More pain sites over time = greater risk of work disability
It struck me today, as I spent a little time with two people who have been returned to Pain Management Centre for a review of their progress, that something we don’t do very well is help people distinguish between an acute or new problem and what might be a flare-up of the old chronic problem. And by ‘we’ I mean all health providers.

Ok, so that the problem is there is not really so surprising – after all, helping clinicians work out that chronic pain doesn’t respond to acute pain management is quite a change of focus (from short-term cure to long-term management), but I guess I hadn’t really thought through how to help people deal with new pain problems as they arise.

Let me illustrate what I mean. Gary (not his real name, and other details are also disguised to protect privacy) has returned to work after nearly five years since his injury. The original injury was a crush injury to his foot and he was left with a complex regional pain syndrome. For at least the first three years he believed, because he was told by surgeons, that surgery would ‘fix’ the problem – and it was a case of him simply waiting for the surgeons to decide what the best surgical option would be. Unfortunately, his foot pain didn’t respond to surgery and he’s ended up with an arthrodesed ankle and chronic pain. The pain is not resolving – but he is feeling quite confident about how to manage it after completing a pain management programme and with some individual input to help with his mood and return to work planning.

Unfortunately, he’s hurt his knee now. He came off a ladder and landed awkwardly on his knee about five months ago. Initially his GP suggested that he simply wait for it to settle, but Gary had learned from his foot problem that it’s better to get on with moving it – and he didn’t want to risk his return to work planning. So he got a knee brace, had some physiotherapy, and carried on. After about two months, he saw a surgeon who said his knee didn’t need surgery right now although it was a little ‘sloppy’ in the ligaments, so Gary should keep on with his exercises, be ‘careful’ and wait for a while before considering a surgical review.

Now the point of this is that Gary didn’t know whether his knee pain was something he should worry about, or whether it was something he should treat as he does his foot pain – using pain management strategies. I’m picking that he found it hard to know whether he was going to do further damage by using his knee normally (ie what are the risks from using a ‘sloppy’ knee), given that he knows that his foot pain is no longer related to damage.

It seems likely that if someone has a central sensitisation problem, for example, they develop a CRPS, the chance of their nervous system responding similarly to another trauma is quite high. A similar case might be someone who has fibromyalgia, with widespread body pain, and a sensitive nervous system – a person in this situation may also be quite likely to take a long time for post-traumatic aches and pains to settle down.

BUT I don’t think I routinely mention this to people I’ve worked with.

What might the implications be for someone who has a chronic pain problem, and then develops a new, acute pain? Well, given the difficulty we find with treatment providers switching from acute management to chronic management, I think the same old problems are likely to rise. Lots of investigations to work out why the pain isn’t settling as it ‘should’ (and as it would if there wasn’t an underlying central nervous system sensitivity), and lots of passive treatments to reduce the pain – but if the pain isn’t directly related to the acute tissue disruption, then it’s unlikely to respond to these treatments – and I’m sure yet more investigations and treatments are tried.

Let’s take a step back and look at whether there are differences between acute management and chronic management.

  1. In acute management, for the majority of problems (and I’m racking my brain to think of one actually) we ask people to start doing things normally as soon as possible – pain doesn’t have to be completely gone before we encourage people to get moving.  In chronic pain management, we ask people to do things despite pain.
  2. In acute management, we encourage a ‘start low and go slow’ approach to increasing activity.  We do the same in chronic pain management.
  3. In chronic pain management, we recognise the pain is a stressor, and that there is a relationship between having pain and physiological arousal.  In acute pain, the same phenomenon occurs.

So is the main difference is in determining the end goal of treatment? – in acute pain management, we are relatively certain that pain will eventually subside.  In chronic pain management, we are relatively sure that pain will persist.    So we are really looking in both cases at encouraging a focus on function – but in acute pain, the ‘end point’ is often reaching when the pain reduces.

