- Email: [email protected]
T237 SENSORY AND PSYCHOLOGICAL PREDICTORS OF DISEASE-SPECIFIC IMPAIRMENT IN PATIENTS WITH FIBROMYALGIA SYNDROME
46
POSTER SESSIONS / European Journal of Pain Supplements 5 (2011) 15–295
and non-steroidal anti-inflammatory drugs. The present study compares the effects of the novel imidazoline-2 ligand CR4056 with gabapentin and amitriptyline, two clinical tools belonging to the family of the currently approved drugs, in a rat pain model mimicking human pathology and characterized by bilateral longlasting allodynia. Methods: Male Wistar rats (Harlan, S.Pietro al Natisone, Italy) were used for all experiments. The right gastrocnemius muscle was injected with 150 mL of pH = 4 sterile saline. Five days later, rats were re-injected using an identical protocol. Ipsilateral and contralateral paw withdrawal thresholds were measured using a Dynamic Plantar Aesthesiometer (Ugo Basile, Comerio, Varese, Italy). Results: Acute oral administration of CR4056 (range 0.6–20 mg/kg) dose-dependently increased the mechanical withdrawal thresholds of both ipsilateral and contralateral hindpaws, compared with vehicle control. The oral dose of 2 mg/kg CR4056 induced a full reversion of bilateral allodynia. The minimal effective dose (MED) of oral gabapentin was 100 mg/kg, while a full reversion of allodynia was achieved after intraperitoneal administration at lower doses (30 mg/kg). In agreement with previous data, oral administration of amitriptyline was found to be active (MED: 3 mg/kg). Conversely, both paracetamol (100 mg/kg) and celecoxib (30 mg/kg) were ineffective. Conclusions: CR4056 has now completed preclinical development and a phase I safety study in humans is currently ongoing to develop the compound as a first in class imidazoline-2 ligand in chronic and neuropathic pain conditions. Disclosure: This study was funded by the Rottapharm group. However, the Rottapharm group as a corporate entity had no role in the conduct of the study; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the abstract for publication.
T235 CORRELATION OF NK CELLS WITH SYMPTOM INTENSITY IN FIBROMYALGIA SYNDROME PATIENTS B. Nugraha1,2 *, C. Korallus1 , S. Zastrutzki3 , U. Hoppmann3 , 3 T. Framke4 , M. May5 , A. Koch4 , S. Engeli5 , B. Jager ¨ , H. Nave6,7 , 1 1 C. Gutenbrunner . Rehabilitation Medicine, Hannover Medical School, Hannover, Germany; 2 Chemistry, University of Indonesia, Depok, Indonesia; 3 Clinic for Psychosomatics and Psychotherapy, 4 Institute for Biometry, 5 Institute for Clinical Pharmacology, 6 Institute for Functional and Applied Anatomy, Hannover Medical School, Hannover, 7 Anatomy and Cell Biology, Martin Luther University of Halle-Wittenberg, Halle, Germany Background and Aims: Etiology fibromyalgia syndrome (FMS) are still poorly understood. Therefore, it is important to further investigate it in order to develop successful management of FMS. Immune cells play roles in many diseases, including FMS symptom. However, there are still lack knowledge related the immune cells function with FMS symptoms. Therefore further study aiming to correlate some immune cells and FMS symptoms are of importance. In this study, we correlated NK cells in FMS patients with FMSsymptoms such as pain, fatigue, anxiety, depression. Methods: All procedures were carried out with written consent of the subjects as approved by local ethics committee (Nr. 5498). In this preliminary study, sixty four FMS patients who matched definition of ACR filled-out 10 cm-visual analog scales of pain and fatigue. In addition, they were asked filled out the Hospital Anxiety and Depression Scale (HADS). NK cells (CD56) were evaluated by fluorescence-activated cell sorting (FACS) method. Statistics evaluation was done with SPSS 18. Results: There are correlations between NKbright and NKdim cells with fatigue (p < 0.005) and depression (p < 0.05). However, the correlation of NK cells and pain was not observed.
