CRPS an enigmatic condition which often leads us to misdiagnose.
In this lecture i tried to explain the diagnostic criteria and the clinical presentation and evidence on treatment methods based of physiotherapy management.
Graded motor imagery is the best for long term goal but there is a research gap for indian context
3. DEFINITION
A syndrome that usually develops after a noxious event is, is not
limited to the distribution of a single peripheral nerve and is
disproportionate to the inciting event.
It is associated at some point with evidence of oedema, changes in
skin blood flow, abnormal sudomotor activity in the region of the
pain, or allodynia or hyperalgesia.
(Merskey and Bogduk, 1994)
7/24/2019
3
4. TYPES
The International Association for the study of pain has proposed
CRPS into two types based on the presence of nerve lesion
following the injury.
Type 1, formerly known as Reflex Sympathetic Dystrophy (RSD),
do not have a definitive nerve lesion.
Type 2, formerly known as causalgia, has a definite nerve lesion
7/24/2019
4
5. SYNONYMS OF CRPS
RSD CAUSALGIA
SUDECK’S
ATROPHY
SHOULDER
HAND
SYNDROME
REGIONAL
MIGRATORY
OSTEOPOROSIS
Birklein F, O’Neill D, Schlereth T. Complex regional pain syndrome: An
optimistic perspective. Neurology. 2015;84(1):89–96.
7/24/2019
5
6. EPIDEMIOLOGY
Incidence
• 5-26/100,000
Some epimeological features
• Women affected more than men
• Incidence increases with age until 70
• Upper limbs (60%) vs. lower limbs (40%)
• CRPS -1 (90%)
7/24/2019
6
7. CAUSES
Peripheral
musculoskeletal
Fractures (45%), Sprains (18),
Other: dislocations, immobilisation, fasciitis,
tendonitis, arthritis, mastectomy, DVT
Peripheral nerves
and dorsal roots
Trauma and injury to brachial plexus and other
peripheral nerves
CNS CRPS can follow after stroke, tumours, Traumatic
Brain Injuries( TBI)
Viscera Can follow after myocardial infarction
Idiopathic Spontaneous ( <10%)
7/24/2019
7
8. CRPS – SIGNS AND SYMPTOMS
Constant pain even at rest
Area of pain larger than area of injury
Limited range of motion
Burning type of pain
Nail growth changes
Pain for non noxious stimuli
7/24/2019
8
11. NATURAL HISTORY( PHASES)
Transition of CRPS are in three phases
Acute/warm phase- oedema, warmth, red & glossy skin
Intermediate/cold phase- cold, hyperhidrosis, cyanosis
Chronic phase- severe motor and trophic changes
7/24/2019
11
12. TAXONOMY
CRPS-1 (Reflex Sympathetic
Dystrophy)
CRPS -2 (Causalgia)
1. Initiating noxious event or a cause of
immobilisation
The presence of a continuous pain,
allodynia or hypoalgesia after an nerve
injury, not necessarily limits to the
distribution of they injured nerve.
2. Continous pain, allodynia or
hyparalgesia & the pain disproportionate
to any inciting event.
Evidence at some time of oedema,
changes in skin blood flow or abnormal
sudomotor activity in the region of the
pain.
3. Evidence at some time of oedema,
changes in skin blood flow or abnormal
sudomotor activity in the region of the
pain.
The diagnosis is excluded by the existence
of conditions that would otherwise
account for the degree of pain and
dysfunction.
4. The diagnosis is excluded by the
existence of conditions that would
otherwise account for the degree of pain
and dysfunction.
Note : All three criteria must be satisfied
7/24/2019
12
23. ELECTRO MODALITIES
TENS
Ultrasound
Interferential therapy
Low level laser
There is a low quality evidence (RCT) that modalities used in physiotherapy are
effective in reducing pain except , TENS has moderate level of evidence in
CRPS only in short term less than 12 weeks.
7/24/2019
23
Effective
Not
effective
25. GRADED MOTOR IMAGERY
NOIGROUP – MOSELEY & DAVID BUTLER
A series of intervention strategies aimed at the
treatment of people with complex pain problems.
Patients with – Neuropathic pain problems
■ Central sensitization
■ Peripheral sensitization –
High fear-avoidance – An inability to move or touch
affected region
As a prophylactic intervention
7/24/2019
25
29. Left/Right discrimination
• It involves implicit training by given cards/orientate software
and patients identifies whether it is left/right.
• The accuracy of the identifying side of the body must be
above 80%, 24 cards and time must be less than 2 sec/image
7/24/2019
29
30. Explicit Motor Imagery (imagined movements)
• Normally active movements send afferent impulses to the cortex
which are programmed and stored in neural engrams but in
pathology they get altered in quantity and quality.
• It was said that 25% of neurons of brain starts firing while
observing/ imaging movements. In this training patient will be asked
to imagine themselves doing the activity.
7/24/2019
30
31. Mirror therapy
• Based on visual stimulation.
• In this therapy, a mirror is placed in patients mid sagittal plane thus
reflecting the non-affected side as if it was affected.
• During this practice start exercising little movements of the fingers
and gradually progressing to complex activities.
• The process involves accommodating and adapting ultimately luring
brain into illusion.
7/24/2019
31
32. The first level involve moving the limb outside mirror.
Further progression of moving the limb inside the mirror at baseline.
Then to both limbs equally
7/24/2019
32
33. DOSAGE OF GMI
The dosage of GMI depends on severity of the condition and
patients understanding of the program.
A study conducted by Cacchio et al, 2009, showed that 4 weeks of
GMI, 7 days a week , 5 times of 30 min sessions have an effect on
pain and disability.
Moseley et al, 2006 , suggested that 12 weeks of GMI 6 days a week
for 15 minutes session 5 times a day found to be effective.
7/24/2019
33
34. Challenges for GMI
Difficult to understand
Requires lot of practice
7/24/2019
34
35. Quality of evidence
There is a low quality(RCT) in treating people with
CRPS, but this was highly recommended first line
of choice in managing pain in CRPS 1 & 2
7/24/2019
35
36. VIRTUAL BODY SWAPPING
There was a low quality evidence (RCT) on virtual
reality training in people with CRPS and they found
that mental rehearsal does not reduce pain in
CRPS-1.
Virtual software will be used in this which swap
patient body
7/24/2019
36
37. TACTILE LOCALISATION THERAPY
Tactile discrimination technique encourage patients
to concentrate on the delivered stimuli- improve
tactile aquity and reduce pain ( via improvements in
cortical reorganisation)
Involving active participation from the patients to
distinguish type and location of the stimuli shows
better results in improving tactile aquity and pain
than passive stimulation( touching the affected limb
without conscious thought)
(Moseley,2008)
7/24/2019
37
38. MINIMISING BODY PERCEPTION
DISTURBANCES
CRPS patients exhibit perception disturbance.
In order to move the affected limb, people
frequently comment on their need to consciously
focus their mental and visual attention to the limb
leading to pain
often describing as ‘’not belonging to me.’’
7/24/2019
38
39. PRISM GLASS
Principles of mirror therapy
They utilise a wedge to add visual distortion toward
the affected side while blocking the vision of the
other eye.
Moving the unaffected limb will give a perception of
moving the affected side.
Use of 20 degree deviated prism glass for 2 weeks
have cause alleviation of pain and improved
function in patients with CRPS.
7/24/2019
39