I wonder whether we need to focus on using the same cognitive behavioural approach to self managing many acute problems that we use for chronic pain. And maybe we should consider whether we need to advise people who have chronic pain of their susceptibility to pain in other parts of their body and manage that pain accordingly.  It might just save an awful lot of money on treatments for ‘acute on chronic’ low back pain (just what is that, really?), or for ‘acute back pain’ when the low back pain has never really gone away…

I included this study from Norway, because I think it illustrates something that we observe very often.  I call it ‘recycling’, but other people call it ‘frequent fliers’ – people who have pain in more than one part of their body are more likely, at least in this study, to eventually move onto Disability payments, and stop work.

I don’t think this is simply the effect of a person having trouble coping with the additional burden of pain – I think it’s much more about a systems problem.  If the participants in this study engage with the health system each time they develop a new pain site, the chance of their encountering another provider who follows an acute pain management model (with all that can entail when problems fail to resolve) is pretty high. And with each new encounter with a health provider challenging their own belief in their ability to self manage, these people have a real struggle to remain confident that they can do things despite their various pain.

For this week I’m going to focus on follow-up and effective use of the health care system – care to join me on this journey?  If you do, you can subscribe using the RSS feed link above, or you can just bookmark this page and come back.  I do write most days during the week, and I do love comments.  If you don’t want people to read your comments, you can send them to me via the ‘About’ page which gets sent directly to my email, otherwise they’ll appear on here for others to respond to.  I’m looking forward to hearing from you!

Kamaleri, Y., Natvig, B., Ihlebaek, C., & Bruusgaard, D. (2009). Does the number of musculoskeletal pain sites predict work disability? A 14-year prospective study European Journal of Pain, 13 (4), 426-430 DOI: 10.1016/j.ejpain.2008.05.009

YouTube Mirror Box videos

I was just looking for a quick video on using mirror box for CRPS (Complex regional pain syndrome) – well I couldn’t find any on YouTube, but I did find a good few on use for stroke.

Take a look at these and let me know what you think!  BTW If you’ve made a video on mirror box therapy in CRPS, or phantom, let me know and I’ll link to it.

This link takes you to jeisea’s blog where she has posted an extensive range of articles and links on using mirror box therapy for CRPS. Thanks jeisea!

BTW you don’t always need the box – you can simply use a mirror…

Here’s another – this time from Australian physiotherapist David Butler

Another recent one from Jeisea.

This is a series of four videos of mirrorbox therapy including history – it’s by Dr Ilan Lieberman, and at a commercial website (note I don’t endorse any specific products)  but it is clear, and a great watch!

Welcome to Monday!

It’s not yet Monday here, it’s Sunday evening and I’m putting a quick post up now because Very Early In the Morning I’m going off to see the sunrise! Mad I know, but this is what happens in our household – the camera will be packed and I can almost taste the bacon and eggs on the beach now!

So…I scoped out some things on Slideshare, and came up with this presentation on Complex Regional Pain Syndrome. It’s not overly technical, but summarises some of the newer material available on this very challenging pain problem.

Enjoy – and have a wonderful day!

Case formulation: A simplified example continues

My final post on case formulation illustrates the slightly simplified case study that I presented here.
I will be simplifying his presentation again today, to make sure this post isn’t too enormous!

Firstly, we identify the relatively stable phenomena:

  • Pain-related anxiety and avoidance
  • Work disability
  • Depression
  • Pain behaviours

Selected biophysical contributing factors:

  • Initial scaphoid fracture
  • Complex regional pain syndrome type i
  • Reduced range of movement and strength
  • Central sensitisation (more…)

Case formulation: A simplified example

Over the past few days I’ve been posting about case formulation. While I’ve presented the abductive theory of method (ATOM) which is a process of inferring from phenomena to underlying causal mechanisms, it’s not the only way to develop a formulation.  I posted on some of the other ways formulations can be developed, and today I’m going to describe a simplified formulation to show how it can work in practice. Don’t forget that when I write about patients I make sure details that can identify the individual are changed – or I describe a composite of several patients.

