crps and graded motor imagery programme emma j mair [email protected] november 2012
TRANSCRIPT
Tonight- an overview
Aetiology Pathophysiology UK Guidelines Diagnosis Treatment Graded Motor Imagery
programme
European Incidence rate of 26/100,000 person-years
Incidence with age till 70 60% in upper limb, 40% in lower limb Approximately 15% of sufferers will have
unrelenting pain and physical impairment 2 years after CRPS onset
Cause Unknown 45% following fracture 18% following sprains 12% following surgery <10% spontaneous
CRPS-1Type 1: sympathetically maintained pain
can start for no apparent reason but most commonly follows distal radial fracture.
Characterised by pain which is disproportionate to inciting event, swelling, autonomic and motor disturbances, changes in skin blood flow
CRPS-2Type 2: Onset develops after injury to a major
peripheral nerve. May occur immediately or be delayed for several months
Most commonly involved are the median and sciatic nerves
Allodynia and hyperalgesia occur but not limited to the territory of one single peripheral nerve
1 + 2 = CRPS
Pathophysiology
Multi-factorial Other factors: environmental, genetic,
psychological The stereotyped stages are now obsolete A definition of recovery has not yet been
agreed CRPS is not associated with a history of pain
preceding psychological problems, or with somatisation or malingering
• Swelling• Glossy skin• Increased nail andhair growth• Hyperaemia‡
Peripheral sensitisation↑IL-1β, IL-6, TNFα, NGF, CGRP,substance P, and bradykininPain, vasodilation of theskin, and oedema
Endothelial dysfunction↓NO and ↑ET-1Impaired circulation (chronic stage)
↓Sympathetic outflowVasodilation (early stage)
Sympathetic–afferent couplingPain
Contralateral cortical changesReorganisation of sensorymaps in S1*Reorganisation of motormaps in M1†↓Inhibition and ↑excitationin M1 and SMA
Ipsilateral cortical changes↓Inhibition and ↑excitation in M1
↓Endogenous pain controlPain
Central sensitisationAllodynia, hyperalgesia, secondaryhyperalgesia, and wind-up
•Sensory abnormalities•Autonomic dysfunction•Neurogenic inflammation•Motor abnormalities•Sensitisation•Central reorganisation
Risk Factors
ACE inhibitors Asthma Migraine Immobilisation ? Genetic
UK Guidelines Published April 2012 Recommendations for assessment and management Speciality Guidelines:
Primary Care Physio & OT Orthopaedic Practice Rheumatology, neurology and neurosurgery Dermatology Pain Medicine Rehabilitation Medicine Long-Term support in CRPS
Available from: http://www.rcplondon.ac.uk/resources/complex-regional-pain-syndrome-concise-guideline
Diagnosis
Physio’s probably best equipped to identify a patient with CRPS
Confirmation of diagnosis based on Budapest guidelines
Confirmation with GP/cons Differential diagnosis Diagnosis tool:
http://www.trendconsortium.nl/diagnosis/
A The patient has continuing pain which is disproportionate to any inciting event
B The patient has at least one sign in two or more of the categories
C The patient reports at least one symptom in three or more of the categories
D No other diagnosis can better explain the signs and symptoms
Category Sign (you can see or feel a problem)
Symptom (the patient reports a problem)
1. SENSORY Allodynia (to light touch and/or temp sensation and/or deep somatic pressure and /or joint movement) and/or hyperalgesia (to pinprick)
Hyperesthesia does also qualify as a symptom
2. VASOMOTOR Temperature asymmetry and/or skin colour changes and/or skin colour asymmetry
Temp asymmetry must be >1°C
3. SUDOMOTOR/ OEDEMA
Oedema and/or sweating changes and/or sweating asymmetry
4. MOTOR/ TROPHIC
Decreased range f motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair/nail/skin)
All A-D must apply
Sensory
Alloydnia – pain due to a stimulus which does not normally cause pain. E.g. touch and temperature
Hyperalgesia– increased response to stimulus that is normally painful
Hyperesthesia– increased sensitivity to stimulation Hyperpathia- a state of exaggerated and very painful
response to stimulation especially repetitive stimulus Hypoesthesia- a reduced sense of touch or sensation,
or a partial loss of sensitivity to sensory stimuli sensory.
