October 2, 2018
TOJ-CRPS study
Temporal Order Judgment (TOJ) task
on patients with:
Complex Regional Pain Syndrome (CRPS)
unilateral wrist pain
unilateral shoulder pain
Researchers:
Lien Van der Biest
Valéry Legrain
Geert Crombez
- Goal
The goal of this study was to investigate processes of spatial attention in patients with complex regional pain syndrome (CRPS). Recently, neglect-like symptoms were found in CRPS patients, similar to those found in post-stroke brain-damaged patients(Moseley, Gallace, & Spence, 2009). Interestingly, this tendency to neglect tactile stimulation on the affected arm reversed when participants were asked to cross their arms. This pointed to a deficit in spatial attention processing, anchored to the region of space where the affected hand normally resides. In other words, it seems that the deficit was based on a spatiotopic frame of reference, rather than a somatotopic frame of reference. However, findings on this topic are scarce and inconsistent. This study aims to replicate the study of Moseley, Gallace and Spence (Moseley et al., 2009) and compare the group of CRPS patients to a group of unilateral wrist pain patients and a group of unilateral shoulder pain patients.
- Recruitment
2.1.Recruitment of patients with Complex Regional Pain Syndrome
Recruitment procedure:
Patients with complex regional pain syndrome (CRPS) were recruited by Prof. Hollevoet of the Orthopedics Department of the University Hospital Ghent and by dr. Jacobs of the Department of Rehabilitation of Maria Middelares Hospital (AZMMSJ) in Ghent. The doctor addressed supposedly eligible patients during consultation about the study and asked these patients permission to have the experimenter call them. The experimenter called interested patients to give more information about the study and were invited to the hospital to participate in the study.
Inclusion criteria:
-Age 18-70yrs
-Dutch-speaking
-CRPS, type I (duration > 3months; situated on the hand/arm)
Exclusion criteria:
-Contralateral upper body pain complaints
-Presence of nerve injury(e.g. CRPS, type II)
-Recent surgery (< 3 weeks) at painful hand
-Insufficiently corrected visual impairments
Post-experimental exclusion criteria for analysis:
-Contralateral upper body pain complaints at time of experiment
-Absence of research diagnosis of CRPS at time of experiment, based on diagnostic screening
Additional post-experimental exclusion criteria for analysis
-|PSS| uncrossed condition > 400analysis uncrossed condition only
-Performance on trials with highest SOA (complete sample)
(200/-200ms) in uncrossed condition < 75%
-|PSS| both conditions > 400
-Performance on trials with highest SOA analysis both conditions
(200/-200ms) in both conditions < 75%(partial sample)
FLOW-CHART RECRUITMENT/INCLUSION CRPS PATIENTS:
39 participants were contacted by telephone for participation/ Not eligible for participation (n=14)
>70yrs (n=1)
No CRPS, type I
CRPS symptoms already cleared (n=9)
Nerve injury (n=1)
Contralateral upper body pain (n=3)
Declinedparticipation (n=6)
No time/interest (n=5)
Other health reasons (n=1)
Unable to be reached (n=3)
16 participants agreed to participate and started the experiment
/ Discontinued participation (n=1)
Unable to perform adequately on task (n=1)
15 participants completed the experiment
/ Excluded from analysis(n=4)
Contralateral upper body pain at time ofexperiment (n=1)
No research diagnosis of CRPS at time of experiment, based on screening (n=3)
11 participants were included foranalysis of the uncrossed condition (complete sample)
/ Excluded fromanalysis both conditions(n=2)
|PSS both conditions| > 400 (n=2)
9 participants were included for the analysis of both conditions (partial sample)
2.2.Recruitment of patients with unilateral wrist pain
Recruitment procedure:
Patients with unilateral wrist pain were recruited by Prof. Hollevoet of the Orthopedics Department of the University Hospital Ghent. The doctor addressed supposedly eligible patients during consultation about the study and asked these patients permission to have the experimenter call them. The experimenter called interested patients to give more information about the study and were invited to the hospital to participate in the study.
