Coping with chronic complex regional pain syndrome: advice from patients for patients

Early versus persistent Complex Regional Pain Syndrome: Is there a difference in patient reported outcomes following rehabilitation?

BACKGROUND

Expert consensus asserts that early treatment of Complex Regional Pain Syndrome (CRPS) leads to better outcomes. Yet no evidence supports this assumption regarding the recognized gold standard of multidisciplinary functional rehabilitation. To address this, we aimed to establish if there is a difference in outcomes between early CRPS (<1 year symptom duration) and persistent CRPS (= >1 year symptom duration) following rehabilitation and whether any gains are maintained at three months.

METHOD

Secondary analysis was conducted on previously collected clinical Patient Reported Outcome Measures (PROMS) data from 218 patients attending a residential multidisciplinary rehabilitation programme. Datasets were categorized into early CRPS (n = 40) or persistent CRPS (n = 178) dependent on symptom duration. Function, pain, self-efficacy, kinesiophobia and psychological health domains were compared using repeated measures analysis of covariance for a two group design for group difference post rehabilitation and at three month follow-up.

RESULTS

Post-rehabilitation, both groups improved in pain, function, kinesiophobia, psychological health and self-efficacy. At three months, the persistent CRPS group maintained improvements in pain and function. This was not achieved in early CRPS.

CONCLUSION

This exploratory study is the first to empirically test the assumption that those with early CRPS have better outcomes following rehabilitation. Our clinical data challenges this, as both early and persistent CRPS groups improved following rehabilitation. Findings indicate that rehabilitation benefits those with CRPS, regardless of symptom duration. However, unlike early CRPS, those with persistent CRPS sustain gains at follow-up. Further prospective exploration is warranted.

SIGNIFICANCE

Expert consensus recommends early treatment for Complex Regional Pain Syndrome, yet there is little empirical evidence to support this. Our findings are the first to challenge this assumption by revealing no difference in outcomes between early and persistent CRPS post-rehabilitation. However, those with persistent CRPS maintain gains after three months, unlike people with early CRPS (symptoms < one year). These findings are relevant to clinical practice as they challenge established assumptions, suggesting a focus on improving early CRPS follow-up outcomes.

Experiences of diagnosis and treatment for upper limb Complex Regional Pain Syndrome: a qualitative analysis

INTRODUCTION

Complex Regional Pain Syndrome (CRPS) most frequently affects the upper limb, with high associated disability. Delays to diagnosis and appropriate treatment can adversely impact prognosis and quality of life, but little is known about the healthcare experiences of people with CRPS. This study aimed to explore lived experiences of diagnosis and treatment for people with upper limb CRPS.

METHODS

Participants were recruited through online support groups and multiple public and private healthcare settings in the Greater Wellington Region, New Zealand. Semi-structured interviews were conducted with participants who had experienced upper limb CRPS for more than three months and less than three years. Interviews were transcribed verbatim and analysed using reflexive thematic analysis.

RESULTS

Thirteen participants (11 female, 2 male) aged between 43 and 68 years were interviewed. Duration of CRPS ranged from 7 months to 2.5 years. Five themes were identified. Participants initially engaged in healthcare out of a desire to return to being the person they were before having CRPS. Three interacting experiences epitomised the overall healthcare experience: (1) not knowing what is going on, (2) not being taken seriously, and (3) healthcare as adding another layer of load. Meanwhile, participants used multiple approaches in an attempt to not let CRPS stop them from continuing to live their lives.

CONCLUSIONS

Participants in this study felt that credible information, validation, and simplification from healthcare providers and systems would support their process of navigating towards a meaningful life and self-concept in the presence of CRPS.

[Lived Experience of Middle-Aged Patients with Complex Regional Pain Syndrome]

PURPOSE

This qualitative study aimed to explore the lived and true meaning of experiences of middle-aged patients with complex regional pain syndrome.

METHODS

The participants were 10 men and women aged 40 to 60 years who received outpatient treatment at a university hospital, could communicate, and agreed to participate in the study. Data were collected through individual interviews using open and semi-structured questions from September 2019 to July 2021 and were analyzed using the content analysis method suggested by Hsieh and Shannon (2005).

RESULTS

As a result of this study, 42 summarized semantic units related to life experience, 15 subthemes, and seven themes were derived. The seven themes were "pressed by severe pain," "frustrated because I cannot be part of the community," "distressed because people do not recognize my disease," "sad about conflicts with family," "unmotivated because of desperate life," "appreciating for support," and "putting oneself together and living daily life."

