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Recent advances in Chronic
Regional Pain Syndrome
By: Siddharth Bagrecha
Manipal University, Manipal
Contents
• Objectives
• Introduction to CRPS
• Pathophysiology
• Diagnostic criteria
• Recent trends and advances
• Evidence for these trends and advances
Objective
• To know the evidence pertaining to treatment options for
Chronic Regional Pain Syndromes
• Recent treatment trends, approach and methods with
focus on rehabilitation
Search strategy
• Databases searched- Cochrane,, PubMed, CINHAL
• Duration-(2010-16)
• Keywords: CRPS, chronic regional pain syndrome,
physiotherapy, rehabilitation, neurostimulation, GMI,
mirror therapy, treatment, diagnosis, intervention, pain
exposure physical therapy, occupation therapy,
management, pain, disability, type 1, type 2
• Booleans used: AND, OR
Inclusion criteria
• Systematic reviews, RCT, case reports or series
assessing either about physiotherapy management or
physiotherapy management along with
pharmachological or surgical management were selected
• The following studies describes the physiotherapy
management from the past, present and the evidence
pertaining to that, along with certain guidelines
Articles retrieved through databases - 81
After removing duplicates and irrelevant
articles 33
• 6 RCT
• 21 reviews
• 6 others
Selected: 2 case report
• 3 reviews
• 1 others
• The above studies were selected because:
The met the inclusion criteria
These were the most recent studies and included most
of the previous studies relevant to this recent advance
Quality scores mentioned were either higher or equal to
other studies
Introduction
• CRPS can be sub classified into two diagnostic subtypes:
• CRPS-I in which no peripheral nerve injury can be identified
(RSD)
• CRPS-II where symptoms are associated with a definable
nerve lesion (causalgia) I. Elias Veizi, 2012
Definition
• A pain syndrome that can develop after physical injury
and is characterized by pain, in combination with
sensory, autonomic, motor and/or trophic changes. The
symptoms exceed the expected clinical course of the
inciting event IASP
Salibi A, 2014
Clinical features
Pathophysiology
• CRPS occurs most commonly following wrist fracture
and subsequent immobilization but may potentially
occur after any often relatively minor trauma
• Role of inflammation, vasomotor dysfunction and CNS
•Role of inflammation:
Minor tissue trauma is sufficient to amplify cytokine
signaling in the traumatized tissue
Cytokines and nerve growth factor can excite
nociceptors and induce long-term peripheral
sensitization
Depolarization of small-diameter primary afferent cause
the release of neuropeptides such as substance P and
calcitonin-gene-related peptide (CGRP) from sensory
terminals in the skin
Cytokines nerve growth factor enhance the release
of inflammatory neuropeptides in primary afferent
neurons
These neuropeptide evoke vasodilation and protein
extravasation in the tissue, and the resulting signs
(reddening, warming, and oedema) are called neurogenic
inflmmation
Increase in pro-inflammatory cytokines (TNF,
Interleukin-1) seen in early CRPS, although not related
to signs and symptoms but to mechanical hyperalgesia –
hallmark of central sensitization
Presence of immunological changes before CRPS
(facilitates onset of CRPS) or after developing CRPS
(role in maintenance of the syndrome)
Increase in interleukin 1b, interleukin 6 in spinal fluid
chronic CRPS
•Role of vasomotor dysfunction:
Three distinct pattern of temperature changes were
noted in people with CRPS
Warm type – the affected limb is warmer and skin
perfusion is higher than the contralateral limb, in
patients with CRPS for a mean of 4 months
Intermediate type – temperature and perfusion were
either warmer and colder depending on the sympathetic
activity, mean duration of CRPS 15 months
Cold type – temperature and perfusion were
consistently lower than the contralateral limb, mean
CRPS duration 28 months
Thus CRPS is associated with unilateral inhibition of
cutaneous vasoconstrictor neurons
This thermoregulatory impairment is caused by
functional changes in spinal cord, brainstem or brain that
is initiated by initial trauma
Not all CRPS cases undergo these different stages – can
have a cold type from the start (20%)
Nociceptors develop catecholamine sensitivity due to
decreased activity of sympathetic vasoconstrictor
neurons
Sympathetic nerve fibers release norepinephrine –
sensitizes the altered afferent neuron
This sympathetic-afferent coupling – sympathetically
