Case Report| Volume 31, ISSUE 2, P255-264, April 2018

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Management of long-term complex regional pain syndrome with allodynia: A case report


      Study design

      Case report.


      Conventional rehabilitation alone may not be effective in reducing symptoms in some patients with complex regional pain syndrome.

      Purpose of the study

      This case report portrays the benefits of a new tailored rehabilitation program for a 39-year-old patient suffering from upper limb complex regional pain syndrome with severe touch-evoked pain (static mechanical allodynia).


      This patient had previously received conventional rehabilitation for a year and a half including physical and nonsurgical medical interventions that did not improve symptoms or function. In the search for an alternative, this patient was referred to occupational therapy to try a tailored rehabilitation program, drawing on multiple strategies used sequentially according to the patient's tolerance and symptom evolution. During this 22-month program, the following methods were added (listed chronologically): somatosensory rehabilitation of pain method, graded motor imagery, pain management modalities, active mobilizations, strengthening exercises, and task simulation. The patient successively showed resolution of mechanical allodynia, decreased pain, reduction of tactile hypesthesia and improvement in active range of motion, strength, and function. These improvements allowed him to return to work.


      This suggests that a tailored rehabilitation program combining somatosensory rehabilitation of pain method, graded motor imagery and more conventional approaches could improve symptoms and functional status in patients with upper limb complex regional pain syndrome, even with persistent refractory symptoms.


      The addition of the somatosensory rehabilitation of pain method and the graded motor imagery approach to conventional therapy could be considered in cases of complex regional pain syndrome that do not respond to conventional rehabilitation alone.


