for patients with recently diagnosed Complex Regional Pain Syndrome Jeanne Earley MHS PT MPTA April 9 2017 Outline Why review History of CRPS the onion theory Theories of chronic pain ID: 1042076
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1. Effectiveness of Graded Motor Imagery for patients with recently diagnosed Complex Regional Pain SyndromeJeanne Earley, MHS PTMPTAApril 9, 2017
2. Outline Why review History of CRPS: the onion theory Theories of chronic pain IASP definition of pain central sensitization Roadmap to pain; SZ George Treatments: education and Graded Motor Imagery Results of Study on 28 patients with CRPS Patient case study
3. Some initial comments on CRPS: “There are only a few diseases that have such a controversial history CRPS …is a condition that can complicate recovery and impair one’s function and psychological well-being…”Wide variety of terminology describing CRPScan lead to misdiagnosis of this conditionPoor evidence-based regarding treatmentsExample: diagnosis of “probable peroneal nerve injury from cast compression at fibular head” vs. CRPS? Oaklander AL & H Horowitz. The complex regional pain syndrome. Handbook of clinical Neurology 2015; vol 131 ( 3rd series)Goh EL, et.al. CRPS: a recent update. Burns & Trauma 2017; 5:2.
4. ONION theory of CRPSOur current knowledge of CRPS is based on the successive layers of research and treatment data over the course of the history of this disease from Mitchell to Moseley.
5. CRPS history 1864S. Weir Mitchell, neurologist described symptoms in soldiers in Civil warSuffering from major injuries to nerves Called symptoms: “causalgia” Causos = heat algia = painGiovanni Iolascon, et al. CRPS type 1: historical perspective and critical issues. Clinical cases in mineral and Bone Metabolism 2015; 12(suppl.1): 4-10.
6. CRPS – history 1946JA Evans, MD: J Am Med Assoc. 1946 Nov 16;132(11):620-3. Sympathectomy for reflex sympathetic dystrophy; report of twenty-nine cases.Chronic distal limb pain plus microvascular dysregulation Named reflex sympathetic dystrophy (RSD) from the rubor, pallor, sweating, bone atrophyIolascon 2015
7. CRPS: history 1950John J. Bonica, founder of IASP 1950sIdentified 3 stages:Acute: from the moment of the trauma to 3 months dystrophic: severe pain, edematous skin, decreased hair growth, discoloration with cyanotic areas, persistent hyperhidrosis, muscle weakness and limited ROM of infected joint or joints. 3. atrophic: 6 weeks onwards is disabling pain improves with rest; worsens with passive movements. Iolascon 2015
8. DEFINITION OF PAIN by IASP 1979: again… Bonica“..an unpleasant sensory, emotional, and cognitive experience associated with actual or potential tissue damage or described in terms of such damage.”Subcommittee on Taxonomy of Pain Terms International Association for the Study of Pain. Pain 1979; 6:249-52
9. CRPS History 1994Name changes: IASP: complex regional pain syndromeOther names: Europe: algodystrophyUS: shoulder – hand syndrome, Sudeck’s atrophy with xray showed bone atrophyIolascon 2015 Paul Sudeck
10. Orlando meeting in 1994Criteria for clinical diagnosis of CRPS:The presence of an initiating noxious event or a cause of immobilization.Continuing pain, allodynia or hyperalgesia, the pain which is disproportionate to any inciting event.Evidence at some time of edema, changes in skin blood flow or abnormal sudomotor activity in the region of painThis diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunctionNote: criteria 2-4 must be satisfied. 71.5% met clinical criteria; 45.8 met research criteria. Lolascon 2015
11. Hyperalgesia: response to painful stimuliAllodynia: pain report from normally non noxious stimuli
12. Budapest conference 2003 authored by Harden 2010Differences in clinical criteria and research criteria.Continuing pain which is disproportionate to any inciting eventMust report at least one symptom in 3 of 4 following categories: Sensory: hyperesthesia/ allodynia Vasomotor: asymmetry or changes in skin color or temperature Sudomotor/edema: asymmetric or changes in sweating or edema Motor/trophic: decreased ROM, weakness, tremor, dystonia or trophic changes in hair, nails or skin. Must have 1 sign in 3 of four of the above categoriesThere is no other diagnosis that better explains the signs and symptoms. Research: 1 symptom in all four areas; 1 sign in 2 or more categories. Iolascon 2015
13. Complex Regional Pain Syndrome:Defined as: “. . burning pain, allodynia and hyperpathia occurring in a region of the limb after partial injury of a nerve or one of its major branches innervating that region.”Goh En Lin, et.al. CRPS: a recent update. Burns & Trauma 2017; 5:1-11.