Inclusion criteria:
-Age 18-70yrs
-Dutch-speaking
-Unilateral wrist pain (duration > 3 months)
Exclusion criteria:
-Contralateral upper body pain complaints
-Presence of nerve injury or CRPS
-Recent surgery (< 3 weeks) at painful wrist
-Insufficiently corrected visual impairments
Post-experimental exclusion criteria for analysis:
-Contralateral upper body pain complaints at time of experiment
-Presence of research diagnosis of CRPS at time of experiment, based on diagnostic screening
Additional post-experimental exclusion criteria for analysis
-|PSS| uncrossed condition > 400analysis uncrossed condition only
-Performance on trials with highest SOA (complete sample)
(200/-200ms) in uncrossed condition < 75%
-|PSS| both conditions > 400
-Performance on trials with highest SOA analysis both conditions
(200/-200ms) in both conditions < 75%(partial sample)
FLOW-CHART RECRUITMENT/INCLUSION UNILATERAL WRIST PAIN PATIENTS:
46 participants were contacted by telephone to participate/ Not eligible for participation (n=17)
Notdutch-speaking (n=1)
No pain at assessment (n=9)
Nerve injury (n=2)
Contralateral upper body pain (n=4)
Post-operative state (n=1)
Declinedparticipation (n=10)
No time/interest (n=6)
Distance to lab (n=2)
Other health reasons (n=2)
Unable to be reached (n=1)
18 participants agreed to participate in the experiment
/ Discontinued participation (n=2)
Cancelled appointment (n=2)
16 participants started and completed the experiment and were included for analysis of the uncrossed condition (complete sample)
/ Excluded from analysis both conditions (n=3)
Performance both conditions < 75% (n=3)
13 participants were included for the analysis of both conditions (partial sample)
2.3.Recruitment of patients with unilateral shoulder pain
Recruitment procedure:
Patients with unilateral shoulder pain were recruited by Prof De Wilde and dr. Van Tongel of the Orthopedics Department of the University Hospital Ghent. The doctor addressed supposedly eligible patients during consultation about the study and asked these patients permission to have the experimenter call them. The experimenter called interested patients to give more information about the study and were invited to the hospital to participate in the study.
Inclusion criteria:
-Age 18-70yrs
-Dutch-speaking
-Unilateral shoulder pain (duration > 3 months)
Exclusion criteria:
-Contralateral upper body pain complaints
-Presence of nerve injury or CRPS
-Recent surgery (< 3 weeks) at painful shoulder
-Insufficiently corrected visual impairments
Post-experimental exclusion criteria for analysis:
-Contralateral upper body pain complaints at time of experiment
-Presence of research diagnosis of CRPS at time of experiment, based on diagnostic screening
Additional post-experimental exclusion criteria for analysis
-|PSS| uncrossed condition > 400analysis uncrossed condition only
-Performance on trials with highest SOA (complete sample)
(200/-200ms) in uncrossed condition < 75%
-|PSS| both conditions > 400
-Performance on trials with highest SOA analysis both conditions
(200/-200ms) in both conditions < 75%(partial sample)
FLOW-CHART RECRUITMENT/INCLUSION UNILATERAL SHOULDER PAIN PATIENTS:
38 participants were contacted by telephone for participation/ Not eligible for participation (n=10)
No pain at assessment (n=4)
Nerve injury (n=1)
Contralateral upper body pain (n=2)
Post-operative state (n=3)
Declined participation (n=4)
No time/interest (n=3)
Distance to lab (n=1)
Unable to be reached (n=3)
21 participants agreed to participate in the experiment
/ Discontinued participation (n=1)
Did not show up for experiment (n=1)
20 participants started the experiment
/ Discontinued participation (n=2)
Unable to perform adequately on task (n=2)
18 participants completed the experiment
/ Excluded from analysis(n=3)
Contralateral upper body pain at time ofexperiment (n=3)
15 participants were included foranalysis of the uncrossed condition (complete sample)
/ Excluded from analysis both conditions(n=3)
Performance both conditions < 75% (n=2)
|PSS both conditions| > 400 (n=1)
12 participants were included for the analysis of both conditions (partial sample)
- Procedure
The procedure was identical for each of the three patient groups and consisted of 3parts:
-Completion of questionnaires
-Diagnostic screening
-Temporal Order Judgment (TOJ) task
All three parts were completed during one experimental session in the University Hospital Ghent.
