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Home training in sensorimotor discrimination reduces pain in complex regional pain syndrome (CRPS)

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Published/Copyright: April 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 15 Issue 1

1 Introduction

In this issue of the Scandinavian Journal of Pain, Schmid and coworkers [1] report on a simple and easy way to use home training in sensory discrimination, which showed significant reductions in pain intensity in patients with complex regional pain syndrome. The 2-week training was performed at the patients’ home and consisted of a braille-like haptic task, which included bi-manual, speed and memory training. Bimanual training was implemented based on previous data suggesting impaired bimanual coupling and potentially deficient interhemispheric transfer in this condition [2].The results are interesting because this is an approach that takes sensorimotor training out of the laboratory. Although this is a pilot study in only 10 patients without a control group, the authors showed that the amount of training was positively correlated with the magnitude of pain reduction suggesting that there is a dose-response-related effect.

2 Review of the topic

The results of this pilot study are in line with similar work on phantom limb pain [3,4] that showed a relationship between improvements in tactile acuity related to active training, changes in phantom pain and a reversal of altered cortical maps. A previous study by David et al. [5] in CRPS patients that used passive stimulation rather than active discrimination and was applied in the laboratory and at home. It indicated significant improvements in tactile acuity but not in pain. A major difference between these studies is that active versus passive stimulation was used and it would be interesting to see if this could account for the differences in pain reduction. A study in patients with chronic back pain, however, found more improvement with passive stimulation, which was considered as a placebo in this study than with active discrimination [6]. The David et al. study [5] was also shorter (5 days), which might have been another factor for different outcomes.

3 Conclusion and implications

Although the results of this pilot study are encouraging, they require testing in larger samples that are placebo-controlled since expectancy may be a major factor that not only motivates pain reduction but also more active participation in the training that could then mediate the dose-response effect observed in this study. Moreover, a recent brain imaging study in CRPS suggested that the major change may not be in the representation of the affected but of the unaffected hand [7] and thus brain imaging data related to the treatment effects would be of great value. In phantom limb pain, for example, effective mirror training or motor imagery has been shown to also alter the cortical map [8,9]. Further questions also arise to the type of training. In addition to tests of active versus passive types of training, purely sensory and sensorimotor tasks need to be compared and the question of unisensory versus multisensory tasks has also not been resolved. Finally, the extent of embodiment and agency related to the affected limb, which were not addressed in this study, may also be important. Despite the fact that this study raises many questions, it is important, because we need to develop easy to use home-based interventions if we want to overcome the problem of insufficient access to efficient treatments for patients with neuropathic pain. A combination of discrimination training with pharmacological interventions that foster training effects and brain plasticity [4,10] might also be of interest. Similarly, brain stimulation methods could be combined with sensory training [11].

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2016.11.003.

Central Institute of Mental Health, J5, D-68159 Mannheim, Germany.

  1. Conflict of interest: None declared.

References

[1] Schmid AC, Schwarz A, Gustin SM, Greenspan JD, Hummel FC, Birbaumer N. Pain reduction due to novel sensory-motor training in Complex Regional Pain Syndrome I – a pilot study. Scan J Pain 2017;15:30–7.Search in Google Scholar

[2] Bank PJ, Peper CE, Marinus J, Hilten JJ, Beek PJ. Intended and unintended (sensory-) motor coupling between the affected and unaffected upper limb in complex regional pain syndrome. Eur J Pain 2015;19:1021–34.Search in Google Scholar

[3] Flor H, Denke C, Schaefer M, Grüsser S. Effect of sensory discrimination training on cortical reorganisation and phantom limb pain. Lancet 2001;357:1763–4.Search in Google Scholar

[4] Huse E, Preissl H, Larbig W, Birbaumer N. Phantom limb pain. Lancet 2001;358:1019.Search in Google Scholar

[5] David M, Dinse HR, Mainka T, Tegenthoff M, Maier C. High-frequency repetitive sensory stimulation as intervention to improve sensory loss in patients with complex regional pain syndrome I. Front Neurol 2015;6:242.Search in Google Scholar

[6] Ryan C, Harland N, Drew BT, Martin D. Tactile acuity training for patients with chronic low back pain: a pilot randomised controlled trial. BMC Musculoskelet Disord 2014;15:59.Search in Google Scholar