maintained pain
Cutaneous sympathetic vasoconstrictor outflow was
activated by whole body cooling – the area and intensity
of the pain and mechanical hyperalgesia increased in
those identified as having sympathetically maintained
pain (pain reduction via sympathetic block), but not in
sympathetically independent pain
Endothelial dysfunction – decreased release of nitric
oxide – sustained vasoconstriction
•Role of CNS:
CNS undergoes structural and functional changes in
people with chronic pain (CRPS) – central sensitization
Involves disinhibition of spinal nociceptive neurons
These spinal nociceptors become more responsive to
peripheral input and might fire even in its absence
•Hyperalgesic priming:
• According to this theory, a transient insult triggers long
lasting changes in primary afferent nociceptors that
prime them to become hyper responsive to future mild
insults that would normally not evoke pain in the
unprimed state
• abnormal afferent activity can trigger plastic changes in
the CNS
•Dystonia:
• Most prevalent movement disorder in CRPS, is
characterised in the arm by persistent flexion postures of
the fingers and wrist and in the leg by plantar flexion
and inversion of the foot, with or without clawing of the
toes
• Dystonia occurs after the acute stage, which suggests
that it is not caused by acute inflammatory mechanism
• Maladaptive changes have also been noted in higher
order cognitive representations in patients with CRPS
• People with longstanding CRPS tend to perceive their
affected limb to be larger than it really is
• Alterations in shape, posture, and temperature of the
whole limb or of discrete parts of the limb, feeling
disgust and limb not belonging to them
• Although these pathophysiological mechanisms have all
been identified in CRPS, they might occur independently
of each other
• The absence of such fixed relations explains the clinical
heterogeneity that is often encountered in this condition
J Marinus, 2011
Diagnosis
• Budapest criteria- sensitivity; 0.66, specificity; 0.99
𝑁𝑜𝑟𝑚𝑎𝑛 𝐻𝑎𝑟𝑑𝑒𝑛, 2010
• Vascular studies
• 3 phase bone scans
• Infrared thermography
• Sympathetic blocks
• Radiodiagnostic studies
Recent advances
Is physiotherapy effective for children
with CRPS type 1?
Clinical journal of pain 2012
Andrea E. et. al.
LOE 1
Objectives
• To provide up-to-date physiotherapy treatment
recommendations and to identify areas that require
further investigation
Search strategy
• Jan 1987 to June 2010
• Out of 303 studies 12 were selected
• 1 RCT
• 1 comparative study
• 10 case series
Quality assessment
• Critical review form - quantitative studies
Inclusion criteria
• Participants who were;
Classified as children or adolescents i.e. < 19yrs
Diagnosed clinically as CRPS type I
Studies where physiotherapy intervention were
evaluated and reported
Interventions
Interventional
Sympathetic
blocks
Surgeries
Psychological
Psychiatry
CBT
Counselling
Pharmacologi
cal
Simple
analgesics
NSAIDS
Tricyclic
antidepressa
nts
PT
Exercise to
facilitate
motion
Water based
exercises
Sensory
desensitizati
on
Outcome measures
• Resolution and relapse
• Activity limitation
• Impairments
• Participation restriction
• Pain
Physiotherapy intervention LOE Results
Desensitization, heat, exercises,
weight bearing + NSAIDS +
psychological treatment
IV 86% of children responded
well to
Exercise, weight bearing,
electrical stimulation,
hydrotherapy, sensory
stimulation + psychological
treatment
IV 83% children responded well
to PT
TENS 1hr, 4 times daily +
analgesics + anti-inflammatory
drugs
IV 70% complete resolution
after 2 months
30% relapse after trauma
Physiotherapy intervention LOE Results
PT once per week vs PT thrice
per week ;Tens, tactile
desensitization, weight bearing,
massage, contrast bath, home
exercises + CBT
II • Function and pain
improved with PT + CBT
• Carry over till 12months
• 50% recurrence after
12months
Graded exercise program,
hydrotherapy, weight bearing,
joint motion, proprioception,
massage, desensitization
IV 75% of participants reported
full recovery in 25weeks
Weight bearing, massage, tactile
discrimination, contrast bath,
1hr/week for 6 weeks and an
individualized home program +
CBT
III • Autonomic symptoms and
pain improved
significantly
• Carry over for 6 months
Physiotherapy intervention LOE Results
PT 4 times per week, home
program twice daily, CBT, drug
therapy
IV • 79% fully recovered in
8wk (range: 2-28 wk.) with
PT ± drug treatment and
CBT.
• Partial recovery :15%
participants.
