More pain means real gain in complex regional pain syndrome treatment

November 12, 2009

The saying "more pain, more gain" may be true for those already in terrible pain due to a chronic and debilitating condition, contrary to received wisdom. For those with Type I Complex Regional Pain Syndrome (CRPS), working through the pain of an aggressive physiotherapy program often leads to far better results than a more cautious pain-free approach. That was the result of a new study in Clinical Rehabilitation, published this week by SAGE. In fact, nearly half those who were given the painful treatment recovered normal physical function, whereas those who avoided painful physiotherapy usually had further loss of physical function.

CRPS is a chronic progressive disease characterized by severe pain, swelling and changes in the skin. The cause of this syndrome is currently unknown. Although CRPS may follow injury and surgery, this is not always the case.

Jan-Willem Ek, Jan C van Gijn and colleagues from the Department of Rehabilitation Medicine at Bethesda Hospital in The Netherlands studied 106 patents suffering severe physical impairments from CRPS Type I, which does not involve nerve lesions (unlike Type II). They found that almost all the patients improved significantly when subjected to a rehabilitation program involving graded pain exposure. In fact, more than half the patients in the study recovered full physical movement, and none of the patients experienced adverse effects from this more aggressive approach. While this "full on" approach doesn't reduce the amount of pain associated with the condition, it does provide sufferers with a significant increase in mobility, function and quality of life. Traditional treatments for this chronic condition typically minimize the pain, which limits physiotherapy significantly and usually leads to greater deterioration of the affected limb.

CPRS can vary from joint stiffness and moderate pain in the arms or legs to paralysis and complete loss of function in more extreme cases. People suffering from this condition usually have a poor prognosis. That's because the condition often leads to extensive changes in the brain itself, making treatment to the affected limb almost ineffective. Given that the brain is usually affected in this chronic condition, it's almost impossible to reduce the pain of this disease by trying to treat the isolated limb. The result is a vicious circle, where the pain of the condition limits the amount of therapy, which in turn causes more deterioration in the limb and the brain, which further hampers any recovery.

Typically, physicians resist therapies where excessive levels of pain are involved, for fear of causing further injuries to the arm or leg. However, the habitual pain from CRPS Type I is often a false warning sign. This seriously limits the extent of therapy that's offered, and often precludes the more aggressive treatments like traction, stretching and massage. Often, the result is that people's joints begin to deteriorate even faster.

"In our experience one of the cornerstones of the success of pain exposure physical therapy is to motivate the patient to undergo both the painful interventions and to keep training and exercising at home," says one of the co-authors, Robert van Dongen. This new insight into this debilitating condition allows doctors and physiotherapists to provide patients with hope for a more functional and normal life.

More information: Pain exposure physical therapy may be a safe and effective treatment for longstanding complex regional pain syndrome type 1: a case series, By Jan-Willem Ek, Jan C van Gijn, Han Samwel, Jan van Egmond, Frank PAJ Klomp, and Robert TM van Dongen is published online now in the journal Clinical Rehabilitation, published by SAGE. http://cre.sagepub.com/cgi/rapidpdf/0269215509339875v1

Source: SAGE Publications