Conclusions: NK cell as one of immune cells have correlation with psychological symptoms of FMS. These results can be suggested as one of possible pathomechanism related to FMS symptom. Disclosure: None declared
T236 BEHAVIORAL AND NEUROPHYSIOLOGICAL INVESTIGATIONS OF HYPERVIGILANCE IN PATIENTS WITH FIBROMYALGIA SYNDROME L. Tiemann1 *, E. Schulz1 , A. Winkelmann2 , P. Henningsen3 , J. Ronel3 , M. Ploner1 . 1 Department of Neurology, TU M¨ unchen, 2 LMU 3 M¨ unchen, Department of Psychosomatic Medicine, TU M¨ unchen, Munich, Germany Background and Aims: Painful stimuli are of utmost behavioral relevance and affect our attentional resources. In health, both paininduced increases and decreases of attentional performance have been observed, indicating alerting as well as distracting effects of pain on attention. In the human brain, these effects are closely related to gamma oscillations. Dysfunctional attentional processes have been implicated in chronic pain states. Thus, as an expression of maladaptive changes in the attentional effects of pain, we assumed pain-induced gamma oscillations to be pathologically altered in chronic pain patients. Methods: We recorded EEG from healthy subjects (n = 22) and patients with fibromyalgia (n = 19) during a visual reaction time task. In 50% of the trials we applied painful laser stimuli. Results: Patients and healthy subjects did not differ concerning the strength of pain-induced gamma oscillations (F[1,39] = 0.95; p = 0.34). The effects of painful stimulation on reaction times and visual gamma oscillations were comparable between groups (F[1,39] = 1.7, p = 0.2; F[1,39] = 0.25; p = 0.6). We found a significant correlation between the pain-induced modulation of visual gamma oscillations and the pain-induced modulation of reaction times (r = 0.4; p = 0.01). However, this relationship did not differ between groups (z = −0.200, p < 0.8). Conclusions: These findings confirm a close relationship between gamma oscillations and the attentional effects of pain. Most importantly, these appear to be comparable in health and disease. Thus, our results do not indicate dysfunctional attentional processes in patients with FMS. Disclosure: None declared
T237 SENSORY AND PSYCHOLOGICAL PREDICTORS OF DISEASE-SPECIFIC IMPAIRMENT IN PATIENTS WITH FIBROMYALGIA SYNDROME L. Tiemann1 *, E. Schulz1 , A. Winkelmann2 , P. Henningsen3 , J. Ronel4 , M. Ploner1 . 1 Department of Neurology, TU M¨ unchen, 2 LMU M¨ unchen, 3 Department of Psychomoatic Medicine, 4 Department of Psychosomatic Medicine, TU M¨ unchen, Munich, Germany Background and Aims: Fibromyalgia syndrome (FMS) is a chronic condition characterized by widespread pain. Compared to healthy persons, patients usually display greater tenderness towards sensory stimulation as well as higher scores of anxiety, depression and attention towards pain. Here, we assessed the predictive value of these sensory and psychological factors for disease-specific impairment in patients with FMS. Methods: 22 healthy subjects and 20 patients with FMS received Quantitative Sensory Testing (QST) and completed questionnaires regarding depression (BDI), anxiety (STAI), catastrophizing (PCS), attention towards pain (PVAQ) and disease-specific impairment (FIQ). Multiple Regression Analysis was used to assess the predictive value of sensory and psychological factors for disease-specific impairment. Results: Compared to healthy subjects, patients with FMS showed significantly lower pressure- and heat pain thresholds (t > −2.0; p < 0.04) and lower laser pain thresholds (t = −1.9; p = 0.06).