• 29% recurrence after
traumatic event, fully
recovered after 3wk of PT
5-6 hrs. of aerobic exercises
(lower limb; jumping, running,
stair climbing, sports )
(upper limb; weight bearing,
writing, carrying, lifting)
Hydrotherapy, massage, 45min
to 3hrs of home exercises daily
IV • 92% complete resolution
of pain with 14 sessions
• 42% no recurrence within
5years
Physiotherapy intervention LOE Results
TENS, cold, splinting, pressure,
desensitization, local injection,
MUGA, surgery
IV 47% reported complete
resolution without recurrence
Desensitization, heat, cold,
stretching, motion exercises,
drug therapy, hydrotherapy,
CBT, sympathetic blocks
IV 69% participants reported
improvement in function
Results and limitations
• Physiotherapy in combination with other treatments may
lead to short term improvements in the signs and
symptoms in children with CRPS type 1
• Difficulty in pooling the data due to heterogeneous
nature of the data available
Conclusion
• Poor to fair quality evidence on effectiveness of
physiotherapy in children with CRPS type 1
Intervention for treating pain and
disability in adults with complex
regional pain syndrome – an
overview of systematic reviews
O'Connell NE, Wand BM, Moseley GL
2013
LOE - 1
Objective
• To provide an overview of evidence from systematic
review to determine the efficacy of any intervention used
to reduce pain, disability or both in patients with CRPS
Grading of studies
• AMSTAR for systematic reviews
• 6 Cochrane and 13 non-Cochrane reviews were included
Outcomes
Primary outcomes
Pain
Disability
Adverse events
Secondary outcomes
QOL
Emotional well being
Subject’s rating of
satisfaction of
improvement
Results
• Divided into four treatment groups:
Drugs/pharmacotherapy
Interventional procedures
Rehab – PT, OT
Alternative therapies
•Oral:
Anti-inflammatory
Anti-convulsants
Opioids
N-Methyl D-aspartate antagonist
Anti-hypertensives
Bisphosphates
Calcitonin
•Topical:
Lidocaine patches
Mixed local anesthesia creams
Capsaicin
Dimethyl sulphoxides
•Interventional procedures:
I.V. regional anesthetic blockade
Blocking of sympathetic nerve activity
Sympathectomy
Neurostimulation
•Rehabilitation – PT, OT:
Manual therapy
Massage
TENS
Therapeutic exercises
Vocational and recreational rehabilitation
•Psychological therapies:
CBT
Counseling
Operant conditioning
Pain education
Relaxation technique
•Additional:
Mirror therapy
Graded motor imagery
Sensory motor retuning
Sensory tactile discrimination training
Pharmacotherapy LOE Results
Bisphosphates vs placebo LQ • Effectively reduces pain in
CRPS
• Improved composite CRPS
scores vs placebo
Calcitonin vs placebo VLQ More effective in reducing pain
vs placebo
NMDA receptors antagonist
vs placebo
VLQ Effective till 4-11 weeks
Neurostimulation LOE Results
Spinal cord stimulation VLQ • SCS + PT reduces pain in
CRPS 1 patients and improve
QOL
• No improvement hand and
foot function
SCS LQ Improves patient’s own
experience of overall
improvement till 2 years
PT and OT LOE Results
General PT and OT VLQ Better than passive attention
control in reducing pain
Manual lymph drainage VLQ Did no complement exercises
GMI and mirror therapy LQ More effective than
conventional physiotherapy
Ordered GMI VLQ More effective than
unordered GMI
Mirror therapy LQ Reduces pain and improves
upper limb in post stroke
Physiotherapy
• GMI may reduce pain and improve function more than
conventional physiotherapy care, these improvements
are maintained for 3 to 6 months
• Mirror therapy may improve function and reduce pain
than a sham treatment in post stroke CRPS
• Relaxation therapy and manual lymphatic drainage are
not effective
• Spinal cord stimulation with physiotherapy is more
effective than physiotherapy alone or spinal cord
stimulation alone
• PT and OT improve pain more than a passive attention
social work control for upto 6 months and that PT but
not OT improves impairment for upto 4 months vs same
control
Conclusion
• There are no high quality evidence for or against the
effectiveness of treatment for CRPS
• However GMI and MVF appears to be superior than
other treatment options
Physiotherapy management of
complex regional pain syndrome
Catherine Pollard
2013
LOE 1
Objectives
• To explore the current research regarding efficacy of
physiotherapy treatment employed to treat CRPS
Physiotherapy management
• Mirror therapy
• Graded motor imagery
• Tactile discrimination
• Exposure therapy
• Virtual reality
• Minimizing body perception differences
Mirror therapy
Movement of the
affected limb not
performed in
synchrony with
reflection
Conflicting
sensory feedback
CRPS related
pain can increase
Both limb moving in
bilateral synchrony
Appropriate
sensory feedback
Pain reduction
• Acute phase < 6 weeks – reduced pain in CRPS 1
• Intermediate stages < 1 year – Reduced stiffness
• Chronic cases – benefits not significant enough
McCabe 2003
Tichelar 2007
Cacchio 2009
GMI
• Participants who followed the sequenced GMI stages
showed better outcomes – reduced pain rating and
increased functional task ability than those who did not
Moseley 2005
Tactile discrimination
• Tactile discrimination techniques encourage patients to
concentrate on the delivered stimuli – improved tactile
aquity and reduce pain (via improvements cortical
reorganization)
• Involving active participation from the patients to distinguish
type and location of stimuli shows better results in improving
tactile acuty and pain than passive stimulation (touching
the affected limb without conscious thought) Moseley, 2008a
Exposure therapy
• In acute CRPS, severity of pain limits function rather
then fear, in contrast in chronic CRPS perceived
harmfulness of activities correlated stronger to
functional limitation than pain intensity De Jong 2011
•Graded exposure therapy:
Screening
Education
Graded
exposure
•Aim: Stimulate the fear then disconfirm the fear by
providing new information on the feared activity an thus
alleviate inaccurate predictions about the activity