3.1.Part 1
In the beginning of the experimental session, participants filled the following battery of questionnaires:
-Anamnestic information (ad hoc developed)
-Items on Coping with Painful Movements (ad hoc developed)
-Pain Grading Scale (Von Korff, Ormel, Keefe, & Dworkin, 1992)
-Hand Dominance Questionnaire (Van Strien, 1992)
-Multidimensional Pain Inventory – part 1 (MPI-part 1; Lousberg et al., 1999)
-McGillPainQuestionnaire(Vanderiet, Adriaensen, Carton, & Vertommen, 1987)
-The Survey of Pain Attitudes (SOPA; Jensen, Karoly, & Huger, 1987)
-DouleurNeuropathique 4 (DN4;Bouhassira et al., 2005)
-State-Trait Anxiety Inventory – Trait Scale (ZBV; Spielberger, 1987)
3.2.Part 2
Each participant underwent a screening procedure to confirm the presence (for CRPS patients) or absence (for unilateral wrist/shoulder patients) of the diagnosis of CRPS. The screening procedure was based on the Budapest Criteria for the researchdiagnosis of CRPS (Harden, 2010):
1)Continuing pain, disproportionate to any inciting event
2)Must report at leastone symptom in all following categories
- Sensory: hyperesthesia and/or allodynia
- Vasomotor: reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
- Sudomotor/edema: reports of edemaand/or sweating changes and/or sweating asymmetry
- Motor/trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nails, skin)
3)Must display at least one sign at time of evaluation on two of more of the following categories:
- Sensory: evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)
- Vasomotor: evidence of temperature asymmetry and/or skin color changes and/or skin color asymmetry
- Sudomotor/edema: evidence of edema and/or sweating changes and/or sweating asymmetry
- Motor/trophic: evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia), and/or trophic changes (hair, nails, skin)
4)There is no other diagnosis that better explains the signs and symptoms
-Criteria 1 was assessed by the responsible doctor
-Criteria 2 was assessed by the experimenter interviewing the patient
-Criteria 3 was assessed by the experimenter observing and measuring the patient
-Criteria 4 was assessed by the responsible doctor
The following methods/devices were used on both hands to assess criteria 3 of the diagnosis of CRPS:
-Hyperalgesia: pricking of Semmes-Weinstein filament no. 19 on hands (painfulness on 10-point Likert scale)
-Thermal allodynia: rolling of Rolltemp. Thermorollers on hands (painfulness on 10-point Likert scale)
-Brush allodynia: stroking of brush on hands (painfulness on 10-point Likert scale)
-Temperature asymmetry:temperature assessment of hands with infrared thermometer (°C of left/right hand)
-Skin color changes/asymmetry:picture and observation of hands
-Edema:volumetry indicator (circumference (cm) of hand and wrist)
-Sweating changes/asymmetry: observation of hands
-Range of motion: inclinometer (degrees of dorsal/palmar wrist flexion)
-Motor dysfunction: observation of hands
-Trophic changes: observation of hands
3.3.Part 3
The last part of the study involved performing a temporal order judgment task. The task consisted of three practice blocks and four experimental blocks. After each experimental block, participants filled in a series of items on how they perceived the stimuli and on how they experienced the experiment. Temperature of the hands was also assessed after each block.
- References
Bouhassira, D., Attal, N., Alchaar, H., Boureau, F., Brochet, B., Bruxelle, J., … Vicaut, E. (2005). Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain, 114(1-2), 29–36. doi:10.1016/j.pain.2004.12.010
Harden, R. N. (2010). Objectification of the diagnostic criteria for CRPS. Pain Medicine (Malden, Mass.), 11, 1212–1215. doi:10.1111/j.1526-4637.2010.00909.x
Jensen, M. P., Karoly, P., & Huger, R. (1987). The development and preliminary validation of an instrument to assess patients’ attitudes toward pain. Journal of Psychosomatic Research, 31(3), 393–400. doi:0022-3999(87)90060-2 [pii]
Lousberg, R., Van Breukelen, G. J. P., Groenman, N. H., Schmidt, A. J. M., Arntz, A., & Winter, F. A. M. (1999). Psychometric properties of the Multidimensional Pain Inventory, Dutch language version (MPI-DLV). Behaviour Research and Therapy, 37(2), 167–182. doi:10.1016/S0005-7967(98)00137-5
Moseley, G. L., Gallace, A., & Spence, C. (2009). Space-based, but not arm-based, shift in tactile processing in complex regional pain syndrome and its relationship to cooling of the affected limb. Brain, 132, 3142–3151. doi:10.1093/brain/awp224
Spielberger, C. D. (1987). State-Trait Anxiety Inventory. Anxiety, 19, 2009. doi:10.1037/t06496-000
Van Strien, J. W. (1992). Classificatie van links- en rechtshandige proefpersonen. Nederlands Tijdschrift Voor de Psychologie En Haar Grensgebieden, 47(2), 88–92.
Vanderiet, K., Adriaensen, H., Carton, H., & Vertommen, H. (1987). The McGill Pain Questionnaire constructed for the Dutch language (MPQ-DV). Preliminary data concerning reliability and validity. Pain, 30(3), 395–408. doi:10.1016/0304-3959(87)90027-3
Von Korff, M., Ormel, J., Keefe, F. J., & Dworkin, S. F. (1992). Grading the severity of chronic pain. Pain, 50(September 2015), 133–49. doi:10.1016/0304-3959(92)90154-4
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