Complex Regional Pain

Syndrome (CRPS)

Amanda Nowak OT/s

What is pain?

Pain is a signal that the body has been damaged or something is wrong

Reaction designed to protect you (makes you stop what you are doing what caused it

Pain can either be acute or chronic

The Process of Pain

Stimulus Pain

receptors Spinal

cord Thalamus

Cerebral cortex

“OUCH”

Complex Regional Pain Syndrome

Abnormality of the processing of pain by the neurologic system

CRPS can be either type I (RSD) or type II (causalgia)

Pain is disproportionate to the initial event An official diagnosis must first rule out any

alternative diagnosis Frequently diagnosed associated with mild

severe injuries/surgeries (commonly carpal tunnel release, Dupuytren’s release, and distal radial fracture)

Can occur either before or after therapy referral

Symptoms

Allodynia Hyperalgia Hyperpathia Swelling Stiffness Discoloration Abnormal hair/

nail growth Hyperhydrosis Motor Dysfunction Bone Degeneration

Stages of CRPS

McGill Pain IndexCRPS Pain rated a 42

Most painful form of chronic pain

Evaluation Ask which areas are

hypersensitive BEFORE touching the patient

Pain assessment is important to determine client’s tolerance

Postpone unnecessary tests to a time when they are not swollen, painful, and stiff

Measuring edema: use warm water and as quickly as you can

Phych eval

Nonoperative Treatment Options

Pain Modalities (moist heat,

fluidotherapy, contrast baths)

Edema Elevation with AROM,

manual edema mobilization, compression, massage

Sensation Desensitization

Range of Motion PROM, stretching,

blocking, tendon gliding, PNF patterns

Splinting Resting position

Stress Loading “load and carry”

Joint Protection Patient Education

“To Improve, Move”

Individualize!

No protocol works for all patients with CRPS. It is

dependent on current pain level, symptoms, and

tolerance (see handout)

Protocols (2011)

OCCUPATIONAL THERAPY PHYSICAL THERAPY

i) to reduce clinical symptoms, and protect and support the affected limb in the most functional and comfortable position by means of a splint. ii) to normalize sensitivity by carrying out an extensive desensitization programiii) to encourage the functional use of the limb within the pain threshold. iv) to encourage independence

i) Increasing the degree of control over the pain and improving the way the patient copes with the syndromeii) Extinguishing the source of pain and treating any dysregulationiii) Improving skills

Role of the COTA/PTA in Treatment

Communicate regarding progress/lack of progress

Monitor symptoms and adjust treatment accordingly

Communicate with therapist regarding goals Discuss maximal pain limits and which pain

reduction techniques are most effective Record progress of home exercise program Provide adaptations and assistive devices for

ADL’s and work related activities Modify/Adjust splints

What does the evidence say?Mirror Therapy

Shows a trend that mirror therapy is effective with CRPS. Mirror therapy was shown to be effective in CRPS patients in Stage I and II but not effective in Stage III patients. It had an immediate analgesic

effect with a reduction in stiffness. In those patients which mirror therapy was not effective, all were lower

extremity affected. 17 different outcome measures were used measuring symptoms, functional levels,

and the treatment itself. It is noted that Mirror therapy in CRPS II patients is worth further

exploration.

Results of these studies were not statistically analyzed

What does the evidence say?Pain exposure

May be safe and effectiveAssumes that avoiding use of a

limb due to pain will result in loss of function

“Graded exposure”Discussion of possible pain

increaseTraction & translation of jointsPassive StretchingFunctional use immediately afterDesensitizationMax of 5 45 min sessions over 3

months with evaluation of treatment 3 months after last treatment

Focuses on FUNCTIONAL improvement only

186 Patients Referred

80 Patients Excluded

106 Patients Included4 Patients Stopped 2 Male 2Female2 arm/hand2 leg/foot

Arm/hand 39 patients18 full recovery19 partial recovery2 patients lost to follow-up

Leg/foot 63 patients31 full recovery27 partial recovery5 no change

Prognosis

Completely individual The sooner treatment begins, the quicker

improvements are noted The longer treatment is delayed, the

more likely it is to require long-term treatment

Is there enough evidence?

No, there is a lack of evidence in all areas of CRPS and more research needs to be done to find the most

effective treatments for these patients.

Case Study

References Cooper, C. (2007). Fundamentals of hand therapy. Mosby-Elsevier: St. Louis, MO. Ek, J., Gijn, J., Samwel, H., Egmond, J., Klomp, F., & Dongen, R. (2009). Pain

exposure physical therapy may be a safe and effective treatment for longstanding complex regional pain syndrome type 1: a case series. Clinical Rehabilitation, 23, 1059–1066. doi: 10.1177/0269215509339875

Ezendam, D., Bongers, R. & Jannik, M. (2009). Systematic review of the effectiveness of mirror therapy in upper extremity function. Disability and Rehabilitation, 31(26), 2135–2149. doi: 10.3109/09638280902887768

Geertzen, J. & Harden, R. (2006). Physical and Occupational Therapies in Complex Regional Pain Syndrome Type I. Joumal of Neuropathic Pain & Symptom Palliation, 2(3), 51-55. doi: doi:10.1300/J426v02n03_11

Kishner, S., Rothaermel, B., Munshi, S., Malalis, J. & Gunduz, O. (2011). Complex regional pain syndrome. Turkish Journal of Physical Medicine and Rehabilitation, 57, 156-164. doi: 10.4274/tftr.09327

Maihofer, C., Seifert, F., & Markovic, K. (2010). Complex regional pain syndromes: new pathophysiological concepts and therapies. European Journal of Neurology, 17, 649–660. doi: doi:10.1111/j.1468-1331.2010.02947.x

Mos, M., Sturkenboom, M., & Huygen, F. (2009). Current understandings of complex regional pain syndrome. Pain Practice, 9(2), 86-99. doi: 10.1111/j.1533-2500.2009.00262.x

Perez, R., Zollinger, P., Dijkstra, P., Thomassen-Hilgersom, I., Zuurmond, W., Rosenbrand, K. & Geertzen, J. (2010). REevseiadrche anrticclee based guidelines for complex regional pain syndrome type 1. BMC Neurology, 10(20), 1-14.