• Used a progressive-loading exercise programme,
desensitizing techniques, forced use of the affected limb
in daily activities and management of pain-avoidance
behavior, without the use of specific CRPS-1 medication
or analgesics Ek et. al. 2009
Function
49 full recovery
46 partial recovery
5 no change
Pain scores
Reduced for 76
Increased in 14
No change 12
• Due to the risk of initially increasing pain intensity, the
studies exploring exposure therapy highlighted the
importance of ensuring the patient was adequately
educated to be compliant with treatment regimes
• These studies provide reassuring evidence that
treatments focusing on activity whilst ignoring pain can
be safely applied with no deterioration of CRPS-1
symptoms
Virtual reality
• Computer based software
• Tested on 5 participants with CRPS-I, weekly one
session for 8 sessions
• Results: 4/5 patients showed 50% reduction in the pain
scores, 2 patients continued to have the analgesic effect
post cessation of the treatment Sato, 2010
Minimizing body perception
disturbances
• CRPS patients exhibit body perception disturbance
• In order to move the affected limb, people with CRPS-1
frequently comment on their need to consciously focus
their mental and visual attention to the limb, often
describing the limb as “not belonging to me”
•Prism glass: Principles of mirror therapy
• They utilize a wedge prism to add visual displacement
towards the affected side while blocking vision in the
other eye
• Moving the unaffected side gives an illusion of moving
the affected side
• 20° prismatic deviation on the unaffected side for 2
weeks caused alleviation of pain and improved
proprioception (Visual subjective body-midline
judgment task) in 5 patients with CRPS
Conclusion
• Although mechanism of CRPS is not completely
understood there is increasing evidence in the role of
central mechanism in maintenance of the disease
• There is some supporting evidence for the use of GMI
however for other techniques higher quality studies
might be required to generate further evidence
Graded motor imagery
Victoria W
JHT
2011
Introduction
• Graded motor imagery is a comprehensive program
designed to sequentially activate cortical motor networks
and improve cortical organization
• Three stages – Limb laterality training, imagined hand
movements and Mirror Visual Feedback
Case study
• 57 year old woman – 3 months post ORIF left distal
radius fracture
• Diagnosed as CRPS using IASP criteria
• The hand was swollen with discoloration, stiff, and
cooler to touch than the other hand
• She had allodynia and experienced severe pain with a
light breeze and light touch
• She held it in a protective posture that included shoulder
elevation, adduction, internal rotation, elbow flexion
with slight finger, and wrist flexion
• Patient’s pain score was 8 of 10
• The patient’s chief complaints involved the extreme
burning pain she experienced and her inability to move
her hand and wrist (kinesiophobia), drive a car, and
perform activities of daily living
Treatment
• The initial laterality training involved having the
patient identify 20 nonthreatening pictures of the right
and left hand in various positions
• Both accuracy of pictures and the time it took to identify
the pictures were recorded
• The patient was instructed to perform the laterality
training four times a day for 10 minutes
• Additional exercises to perform at home were scapular
strengthening, diaphragmatic breathing, and gentle no
painful ROM along with edema control
• The patient was instructed on positions of the wrist and
forearm to reduce swelling and gentle wrapping of the
extremity for edema control
• At the second visit, the patient was able to progress to
step 2, which consisted of visual imaging and mirror
therapy without movement. It was reinforced to the
patient to visualize specific hand postures without
actually moving the hand
• At the fourth visit, the patient was progressed to mirror
visual therapy in which the patient was instructed to look
at the unaffected hand in the mirror and then move the
unaffected hand with hopes of not increasing pain in the
involved hand
• GMI for 4 weeks showed reduction in symptoms, thus
GMI was discontinued
• The patient continued treatment for two more months in
therapy for desensitization and sensory reeducation,
nervous system mobilization, cervical and thoracic
mobilization, ROM, and scapular and upper extremity
strengthening, along with functional activities for daily
living
Outcomes
• At six months post injury, the patient showed decreasing
pain and disability, improvement in ROM, and
normalization of autonomic dysfunction
• Kinesiophobia and allodynia were no longer present
• The patient achieved her long-term goals of decreased
pain (which occasionally fluctuated from 0 to 2)
functional ROM of the left upper extremity, and strength
gains sufficient to perform all activities of daily living,
including driving and leisure activities
Conclusion
• The study demonstrates how GMI can be incorporated
into a pain management program
Physical therapy treatment for
patients diagnosed with Complex
Regional Pain Syndrome
J. Connole
2015
Objective
• To analyze the effects of physical therapy interventions
on a patient diagnosed with type 1 CRPS to determine
the most beneficial treatments
Case description
• A 46-year-old female referred to physical therapy for
post-op care of knee and foot surgery
• She developed CRPS 1 of the left foot secondary to
surgical trauma
• Chevron osteotomy for left hallux valgus deformity
Patient presentation
• The patient complains of sharp stabbing pain and
throbbing of ankle, foot, and calf of left lower extremity
• Spasms approximately every 30 minutes in left plantar
region and area of dorsal great toe
• In the same region, she presents with sensitivity to touch
and cold, swelling, change in temperature and color,
change in skin texture, change in hair and nails, joint
stiffness, and decreased motion below the ankle
Examination
• Foot/Ankle Disability Index – 52%