POSTER SESSIONS / European Journal of Pain Supplements 5 (2011) 15–295
Moreover, patients displayed higher scores of depression, anxiety, catastrophizing and attention towards pain (t > 3.4; p < 0.002). Regression analysis indicated that sensory factors including pressure pain threshold and laser pain threshold were the best predictors of disease-specific impairment. Conclusions: Patients with FMS differ from healthy subjects concerning few sensory and numerous psychological factors. However, disease-specific impairment is best explained by sensory factors. In conformity with the central sensitization hypothesis, these findings emphasize the relevance of altered sensory processing for FMS. In contrast, augmented depressiveness, anxiety and catastrophizing may be a consequence of the disease rather than a causal element in its pathogenesis. Disclosure: None declared
T238 PAIN EXPOSURE PHYSICAL THERAPY (PEPT) IS A SAFE AND PROBABLY EFFECTIVE TREATMENT FOR LONGSTANDING COMPLEX REGIONAL PAIN SYNDROME TYPE 1 J.-W. Ek1 *, J. van Gijn1 , H. Samwel2 , J. van Egmond3 , F. Klomp4 , R. van Dongen3 . 1 Department of Rehabilitation Medicine, Bethesda Hospital Hoogeveen, Hoogeveen, 2 Institute for Anesthesiology, Pain Centre and Department of Clinical Psychology, 3 Institute for Anesthesiology, Pain Centre, 4 Department of Physical Therapy, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Background and Aims: To investigate a new and promising functional approach neglecting the pain (Pain Exposure Physical Therapy) for chronic crps type 1. Methods: Patients with longstanding crps (meeting the IASPcriteria for crps type 1) were included and treated with a functional approach, neglecting the pain. This approach is not in line with the usual approach with radical scavangers and physiotherapy restricted by pain tolerance. The mobility of the affected limb was measured with functional tests [Radboud Skills Test (arm), 7 meters walking, 3 steps up and down, walking distance (leg)]. Pain was measured with an NRS. Results: In 94 out of 102 patients with end stage crps type 1, earlier treated with various accepted therapies, the function of the affected extremity improved. Pain, although not directly treated, decreased in 75 patients. In a total of 45 patients function was completely restored. The RST limitation score improved 15 points and the effort score improved 5 points. The walking duration improved from 9.4 to 60 minutes. Conclusions: This pilot study provides evidence that this approach is safe and effective. The treatment is short, monodisciplinary, cheap and no side effects were observed. The main issue in the treatment is, that pain in crps 1 has no physiological aim and should not interfere with functional use by the patient, or with treatment by the therapists. The therapist ignores the pain, verbally and nonverbally. This must also be understood by the patients (and their relatives). Disclosure: None declared
T239 HOME TREATMENT OF CRPS WITH REPEATED DOSE SUBCUTANEOUS IMMUNOGLOBULIN OVER ONE YEAR: A CASE STUDY H. Poole1,2 *, B. Frank3 , L. Haynes2 , K. Maciver2 , L. Wyatt3 , A. Goebel2,3 . 1 Faculty of Science, Liverpool John Moores University, 2 Pain Research Institute, University of Liverpool, 3 The Walton Centre, Liverpool, UK Background and Aims: Chronic CRPS is a painful, debilitating condition associated with reduced quality of life (QoL). Single low dose (0.5 g/kg) intravenous immunoglobulin (IVIG) has been shown to be effective in some patients [1]. The current
47
investigation examined the effects of repeated subcutaneous homeadministration of immunoglobulin (SCIG) over one year. We evaluated treatment effect on pain, QoL and function Methods: Single case nested within an ongoing prospective open case control study. Patient AS (a single-dose IVIG-responder 5 years ago1 ), female, aged 43, had CRPS of 6 years duration affecting her left leg, and pain intensity of 7 (0–10 NRS) during screening. She received a single dose of IVIG, which reduced her pain. Subsequently AS self-administered SCIG weekly at home (1 g/kg/per month for 6 months, then 0.5 g/kg/month). AS measured pain and sleep daily, and Qol, physical functioning, mood and illness perceptions monthly. Clinical and psychosocial assessments were carried out bi-monthly. Quantitative sensory testing (QST) was performed before, and 2 months into SCIG therapy. In addition to receiving SCIG, AS saw a physiotherapist, occupational therapist and psychologist. Results: Pain intensity was reduced by 50% following IVIG, and was then further reduced by SCIG to a mean of NRS2.2, which remained stable. QoL (0.4 Quali gain), mood, physical functioning (walking) and allodynia improved. Conclusions: Treatment dramatically reduced symptoms of very longstanding CRPS and improved QoL, without apparent development of tolerance. SCIG home-application may be a viable option for IVIG responders. The lowest effective dose has yet to be established. Reference(s) [1] Goebel et al., Ann Intern Med, 2010. Disclosure: Dr. Goebel has received recearch support and speaker honoraria from CSL-Behring, Baxter and Talecris. These companies produce IVIG.
