted Wind criteria. Results: Five questionnaires (Fear-Avoidance Beliefs Questionnaire (FABQ), Fear-Avoidance of Pain Scale (FAPS), Fear of Pain Questionnaire (FPQ), Pain and Anxiety Symptoms Scale (PASS), and the Tampa Scale for Kinesiophobia (TSK)) were included in the review. The main findings were that for most questionnaires, there was no underlying conceptual model to support the questionnaire's construct. Psychometric properties were evaluated by diverse methods, which complicated comparisons of different versions of the same questionnaires. Construct validity and responsiveness was generally not supported and/or untested. Conclusion: The weak construct validity implies that no measure can currently identify who is fearful. The lack of evidence for responsiveness restricts the current use of the instruments to identify clinically relevant change from treatment. Finally, more theoretically driven research is needed to support the construct and thus the measurement of pain-related fear.

Pain-related fear, perceived harmfulness of activities, and functional limitations in complex regional pain syndrome type I

Numerous studies have shown that pain-related fear is one of the strongest predictors of pain disability in patients with chronic musculoskeletal pain, and there is evidence that the reduction of pain-related fear through an exposure treatment can be associated with restoration of functional abilities in patients with complex regional pain syndrome type I (CRPS-I). These findings suggest that pain-related fear may be associated with functional limitations in neuropathic pain as well. The aim of the current study was to test whether the debilitating role of pain-related fear generalizes to patients with CRPS-I. The results of 2 studies are presented. Study I includes a sample of patients with early CRPS-I referred to an outpatient pain clinic. In Study II, patients with chronic CRPS who are members of a patients' association were invited to participate. The results show that in early CRPS-I, pain severity but not fear of movement/(re)injury as measured with the Tampa Scale for Kinesiophobia was related to functional limitations. In patients with chronic CRPS-I, however, perceived harmfulness of activities as measured with the pictorial assessment method significantly predicted functional limitations beyond and above the contribution of pain severity. Not fear of movement/(re)injury in general, but the perceived harmfulness of activities appears a key factor that might be addressed more systematically in the clinical assessment of patients with CRPS-I. These results support the idea that pain-related fear might be a promising concept in the understanding of pain disability in patients with neuropathic pain.

PERSPECTIVE

This is the first study showing that perceived harmfulness of activities contribute to the functional limitations in CRPS-I. The current findings may help clinicians customizing cognitive-behavioral treatments for patients with chronic neuropathic pain.

The impact of fear-avoidance model variables on disability in patients with specific or nonspecific chronic low back pain

STUDY DESIGN

A prospective cross-sectional design.

OBJECTIVE

The objectives were to describe the occurrence and to investigate the association of the fear-avoidance model variables (pain intensity, kinesiophobia, depression, and disability) in patients with specific or nonspecific chronic low back pain (CLBP).

SUMMARY OF BACKGROUND DATA

Affective factors, particularly fear, have proven to be central in the explanation and understanding of chronic pain. The fear-avoidance model has shown that fearful patients with CLBP are at risk of becoming trapped in a vicious cycle of pain, fear, disability, and depressive symptoms. Little is known about the relationship between these factors in patients subgrouped as specific or nonspecific CLBP.

METHODS

All 147 patients (81 women and 66 men) were examined by an orthopedic surgeon and diagnosed as either specific or nonspecific CLBP on the basis of that examination. Hierarchical multiple regression analysis was used to assess the ability of three independent variables (back pain intensity, VAS; kinesiophobia, TSK; depressed mood, Zung) to predict levels of disability after controlling for the influence of age and sex. RESULTS.: Both groups (specific and nonspecific CLBP) presented elevated values on the fear-avoidance model variables. All the independent fear-avoidance variables contributed in a statistically significant manner to predict disability in patients with specific CLBP, 67.0%, F (5, 59) = 24.46, P < 0.000. In patients with nonspecific CLBP, all variables except kinesiophobia predicted disability in a statistically significant manner, 63.0%, F (5, 59) = 22.64, P < 0.000.

CONCLUSION

We conclude that persistent musculoskeletal pain affects the individual in a similar manner, regardless of the cause of the pain. In clinical terms, this means that pain must be analyzed and treated as a parallel process to searching for the cause of the pain.

