Assessment ofAssessment ofComplex Regional Pain Complex Regional Pain

SyndromeSyndromeDr. Candy McCabe Dr. Candy McCabe

Consultant NurseConsultant Nursearc Senior Lecturer in Rheumatology Nursingarc Senior Lecturer in Rheumatology Nursing

Royal National Hospital for Rheumatic Royal National Hospital for Rheumatic Diseases Diseases

& School for Health, University of Bath, & School for Health, University of Bath, BathBath

The North British Pain Association 2008

Rene Descartes 1596-1650

“I think therefore I am”

Jean-Jacques Rousseau, 1712-1778

“I FEEL therefore I am”

Silas Weir Mitchell 1829-1914Turner’s Lane Hospital, Philadelphia

IASP Current diagnostic criteriaIASP Current diagnostic criteria

Complex Regional Pain Syndrome Type IComplex Regional Pain Syndrome Type I Follows an initiating noxious eventFollows an initiating noxious event Spontaneous pain and/or allodynia and Spontaneous pain and/or allodynia and

hyperalegesia occur beyond area of a single hyperalegesia occur beyond area of a single peripheral nerve and disproportionate to the peripheral nerve and disproportionate to the inciting event.inciting event.

Evidence or has been evidence of oedema, Evidence or has been evidence of oedema, skin blood flow abnormality and sudomotor skin blood flow abnormality and sudomotor changes.changes.

CRPS Type IICRPS Type II Follows nerve injuryFollows nerve injury More regionally confined areaMore regionally confined area

Stanton-Hicks M, Janig W, et al. Pain, 1995; 63: 127-133.

IASP SIG proposed revised IASP SIG proposed revised diagnostic criteriadiagnostic criteria

Hyperalagesia/ hyperaesthesia (sensory)Hyperalagesia/ hyperaesthesia (sensory) Temperature and colour changes Temperature and colour changes

(vasomotor)(vasomotor) Oedema and sweating (sudomotor)Oedema and sweating (sudomotor) Trophic and motor changesTrophic and motor changes

Clinical criteria: 2 signs and 3 symptomsClinical criteria: 2 signs and 3 symptoms Research criteria: 2 signs and 4 Research criteria: 2 signs and 4

symptomssymptoms

Galer et al., 1998. Pain; 14:48-54 Bruehl et al., 1999. Pain; 81:147-54

Presentation of CRPSPresentation of CRPS Incidence rates of 5.46 to 26.2 per 100,000 Incidence rates of 5.46 to 26.2 per 100,000

person years. UK incidence unknown. person years. UK incidence unknown. Sandroni et al Pain 2003 (Minnesota, USA); Sandroni et al Pain 2003 (Minnesota, USA); De Mos et al Pain 2007 (Netherlands)De Mos et al Pain 2007 (Netherlands) Onset of symptoms may be immediate following Onset of symptoms may be immediate following

trauma or within one month of limb trauma or within one month of limb immobilisationimmobilisation

50% go on to suffer chronic symptoms and long 50% go on to suffer chronic symptoms and long term physical impairmentterm physical impairment

Field et al. Journal of hand Surgery 1992, Field et al. Journal of hand Surgery 1992, Schasfoort et al. Arch. Physical Med. & rehab. 2004.Schasfoort et al. Arch. Physical Med. & rehab. 2004. Disturbance in sensory, motor and autonomic Disturbance in sensory, motor and autonomic

systems which may fluctuate over time and even systems which may fluctuate over time and even over a single day. over a single day.

Diagnosis and therapy delayed by closeness in Diagnosis and therapy delayed by closeness in nomenclature between ‘Chronic’ and ‘Complex’ nomenclature between ‘Chronic’ and ‘Complex’ regional pain syndrome. regional pain syndrome.

