Hypnotherapy for reflex sympathetic dystrophy

Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition

There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for "better research." This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of "elder statesman" researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the "Budapest" criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient.

Physical therapy under hypnosis for the treatment of patients with type 1 complex regional pain syndrome of the hand and wrist: Retrospective study of 20 cases

Type 1 complex regional painful syndrome (CRPS-1) has a complex physiopathology. The aim of this study was to evaluate the effectiveness of physical therapy under hypnotherapy to treat this condition. Twenty patients with CRPS-1 at the wrist and hand were evaluated retrospectively: 13 women and 7 men with an average age of 56 years (34-75). Thirteen patients were in the inflammatory phase and 7 in the dystrophic phase. The main endpoints were pain (VAS, analgesic use), stiffness (wrist and finger range of motion), and strength (pinch and grasp). Secondary endpoints were functional scores (QuickDASH, PWRE), patient satisfaction, return to work, and side effects. Results were satisfactory in all cases after 5.4 sessions on average. VAS decreased by 4 points, PWRE-pain by 4.1 points, and analgesic use was limited to paracetamol upon request. Finger and wrist range of motion increased and the QuickDASH decreased by 34 points, PRWE-function by 3.8 points, pinch strength increased 4 points, and grasp strength by 10 points. Return to work was possible in 80% of the cases. All patients were satisfied or very satisfied with the treatment. Physical therapy under hypnosis appears to be an effective treatment for CRPS-1 at the wrist and hand no matter the etiology.

The center core in ego state therapy and other hypnotically facilitated psychotherapies

Center core phenomena have been utilized in the practice of ego state therapy and other forms of hypnotically facilitated psychotherapy for nearly 40 years. Despite the frequency with which they are employed, many confusions, contradictions, and questions remain concerning them. In this article relevant center core phenomena literature is reviewed and an essential differentiation between two different kinds of center core phenomena is clarified. Psychodynamic explanations are offered for the therapeutic benefits of archetypal center core experiences such as inner strength and inner wisdom. The information provided offers clinicians a sturdier platform from which to decide whether to incorporate center core experiences into clinical practice. The persistent question of whether center core phenomena are ego states is revisited and addressed.

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.

Treatment considerations in neuropathic pain

Neuropathy is a relatively common source of acute and chronic pain. Emerging evidence suggests several pathophysiological mechanisms underlying the neuropathic pain associated with various disorders. Antidepressants and anticonvulsants have largely been the mainstay of treatment. Pharmacologic treatment of neuropathy frequently requires use of multiple medications. Ideally, the selection of which medications to use should be based on targeting the multiple pathophysiologic mechanisms contributing to neuropathic pain transmission. Psychological variables may play a role in predisposing patients to chronic neuropathy after acute illness. In addition, comorbid conditions, especially depression, can complicate the presentation, clinical course, and response to treatment of patients with chronic pain. Treatment of depression may be essential to fully enlist the chronic neuropathic pain patient in comprehensive pain management and rehabilitative approaches.

The neurophysiology of pain perception and hypnotic analgesia: implications for clinical practice

Although there remains much to be learned, a great deal is now known about the neurophysiological processes involved in the experience of pain. Research confirms that there is no single focal "center" in the brain responsible for the experience of pain. Rather, pain is the end product of a number of integrated networks that involve activity at multiple cortical and subcortical sites. Our current knowledge about the neurophysiological mechanisms of pain has important implications for understanding the mechanisms underlying the effects of hypnotic analgesia treatments, as well as for improving clinical practice. This article is written for the clinician who uses hypnotic interventions for pain management. It begins with an overview of what is known about the neurophysiological basis of pain and hypnotic analgesia, and then discusses how clinicians can use this knowledge for (1) organizing the types of suggestions that can be used when providing hypnotic treatment, and (2) maximizing the efficacy of hypnotic interventions in clients presenting with pain problems.

Psychological and behavioral aspects of complex regional pain syndrome management

Psychological and behavioral factors can exacerbate the pain and dysfunction associated with complex regional pain syndrome (CRPS) and could help maintain the condition in some patients. Effective management of CRPS requires that these psychosocial and behavioral aspects be addressed as part of an integrated multidisciplinary treatment approach. Well-controlled studies to guide the development of a psychological approach to CRPS management are not currently available. A sequenced protocol for psychological care in CRPS is therefore proposed based on available data and clinical experience. Regardless of the duration of the condition, all CRPS patients and their families should receive education about the negative effects of disuse, the pathophysiology of the syndrome, and possible interactions with psychological/behavioral factors. Patients with acute CRPS (<6-8 weeks) may not need additional psychological care. All patients with chronic CRPS should receive a thorough psychological evaluation, followed by cognitive-behavioral pain management treatment, including relaxation training with biofeedback. Patients making insufficient overall treatment progress or in whom comorbid psychiatric disorders/major ongoing life stressors are identified should additionally receive general cognitive-behavioral therapy to address these issues. The psychological component of treatment can work synergistically with medical and physical/occupational therapies to improve function and increase patients' ability to manage the condition successfully.

Pain reduction is related to hypnotizability but not to relaxation or to reduction in suffering: a preliminary investigation

The present study examined the facilitation of pain reduction through the use of a pain reduction protocol. The protocol emphasized converting pain sensations into visual and auditory representations, which then were manipulated through therapeutic suggestion. Hypnosis was not mentioned in the intervention, minimizing creation of expectancy effects related to hypnosis. At the conclusion of the study, the Stanford Clinical Hypnotic Scale was administered. Measures of relaxation and reduction of suffering were not related to hypnotizability. However, pain reduction was significantly related to hypnotizability (r = .55, P < .001). High hypnotizables had a greater reduction in pain than low hypnotizables, even though both had equivalent degrees of relaxation.