[7] Di Pietro F, Stanton TR, Moseley GL, Lotze M, McAuley JH. Interhemispheric somatosensory differences in chronic pain reflect abnormality of the healthy side. Hum Brain Map 2015;36:508–18.Search in Google Scholar

[8] Foell J, Bekrater-Bodmann R, Diers M, Flor H. Mirror therapy for phantom limb pain: brain changes and the role of body representation. Eur J Pain 2014;18:729–39.Search in Google Scholar

[9] MacIver K, Lloyd DM, Kelly S, Roberts N, Nurmikko T. Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. Brain 2008;131:2181–91.Search in Google Scholar

[10] Dinse HR, Ragert P, Pleger B, Schwenkreis P, Tegenthoff M. Pharmacological modulation of perceptual learning and associated cortical reorganization. Science 2003;301:91–4.Search in Google Scholar

[11] Massé-Alarie H, Beaulieu LD, Preuss R, Schneider C. Repetitive peripheral magnetic neurostimulation of multifidus muscles combined with motor training influences spine motor control and chronic low back pain. Clin Neurophysiol 2016;128:442–53.Search in Google Scholar
Published Online: 2017-04-01
Published in Print: 2017-04-01

© 2017 Scandinavian Association for the Study of Pain

Articles in the same Issue

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Cardiovascular risk reduction as a population strategy for preventing pain?
  5. Observational study
  6. Diabetes mellitus and hyperlipidaemia as risk factors for frequent pain in the back, neck and/or shoulders/arms among adults in Stockholm 2006 to 2010 – Results from the Stockholm Public Health Cohort
  7. Editorial comment
  8. Exercising non-painful muscles can induce hypoalgesia in individuals with chronic pain
  9. Clinical pain research
  10. Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders
  11. Editorial comment
  12. Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough
  13. Observational study
  14. Acute pain in the emergency department: Effect of an educational intervention
  15. Editorial comment
  16. Home training in sensorimotor discrimination reduces pain in complex regional pain syndrome (CRPS)
  17. Original experimental
  18. Pain reduction due to novel sensory-motor training in Complex Regional Pain Syndrome I – A pilot study
  19. Editorial comment
  20. How can pain management be improved in hospitalized patients?
  21. Original experimental
  22. Pain and pain management in hospitalized patients before and after an intervention
  23. Editorial comment
  24. Is musculoskeletal pain associated with work engagement?
  25. Clinical pain research
  26. Relationship of musculoskeletal pain and well-being at work – Does pain matter?
  27. Editorial comment
  28. Preoperative quantitative sensory testing (QST) predicting postoperative pain: Image or mirage?
  29. Systematic review
  30. Are preoperative experimental pain assessments correlated with clinical pain outcomes after surgery? A systematic review
  31. Editorial comment
  32. A possible biomarker of low back pain: 18F-FDeoxyGlucose uptake in PETscan and CT of the spinal cord
  33. Observational study
  34. Detection of nociceptive-related metabolic activity in the spinal cord of low back pain patients using 18F-FDG PET/CT
  35. Editorial comment
  36. Patients’ subjective acute pain rating scales (VAS, NRS) are fine; more elaborate evaluations needed for chronic pain, especially in the elderly and demented patients
  37. Clinical pain research
  38. How do medical students use and understand pain rating scales?
  39. Editorial comment
  40. Opioids and the gut; not only constipation and laxatives
  41. Observational study
  42. Healthcare resource use and costs of opioid-induced constipation among non-cancer and cancer patients on opioid therapy: A nationwide register-based cohort study in Denmark
  43. Editorial comment
  44. Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies
  45. Clinical pain research
  46. Trajectory of phantom limb pain relief using mirror therapy: Retrospective analysis of two studies
  47. Editorial comment
  48. Qualitative pain research emphasizes that patients need true information and physicians and nurses need more knowledge of complex regional pain syndrome (CRPS)
  49. Clinical pain research
  50. Adolescents’ experience of complex persistent pain
  51. Editorial comment
  52. New knowledge reduces risk of damage to spinal cord from spinal haematoma after epidural- or spinal-analgesia and from spinal cord stimulator leads
  53. Review
  54. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors
  55. Review
  56. Neuraxial blocks and spinal haematoma: Review of 166 cases published 1994 – 2015. Part 2: diagnosis, treatment, and outcome
  57. Editorial comment
  58. CNS–mechanisms contribute to chronification of pain
  59. Topical review
  60. A neurobiologist’s attempt to understand persistent pain
  61. Editorial Comment
  62. The triumvirate of co-morbid chronic pain, depression, and cognitive impairment: Attacking this “chicken-and-egg” in novel ways
  63. Observational study
  64. Pain and major depressive disorder: Associations with cognitive impairment as measured by the THINC-integrated tool (THINC-it)
https://doi.org/10.1016/j.sjpain.2017.02.003

