Ernst Schrier

Amputation for Long-Standing, Therapy-Resistant Type-I Complex Regional Pain Syndrome

BACKGROUND Some patients with long-standing, therapy-resistant type-I complex regional pain syndrome consider an amputation. There is a lack of evidence regarding the risk of recurrence of the pain syndrome and patient outcomes after amputation. The goal of the present study was to evaluate the impact of an amputation on pain, participation in daily life activities, and quality of life as well as the use of a prosthesis and the risk of recurrence of the pain syndrome in patients with long-standing, therapy-resistant type-I complex regional pain syndrome. METHODS From May 2000 to October 2008, twenty-two patients underwent an amputation of a nonfunctional limb at our institution because of long-standing, therapy-resistant type-I complex regional pain syndrome. Twenty-one of these patients were included in our study. The median age was forty-six years (interquartile range [IQR], thirty-seven to fifty-one years), the median duration of the complex regional pain syndrome was six years (IQR, two to ten years), and the median interval between the amputation and the study was five years (IQR, three to seven years). A semistructured interview was conducted, physical examination of the residual limb was performed, and the patients completed two questionnaires. RESULTS Twenty patients (95%) reported an improvement in their lives. Nineteen patients (90%) reported a reduction in pain, seventeen patients (81%) reported an improvement in mobility, and fourteen (67%) reported an improvement in sleep. Eighteen of the twenty-one patients stated that they would choose to undergo an amputation again under the same circumstances. Ten of the fifteen patients with a lower-limb amputation and one of the six with an upper-limb amputation regularly used a prosthesis. The type-I complex regional pain syndrome recurred in the residual limb of three patients (14%) and symptoms recurred in another limb in two patients (10%). CONCLUSIONS Amputation may positively contribute to the lives of patients with long-standing, therapy-resistant type-I complex regional pain syndrome. Patients were likely to use a prosthesis after a lower-limb amputation. The risk of recurrence of the type-I complex regional pain syndrome was 24%.

Chronic pain in Rehabilitation Medicine

In this paper the chronicity of pain in non-specific pain syndromes is discussed. Experts in the study of pain with several professional backgrounds in rehabilitation are the authors of this paper. Clinical experience and literature form the basis of the paper. Non-specific low back pain and Complex Regional Pain Syndrome type I (CRPS-I) are discussed in the light of chronic pain. Many definitions of chronic pain exist. Yellow flags are important factors to identify possible chronic pain. In the acute phase of a non-specific pain complaint one should try to identify possible psychosocial inciting risk factors. Behavioural and cognitive treatment seems to be effective for chronic pain patients.

Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: Rehabilitation process and prosthetics. Part 2

Background: A structured, multidisciplinary approach in the rehabilitation process after amputation is needed that includes a greater focus on the involvement of both (para)medics and prosthetists. There is considerable variation in prosthetic prescription concerning the moment of initial prosthesis fitting and the use of replacement parts. Objectives: To produce an evidence-based guideline for the amputation and prosthetics of the lower extremities. This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice. Part 2 focuses on rehabilitation process and prosthetics. Study design: Systematic literature design. Methods: Literature search in five databases and quality assessment on the basis of evidence-based guideline development. Results: An evidence-based multidisciplinary guideline on amputation and prosthetics of the lower extremity. Conclusion: The best care (in general) for patients undergoing amputation of a lower extremity is presented and discussed. This part of the guideline provides recommendations for treatment and reintegration of patients undergoing amputation of a lower extremity and can be used to provide patient information. Clinical relevance This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice.

Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: Amputation surgery and postoperative management. Part 1

Background: Surgeons still use a range of criteria to determine whether amputation is indicated. In addition, there is considerable debate regarding immediate postoperative management, especially concerning the use of ‘immediate/delayed fitting’ versus conservative elastic bandaging. Objectives: To produce an evidence-based guideline for the amputation and prosthetics of the lower extremities. This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice. Part 1 focuses on amputation surgery and postoperative management. Study design: Systematic literature design. Methods: Literature search in five databases. Quality assessment on the basis of evidence-based guideline development. Results: An evidence-based multidisciplinary guideline on amputation and prosthetics of the lower extremity. Conclusion: The best care (in general) for patients undergoing amputation of a lower extremity is presented and discussed. This part of the guideline provides recommendations for diagnosis, referral, assessment, and undergoing amputation of a lower extremity and can be used to provide patient information. Clinical relevance This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice.

