HYPNOSIS AND RSD
The use of Hypnosis in the treatment of RSD is somewhat controversial and has had mixed results. Some of this stems from the fact that RSD patients are wary of any treatment that might possibly insinuate the pain is in your head and that reported positive results have been few and far between. Because of the recent work by Dr Flemming though, some of these ideas need to be re-considered. He has had some very positive results but cautions that if done incorrectly, it can cause more harm than good. I recently had a discussion with him regarding this and he shared his results with me as follows. In RSD, hypnosis is the generation of images in the mind that can alter function of the autonomic nervous system. This is a normal ability -- examples include generation of images of food leading to salivation, imagining something scary which can lead to fast heart rate and so on. In a normal population, some people are totally fluent at this, some can barely do it at all. Most people have an average capacity, they can use images to alter autonomic function moderately well.
If RSD is vectored by autonomic function, (which it definitely is) one might not be surprised if using appropriate images can alter both symptoms and physical signs of RSD. My jaw hit the floor when I saw this happen the first time. The woman had long established RSD with her left arm contracted so it was stuck at her right shoulder with the head pulled down to the left. Using specific images, her arm relaxed totally, it became totally pain free, the muscular spasm faded and she regained full movement of her arm, shoulder neck and head. More importantly the vascular spasm released so the arm and hand became normally perfused. After recovering composure, I decided to explore this technique on a series of patients at the Univesity of Chicago, and in my first 13 patients, saw long term remission in about two thirds. We put these cases into the American Pain Society annual meeting as a poster presentation in about 1992, and at this meeting, found Michael Gainer, a psychologist who had been using similar techniques on a series of patients in Akron, Ohio. He and I decided to form a free-standing clinic specifically to treat RSD and this opened in 1994. We continued work until 1999 and closed after selling the clinic to a physician's practice management group.
Over these years, we saw approximately 1000 patients with RSD. Almost all these patients had been credibly diagnosed at academic pain treatment centers in the Chicago area and all had failed in conventional treatment protocols. We applied a seamlessly integration of standard medicine, advanced hypnotic and psycological methods together with rehabilitative therapy including massage therapy (not a la Craig's List). We were able to follow up firstly on about 42 patients in whom we saw the same outcome as our initial 13, and then on the 250 with whom we could still communicate. Again, 60% were able to gain long term remission as defined by loss of symptoms, absent need for medications and resotration of function. We published in the Clinical Bulletin of Myofascial Therapy (such a waste) and did a more extensive poster presentation at the APS.
This is a summary of what we learned:
1. RSD seemed to affect people at either of the extremes of hypnotic ability. An average hypnotic ability seemed to afford immunity to the disease.
2. People at the high end of the scale were able to modify symptoms with fluency. 85% of patients had an extreme hypnotic ability. 15% had essentially none.
3. People at the low end of the scale had no capacity to modify symptoms. None of these patients recovered.
4. The extent to which patients were able to reduce symptoms during their first experience of hypnosis was predictive of their ability to gain long term remission.
5. Patients able to reduce symptoms using hypnosis fell into 3 approximately even groups:
a. Group 1 -- patients quickly learned these techniques -- they essentially gained recovery during their first 2 weeks of treatment.
b. Group 2 -- in which RSD was kept alive by diagnosable sources of pain, such as nerve entrapment, mononeuropathy, arthritis and so on. I only remember one smoker who recovered -- nicotine stimulates sympathetic activity and makes it more difficult to take control using hypnosis.
c. Group 3 -- in which the symptoms of RSD formed the presentation of behavioral issues.
We were left convinced that hypnosis, when integrated with standard medical management and rehabilitative therapy has an extremely powerful role in the management of RSD.
Points to remember:
First -- it is difficult to discern which patient will fit into which group early in evaluation.
Second -- If a patient has a psychological/behavioral component to RSD, a lay hypnotist can cause SERIOUS DAMAGE by attempting to coax remission without addressing the psychological issues. This work requires EXTREME SKILL and must be taken VERY SERIOUSLY.
Third -- RSD is definitely a physical disease. However behavioral involvement is clear -- for example most patients describe worsening of symptoms with stress, the placebo response is about 60%, people with average hypnotizability don't seem to suffer from RSD, patients receiving specific forms of behavioral therapy seem to gain remission much more commonly than those who do not. Behavioral components do not necessily indicate psychological disease -- Again, behaviors can be normal responses to life's situations, but they can suggest routes to remission.
DO NOT BE AFRAID of psychological/behavioral issues to do with RSD. It does NOT mean that RSD is "all in your head." RSD is definitely a physical disease, but behavioral components do exist, as they do in practically all illnesses, and addressing them may be vital to gaining remission. The above represents only the tip of the iceberg of information applicable to this field. Please let me know if you would like more information, and if you would like me to send the text and figures from our scientific presentations. I am aware, of course, of the controversy in which various teams suggest that behavioral components exist vs. do not exist. Each side to this argument has merit, the most important feature of this note is the implied invitiation for the various contenders to begin sensible dialogue.
David Flemming, MD.