The significant pain, loss of function, and emotional consequences of CRPS can be overwhelming. A biopsychosocial approach, one that focuses on treating the “whole person” not just the syndrome, allows people with CRPS to actively participate in their treatment program. Successful treatment includes learning the difference between physical pain and suffering—the emotional and psychological toll of living with chronic pain and the associated limitations.

This article focuses on nonphysical—psychological, behavioral, emotional, and educational—treatment approaches. Biopsychosocial (biological/psychological/social) factors are addressed through a combination of cognitive behavioral therapy (CBT) and relaxation training, which includes education, relaxation and biofeedback, cognitive restructuring, stress management, communication, social support, and pacing.

Education
Education for both the person and the family is vital for treatment and recovery. It is common for someone with CRPS to have received mixed messages or minimal information regarding diagnosis, conservative treatments, and how the CRPS relates to his or her personal experience. This information allows everyone involved to make the needed mental change (cognitive shift) from a passive to an active approach for managing pain. Expectations and reasonable goals should also be discussed. The goal is to increase function and self-efficacy while decreasing pain, suffering, and disability.

Relaxation and Biofeedback
Relaxation is a vital skill for managing chronic pain. In CRPS, the nervous system is out of balance, and relaxation skills focus on challenging the nervous system to achieve a balanced state. The sympathetic nervous system is over activated, and engaging the “restorative” parasympathetic nervous system (PNS) helps to interrupt this cycle by allowing the person to feel more relaxed and in control of his or her pain. A relaxed mind and body is less reactive and less sensitive to pain. Mastering relaxation is important since many effective treatments for CRPS include exercise and desensitization, which tend to be uncomfortable and can often increase anxiety.

Biofeedback is invaluable when teaching relaxation, since it provides real-time feedback of specific physiological processes (heart rate, breathing, skin conductance, hand or foot temperature, muscle activity). In the early stages of relaxation training, it is often difficult for people to recognize the physiological changes that occur when they relax. For example, biofeedback will show changes in hand or foot temperature; relaxation results in vasodilatation that increases blood flow to hands/feet, thus increasing temperature. This feedback shows the individual which relaxation skills are helping a relaxation response so he or she can later use those same skills to manage a pain flare or stressful situation.

The goal is to have people generalize the relaxation response into their daily lives, as achieved through “practice, practice, practice.” Types of relaxation include: guided imagery, affirmations, autogenic training, self-hypnosis, mindfulness, meditation, and progressive muscle relaxation (PMR). Active mind-body techniques include: tai chi, qi gong, yoga, Feldenkrais, and walking meditation. These techniques are active ways of coping and should be encouraged.

Cognitive Restructuring and Fear of Re-injury and Movement
Having chronic pain can lead to anxiety and depression as well as fear of re-injury and movement. Cognitive behavioral therapy (CBT) theorizes that thoughts affect feelings and behaviors. Identifying automatic maladaptive thoughts and replacing them with more balanced adaptive thoughts is crucial to recovery. Thought logs are a great tool to help identify and challenge the kinds of statements, such as, “I am never going to get better,” or “If I do that exercise my pain will only get worse” that can affect mood and willingness to participate in physical therapy, recreation, or social activities. Challenging negative thinking will help increase the person’s sense of control, which in turn can decrease distress, disability, and suffering. Recognizing when depression and anxiety are skewing thoughts toward the negative is important and keeping a positive attitude will help fight off the effects of negative thinking.

The unrelenting pain of CRPS increases the underlying fear of further pain or the threat of further damage, so many people with CRPS restrict their activities. This can lead to physical deconditioning, loss of flexibility and muscle strength, and increased pain.  CBT helps people identify how their beliefs and behaviors can lead to a cycle of catastrophic thoughts, fear, avoidance, disability, and pain. Challenging these thoughts allows them to overcome fear and move toward higher function and control over their pain.

Pacing
Pacing involves learning how to be as active and productive as possible while maintaining control over pain levels. Actually more an art than a science, pacing identifies how long a person can participate in an activity before the pain increases. Listing the activities that are activating “Uptime”—physically or emotionally demanding activities —and “Downtime”—restorative or physically and emotionally neutral activities—can help this process. Patients can participate in an Uptime activity until their pain begins to increase past the safe zone at which point they take a break and participate in a Downtime activity until the pain returns to baseline. This helps stop the “crash and burn” cycle of overdoing activities, which lead to a pain flare.

