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May 2001; Volume 4; 56-58
By V. Jane Kattapong, MD
Who except the gods can live time through forever without any pain?
Aeschylus, Prometheus Bound
Complex regional pain syndrome (CRPS), also known as reflex sympathetic dystrophy or sympathetically mediated pain, is a poorly understood pain syndrome that often is refractory to medical management. CRPS typically begins after an injury, usually involving the distal extremities.1 Often the inciting injury is a bony fracture. A wide variety of other factors have been reported to potentiate CRPS, including soft tissue injury, venipuncture, intramuscular injection, dental extraction, casts, medications, myocardial or cerebrovascular ischemia, carcinoma, osteomyelitis, multiple sclerosis, spondylosis, seizures, and peripheral neuropathy.1 After the initial insult, an intense burning, throbbing, or aching pain develops in a region that often involves a much greater area than was initially injured. Signs of vasomotor instability, including swelling, sweating, and color and temperature changes, typically develop.2
|Table 1: Factors associated with the development of CRPS|
Bony fracture of the distal extremities
Early mobilization of injured extremities decreases the incidence of reflex sympathetic dystrophy.3 If CRPS does develop, physical therapy helps relieve pain and maintain range of motion. Pharmacologic treatment options include alpha- and beta-blockers to inhibit local sympathetic output and modulate vasomotor tone. Calcitonin is beneficial in about 60% of patients, via an unknown mechanism.1 Medications that combat neuropathic pain syndromes also may be beneficial; these include tricyclic and tetracyclic antidepressants and antiepileptic agents. Non-steroidal anti-inflammatory agents, prednisone, and lidocaine patches all have a place in the pharmacologic armamentarium for this disorder as well.4 For patients who respond incompletely to these medications, sympathetic blocks may offer temporary relief.
While early treatment with sympathetic blockade or pharmacologic therapy may provide relief in early-stage CRPS, treatment of late-stage CRPS is much more problematic.5 Late-stage CRPS is regarded as generally being refractory to traditional modalities of pain therapy. Consequently, late-stage CRPS lends itself well to therapeutic trials of complementary or integrative therapeutic modalities, such as traditional Chinese medicine (TCM).
What is Qigong?
Qigong is one form of TCM. Qi means vital energy, and gong means training. Qi is composed of yin and yang, or negative and positive energy. TCM practitioners believe that when yin and yang are not in equilibrium, illness may occur.5 The Qigong Association of America describes qigong in the following way: "Qigong is a self-healing art that combines movement and meditation. Visualizations are employed to enhance the mind/body connection and assist healing."6 According to the National Qigong Association, qigong is a 3,000-year-old Chinese healing practice that is based on the precept: "Stagnation equals illness. Movement creates wellness."7
The principles upon which the practice of qigong was founded include the belief that the sensation or feeling of poor physical or emotional health is correlated with inadequate movement of the body, mind, and spirit. Traditional qigong practitioners incorporated forms of physical movement such as dance to alter their own energy or qi.7 As qigong principles and practice evolved, simple dance became replaced with specific patterns of movement, breathing, and meditation. According to the Qigong Association of America, "Regular practice of qigong can: prevent and treat illness, reduce stress—establish balance, integrate mind/body/spirit—bring peace."6The Practice of Qigong
Qigong can be practiced at any time or any place, while sitting, standing, lying, or walking. It can be practiced for as little as a few minutes at a time or for longer amounts of time. Thus, few spatial or temporal requirements are needed for the practice of qigong.8 In comparison to Tai Chi, which incorporates physical movement and meditation, qigong utilizes breathing techniques and meditation to promote internal movement. Thus, to an outside observer, an individual engaging in qigong might not appear noticeably different from an individual standing quietly.Qigong and Physiological Parameters
Although the reproducibility of these results is unclear, qigong exercise has been reported to produce alterations in many physiological parameters. Qigong exercise has been reported to alter neurotransmitter levels, cardiovascular parameters, joint pain, and muscle spasm; vasoconstriction also has been reported.9-13
Controlled Trial of Qigong and CRPS
Methods. Few rigorously gathered data have been published about qigong and CRPS. In the one randomized study, 26 patients with intractable CRPS, ranging in age from 18 to 65 years of age, were recruited to participate in a 10-week, blinded protocol.5 The patients received either actual qigong training or sham qigong training. Diagnostic criteria for study inclusion included the requirement that at least five of the following attributes were present:
All patients were classified as treatment failures, defined as failure to experience 50% reduction in pain through conventional pharmacologic therapy, physical therapy, or chiropractic therapy.
