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Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Werner, Mads


CiteScore 2018: 0.85

SCImago Journal Rank (SJR) 2018: 0.494
Source Normalized Impact per Paper (SNIP) 2018: 0.427

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1877-8879
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Volume 19, Issue 2

Issues

Symptom reduction and improved function in chronic CRPS type 1 after 12-week integrated, interdisciplinary therapy

Minna Elomaa
  • Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
  • Other articles by this author:
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/ Jaakko Hotta
  • Clinical Neurosciences, Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
  • Department of Neuroscience and Biomedical Engineering, Aalto University, Espoo, Finland
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  • De Gruyter OnlineGoogle Scholar
/ Amanda C de C Williams
  • Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
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/ Nina Forss
  • Clinical Neurosciences, Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
  • Department of Neuroscience and Biomedical Engineering, Aalto University, Espoo, Finland
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  • De Gruyter OnlineGoogle Scholar
/ Anni Äyräpää
  • Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
  • Internal Medicine and Rehabilitation, Physiotherapy, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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/ Eija Kalso
  • Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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/ Hanno Harno
  • Corresponding author
  • Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
  • Pain Clinic, Department of Clinical Neurosciences, Neurology, Helsinki University Hospital and University of Helsinki, P.O Box 140, 00029 HUS, Helsinki, Finland, Phone: +358504639469, Fax: +358947175641
  • Email
  • Other articles by this author:
  • De Gruyter OnlineGoogle Scholar
Published Online: 2019-02-21 | DOI: https://doi.org/10.1515/sjpain-2018-0098

Abstract

Background and aims

Complex Regional Pain Syndrome (CRPS) often recovers spontaneously within the first year, but when it becomes chronic, available rehabilitative therapies (pharmacological management, physiotherapy, and psychological intervention) have limited effectiveness. This study examined the effect of a 12-week intensive outpatient rehabilitation on pain relief and function in chronic CRPS patients. Rehabilitation program included memantine and morphine treatment (added to patient’s prior pain medication) and concurrent psychological and physiotherapeutic intervention. Primary outcome measure was a change in CRPS symptom count and secondary outcomes were motor performance, psychological factors, pain intensity, and quality of life.

Methods

Ten patients with chronic upper limb CRPS I (median 2.9 years, range 8 months to 12 years) were recruited to the study and were assessed before and after the intervention. Hand motor function of the patients was evaluated by an independent physiotherapist. There were standardized questionnaires for depression, pain anxiety, pain acceptance, quality of life, and CRPS symptom count. In addition, psychological factors were evaluated by a semi-structured interview. Severity of experienced pain was rated at movement and at rest. In addition, a video experiment of a hand action observation was conducted pre- and post-intervention to study possible change in neuronal maladaptation. Intervention consisted of pharmacological, psychological and physiotherapeutic treatment. First, 10 mg daily morphine was started and increased gradually to 30 mg daily, if tolerated. After 30 mg/day or tolerated dose of morphine was achieved, 5 mg daily memantine was started and increased gradually to 40 mg, if tolerated. Psychological intervention consisted of weekly group sessions, using cognitive and behavioral methods (relaxation, behavioral activation, and exposure) and acceptance and commitment therapy (ACT) and daily home practice. Physiotherapeutic intervention consisted of graded motor imagery and physiotherapy exercises with weekly group sessions and/or individual guidance by the physiotherapist, and individual exercise of the affected upper limb.

Results

Multimodal intensive intervention resulted in significant decrease in CRPS symptom count. The effect was strongest in motor and trophic symptoms (19% decrease after intervention) and in sensory symptoms (18% decrease). Additionally, improvement was seen in some, but not all, secondary outcomes (movement pain, motor symptoms, change in perceptions during video experiment of hand actions, and summary index with motor functioning, pain, and psychological factors). There were no dropouts.

Conclusions

Intensive 12-week multimodal intervention reduced some CRPS symptoms but was not sufficient to alter patients’ rest pain, distress, or quality of life.

Implications

These results support the efficacy of an interdisciplinary rehabilitation program for pain and function in chronic CRPS patients. After intervention, some CRPS symptoms reduced and function improved, but distress and quality of life were unchanged. This may be due to the relatively short duration of this program; to delayed effects; to particular cognitive problems of CPRS patients; and/or to low distress levels at baseline that make statistically significant reduction less likely.

Keywords: CRPS; multidisciplinary; interdisciplinary; intervention; pain; symptom

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About the article

aMinna Elomaa and Jaakko Hotta: These authors contributed equally to this work.


Received: 2018-06-01

Revised: 2018-10-23

Accepted: 2018-10-29

Published Online: 2019-02-21

Published in Print: 2019-04-24


Authors’ statements

Research funding: The study was funded by a Governmental Research Grant (TYH2016222, EK) and SHOK, SalWe Ltd., Finland (NF).

Conflict of interest: The authors have no conflicts of interest regarding this paper.

Informed consent: All patients gave their written informed consent.

Ethical approval: The Ethical board of the Helsinki University Hospital and Uusimaa district approved the study (310/13/03/01/2010) and the Finnish Medicines Agency (FIMEA) gave permission for the medical intervention (EudraCT number: 2010-024558-12). The trial was registered in ClinicalTrials.gov (NCT02467556).

Author contributions: Study design: ME, JH, EK, HH, AÄ. Patient selection and clinical examination: HH. Statistical analysis: ME, JH. Writing of the article and scientific contribution to it: ME, JH, EK, HH, AW, AÄ, NF.


Citation Information: Scandinavian Journal of Pain, Volume 19, Issue 2, Pages 257–270, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1515/sjpain-2018-0098.

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