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SPECIAL TOPIC SERIES

Psychological and Behavioral Aspects of Complex Regional Pain Syndrome Management

Stephen Bruehl, PhD and Ok Yung Chung, MD, MBA

Abstract: Psychological and behavioral factors can exacerbate the pain and dysfunction associated with complex regional pain syndrome (CRPS) and could help maintain the condition in some patients. Effective management of CRPS requires that these psychosocial and behavioral aspects be addressed as part of an integrated multidisciplinary treatment approach. Wellcontrolled studies to guide the development of a psychological approach to CRPS management are not currently available. A sequenced protocol for psychological care in CRPS is therefore proposed based on available data and clinical experience. Regardless of the duration of the condition, all CRPS patients and their families should receive education about the negative effects of disuse, the pathophysiology of the syndrome, and possible interactions with psychological/behavioral factors. Patients with acute CRPS (<6­8 weeks) may not need additional psychological care. All patients with chronic CRPS should receive a thorough psychological evaluation, followed by cognitive-behavioral pain management treatment, including relaxation training with biofeedback. Patients making insufficient overall treatment progress or in whom comorbid psychiatric disorders/major ongoing life stressors are identified should additionally receive general cognitive-behavioral therapy to address these issues. The psychological component of treatment can work synergistically with medical and physical/ occupational therapies to improve function and increase patients' ability to manage the condition successfully. Key Words: complex regional pain syndrome, reflex sympathetic dystrophy, psychological, behavioral, psychotherapy, multidisciplinary (Clin J Pain 2006;22:430­437)

medical interventions for CRPS reveal only limited support for their long-term efficacy.1,2 It is therefore not surprising that in the absence of any widely efficacious medical treatment, two consensus panels of CRPS clinicians and researchers have emphasized the need for multidisciplinary management of the syndrome.3,4 CRPS, like all chronic pain conditions, is most appropriately viewed as a biopsychosocial disorder, for which successful treatment must target concurrently the biological, psychological, and social components.3­5 For reasons that will be described below, addressing psychological and behavioral factors may be even more central to successful treatment in patients with CRPS than in other types of chronic pain. A rationale for psychological/behavioral management of CRPS in part derived from the presumed pathophysiology of the disorder will first be overviewed. The limited data-based literature regarding psychological interventions in CRPS will then be reviewed, followed by presentation of a protocol for psychological management of CRPS patients.

Rationale for a Psychological/Behavioral Management Approach

Several pathophysiologic mechanisms believed to contribute to CRPS may be relevant to understanding how psychological/behavioral factors could have an impact on the disorder. Figure 1 summarizes hypothesized interactions between psychological/behavioral factors and a number of pathophysiologic mechanisms that may underlie CRPS. Sympathetic hypofunction after peripheral nerve injury is believed to lead to upregulation of peripheral catecholaminergic receptors.6­8 The resulting supersensitivity to circulating catecholamines produces exaggerated vasoconstriction,7­10 thereby leading to the characteristic cool, blue extremity typically seen in chronic CRPS. Nociceptive afferents may also become sensitive to adrenergic excitation after nerve injury, leading to increased firing in the presence of sympathetic discharge or circulating catecholamines.7,11,12 This catecholamine-induced nociceptive firing contributes to the persistent nociceptive input that is believed to produce and maintain the altered central signal processing underlying allodynia and hyperalgesia in CRPS.13,14 A vicious cycle may be created in which altered central processing leads to increased pain, which provokes catecholamine release that further stimulates the nociceptive input maintaining the central processing alterations.

Clin J Pain

BACKGROUND The Need for Multidisciplinary Management

Successful management of complex regional pain syndrome (CRPS) presents a significant challenge to clinicians. Meta-analyses of clinical trials examining

Received for publication July 25, 2005; accepted July 25, 2005. From the Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN. Reprints: Stephen Bruehl, PhD, Vanderbilt University Medical Center, Suite 324 Medical Arts Building, 1211 Twenty-First Avenue South, Nashville, TN 37212 (e-mail: [email protected]). Copyright r 2006 by Lippincott Williams & Wilkins

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Inflammation

Injury

Learned Disuse

Trophic Changes

Pain

Systemic Catecholamine Release

Adrenoceptors Sprout on Nociceptive Fibers

Spontaneous Nerve Firing

Diminished Sympathetic Outflow

Stress/ Distress

Pain

Central Signal Processing Changes

Upregulation: Adrenergic Supersensitivity

Allodynia Hyperalgesia

Diminished Blood Flow

FIGURE 1. Possible interactions between psychological/ behavioral factors and pathophysiologic mechanisms contributing to CRPS.

