Outcomes of Treatment for Pain and Disability
Associated with Complex Regional Pain Syndrome
RIC 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 CRPS
Mirror Therapy
Contrast Baths
Exposure Therapy
Edema Control
Isometric Strengthening Exercises
Maintaining Flexibility
Isotonic Strengthening
Desensitization
Ergonomics
Injections
(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 Review
Purpose: 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 Intervention
Full Day 4-Week, Monday through Friday
8am to 4pm x 4 weeks total
Interdisciplinary 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
• Patients missing at
least 2 of the following:
• 4 week full day
Interdisciplinary Pain
Management Program
• Fulfilled Budapest
Criteria
(Harden, et al. 2010)
-NRS Pain Scores
-Functional
Measurements
-Medication usage
Budapest Clinical Diagnostic Criteria for CRPS
(Harden, et al. 2010)
A. Pain disproportionate to inciting event
B. Report 1 symptom in 3 of the 4 categories
C. Display 1 sign in 2 or more of 4 categories
I. Hyperesthesia; Allodynia
II. Temperature asymmetry; Skin color changes;
Skin color asymmetry
III. Edema; Sweating changes; Sweating asymmetry
IV. 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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