CONCLUSION

The vivid experiences of the participants derived in this study are the basic data for developing treatment guidelines. In the future, we propose a study on life and family care experiences according to the developmental characteristics of the life cycle of patients with complex regional pain syndrome and develop and apply programs to support patients and their families.

What do I need to know? Essential educational concepts for complex regional pain syndrome

Background

Methods

Results

Conclusion

Significance

"I Don't Identify with It": A Qualitative Analysis of People's Experiences of Living with Complex Regional Pain Styndrome

OBJECTIVE

Complex regional pain syndrome (CRPS) is a painful limb condition known to cause significant disability and distress. However, little previous research has explored CRPS from a patient perspective. The present qualitative study aimed to describe the experiences of people living with CRPS.

SUBJECTS

Forty-eight people with CRPS participated in this research.

METHODS

Participants completed a face-to-face or telephone interview about their perceptions and experiences of CRPS and completed three drawings to illustrate their experiences. Data were analyzed through reflexive thematic analysis, and images in drawings were grouped and coded by theme.

RESULTS

Three overarching themes encapsulated the data, including that 1) people experience CRPS as a source of severe symptoms and emotional difficulties, 2) CRPS undermines personal and social identity, and 3) this results in psychological responses that protect against the emotional and social impact of severe symptoms. Psychological responses include: a) searching for an explanation, b) "nothing is my fault," emphasizing a lack of personal responsibility and personal control, and c) detaching the limb from the self.

CONCLUSIONS

CRPS is experienced as highly threatening to physical ability, psychological state, and identity. In response to these threats, people may develop their own explanations for CRPS and may mentally detach themselves from responsibility, control, and the painful limb itself. Future research could explore the impact of these factors on psychological well-being and CRPS symptoms and outcomes.

Determining the credibility, accuracy and comprehensiveness of websites educating consumers on complex regional pain syndrome accessible in Australia: a systematic review

Complex regional pain syndrome (CRPS) is a distressing and disabling pain condition. Many people with CRPS and the health professionals who treat them seek information about the condition via the Internet. The credibility, accuracy and comprehensiveness of online CRPS information remains unknown. The aim of this study was to determine the credibility, accuracy and comprehensiveness of information presented on freely accessible websites that aim to educate people about CRPS. Keyword searches were conducted on the Australian Google site, with 'trustworthy' websites included and critically appraised. Primary outcomes were recognised metrics of credibility (JAMA benchmark credibility criteria) and website accuracy (according to European CRPS guidelines). Comprehensiveness was assessed using the proportion of European CRPS guidelines covered by the websites. In all, 30 websites with 819 recommendations were critically appraised. Five (17%) websites met all credibility criteria; of the recommendations, 349 (43%) were accurate, 252 (31%) were inaccurate and 218 (26%) were unclear. For comprehensiveness, an average of 17% of general guidelines, 15% of therapeutic guidelines and 6% of medication/supplement guidelines were covered. Online information about CRPS available to Australians has low credibility, accuracy and comprehensiveness. Many website recommendations are inaccurate or unclear, and many websites endorse inappropriate treatments. There is an urgent need for accurate and comprehensive sources of CRPS information online.

The Role of Nonmedical Therapeutic Approaches in the Rehabilitation of Complex Regional Pain Syndrome

Purpose of the Review

Nonmedical therapeutic approaches are fundamental to the management of of Complex Regional Pain Syndrome (CRPS) in order to promote the best outcome for patients. This review focuses on three key approaches underpinning CRPS rehabilitation, namely, physiotherapy and occupational therapy, psychological approaches and education and self-management.

Recent Findings

Recently published European standards outline the quality of therapeutic care that people with CRPS must receive. Early initiated therapy is essential to optimise outcomes, underpinned by patient education. Therapists should promote early movement of the affected limb and encourage re-engagement with usual activities as immobilisation is known to have negative outcomes. There is evidence to support the possible long-term benefit of graded motor imagery and mirror therapy. Psychological assessment should include identification of depression and post-traumatic stress disorder, as treatment of these conditions may improve the trajectory of CRPS. Novel therapies include neurocognitive approaches and those addressing spatial bias, both of which should provide a focus for future research.

Summary

There exists a broad range of nonmedical therapeutic approaches to rehabilitation for CPRS that are thought to be important. However, the evidence for their efficacy is limited. Further research using standardised outcomes would be helpful in developing targeted therapies for the future.