Another important pathophysiologic mechanism that may contribute to CRPS is the sometimes profound disuse of the affected extremity that develops in an effort to avoid stimuli that may trigger hyperalgesia and allodynia. This possibility is supported by work suggesting that, in healthy individuals, prolonged disuse alone may lead to temperature/color changes and hyperalgesia like those observed in CRPS.15 Diminished active range of motion is common even in early CRPS,16 and CRPS is associated with significantly reduced mobility and impaired ability to use the affected area normally.17 That pain avoidance may lead to these activity impairments is suggested by significant inverse correlations between CRPS pain intensity and ability to carry out activities of daily living.18 Operantly conditioned disuse of the affected extremity, reinforced by avoidance of pain or expected pain, can prevent desensitization and eliminate the normal tactile and proprioceptive input from the extremity that may be necessary to restore normal central signal processing.3,19 Learned disuse may also impair the natural pumping action associated with movement that helps prevent accumulation of catecholamines and tachykinins in the affected extremity that can exacerbate CRPS signs and symptoms.11,20 Pain-related learned disuse may therefore interact with other pathophysiologic mechanisms to prevent the patient from ending the vicious cycle that maintains the primary features of CRPS.5 Moreover, given the pathophysiologic mechanisms above, any psychological factor associated with altered catecholamine activity could directly affect pain intensity and vasomotor changes and by exacerbating pain could indirectly help maintain the central signal processing changes associated with CRPS. Psychological factors including life stress and dysphoric emotional states (eg, anxiety, anger, depression) can be associated with increased catecholaminergic activity and could therefore interact with the pathophysiologic mechanisms above.21 Although data directly testing this

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possibility are unavailable, results of a small study are suggestive.22 Levels of plasma epinephrine were found to correlate positively and significantly with depressive symptoms as reflected on the Beck Depression Inventory in a sample of 16 CRPS patients.22 In light of these findings, it is notable that depression levels on a given day have been found to be significant predictors of CRPS pain intensity on the next day in a study using time-series diary methodology.23 That such issues are relevant to management of CRPS is reinforced by several studies suggesting that CRPS patients may be more distressed than other chronic pain patients,24­28 and that emotional arousal and style of emotional regulation may have a greater impact on pain intensity in CRPS than in other types of chronic pain.26,29 In summary, although the contribution of psychophysiologic interactions to CRPS is speculative, it is theoretically consistent and highlights the importance of addressing psychological factors in CRPS patients. A vicious cycle in which pain provokes disuse and emotional arousal, both of which in turn exacerbate the pain, could contribute to maintenance of CRPS. Therefore, the rationale for providing psychological/behavioral treatment of CRPS patients is twofold: (1) to target learned disuse and stress/distress to help break a vicious cycle that may help maintain CRPS, and (2) to provide pain coping skills to improve functioning and quality of life.

LITERATURE REVIEW: PSYCHOLOGICAL TREATMENTS FOR CRPS

A thorough review of the Medline and CINAHL databases revealed only one published randomized trial specifically testing psychological interventions in CRPS patients. Fialka et al30 randomized 18 CRPS patients to receive either home physical therapy (PT) or home PT plus once-weekly autogenic relaxation training for 10 weeks. Both groups showed improved pain, range of motion, and edema, with no significant differences between groups. However, patients in the PT plus autogenics group showed significantly greater improvements in limb temperature compared with PT alone. Although the small sample size limited statistical power for testing intervention efficacy, these results suggest that relaxation-based interventions may have some benefit in management of CRPS. Results of several published case studies and small case series further suggest that the pain of CRPS may be reduced through use of techniques such as hypnotherapy, imagery, progressive muscle relaxation, autogenic training, and thermal biofeedback.31­35 Other research has addressed the multidisciplinary aspects of treatment, suggesting that integration of psychological methods with medical and physical therapy may assist in the successful management of CRPS.36­38 Among a prospective case series of 103 primarily adolescent CRPS patients, treatment incorporating conservative medication management, regular active physical therapy, and psychological counseling reportedly resulted