Vasomotor
Temperature asymmetry Skin colour changes
Sudomotor / Oedema
Oedema Sweating changes or asymmetry
Motor / Trophic
Decreased range of movement and/or
Motor dysfunction (weakness, tremor, dystonia) and/or
Trophic changes (hair, nails, skin)
Body Perception Disturbance
DISLIKE DISOWNERSHIP DESIRE TO
AMPUTATE DISTORTED
MENTAL VISUALISATION
Body Perception Disturbance
General Screening: Targeted questioning
1. Emotions
2. Sense of belonging
3. Perceived size
Simple observation of position of limb
The Bath CRPS Body Perception Disturbance Scale*Developed by Jennifer S. Lewis, The Royal National Hospital for Rheumatic DiseasesBath, England. v2. ©2008. All rights reserved.Patient name ________________________ Date ________ Assessment no. 1 2 3 4 5 Diagnosis___________________________ Date of symptom onset____________ Body part affected: 1)_________________________ 2)_________________________ 3)_________________________ 1) On a scale of 0-10 how much a part of your body does the affected part feel? Very much a part = 0__1__2__3__4__5__6__7__8__9__10 = Completely detached 2) On a scale of 0-10 how aware are you of the physical position of your limb? Very aware = 0__ 1__2__3__4__5__6__7__8__9__10 = Completely unaware 3) On a scale of 0-10 how much attention do you pay to your limb in terms of looking at it and thinking about it? Full attention = 0__ 1__2__3__4__5__6__7__8__9__10 = No attention 4) On a scale of 0-10 how strong are the emotional feelings that you have about your limb? Strongly positive = 0__ 1__2__3__4__5__6__7__8__9__10 = Strongly negative 5) Is there a difference between how your affected limb looks or is on touch compared to how it feels to you in terms of the following: Size yes no Comment ________________________Temperature yes no Comment ________________________Pressure yes no Comment ________________________Weight yes no Comment ________________________6a) Have you ever had a desire to amputate the limb? Yes No 6b) If yes, how strong is that desire now? Not at all = 0__ 1__2__3__4__5__6__7__8__9__10 = Very strong Desired amputation site________________________________7) With eyes closed describe a mental image of your affected and unaffected body parts (drawn by assessor during patient description then verified by the patient)
This is an accurate account of my image of my affected body part. Signature __________________________________ Date____________________
The Environment Therapy environment – breezes, open windows,
fans Lighting Invasion of personal space Therapist movement and language (“your” vs
“it”) Other people nearby Noise Privacy
Treatment
Prompt diagnosis and early treatment are considered best practice
Aims of treatment:Reduce painPreserve or restore functionEnable patients to manage their
condition Improve quality of life
Primary Care Physiotherapy & Occupational Therapy
Best practice recommendations
Be aware of CRPS and identify the clinical signs Be aware of the Budapest criteria for diagnosing
CRPS Initiate treatment as early as possible Provide patient education about the condition Know of the nearest MDT pain service or CRPS
centre Recognising non-resolving or moderate symptoms for
onward referral
Rehabilitation Algorithm
Identify CRPS signs and symptoms
Consider Differential Diagnosis
Meet Budapest criteria
Confirm DiagnosisVia GP or consultant
Mild/Moderatesymptoms
Moderate/ severe symptoms
Educate, commence treatments
Educate, refer via GP To specialist pain clinic
Failing to respond to treatment in 4 weeks
Noticeable response to Treatment within 4 weeksAnd ongoing improvement
Pain Management programme
Consider yellow flags
Pain Medicine and Interdisciplinary Specialist Rehabilitation Programmes
Four Pillars of TreatmentPhysical and
vocational rehabilitation
Psychological interventions
Patient information and education to
support self- management
Pain relief (medication and procedures)
Engagement: education and information for the patient & family Understanding pain and CRPS Learning self management principles Self efficacy- the patient remains
responsible and involved Empowering the patient and the family
Medical Management
Investigation and confirmation of diagnosis Pharmacological intervention to provide a
window of pain relief Reassurance that PT and OT are safe and
appropriate Provide medical follow up Support any litigation/ compensation claim
Pain Medicine Guideline Recommendations No drugs are licensed to treat CRPS in the UK Neuropathic drugs should be used in according to NICE & IASP
guidelines Pamidronate (single 60mg intravenous dose) should be
considered in suitable patients with less than 6mths duration as a one off treatment
Intravenous regional sympathetic blocks with guanethidine should not be routinely used
Other additional drugs demonstrate efficacy but a lot of the evidence is still preliminary
Spinal Cord Stimulators
Psychosocial and behavioural management Psychological intervention is based on individualised
assessment, to identify and proactively manage any factors which may perpetuate pain or disability/ dependency including: Mood evaluation- management of anxiety and depression Internal factors, eg counter productive behaviour patterns Any external influences or perverse incentives
It usually follows principles of CBT delivering: Coping skills and positive thought patterns Support for family/carers
Physical Management Emphasis should be on restoration of normal function and
activities through acquisition of self management skills, with the patients actively engaged in goal setting
The programme may include elements of chronic pain management including: General body re-conditioning through graded exercise,
gait re-education, postural control Restoration of normal activities, including self care,
recreational physical exercise and social/ leisure activities Pacing and relaxation strategies Vocational support
It may also include specialised techniques to address altered perception and awareness of the limb, for example:Self administered desensitisation with tactile
and thermal stimuliFunctional movement to improve motor
control and limb position awarenessGraded motor imagery, mirror visual
feedback, mental visualisationManagement of CRPS- dystonia
Activities of ADL and societal participation Support graded return to independence in ADLs
and clear functional goals Assessment and provision of appropriate
specialist equipment to support independence Adaptation of environment Extend social and recreational activities in and
outside the home Workplace assessment/ vocational re-training
Overview
Understand Recognise Prompt diagnosis Educate Early treatment MDT approach
CRPS Treatment
Explain & EducateMindfulness /
AwarenessProblem Solving Reducing Threat
Treatment- what are the options? Based on evidence based practise, guidelines
and innovative clinicians Good quality evidence for graded motor
imagery(GMI) combined with pharmacological management is the most effective
Educate, educate, educate
About CRPS About Pain
We do not know why some people get CRPS and others don’t
We DO know that it is not because of psychological frailty or abnormality
Several important changes in the brain seem to accompany CRPS
To normalise these changes, we have to identify ALL combinations to perceived threat and train the brain
Movement versus Pain
Remember pain science and pathophysiology
Sensitisation of CNS More harm than good?!