The Challenge to Manage Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome

The challenge to understand reflex sympathetic dystrophy/complex regional pain syndrome may require a better understanding of the complex relationship between the central and peripheral nervous systems. There is no comprehensive hypothesis that clearly explains the etiology and no uniformly successful treatment method. This brief summary of the challenge reviews some of what is known, hypothesizes a possible etiologic mechanism, and proposes 10 common-sense principles for management that recognizes the handicap of limited knowledge.

Hypnosis and clinical pain

Hypnosis has been demonstrated to reduce analogue pain, and studies on the mechanisms of laboratory pain reduction have provided useful applications to clinical populations. Studies showing central nervous system activity during hypnotic procedures offer preliminary information concerning possible physiological mechanisms of hypnotic analgesia. Randomized controlled studies with clinical populations indicate that hypnosis has a reliable and significant impact on acute procedural pain and chronic pain conditions. Methodological issues of this body of research are discussed, as are methods to better integrate hypnosis into comprehensive pain treatment.

Psychological assessment and treatment of patients with neuropathic pain

Studies on the psychological assessment and treatment of neuropathic pain conditions, including postherpetic neuralgia (PHN), diabetic neuropathy, complex regional pain syndrome, post spinal cord injury, post amputation, and AIDS-related neuropathy, are reviewed. Although limited information is currently available, the findings are consistent with the larger literature on chronic pain and indicate that the assessment of neuropathic pain needs to include measurement of multiple dimensions of quality of life. Mood, physical and social functioning, and pain-coping strategies such as catastrophizing and social support are all important domains. Clinical trials of psychological interventions have not been reported in the scientific literature. Case series of successful treatment of neuropathic pain are reported, primarily in the area of biofeedback. As with other chronically painful conditions, it is likely that cognitive-behavioral interventions will improve the quality of life in neuropathic pain conditions.

New developments in rehabilitation of neuropathic pain syndromes

The common medical treatments of neuropathic pain, medication and nerve blocks, are often only partially effective in providing significant and long-term pain relief. Patients suffering chronic pain often fall prey to associated emotional suffering, functional impairment, and difficulties in multiple areas of their lives, including family disruption, social withdrawal, and vocational disability. An interdisciplinary approach to pain management draws on the skills of physical and occupational therapists, pain psychologists, biofeedback specialists, and vocational counselors. It focuses on both pain management and functional restoration, and should be considered standard treatment for chronically painful conditions. Interdisciplinary pain management views the patient as an active agent, responsible for learning and applying self-management techniques for controlling pain, with the staff assuming a teaching and consulting role. Although much more labor intensive, interdisciplinary pain management is more effective over time in managing chronic pain, in preventing unnecessary emotional and physical impairment, and in controlling overall medical costs.

Hypnosis as adjunctive therapy for multiple sclerosis: a progress report

Several reports suggest that hypnosis can facilitate healing in various physical pathologies. This is a preliminary report, supported by three cases. They demonstrate that suggestion by a hypnotist of symptom improvement can be used beneficially in the treatment of the physical impairment caused by Multiple Sclerosis. The first patient, severely affected, had Multiple Sclerosis for over 35 years. He had been wheelchair bound for many years. The second, recently diagnosed and minimally affected, had difficulty with balance and walked with the aid of a cane. The third, also minimally affected, reported pain in her right leg. All three showed improvement either immediately or within several weeks when the hypnotist suggested improvement or displacement of symptoms with the patients in hypnosis. No attempt was made to deal with psychodynamics or to suggest alternative symptoms to the patients. Symptom substitution did not occur. When symptoms improved, even slightly, these patients exhibited increased hopefulness.

Reflex sympathetic dystrophy syndrome: diagnosis and treatment

The reflex sympathetic dystrophy syndrome is a very common, poorly recognized syndrome which is associated with marked disability in some cases. The historical aspects, current ideas about the pathogenesis and pathophysiology, clinical features and staging are discussed. Early recognition and appropriate intervention are the cornerstone of successful treatment and are also discussed.

Hypnosis treatment of clinical pain: understanding why hypnosis is useful

Clinical and experimental research literature indicates hypnosis is very useful for severe and persistent pain, yet reviews suggest hypnosis is not widely used. To encourage more widespread clinical application, the author reviews recent controlled clinical studies in which hypnosis compares favorably with other interventions; links advances in understanding endogenous pain modulation to a neurophysiologic view of hypnosis and hypnoanalgesia; relates the neurophysiology of hypnoanalgesia to management of chronic pain; challenges the view that hypnotic pain control is only for the highly hypnotizable patient; and raises issues about how people learn to control pain with hypnosis. Training in hypnotic analgesia may usefully enhance nervous system inhibitory processes that attenuate pain.

Somatization of dissociated traumatic memories in a case of reflex sympathetic dystrophy

In this single case report, I examine the treatment of reflex sympathetic dystrophy (RSD) with hypnosis and ego-state therapy in a subject with a dissociative disorder. RSD is an unusual, debilitating, chronic pain syndrome with a usually poor outcome. The subject achieved temporary symptomatic relief using hypnosis and auto-hypnotic pain-management techniques. Eventually, she achieved permanent relief of RSD symptoms that continued over a two-year follow-up period. She achieved this permanent relief through a process of psychologically integrating physical functions that she experienced as specific to several dissociated ego states. This case illustrates the role of metaphor and imaginative symbolism in constituting a physical condition. It also illustrates how imaginative transformation of the symbolic imagery can induce psychological and physical change.