Complex regional pain syndrome in adults

Complex regional pain syndrome (CRPS) is a highly painful, limb-confined condition, which arises usually after trauma. It is associated with a particularly poor quality of life, and large health-care and societal costs. The causes of CRPS remain unknown. The condition's distinct combination of abnormalities includes limb-confined inflammation and tissue hypoxia, sympathetic dysregulation, small fibre damage, serum autoantibodies, central sensitization and cortical reorganization. These features place CRPS at a crossroads of interests of several disciplines including rheumatology, pain medicine and neurology. Significant scientific and clinical advances over the past 10 years hold promise both for an improved understanding of the causes of CRPS, and for more effective treatments. This review summarizes current concepts of our understanding of CRPS in adults. Based on the results from systematic reviews, treatment approaches are discussed within the context of these concepts. The treatment of CRPS is multidisciplinary and aims to educate about the condition, sustain or restore limb function, reduce pain and provide psychological intervention. Results from recent randomized controlled trials suggest that it is possible that some patients whose condition was considered refractory in the past can now be effectively treated, but confirmatory trials are required. The review concludes with a discussion of the need for additional research.

Pain and emotion: a biopsychosocial review of recent research

OBJECTIVE AND METHOD

Research on emotion and pain has burgeoned. We review the last decade's literature, focusing on links between emotional processes and persistent pain.

RESULTS

Neurobiological research documents the neural processes that distinguish affective from sensory pain dimensions, link emotion and pain, and generate central nervous system pain sensitization. Psychological research demonstrates that greater pain is related to emotional stress and limited emotional awareness, expression, and processing. Social research shows the potential importance of emotional communication, empathy, attachment, and rejection.

CONCLUSIONS

Emotions are integral to the conceptualization, assessment, and treatment of persistent pain. Research should clarify when to eliminate or attenuate negative emotions, and when to access, experience, and express them. Theory and practice should integrate emotion into cognitive-behavioral models of persistent pain.

The role of psychological interventions in the management of patients with chronic pain

Chronic pain can be best understood from a biopsychosocial perspective through which pain is viewed as a complex, multifaceted experience emerging from the dynamic interplay of a patient's physiological state, thoughts, emotions, behaviors, and sociocultural influences. A biopsychosocial perspective focuses on viewing chronic pain as an illness rather than disease, thus recognizing that it is a subjective experience and that treatment approaches are aimed at the management, rather than the cure, of chronic pain. Current psychological approaches to the management of chronic pain include interventions that aim to achieve increased self-management, behavioral change, and cognitive change rather than directly eliminate the locus of pain. Benefits of including psychological treatments in multidisciplinary approaches to the management of chronic pain include, but are not limited to, increased self-management of pain, improved pain-coping resources, reduced pain-related disability, and reduced emotional distress - improvements that are effected via a variety of effective self-regulatory, behavioral, and cognitive techniques. Through implementation of these changes, psychologists can effectively help patients feel more in command of their pain control and enable them to live as normal a life as possible despite pain. Moreover, the skills learned through psychological interventions empower and enable patients to become active participants in the management of their illness and instill valuable skills that patients can employ throughout their lives.

Safety of "pain exposure" physical therapy in patients with complex regional pain syndrome type 1

"Pain exposure" physical therapy (PEPT) is a new treatment for patients with complex regional pain syndrome type 1 (CRPS-1) that consists of a progressive-loading exercise program and management of pain-avoidance behavior without the use of specific CRPS-1 medication or analgesics. The aim of this study was to investigate primarily whether PEPT could be applied safely in patients with CRPS-1. Twenty patients with CRPS-1 were consecutively enrolled in the study after giving informed consent. The diagnosis of CRPS-1 was defined using the Bruehl and Harden/IASP diagnostic criteria. CRPS-1 was diagnosed between 3 and 18 months after the inciting event (trauma). According to a multiple single-case design (baseline [A1], treatment [B], follow-up [A2]), multiple baseline and follow-up measurements were performed to evaluate changes in CRPS signs and symptoms and to assess functional parameters. When comparing the baseline with the follow-up phase, patients improved significantly with respect to pain on the visual analogue scale (57%), pain intensity (48%), muscle strength (52%), arm/shoulder/hand disability (36%), 10-meter walking speed (29%), pain disability index (60%), kinesiophobia (18%), and the domains of perceived health change in the SF-36 survey (269%). Three patients initially showed increased vegetative signs but improved in all other CRPS parameters and showed good functional recovery at follow-up. We conclude that PEPT is a safe and effective treatment for patients with CRPS-1. A progressive-loading exercise program and management of pain-avoidance behavior without the use of specific medication ("pain exposure" physical therapy) is safe and effective for patients with complex regional pain syndrome.