14. CRPS Incidence Risk factors for developing after trauma characteristics peripheral sensitization central sensitization cortical reorganization emotional, cognitive, mental, social changes
15. Reported Incidence of CRPS following surgical proceduresRegion Operation Study Incidence NumbersShoulder: Chalmers et al. 2014 11.1% (1:8) Arndt et al. 2012 3.0% (3:97) Gonzalez et al. 2011 0.9% (35:3975) Bishop et al. 2005 1.3% (1:79) Borgeat et al. 2001 1.0% (5:516)Carpal tunnel release Shinya et al. 1995 1.9% (2:105) Litchman et al. 1979 5.0% (5:95) MacDonald et al. 1978 2.2% (4:182)Dupuytren’s contracture Lily and Stern 2010 2.0% (1:49) Bulstrode et al. 2005 2.4% (6:247)Tibial arangi et al. 1993 31% (9:20)Ankle and foot Rewhorn et al. 2014 4.4% (17:373)Goh. et al. Burns and Trauma (2017) 5:2
16. Risk factors for Developing CRPSNOT risk factors: Preoperative psychological distressPreoperative pain levelsPsychological behaviorDiagnostic bone scanRisk factors:FemaleFracture of distal radiusSuffering an ankle dislocation or intra-articular Reports of usual levels of pain in early phases after trauma. Pons T, et.al. Potential Risk Factors for the Onset of CRPS Type 1: A systematic Literature Review. Anes Res and Prac. 2015: 1-15.
17. Additional contributions to understanding of chronic pain Steven George: Nociception vs. experientialCentral sensitization syndromeIASP definition of pain
18. Steven Z George. Pain Management: Road Map to Revolution. PTJ 2017; 97: 217-226.
19. Steven Z George 2017 discussion with Tatoo artist
20. Central sensitization Cortical reorganizationNeural plasticity
21. Peripheral sensitization 5 signs of Inflammation: pain, edema, erythema, increased temperature, impaired function Altered cutaneous innervation of C-type and A delta fibers Nociceptors are damage sensing in organs, muscles and skin appropriate to specific sense: EX: heat receptors send danger alarm at 115 to 1250 Inhibition and excitation Decisions as to signaling brain stem and brain
22. Central Sensitization SyndromeCentral sensitization is: “a group of medically indistinct disorders for which no organic cause can be found.” Research using fMRI, scans diagnoses: fibromyalgia, chronic fatigue syndrome, IBS, TMJD, headache, CRPS, phantom limb painEL Girbes, et.al. Pain treatment for patients with OA and CS. PT 2013: 93(6): 842-851.
23. Central sensitization (CS) “ persistent and intense noxious stimulation of peripheral nociceptive neurons can result in CS” Increased excitability of secondary central nociceptive neurons in SC Allodynia: reported pain with non painful stimulus Hyperalgesia: reported pain greater than stimulus decreased space in brain of area representing affected limb fMRI for determining extent and location of pain distorted homunculus related to the reports of painEL Girbes 2013
24. Central Sensitization/ cortical reorganization / neural plasticitySecondary brain dysfunction: motor difficulties impaired cognition neglectEL Girbes, et.al. 2013
25. Cortical reorganizationBowering KJ, et.al. 2013 “CR…has been demonstrated for chronic LBP, in which representation of the painful side of the back was enlarged and shifted medially as compared with representation in healthy controls.” Other changes: gliaBowering KJ, et.al. The effects of GMI and its components on chronic Pain: a systematic review & meta analysis. Jl Pain 2013: 3-13.