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in 92% of the sample achieving symptom-free status.36 Results of the only other randomized trials of nonmedical interventions for CRPS are also notable, indicating that an intervention combining passive physical therapy, pain coping skills, and relaxation training resulted in significantly improved pain, active range of motion, and impairment levels compared with a social work control group.37,38 In summary, randomized controlled studies of psychological interventions for CRPS, alone or in the multidisciplinary context, are almost entirely absent from the literature. The clinical studies available, however, do suggest that psychological interventions are likely to be a useful part of a comprehensive multidisciplinary treatment package.

CLINICAL RECOMMENDATIONS

As noted above, there is little controlled outcomes research on which to base psychological treatment recommendations for CRPS. The protocol presented below is therefore based on both the existing clinical literature and clinical experience.

Treatment Sequencing

There are no controlled data to indicate the optimal sequencing for psychological treatment in CRPS patients. The following sequence of treatment components (a flowchart is presented in Fig. 2) is therefore proposed based on theoretical considerations as well as practical constraints, such as limitations on the number of psychological treatment sessions likely to be approved by insurers. Within the proposed treatment sequence, it is recommended that all patients and their families receive detailed CRPS education immediately upon initiation of medical treatment. In brief, this education should provide an explanation of CRPS pathophysiology appropriate to the patient's level of education; education about the negative effects of disuse, the importance of reactivation,

All Patients

"Acute" CRPS (<6-8 weeks) Monitor for Progress in PT/OT and MD

Patient/Family Education *CRPS Pathophysiology *Influence of Psych *Active Patient Role *Disuse Issues

and the need for an active self-management approach to treatment; and an explanation of how psychophysiologic interactions could affect the severity of CRPS. The latter is likely to be received most constructively by patients if it is framed in terms of providing an aspect of the syndrome over which they may have some degree of control. Beyond this basic education provided to all patients, the primary determinant of whether a patient receives individualized psychological assessment and treatment in this protocol is the duration of the condition. Although somewhat arbitrary, a cutoff of 6 to 8 weeks' duration of CRPS has been suggested for decision making about initiation of the psychological component of treatment.4 This is based on a presumption that CRPS-like symptoms of brief duration do not necessarily show a progressive deteriorating course,39­41 but rather may resolve spontaneously or in response to limited medical and physical therapy intervention. ``Acute CRPS'' patients are generally assumed to have minimal psychological overlay. This general recommendation does not imply that appropriate psychological/behavioral intervention at this acute phase may not help prevent the development of chronic CRPS in certain patients, but such intervention is likely to be unnecessary in most acute CRPS patients. Psychological evaluation and phased treatment are recommended for all patients with a CRPS duration greater than 6 to 8 weeks, who are likely to represent the majority of patients in tertiary care settings. For all such ``chronic CRPS'' patients, individualized psychological evaluation is recommended, followed by focused psychological pain management treatment. It is suggested that this pain management treatment include relaxation training (possibly with biofeedback), training in cognitive pain coping skills, and behavioral intervention to address disuse and activity avoidance issues, as well as family reinforcement issues. More general cognitive-behavioral therapy is initiated in this model only if treatment progress with the above protocol is inadequate or specific issues are identified during evaluation that may affect the condition or the patient's ability to engage effectively in treatment (eg, major ongoing life stressors or axis I psychiatric disorders).