Self talk drives behavior—if a person feels guilty about taking a break, he or she is less likely to take it.

Stress Management
Prioritizing tasks, balancing life responsibilities, and taking time for self-care are challenging. Creating a stress management program helps to reinforce active coping skills, and learning to differentiate between what a person can and can’t control is essential to stress management. Why spend your time worrying about things that you can’t control? People who have underlying mood disorders, should seek help from a mental health professional.

Communication
Living with chronic pain can cause communication shut down. People with CRPS are tired of talking about pain and their friends and family are tired of hearing about it. Change, such as that caused by chronic illness, disrupts the balance within the family and social systems.
Self-care is important for people with CRPS and assertive communication allows them to state their individual opinions and needs effectively while respecting the needs of others.

Having support and love is important to recovery; however friends and family can also unknowingly reinforce maladaptive (negative) behaviors. Educating them about CRPS is vital. Statement such as: “You should lie down and rest if you are in pain,” “Do you think you need to call the doctor or take your medication?” and “Don’t do that, I will do it for you,” reinforce passive behavior. Family members need to be educated on appropriate behavior and encouraged to support active coping.  Although this information is available from several sources, support groups can be an excellent place to start and many of them are open to family and friends.

Questions to Ask a Therapist
The most successful approach will focus on treating the whole person from a biopsychosocial perspective and it is important to know if the therapist follows this model. Other questions to ask are:

• Do you have experience treating CRPS?
• What percentage of your patient population has CRPS?
• What therapeutic orientation and modalities are used in treatment?
• What is the average length of a session?

A phone consultation can determine if the therapist is a good fit. Feeling confident in the psychologist’s level of expertise and comfortable with his or her style is an important aspect of a successful therapy experience.

Summary
CRPS can be devastating, but, as one can see from the RSDSA’s website (www.rsds.org) and written materials, much can be done to manage this condition successfully. This article has discussed various nonphysical—psychological, behavioral, emotional, and educational—treatment approaches, using a combination of cognitive behavioral therapy and relaxation training. These skills include: education, relaxation and biofeedback, cognitive restructuring, stress management, communication, social support, and pacing.

Steven D. Feinberg, MD, is Adjunct Clinical Professor at Stanford University School of Medicine, and is board certified in Physical Medicine and Rehabilitation as well as Pain Medicine.

Heather Poupore King, PhD, is Director of Psychology at the Feinberg Medical Group in Palo Alto, California.

Rachel M. Feinberg, PT, DPT, is Director of Physical Therapy at the Feinberg Medical Group in Palo Alto, California.

Further Reading

Beerthuizen A, van’t Spijker A, Huygen FJPM, Klein J, de Wit R. Is there an association between psychological factors and the Complex Regional Pain Syndrome type 1 (CRPS1) in adults? A systematic review. Pain. 2009;145(1-2):52-59.

Bruehl S. Psychological Interventions. In: Harden RN, Ed. Complex Regional Pain Syndrome: Treatment Guidelines. Milford, CT: RSDSA Press; 2006:37-50. http://www.rsds.org/3/clinical_guidelines/TXguidelines_psychological.pdf.

Bruehl S, Chung OY. Psychological and behavioral aspects of complex regional pain syndrome management. Clin J Pain. 2006;22(5):430-437.

Sidebar

Finding a Pain Psychologist and a Functional Restoration Program
Some of the organizations that provide information about chronic pain, such as how to locate a psychologist or program that specializes in the treatment of chronic pain including CRPS are:

• Reflex Sympathetic Dystrophy Syndrome Association (RSDSA): www.rsds.org
• American Chronic Pain Association ACPA): www.theacpa.org
• American Psychological Association (APA): www.apa.org
• American Academy of Pain Medicine AAPM): www.painmed.org
• American Pain Foundation (APF): www.painfoundation.org
• Pain.com: www.pain.com
• Biofeedback Certification International Alliance (BCIA), to locate a biofeedback specialist: www.bcia.org
• Chronic Pain Connection: www.healthcentral.com/chronic-pain
• Pain Treatment Topics: www.pain-topics.org
• painACTION: www.painaction.com
• Pain Connection: www.painconnection.org