26. Areas involved in pain processing:pre-motor/motor areas (blue SMA)Cingulate Areas (Green & PCC)Basal ganglia (BG)Sensory cortex (red / orange)Hypothalamus (HT)Amygdala (Amyg)Thalamus (yellow)Insula (light blue)Pre frontal cortex (purple)Parabrachial nuclei (PN)Cerebellum & Spinal cordFlor H 2002. Painful memories. EMBO reports v. 3 no. 4
27. Maihöfner, et.al. Cortical reorganization during recovery from CRPS. Neurology 2004; 63: 693-701.
28. Acute CRPSAfter treatmentMaihöfner 2004
29. Treatments for Complex Regional Pain Syndrome (CRPS)
30. TREATMENTS FOR CRPS Traditional (ROM, strength, massage, wrapping, TENS, ESTIM, etc.) Medications Sympathetic blocks for symptom management Pain education Graded motor imagery
31. Education: A Louw 2016:“Despite having ongoing pain and disability the Pain Neuroscience education group (PNE) spent 45% less on healthcare in the year following surgery compared to the non – PNE group”Role of education in treating CRPS: Louw A et.al. Preoperative Pain Neuroscience Education for lumbar Radiculopathy: a multicenter RCT with 1 year Follow up. Spine 2014; 29: 1449-57.
32. GRADED MOTOR IMAGERY
33. Graded Motor Imagery (1)Definition: GMI is a comprehensive program designed to sequentially activate cortical motor networks and improve cortical organization in three steps: 1) Laterality training 2) Imagined movements 3) Mirror visual feedbackRationale: if cortical changes are the underpinnings for chronic pain, then reorganizing the cortex would help decrease the pain. Treating symptoms: motor, sensory, sudomotor, vascular, etc.Priganc VW, SW Stralka. Graded Motor Imagery. J of Hand Therapy 2011;24:169
34. Graded Motor Imagery (2)Dickstein, 2011: “ … imagining techniques have reduced subjectivity associated with Motor imagery by elucidating neural substrate. “Subjectivity: ie. Cognitive, emotional, perception of damage, functional limitationsDickstein R & JE Deutsch. Motor Imagery in physical therapist practice, Phys Ther 2007; 87: 942-953.
35. Graded Motor Imagery (3)STAGE 1: LATERALITY (Implicit)Goal: To restore to normal the accuracy and speed recognizing left and right limbsTarget tissues: pre motor area & mirror neuronsTechniques: Cataloguesflash cardsRecognise.com
36. Graded Motor Imagery (4)Stage 2: ImageryGoal: Observe others >> imaging self >> perform self **Used in sports, childbirth, healthy etc. Target tissues: mirror neurons Using: youtube, flashcards, movies, at work, in public, sports, etc.Progression from Stage 1: Static to dynamic Third person to self Introduce functional movements and tools
37. Mirror Neurons (1)“In watching the investigator reach for a morsel of food, mirror neurons in the motor cortex respond similarly when the subject reaches for morsel.”VS Ramachandran, The Tell-tale Brain. WW Norton & Co. 2011.
38. Mirror Neurons (2)Study: 2 Groups with wrist Pain (CRPS & non CRPS) 37 subjects imagining wrist flexionEMG on wrist flexors to detect actual tendon activity2 Measures, pre and post 1. pain and 2. girth measurementsResults: pain & swelling with both groups Moseley GL. Imagined movements cause pain and swelling in a patient with CRPS. Neurology 2004b; 62: 1644.
39. Mirror Neurons (2 cont’d)Moseley 2004b“. .Highlights the contri- bution of cortical mechanisms to pain on movement, which has implications for treatment.”
40. REVIEWS
41. Systematic review (1)29 RCT for treatment of CRPS I Treatments: bisposphonates, transcranial magnetic stimulation, GMI, anesthetic blocks, SCS, sympathectomy Results: “GMI has strong evidence of effectiveness in CRPS.” . . based on 2 high quality trials (Moseley, 2004, 2005)Cossins L, et.al. Treatment of CRPS in adults: a systematic review of randomized controlled trials published from June 2000 to February 2012. EJP 2013:1-17.
42. Systematic review (2) Systematic review PT management of adult CRPS I 11 studies Tx: education, Desensitization, ROM & stretching, mirror visual feedback, GMI, cognitive therapy, TENS, E-Stim, magnets “Good to very good quality level II evidence that GMI is effective in reducing pain in adults with CRPS-1, irrespective of the outcome measure used.”Daly AE & AE Bialocerkowski. Does evidence support physiotherapy management of adult CRPS I? A systematic review. Eur Jl of Pain 2009:13: 339-353.