The experiences and beliefs of patients with complex regional pain syndrome: An exploratory survey study

Objectives To determine the beliefs and describe the health care experiences of patients with complex regional pain syndrome. Methods A survey tool for patients with complex regional pain syndrome was designed for this study. The survey tool collected self-reported measures associated with pain, disability, health care experiences, education, beliefs, and treatments. Results Thirty-one patients attending physical therapy for complex regional pain syndrome (mean age 40.48; female n = 20) completed the survey. Patients with presented with high levels of pain and disability and reported various changes associated with altered neuroplasticity such as confused body part recognition, left/right discrimination, neglect, and spreading pain. The patients' experiences with diagnostic testing and interventions are not in line with the current pain science research and/or evidence-based practice. Overall, patients are ill-informed, confused, and receive conflicting information. Discussion The suffering associated with complex regional pain syndrome is real, as told by patients. This suffering coincides with a lack of consensus by health care providers and conflicting information on complex regional pain syndrome. Overall, patient experiences show health care providers are not up to date with the current best-evidence regarding complex regional pain syndrome.

Recommendations for a first Core Outcome Measurement set for complex regional PAin syndrome Clinical sTudies (COMPACT)

Complex regional pain syndrome (CRPS) is a persistent pain condition that remains incompletely understood and challenging to treat. Historically, a wide range of different outcome measures have been used to capture the multidimensional nature of CRPS. This has been a significant limiting factor in the advancement of our understanding of the mechanisms and management of CRPS. In 2013, an international consortium of patients, clinicians, researchers, and industry representatives was established, to develop and agree on a minimum core set of standardised outcome measures for use in future CRPS clinical research, including but not limited to clinical trials within adult populations. The development of a core measurement set was informed through workshops and supplementary work, using an iterative consensus process. "What is the clinical presentation and course of CRPS, and what factors influence it?" was agreed as the most pertinent research question that our standardised set of patient-reported outcome measures should be selected to answer. The domains encompassing the key concepts necessary to answer the research question were agreed as follows: pain, disease severity, participation and physical function, emotional and psychological function, self-efficacy, catastrophizing, and patient's global impression of change. The final core measurement set included the optimum generic or condition-specific patient-reported questionnaire outcome measures, which captured the essence of each domain, and 1 clinician-reported outcome measure to capture the degree of severity of CRPS. The next step is to test the feasibility and acceptability of collecting outcome measure data using the core measurement set in the CRPS population internationally.

Building the evidence for CRPS research from a lived experience perspective

Background and aims

Pain is known to be a subjective experience yet the majority of pain related research does not address the lived experience of the condition. Difficult to diagnose, Complex Regional Pain Syndrome (CRPS) is often poorly managed. The aim of this paper was to identify and synthesise the currently available literature on experiences of living with chronic pain in order to understand where and how CRPS research may be best situated in the future.

Methods

A narrative review was performed and ProQuest, EBSCO, Informit, Scopus/Science Direct and Web of Science, Medline, CINHAL and Google Scholar were searched in order to identify the literature from 1998 until 2015. 301 papers were identified of which 197 described the lived experience of chronic pain conditions. 12 papers were examined closely to determine the experience of living with CRPS or a similar chronic pain condition that does not have a definite pain origin such as cancer or endometriosis.

Results

Known understandings of pain were identified and a model was developed depicting the lived experience of chronic pain starting with loss of the former healthy, pain free self and culminating in acceptance of the condition. Major themes identified were disbelief/invisibility of pain, loss, coping with a non-compliant/constant painful body, self-management and alleviating pain/treatment. The review also found that there is no peer-reviewed published literature on the lived experience of CRPS.

Conclusions

Little is known about the lived experience of CRPS. There appears to be a clear indication that research needs to be conducted into CRPS from a lived experience perspective in order to provide information to patients, the general public, health practitioners and policy makers of previously unknown characteristics of this condition which may improve health outcomes for this patient cohort.

It has been identified that patients and their families should be active participants in education of health practitioners and in providing information to inform the development of National Pain Strategies currently being devised throughout the world.

Implications

Research into the lived experience of chronic pain conditions, and CRPS in particular, can help to provide information to enhance understanding enabling national pain strategies and future treatment guidelines strategies to be devised appropriately.

Co-creation of information leaflets to meet the support needs of people living with complex regional pain syndrome (CRPS) through innovative use of wiki technology

OBJECTIVE

People living with complex regional pain syndrome (CRPS) experience frustration with the lack of knowledge and understanding of CRPS as a pain condition. We report on our attempt to address this issue.