• Pain VAS – 8/10
• Sensation diminished below the ankle
• MMT - untestable due to pain
• Reflexes – 2+ for Achilles, Hamstring, and Patellar
• ROM – MTP extension L=7 R= 65, flexion L=22 R=55
• Pitting edema – lasted >30 sec. Circumference L=56cm
R=49.5cm
Intervention
• Duration of intervention and re examination was decided
to be one hour of therapy 3x/week for 4weeks
• The main interventions provided during treatment
consisted of: Patient related instructions, communication
with other health professionals, direct interventions
using specific therapeutic approaches and strategies
• PROM/AROM, myofascial release, soft tissue and deep
tissue massage, edema massage, TENS, low load long
duration stretches, graded imagery, graded exposure,
scar mobilization, post op knee rehab
• Gait training, proprioception, compression stocking,
great toe extension night splint use, and education
• Home program was given
Outcomes
• Lack of extension was affecting her gait and was her
chief complaint at the time
• Her Foot and Ankle Disability Score improved to 14%
and her pain VAS was 2/10 at its worst
• Physiotherapy was decreased to 1x/week and was given
a night splint for big toe extension
Conclusions
• An extensive approach including not just one but various
adjunct treatment technique for better management of
CRPS
Using graded motor imagery for
complex regional pain syndrome in
clinical practice: Failure to improve
Johnson et. al.
2011
Objective
• To establish whether GMI is effective in clinical practice
or not
Methods
• Audit of GMI treatment at two UK centers with a special
interest in the management of patients with CRPS
• All patients received GMI, in conjunction with a range
of other physical and psychological interventions
Assessment
• At baseline, at the start of each treatment stage and at the
end of the programme, patients were asked to complete a
Brief Pain Inventory (BPI)
• Along with GMI other medical management and
physical therapy interventions were continued as
required
Outcomes
Primary outcomes
Average pain intensity
Secondary outcomes
Worst pain intensity
Accuracy of hand
judgment before and
after laterality training
Mood
Sequence of treatment
Results
• Average pain intensity: did not decrease than the
baseline in either centers
• Worst pain: At center 1, but not 2 there was decrease in
the worst pain scores of the patients
• Effects of limb laterality training: did not show any
significant change
• Function: Moderate to high pain interference at
baseline, significant improvements noted
• Increased pain: some patients experienced increment in
pain
Conclusion
• GMI might be effective in reducing the worst pain
experience and to improve pain experience but does not
significantly improve average pain intensity which
might be of more relevance
Final conclusion
• Physical and occupational therapy plays an important
role in managing the symptoms of CRPS
• Conventional physiotherapy in conjunction with other
management (Sx or Pharmacological) can help in
reduction of pain and improve function
• Physiotherapy interventions targeting central
mechanisms (GMI) have shown to be effective in
managing pain and symptoms as an stand alone
treatment when used appropriately especially in chronic
cases
• Virtual reality based treatments might be an upcoming
therapeutic option in terms of patient adherence to
therapy as the are more fun to perform for the patient
• Special emphasis has to be paid on patient education and
motivation for therapy as there has been reports of
increment in the pain levels with interventions such as
exposure therapy, mirror therapy as well as GMI
• At the end a holistic approach is required for better
management of CRPS
Questions???
Thank you!!!

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Recent advances in crps (Physiotherapy perspective)

  • 1. Recent advances in Chronic Regional Pain Syndrome By: Siddharth Bagrecha Manipal University, Manipal
  • 2. Contents • Objectives • Introduction to CRPS • Pathophysiology • Diagnostic criteria • Recent trends and advances • Evidence for these trends and advances
  • 3. Objective • To know the evidence pertaining to treatment options for Chronic Regional Pain Syndromes • Recent treatment trends, approach and methods with focus on rehabilitation
  • 4. Search strategy • Databases searched- Cochrane,, PubMed, CINHAL • Duration-(2010-16) • Keywords: CRPS, chronic regional pain syndrome, physiotherapy, rehabilitation, neurostimulation, GMI, mirror therapy, treatment, diagnosis, intervention, pain exposure physical therapy, occupation therapy, management, pain, disability, type 1, type 2 • Booleans used: AND, OR
  • 5. Inclusion criteria • Systematic reviews, RCT, case reports or series assessing either about physiotherapy management or physiotherapy management along with pharmachological or surgical management were selected • The following studies describes the physiotherapy management from the past, present and the evidence pertaining to that, along with certain guidelines
  • 6. Articles retrieved through databases - 81 After removing duplicates and irrelevant articles 33 • 6 RCT • 21 reviews • 6 others Selected: 2 case report • 3 reviews • 1 others
  • 7. • The above studies were selected because: The met the inclusion criteria These were the most recent studies and included most of the previous studies relevant to this recent advance Quality scores mentioned were either higher or equal to other studies
  • 8. Introduction • CRPS can be sub classified into two diagnostic subtypes: • CRPS-I in which no peripheral nerve injury can be identified (RSD) • CRPS-II where symptoms are associated with a definable nerve lesion (causalgia) I. Elias Veizi, 2012
  • 9. Definition • A pain syndrome that can develop after physical injury and is characterized by pain, in combination with sensory, autonomic, motor and/or trophic changes. The symptoms exceed the expected clinical course of the inciting event IASP
  • 12.
