Kinesiophobia after complex regional pain syndrome type one in a case of stroke hemiplegia and effect of cognitive behavior therapy.

Sir,

Complex regional pain syndrome type one (CRPS-I) is a heterogeneous disorder that falls in the spectrum of neuropathic pain disorders.[1] More than 12% of hemiplegic patients’ rehabilitation programs are often seriously hampered by the development of CRPS-I.[2] Kinesiophobia is a condition, in which a patient has an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or reinjury.[3] Vlaeyen et al.[4] elaborated on the kinesiophobia phenomenon, defining it as a fear of movement/(re) injury, a specific fear believed to cause injury or reinjury. Since kinesiophobia is said to have a negative influence on the outcome of rehabilitation, this phenomenon ought to be taken into account in the clinical situation. Cognitive behavior therapy (CBT) is a psychological management strategy that may be helpful in reducing pain and kinesiophobia by treating the associated psychological and behavioral factors.[567] As kinesiophobia is associated with irrational and debilitating fear of physical movement and activity, which is a maladaptive and dysfunctional thought, CBT may be effective in reducing the pain-related fear, and thereby reducing pain and improving function.

A 57-year-old woman had a cerebrovascular accident resulting in the right-sided hemiparesis on October 26, 2016. She was treated at R. G. Kar Medical College and Hospital, West Bengal, India. After 1½ months of the incident, she developed CRPS-I in her right shoulder, wrist, and hand due to incorrect handling of the upper limb after stroke. Before her admission to Occupational Therapy at National Institute for Locomotor Disabilities, Kolkata, she was under nonsteroidal anti-inflammatory drugs/analgesics but that did not improve her complaints. Consent was obtained from the patient before participation in this study. On evaluation, she had pain and swelling over shoulder joint, wrist joint, and dorsum of the hand. On range of motion assessment, she had restriction of range of motion at shoulder, wrist, and finger joints. The forearm was cold and atrophic. Pain was always present; it was provoked by trying to move the arm, or by contact with surroundings or cloth even with slightest touch. She was not following the activities prescribed for upper limb rehabilitation by the occupational therapist due to fear of increase of pain with exercise. The patient was evaluated for pain, kinesiophobia, and upper limb function before and 6 weeks after CBT. Tampa Scale of Kinesiophobia (TSK) was used to measure Kinesiophobia. Visual analog scale (VAS): A 10-cm VAS was used to evaluate the hemiplegic upper limb pain. Function of the arm, shoulder, and hand was assessed by the Disability of Arm, Shoulder and Hand (DASH) measure.

The patient received CBT incorporating (1) cognitive reconditioning, that included relaxation training, deep breathing exercises, active engagement in activities for attention diversion and guided imagery and (2) behavioral modifications of specific activities (e.g., operant treatment, pacing, graded exposure to activities, and exercises) to modify and/or reduce the impact of pain and physical and psychosocial disability and to overcome barriers to physical and psychosocial recovery. The patient received CBT for 18 sessions, a session of 1 h duration, over 6 weeks.

After 6 weeks of CBT intervention, the intensity of pain reduced from a high score of 9-4, which says that though pain did not reduce completely, there was a definite reduction of pain after the implementation of CBT. The cognitive relearning and reconditioning used for this patient might have helped her in accepting pain, developing awareness of the problem, and seeking a means of coping with frightening thoughts and mood alterations. Kinesiophobia was significantly associated with pain intensity and poor self-perceived health. Kinesiophobia reduced from an initial score of 22-14 on TSK. With the reduction of pain intensity, kinesiophobia reduced. The intervention worked by means of modifying maladaptive and dysfunctional thoughts and improving mood (e.g., anxiety and depression), leading to gradual changes in cognition and illness behavior. Thus, upper limb function in DASH scale also improved (pre-DASH score 63 and post-DASH score 54).

Although kinesiophobia is a poorly addressed problem in stroke upper limb rehabilitation, if identified and managed through CBT at an early stage, there will be a better functional recovery of the upper limb in patients with stroke hemiplegia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.