Resilience in patients with amputation because of Complex Regional Pain Syndrome type I

Abstract Purpose: Although controversial, an amputation for longstanding and therapy-resistant Complex Regional Pain Syndrome Type I (CRPS-I) may improve quality of life and pain intensity. Resilience, the way people deal with adversity in a positive way may be related to these positive outcomes. This study focused on the relationship between resilience and post-amputation outcomes, i.e. quality of life, pain and recurrence of CRPS-I and psychological distress. Method: Twenty-six patients with an amputation related to CRPS-I filled in the Connor-Davidson Resilience Scale (CD-RISC), World Health Organisation -- Quality of life Assessment (WHOQOL-Bref) and the Symptom Checklist-90 Revised (SCL-90-R). An interview was conducted and a physical examination performed. Results were compared with reference groups from literature and a control group from the outpatient rehabilitation clinic at our medical center. Results: Resilience correlated significantly with all domains of the WHOQOL-Bref (ρ ranged from 0.41 to 0.72) and negatively with all domains of the SCL-90-R (ρ ranged from −0.39 to −0.68). Patients with an amputation because of CRPS-I have higher scores on resilience and quality of life than the control group. Resilience was lower in patients who reported CRPS-I symptoms compared to those who did not. Conclusions: The results confirmed our hypothesis that patients with an amputation because of CRPS-I who have a higher resilience also have a higher quality of life and experience lower psychological distress. The prognostic value of resilience in this patient group requires further research. Implications for Rehabilitation Until characteristics of patients with positive quality of life outcome have been further unraveled, amputation for CRPS-I should only be performed in expertise centers. Resilience, the process of adapting well in the face of adversity, should be further explored in Rehabilitation Medicine research in general. Measurement of resilience should be a standard procedure when patients with CRPS-I request an amputation. Improving resilience of patients in in- and outpatient rehabilitation clinics might be an additional treatment in rehabilitation care.

Patients First: Toward a Patient-Centered Instrument to Measure Impact of Chronic Pain

Background. Numerous instruments are available to measure the impact of chronic pain, yet most have been developed with little or no patient involvement. This study seeks to start bridging that gap by determining which health aspects or attributes (to be included in a future instrument) are considered most important by people with chronic pain. Objective. The goal of this study was to reveal which attributes reflecting impact of chronic pain are considered most important by people with chronic pain and to analyze differences in importance according to gender, age categories, diagnostic subgroups, and pain intensity categories. Design. This study used a sequential explanatory mixed‐methods design: literature search, focus group meetings, and online survey. Methods. First, a literature search was performed to identify the attributes in existing instruments. In 68 instruments meeting inclusion criteria, 155 unique attributes were identified, 85 of which remained after applying the exclusion criteria. Second, 2 focus group meetings, with 6 and 4 patients, respectively, were held to verify that no attributes had been missed. Three attributes were subsequently added. Third, individuals with chronic pain were then sent an online survey through several patient organizations. Results. A total of 939 patients were asked to select the 8 attributes they deemed most important, which resulted in the following list: fatigue, social life, cramped muscles, sleeping, housekeeping, concentration, not being understood, and control over pain. The importance assigned to these 8 attributes varied slightly according to age, gender, and diagnostic subgroup. Limitations. Participation rate could not be established because of the online survey. Conclusions. Attributes reflecting impact of chronic pain deemed most important by patients are revealed. Importance of impact differs according to subgroups. The “patients‐first” methodology used here revealed attributes that were not comprehensively covered in currently available instruments for measuring the impact of chronic pain.

Decision making process for amputation in case of therapy resistant complex regional pain syndrome type-I in a Dutch specialist centre

Deciding for an amputation in case of complex regional pain syndrome type I (CRPS-I) is controversial. Evidence for favorable or adverse effects of an amputation is weak. We therefore follow a careful and well-structured decision making process. After referral of the patient with the request to amputate the affected limb, it is checked if the diagnosis CRPS-I is correct, duration of complaints is more than 1 year, all treatments described in the Dutch guidelines have been tried and if consequences of an amputation have been well considered by the patient. Thereafter the patient is assessed by a multidisciplinary team (psychologist, physical therapist, anesthesiologist-pain specialist, physiatrist and vascular surgeon). During a multidisciplinary meeting professionals summarize their assessment. Pros and cons of an amputation are discussed, taking into account level of amputation and expectations about post amputation functioning of patient and team. Based on assessments and discussion a consensus based decision is formulated and the patient is informed. If it is decided that an amputation is to be performed, the amputation will follow shortly. If it is decided not to amputate, the decision is extensively explained to the patient. Incidence of patients suffering from therapy resistant CRPS-I referred for amputation is low and because referred patients are strongly in favor of an amputation, a randomized controlled trial will be difficult to perform. Hence level of evidence in favor or against an amputation will remain low. We therefore report our decision making process to facilitate discussion about this difficult and delicate matter.