Clinical impact and evidence base for physiotherapy in treating childhood chronic pain

PURPOSE

As part of the special series on pain, our objectives are to describe the key features of chronic pain in children, present the rationale for interdisciplinary treatment, report a case study based on our biopsychosocial approach, and highlight the integral role of physiotherapy in reducing children's pain and improving function. We also evaluate the evidence base supporting physiotherapy for treating chronic neuropathic pain in children.

SUMMARY OF KEY POINTS

Chronic pain affects many children and adolescents. Certain challenging pain conditions begin primarily during adolescence and disproportionately affect girls and women. Children with these conditions require an interdisciplinary treatment programme that includes physiotherapy as well as medication and/or psychological intervention. Converging lines of evidence from cohort follow-up studies, retrospective chart reviews, and one randomized controlled trial support the effectiveness of physiotherapy within an interdisciplinary programme for treating children with chronic pain.

CONCLUSIONS

Evidence-based practice dictates that health care providers adopt clear guidelines for determining when treatments are effective and for identifying children for whom such treatments are most effective. Thus, additional well-designed trials are required to better identify the specific physiotherapy modalities that are most important in improving children's pain and function.

Fatigue and physical disability in patients with multiple sclerosis: a structural equation modeling approach

Although fatigue is one of the most common and disabling symptoms in patients with multiple sclerosis (MS), its pathogenesis is still poorly understood and it is difficult to treat. The aim of the current study was to test the assumptions of a cognitive-behavioral model that explains fatigue and physical disability in MS patients, by comparing this approach with a more traditional biomedical approach. Structural equation modeling was applied to a sample of 262 MS patients. Neither the cognitive-behavioral, nor the biomedical model showed an adequate fit of our data. The modification indices supported an integration of both models, which showed a better fit than those of the separate models. This final model, is notable for at least three features: (1) fatigue is associated with depression and physical disability, (2) physical disability is associated with disease severity and fatigue-related fear and avoidance behavior, and (3) catastrophic interpretations about fatigue, fueled by depression, mediated the relationship between fatigue and fatigue-related fear and avoidance behavior. Our results suggest that an integrated approach, including the modification of catastrophic thoughts about fatigue, would be beneficial in the treatment of fatigue in MS patients.

Fear of pain as a prognostic factor in chronic pain: conceptual models, assessment, and treatment implications

Chronic pain is a pervasive health care issue affecting over 50 million Americans and costing more than $100 billion dollars annually in lost productivity and health care costs. As a financially and emotionally taxing condition, the families and friends of people with chronic pain, as well as society at large, are affected. Current theory supports the role of biological, psychological, and environmental factors in the etiology, exacerbation, and maintenance of chronic pain. Recently, the specific role of pain-related fear in pain experience has received increasing attention. This article summarizes current understanding of the role of pain-related fear in the onset of acute pain incidents, the transition of acute pain to chronic, and the pain severity and disability of patients with ongoing chronic pain conditions. Treatments demonstrated to reduce pain-related fear are presented, evidence demonstrating their efficacy at reducing disability and pain severity are summarized, and recent criticisms of the fear-avoidance model and future directions are considered.

Psychologic factors in the development of complex regional pain syndrome: history, myth, and evidence

OBJECTIVE

The present paper examines the literature that addresses psychologic aspects involved in complex regional pain syndrome from a historic perspective to provide a rationale for the emergence of psychologic theories to explain its pathogenesis. The support of such perspective is then analyzed through the review of evidence-based studies.

METHODS

A review of the literature from a historic perspective was presented since its first description to the present time, including the clinical presentation and associated symptoms. An evidence-based approach was used to review the literature on complex regional pain syndrome and psychologic factors associated with the etiology or as predictors in the development of the disorder.

RESULTS

After reviewing the literature on the history and the myths associated with complex regional pain syndrome, a hypothesis is provided based on an analysis of the Zeitgeist in the development of the psychologic theory associated with the disorder. We also concluded there is no evidence to support a linear relationship that establishes a psychologic predisposition to develop the disorder.

DISCUSSION

An analysis of the Zeitgeist when complex regional pain syndrome was first described helps to understand the long-standing theories associated with a psychological theory of its etiology. This understanding should help to undermine the perpetuation of such claims which may contribute to undertreatment and misdiagnosis. To be consistent with todays Zeitgeist we must incorporate psychologic aspects, which while not causal in nature or exclusive of complex regional pain syndrome, are strongly associated with a wide spectrum of chronic pain disorders.