Articles in the same Issue

  2. Scandinavian Journal of Pain
  3. Editorial comment
  4. Cardiovascular risk reduction as a population strategy for preventing pain?
  5. Observational study
  6. Diabetes mellitus and hyperlipidaemia as risk factors for frequent pain in the back, neck and/or shoulders/arms among adults in Stockholm 2006 to 2010 – Results from the Stockholm Public Health Cohort
  7. Editorial comment
  8. Exercising non-painful muscles can induce hypoalgesia in individuals with chronic pain
  9. Clinical pain research
  10. Exercise induced hypoalgesia is elicited by isometric, but not aerobic exercise in individuals with chronic whiplash associated disorders
  11. Editorial comment
  12. Education of nurses and medical doctors is a sine qua non for improving pain management of hospitalized patients, but not enough
  13. Observational study
  14. Acute pain in the emergency department: Effect of an educational intervention
  15. Editorial comment
  16. Home training in sensorimotor discrimination reduces pain in complex regional pain syndrome (CRPS)
  17. Original experimental
  18. Pain reduction due to novel sensory-motor training in Complex Regional Pain Syndrome I – A pilot study
  19. Editorial comment
  20. How can pain management be improved in hospitalized patients?
  21. Original experimental
  22. Pain and pain management in hospitalized patients before and after an intervention
  23. Editorial comment
  24. Is musculoskeletal pain associated with work engagement?
  25. Clinical pain research
  26. Relationship of musculoskeletal pain and well-being at work – Does pain matter?
  27. Editorial comment
  28. Preoperative quantitative sensory testing (QST) predicting postoperative pain: Image or mirage?
  29. Systematic review
  30. Are preoperative experimental pain assessments correlated with clinical pain outcomes after surgery? A systematic review
  31. Editorial comment
  32. A possible biomarker of low back pain: 18F-FDeoxyGlucose uptake in PETscan and CT of the spinal cord
  33. Observational study
  34. Detection of nociceptive-related metabolic activity in the spinal cord of low back pain patients using 18F-FDG PET/CT
  35. Editorial comment
  36. Patients’ subjective acute pain rating scales (VAS, NRS) are fine; more elaborate evaluations needed for chronic pain, especially in the elderly and demented patients
  37. Clinical pain research
  38. How do medical students use and understand pain rating scales?
  39. Editorial comment
  40. Opioids and the gut; not only constipation and laxatives
  41. Observational study
  42. Healthcare resource use and costs of opioid-induced constipation among non-cancer and cancer patients on opioid therapy: A nationwide register-based cohort study in Denmark
  43. Editorial comment
  44. Relief of phantom limb pain using mirror therapy: A bit more optimism from retrospective analysis of two studies
  45. Clinical pain research
  46. Trajectory of phantom limb pain relief using mirror therapy: Retrospective analysis of two studies
  47. Editorial comment
  48. Qualitative pain research emphasizes that patients need true information and physicians and nurses need more knowledge of complex regional pain syndrome (CRPS)
  49. Clinical pain research
  50. Adolescents’ experience of complex persistent pain
  51. Editorial comment
  52. New knowledge reduces risk of damage to spinal cord from spinal haematoma after epidural- or spinal-analgesia and from spinal cord stimulator leads
  53. Review
  54. Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors
  55. Review
  56. Neuraxial blocks and spinal haematoma: Review of 166 cases published 1994 – 2015. Part 2: diagnosis, treatment, and outcome
  57. Editorial comment
  58. CNS–mechanisms contribute to chronification of pain
  59. Topical review
  60. A neurobiologist’s attempt to understand persistent pain
  61. Editorial Comment
  62. The triumvirate of co-morbid chronic pain, depression, and cognitive impairment: Attacking this “chicken-and-egg” in novel ways
  63. Observational study
  64. Pain and major depressive disorder: Associations with cognitive impairment as measured by the THINC-integrated tool (THINC-it)
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