Robert is a 39 year old previously self-employed electrician who sustained a fracture of a his nondominant hand when he fell from a ladder two years ago.  This fracture developed into a complex regional pain disorder type i which had been slowly resolving with the use of medication, functional restoration (graded daily use of the hand), and mirrorbox therapy.  Robert presented for pain management assessment when his progress plateaued, and he became increasingly distressed.

He was assessed in a three-part comprehensive pain assessment in which he was seen by a pain management medical specialist, a functional assessor and a psychosocial assessor.  He completed a set of questionnaires prior to the assessment which were used to ‘flag’ areas for closer investigation.  Information was made available from the referrer (the GP), the case manager (clinical notes from the orthopaedic surgeon and initial physiotherapy treatment provider), and an initial workplace assessment which provided details of his work demands.

The medical assessment consists of reviewing his previous medical history, a full musculoskeletal examination, general ‘systems’ examination, current and past medications used for pain management, and pain specific examination.  The purpose is to identify whether all the appropriate investigations have been completed, the appropriate medical treatments have been pursued, and the medication regime is rationalised. (more…)

Reduction of pain-related fear in complex regional pain syndrome
As promised, at last a post on graded exposure for pain-related anxiety and avoidance, as applied to complex regional pain syndrome, or CRPS. This paper was published in 2005, and as far as I know, there have not been any replications carried out, so it must be seen as an initial experimental approach that needs a good deal of refinement before being applicable to people with CRPS in general, but I think the model itself has received considerable support, and therefore it merits further examination.

So, what did they do? Well the basic premise of the pain-related anxiety and avoidance model is that people can rapidly develop a ‘phobia’ for movements that are associated with increased pain and/or fear of further harm. As a result of this fear, individuals avoid movements that are the same or similar to those that they associate with increased pain or harm. And the resultant avoidance interferes significantly with participating in normal life tasks.

So far, this model has been strongly supported in people with a wide range of types of pain, and treatments based on this model have similarly given some very useful results, although not always as positive as those in the initial few papers.

In CRPS, many people describe their painful limb in terms bordering on disgust, loathing and resentment. Some ignore the limb, while others ask for it to be amputated. It’s not clear to me whether this resentment or desire for it to be removed is an artifact of having pain in a distal part of the body (where amputation is possible – unlike back pain), or whether it represents some degree of neglect as in stroke. Nevertheless, people with CRPS often report being unwilling and/or unable to use their limb in normal functional activities. As a result, their pain interferes with normal life to a considerable extent.

High distress, high reported pain intensity, and avoidance of many activities can result – and some continue to fear that their limb has not ‘healed’ and that they are continuing to ‘damage’ or ‘harm’ their painful extremity.

In this paper, de Jong and colleagues in Maastricht, The Netherlands, set out to test whether the graded exposure approach that had been used for low back pain could also be applied to CRPS. The aim of the study was: ‘Using a replicated single case experimental design, we decided to experimentally examine whether the validity of graded exposure in vivo extends to patients with CRPS-I. The main research question of this study was whether the reduction of pain-related fear through graded exposure in vivo also resulted in a decrease of disability in a subgroup of patients with CRPS-I who report substantial pain-related fear.’

This paper also again illustrates the utility of the replicated single case experimental design for testing the effect of an intervention – for me, clinically, this model of research has a good deal of merit, because it can be applied routinely as part of normal treatment, and doesn’t require elaborate randomisation or the use of control groups, as the subjects act as their own controls, and the interventions are experimentally and systematically manipulated and the results measured.

The study took 8 female patients with CRPS-1, aged 40 years (+/-10 years), and a mean duration of pain of 3 years. In two patients CRPS-I was located in the right lower extremity, one patient in the left lower extremity, four patients in the right upper extremity, and one patient in the left upper extremity. In six patients, CRPS-I occurred on the dominant side. The IASP criteria was used to determine CRPS diagnosis, and it was evaluated both by physician and based on Bruehl et al. (1999), and Veldman et al. (1993) signs: altered skin color, altered skin temperature, edema (swelling), reduced range of motion, trophic (hair, nail skin). Additionally, other inclusion criteria were that the patients reported substantial fear of movement/(re)injury (Tampa Scale for Kinesiophobia (TSK: Miller et al., 1991) score >39), pain for at least 6 months and age between 18 and 65. The TSK score was the median of the TSK distribution from a previous study of low back pain patients.

