Physical therapy under hypnosis for the treatment of patients with type 1 complex regional pain syndrome of the hand and wrist: retrospective study of 20 cases

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Lebon, Julie and Rongières, Michel and Aprédoaei, Costel and Delclaux, Stéphanie and

Mansat, Pierre Physical therapy under hypnosis for the treatment of patients with type 1

complex regional pain syndrome of the hand and wrist: Retrospective study of 20 cases. (2017)

Hand Surgery and Rehabilitation, 36 (3). 215-221. ISSN 2468-1229

OATAO

Physical

therapy

under

hypnosis

for

the

treatment

of

patients

with

type

1

complex

regional

pain

syndrome

of

the

hand

and

wrist:

Retrospective

study

of

20

cases

Re´e´ducation

sous

protocole

HKM

(hypnothe´rapie

combine´e

a`

la

kine´sithe´rapie



Meopa)

:

une

solution

the´rapeutique

pour

la

prise

en

charge

du

syndrome

douloureux

complexe

de

type

1

de

la

main

et

du

poignet.

E´tude

re´trospective

a`

propos

de

20

cas

J.

Lebon

*

,

M.

Rongie`

res,

C.

Apredoaei,

S.

Delclaux,

P.

Mansat

Unite´ d’orthope´dieettraumatologiedePurpan,institutdel’appareillocomoteur,CHUdeToulouse,placeduDr-Baylac,31059Toulousecedex,France

Keywords:

Complexpainregionalsyndrome Hypnosis

Therapy Wrist Hand

Motscle´s:

Syndromedouloureuxre´gionalcomplexe Hypnose

Re´e´ducation Poignet Main

ABSTRACT

Type1complexregionalpainfulsyndrome(CRPS 1)hasacomplexphysiopathology.Theaimofthis studywastoevaluatetheeffectivenessofphysicaltherapyunderhypnotherapytotreatthiscondition. TwentypatientswithCRPS 1atthewristandhandwereevaluatedretrospectively:13womenand 7menwithanaverageageof56years(34 75).Thirteenpatientswereintheinflammatoryphaseand 7inthedystrophicphase.Themainendpointswerepain(VAS,analgesicuse),stiffness(wristandfinger range of motion), and strength (pinch and grasp). Secondary endpoints were functional scores (QuickDASH,PWRE),patientsatisfaction,returntowork,andsideeffects.Resultsweresatisfactoryinall casesafter5.4sessionsonaverage.VASdecreasedby4points,PWRE painby4.1points,andanalgesic usewas limitedtoparacetamolupon request.Fingerandwristrangeofmotionincreasedandthe QuickDASHdecreasedby34points,PRWE functionby3.8points,pinchstrengthincreased4points,and graspstrengthby10points.Returntoworkwaspossiblein80%ofthecases.Allpatientsweresatisfiedor verysatisfiedwiththetreatment.Physicaltherapyunderhypnosisappearstobeaneffectivetreatment forCRPS 1atthewristandhandnomattertheetiology.

R E´ SUM E´

Lesyndromedouloureuxre´gionalcomplexedetype1(SDRC 1)estlie´ a` unephysiopathologiecomplexe. L’objectifdecettee´tudee´taitd’e´valuerl’efficacite´ dese´ancesdekine´sithe´rapiesoushypnosepourla priseenchargedecesyndrome.Vingtpatientspre´sentantunSDRC 1auniveaudelamainetdupoignet onte´te´ e´value´sdemanie`rere´trospective:13femmeset7hommesde56ansenmoyenne(34 75).Treize patientse´taientenphaseinflammatoireet7enphasedystrophique.Lecrite`redejugementprincipal e´tait l’efficacite´, e´value´e par la douleur (e´chelle visuelle analogique [EVA], la consommation d’antalgiques),laraideur(mobilite´sdupoignetetdesdoigts)etlaforce(pinceetpoigne).Lescrite`res dejugementsecondairese´taientlesscoresfonctionnels(QuickDASH,PWRE),lasatisfactiondupatient,la reprisedutravailetleseffetsinde´sirables.Lesre´sultatse´taientsatisfaisantsdanstouslescasapre`s 5,4se´ancesenmoyenne.Ladouleure´value´eparl’EVAdiminuaitde4points,lescorePWRE douleurde 4,1points,etlaconsommationd’antalgiquee´taitlimite´eauparace´tamola` lademande.Lesamplitudes articulairese´taienttoujoursaugmente´es,lescoreQuickDASHmoyendiminuaitde34points,lescore PWRE fonctionde3,8points,laforcedepinceaugmentaitde4pointsetlaforcedepoignede10points.