"Chronic" CRPS (>6-8 weeks))

Psychological Evaluation: *Axis I Disorders *Cogn/Behav/Emotional Response *Major Stressors *Family Responses Pain Management Treatment: *Relaxation/Biofeedback *Cognitive Coping Skills *Behavioral Intervention: -Incremental Reactivation -Reinforcing Activity -Family Reinforcement

ASSESSMENT COMPONENT

Outlined below are a number of specific psychological assessment issues that should be addressed in CRPS patients for use in optimizing responses to psychological intervention; assessment and treatment are necessarily intertwined. In general, the formal psychological evaluation process should at a minimum address these areas: (1) presence of comorbid axis I psychiatric disorders, (2) cognitive, behavioral, and emotional responses to CRPS, (3) ongoing life stressors, and (4) responses by significant others to the patient's CRPS. Axis I psychiatric disorders such as Major Depression, Panic Disorder, Generalized Anxiety Disorder, and Posttraumatic Stress Disorder are at least as common in CRPS patients as in other chronic pain patients.42 For example, 24% of CRPS

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No Progress

Progress

Discharge

Progress

No Progress

No Progress OR Axis I/Stressor Present General CBT for Identified Issues

Progress

FIGURE 2. Proposed sequence for psychological component of treatment in CRPS patients.

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patients in one study met the diagnostic criteria for an axis I disorder, with Major Depression most common.42 Depression-related amotivation, if present, may be a significant barrier to success in active physically focused treatment modalities (eg, physical and occupational therapy). Identification of specific life stressors and general emotional arousal (depression, anxiety, fear, anger), even in the absence of a clinically diagnosable psychiatric disorder, may be equally important given the possible psychophysiologic interactions hypothesized above. It is important that the psychological evaluation assess the patient's pain as well, although with a somewhat different emphasis than in the medical evaluation. The assessment of pain should address how the pain relates to functioning and the patient's cognitive and emotional state. For example, the persistence, intensity, and pattern of pain should be assessed, focusing on associations with stress, emotional state, and activity. Assessment of the patient's experience of allodynia and hyperalgesia is also important, given its frequent relationship to fear of pain. Research in chronic back pain patients suggests that fear of pain is more disabling than pain itself,43 a finding likely to be even more prominent in CRPS patients. Evidence from studies in chronic back pain patients indicates that pain-related fear helps perpetuate pain and disability, in part through its effects on increased muscular tension.44 These effects appear to be due to chronic guarding and bracing related to fears that movement will lead to increased pain and reinjury.44 In the context of the significant allodynia and hyperalgesia associated with CRPS, this fear-related activity avoidance is likely to be even more striking. Therefore, it is important to assess thoroughly the degree of pain-avoidance and allodynia-avoidance behaviors and their functional impact. As noted above, pain and allodynia avoidance may be expressed in the form of severe guarding, bracing, and disuse. Although some activity avoidance may seem reasonable and directly tied to pain (eg, avoiding heavy lifting with the affected hand), other activity avoidance may be extreme and unreasonable. For example, we have encountered several CRPS patients who display extreme social avoidance, including reduced contact with family members, which might be mistaken for agoraphobia. Upon questioning, these patients report that they are trying to avoid being accidentally bumped in their allodynic extremity by those around them. Although patients admit that this is unlikely to occur, the behavior persists. This pattern highlights the fact that activity avoidance and disuse in chronic pain can be operantly reinforced by the decreased fear that accompanies avoidance of expected pain exacerbations.45 Centrally mediated neglect-like phenomena may also contribute to disuse in some CRPS patients.46­48 Assessment of the cognitive impact of CRPS should include thorough exploration of the patient's beliefs regarding CRPS. Several misconceptions are common among patients, particularly those who have failed to

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respond to previous treatments. For example, patients may believe that CRPS is an untreatable, progressively deteriorating condition, and that it will necessarily spread throughout the body. Catastrophic cognitions such as these are often a contributor to negative emotional states that may have a deleterious impact on CRPS and responses to treatment. Patients may also possess incorrect beliefs regarding the meaning of CRPS pain. Not surprisingly, given the intensity and unusual nature of allodynic pain, patients may assume that pain signals damage, and as a corollary, ``if it hurts, don't do it.'' Such beliefs may be a primary contributor to disuse, and it is therefore very important that patients understand that neuropathic pain as in CRPS does not signal tissue damage. Mistaken beliefs regarding how CRPS treatment should progress may also be problematic. Common misconceptions include beliefs that sympathetic blocks alone are curative, and that treatments that exacerbate pain temporarily cannot be valuable. Invasive and expensive interventional procedures, such as spinal cord stimulation, may prove valuable for some patients in the later stages of treatment. However, excessive focus by patients upon such treatments viewed as a ``quick fix'' before they have participated in a comprehensive multidisciplinary program leads to reduced motivation to engage actively in multidisciplinary care, and outcomes are likely to suffer.