The paper clearly describes the study design – an ABCD -design with random determination of the start of the intervention. At point A – baseline measures were undertaken. All patients received education, then measures were taken (B), Graded exposure was then undertaken (C), and finally there was a 6 month follow up (D). Commencement of the various treatment phases was started at random time periods. A number of outcome measures were also taken including functional disability – measured in the upper limb by the Radboud Skills Questionnaire (RASQ: Oerlemans et al., 1999, 2000); and in the lower limb the Walking Stairs Questionnaire (WSQ: Roorda et al., 1996a; 2004) and Questionnaire Rising and Sitting Down (QRS: Roorda et al.,1996b) were used.

Fear of movement was assessed using the Tampa Scale for Kinesiophobia, and the PHODA, or Photographs of Daily Living. The final set of measures were self reports of signs and symptoms, using a daily diary method.

I’ll describe the exposure treatment more fully. Each person developed an individualised fear hierarchy by means of the Photograph series of Daily activities for the upper extremities (PHODA-UE: Dubbers and Vikstro¨m, 2003) or the lower extremities (PHODA-LE: Jelinek et al., 2003).

The most essential step consisted of graded exposure to the situations the patients had identified as ‘dangerous’ or ‘threatening’. Based on the graded hierarchy of fear-eliciting situations (PHODA), individually tailored practice tasks were developed. Further, the general principles for exposure were followed. The patient agreed to perform certain activities or movements or stay in situations that he or she had been avoiding. Patients were also encouraged to engage in these fearful activities, movements or situations as much as possible until anxiety levels had decreased. The therapist first modeled each activity or movement. Finally, the graded exposure was presented as a start only, and the patient was encouraged to continue exposing him or herself to more activities in everyday life after termination of the treatment sessions. To facilitate independence and to promote generalization, the presence of the therapist was gradually withdrawn, and contexts were created that mimicked those of the home situation.

Well, what did the study show? The first surprising result was that ‘in every case, at the end of the GEXP all the patients report a positive change for the better in CRPS-related signs and symptoms.’

For all patients a significant reduction in TSK scores is observed at the end of graded exposure and during followup as compared to baseline and education alone. TSK scores decrease from a mean score of 55.0 (>80th percentile) to a mean score of 19.75 (<10th percentile). Similar results were found for the PHODA.

And functionally? All patients reported reduction in pain-related disability as measured both by standardised measures, and on the individualised tasks the patients had identified as things they would like to work on.

To summarise, all the patients reported, after the graded exposure treatment, decreasing levels of pain-related fear, pain disability, and pain intensity. As the authors say ‘This last result is remarkable because pain intensity is not the target of the graded exposure treatment.’

For theorists, it would be great to try to work out how this approach works – graded exposure in vivo is a strategy that aims to activate cortical networks. Graded exposure may disrupt internal body schema by focusing on how the body prepares for movement (eg motor intent), perhaps by practicing a movement the mismatch between motor intent and sensory feedback is ‘rewired’. Alternatively it could have been the process of visual and mental attention on the limb which reintegrates the neural networks, reorganising the cortical representation of the painful limb.

For me, graded exposure directly addresses the meaning people attach to their pain (in particular the belief that ‘I can’t cope with variations in pain’, or ‘this pain means harm’), as well as the behavioural avoidance that interferes so much with daily function – and serves to reinforce the belief that ‘I can’t cope with this pain’. We know that pain intensity is influenced by the meaning people associate with the sensation – and the judgements about what the pain means about them and their lives. If we can help people gradually return to enjoyable activities, we will be doing them a real favour.

I encourage you to review single subject experimental design – and I’ll post more on it!
I also encourage you to consider developing your skills in graded exposure and perhaps reduce the focus in CRPS on avoiding activities that ‘flare pain up’ and instead, consider gradually working up to normal and enjoyable activities on the basis of addressing and experimenting with fears and avoidance.

