Date Published: March 13, 2019
Publisher: Public Library of Science
Author(s): Ernst Schrier, Jan H. B. Geertzen, Jelmer Scheper, Pieter U. Dijkstra, Arezoo Eshraghi.
Amputation for longstanding therapy resistant complex regional pain syndrome type-I (CRPS-I) is controversial. Reported results are inconsistent. It is assumed that psychological factors play a role in CRPS-I.
To explore which psychological factors prior to amputation are associated with poor outcomes after amputation in the case of longstanding therapy resistant CRPS-I.
Between May 2008 and August 2015, 31 patients with longstanding therapy resistant CRPS-I were amputated. Before the amputation 11 psychological factors were assessed. In 2016, participants had a structured interview by telephone and filled out questionnaires to assess their outcome. In case of a perceived recurrence of CRPS-I a physician visited the patient to examine the symptoms. Associations between psychological factors and poor outcomes were analysed.
Four of the 11 psychological factors were associated with poor outcomes. Regression analyses showed that change in the worst pain in the past week was associated with poor social support (B = 0.3, 95% confidence interval: 0.1;0.6) and intensity of pain before amputation (B = 2.0, 95% confidence interval 0.9;3.0). Patients who reported important improvements in mobility (n = 23) had significantly higher baseline resilience (median 79) compared to those (n = 8) who did not report it (median 69)(Mann-Whitney U, Z = -2.398, p = 0.015). Being involved in a lawsuit prior to amputation was associated with a recurrence in the residual limb (Bruehl criteria). A psychiatric history was associated with recurrence somewhere else (Bruehl criteria).
Poor outcomes of amputation in longstanding therapy resistant CPRS-1 are associated with psychological factors. Outstanding life events are not associated with poor outcome although half of the participants had experienced outstanding life events.
Complex regional pain syndrome type-I (CRPS-I) is characterized by severe pain, sensory, vasomotor, sudomotor and trophic changes and can have a devastating effect on a person. CRPS-I generally develops after an injury but sometimes it develops spontaneously. Many treatments have been described but only a few are evidence based. Amputation in the case of longstanding therapy resistant CRPS-I is rare and controversial. It is rare because many patients with CRPS-I, recover within 6 to 13 months. It is controversial because some patients benefit from the amputation, while others experience the same symptoms or even experience an increase of symptoms after the amputation. These unpredictable outcomes make an amputation in longstanding therapy resistant CRPS-I debatable as treatment. Hesitation to amputate is strengthened by the assumed role of psychological factors or psychiatric disorders in the aetiology, development and maintenance of CPRS-I.[6–10] However, data supporting this assumption are scant. In the University Medical Centre Groningen (UMCG) the decision to amputate or not is made by a team of specialists together with the patient. For the psychologist, working in that team, a working hypothesis was that outcomes of an amputation would be negatively influenced by presence of some psychological factors: Poor Quality of Life (QOL) in the physical domain or psychological domain, low resilience, depression, anxiety, psychological distress, childhood adversity, life events, psychiatric (DSM-IV) history or psychiatric disorder, current lawsuit, and or poor social support.[12–14] In patients with an amputation for other causes, associations with poor QOL post amputation have been reported.[15–17] Poor QOL was associated with many factors including depression, social support, cognition, pain, independence in activities of daily living and comorbidity.[18, 19] Starting in May 2008 these factors were therefore routinely assessed during intake of patients who requested an amputation in the case of longstanding therapy resistant CRPS-I in our centre. Insight regarding which psychological factors are associated with poor outcomes could help the team to predict which patients suffering from longstanding therapy resistant CRPS-I should not be amputated. Current study is part of a larger outcome study of CRPS-I patients, amputated in the UMCG, starting in 2000. Of all the 48 patients participating in that study, 31 were assessed by a psychologist (ES) prior to amputation by means of a standardized interview and a set of questionnaires. The larger study focuses on several outcomes after amputation, assessed in 2015, but is cross-sectional in design. Focus of current study was to explore which psychological factors assessed prior to amputation are associated with poor outcomes after amputation.
The research protocol was approved by the local Medical Research Ethics Committee (METc 2015/561) and all participants signed an informed consent before the start of the study.
Thirty-one patients, mean (sd) age 41 (12.1), 6 men and 25 women, participated (Table 1).
This study focussed on associations between psychological factors before amputation and poor outcomes after amputation because of longstanding therapy resistant CRPS-I. Four risk factors were associated with poor outcomes. Poor social support or lower score on resilience were associated with poor outcomes regarding pain and mobility. Having a psychiatric disorder or a history of a psychiatric disorder or involvement in a lawsuit were associated with recurrence.
Poor outcomes of amputation in longstanding therapy resistant CPRS-1 are associated with psychological factors.