PSYCHOLOGICAL PAIN MANAGEMENT COMPONENT

The psychological pain management component of treatment is conceptualized as time-limited cognitivebehavioral therapy focused specifically on pain management and CRPS-related issues. Although the duration of this component may vary, 12 sessions is likely to be a reasonable time frame for initial exposure to this treatment component if there is sufficient compliance with home practice assignments. This element of treatment is intended to be carried out concurrently with medical and physical/occupational therapy components and is likely to be most successful in the context of regular communication between disciplines regarding the patient's progress and treatment barriers. Specific elements of this treatment component are summarized below.

Relaxation/Biofeedback Training

The goal of relaxation training with biofeedback is to increase the patient's ability to control his or her pain and decrease emotional arousal that may have a negative impact on the condition. Consistent with clinical trials in non-CRPS pain disorders,49­51 the results of the studies described above suggest that various types of relaxation training may have potential benefits for CRPS patients.31­35 Breathing-focused relaxation, relaxing imagery, and autogenics all may be useful, with selection of specific techniques guided primarily by patient and therapist preference. To the extent that secondary myofascial pain (typically proximal to the affected area) is a contributor to the overall pain complaints, training in

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progressive muscle relaxation (PMR) may be particularly appropriate. When PMR is conducted in a manner that initially avoids tension/release cycles directly in the affected area, but with practice begins to include the region directly affected by CRPS, substantial pain relief may ensue. PMR has in some patients contributed to a reversal of what patients mistakenly believed was proximal spreading of CRPS (in actuality, secondary myofascial pain).52 EMG biofeedback may be a good adjunct to relaxation, particularly with muscle-focused relaxation procedures. Thermal biofeedback may also be a good adjunct to all relaxation techniques, although it should initially be restricted to the unaffected extremity until skills have been sufficiently acquired to permit a reasonable chance of increasing temperature directly in the CRPS-affected area. With all relaxation/biofeedback techniques, ensuring home practice and generalization are the critical issues that will determine whether clinical benefits are achieved. It is recommended that home relaxation practice assignments and home relaxation monitoring logs be used to help ensure maximal benefits to patients in the shortest amount of time. Providing supplementary audiotapes of the relaxation procedures used in clinic sessions is an effective means of ensuring rapid skills acquisition with home relaxation practice.50 Once relaxation/biofeedback techniques have been mastered, it is important for the therapist to reframe exacerbated pain as a cue to immediately practice relaxation skills. Generalized use of these pain management skills may be facilitated if family and treatment team members are encouraged to provide cues to practice relaxation skills in vivo, such as physical therapists encouraging use of these skills when patients are engaging in painful therapeutic exercises.

patients may benefit from taking an active role in seeking information about their condition, they should be forewarned to maintain some degree of skepticism about this information.

Reframing

Given the emphasis in recent consensus guidelines for CRPS management on an active rehabilitation approach,3,4 it is important to reframe the CRPS patient's role as that of an active participant in the treatment process rather than a passive object of treatment interventions. Clinical experience indicates that it is a virtual certainty that patients will not improve if they do not take an active role in treatment. Patients may mistakenly get the impression that interventional procedures (eg, sympathetic blocks) are curative, and must come to understand that such procedures are intended largely to provide temporary pain relief that will facilitate participation in the active rehabilitation process. Although integrated medical and physical therapy procedures may contribute to resolution of the syndrome, the patient should be encouraged to focus on pain management rather than cure, given that outcomes may be unpredictable and that pain and function may change independently. As part of this active treatment focus, exacerbated pain should be reframed as a cue to practice selfmanagement interventions that may help the patient gain control over the situation. As patients learn relaxation skills and begin to understand the cognitive and behavioral aspects of the syndrome, they will have increasing resources for exerting at least some degree of control over their CRPS. Increased sense of perceived control, even if that control is limited in scope, may be an important factor in determining outcomes in chronic pain treatment.54