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        • Marinus J.
        • Moseley G.L.
        • Birklein F.
        • et al.
        Clinical features and pathophysiology of complex regional pain syndrome.
        Lancet Neurol. 2011; 10: 637-648
        • Sandroni P.
        • Benrud-Larson L.M.
        • McClelland R.L.
        • Low P.A.
        Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study.
        Pain. 2003; 103: 199-207
        • Harden R.N.
        • Bruehl S.
        • Perez R.S.
        • et al.
        Validation of proposed diagnostic criteria (the “Budapest criteria”) for complex regional pain syndrome.
        Pain. 2010; 150: 268-274
        • Galer B.S.
        • Henderson J.
        • Perander J.
        • Jensen M.P.
        Course of symptoms and quality of life measurement in complex regional pain syndrome: a pilot survey.
        J Pain Symptom Manage. 2000; 20: 286-292
        • de Mos M.
        • Huygen F.J.
        • van der Hoeven-Borgman M.
        • Dieleman J.P.
        • Stricker B.H.C.
        • Sturkenboom M.C.
        Outcome of the complex regional pain syndrome.
        Clin J Pain. 2009; 25: 590-597
        • Bean D.J.
        • Johnson M.H.
        • Kydd R.R.
        The outcome of complex regional pain syndrome type 1: a systematic review.
        J Pain. 2014; 15: 677-690
        • Borchers A.
        • Gershwin M.
        Complex regional pain syndrome: a comprehensive and critical review.
        Autoimmun Rev. 2014; 13: 242-265
        • Geertzen J.H.
        • de Bruijn-Kofman A.T.
        • de Bruijn H.P.
        • van de Wiel H.B.
        • Dijkstra P.U.
        Stressful life events and psychological dysfunction in complex regional pain syndrome type I.
        Clin J Pain. 1998; 14: 143-147
        • Sharma A.
        • Agarwal S.
        • Broatch J.
        • Raja S.N.
        A web-based cross-sectional epidemiological survey of complex regional pain syndrome.
        Reg Anesth Pain Med. 2009; 34: 110-115
        • Gierthmuhlen J.
        • Maier C.
        • Baron R.
        • Tolle T.
        • Treede R.D.
        • Birbaumer N.
        • German Research Network on Neuropathic Pain study, g
        Sensory signs in complex regional pain syndrome and peripheral nerve injury.
        Pain. 2012; 153: 765-774
        • Rommel O.
        • Malin J.-P.
        • Zenz M.
        • Jänig W.
        Quantitative sensory testing, neurophysiological and psychological examination in patients with complex regional pain syndrome and hemisensory deficits.
        Pain. 2001; 93: 279-293
        • Huge V.
        • Lauchart M.
        • Magerl W.
        • et al.
        Complex interaction of sensory and motor signs and symptoms in chronic CRPS.
        PLoS One. 2011; 6: e18775
        • Savas S.
        • Baloglu H.H.
        • Ay G.
        • Cerci S.S.
        The effect of sequel symptoms and signs of Complex Regional Pain Syndrome type 1 on upper extremity disability and quality of life.
        Rheumatol Int. 2009; 29: 545-550
        • Merskey H.
        • Bogduk N.
        • Taxonomy I.A.
        • f. t. S. o. P. T. F. o
        Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms.
        IASP Press, Seattle1994
        • Lolignier S.
        • Eijkelkamp N.
        • Wood J.N.
        Mechanical allodynia.
        Pflügers Arch. 2015; 467: 133-139
        • Mailis-Gagnon A.
        • Lakha S.F.
        • Allen M.D.
        • Deshpande A.
        • Harden R.N.
        Characteristics of complex regional pain syndrome in patients referred to a tertiary pain clinic by community physicians, assessed by the Budapest clinical diagnostic criteria.
        Pain Med. 2014; 15: 1965-1974
        • Harden R.N.
        • Bruehl S.
        • Galer B.S.
        • et al.
        Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive?.
        Pain. 1999; 83: 211-219
        • Bruehl S.
        An update on the pathophysiology of complex regional pain syndrome.
        Anesthesiology. 2010; 113: 713-725
        • Packham T.
        • MacDermid J.C.
        • Henry J.
        • Bain J.
        A systematic review of psychometric evaluations of outcome assessments for complex regional pain syndrome.
        Disabil Rehabil. 2012; 34: 1059-1069
        • Treede R.D.
        • Jensen T.S.
        • Campbell J.N.
        • et al.
        Neuropathic pain: redefinition and a grading system for clinical and research purposes.
        Neurology. 2008; 70: 1630-1635
        • Goh E.L.
        • Chidambaram S.
        • Ma D.
        Complex regional pain syndrome: a recent update.
        Burns Trauma. 2017; 5: 2
        • Smart K.M.
        • Wand B.M.
        • O'Connell N.E.
        Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II.