The pain provocation technique for adolescents with chronic pain: preliminary evidence for its effectiveness

OBJECTIVE

This study aims to investigate the effectiveness of the "pain provocation technique" (PPT)--a focused treatment strategy incorporating interoceptive exposure (i.e., imagining increases in pain intensity), bilateral stimulation (tactile stimulation), and implementation of pain-related coping to decrease pain intensity--for adolescents suffering from chronic pain.

DESIGN

Prospective observational comparative study.

METHODS

Adolescents utilizing PPT (19 boys and 21 girls) within multimodal inpatient treatment were compared with adolescents in standard multimodal inpatient treatment matched for age, gender, and diagnosis. Core outcome variables (pain intensity, disability, emotional distress) were assessed at admission and 3 months posttreatment.

RESULTS

Adolescents in the PPT group demonstrated a sharper decrease in pain intensity and school aversion. Both groups demonstrated significant reductions in disability and emotional distress.

CONCLUSIONS

Results are discussed in terms of the importance of focused treatment strategies such as interoceptive exposure for adolescents suffering from disabling chronic pain. Future studies are warranted to carefully investigate the effectiveness and possible process of change during the PPT such as sensory, cognitive, emotional, and memory aspects.

Treatment of complex regional pain syndrome: a review of the evidence

PURPOSE

This narrative review summarizes the evidence derived from randomized controlled trials pertaining to the treatment of complex regional pain syndrome (CRPS).

SOURCE

Using the MEDLINE (January 1950 to April 2009) and EMBASE (January 1980 to April 2009) databases, the following medical subject headings (MeSH) were searched: "Complex Regional Pain Syndrome", "Reflex Sympathetic Dystrophy", and "causalgia" as well as the key words "algodystrophy", "Sudeck's atrophy", "shoulder hand syndrome", "neurodystrophy", "neuroalgodystrophy", "reflex neuromuscular dystrophy", and "posttraumatic dystrophy". Results were limited to randomized controlled trials (RCTs) conducted on human subjects, written in English, published in peer-reviewed journals, and pertinent to treatment.

PRINCIPAL FINDINGS

The search criteria yielded 41 RCTs with a mean of 31.7 subjects per study. Blinded assessment and sample size justification were provided in 70.7% and 19.5% of RCTs, respectively. Only biphosphonates appear to offer clear benefits for patients with CRPS. Improvement has been reported with dimethyl sulfoxide, steroids, epidural clonidine, intrathecal baclofen, spinal cord stimulation, and motor imagery programs, but further trials are required. The available evidence does not support the use of calcitonin, vasodilators, or sympatholytic and neuromodulative intravenous regional blockade. Clear benefits have not been reported with stellate/lumbar sympathetic blocks, mannitol, gabapentin, and physical/occupational therapy.

CONCLUSIONS

Published RCTs can only provide limited evidence to formulate recommendations for treatment of CRPS. In this review, no study was excluded based on factors such as sample size justification, statistical power, blinding, definition of intervention allocation, or clinical outcomes. Thus, evidence derived from "weaker" trials may be overemphasized. Further well-designed RCTs are warranted.

Pain exposure physical therapy may be a safe and effective treatment for longstanding complex regional pain syndrome type 1: a case series

OBJECTIVE

To determine if treatment of longstanding complex regional pain syndrome type 1, focusing on functional improvement only while neglecting pain, results in clinical improvement of this syndrome.

DESIGN

Prospective description of a case series of 106 patients.

SETTING

Outpatient clinic for rehabilitation.

INTERVENTIONS

Physical therapy of the affected limb directed at a functional improvement only while neglecting the pain, was performed following an extensive explanation. Normal use of the limb between the treatments was encouraged despite pain. A maximum of five of these sessions were performed in three months.

MEASURES

Radboud Skills Test was used to monitor functional improvement of the arms. Speed and walking distance was used as the measure of outcome for the legs.

RESULTS

The function of the affected arm or leg improved in 95 patients. Full functional recovery was experienced in 49 (46%) of them. A reduction in pain presented in 75 patients. In 23 patients functional recovery was reached despite an increase in pain. Four patients stopped early due to pain increase.

CONCLUSIONS

Our results suggest that 'pain exposure physical therapy' is effective and safe for patients who are unresponsive to accepted standard therapies. Avoiding the use of a limb due to pain will result in loss of function. Forced usage of limbs restores the function, reverses these adaptive processes and leads to regain of control by practice with a reduction of pain in most cases.

