Could your state of mind influence CRPS recovery?

We know that recovery from Complex Regional Pain Syndrome (CRPS) is variable: whilst some people make a relatively full recovery in a few months, others are left with pain and symptoms that persist for years [2].  What factors might influence this recovery process?  Current theories argue that in a way, CRPS can be viewed as an overprotective response, where for some reason the brain perceives that the body’s tissues are under threat, and engages the body’s defence mechanisms [3].  These mechanisms include activating the sympathetic nervous system, the immune system, and increasing the person’s sensitivity to pain.  In addition, it’s not surprising that people with CRPS often try to protect their limb by avoiding painful activities.  Interestingly, whilst lots of research has looked at the physiological aspects of this “threat response”, not much research has looked at the psychological factors or state of mind that might contribute to it.  This is surprising, as for many other pain conditions, theory and research suggest that pain-related fear, pain-catastrophizing (thinking the worst) and avoidance of movement all influence people’s pain experience [5].

We recently did a study designed to investigate whether thoughts, beliefs and emotions are associated with the extent to which people with CRPS recover in the first 12 months of their condition [1].  We recruited 66 CRPS patients within the first 3 months of developing CRPS symptoms, and assessed them straight away, then at 6 months and 12 months after their CRPS began.  Each time, we measured their signs and symptoms of CRPS, their pain, level of disability, and various thoughts, beliefs and emotions that might be associated with a threat response.  These included questionnaires about stress, anxiety and depression, pain catastrophizing, fear of pain/movement/re-injury, and the person’s thoughts and feelings about their painful limb (which we measured using a neat scale called the Bath CRPS Body Perception Disturbance Scale).

We looked to see if any of the thoughts, beliefs and emotions on the first visit predicted the subsequent outcomes over the year.  We looked at 3 outcome variables: pain intensity, levels of disability, and the number of symptoms/signs of CRPS each person was experiencing.  What we found was that those who were more anxious and disabled at the start had greater levels of pain over the 12 months.  Those who had more pain and who were more fearful of pain/movement were more disabled over the year.  And females, those who had more pain and who were more disabled at the start experienced a greater number of CRPS signs and symptoms over the 12 months.

What this suggested to us was that people whose state of mind makes them more likely to perceive threat (i.e. those who are more anxious and fearful of pain/movement) might experience a poorer recovery from CRPS.  It is possible that this could operate in a bit of a vicious cycle, with those whose pain is severe experiencing more anxiety, which could in turn exacerbate the pain.  Keep in mind that when we talk about anxiety and pain-related fear we don’t mean anything terribly abnormal – such feelings are a common response to health problems.  We know that anxiety and fear influence the activity of the sympathetic nervous system, immune system, the body’s endogenous ability to modulate pain, and of course change a person’s behaviour, so there are lots of possible mechanisms by which anxiety and fear could influence pain in CRPS.

Additionally, those CRPS patients who were more disabled by pain at the start had a poorer recovery.  We wondered if this might be an effect of immobilization: lots of the patients were given splints or braces or had their limb put in plaster, and it’s likely that these people would rate themselves as more disabled.  Immobilizing a limb, even for a short time, has been shown to lead to lots of symptoms that feature in CRPS [4], so this is something that would also be worth investigating in future studies.  Finally, and not surprisingly, we found that having greater pain from the outset was associated with poorer outcomes for people.  Hopefully this will further encourage clinicians to be proactive with providing pain relief for people with new cases of CRPS, whenever these treatments are beneficial.

The next step for the field of research would be to see if it’s possible to reduce people’s levels of anxiety, fear, and disability and manage their pain better in the early stages of CRPS and see if this has any meaningful long term benefit.

About Debbie Bean

Debbie BeanDebbie Bean is a Health Psychologist at The Auckland Regional Pain Service (TARPS) and has recently completed her PhD at The University of Auckland, looking at recovery from Complex Regional Pain Syndrome.

References

[1] Bean DJ, Johnson MH, Heiss-Dunlop W, Lee AC, Kydd RR. Do psychological factors influence recovery from complex regional pain syndrome type-1? A prospective study. Pain 2015;E-pub ahead of print.

[2] Bean DJ, Johnson MH, Kydd RR. The outcome of complex regional pain syndrome type 1: A systematic review. J Pain 2014;15:677-690.

[3] Moseley GL. Reconceptualising pain according to modern pain science. Phys Ther Rev 2007;12:169-178.

[4] Pepper A, Li W, Kingery WS, Angst MS, Curtin CM, Clark JD. Changes resembling complex regional pain syndrome following surgery and immobilization. J Pain 2013;14:516-524.

[5] Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: A systematic review. Spine J 2014;14:816-836.e814.

Comments

  1. Cathie Livingstone says:

    Jan Carstoniu, I agree entirely.
    When I was diagnosed with CRPS 4 years ago, my doctor couldn’t provide me with any fact sheets, and told me I had caused it. My doctor told me I could end up with so much pain I might not be able to bear the weight of a sheet against my skin. It was a totally distressing experience. My anxiety levels were sky high.
    It is admirable that psychologists want to reduce the anxiety associated with CRPS. Now there are good fact sheets available. I would recommend the fact sheet from The NIH National Institue of Neurological Disorders and Stroke on CRPS. Not all patients want a scientific explanation, but it is very reassuring for those of us who do to know that the pain is caused by local cell damage. It is reassuring to know that there are treatments available, and patients recover if treated promptly.
    There is discussion now that CRPS may be an autoimmune disease. it will be interesting to see what the cause is attributed to in another 4 years.

