SLR - July 2019 - Christine A. Mariano

Are You Better? A Multi-centre Study of Patient-defined Recovery from Complex Regional Pain Syndrome

Reference: Llewellyn A, McCabe CS, Hibberd Y, White P, Davies L, Marinus J, Perez RGSM, Thomassen I, Brunner F, Sontheim C, Birklein F, Schlereth T, Goebel A, Haigh R, Connett R, Maihöfner C, Knudsen L, Harden RN, Zyluk A, Shulman D, Small H, Gobeil F, Moskovitz P. Are You Better? A Multi-centre Study of Patient-defined Recovery from Complex Regional Pain Syndrome. Eur J Pain. 2018 Mar;22(3):551-564.

Scientific Literature Review

Reviewed By: Christine A. Mariano, DPM
Residency Program: MetroWest Medical Center – Framingham, MA

Podiatric Relevance:
Complex regional pain syndrome is a complication of many podiatric injuries and surgeries. While relatively uncommon, CRPS can lead to patient dissatisfaction and continued severe pain. There is often a disconnect between the patient’s and the physician’s perception of CRPS which can lead to frustration of both the provider and the patient.

Methods: Using a multicounty consortium across North America and Europe, a series of surveys was sent to 679 potential participants. Possible participants were greater than the age of 18 and had previously been diagnosed with CRPS greater than one year ago in 8 different countries. The goal of the surveys was to determine whether patients saw themselves as recovered from CRPS and to collect data about their perception of recovery and health data. Using statistical analysis both quantitative and qualitative evidence was performed.

Results: Three hundred forty-seven questionnaires were returned after round one of surveys. Dominant themes of responses were identified and organized into four headings: activities of daily living, bodily functions and structures including pain, external factors including medication use, and participation. Psychological factors were the least represented. 310 participants responded to a round two survey which looked at recovery status and health outcome. Common lasting symptoms in participants who considered themselves not recovered were muscle weakness, decreased ROM, and temperature differences. Of note, many patients who considered themselves recovered also reported the same three symptoms but in much lower rates. For those reporting <5 symptoms, 34 percent reported themselves as recovered, compared to 2 percent of those with five or more symptoms. 252 participants responded to a survey which asked them to rank the relevance of statement associated with CRPS symptoms. The top-rated statements in in which participants state definite recovery were decrease in CRPS related pain, decrease in generalized pain, decrease in restricted ROM, less need for medication, and decreased limb stiffness.

Conclusions: While CRPS can resolve, it sometimes leads to long term disability. In order to improve treatment and reduce long term morbidity, we must understand recovery from a patient perspective. Expectedly, many patients report the importance of ADL participation and pain as important factors for recovery. Surprisingly, the psychologic factors were quite under-reported despite other current research which often links CRPS and anxiety. Additionally, most patients rank the decrease in CRPS pain as important for recovery. Interestingly, there was a large number of patients who state increase in ROM and decrease in joint stiffness is an important factor in defining themselves as recovered. These findings suggest more focus should be placed on the mobility aspects of the disease process. 

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