Outcomes of Treatment for Pain and Disability Associated with Complex Regional Pain

SyndromeRIC Center for Pain Management

Randy Calisoff, MD1

Zachary McCormick, MD2

Jaymin Patel, MD3

Mary Caldwell, DO1

George C. Chang-Chien, DO4

James Atchison, DO1

Christine Gagnon, Ph.D1

Steven Stanos, DO5

R. Norman Harden, MD6

1. Rehabilitation Institute of Chicago, Northwestern McGaw Medical Center. Department of Physical Medicine and Rehabilitation. Chicago, IL.

2. Pain Fellow, PGY5, Northwestern University Medical Center, Department of Anesthesiology, Northwestern University, Chicago, IL.

3. Pain Fellow, PGY5, University of Pittsburgh Medical Center, Pittsburgh, PA.4. Medical Director, Ventura County Medical Center, Ventura, CA.5. Medical Director, Swedish Pain Services, Swedish Health Systems, Seattle, WA.6. Professor Emeritus, Northwestern University; Director, Analgesic Research Consultants, LLC, Athens, GA.

Disclosures:None

Background: CRPS

• CRPS: Difficult to treat• A more comprehensive approach• Interdisciplinary care

Treatments for CRPSMirror TherapyContrast BathsExposure TherapyEdema ControlIsometric Strengthening ExercisesMaintaining FlexibilityIsotonic StrengtheningDesensitizationErgonomicsInjections

(Stanton-Hicks, et al.)

Background: CRPS• One cohort study of 12 patients with CRPS who underwent an intensive interdisciplinary pain management program (Singh, 2004)

• Study Design:• 12 patients, 4 weeks of interdisciplinary rehabilitation• PT/OT/Pool Therapy/Group Psychology/Med Management• Weight Bearing• Pressure Tolerance• Upper Extremity Isometric Endurance• Fine Motor Skills

Background: CRPS•Study Findings:•Improved:• Weight Bearing, • Pressure Tolerance, • Upper Extremity Isometric Endurance,• Fine Motor Skills

•Limitations:• 12 patients• No psychological indices were used, only function• No medication usage was determined• Pain scores were not included

RIC Clinical ReviewPurpose: Determine if CRPS can be effectively treated in a comprehensive interdisciplinary pain management program • Larger cohort of patients• Changes in function• Changes in pain• Changes in pain medication usage•Changes in mood•Changes in coping

Methods

• Retrospective cohort study

• Rehabilitation Institute of Chicago Center for Pain Management

RIC InterventionFull Day 4-Week, Monday through Friday8am to 4pm x 4 weeks totalInterdisciplinary Pain Management Program• Physical Therapy• Occupational Therapy• Pain Psychology• Relaxation Training• Pool Therapy, Aerobic Conditioning• Weekly Physician Visits• Nursing Education

Inclusion Criteria Exclusion Criteria• 18-89 years of age

• 4 week full day Interdisciplinary Pain Management Program

• Fulfilled Budapest Criteria (Harden, et al. 2010)

• Patients missing at least 2 of the following:

-NRS Pain Scores

-Functional Measurements

-Medication usage

Budapest Clinical Diagnostic Criteria for CRPS(Harden, et al. 2010)

A. Pain disproportionate to inciting eventB. Report 1 symptom in 3 of the 4 categories C. Display 1 sign in 2 or more of 4 categories

I. Hyperesthesia; AllodyniaII. Temperature asymmetry; Skin color changes; Skin color asymmetryIII. Edema; Sweating changes; Sweating asymmetryIV. Decreased range of motion; Motor dysfunction; Trophic changes

(D) There is no other diagnosis

Time Points of Data Collection

• Start of 4 week RIC Interdisciplinary Program

• End of 4 week RIC Interdisciplinary Program

Patient Characteristics: RIC Study

Total: 49 patients

- Female: 67%

- Average age: 39.6 years

- Workers Compensation: 33%

RIC Outcome Measures

Mood• Center for Epidemiologic Studies Depression Scale (CESD-10)• Pain Anxiety Symptoms Scale (PASS-20)

Chronic Pain Acceptance• Chronic Pain Acceptance Questionnaire (CPAQ)

Coping with Pain• Coping Strategies Questionnaire-Revised (CSQ-R)

Pain Ratings• NRS Pain scores (Best, Worst, Current)

RIC Outcome Measures (continued)

Physical Functioning• 6 Minute Walk Test• 2 Minute Sit to Stand Test

Perceived Disability• Pain Disability Index (PDI)

RIC Outcome Measures (continued)

Medication Usage• Medication Quantification Scale III (MQS III) Score•Assigns detriment weights to each medication•Overall risk of medication usage

(Gallizzi, et al. 2008)

RIC Outcome Measures (continued)RIC Multidimensional Patient Impression of Change (RIC-MDPIC)•Overall Status• Overall Pain• Sleep• Mood• Physical Functioning • Effectiveness of Medication• Ability to Cope with Pain, Flare-ups

Results of RIC Study

Perceived Disability: Pain Disability Index (PDI)

Physical Function: Two Minute Sit-to-Stand Test

Physical Function: Six Minute Walk Test

Center for Epidemiologic Studies Depression Scale (CESD-10)

Pain Anxiety Symptoms Scale (PASS-20)

Coping Strategies Questionnaire-Revised (CSQ-R)

Coping Strategies Questionnaire-Revised (CSQ-R)

Chronic Pain Acceptance Questionnaire (CPAQ)

Numerical Rating Scale (NRS)

Medical Usage: Medical Quantification Score (MQS)

RIC Multidimensional Patient Impression of Change

Note:N = 25 for all categories except Effectiveness of Medication (N=24)

Conclusions: RIC Study

Patients’ improved with regards to:• Function• Psychometrics• Pain

Conclusions: RIC Study

Function:- Walking - Lower Extremity Transfers- Overall Activity- Perceived Disability

Conclusions: RIC Study

Psychometrics:- Depression- Pain Related Anxiety- Catastrophizing- Acceptance of pain

Conclusions: RIC Study

Pain:- Worst pain is significantly less-Current pain is significantly less-Best pain is worse at end of program, but not significantly worse

Conclusions: RIC Study Medication Use:

-Use is lower, but not significantly lower, trending

Conclusions: RIC Study

Interdisciplinary Approaches:-Benefits-Chronic Pain Conditions

Future Research at RIC• Larger Sample Size• Longer Term Outcomes•Adding a Prospective Component •Phone Call Follow Up

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References

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