Received Mar 25; Accepted Feb This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly credited. This article has been cited by other articles in PMC. Abstract Objective To investigate whether pain-related fears are mediators for reducing disability and pain in patients with Complex Regional Pain Syndrome type 1 when treating with Pain Exposure Physical Therapy.
Design An explorative secondary analysis of a randomised controlled trial. Interventions The experimental group received Pain Exposure Physical Therapy in a maximum of five treatment sessions; the control group received conventional treatment following the Dutch multidisciplinary guideline. Outcome measures Levels of disability, pain, and pain-related fears fear-avoidance beliefs, pain catastrophizing, and kinesiophobia were measured at baseline and after 3, 6, and 9 months follow-up.
Results The experimental group had a significantly larger decrease in disability of 7. Conclusion The reduction of pain-related fears was comparable in both groups. Open in a separate window. Fig 1. The fear-avoidance model, showing the targets of Pain Exposure Physical Therapy and graded exposure treatment. Experimental treatment At the start of treatment with PEPT all medication aimed at CRPS-1, including analgesics, was stopped, as use of medication is not part of the treatment. Control treatment Conventional treatment CONV was based on the current Dutch national guideline and included pharmacological interventions combined with physical therapy in a pain-contingent manner [ 16 ].
Outcome measures The outcomes of interest for the mediation analysis were pain-related disability, pain, fear-avoidance beliefs, pain catastrophizing, and fear of movement and re injury kinesiophobia. Data analysis Because of the exploratory nature of this particular study, we did not abide to the randomization protocol and analysed all patients according to the treatment they received from the beginning of the trial. Fig 2.
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Model for the mediation analysis. Table 1 Baseline characteristics of the participants. Disability and pain step 1 Disability and pain improved significantly in both groups, as is shown in Fig 3 and Table 2. Fig 3. Outcomes for both treatment groups at baseline and at 3, 6, and 9 months follow-up. Table 2 Descriptives of the dependent variables and the mediator variables. All data are mean SD. CONV 7.
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CONV 2. CONV 0. Fear-avoidance beliefs, catastrophizing, and kinesiophobia step 2 Fear-avoidance beliefs, catastrophizing, and kinesiophobia decreased significantly in both groups Fig 3 , Table 2. Mediation step 3 Because there were no significant effects of treatment on pain-related fears, we did not perform step 3 of the mediation analysis, nor could we assess the proportion of the mediated effect.
Discussion Statement of principal findings With this exploratory study on the working mechanism of Pain Exposure Physical Therapy, we found that in this population the effect of PEPT, compared to conventional treatment, on disability and pain was not mediated by pain-related fears. Meaning of the study In contrast to standard physical therapy and other conventional treatment modalities [ 16 ], PEPT does not primarily focus on reducing pain, but on reducing disability and improving motor activities.
Strengths and weaknesses of the study We did not abide to the randomization protocol. Unanswered questions and future research It should be emphasized that our study findings need to be replicated in other, preferably larger, studies to elucidate the potential role of pain-related fears as mediators of the effects of PEPT on pain and disability. Acknowledgments We are grateful to Tjarda Tromp, who performed all of the measurements and data management, and to all the participants in this study. References 1. International Association for the Study of Pain. Clinical features and pathophysiology of complex regional pain syndrome.
Lancet Neurol. Sensorimotor retuning [corrected] in complex regional pain syndrome parallels pain reduction. Ann Neurol. A review of psychosocial factors in complex regional pain syndrome. J Clin Psychol Med Settings.
Pain-related fear, perceived harmfulness of activities, and functional limitations in complex regional pain syndrome type I. J Pain. Clin J Pain. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Reduction of pain-related fear and increased function and participation in work-related upper extremity pain WRUEP : effects of exposure in vivo. The role of pain coping and kinesiophobia in patients with complex regional pain syndrome type 1 of the legs. The relation between pain-related fear and disability: a meta-analysis.
Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo. Vlaeyen JW, Morley S.
Cognitive-behavioral treatments for chronic pain: what works for whom? Sloot S. Macedonische methode nu onderbouwd. Medisch contact. Pain exposure physical therapy may be a safe and effective treatment for longstanding complex regional pain syndrome type 1: a case series. Clin Rehabil. CRPS I task force. Evidence based guidelines for complex regional pain syndrome type 1. BMC Neurol. The effectiveness and cost evaluation of pain exposure physical therapy and conventional therapy in patients with complex regional pain syndrome type 1.
Rationale and design of a randomized controlled trial. BMC Musculoskelet Disord. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med. Extensive validation of the Pain Disability Index in three groups of patients with musculoskeletal pain. Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid? Arch Phys Med Rehabil. Nederlandse vertaling en bewerking van de Fear-Avoidance Beliefs Questionnaire. Nederlands tijdschrift voor pijn en pijnbestrijding. J Occup Rehabil. The Pain Catastrophizing Scale: development and validation.
Psychol Assess. Pain catastrophizing and general health status in a large Dutch community sample. The Pain Catastrophizing Scale: further psychometric evaluation with adult samples. J Behav Med.
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The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. The working mechanism of manual therapy in participants with chronic tension-type headache. J Orthop Sports Phys Ther.
Twisk JWR. Inleiding in de toegepaste biostatistiek. Health-related quality of life in patients with complex regional pain syndrome type 1. Altered central sensorimotor processing in patients with complex regional pain syndrome. Flor H. Cortical reorganisation and chronic pain: implications for rehabilitation. J Rehabil Med.
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Cortical reorganization during recovery from complex regional pain syndrome. Catastrophizing, pain, and disability in patients with soft-tissue injuries. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. Please send your word proposal, together with a short bio-bibliographical statement listing your current affiliation by April 1st, , to both conference organizers: Alicia Montoya, a.
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Each of the international and national arbitral bodies has their own standard Arbitration and Mediation reference clauses and these should be incorporated in the corresponding commercial agreements if the parties wish to use them. In the case of sports disputes, the Court of Arbitration for Sport offers the following standard 'Med-Arb' clause - a popular form of ADR: Mediation to identify the issues, and, if not successful, 3 arbitration to settle them - for inclusion in sports-related Commercial Agreements: 4.
If, and to the extent that, any such dispute has not been settled within 90 days of the commencement of the mediation, or if, before the expiration of the said period, either party fails to participate or continue to participate in the mediation, the dispute shall, upon filing of a Request for Arbitration by either party, be referred to and finally settled by CAS arbitration pursuant to the Code of Sports-related Arbitration.
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