        Cochrane Database Syst Rev. 2016; : CD010853
        • Maihöfner C.
        • Handwerker H.O.
        • Neundörfer B.
        • Birklein F.
        Patterns of cortical reorganization in complex regional pain syndrome.
        Neurology. 2003; 61: 1707-1715
        • Campero M.
        • Bostock H.
        • Baumann T.K.
        • Ochoa J.L.
        A search for activation of C nociceptors by sympathetic fibers in complex regional pain syndrome.
        Clin Neurophysiol. 2010; 121: 1072-1079
        • Spicher C.
        • Mathis F.
        • Degrange B.
        • Freund P.
        • Rouiller E.M.
        Static mechanical allodynia (SMA) is a paradoxical painful hypo-aesthesia: Observations derived from neuropathic pain patients treated with somatosensory rehabilitation.
        Somatosens Mot Res. 2008; 25: 77-92
        • Moseley G.L.
        Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial.
        Pain. 2004; 108: 192-198
        • Yerxa E.J.
        • Barber L.M.
        • Diaz O.
        • Black W.
        • Azen S.P.
        Development of a hand sensitivity test for the hypersensitive hand.
        Am J Occup Ther. 1983; 37: 176-181
        • Spicher C.
        • Quintal I.
        • Vittaz M.
        Rééducation sensitive des douleurs neuropathiques.
        (Préface: S. Marchand, PhD)3e éd. Sauramps Médical, Montpellier, Paris2015
        • Nedelec B.
        • Calva V.
        • Chouinard A.
        • et al.
        Somatosensory rehabilitation for neuropathic pain in burn survivors: a case series.
        J Burn Care Res. 2016; 37: e37-e46
        • Packham T.L.
        • Spicher C.J.
        • MacDermid J.C.
        • Michlovitz S.
        • Buckley D.N.
        Somatosensory rehabilitation for allodynia in complex regional pain syndrome of the upper limb: a retrospective cohort study.
        J Hand Ther. 2017; 31: 10-19
        • Moseley G.L.
        • Butler D.S.
        • Beames T.B.
        • Giles T.J.
        The graded motor imagery handbook.
        Noigroup publications, Adelaide, Australia2012
        • Bowering K.J.
        • O'Connell N.E.
        • Tabor A.
        • et al.
        The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis.
        J Pain. 2013; 14: 3-13
        • Daly A.E.
        • Bialocerkowski A.E.
        Does evidence support physiotherapy management of adult Complex Regional Pain Syndrome Type One? A systematic review.
        Eur J Pain. 2009; 13: 339-353
        • Moseley G.L.
        Graded motor imagery for pathologic pain A randomized controlled trial.
        Neurology. 2006; 67: 2129-2134
        • Walz A.D.
        • Usichenko T.
        • Moseley G.L.
        • Lotze M.
        Graded motor imagery and the impact on pain processing in a case of CRPS.
        Clin J Pain. 2013; 29: 276-279
        • Moseley G.L.
        • Flor H.
        Targeting cortical representations in the treatment of chronic pain: a review.
        Neurorehabil Neural Repair. 2012; 26: 646-652
        • Perez R.S.
        • Zollinger P.E.
        • Dijkstra P.U.
        • Thomassen-Hilgersom I.L.
        • Zuurmond W.W.
        • Rosenbrand K.C.
        • force, C. I. t
        Evidence based guidelines for complex regional pain syndrome type 1.
        BMC Neurol. 2010; 10: 20
        • Bharwani K.D.
        • Dirckx M.
        • Stronks D.L.
        • Dik W.A.
        • Schreurs M.W.J.
        • Huygen F.
        Elevated Plasma levels of sIL-2R in complex regional pain syndrome: a Pathogenic Role for t-Lymphocytes?.
        Mediators Inflamm. 2017; 2017: 2764261
        • Farrar J.T.
        • Young J.P.
        • LaMoreaux L.
        • Werth J.L.
        • Poole R.M.
        Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale.
        Pain. 2001; 94: 149-158
        • Scott J.
        • Huskisson E.
        Graphic representation of pain.
        Pain. 1976; 2: 175-184
        • Kersten P.
        • White P.J.
        • Tennant A.
        Is the pain visual analogue scale linear and responsive to change? An exploration using Rasch analysis.
        PLoS One. 2014; 9: e99485
        • Boureau F.
        • Luu M.
        • Doubrère J.F.
        Comparative study of the validity of four French McGill Pain Questionnaire (MPQ) versions.
        Pain. 1992; 50: 59-65
        • Bell-Krotoski J.A.
        • Fess E.E.
        • Figarola J.H.
        • Hiltz D.
        Threshold detection and Semmes-Weinstein monofilaments.
        J Hand Ther. 1995; 8: 155-162
        • Spicher C.
        • Hecker E.
        • Thommen E.
        • Rouiller E.
        La place du test de discrimination de 2 points statiques dans l’examen clinique.
        Douleur Analgésie. 2005; 18: 73-78
        • Pendleton H.M.H.