  • 13. Pathophysiology • CRPS occurs most commonly following wrist fracture and subsequent immobilization but may potentially occur after any often relatively minor trauma • Role of inflammation, vasomotor dysfunction and CNS
  • 14. •Role of inflammation: Minor tissue trauma is sufficient to amplify cytokine signaling in the traumatized tissue Cytokines and nerve growth factor can excite nociceptors and induce long-term peripheral sensitization
  • 15. Depolarization of small-diameter primary afferent cause the release of neuropeptides such as substance P and calcitonin-gene-related peptide (CGRP) from sensory terminals in the skin Cytokines nerve growth factor enhance the release of inflammatory neuropeptides in primary afferent neurons
  • 16. These neuropeptide evoke vasodilation and protein extravasation in the tissue, and the resulting signs (reddening, warming, and oedema) are called neurogenic inflmmation Increase in pro-inflammatory cytokines (TNF, Interleukin-1) seen in early CRPS, although not related to signs and symptoms but to mechanical hyperalgesia – hallmark of central sensitization
  • 17. Presence of immunological changes before CRPS (facilitates onset of CRPS) or after developing CRPS (role in maintenance of the syndrome) Increase in interleukin 1b, interleukin 6 in spinal fluid chronic CRPS
  • 18. •Role of vasomotor dysfunction: Three distinct pattern of temperature changes were noted in people with CRPS Warm type – the affected limb is warmer and skin perfusion is higher than the contralateral limb, in patients with CRPS for a mean of 4 months
  • 19. Intermediate type – temperature and perfusion were either warmer and colder depending on the sympathetic activity, mean duration of CRPS 15 months Cold type – temperature and perfusion were consistently lower than the contralateral limb, mean CRPS duration 28 months
  • 20. Thus CRPS is associated with unilateral inhibition of cutaneous vasoconstrictor neurons This thermoregulatory impairment is caused by functional changes in spinal cord, brainstem or brain that is initiated by initial trauma Not all CRPS cases undergo these different stages – can have a cold type from the start (20%)
  • 21. Nociceptors develop catecholamine sensitivity due to decreased activity of sympathetic vasoconstrictor neurons Sympathetic nerve fibers release norepinephrine – sensitizes the altered afferent neuron This sympathetic-afferent coupling – sympathetically maintained pain
  • 22. Cutaneous sympathetic vasoconstrictor outflow was activated by whole body cooling – the area and intensity of the pain and mechanical hyperalgesia increased in those identified as having sympathetically maintained pain (pain reduction via sympathetic block), but not in sympathetically independent pain Endothelial dysfunction – decreased release of nitric oxide – sustained vasoconstriction
  • 23.
  • 24. •Role of CNS: CNS undergoes structural and functional changes in people with chronic pain (CRPS) – central sensitization Involves disinhibition of spinal nociceptive neurons These spinal nociceptors become more responsive to peripheral input and might fire even in its absence
  • 25. •Hyperalgesic priming: • According to this theory, a transient insult triggers long lasting changes in primary afferent nociceptors that prime them to become hyper responsive to future mild insults that would normally not evoke pain in the unprimed state • abnormal afferent activity can trigger plastic changes in the CNS
  • 26. •Dystonia: • Most prevalent movement disorder in CRPS, is characterised in the arm by persistent flexion postures of the fingers and wrist and in the leg by plantar flexion and inversion of the foot, with or without clawing of the toes • Dystonia occurs after the acute stage, which suggests that it is not caused by acute inflammatory mechanism
  • 27. • Maladaptive changes have also been noted in higher order cognitive representations in patients with CRPS • People with longstanding CRPS tend to perceive their affected limb to be larger than it really is • Alterations in shape, posture, and temperature of the whole limb or of discrete parts of the limb, feeling disgust and limb not belonging to them
  • 28.