T240 FOLLOW-UP OF PAIN EXPOSURE PHYSICAL THERAPY FOR CRPS-1 J. van Egmond1 *, C. Koen2 , J.W. Ek2 , R. van Dongen3 , H. Samwel3 , F. Klomp4 , E. Draaijer2 . 1 Anesthesiology, University Medical Centre St Radboud, Nijmegen, 2 Department of Rehabilitation Medicine, Bethesda Hospital, Hoogeveen, 3 Anesthesiology, Pain, Palliative Medicin, 4 Physical Therapy, University Medical Centre St Radboud, Nijmegen, The Netherlands Background and Aims: Pain Exposure Physical Therapy (PEPT) is a therapy of reactivation, by functional approach and neglecting pain, for patients with long standing CRPS [1]. The present study investigates the evolution of CRPS symptoms of patients treated with PEPT 5 years ago. Methods: All patients fulfilling IASP criteria (199) treated with PEPT from 2004 to 2006 were invited to the hospital to reevaluate the same set of measurements as performed before and immediately after treatment. This set of measurements includes daily activity level, limb functionality and pain. Results: A group of 79 patients visited the hospital for reevaluation. Another group (63) was contacted for a structured interview by telephone. Both groups demonstrate further improvements, as shown in the table. Table: PEPT results Full recovery Hospital visit (n = 79)
T1
T2
P(T2-T1)
T3
P(T3-T2)
T2
T3
Max walking distance (legs, N = 44) (km) Radboud Skills Test (arms, N = 35) (range 0 to 20) Telephone (N = 63) Functionality NRS (0–10) Activity level NRS (0–10) Pain NRS (0–10)
0.52
3.8
<0.0001
5.3
0.035
20
25
20.0
7.3
<0.0001
3.5
0.0004
18
24
2.9 3.0 7.6
6.1 5.8 5.1
<0.0001 <0.0001 <0.0001
7.1 7.0 3.6
0.0017 0.0002 <0.0001
T1 = Before PEPT, T2 = after PEPT, T3 = after 5–6 years (2010).
Conclusions: PEPT is a safe and effective therapy for long standing CRPS. Sustained activity endures and improves the effects obtained by PEPT without recurrence of symptoms.
POSTER SESSIONS / European Journal of Pain Supplements 5 (2011) 15–295
and non-steroidal anti-inflammatory drugs. The present study compares the effects of the novel imidazoline-2 ligand CR4056 with gabapentin and amitriptyline, two clinical tools belonging to the family of the currently approved drugs, in a rat pain model mimicking human pathology and characterized by bilateral longlasting allodynia. Methods: Male Wistar rats (Harlan, S.Pietro al Natisone, Italy) were used for all experiments. The right gastrocnemius muscle was injected with 150 mL of pH = 4 sterile saline. Five days later, rats were re-injected using an identical protocol. Ipsilateral and contralateral paw withdrawal thresholds were measured using a Dynamic Plantar Aesthesiometer (Ugo Basile, Comerio, Varese, Italy). Results: Acute oral administration of CR4056 (range 0.6–20 mg/kg) dose-dependently increased the mechanical withdrawal thresholds of both ipsilateral and contralateral hindpaws, compared with vehicle control. The oral dose of 2 mg/kg CR4056 induced a full reversion of bilateral allodynia. The minimal effective dose (MED) of oral gabapentin was 100 mg/kg, while a full reversion of allodynia was achieved after intraperitoneal administration at lower doses (30 mg/kg). In agreement with previous data, oral administration of amitriptyline was found to be active (MED: 3 mg/kg). Conversely, both paracetamol (100 mg/kg) and celecoxib (30 mg/kg) were ineffective. Conclusions: CR4056 has now completed preclinical development and a phase I safety study in humans is currently ongoing to develop the compound as a first in class imidazoline-2 ligand in chronic and neuropathic pain conditions. Disclosure: This study was funded by the Rottapharm group. However, the Rottapharm group as a corporate entity had no role in the conduct of the study; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the abstract for publication.