        • Schultz-Krohn W.
        Pedretti's Occupational Therapy: Practice Skills for Physical Dysfunction.
        Elsevier/Mosby, St-Louis, Missouri2013
        • Mathiowetz V.
        • Kashman N.
        • Volland G.
        • Weber K.
        • Dowe M.
        • Rogers S.
        Grip and pinch strength: normative data for adults.
        Arch Phys Med Rehabil. 1985; 66: 69-74
        • Angst F.
        • Schwyzer H.K.
        • Aeschlimann A.
        • Simmen B.R.
        • Goldhahn J.
        Measures of adult shoulder function: disabilities of the arm, shoulder, and hand questionnaire (DASH) and its short version (QuickDASH), shoulder pain and disability index (SPADI), American Shoulder and Elbow Surgeons (ASES) Society standardized shoulder assessment form, Constant (Murley) score (CS), simple shoulder test (SST), Oxford shoulder score (OSS), shoulder disability questionnaire (SDQ), and Western Ontario shoulder instability index (WOSI).
        Arthritis Care Res. 2011; 63: S174-S188
        • Dowrick A.S.
        • Gabbe B.J.
        • Williamson O.D.
        • Cameron P.A.
        Outcome instruments for the assessment of the upper extremity following trauma: a review.
        Injury. 2005; 36: 468-476
        • Hudak P.L.
        • Amadio P.C.
        • Bombardier C.
        Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
        Am J Ind Med. 1996; 29: 602-608
        • Beaton D.E.
        • Katz J.N.
        • Fossel A.H.
        • Wright J.G.
        • Tarasuk V.
        • Bombardier C.
        Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity.
        J Hand Ther. 2001; 14: 128-146
        • Durand M.J.
        • Vachon B.
        • Hong Q.N.
        • Loisel P.
        The cross-cultural adaptation of the DASH questionnaire in Canadian French.
        J Hand Ther. 2005; 18: 34-39
        • De Smet L.
        Does restricted wrist motion influence the disability of the upper limb?.
        Acta Orthop Belg. 2007; 73: 446-450
        • Bouhassira D.
        • Attal N.
        Douleurs neuropathiques.
        Wolters Kluwer, France2012
        • Von Prince K.
        • Butler Jr., B.
        Measuring sensory function of the hand in peripheral nerve injuries.
        Am J Occup Ther. 1967; 21: 385-395
        • Pleger B.
        • Tegenthoff M.
        • Ragert P.
        • et al.
        Sensorimotor returning in complex regional pain syndrome parallels pain reduction.
        Ann Neurol. 2005; 57: 425-429
        • Rho R.H.
        • Brewer R.P.
        • Lamer T.J.
        • Wilson P.R.
        Complex regional pain syndrome.
        in: Paper presented at the Mayo Clinic Proceedings. 2002
        • Sebastin S.J.
        Complex regional pain syndrome.
        Indian J Plastic Surg. 2011; 44: 298
        • Stanton-Hicks M.D.
        • Burton A.W.
        • Bruehl S.P.
        • et al.
        An updated interdisciplinary clinical pathway for CRPS: report of an expert panel.
        Pain Pract. 2002; 2: 1-16
        • O'Connell N.
        • Wand B.
        • McAuley J.
        • Marston L.
        • Moseley G.
        Interventions for treating pain and disability in adults with complex regional pain syndrome.
        Cochrane Database Syst Rev. 2013; : CD009416
        • Johnson S.
        • Hall J.
        • Barnett S.
        • et al.
        Using graded motor imagery for complex regional pain syndrome in clinical practice: Failure to improve pain.
        Eur J Pain. 2012; 16: 550-561

      JHT Read for Credit

      Quiz: #539

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to There is only one best answer for each question.
      • #1.
        The rehab program consisted of
        • a.
          resistive exercise
        • b.
          graded motor imagery
        • c.
          somatosensory rehab
        • d.
          all of the above
      • #2.
        The study design was a
        • a.
          systematic review
        • b.
          single RCT
        • c.
          case study
        • d.
          qualitative report
      • #3.
        The primary feature of the patient’s CRPS was
        • a.
          mechanical allodynia
        • b.
          thermal allodynia
        • c.
          sensory disturbance
        • d.
          coordination disturbance
      • #4.
        Clinic visits were
        • a.
          daily for 22 weeks
        • b.
          BIW for the first 15 weeks; once per week thereafter
        • c.
          TIW for one year
        • d.
          on an as needed basis
      • #5.
        The authors were able to isolate the single most effective intervention that contributed to the resolution of the CRPS
        • a.
        • b.
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.