If you’ve enjoyed this post, and want more – take a moment to comment below, and you can always use the RSS feed or bookmarks to make sure you don’t miss any future posts from me!

DEJONG, J., VLAEYEN, J., ONGHENA, P., CUYPERS, C., HOLLANDER, M., RUIJGROK, J. (2005). Reduction of pain-related fear in complex regional pain syndrome type I: The application of graded exposure in vivo. Pain, 116(3), 264-275. DOI: 10.1016/j.pain.2005.04.019

Bruehl S, Harden RN, Galer BS, Saltz S, Bertram M, Backonja M,
Gayles R, Rudin N, Bhugra MK, Stanton-Hicks M. External validation
of IASP diagnostic criteria for complex regional pain syndrome and
proposed research diagnostic criteria. international association for the
study of pain. Pain 1999;81(1–2):147–54.

Dubbers AT, Vikstro¨m MH. The Photograph Series of Daily Activities
(PHODA): Cervical Spine and Shoulder. CD-rom Version 1.2. The
Netherlands: Hogeschool Zuyd, University Maastricht and Institute for
Rehabilitation Research (iRv); 2003.

Jelinek S, Germes D, Leyckes N. The Photograph Series of Daily Activities
(PHODA): Low Extremities. CD-rom Version 1.2. The Netherlands:
Hogeschool Zuyd, University Maastricht and Institute for Rehabilitation
Research (iRv); 2003.

Miller RP, Kori, SH, Todd, DD. The Tampa Scale for Kinisophobia.
Unpublished Report, Tampa, FL; 1991.

Oerlemans HM, Oostendorp RA, de Boo T, Goris RJ. Pain and reduced
mobility in complex regional pain syndrome I: outcome of a
prospective randomised controlled clinical trial of adjuvant physical
therapy versus occupational therapy. Pain 1999;83(1):77–83.

Oerlemans HM, Oostendorp RA, de Boo T, van der Laan L, Severens JL,
Goris JA. Adjuvant physical therapy versus occupational therapy in
patients with reflex sympathetic dystrophy/complex regional pain
syndrome type I. Arch Phys Med Rehabil 2000;81(1):49–56.

Roorda LD, Roebroeck ME, Lankhorst GJ, van Tilburg TG. The walking
ability questionnaire: hierarchical scales to measure disabilities in rising
and walking [in Dutch]. Revalidata 1996a;18:34–8.

Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms of
reflex sympathetic dystrophy: prospective study of 829 patients. Lancet

A nice lay summary of pain

I ran across this post today in my ongoing search through the net – Why do we have pain?. It’s a very brief article written by someone with fibromyalgia giving a pretty useful description of the difference between pain and injury or tissue damage. And a bunch of links to articles found on Associated Content.

I’m not comfortable with her definition of pain as ‘perception of pain’ because that’s tautological and circular and tells me nothing. So – pain is the perception by the brain of signals that the brain detects as harmful or threatening to the person and wants to ensure action is taken. Howzat for an on-the-run definition? Overall though, I don’t think you can go far from Professor Harold Merskey and co’s original IASP definition of pain. But for lay people, or people in the community, perhaps the definition needs to be a wee bit shorter.

I clicked into the link ‘pain’ on that website, and came across a whole range of brief articles of varying quality about pain and pain management. Like most things on the web, read with a good degree of thought and criticism, and be aware of the quality of what you read. If you’re wanting to establish whether a site has been reviewed for quality, the Health on the Net is a good way to determine whether the author has decided to voluntarily comply with ethical standards. You should also apply your own critical thinking by referring to the literature yourself – and not just a single reference either! You do need to survey several papers on any topic, thinking about the quality of the research supporting any contention, and particularly the generalisability of any research to your specific area of practice, before transferring any new treatment technique into your daily routine!

’nuff said – I’ll be posting on CRPS and an exposure-based treatment later shortly so – y’all come on back now!!