Excessive pain in the presence of Excessive pain in the presence of minor or no injury tends to be minor or no injury tends to be

disbelieveddisbelieved

Case study-limb perceptionCase study-limb perception

Altered body perception Altered body perception with and without visual with and without visual feedbackfeedback

Finger misidentificationFinger misidentification Forderreüther et al. Pain 2004

Referred sensations-Referred sensations-face to wrist face to wrist

McCabe et al. Rheumatology 2003

Referred Sensations in CRPSReferred Sensations in CRPS

Halligan PW et al. BMJ 1999

Referred Sensations in AmputeesReferred Sensations in Amputees

Cortical reorganisation in CRPSCortical reorganisation in CRPS Juottonen et al., Altered central Juottonen et al., Altered central

sensorimotor processing in sensorimotor processing in patients with CRPS. Pain 2002; patients with CRPS. Pain 2002; 98:315-323. 98:315-323.

Maihöfner et al., Patterns of Maihöfner et al., Patterns of cortical reorganisation in CRPS cortical reorganisation in CRPS Neurology 2003; 61:1707-Neurology 2003; 61:1707-1715. Neurology 2004, Pain 1715. Neurology 2004, Pain 20052005

Maihöfner et al.,The motor Maihöfner et al.,The motor system shows adaptive system shows adaptive changes in CRPS. Brain changes in CRPS. Brain 2007;130:2671-87.2007;130:2671-87.

Pleger et al., Sensorimotor Pleger et al., Sensorimotor returning in CRPS parallels pain returning in CRPS parallels pain reduction. Annals of Neurology reduction. Annals of Neurology 2005;57(3):425-4292005;57(3):425-429

Wilder PenfieldWilder Penfield

Motor assessmentMotor assessment Reduced grip Reduced grip

strengthstrength and ROMand ROM Slow to ‘connect’ Slow to ‘connect’

with affected limb with affected limb when asked to move when asked to move itit

Greater range with Greater range with imagined movement imagined movement

Able to perform Able to perform bilateral bilateral synchronised synchronised movements with movements with mirror visual mirror visual feedbackfeedback

Motor abnormalities in CRPSMotor abnormalities in CRPS Slower response times in the affected limb with limb Slower response times in the affected limb with limb

laterality tasks. laterality tasks. Schwoebel et al Brain 2001Schwoebel et al Brain 2001 Increased pain and swelling with imagined Increased pain and swelling with imagined

movementsmovements. . Moseley Neurology 2004Moseley Neurology 2004

Weakness, Dystonias, Myoclonus, Tremor Weakness, Dystonias, Myoclonus, Tremor Slowness of repetitive movements (bradykinesia)Slowness of repetitive movements (bradykinesia) Frequency of motor disorders increases with disease Frequency of motor disorders increases with disease

durationduration Dysfunction of central neural networks involved with Dysfunction of central neural networks involved with

inhibition of movement. vinhibition of movement. van Hilten et al. IASP press 2005.an Hilten et al. IASP press 2005. Increased difficulty with motor tasks may link to Increased difficulty with motor tasks may link to

autonomic changes via dorsal anterior cingulate autonomic changes via dorsal anterior cingulate cortex .cortex .Critchely et al. Brain 2003.Critchely et al. Brain 2003.

Re-mapping in motor cortex with representation of Re-mapping in motor cortex with representation of painful area enlarged.painful area enlarged. Ma Maïhöfner et al. Brain 2007.ïhöfner et al. Brain 2007.

Summary Summary CRPS Altered PerceptionsCRPS Altered Perceptions

SensorySensory PainPain Altered body schemaAltered body schema including macro- including macro-

and and microsomatognosis microsomatognosis

Reduced and Reduced and heightened heightened awareness of limbawareness of limb

Increased peri-Increased peri-personal spacepersonal space

Referred sensationsReferred sensations Hostile feelingsHostile feelings

MotorMotor Difficulty in Difficulty in

locating limb prior locating limb prior to and on to and on initiation of initiation of movementmovement