* Correspondingauthor.

1. Introduction

Aftermanyyearsofobscurity,wenowhavesomeinsightinto thepathophysiology oftype1 complexregionalpainsyndrome (CRPS 1):overexcitedsympatheticnervoussystem,perturbations of thebody map and contribution of psychologicalfactors [1 3].Despitebetterunderstanding ofthis disease,itstreatmentis longanddifficultwithunpredictableresults.Thereisasignificant socioeconomicimpactduetoitsincidence(25/100,000people).

There are multiple treatment options (corticosteroids, anti psychotics,antidepressants)that havevarying degreesof effec tiveness. To this day, few treatments that make use of psychologicalmediation have been validated. Hypnotherapy is beingusedincreasinglytoaddresspain,particularlychronicpain, and various psychological disorders. Since 2006, our surgery departmenthasbeenprovidingpatientssufferingfromCRPS 1of thehandandwristwithphysicaltherapyunderhypnosisMEOPA (50%nitrousoxide50%oxygenmixture).

Thegoalofthisstudywastospecificallyevaluatetheeffectsof thisstrategy.Wehypothesizedthathypnoticsuggestionreduces theactivity of certain cerebral areas stimulated during painful treatment procedures, thereby resulting in better progression duringrehabilitation.

2. Materialsandmethods 2.1. Materials

Thiswasaretrospectivestudyofdatacollectedprospectively andcontinuouslyin theorthopedicand traumasurgerydepart mentofaFrenchUniversityhospital.BetweenMay1,2014and April30,2015,allpatientswithCRPS 1ofthehandand/orwrist wereincludedinthestudy,nomattertheetiology,timeelapsed before treatment, prior treatments and disease phase (acute inflammatory,dystrophic,atrophic).ThediagnosisofCRPS 1was confirmedbasedonthepresenceoftheInternationalAssociation fortheStudyofPain(IASP)criteriadescribedbyMerskeyin1994, asmodifiedbyHardenin2007[4].SincetheIASPcriteriadonot includeabonescan,itwasnotperformedregularly.

Patients were excluded if this treatment strategy was not applicabletothem,iftheycouldnotspeakFrenchreasonablywell, were hard of hearing or refused hypnotherapy. All patients providedwrittenconsent.

2.2. ProtocolandPT Hmethod

Oncethediagnosishadbeenmade,theenrolledpatientswere asked to return to the pain clinical at the hospital, which is managedbyanesthesiologists.Thegoalsofthisinitialvisitwereto havean introductory meetingbetween the patientand hypno therapist(nurseanesthetistwithhypnotherapytraining),totake the mystery out of hypnosis and to explain the details of application,andtocollectallthepretreatment clinicaldata. All patientsreceivedcarefromahypnotherapistandphysiotherapist team.Thesamehypnotherapistworkedwithallpatients,while twodifferentphysiotherapistscaredforthepatients.

Allpatientsunderwentafullclinicalexaminationbythesame examinerbeforethefirstPT Hsessionandafterthelastsession. Thefollowingclinicalparameterswereassessed:

 pain(daytimeandnighttimeVAS);

 wristandfingerrangeofmotion(ROM):wristflexion/extension, pronation/supinationandulnar/radialdeviation;fingerflexion/ extension of the metacarpophalangeal (MCP) and proximal/ distalinterphalangeal(PIP,DIP)joints(retainedvaluewasthe meanofthevaluesinallfourfingers);

 functionalscores:QuickDASH,PWRE,andasubjectiveevalua tion of theoverall functionof thehand andwrist calledthe simplehandvalue(SHV);

 pinchstrengthandgripstrength. EachPT Hsessiontookplaceasfollows:

 first,aninductionphasethatallowedthepatienttodissociate andprotectthemselvesfrompain;

 second,atreatmentphaseduringwhichthephysicaltherapist performed pain relievingmodalities,lymphaticdrainagemas sage and passive mobilizationof the wristand fingers in all directions.