  • 29. • Although these pathophysiological mechanisms have all been identified in CRPS, they might occur independently of each other • The absence of such fixed relations explains the clinical heterogeneity that is often encountered in this condition J Marinus, 2011
  • 30. Diagnosis • Budapest criteria- sensitivity; 0.66, specificity; 0.99 𝑁𝑜𝑟𝑚𝑎𝑛 𝐻𝑎𝑟𝑑𝑒𝑛, 2010 • Vascular studies • 3 phase bone scans • Infrared thermography • Sympathetic blocks • Radiodiagnostic studies
  • 31.
  • 33. Is physiotherapy effective for children with CRPS type 1? Clinical journal of pain 2012 Andrea E. et. al. LOE 1
  • 34. Objectives • To provide up-to-date physiotherapy treatment recommendations and to identify areas that require further investigation
  • 35. Search strategy • Jan 1987 to June 2010 • Out of 303 studies 12 were selected • 1 RCT • 1 comparative study • 10 case series
  • 36. Quality assessment • Critical review form - quantitative studies
  • 37. Inclusion criteria • Participants who were; Classified as children or adolescents i.e. < 19yrs Diagnosed clinically as CRPS type I Studies where physiotherapy intervention were evaluated and reported
  • 39. Outcome measures • Resolution and relapse • Activity limitation • Impairments • Participation restriction • Pain
  • 40. Physiotherapy intervention LOE Results Desensitization, heat, exercises, weight bearing + NSAIDS + psychological treatment IV 86% of children responded well to Exercise, weight bearing, electrical stimulation, hydrotherapy, sensory stimulation + psychological treatment IV 83% children responded well to PT TENS 1hr, 4 times daily + analgesics + anti-inflammatory drugs IV 70% complete resolution after 2 months 30% relapse after trauma
  • 41. Physiotherapy intervention LOE Results PT once per week vs PT thrice per week ;Tens, tactile desensitization, weight bearing, massage, contrast bath, home exercises + CBT II • Function and pain improved with PT + CBT • Carry over till 12months • 50% recurrence after 12months Graded exercise program, hydrotherapy, weight bearing, joint motion, proprioception, massage, desensitization IV 75% of participants reported full recovery in 25weeks Weight bearing, massage, tactile discrimination, contrast bath, 1hr/week for 6 weeks and an individualized home program + CBT III • Autonomic symptoms and pain improved significantly • Carry over for 6 months
  • 42. Physiotherapy intervention LOE Results PT 4 times per week, home program twice daily, CBT, drug therapy IV • 79% fully recovered in 8wk (range: 2-28 wk.) with PT ± drug treatment and CBT. • Partial recovery :15% participants. • 29% recurrence after traumatic event, fully recovered after 3wk of PT 5-6 hrs. of aerobic exercises (lower limb; jumping, running, stair climbing, sports ) (upper limb; weight bearing, writing, carrying, lifting) Hydrotherapy, massage, 45min to 3hrs of home exercises daily IV • 92% complete resolution of pain with 14 sessions • 42% no recurrence within 5years
  • 43. Physiotherapy intervention LOE Results TENS, cold, splinting, pressure, desensitization, local injection, MUGA, surgery IV 47% reported complete resolution without recurrence Desensitization, heat, cold, stretching, motion exercises, drug therapy, hydrotherapy, CBT, sympathetic blocks IV 69% participants reported improvement in function
  • 44. Results and limitations • Physiotherapy in combination with other treatments may lead to short term improvements in the signs and symptoms in children with CRPS type 1 • Difficulty in pooling the data due to heterogeneous nature of the data available
  • 45. Conclusion • Poor to fair quality evidence on effectiveness of physiotherapy in children with CRPS type 1
  • 46. Intervention for treating pain and disability in adults with complex regional pain syndrome – an overview of systematic reviews O'Connell NE, Wand BM, Moseley GL 2013 LOE - 1
  • 47. Objective • To provide an overview of evidence from systematic review to determine the efficacy of any intervention used to reduce pain, disability or both in patients with CRPS
  • 48.
