Assessment Of Complex Regional Pain Syndrome Dr Candy Mccabe

Assessment of Complex Regional Pain Syndrome Dr. Candy McCabe Consultant Nurse arc Senior Lecturer in Rheumatology Nursing Royal National Hospital for Rheumatic Diseases & School for Health, University of Bath, Bath 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 1829-1914 Turner’s Lane Hospital, Philadelphia

IASP Current diagnostic criteria
Complex Regional Pain Syndrome Type I
Follows an initiating noxious event
Spontaneous pain and/or allodynia and hyperalegesia occur beyond area of a single peripheral nerve and disproportionate to the inciting event.
Evidence or has been evidence of oedema, skin blood flow abnormality and sudomotor changes.
CRPS Type II
Follows nerve injury
More regionally confined area
Stanton-Hicks M, Janig W, et al. Pain, 1995; 63: 127-133 .

IASP SIG proposed revised diagnostic criteria
Hyperalagesia/ hyperaesthesia (sensory)‏
Temperature and colour changes (vasomotor)‏
Oedema and sweating (sudomotor)‏
Trophic and motor changes
Clinical criteria: 2 signs and 3 symptoms
Research criteria: 2 signs and 4 symptoms
Galer et al., 1998. Pain; 14:48-54 Bruehl et al., 1999. Pain; 81:147-54

Presentation of CRPS
Incidence rates of 5.46 to 26.2 per 100,000 person years. UK incidence unknown.
Sandroni et al Pain 2003 (Minnesota, USA);
De Mos et al Pain 2007 (Netherlands)‏
Onset of symptoms may be immediate following trauma or within one month of limb immobilisation
50% go on to suffer chronic symptoms and long term physical impairment
Field et al. Journal of hand Surgery 1992,
Schasfoort et al. Arch. Physical Med. & rehab. 2004.
Disturbance in sensory, motor and autonomic systems which may fluctuate over time and even over a single day.
Diagnosis and therapy delayed by closeness in nomenclature between ‘Chronic’ and ‘Complex’ regional pain syndrome.

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

Case study-limb perception
Altered body perception with and without visual feedback
Finger misidentification
Forderreüther et al. Pain 2004
Referred sensations-face to wrist

McCabe et al. Rheumatology 2003 Referred Sensations in CRPS

Halligan PW et al. BMJ 1999 Referred Sensations in Amputees

Juottonen et al., Altered central sensorimotor processing in patients with CRPS. Pain 2002; 98:315-323.
Maihöfner et al., Patterns of cortical reorganisation in CRPS Neurology 2003; 61:1707-1715. Neurology 2004, Pain 2005
Maihöfner et al.,The motor system shows adaptive changes in CRPS. Brain 2007;130:2671-87.
Pleger et al., Sensorimotor returning in CRPS parallels pain reduction. Annals of Neurology 2005;57(3):425-429
Cortical reorganisation in CRPS

Wilder Penfield

Motor assessment
Reduced grip strength
and ROM
Slow to ‘connect’ with affected limb when asked to move it
Greater range with imagined movement
Able to perform bilateral synchronised movements with mirror visual feedback

Motor abnormalities in CRPS
Slower response times in the affected limb with limb laterality tasks. Schwoebel et al Brain 2001
Increased pain and swelling with imagined movements . Moseley Neurology 2004
Weakness, Dystonias, Myoclonus, Tremor
Slowness of repetitive movements (bradykinesia)‏
Frequency of motor disorders increases with disease duration
Dysfunction of central neural networks involved with inhibition of movement. v an Hilten et al. IASP press 2005.
Increased difficulty with motor tasks may link to autonomic changes via dorsal anterior cingulate cortex . Critchely et al. Brain 2003.
Re-mapping in motor cortex with representation of painful area enlarged. Ma ïhöfner et al. Brain 2007.

Summary CRPS Altered Perceptions
Sensory
Pain
Altered body schema
including macro- and microsomatognosis
Reduced and heightened awareness of limb
Increased peri-personal space
Referred sensations
Hostile feelings
Motor
Difficulty in locating limb prior to and on initiation of movement
Poor motor control
Dystonia
Tremor
Neglect of affected limb
Altered posture and gait
Galer & 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

Summary
Both motor and sensory perceptions are altered in CRPS
Distressing and often disbelieved
Only careful history taking will elicit these descriptions
Clinical and imaging evidence of central reorganisation in motor and sensory cortices

Sensory events are analysed in terms of appropriate motor response. Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000 Baseline information

Motor simulation network and motor planning Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000 Baseline information MSN

Altered sensory and motor perceptions are generated
Thermal
Body perception
Reduced and heightened awareness of limb
Pain, stiffness, pins and needles
Difficulty in locating limb prior to, and on initiation of movement
Poor motor control
When sensory input and motor output conflict? McCabe et al Rheumatology 2005 Sensorimotor conflict

CRPS and sensory-motor conflict Baseline information MSN Corrupted Imagined or actual movements will cause a range of sensory/motor disturbances

Access to the basic building blocks Snyder AW, Mitchell DJ. Proc.R.Soc. Lond. 1999;2666:587-592.

Link to current clinical signs? Foreshortened limbs/ Altered body perception? Autotomy/ desire for amputation?

Link to current clinical signs? Increased peri-personal space Farné A, Làdavas E. Neuropreport 2000; 85:1645-1649.

Correcting motor sensory mismatch – 3 potential target areas Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000 Baseline information MSN

Sensorimotor integration
Sensory and motor systems work in partnership
When discordance occurs altered sensory and motor perceptions are generated
Therapies designed to target this discrepancy appear effective.

Multidisciplinary inpatient and outpatient service at the RNHRD
National referral centre
Mobilisation of limb priority
Physiotherapy twice daily (land based and hydrotherapy)‏
Occupational therapy
Mirror visual feedback and motor imagery programme
Enable above activities by providing pharmacological and psychological support
Education, education, education!
2006 Established UK CRPS Clinical & Research Network

Acknowledgements
Funding 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

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