Eachsessionlastedanaverageof45to60minutes.Onesession wasperformedeveryweekortwo,dependingontheavailabilityof thepatient,hypnotherapistand physicaltherapist.Betweenthe PT H sessions,patientsparticipated ina standard rehabilitation program with three sessions per week that combined pain relievingmodalities, contrastbaths, andgradualincrease ofthe range of motion below thepain threshold. The sessionsended when the patients decided that they had recovered enough strengthandROMtodoactivitiesofdailylivingwithnoorminimal pain.

2.3. Endpoints

The primary endpoint was efficacy evaluated through pain (daytime and nighttime VAS, analgesic consumption), stiffness (finger and wrist ROM) and strength (pinch and grip). The secondary endpoints were the functional scores (QuickDASH, PWRE,SHV),returntoworkandhypnosis relatedsideeffects. 2.4. Statisticalanalysis

Thequalitativevariablesweredescribedwithsamplesizesand percentagesassociatedwiththevariousparametersofthestudy population.Thequantitativevariablesweredescribedwithmeans and standard deviations (along with median and minimum, maximum), since the distribution of the quantitative variables met the normality assumptions. Student’s t test was used to comparetwomeasurementsofaquantitativevariableinthesame patient at different time points. The difference between two variableswasconsideredsignificantwhenP<0.05(5%threshold). Nosubgroupanalysiswasperformedduetothesmallsamplesize (20patients).

3. Results

3.1. Patientcharacteristics

Twentypatientswereincluded:13 women(65%)and7men (35%)withanaverageageof56.6years(34 75)(Table1).Noneof

Quatre vingtpourcentdespatientsontpureprendreleurtravailaumeˆmeposte.Touslespatientsse disaientsatisfaitsoutre`ssatisfaits.L’hypnoseassocie´ea` lakine´sithe´rapiesembleeˆtreunmoyenefficace pourlapriseenchargeduSDRC 1main poignetquellequesoitsaphasee´volutive.

thepatients had a history ofcomplex regionalpain syndrome, however10patients(50%)hadafragilepsychologicalbackground. Sixpatientshadarecentmajorepisodeofdepressionoranxiety provoking event (bereavement, separation) and 4 patients had highlyanxiousand/orhighlystressedpersonality.Thepatientshad variousoccupationsandlessthanhalfweremanuallaborers.At inclusion,13ofthe15employedpatientswereonsickleave(87%) foranaverageof6.5months(range2.5 24).AlthoughtheCRPS hadvariouscausesinourcohort,90%ofcasesoccurredfollowing surgery (18 patients). Only two patients had not undergone surgery: one non displaced fracture of the scaphoid and one contusiontothedorsalsideofthehand.

TheIASPcriteriawerepositivein100%,confirmingthepresence ofCRPS 1.Asthediagnosiswasuncertainin9patients(45%),a bonescanwasalsoperformedtoconfirmthediagnosis.Atthetime of inclusion, most patients (13 cases, 65%) were in the acute inflammatorystage.The meantimetodiagnosiswas4 months (median2months,range15daysto22months).Themeantimeto treatmentoncethediagnosiswasmadewas10 weeks(median 7weeks,range2 44weeks).

Atthetimeofinclusion,varioustreatmentshadalreadybeen performed. Analgesics with physical therapy below the pain thresholdhadbeenusedin100%ofpatients.Fifteenpatients(75%) alsohadcontrastbaths andthena varietyofothertreatments: homeopathy,acupuncture,corticosteroidinjections,essentialoils, electrostimulation,osteopathy,ultrasound.

3.2. Pre PT Hclinicalassessment

Acompletebilateralclinicalassessmentwasdoneinallpatients beforethefirstPT Hsession(Table2).Allpatientshadmoderateto severepainwithanaveragedaytimeVASof6.2/10andaverage PWRE painof6.9/10.TheactiveROMofthewristandfingerswas clearly reduced relative to the contralateral side: nearly 50% reductionintheflexion/extensionrangeofthewristMCP,DIPand PIPjoints.Painassociatedwithstiffnessresultedinalossofpinch

strength and especially gripstrength,which wasan average of three times lower than thecontralateral side. The general and specific functionalscoreswerealtered:theSHV intheaffected handwas35%onaveragerelatedtoa‘‘normal’’hand,QuickDASH of62/100onaverageandPWRE functionof5.7/10.

All patients had already received suitable analgesic and rehabilitationtreatments,typicallyincludingpain relievingphysi caltherapymodalitiesandcontrastbaths.Despitethesetreatment, manysymptomsofCRPS werepresentbeforethePT Hsessions started:pain (100%),stiffness(85%),edema(70%),hypoesthesia/ paresthesia(55%),muscleweakness(50%),hotskin(50%),dryskin (50%), cold/cyanotic skin (30%), involvement of integumentary system(25%),skinredness(20%),excessiveperspiration(10%).