Patients assigned to the treatment group received six biweekly, 40-minute training sessions from a recognized qigong master. The sessions included exposure to qigong musical compositions and art, as well as qigong exercise. Patients in the control group received simulated training sessions with an instructor who was not a qigong master. The sham instructor was an individual of Asian descent. These patients viewed abstract art images and listened to non-qigong influenced music.
After the completion of these sessions, each group was asked to practice the techniques and exercises that they had been taught for seven additional weeks.
Outcome Measures. At the time of study entry, all participants completed a series of evaluations, including a comprehensive history and physical exam, diagnostic testing such as three-phase bone scan, a 90-item symptom check list, a test of responsiveness to suggestions, and an evaluation of patient expectation.5
Monitoring of patients occurred during weeks one, three, six, and 10. Outcome measures that were utilized included thermography (assessment of skin surface temperatures), range of motion of the affected limb, physical findings, response to pain intensity rating scales, medication usage, behavioral assessment via a subscale of the Sickness Impact Profile, determination of frequency of night-time awakening caused by pain, mood assessment via the Beck Depression Inventory, and an assessment of anxiety level. In addition, participants were asked to complete a 10-point rating scale regarding their level of confidence that they had been assigned to the treatment group rather than the control group.
Results. Eleven patients completed the protocol in each of the two groups. Participants in both the treatment and control groups tended to believe they were participating in the treatment group: On a 10-point scale with 10 indicating complete confidence in having participated in the treatment group, the mean score for qigong participants was 7.9 and the mean score for control group participants was 6.2. There was no statistically significant difference in the scores of these two groups.
There was no statistically significant long-term difference between the two groups in pain intensity rating on a visual analog pain scale. However, an analysis of variance including the variables group membership (qigong or control), treatment session (session 1 or session 6), and time of assessment (before or after session) demonstrated a significant two-way interaction of group membership with time of assessment, suggesting that a temporary improvement in pain perception may occur during qigong performance.5
There were no statistically significant differences between the treatment and control groups in scoring of physical indicators including swelling, skin discoloration, dystonia, dystrophic changes, joint range of motion, or thermography. In addition, no statistically significant differences were found between groups in a behavioral assessment using the Sickness Impact Profile.5 However, the mood assessment evaluation suggested that all participants experienced less anxiety with time, and that participants who received qigong training experienced less anxiety than those who did not.5
Although Wu et al did not report side effects in the group of patients studied, other sources have reported mental side effects, ranging from serious mental disorders to mild mental symptoms. These have included qigong-induced or qigong-precipitated psychosis. It has been suggested that psychosis only occurs in individuals predisposed to development of this disorder.14 Mild symptoms have included the experience of transient illusions or "pseudohallucinations"15 and alterations in perception, thinking, and behavior.16
The only study of qigong and CRPS has notable limitations. Small numbers of patients participated, the randomization procedure was unclear, the control group differed from the treatment group in terms of gender distribution, and the trainers were not blinded. Thus, the finding that qigong training may give rise to short-term perceived decreases in pain intensity in patients with late-stage CRPS, and may result in long-term reduction in anxiety in these patients, cannot be confirmed. On the other hand, qigong’s long tradition, simplicity, ease, and structure are appealing and warrant further study.
Since only a few transitory side effects have been reported to be associated with qigong, and one limited controlled study has suggested some beneficial effects, it appears that qigong may be recommended appropriately as a useful therapeutic modality for most patients with end-stage CRPS. However, patients who are predisposed to the development of psychotic symptoms should engage in this technique with caution or not at all.
Dr. Kattapong is a board-certified neurologist and a principal in MediCat Consulting, a health services consulting firm in Tucson, AZ.
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