Pain Exposure Physical Therapy (PEPT) in CRPS
Chronic Regional Pain Syndrome (CRPS-1) has puzzled doctors and therapists alike for decades. Recently a new form of treatment, Pain Exposure Physical Therapy (PEPT) has shown radical and swift improvement of symptoms and function.
Although disability in CRPS-1 reduces significantly after a maximum of 5 treatment sessions of PEPT, the mediating factors are not yet understood. This RCT explores if a reduction of pain-related fears is the mechanism behind this new treatment method. Surprisingly, a significant reduction of fear was observed in conventional and PEPT treatment; there must be other factors explaining the superior results of PEPT in CRPS.
Complex Regional Pain Syndrome type 1 (CRPS-1) is a debilitating condition that develops spontaneously or after physical injury, and is characterized by pain and sensory, autonomic, motor, ROM and/or trophic changes.
The exact cause of CRPS-1 is still not fully understood, but various pathophysiologic pathways have been identified. It has been shown that, in chronic musculoskeletal pain, patients’ beliefs about their pain are a disabling factor, and that pain-related fear and associated avoidance behaviours contribute to the development of chronic pain-related disability. See Fig 1.
According to the principles of the fear-avoidance model, pain catastrophizing and pain-related fear have to be treated first, in order to restore functional abilitie (Gradual Exposure Therapy). However, it may be possible that a more functionally directed approach, with the focus on increased motor activity and normal use of the affected limb in daily life, could also lead to improved patient outcomes.
PEPT is a patient-centred physical therapy, also know as the “Macedonian method”, developed by Ms. Shinka in 2003, and is based on the supposition that limited use or even non-use of an ex- tremity, whether or not caused by fear of movement or pain, can lead to disease deterioration
PEPT is tailored towards improving activities in daily life, using progressive-loading exercises, desensitization and “self-forced” use, in which patients have to encourage themselves to use their affected extremity, both during treatment exercises and in daily activities, without the use of medication.
Whereas GET focuses on fear, PEPT puts disuse at the centre.
56 patients were treated in this trial; disability (PDI) decreased with 69% in the PEPT group, compared to 37% in the conventional group. Pain (VAS) reduced with 57% and 23%, respectively.
Surprisingly, fear avoidance beliefs (FABQ), catastophizing (PCS), and kinesiophobia (Tampa-11) decreased significantly in both groups. Reduction of fear thus does not explain the working mechanism of PEPT.
Why does PEPT work? Restoration of ROM, forced functional use, involvement of family, 2 therapists, standardized education on pain? Tell us your thought and experience with CRPS and PEPT.
> From: Barnhoorn et al., PLoS One 10 (2015) . All rights reserved to The Author(s). Click here for the Pubmed summary.