Analgesic intakewashighand 87%of patients wereon sick leaveatthetimeofinclusion(13/15employedpatients). 3.3. Post PT Hclinicalassessment

Sessionsweredoneonceperweekorevery15days.MEOPAwas neededin12patients(60%)duringtheinitialsessionstocontrol painduringpassivemobilization. Oncethetreatment goals had Table1

Descriptionofstudypopulation.

Populationcharacteristics Number/%

Sex

Male 7cases(35%)

Female 13women(65%)

Age

Mean(std.dev.) 56.6years(8.7years)

Median 56.5years

Min–Max 34–75years

Dominanthandaffected 10cases(50%)

HistoryofCRPS-1 0cases(0%)

High-riskpsychologicalbackground 10cases(50%)

Work-relatedinjury 3cases(15%)

Smoker 4cases(20%)

EtiologyofCRPS-1

Postoperative 18cases(90%)

Nosurgicalprocedure 2cases(10%)

IASPcriteriapresent 20cases(100%)

Confirmationbybonescan 9cases(45%)

PhaseofCRPS-1

Acuteinflammatory(I) 13cases(65%)

Dystrophic(II) 7cases(35%)

Atrophic(III) 0cases(0%)

Timetodiagnosis

Mean(std.dev.) 4months(5months)

Median 2months

Min–Max 0.5–22months

TimebetweendiagnosisandPT-Htreatment

Mean(std.dev.) 10weeks(10weeks)

Median 7weeks

Min–Max 2–44weeks

CRPS-1:type1complexregionalpainfulsyndrome.

Table2

Pre-PT-Hclinicalevaluation.

Affectedside Mean(std.dev.) Median Min–Max Healthyside Mean(std.dev.) Median Min–Max

DaytimeVAS(outof10) 6.21.6

6 3–9 NighttimeVAS(outof10) 33.2

3 0–10 SHV(%) 3516 32.5 0–60 QuickDASH(outof100) 6218 64 23–100 PWRE-pain(outof10) 6.91.5 7.1 3.1–9.2 PWRE-function(outof10) 5.71.8 5.2 2.8–9.5

WristFEROM(degrees) 6831

67 20–120

11415 110 85–140

WristPSROM(degrees) 13322

140 90–170

1547 140 90–170

WristURDROM(degrees) 3616

40 0–60

507 50 35–65 FingerMCPFEROM(degrees) 5319

60 10–90

875 90 80–95 FingerPIPFEROM(degrees) 6125

60 5–110

1157 117 100–120 FingerDIPFEROM(degrees) 2812

30 10–50 515 50 45–60 Pinchstrength(kg) 8.55 7.5 0–21 15.57 14.5 5–33 Gripstrength(kg) 96 9 0–19 26.59.5 23.5 17–50

VAS:visualanalogscale;SHV:simplehandvalue(subjectivefunctionaccordingto patient of affected hand out of 100%); FE: flexion/extension; PS: pronation/ supination; URD:ulnar/radialdeviation;MCP: metacarpophalangealjoint;PIP: proximalinterphalangealjoint;DIP:distalinterphalangealjoint.

beenachieved(minimalornopain,abilitytocarryoutactivitiesof dailyliving),thePT Hsessionswerestopped.Patientsparticipated inanaverageof5.4(1.5)sessions(median5,range3 9).Themean treatmenttimewas6.5(2)weeks(median6weeks,range3 12 weeks).

OncethelastPT Hsessionhadbeencompleted,thefullclinical assessmentwasrepeated(Table3).Inmostpatients,edemaand sympathetic symptoms were the first to disappear, typically withinoneortwosessions(Fig.1).Painwasminimalorcompletely gonewithanaveragedaytimeVASof2.2/10andaveragePWRE painof2.8/10.ActivewristandfingerROMwereclearlyimproved in all directions. The pinch and grip strength were similarly improved.Consequently,thegeneralandspecificfunctionalscores forthehandwerealsoimproved:theSHVintheaffectedhadwas 75%onaveragerelativetoa‘‘normal’’hand,QuickDASHof28/100 onaverageandPWRE functionof1.9/10.