Cognitive Interventions Information Provision

A second aspect of the pain management treatment component is cognitive intervention. As a prelude to such intervention, it is important to address the common patient belief that referral to a psychologist implies that the treatment team believes that his or her CRPS is psychogenic. Being direct is recommended: ``CRPS is not in your head and we don't think you are crazy, but addressing the psychological issues related to CRPS will give you the best chance of success in managing your CRPS.'' As a follow-up to the basic education provided initially, it is important to address possible misinformation about CRPS. Chronic pain patients who believe their condition is enduring and mysterious are less likely to use the cognitive pain coping strategies that would ultimately contribute to improved pain and function,53 and this certainly applies to CRPS patients. Therefore, the patient should be asked his or her understanding of the problem and its treatment, and misconceptions should be addressed. Unfortunately, the Internet can be a source of incorrect or distorted information, and although some

Addressing Dysfunctional Cognitions

As in all chronic pain conditions, catastrophizing cognitions are common in CRPS patients.26 Such cognitions contribute to elevated distress, which may have an impact on catecholamines and thereby aggravate CRPS pain and temperature changes. It is therefore important to help patients learn to identify their specific dysfunctional cognitions regarding CRPS, and replace them with more adaptive cognitions. Several specific dysfunctional cognitions are common in CRPS patients. Given the crucial importance of addressing learned disuse and reactivating the affected extremity, thoughts such as ``I can't do that; it makes my pain worse'' may be particularly problematic. Such cognitions may be best addressed through a combination of learning to use positive coping self-statements (``I won't know until I try it,'' ``I can handle it'') and an empirical approach. Patients need to be encouraged to test in vivo their improved physical capabilities that may result from physical and occupational therapy. In the absence of encouraging self-statements and in vivo experiments, the fear of pain may prevent improved daily

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function even in the face of objectively improved capabilities during therapy. Patients also benefit from reminding themselves that they now have the psychological pain management tools (eg, relaxation/biofeedback) to manage any pain exacerbation that might occur. Dysfunctional cognitions such as, ``I can't go outside because someone might bump my arm/leg'' may be similarly addressed through questioning the assumptions (ie, ``How many times has that actually happened?''), use of positive coping self-statements (``I can practice my relaxation skills if it happens''), and in vivo experiments. Another problematic cognition that may occur with regularity in chronic CRPS patients is: ``I've done treatment before and this is hopeless; CRPS is incurable.'' Although the course of improvement in CRPS patients may be unpredictable, we have seen numerous patients considered previous ``treatment failures'' who improved substantially after receiving comprehensive multidisciplinary treatment. Patients should therefore be encouraged to adopt more realistic self-statements, such as ``Every CRPS patient is different,'' ``I will do everything I can to help my condition improve,'' and ``I am learning skills to live my life even if CRPS doesn't go away.'' Every successful experience patients have in using their pain management skills reinforces these more realistic cognitions. Patients can and do learn to live effectively despite ongoing CRPS symptoms, but this process is facilitated by a treatment team focus on pain management and functioning, rather than complete resolution of the condition. Resolution of CRPS may be most constructively viewed not as the primary goal but as a possible byproduct of full engagement in multidisciplinary treatment. Having realistic expectations is an important determinant of patient satisfaction with treatment outcomes. Dysfunctional cognitions related to those above, such as ``If I can't use my hand, my life is over,'' are important to address as well to help patients see the possibility of life beyond CRPS. Practical problem solving through referral to occupational therapy, vocational rehabilitation, and recreation therapy may facilitate modification of these dysfunctional cognitions.

Behavioral Interventions

The multidisciplinary rehabilitation-focused approach currently advocated for management of CRPS emphasizes reactivation of the affected extremity.3,4 The potential importance of reactivation is suggested by findings that the treatment of muscular-related issues contributed substantially to diminished pain and disability in more than 80% of a series of 59 CRPS patients.55 Given the impact of learned disuse as a potential barrier to reactivation, behavioral interventions targeting this disuse can be an integral component of the overall treatment program. Reactivation and behavioral goals must necessarily balance disuse concerns with avoiding severe pain exacerbations that could potentially contribute to maintenance of CRPS and reinforce learned disuse. Realistic pain-limited incremental reactivation is key.