It’s not enough just to feel – it’s about ‘what do you feel?’


Pain. 2007 Dec 1

Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain.

Moseley GL, Zalucki NM, Wiech K

This interesting study by the prolific Lorimer Moseley suggests that it’s not good enough for people with complex regional pain syndrome to just be exposed to tactile stimuli, but they need to do something with that stimulus for it to translate into changes in pain intensity and ability to discriminate.
This study was a four phase (A–B–C–D) within subjects repeated measures design. The first phase was a no-treatment waiting period. The second phase was the stimulation only condition. The third phase was the discrimination condition. The duration of each of these phases was between 11 and 17 days (randomly allocated for each participant). The fourth phase was a three-month follow-up period.
The stimulation only condition involved On a digital photograph of the affected limb, five points were marked Two cork probes (2 and 11 mm in diameter, respectively) were mounted atop a spring-loaded cartridge such that the pressure with which each probe could be applied to the skin was standardised.A screen was positioned to prevent the subject from seeing the affected area. Stimulation involved applying one of the probes to one of the marked points. The type of probe and the marked point were randomised using a random numbers table. Interstimulus interval was 15 s. Three 6-min blocks of 24 stimuli were undertaken with a 3-min rest period between blocks. Thus, each treatment session involved 72 stimuli and lasted 24 min, and was repeated every week day.
The discrimination phased was exactly the same, however, participants were given a photograph of their limb on which the stimulation points were marked. They were also shown the two probes. During the tactile stimulation, participants responded to each stimulus by stating (i) the location of the stimulus (i.e. the corresponding number on the photograph) and (ii) the type of probe.
The effect of tactile stimulation and discrimination on function (task-specific NRS)Tasks selected by each participant reflected the body part that was affected. For example, most participants selected sleeping; most participants with CRPS of the upper limb selected ‘dressing’, ‘eating’ and ‘driving’; participants with CRPS of the dominant upper limb selected ‘writing’ or ‘using my hand’; all participants with CRPS of the lower limb selected ‘walking’ and ‘wearing a shoe’.At baseline, means ± SD function score was 2.2 ± 0.8. Function changed over the course of the study (main effect of time; (F(4, 48) = 70.05, p < 0.001). Pairwise comparisons revealed that there was no change in function during the stimulation phase [mean (95% CI) = 3.1 (2.0–4.1)], nor during the waiting period [2.5 (1.9–3.2); p > 0.34 for both)]. Function was higher at post-discrimination [5.5 mm (34–38 mm)] than it was at post-stimulation, post-waiting period or at baseline (p < 0.001 for all). The mean (95% CI) effect size for the function score was 1.9 (1.1–2.8). Function had not changed further at follow-up [5.5 (4.5–6.5), p = 0.98], but it was still higher than it was at post-stimulation, post-waiting period or at baseline (p < 0.001 for all)

Unfortunately, this study was conducted with a group of only 13 people with complex regional pain syndrome, so we don’t know whether it is readily generalisable, but it does provide some food for thought for both occupational therapists and physiotherapists. Both occupational therapists and physiotherapists would argue that goal-directed activities that are relevant to the individual are much more likely to engage the interest and hence ‘motivate’ people to carry them out more readily than ‘exercises’. The challenge has been to identify suitable activities – and to establish why this type of activity should be provided as opposed to the more easily developed ‘exercises’. Now here is a clinical study demonstrating that yes, outcomes can be maximised by engaging the person in active involvement in the activity.

What I really liked about this study was the use of real functional tasks as the ‘ultimate’ measure of whether the intervention worked. Of course it would be great to see a truly randomised study in which an alternative and perhaps competing treatment such as graded exposure is used – I wonder whether by providing an ‘interesting’ activity there is reduction of anxiety and hence more likelihood that the person will use their affected limb. If a really interesting and engaging activity is used in a graded hierarchy, it may prove even more successful. An additional measure to use in this case would be one assessing fear or anxiety about pain, or even one assessing acceptance.

PMID: 18054437 [PubMed – as supplied by publisher]