Some symptoms of CRPS persisted but were minimally

disruptive:stiffness (90%),pain(40%),paresthesia (10%),edema (10%),cutaneousdisorders(5%),muscleweakness(5%).Theintake ofanalgesicswasnearlyzeroand80%ofthepatientswhohadbeen onsickleave(10patients)atthetimeofinclusionwerebackto

work in the same job, immediately after the sessions ended. However,becauseofthepersistenceofsomesymptomsatthefinal assessment,allpatientscontinuedtherehabilitationprotocolwith two or three gentle physical therapy sessions per week until completepainreliefwasachievedandfullROMwasrestored.Asof May2016,norelapseshadoccurred.

3.4. Evaluationofendpoints 3.4.1. Primaryendpoint:efficacy

There was a statistically significant improvement in pain betweenthepre andpost PT Hasevidencedbythedaytimeand nighttimeVASandthePWRE painscore(Figs.2and3).

Analgesicusewasalsosignificantlyreduced:12patients(60%) didnotuseanyanalgesicsafterthehypnotherapyversus0before (P<0.001).Therewasasignificantimprovementinallthejoint ROMdirections(Fig.4).Pinchandparticularlythegripstrength werealsosignificantlyincreased(Fig.5).

3.4.2. Secondaryendpoints

TheROM,analgesiaandstrengthweresignificantlyimproved, as were the three functional scores; the SHV had more than doubled(35%to75%)(Fig.6).Ofthe15 patientswhowerestill working,2(13%)hadreturnedtoworkbeforethePT Hsessions versus12(80%)afterthePT Hsessions.Ofthethreepatientswho couldnotreturntowork,twowereheavymanuallaborersandone didanoccupationthatrequireddelicate,precisehandmotionsthat hadnotyetbeenrecovered.

Allthepatientswereeithersatisfiedorverysatisfiedwiththis treatment. The following adverse effects were documented: fatigueforafew hoursafterthePT Hsessionsin8cases(40%) andminorvertigoin2cases(10%).Seventypercentofpatientssaid Table3

Post-PT-Hclinicalevaluation.

Affectedside Mean(std.dev.) Median Min–Max Healthyside Mean(std.dev.) Median Min–Max

DaytimeVAS(outof10) 2.21.1

2.5 0–4 NighttimeVAS(outof10) 0.30.9

0 0–3 SHV(%) 759 75 60–95 QuickDASH(outof100) 2810 30 11–45 PWRE-pain(outof10) 2.81.2 2.6 0.8–4.5 PWRE-function(outof10) 1.90.8 2 0.6–3

WristFEROM(degrees) 10517

102 75–130

11515 110 95–140

WristPSROM(degrees) 15012

150 120–170

1539 150 130–170

WristURDROM(degrees) 477

50 35–55

506 50 35–60 FingerMCPFEROM(degrees) 809

80 65–90

875 90 80–100 FingerPIPFEROM(degrees) 9415

100 65–110

1156 115 100–120 FingerDIPFEROM(degrees) 437

45 30–60 516 50 45–60 Pinchstrength(kg) 12.55 11.5 5–21 14.55 14 6–25 Gripstrength(kg) 196 18.5 12–33 269 24 15–50

VAS:visualanalogscale;SHV:simplehandvalue(subjectivefunctionaccordingto patientof affected hand out of 100%); FE: flexion/extension; PS: pronation/ supination;URD:ulnar/radialdeviation; MCP:metacarpophalangealjoint;PIP: proximalinterphalangealjoint;DIP:distalinterphalangealjoint.

Fig.1.A39-year-oldfemalepatientwithtype1complexregionalpainfulsyndrome (CRPS-1)whohassignificantswellinginherhandbeforethePT-Hsessions(left photos)andwhosehandisnormalafter5sessions(rightphotos).ShehadCRPS-1 secondaryto opencarpaltunnel release.Shedeveloped CRPS-1at2 months postoperativeandtheleftphotos showher handafter7monthsofstandard treatment (lightphysicaltherapy, contrast baths, analgesics).After fivePT-H sessions,thepatientsstoppedtakingallanalgesicsandreturnedtowork.Beforethe PT-Hsessions,shetookmorphinedaily.

they were deeply relaxed and even mildly sedated after the sessions.