T235 CORRELATION OF NK CELLS WITH SYMPTOM INTENSITY IN FIBROMYALGIA SYNDROME PATIENTS B. Nugraha1,2 *, C. Korallus1 , S. Zastrutzki3 , U. Hoppmann3 , 3 T. Framke4 , M. May5 , A. Koch4 , S. Engeli5 , B. Jager ¨ , H. Nave6,7 , 1 1 C. Gutenbrunner . Rehabilitation Medicine, Hannover Medical School, Hannover, Germany; 2 Chemistry, University of Indonesia, Depok, Indonesia; 3 Clinic for Psychosomatics and Psychotherapy, 4 Institute for Biometry, 5 Institute for Clinical Pharmacology, 6 Institute for Functional and Applied Anatomy, Hannover Medical School, Hannover, 7 Anatomy and Cell Biology, Martin Luther University of Halle-Wittenberg, Halle, Germany Background and Aims: Etiology fibromyalgia syndrome (FMS) are still poorly understood. Therefore, it is important to further investigate it in order to develop successful management of FMS. Immune cells play roles in many diseases, including FMS symptom. However, there are still lack knowledge related the immune cells function with FMS symptoms. Therefore further study aiming to correlate some immune cells and FMS symptoms are of importance. In this study, we correlated NK cells in FMS patients with FMSsymptoms such as pain, fatigue, anxiety, depression. Methods: All procedures were carried out with written consent of the subjects as approved by local ethics committee (Nr. 5498). In this preliminary study, sixty four FMS patients who matched definition of ACR filled-out 10 cm-visual analog scales of pain and fatigue. In addition, they were asked filled out the Hospital Anxiety and Depression Scale (HADS). NK cells (CD56) were evaluated by fluorescence-activated cell sorting (FACS) method. Statistics evaluation was done with SPSS 18. Results: There are correlations between NKbright and NKdim cells with fatigue (p < 0.005) and depression (p < 0.05). However, the correlation of NK cells and pain was not observed.
Conclusions: NK cell as one of immune cells have correlation with psychological symptoms of FMS. These results can be suggested as one of possible pathomechanism related to FMS symptom. Disclosure: None declared
T236 BEHAVIORAL AND NEUROPHYSIOLOGICAL INVESTIGATIONS OF HYPERVIGILANCE IN PATIENTS WITH FIBROMYALGIA SYNDROME L. Tiemann1 *, E. Schulz1 , A. Winkelmann2 , P. Henningsen3 , J. Ronel3 , M. Ploner1 . 1 Department of Neurology, TU M¨ unchen, 2 LMU 3 M¨ unchen, Department of Psychosomatic Medicine, TU M¨ unchen, Munich, Germany Background and Aims: Painful stimuli are of utmost behavioral relevance and affect our attentional resources. In health, both paininduced increases and decreases of attentional performance have been observed, indicating alerting as well as distracting effects of pain on attention. In the human brain, these effects are closely related to gamma oscillations. Dysfunctional attentional processes have been implicated in chronic pain states. Thus, as an expression of maladaptive changes in the attentional effects of pain, we assumed pain-induced gamma oscillations to be pathologically altered in chronic pain patients. Methods: We recorded EEG from healthy subjects (n = 22) and patients with fibromyalgia (n = 19) during a visual reaction time task. In 50% of the trials we applied painful laser stimuli. Results: Patients and healthy subjects did not differ concerning the strength of pain-induced gamma oscillations (F[1,39] = 0.95; p = 0.34). The effects of painful stimulation on reaction times and visual gamma oscillations were comparable between groups (F[1,39] = 1.7, p = 0.2; F[1,39] = 0.25; p = 0.6). We found a significant correlation between the pain-induced modulation of visual gamma oscillations and the pain-induced modulation of reaction times (r = 0.4; p = 0.01). However, this relationship did not differ between groups (z = −0.200, p < 0.8). Conclusions: These findings confirm a close relationship between gamma oscillations and the attentional effects of pain. Most importantly, these appear to be comparable in health and disease. Thus, our results do not indicate dysfunctional attentional processes in patients with FMS. Disclosure: None declared
T237 SENSORY AND PSYCHOLOGICAL PREDICTORS OF DISEASE-SPECIFIC IMPAIRMENT IN PATIENTS WITH FIBROMYALGIA SYNDROME L. Tiemann1 *, E. Schulz1 , A. Winkelmann2 , P. Henningsen3 , J. Ronel4 , M. Ploner1 . 1 Department of Neurology, TU M¨ unchen, 2 LMU M¨ unchen, 3 Department of Psychomoatic Medicine, 4 Department of Psychosomatic Medicine, TU M¨ unchen, Munich, Germany Background and Aims: Fibromyalgia syndrome (FMS) is a chronic condition characterized by widespread pain. Compared to healthy persons, patients usually display greater tenderness towards sensory stimulation as well as higher scores of anxiety, depression and attention towards pain. Here, we assessed the predictive value of these sensory and psychological factors for disease-specific impairment in patients with FMS. Methods: 22 healthy subjects and 20 patients with FMS received Quantitative Sensory Testing (QST) and completed questionnaires regarding depression (BDI), anxiety (STAI), catastrophizing (PCS), attention towards pain (PVAQ) and disease-specific impairment (FIQ). Multiple Regression Analysis was used to assess the predictive value of sensory and psychological factors for disease-specific impairment. Results: Compared to healthy subjects, patients with FMS showed significantly lower pressure- and heat pain thresholds (t > −2.0; p < 0.04) and lower laser pain thresholds (t = −1.9; p = 0.06).