METHODS

People living with CRPS taking part in a larger study were invited to co-construct a CRPS wiki page that addressed the areas in which they had experienced the most difficulty. A blank wiki page was set up for participants to populate with issues they felt needed to be raised and addressed.

RESULTS

Participants failed to engage with the wiki technology. We modified our procedure and completed an inductive analysis of a sister-forum which participants were using as part of the larger study. Six issues of importance were identified. We used the discussion forum threads to populate the themes. Due to a continued lack of engagement with the wiki technology, the team decided to create a suite of leaflets which were piloted with delegates at a CRPS patient conference.

CONCLUSIONS

Future work should be mindful of the extent to which patients are able and willing to share their experiences through such technology. Striking the balance between patient-endorsed and researcher-driven co-creation of such material is imperative.

Management of Bilateral Complex Regional Pain Syndrome in a Pediatric Patient

PURPOSE

To describe the physical therapy management of a pediatric patient with bilateral lower extremity complex regional pain syndrome (CRPS).

CASE DESCRIPTION

The participant was a 13-year-old adolescent girl who was admitted to an inpatient rehabilitation unit with bilateral lower extremity CRPS-I. Examination included assessment of lower extremity active range of motion, transfers, mobility, and completion of the Functional Independence Measure for Children (WeeFIM). Intervention consisted of gradual desensitization techniques, progressive weight bearing and mobility, functional transfer training, progressive strengthening, and cardiovascular exercises-all conducted using a modified pain exposure therapy approach.

OUTCOME

WeeFIM scores increased to modified independence or independent in all areas.

DISCUSSION

The severity of the patient's CRPS necessitated a progressive and function-based approach to physical therapy management. Motivation, a pain exposure-based approach, and a multidisciplinary team approach appeared to affect the participant's recovery of function and reintegration into school and leisure activities.

Meeting the support needs of patients with complex regional pain syndrome through innovative use of wiki technology: a mixed-methods study

Background

Using online discussion forums can have a positive impact on psychological well-being through development of shared group identity and validation of thoughts, feelings and experiences. This may be particularly beneficial to people with complex regional pain syndrome (CRPS), who often become socially isolated, lack mobility and face threats to their sense of identity. We set up a peer-support online forum to identify the nature of support provided and to explore its development over time. We then introduced a collaborative writing task to facilitate further the development of social processes implicated in psychological support.

Research questions

(1) What constitutes support in newly developed online interactions? (2) How does the process of giving and receiving support online evolve? (3) Can the combination of an online forum and a collaborative writing task increase support relative to an online forum alone?

Design

This is a three-phase mixed-methods research design. Phase 1: an online forum was launched. Phase 2: forum members were invited to cowrite a patient-centred CRPS information resource. Phase 3: the resource was shared and feedback was sought.

Participants

Posts from 26 members (seven males, 19 females) were analysed. The mean age of members was 35.6 years. The number of years since diagnosis was available for 14 members (ranging from 5 months to 10 years with a mean duration of 3.9 years).

Data analysis

In order to explore what constitutes support in newly developed online interactions, an inductive thematic analysis was conducted on all ‘introductory posts’ posted during phase 1. In order to explore how the process of giving and receiving support online evolved, a deductive content analysis using the Social Support Behavior Code was conducted on all forum posts posted during the first 12 months.

Results

Five themes were identified in members’ first posts. Three of these themes contributed to the development of a ‘common-identity’ community, while the remaining two established a positive tone, consistent with that of a ‘common-bond’ community. Content analysis revealed that support requests were present in 15.5% of posts: predominantly informational support (8.6%) with the remaining support categories ranging from 1.3% to 2.6%. Social support was present in 88.8% of posts; predominantly emotional support (72.8%) followed by informational (36.2%) and esteem (30.2%) support. For a variety of reasons, we were unable to address the third question fully; we gave all members the option of contributing to the collaborative writing task and anticipated comparing those who accepted the invitation with those who did not. However, either participants continued to take part in the forum and contributed to the writing task, or they ceased to interact with the forum altogether, thereby limiting our ability to compare across time and task.

Conclusions

Few members of the forum explicitly requested social support, but many offered it (emotional support was the most prevalent). There was evidence of both common-identity and common-bond community development from the outset. This continued to shape forum interactions throughout the 12 months of the study and set up a space that had an over-riding positive and supportive tone which enabled the members to reach out and offer support to similar others, in effect helping them to re-engage with the wider world. Future work that examines support across networked online communities is necessary.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.