4. Discussion

CRPSwasfirstdescribedbyAmbroisePare´ inthe17thcentury. Variousnameshavebeenusedtodescribeitsincethen:causalgia,

algodystrophy,reflexsympatheticdystrophy,Sudeck’ssyndrome

[2].Typically,CRPSischaracterizedbydisproportionatechronic pain,significantstiffness,involvementoftheautonomousnervous systemandsensory motorsymptoms[5].Type1correspondsto

the absence of underlying nerve damage. Although many

paraclinical methods canbeused toconfirmthediagnosis,the diagnosisisaclinicalonebasedontheIASPcriteriapublishedin Fig.2.Outcomesintermsofpain.

Fig.3.Outcomesintermsofanalgesicuse.

Fig.4.Outcomesintermsofrangeofmotion(ROM).FE:flexion-extension;PS:pronation-supination;URD:ulnar/radialdeviation;MCP:metacarpophalangealjoint;IPP: proximalinterphalangealjoint;IPD:distalinterphalangealjoint.

8 7 6 5 4 3 2 1 0

VAS daytime (p<0.001) VAS nighttime (p<0.001) PWRE-pain (p<0.001)

•

Pre-PT-H 6.2 3 6.9

•

Post-PT-H 120 100 80 60 40 20 0 2.2 No analgesia

•

After hypnotherapy (%) 60

•

Before hypnotherapy (%) 0 160 140 120 100 80 60 40 20 0 Wrist FE (p<0.001)

•

Pre-PT-H 68

•

Post-PT-H 105 Wrist PS (p=0.007) 133 150 Step 1 (on demand) 40 0 Wrist URD (p=0.007) 36 47 0.3 Step 1 (regularly) 0 100 MCP FE (p<0.001) 53 80 2.8 Step 2 0

so

PIP FE (p<0.001) 61 94 Other (NSAIDs, Lyrica, etc.) DIP FE (p<0.001) 28 43 0 5

2004[1,4].Rene´ Lerichein1916 1923andEvansin1947 1948 developedthe‘‘sympathetic’’theoryofCRPS.Sincethemid 1990s, thedevelopmentofneurosciencehasledtoabetterunderstanding of the pathophysiology of CRPS with overexcitation of the sympatheticnervoussystem,perturbationsofthebodymapand contributionofpsychologicalfactors[3,4].Recentneurophysiology studieshavebeenconsistentinfindingthatcentralmechanisms notperipheralones haveanessentialrole.Theappearanceofa prolonged reaction of the sympathetic nervous system at the peripheryof aninjured area is physiological, however it is the persistenceandoverexcitationthatarepathological[6,7].Patients haveanabnormalcorticalbodymapoftheaffectedlimbandits movements.Thisleadstoperturbationintherecordingofparietal activityinthemotorandpremotorareas[6,7].

Varioustreatmentshave beenused totreat CRPS 1:NSAIDs, anticonvulsants,antidepressants,sodium channelblockers,vaso dilators.Theefficacyofthesetreatmentsvaries,althoughnonehas been able to quickly and effectively cure CRPS 1 [1 3]. These treatmentsareusedincombinationwithpain relievingphysical therapy modalities and contrast baths; however, no physical therapymodalityhasbeendemonstratedtobeeffective.

Up to now, few treatment strategies that use psychological mediationhavebeenevaluatedandnostudyonthepsychological profile of patients has revealed any reliable preoperative risk factors.

Inrecentyears,hypnosishasbeenusedtotreatpainandvarious psychologicaldisorders [5,8]. Hypnosisactsbothat thecortical

areasforpainandatthemedullarylevelontheRIIIornociceptive flexionreflex[9].ThiseffectisnotspecifictoCRPS:itcontributesto alltypesof pain,whetheracute orchronic.Thehypnoticeffect helpspatientsfocustheirattentionontheirrepresentationofpain, therebyalteringitsperception[9].

This led us in 2006 toimplement a PT H strategy in CRPS patients. The results were very good, particularly in terms of analgesicuse,sympatheticsymptomsand stiffness,althoughall patientsweretreatedwhethertheyhadtype1ortype2CRPS,in theupperlimborlowerlimb.Wewantedtovalidateourclinical observationswithascientificstudyfocusedonCRPS 1inthehand andwrist.

Inourstudy,allpatientsbenefitedfromthehypnotherapyas evidenced by the significant improvement in pain, ROM and strength.TheimprovementinthejointROMofthefingersresulted inbetterfingercurling,thusbettergrippingabilityandsignificant improvementingripstrength.Thecombinedimprovementinpain, stiffnessandstrengthledtoareductioninanalgesicuseandreturn toworkinmanycases.