  2. Jan Carstoniu says:

    This is a correlational study and as such does not allow for any statements regarding causality. It noted that people with greater levels of pain and disability at the start of their condition also had higher levels of psychological distress.

    It is just as likely that higher levels of distress were the result of higher levels of pain instead of the other way around. It is possible that the precipitating injury was simply more severe among these patients. Perhaps this or some other factor was responsible for both increased pain and increased distress.

    If this is the case, and the study does nothing to refute this notion, then it is not exactly a mystery that people with more pain and distress at three months would also have increased pain and distress at 12 months. Perhaps their problems are more resistant to treatment because the original “injury” was more severe.

    To me, the study was a good one because of all the questions it raises. However, I believe it is premature to make causal statements about one’s state of mind and pain/disability levels.

  3. Hi Debbie,
    thanks for the post.
    I am interested in your opinion of the common Hand Therapy approach to upper limb crps that I see at the acute hospital where I work. Patients just out of plaster post colles fracture displaying signs and symptoms of crps are put in a neutral resting splint to help prevent flexion contractures. They take the splint off for active exercise and passive stretches performed by self and hand therapist. I can see some logic in using a resting splint from a biomedical model of management, but it seems contrary to the approach suggested by your research.
    When looking through the literature, advice about splinting is often unclear. For example, the following reference recommends “Resting and splinting of the affected part (for a short period only) if symptoms are
    severe.”
    http://www.anzca.edu.au/resources/college-publications/pdfs/books-and-publications/Australasian%20Anaesthesia/australasian-anaesthesia-2005/05_Visser.pdf

    Whereas more recent research usually recommends sustained attention to the affected limb.
    I look forward to hearing your views on the use of resting splints

  4. lovely work. thanks for the post.
    quick question: at the end, based on the finding that those with greater pain from the outset had poorer outcomes, you state “Hopefully this will further encourage clinicians to be proactive with providing pain relief for people with new cases of CRPS”. this is definitely appealing intuitively, and nobody wants to see these people suffer. but a recent study on whiplash by Gwen Jull’s group showed that attempts to provide more pain relief to those with highest baseline pain (justified as above) did not help – with one significant reason being the poor ability of this group to tolerate stronger pain medications. This poor tolerance to medication fits with the hypothesis that patients experiencing severe pain are sensitive in many ways – but it might also mean that “better pain relief” (if interpreted as stronger medication, which it would be i think) is just not a feasible option for many of these patients.
    To be clear – I don’t have evidence for a better option either. i would just appreciate your thoughts on how we can address this situation in terms of targetting the high initial pain status. Is our best bet targetting the factors which enhance threat value – fear, catastrophising, vigilance etc…. as at least they might be more tolerable to patients in a lot of pain?

  5. Hi Debbie,
    I can think of two patients that would fit very well with what you write in your blog post related to the research you are doing. She is a young girl and has been suffering from severe CRPS for 2 1/2 years. When I first saw her one year ago she came to me in a wheelchair, not being able to walk, being out of school for the last year. Her bilateral pain was ranging from 7-9. She had been trough all medical treatments you can think of. Today she is back in school, walking and living an active life. However, she still has 7+- pain, but she is not afraid of it. The numbers does not matter, her feelings does.

    The treatments she received were ranging from graded exercise therapy as medical exercise therapy, connective tissue massage, mirroring and stroking techniques. What I believe made a great difference in all this were the discussions we had about her feelings about pain. We talked a lot about pain that felt dangerous increasing anxiety versus pain that was acceptable, having a healing effect, a type of meaningful pain. A meaningful type of pain making it possible to get her life back. As time passed by she also trusted me, trusted that the treatments I suggested was helpful and meaningful in relation to her feelings about pain. One of her biggest concerns, stressing her, giving her anxiety, was all the misunderstandings she had experienced from different health professionals she had met. We talked about that in a relaxed manner without me criticizing others. And finally, she said, how can a medical person help me when that person is stressed out showing anxiety for me. Showing anxiety for my pain.

    The other patient is an older female that I treated for a heart condition. During last winter she fell and fractured a bone in her hand. She is an active coper having a high level of self-efficacy. When something needs to get fixed she is doing it. So I added relevant exercises for her hand and arm. The exercises were graded pain free or close to pain free…I thought. Suddenly she told me that the pain in her hand was constant 4-5 and was spreading up in to her arm. She was developing CRPS and I was helping her.
    The treatment was changed, exercises were deleted, and we had a serious discussion about not pushing into pain. Not pushing into pain doing domestic work working in the kitchen preparing and making meals. Her husband had to take over, which she also experienced as painful, what she defined as “painful domestic work”.

    Her high level of self-efficacy had become her own enemy. We also discussed how she had become more anxious thinking that this small fracture in her hand should have healed quickly pain disappearing. Frankly, she had so much to do that she had no time to take it easy. As I see it, being active pushing into the pain, not listening to her bodily symptoms, turned her endurance behavior into fear and anxiety. Today she is symptom free at rest, but if she is doing to much it triggers her pain experience.

    Debbie, thanks again for an excellent blog post focusing on these important psychological factors that I believe are fundamental for understanding pain. And I hope we all continue to learn more about ourselves, how we understand pain and how our patients understand pain, decreasing stigmatization of patients with CRPS making us more able to help them.