Regulation of peripheral blood flow in complex regional pain syndrome: clinical implication for symptomatic relief and pain management

BACKGROUND

During the chronic stage of Complex Regional Pain Syndrome (CRPS), impaired microcirculation is related to increased vasoconstriction, tissue hypoxia, and metabolic tissue acidosis in the affected limb. Several mechanisms may be responsible for the ischemia and pain in chronic cold CPRS.

DISCUSSION

The diminished blood flow may be caused by either sympathetic dysfunction, hypersensitivity to circulating catecholamines, or endothelial dysfunction. The pain may be of neuropathic, inflammatory, nociceptive, or functional nature, or of mixed origin.

SUMMARY

The origin of the pain should be the basis of the symptomatic therapy. Since the difference in temperature between both hands fluctuates over time in cold CRPS, when in doubt, the clinician should prioritize the patient's report of a persistent cold extremity over clinical tests that show no difference. Future research should focus on developing easily applied methods for clinical use to differentiate between central and peripheral blood flow regulation disorders in individual patients.

No recovery of cold complex regional pain syndrome after transdermal isosorbide dinitrate: a small controlled trial

The microcirculation appears to be impaired in cold chronic complex regional pain syndrome (CRPS). This double-blind, placebo-controlled, randomized trial investigated the effect of the nitric oxide (NO) donor isosorbide dinitrate (ISDN) on the peripheral blood flow in patients with chronic CRPS. Twenty-four patients received 1% ISDN in Vaseline or a placebo ointment applied to the dorsum of the affected hand four times daily for 10 weeks. The patients participated in a physical therapy program to improve activity. The primary outcome measure was blood distribution in the affected extremity, which was determined by measuring the skin temperature using videothermography. We also measured NO and endothelin-1 concentrations in blister fluid, pain using the visual analog scale, and activity limitations using an upper limb activity monitor and the Disabilities of Arm Shoulder and Hand Questionnaire. ISDN failed to produce a significant improvement in temperature asymmetry in chronic cold CRPS patients, and it did not result in the expected reduction in pain and increase in activity compared with placebo either. There may be other central or peripheral factors contributing to the disturbed vasodynamics in cold chronic CRPS that are not influenced by NO substitution. This study does not show an improvement of the regional blood distribution by ISDN in the involved extremity of patients with cold-type CRPS.

Screening for elevated levels of fear-avoidance beliefs regarding work or physical activities in people receiving outpatient therapy

BACKGROUND

Screening people for elevated levels of fear-avoidance beliefs is uncommon, but elevated levels of fear could worsen outcomes. Developing short screening tools might reduce the data collection burden and facilitate screening, which could prompt further testing or management strategy modifications to improve outcomes.

OBJECTIVE

The purpose of this study was to develop efficient yet accurate screening methods for identifying elevated levels of fear-avoidance beliefs regarding work or physical activities in people receiving outpatient rehabilitation.

DESIGN

A secondary analysis of data collected prospectively from people with a variety of common neuromusculoskeletal diagnoses was conducted.

METHODS

Intake Fear-Avoidance Beliefs Questionnaire (FABQ) data were collected from 17,804 people who had common neuromusculoskeletal conditions and were receiving outpatient rehabilitation in 121 clinics in 26 states (in the United States). Item response theory (IRT) methods were used to analyze the FABQ data, with particular emphasis on differential item functioning among clinically logical groups of subjects, and to identify screening items. The accuracy of screening items for identifying subjects with elevated levels of fear was assessed with receiver operating characteristic analyses.

RESULTS

Three items for fear of physical activities and 10 items for fear of work activities represented unidimensional scales with adequate IRT model fit. Differential item functioning was negligible for variables known to affect functional status outcomes: sex, age, symptom acuity, surgical history, pain intensity, condition severity, and impairment. Items that provided maximum information at the median for the FABQ scales were selected as screening items to dichotomize subjects by high versus low levels of fear. The accuracy of the screening items was supported for both scales.

LIMITATIONS

This study represents a retrospective analysis, which should be replicated using prospective designs. Future prospective studies should assess the reliability and validity of using one FABQ item to screen people for high levels of fear-avoidance beliefs.

CONCLUSIONS

The lack of differential item functioning in the FABQ scales in the sample tested in this study suggested that FABQ screening could be useful in routine clinical practice and allowed the development of single-item screening for fear-avoidance beliefs that accurately identified subjects with elevated levels of fear. Because screening was accurate and efficient, single IRT-based FABQ screening items are recommended to facilitate improved evaluation and care of heterogeneous populations of people receiving outpatient rehabilitation.

The management of patients with painful total knee replacement

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient's pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.