POSTER SESSIONS / European Journal of Pain Supplements 5 (2011) 15–295
Moreover, patients displayed higher scores of depression, anxiety, catastrophizing and attention towards pain (t > 3.4; p < 0.002). Regression analysis indicated that sensory factors including pressure pain threshold and laser pain threshold were the best predictors of disease-specific impairment. Conclusions: Patients with FMS differ from healthy subjects concerning few sensory and numerous psychological factors. However, disease-specific impairment is best explained by sensory factors. In conformity with the central sensitization hypothesis, these findings emphasize the relevance of altered sensory processing for FMS. In contrast, augmented depressiveness, anxiety and catastrophizing may be a consequence of the disease rather than a causal element in its pathogenesis. Disclosure: None declared
T238 PAIN EXPOSURE PHYSICAL THERAPY (PEPT) IS A SAFE AND PROBABLY EFFECTIVE TREATMENT FOR LONGSTANDING COMPLEX REGIONAL PAIN SYNDROME TYPE 1 J.-W. Ek1 *, J. van Gijn1 , H. Samwel2 , J. van Egmond3 , F. Klomp4 , R. van Dongen3 . 1 Department of Rehabilitation Medicine, Bethesda Hospital Hoogeveen, Hoogeveen, 2 Institute for Anesthesiology, Pain Centre and Department of Clinical Psychology, 3 Institute for Anesthesiology, Pain Centre, 4 Department of Physical Therapy, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Background and Aims: To investigate a new and promising functional approach neglecting the pain (Pain Exposure Physical Therapy) for chronic crps type 1. Methods: Patients with longstanding crps (meeting the IASPcriteria for crps type 1) were included and treated with a functional approach, neglecting the pain. This approach is not in line with the usual approach with radical scavangers and physiotherapy restricted by pain tolerance. The mobility of the affected limb was measured with functional tests [Radboud Skills Test (arm), 7 meters walking, 3 steps up and down, walking distance (leg)]. Pain was measured with an NRS. Results: In 94 out of 102 patients with end stage crps type 1, earlier treated with various accepted therapies, the function of the affected extremity improved. Pain, although not directly treated, decreased in 75 patients. In a total of 45 patients function was completely restored. The RST limitation score improved 15 points and the effort score improved 5 points. The walking duration improved from 9.4 to 60 minutes. Conclusions: This pilot study provides evidence that this approach is safe and effective. The treatment is short, monodisciplinary, cheap and no side effects were observed. The main issue in the treatment is, that pain in crps 1 has no physiological aim and should not interfere with functional use by the patient, or with treatment by the therapists. The therapist ignores the pain, verbally and nonverbally. This must also be understood by the patients (and their relatives). Disclosure: None declared
T239 HOME TREATMENT OF CRPS WITH REPEATED DOSE SUBCUTANEOUS IMMUNOGLOBULIN OVER ONE YEAR: A CASE STUDY H. Poole1,2 *, B. Frank3 , L. Haynes2 , K. Maciver2 , L. Wyatt3 , A. Goebel2,3 . 1 Faculty of Science, Liverpool John Moores University, 2 Pain Research Institute, University of Liverpool, 3 The Walton Centre, Liverpool, UK Background and Aims: Chronic CRPS is a painful, debilitating condition associated with reduced quality of life (QoL). Single low dose (0.5 g/kg) intravenous immunoglobulin (IVIG) has been shown to be effective in some patients [1]. The current