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As suggested in the discussion above, cognitive interventions and behavioral interventions can be mutually reinforcing and should be used concurrently. With regard to behavioral interventions, the psychologist may serve the role of coach and cheerleader, helping guide and reinforce incremental reactivation efforts, encouraging successive approximations of normalized function, and helping the patient eliminate barriers to problem solving. Behavioral interventions for CRPS require realistic activity goal-setting, and these goals are developed most appropriately in conjunction with the physical and occupational therapists involved in the patient's care. Use of homework assignments incorporating incremental increases in activity (including activities of daily living, social, recreational, and work arenas) can be effective if used in conjunction with the cognitive strategies described above. It is generally most effective to target first the areas of learned disuse in which reactivation is unlikely to lead to significant pain exacerbations (eg, social avoidance). Success in these more easily addressed areas will greatly facilitate reactivation in more challenging areas. Successful reactivation is unlikely to be achieved unless patients successfully integrate their use of active pain coping skills into their daily lives. As progress is made in reactivation, opportunities for distracting and enjoyable activities are increased, further contributing to pain control and improved mood that may have beneficial effects on CRPS. In the context of improving behavioral management of CRPS, it is very helpful to address family reinforcement issues. More than half of caregivers of CRPS patients experience significant strain and dysphoric mood that are associated with poor adjustment to the patient's CRPS and increased patient disability.56 Using a time-series diary design, positive support from significant others has been shown to be directly related to subsequent improved mood among CRPS patients and appears to buffer the negative impact of dysphoric patient mood on CRPS pain intensity.23 These studies highlight the interrelationships between CRPS patients and significant others. Not surprisingly, including family sessions in treatment is likely to improve outcomes. Family sessions should target several areas. The most important of these areas is the possibility that some family members may be a barrier to reactivation due to solicitous responses and fear of pain exacerbations. Unless detailed education about CRPS and disuse issues is provided, family members may consider any activity that increases pain as dangerous to the patient and something to be discouraged. It is therefore important to ensure that family members understand the necessity of reactivation and that this might be associated with transient increases in pain. Providing family members with more constructive alternative responses to the patient's pain behavior, such as encouraging use of relaxation techniques or suggesting distracting activity, is likely to reduce the incidence of inappropriate solicitous responses. As implied by the work of Feldman et al,23 increasing patients' perceived level of support and addressing sources of relationship conflict may also be important

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contributors to successful CRPS management. Changes in family roles caused by activity limitations may be a particularly important source of conflict to address. Overall, including family members in the patient's CRPS treatment can remove barriers to progress and can lead to the family becoming treatment team members who on a daily basis can reinforce the patient's engagement in functionally focused treatments in the home environment.

Extended Cognitive-Behavioral Therapy

Within the treatment model proposed, patients proceed to extended cognitive-behavioral therapy (CBT) that is more general in nature (ie, not exclusively painfocused) if overall medical/functional progress is inadequate even after sufficient exposure to the psychological pain management component. Patients are also referred to extended CBT after completion of the psychological pain management component if psychiatric disorders or ongoing major stressors (other than pain) were identified during evaluation. This extended CBT is conceptualized as being focused on the relevant issues identified during evaluation rather than pain itself, but it may help reinforce use of the coping skills acquired in the initial pain management training component. This treatment approach has been detailed in depth elsewhere.57

CONCLUSIONS

Controlled studies in CRPS patients are not available to guide the psychological/ behavioral aspects of CRPS management. However, cognitive-behavioral interventions proven effective in the broader chronic pain literature are likely to be beneficial for CRPS patients as well. Successful implementation of these interventions requires recognition of the unique issues in CRPS patients, particularly the pervasive learned disuse often seen in such patients. The treatment protocol described above provides guidelines for a sequenced psychological treatment approach with an emphasis on CRPS-specific issues. Clinical experience using a similar approach in an integrated multidisciplinary context indicates that many CRPS patients can achieve significant improvements in functioning and ability to control pain. REFERENCES

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