Desensitisation Activities of daily living
Washing and dressing
Sensory Discrimination
Two-point discrimination
Electrical Stimulation
Graded Motor Imagery
Sequential activation of cortical pre-motor and motor networks
Laterality and Imagery = pre motor
Mirror Therapy = Primary Motor Cortex and S1 cortices
?reversal of cortical reorganisation
Limb Laterality
What do you see?
Right or Left?
Right or Left?
Laterality Recognition Make a quick decision
about the laterality then you mentally rotate mental representation of the limb into the position viewed to confirm initial selection!
Limb Laterality Recognition
Pain affects the brains ability to recognise laterality of images of limbs
Information processing bias Working body Schema
“Normal Scores”
Accuracy of 80% and above Speed of hands and feet ~ 2 seconds Accuracies and RT should be equal
Differences in Speed Identifies problems with
Information processing
… but what does that mean?
Acute Pain
Acute LEFT hand injury looking at RIGHT hand
Difficult decision, safest to presume its LEFT hand because my LEFT hand is injured, chose LEFT hand.
Mentally move LEFT hand
X
Wrong choice,
start again
Mentally move
RIGHThand
correct
RT
R>L
Accuracy
L=R
Acute LEFT hand injury looking at LEFT hand
Difficult decision, safest to presume its LEFT hand because my LEFT hand is injured, chose LEFT hand.
Mentally move LEFT hand
correct
Chronic Pain
Chronic LEFT hand injury
looking at RIGHT hand
Difficult decision, safest to presume its RIGHT hand because my LEFT hand is in trouble and I’m protecting it by not focusing on it.
Mentally move
RIGHT
hand
X
Wrong choice,
start again
Mentally move LEFThand
correct
RT
L>R
Accuracy
L=R
Chronic LEFT hand injury
looking at RIGHT hand
Difficult decision, safest to presume its RIGHT hand because my LEFT hand is in trouble and I’m protecting it by not focusing on it.
Mentally move
RIGHT hand
correct
Why? Incorrect selection leads to longer
reaction time as need to repeat mental rotation of limb to confirm laterality choice
Pain & information processing, patients wrongly select
Differences in Accuracy Difference in accuracy
suggests issues with the working body schema
Why?
Cortical reorganisation Easier access to painful working body
schema?
Laterality Reconstruction Hands, Feet, Neck/Shoulder Vanilla, Abstract, Context Online and Flash cards Recognise Phone Apps Other methods:
Shadow Puppets Digital cameras Magazines
Recognise
Recognise online:
http://recognise.noigroup.com/recognise/
Motor Imagery
Motor Imagery
Sports Performance Neuro-Rehabilitation Cognitive Psychology Graded Motor Imagery
Motor Imagery Observing and
Imagining movements Imagining yourself
doing the movement not imagining observing themselves doing the movement
The Why? If you can’t feel it, how can
you use it?
The What?
Patient ExplanationFoodBack pain & bending
The How?
Prompts:ShapeSkinColourDigitsMovement
Motor Imagery Awareness of body
part Imagining movements Imagining functional
activities Flash cards and online
images can be used as prompts
Mirror Therapy
The Why?
Illusion Tricking the brain Motor Cortex / S1 Mirror Neurons
The How?
Observation De-sensitisation Movement Context- emotional, threat Weight bearing Functional rehab
Mirror Therapy
Practical:Try bilateral movements with the mirrorTry asynchronous movements whilst watching
your limb in the mirrorGet someone to tap or stroke the unaffected
limb whilst looking at the reflected limb
Mirror therapy for the 21st century?
Prism Glasses www.prismglasses.co.uk
Brain Training
Educate Desensitise Habituate Develop Function
Bilateral synchronised movements in a mirror
Mirror visual feedback
? Physical rehabilitation approaches
Rehearse motor imagery
Limb Laterality Limb Laterality programme
Sensory discrimination Electrical or manual
Concurrent medical and psychological support
Imagined movement of affected limb
Can’t Perform
Can’t Perform
Can’t Perform
Can’t Perform
Can’t Perform
Can’t Perform
Can’t Perform
Resources & Research
Questions from you and from me? How do we support
our primary & secondary care clinicians treating this condition?
Specialised Pathways and Clinics required?