47
investigation examined the effects of repeated subcutaneous homeadministration of immunoglobulin (SCIG) over one year. We evaluated treatment effect on pain, QoL and function Methods: Single case nested within an ongoing prospective open case control study. Patient AS (a single-dose IVIG-responder 5 years ago1 ), female, aged 43, had CRPS of 6 years duration affecting her left leg, and pain intensity of 7 (0–10 NRS) during screening. She received a single dose of IVIG, which reduced her pain. Subsequently AS self-administered SCIG weekly at home (1 g/kg/per month for 6 months, then 0.5 g/kg/month). AS measured pain and sleep daily, and Qol, physical functioning, mood and illness perceptions monthly. Clinical and psychosocial assessments were carried out bi-monthly. Quantitative sensory testing (QST) was performed before, and 2 months into SCIG therapy. In addition to receiving SCIG, AS saw a physiotherapist, occupational therapist and psychologist. Results: Pain intensity was reduced by 50% following IVIG, and was then further reduced by SCIG to a mean of NRS2.2, which remained stable. QoL (0.4 Quali gain), mood, physical functioning (walking) and allodynia improved. Conclusions: Treatment dramatically reduced symptoms of very longstanding CRPS and improved QoL, without apparent development of tolerance. SCIG home-application may be a viable option for IVIG responders. The lowest effective dose has yet to be established. Reference(s) [1] Goebel et al., Ann Intern Med, 2010. Disclosure: Dr. Goebel has received recearch support and speaker honoraria from CSL-Behring, Baxter and Talecris. These companies produce IVIG.
T240 FOLLOW-UP OF PAIN EXPOSURE PHYSICAL THERAPY FOR CRPS-1 J. van Egmond1 *, C. Koen2 , J.W. Ek2 , R. van Dongen3 , H. Samwel3 , F. Klomp4 , E. Draaijer2 . 1 Anesthesiology, University Medical Centre St Radboud, Nijmegen, 2 Department of Rehabilitation Medicine, Bethesda Hospital, Hoogeveen, 3 Anesthesiology, Pain, Palliative Medicin, 4 Physical Therapy, University Medical Centre St Radboud, Nijmegen, The Netherlands Background and Aims: Pain Exposure Physical Therapy (PEPT) is a therapy of reactivation, by functional approach and neglecting pain, for patients with long standing CRPS [1]. The present study investigates the evolution of CRPS symptoms of patients treated with PEPT 5 years ago. Methods: All patients fulfilling IASP criteria (199) treated with PEPT from 2004 to 2006 were invited to the hospital to reevaluate the same set of measurements as performed before and immediately after treatment. This set of measurements includes daily activity level, limb functionality and pain. Results: A group of 79 patients visited the hospital for reevaluation. Another group (63) was contacted for a structured interview by telephone. Both groups demonstrate further improvements, as shown in the table. Table: PEPT results Full recovery Hospital visit (n = 79)
T1
T2
P(T2-T1)
T3
P(T3-T2)
T2
T3
Max walking distance (legs, N = 44) (km) Radboud Skills Test (arms, N = 35) (range 0 to 20) Telephone (N = 63) Functionality NRS (0–10) Activity level NRS (0–10) Pain NRS (0–10)
0.52
3.8
<0.0001
5.3
0.035
20
25
20.0
7.3
<0.0001
3.5
0.0004
18
24
2.9 3.0 7.6
6.1 5.8 5.1
<0.0001 <0.0001 <0.0001
7.1 7.0 3.6
0.0017 0.0002 <0.0001
T1 = Before PEPT, T2 = after PEPT, T3 = after 5–6 years (2010).
Conclusions: PEPT is a safe and effective therapy for long standing CRPS. Sustained activity endures and improves the effects obtained by PEPT without recurrence of symptoms.