Poor motor Poor motor controlcontrol

DystoniaDystonia TremorTremor Neglect of Neglect of

affected limbaffected limb Altered posture Altered posture

and gaitand gaitGaler & Jensen. J Pain Symptom Manage 1999. Forderreüther et al. Pain 2004. McCabe et al. Pain 2005; Lewis et al. Pain 2007, McCabe & Blake. Rheumatology in press

SummarySummary Both motor and Both motor and

sensory perceptions sensory perceptions are altered in CRPSare altered in CRPS

Distressing and Distressing and often disbelievedoften disbelieved

Only careful history Only careful history taking will elicit taking will elicit these descriptions these descriptions

Clinical and imaging Clinical and imaging evidence of central evidence of central reorganisation in reorganisation in motor and sensory motor and sensory corticescortices

Sensory events are analysed in Sensory events are analysed in terms of appropriate motor terms of appropriate motor

response.response.

Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000

Baseline information

Motor simulation network Motor simulation network and motor planningand motor planning

Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000

Baseline information

MSN

Altered sensory and motor Altered sensory and motor perceptions are generatedperceptions are generated ThermalThermal Body perceptionBody perception Reduced and heightened Reduced and heightened

awareness of limbawareness of limb Pain, stiffness, pins and Pain, stiffness, pins and

needles needles Difficulty in locating limb prior Difficulty in locating limb prior

to, and on initiation of to, and on initiation of movementmovement

Poor motor controlPoor motor control

When sensory input and When sensory input and motor output conflict?motor output conflict?

McCabe et al Rheumatology 2005Sensorimotor conflict

CRPS and sensory-motor CRPS and sensory-motor conflictconflict

Baseline information

MSN

Corrupted

Imagined or actual movements will cause a range of sensory/motor disturbances

Access to the basic Access to the basic building blocksbuilding blocks

Snyder AW, Mitchell DJ. Proc.R.Soc. Lond. 1999;2666:587-592.

Link to current clinical Link to current clinical signs?signs?

Foreshortened limbs/Altered body perception?

Autotomy/ desire for amputation?

Link to current clinical Link to current clinical signs?signs?

Increased peri-personal space

Farné A, Làdavas E. Neuropreport 2000; 85:1645-1649.

Correcting motor sensory mismatch Correcting motor sensory mismatch ––

3 potential target areas3 potential target areas

Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000

Baseline information

MSN

Sensorimotor integrationSensorimotor integration Sensory and motor Sensory and motor

systems work in systems work in partnershippartnership

When discordance When discordance occurs altered occurs altered sensory and motor sensory and motor perceptions are perceptions are generatedgenerated

Therapies designed to Therapies designed to target this target this discrepancy appear discrepancy appear effective.effective.

Multidisciplinary inpatient and Multidisciplinary inpatient and outpatient service at the outpatient service at the

RNHRDRNHRD National referral centreNational referral centre Mobilisation of limb priorityMobilisation of limb priority Physiotherapy twice daily (land based and Physiotherapy twice daily (land based and

hydrotherapy)hydrotherapy) Occupational therapyOccupational therapy Mirror visual feedback and motor imagery programmeMirror visual feedback and motor imagery programme Enable above activities by providing pharmacological Enable above activities by providing pharmacological

and psychological supportand psychological support Education, education, education!Education, education, education! 2006 Established UK CRPS Clinical & Research 2006 Established UK CRPS Clinical & Research

NetworkNetwork

AcknowledgementsAcknowledgementsFunding Bodies & Other

Partners Arthritis Research

Campaign Gwen Bush Foundation Remedi RSD-UK Pfizer Pharmaceuticals Royal National Hospital

for Rheumatic Diseases Donated Funds

Wiltshire College of Higher Education

Email: c.mccabe@bath.ac.uk

CRPS Clinical Research Team Professor David Blake Dr. Helen Cohen Dr. Jane Hall Dr. Nigel Harris Ms Keri Johnson Ms. Jenny Lewis Dr. Karen Rodham