Subjective cognitive dysfunction in rehabilitation outpatients with musculoskeletal disorders or chronic pain.

BACKGROUND Rehabilitation patients, without brain damage, sometimes complain about poor concentration and problems with their memory. The magnitude and associations, of this cognitive dysfunction, with different factors is unclear. AIM To determine the magnitude of cognitive dysfunction in rehabilitation outpatient and to explore its associations with patient characteristics, diagnosis, surgery, pain, stress, anxiety and depression. DESIGN Cross-sectional. SETTING Rehabilitation outpatients. POPULATION Between July 2009 and January 2012, 274 rehabilitation outpatients were included and divided in 8 different groups through diagnosis. METHODS Cognitive functioning was assessed using the cognitive failure questionnaire and compared with the general Dutch population. Associations of gender, age, diagnosis, recent surgery, pain and stress coping ability with cognitive function was explored. Mediation of depression and anxiety was explored. RESULTS The rehabilitation patients had a significantly higher score on the CFQ (mean 35.9±13.4) when compared to the general Dutch population (mean 31.8±11.1). Mean difference is 4.1, 95% confidence interval 2.60 to 5.60. In the stepwise linear regression analysis only gender, diagnosis and stress coping ability were significantly associated. A significant mediation effect was found of anxiety (P≤0.001) and depression (P≤0.005) between stress coping ability and cognitive function. CONCLUSIONS Rehabilitation outpatients experience more cognitive problems in comparison to the general Dutch population. Reported dysfunction of cognition in rehabilitation outpatients are associated with stress coping ability and for a small amount to gender and diagnosis. The association of stress coping ability and cognitive dysfunction is mediated by depression and anxiety. Women tend to report more dysfunctional cognition compared to men. Patient characteristics, surgery and experienced pain have no significant influence on the experienced cognitive dysfunction. CLINICAL REHABILITATION IMPACT Cognitive problems reported by patients should be addressed by adapting the rehabilitation program, for instance write down instructions, repeat explanations and take more time for instructions. Cognitive problems in rehabilitation patients without brain damage is probably a stress coping problem and can be addressed by boosting resilience. Targeting depression or anxiety is another option of treatment cognition if those are mediating between stress coping and cognitive problems.

Biomedical and psychosocial factors influencing transtibial prosthesis fit: a Delphi survey among health care professionals

Abstract Purpose: We aimed to reach consensus among professionals caring for prosthesis users, on definitions of biomedical and psychosocial factors, to assess their influence on fit of transtibial prosthesis and to identify new factors. Method: A three-round, internet-based, Delphi survey was conducted among experts recruited via the Dutch National Amputee and Prosthesis Work Group. The main outcome measure was consensus among care professionals on statements concerning new and presented biomechanical and psychosocial factors that influence transtibial prosthesis fit. Results: Fifty-four experts participated in the survey, and consensus was reached on 67% (46/69) of all statements. Consensus on statements relevant for good prosthesis fit was reached in most of the statements concerning psychosocial factors and on statements concerning the biomedical factors “prosthesis support and suspension”. Least consensus was reached on statements concerning the biomedical factor “skin problems and pain in the residual limb”. Conclusions: Biomedical and psychosocial factors influence transtibial prosthesis fit. Consensus was reached among care professionals in a majority of the presented statements concerning these factors. Implications for Rehabilitation Prosthesis fit and comfort is suboptimal in many prosthesis users. Both biomedical and psychosocial factors influence fit. Biomedical and psychosocial factors should be checked during transtibial prosthesis prescription to achieve and maintain an optimal fit. Consensus on many factors influencing prosthesis fit is achieved among care professionals. Consensus was largest regarding prosthesis support and suspension and least regarding skin problems and pain in the residual limb. This consensus contributes to systematic assessment of prosthesis fit.