Nomatter theetiology,thewaitbeforetreatment initiation, priortreatments,sex,andage,thePT Hstrategywaseffectiveand required about 6 weeks (average of 5.4 sessions) to achieve a satisfactory result, versus 6 months to 2 years with typical treatmentstrategies.

Moreover,earlydiagnosisandtreatmentareimportantfactors indeterminingtheoutcomesofCRPStreatments[10].Inourstudy, therewasa trendtowardsbetterclinicaloutcomesandshorter treatment timewhenCRPS 1wasdiagnosedearlier(duringthe acuteinflammatoryphase).However,ourcohortwastoosmallto carryoutsubgroupanalysisoracomparativestudy.

Ourstudyhascertainlimitations:smallsamplesize,inclusion ofallCRPS 1casesindependentofthediseasephaseorthedisease duration.Continuingthestandardtreatmentatthesametimeas thePT Hstrategyisalsoasourceofbias,asitmayhavefalsely improvedtheoutcomes.

Despite these good outcomes, all patients had to continue receiving light physicaltherapy in thefollowingweeks tofully recover the last degrees of ROM that weremissing. The PT H strategy was essentially able to surpass the hyperalgesic and highlysymptomaticthresholdtypicalofCRPS.

Thisstrategyisrelevantforthepatientandthephysicianasitis aconcretesolutiontoacondition thatcurrentlydoesnotreally have a treatment. But the mechanism of action that makes hypnosiseffectivehasnotbeenexplained.

Thereare nopublishedstudiesof hypnosisbeingusedasa treatmentforCRPS;however,therearemanyarticlesontheuse Fig.5.Outcomesintermsofstrength.

Fig.6.Outcomesintermsoffunctionalscores.

20 18 16 14 12 10 8 6 4 2 0 Pinch strength (p=0.016)

•

Pre-PT-H 8.5

•

Post-PT-H 12.5 80 70 60 50 40 30 20 10 0

•

Pre-PT-H

•

Post-PT-H Grip strength (p<0.001) 9 19 QuickDASH (p<0.001) 62 28 PWRE-function (p<0.001) 5.7 1.9 SHV (p<0.001) 35 75

ofhypnosistorelievechronicpain[11 15].Hypnoticsuggestion therapy reduces the activity of certain brain areas that are generallystimulatedduring painfultreatments. Italso allows virtualactivationofapathologicallimbthatstimulatesthesame brain areas activated during true limb mobilization: frontal premotorcortex,supplementarymotorareaandmotorcortex. Voluntarymovementsduringhypnoticsuggestiondonotacton the same brain areas as during simple mobilization; in particular, theposterior frontal premotorareas are activated. These topographic areas coincide with the altered ones in patientswithCRPS[16,17].Stimulationofthepremotorareas, duetoactivationofthecanonicalneuronsandmirrorneurons,is oneofthekeystorehabilitationofthephantomlimbandithas beenappliedsuccessfullytoCRPS [18].The brainprojectsthe actionbefore itisperformed(mirrorneurons)byreproducing either an acquired movement or an imitated movement. The canonical neurons are the preliminary stagein the brain, for examplewhenseeinganobject,andwillbecomesystemically excited[19].

Hypnosisiscloselyakintoothertechniquesthathavealready beenvalidated for the treatment of CRPS suchas the Moseley mirrortherapy[16]andvibrationtherapy[4].Theobjectiveisto recreatethe illusionof movement: using thesymmetry of the mirrorinwhichthecontralaterallimbappears,byproprioceptive routes excited by vibration or hypnotic induction, which will provoketheillusionofmovement.Therearedifferentmodelsof movement induction but all have the same goal: recreate the illusionofmovementtodisrupttheblockageandexclusionofthe affectedlimbsegment,therebyfreeingthepatientfrompainand functionaldisability.

Moreover,hypnosis actsonthe affective/emotionalcompo nentofpainbyreducingitsunpleasantnatureandtheperception of its intensity. Lastly, it allows the release of suppressed emotions.Infact,patientshaveaneasiertimeconfidingandin mostcases,findanotablefactoreventthatcoincidedwiththe developmentofCRPS,suchaslossofjob,break up,bereavement, orevenoldfearsorchildhoodtrauma.Suchemotionalreleases arefrequentlyobservedduringthesessionsandoftengivethe patientimmediate relief. Thus,it seems essential tointegrate thispsychological dimensioninthe overalltreatmentstrategy forCRPS.