43. Systematic review (2b)Da009 (2) Sample Quality Mean ▲ [ Ranges] size Score 95% CIGMI vs PT + MM (pain intensity: 0–100 VAS) Moseley (2006) – end 6 weeks of Rx 51 13 12.9 [1.7 to 21.4] Moseley (2006) – 6 month follow-up 51 13 20.5 [8.2 to 32.8]*GMI vs PT + MM (pain: NPS: 0–100) Moseley (2004) – end 6 weeks of Rx 13 12 22 [10.1 to 29.9]* Moseley (2004) – 12 week follow-up 13 12 22 [13.4 to 30.6]*GMI vs PT + MM (pain intensity: NPS item on intensity: 0–10) Moseley (2004) – end 6 weeks of Rx 13 12 3.0 [2.6 to 5.4]* Moseley (2004) – 12 week follow-up 13 12 3.0 [2.8 to 5.6]*GMI vs PT + MM (finger circumference: mm) Moseley (2004) – end 6 weeks of Rx 13 12 9.0 [2.3 to 15.7]* Moseley (2004) – 12 week follow-up 13 12 10.0 [2.6 to 17.3]*GMI vs PT + MM (function: NRS: 0–10) Moseley (2006) – end 6 weeks of Rx 51 13 1.6 [0.6 to 2.6]* Moseley (2006) – 6 month follow-up 51 13 2.2 [1.1 to 3.3]* Daly & Bialocerkowski. 2009
44. Cochran review. 2017 (3) “ We found statistically significant improvements in pain and function in the correctly ordered GMI group compared to both comparison groups, as measured by the NPS and an 11 point NRS respectively at 12 weeks post treatment.”“Moseley 2005 reported that at 12 week follow up the mean reduction in NPS score for the correctly ordered GMI group was approximately 7 and 18 points greater than the mean reductions in the other two groups respectively.”The quality of evidence was very low or low quality, few numbers . . . for these treatments for PT. O’Connell NE, et.al. Interventions for treating pain and disability in adults with CRPS. Cochran Database Syst rev. 2013; 30; 4.
45. STUDY DESCRIPTION
46. OCM: Quick DASH11 item self report measure condition specific disability measureInternal consistency: .96 to .97Change score: 15 pointsForget NJ et.al. Psychometric evaluation of the Disabilities of the Arm, Shoulder and Hand (DASH) with Dupuytren’s contracture: validity evidence using Rasch modeling. BMC Musculoskelet Disord 2014 Oct 30;15:361
47. OCM: LE functional scale 20 questions self report measure test – retest reliability : r= .94 clinical significant difference: 9 pointsBrinkley JE, et.al. The LE functional scale (LEFS): Scale development, measurement properties and clinical application. NA Orthopedic Rehab. Research Network. Phys Ther. 1999; 79(4): 371-383.
48. OCM: VAS Pain at time of visit on 0 to 10 scale At visits 1, 2 and 3at final appointment/ phone call: Range of pain: in last month of CRPS since each visit2 weeks after visit 3
49. Sympathetic block by Physician Before each visit to PT and/or On regular visits to physician if determined that they are of benefit to sympathetic symptoms. Hayashi K et. Al.: combination of continuous epidural block and rehabilitation in a case of CRPS.J Nippon Med Sch 2016; 83: 262-267.
50. Mesick S. et.al. Timing of GMI in treatment of CRPS may be critical to outcome.Number: 28 patients.Outcomes: 1. Quick Dash or LE functional scale; 2. Change in VAS rangeIndep variables: Disease durationsympathetic blocklimb affected agesex Used t-test and ANOVA
51. Mesick S. et.al. (continued)Results: 1. Statistically significant improvement in affected limb function and pain scores after GMI in all patients. 2. < 1 year disease duration, marked improvement in OCM and pain ranges. 3. Sympathetic blocks might improve limb function in pts with duration <1yr. patients w/o blocks tended to more improvement.4. Age, sex, limb affected did not influence outcome.
52. Mesick S. et.al. (continued)Conclusions: “Early treatment with GMI within 1 year of injury significantly impacts degree of functional recovery in CRPS”“Sympathetic blockade may lead to better functional OCM in patients with less than 1 year disease duration, however, duration is likely a more important factor.”
53. Patient case study: MS with Left LE CRPSSurgery on 9-15-16Visit 1Visit 2Visit 3Visit 4Visit 5Δ Pain range3-8/100-4/100-4/100-8/100-0/103 to 8 ptsCurrent pain3/100/100/100/100/103 to 0/10LEFS score:72.5%43.8%43.8%31.3%13.8%58.7 ptsInjection: 10-27nonononoPatient able to return to wearing normal shoes, hiking, functional walking.
54. QUESTIONS?