Thesevariousaspectsof hypnosisexplaintheimportanceof this practice in the context of CRPS 1, both for performing potentiallypainfulphysicaltherapyproceduresandforallowing painanddysautonomiasymptomstodisappear.Thismethodnow provides us with a safe and effective tool for treating CRPS; however, a large, multicenter, prospective study is needed to confirmourfindings.

5. Conclusion

Hypnotherapycombinedwithphysicaltherapyappearstobe aneffectivetreatmentstrategyforCRPS 1inthehandandwrist,no matterthediseasestage.Itcanbeusedwithallpatientsandhadno noteworthysideeffects.

Disclosureofinterest

Theauthorsdeclarethattheyhavenocompetinginterest. References

[1]GayAM,Be´re´niN,Legre´ R.TypeIcomplexregionalpainsyndrome.ChirMain 2013;32:269–80.

[2]Coderre TJ.Complex regional pain syndrome: what’s ina name?J Pain 2011;12:2–12.

[3]BussaM,GuttillaD,LuciaM,MascaroA,RinaldiS.Complexregionalpain syndrome type I: a comprehensive review. Acta Anaesthesiol Scand 2015;59:685–97.

[4]GayA,ParratteS,SalazardB,GuinardD,PhamT,Legre´ R,etal.Proprioceptive feedbackenhancementinducedbyvibratorystimulationincomplexregional painsyndrometypeI:anopencomparativepilotstudyin11patients.Joint BoneSpine2007;74:461–6.

[5]MarinusJ,VanHiltenJJ.Clinicalexpressionprofilesofcomplexregionalpain syndrome,fibromyalgiaanda-specificrepetitivestraininjury:morecommon denominatorsthanpain?DisabilRehabil2006;28:351–62.

[6]Ja¨nigW,BaronR. Complex regional painsyndrome: mysteryexplained? LancetNeurol2003;2:687–97.

[7]BarberA,MoreniA.Placedel’hypnosedansletraitementduSDRC.Kinesither Rev2015;15:45–9.

[8]MoltonIR,GrahamC,StoelbBL,JensenMP.Currentpsychologicalapproaches tothemanagementofchronicpain.CurrOpinAnaesthesiol2007;20:485–9. [9]FaymonvilleME,BolyM,LaureysS.Functionalneuroanatomyofthehypnotic

state.JPhysiolParis2006;99:463–9.

[10]PerezRS,ZollingerPE,DijkstraPU,Thomassen-HilgersomIL,ZuurmondWW, RosenbrandKC,etal.Evidencebasedguidelinesforcomplexregionalpain syndrometype1.BMCNeurol2010;10:20.

[11]TanG,RintalaDH,JensenMP,FukuiT,SmithD,WilliamsW.Arandomized controlledtrialofhypnosiscomparedwithbiofeedbackforadultswithchronic lowbackpain.EurJPain2015;19:271–80.

[12]GainerMJ.Hypnotherapyforreflexsympatheticdystrophy.AmJClinHypn 1992;34:227–32.

[13]ElkinsG,JensenMP,PattersonDR.Hypnotherapyforthemanagementof chronicpain.IntJClinExpHypn2007;55:275–87.

[14]ArtimonHM.Hypnotherapyofapaindisorder:aclinicalcasestudy.IntJClin ExpHypn2015;63:236–46.

[15]JensenM,PattersonDR.Hypnotictreatmentofchronicpain.JBehavMed 2006;29:95–124.

[16]MoseleyGL.Gradedmotorimageryiseffectiveforlong-standingcomplex regionalpainsyndrome:arandomisedcontrolledtrial.Pain2004;108:192–8. [17]SchwartzmanRJ,ErwinKL,AlexanderGM.Thenaturalhistoryofcomplex

regionalpainsyndrome.ClinJPain2009;25:273–80.

[18]McCabeCS,HaighRC,RingEFJ,HalliganPW,WallPD,BlakeDR.Acontrolled pilotstudyoftheutilityofmirrorvisualfeedbackinthetreatmentofcomplex regionalpainsyndrome(type1).Rheumatol(Oxford)2003;42:97–101. [19]Desmurget M,Reilly KT,Richard N,Szathmari A, MottoleseC, SiriguA.

Movementintentionafterparietal cortexstimulationin humans.Science 2009;324:811–3.