  • 49. Grading of studies • AMSTAR for systematic reviews • 6 Cochrane and 13 non-Cochrane reviews were included
  • 50. Outcomes Primary outcomes Pain Disability Adverse events Secondary outcomes QOL Emotional well being Subject’s rating of satisfaction of improvement
  • 51. Results • Divided into four treatment groups: Drugs/pharmacotherapy Interventional procedures Rehab – PT, OT Alternative therapies
  • 53. •Topical: Lidocaine patches Mixed local anesthesia creams Capsaicin Dimethyl sulphoxides
  • 54. •Interventional procedures: I.V. regional anesthetic blockade Blocking of sympathetic nerve activity Sympathectomy Neurostimulation
  • 55. •Rehabilitation – PT, OT: Manual therapy Massage TENS Therapeutic exercises Vocational and recreational rehabilitation
  • 57. •Additional: Mirror therapy Graded motor imagery Sensory motor retuning Sensory tactile discrimination training
  • 58. Pharmacotherapy LOE Results Bisphosphates vs placebo LQ • Effectively reduces pain in CRPS • Improved composite CRPS scores vs placebo Calcitonin vs placebo VLQ More effective in reducing pain vs placebo NMDA receptors antagonist vs placebo VLQ Effective till 4-11 weeks
  • 59. Neurostimulation LOE Results Spinal cord stimulation VLQ • SCS + PT reduces pain in CRPS 1 patients and improve QOL • No improvement hand and foot function SCS LQ Improves patient’s own experience of overall improvement till 2 years
  • 60. PT and OT LOE Results General PT and OT VLQ Better than passive attention control in reducing pain Manual lymph drainage VLQ Did no complement exercises GMI and mirror therapy LQ More effective than conventional physiotherapy Ordered GMI VLQ More effective than unordered GMI Mirror therapy LQ Reduces pain and improves upper limb in post stroke
  • 61. Physiotherapy • GMI may reduce pain and improve function more than conventional physiotherapy care, these improvements are maintained for 3 to 6 months • Mirror therapy may improve function and reduce pain than a sham treatment in post stroke CRPS
  • 62. • Relaxation therapy and manual lymphatic drainage are not effective • Spinal cord stimulation with physiotherapy is more effective than physiotherapy alone or spinal cord stimulation alone
  • 63. • PT and OT improve pain more than a passive attention social work control for upto 6 months and that PT but not OT improves impairment for upto 4 months vs same control
  • 64.
  • 65.
  • 66.
  • 67. Conclusion • There are no high quality evidence for or against the effectiveness of treatment for CRPS • However GMI and MVF appears to be superior than other treatment options
  • 68. Physiotherapy management of complex regional pain syndrome Catherine Pollard 2013 LOE 1
  • 69. Objectives • To explore the current research regarding efficacy of physiotherapy treatment employed to treat CRPS
  • 70. Physiotherapy management • Mirror therapy • Graded motor imagery • Tactile discrimination • Exposure therapy • Virtual reality • Minimizing body perception differences
  • 71. Mirror therapy Movement of the affected limb not performed in synchrony with reflection Conflicting sensory feedback CRPS related pain can increase Both limb moving in bilateral synchrony Appropriate sensory feedback Pain reduction
  • 72. • Acute phase < 6 weeks – reduced pain in CRPS 1 • Intermediate stages < 1 year – Reduced stiffness • Chronic cases – benefits not significant enough McCabe 2003 Tichelar 2007 Cacchio 2009
  • 73. GMI • Participants who followed the sequenced GMI stages showed better outcomes – reduced pain rating and increased functional task ability than those who did not Moseley 2005
  • 74. Tactile discrimination • Tactile discrimination techniques encourage patients to concentrate on the delivered stimuli – improved tactile aquity and reduce pain (via improvements cortical reorganization) • Involving active participation from the patients to distinguish type and location of stimuli shows better results in improving
  • 75. tactile acuty and pain than passive stimulation (touching the affected limb without conscious thought) Moseley, 2008a
  • 76. Exposure therapy • In acute CRPS, severity of pain limits function rather then fear, in contrast in chronic CRPS perceived harmfulness of activities correlated stronger to functional limitation than pain intensity De Jong 2011
  • 78. •Aim: Stimulate the fear then disconfirm the fear by providing new information on the feared activity an thus alleviate inaccurate predictions about the activity • Used a progressive-loading exercise programme, desensitizing techniques, forced use of the affected limb in daily activities and management of pain-avoidance behavior, without the use of specific CRPS-1 medication or analgesics Ek et. al. 2009
  • 79. Function 49 full recovery 46 partial recovery 5 no change Pain scores Reduced for 76 Increased in 14 No change 12
  • 80. • Due to the risk of initially increasing pain intensity, the studies exploring exposure therapy highlighted the importance of ensuring the patient was adequately educated to be compliant with treatment regimes • These studies provide reassuring evidence that treatments focusing on activity whilst ignoring pain can be safely applied with no deterioration of CRPS-1 symptoms
  • 81. Virtual reality • Computer based software • Tested on 5 participants with CRPS-I, weekly one session for 8 sessions • Results: 4/5 patients showed 50% reduction in the pain scores, 2 patients continued to have the analgesic effect post cessation of the treatment Sato, 2010
  • 82. Minimizing body perception disturbances • CRPS patients exhibit body perception disturbance • In order to move the affected limb, people with CRPS-1 frequently comment on their need to consciously focus their mental and visual attention to the limb, often describing the limb as “not belonging to me”
  • 83. •Prism glass: Principles of mirror therapy • They utilize a wedge prism to add visual displacement towards the affected side while blocking vision in the other eye • Moving the unaffected side gives an illusion of moving the affected side
  • 84.
  • 85. • 20° prismatic deviation on the unaffected side for 2 weeks caused alleviation of pain and improved proprioception (Visual subjective body-midline judgment task) in 5 patients with CRPS
  • 86. Conclusion • Although mechanism of CRPS is not completely understood there is increasing evidence in the role of central mechanism in maintenance of the disease • There is some supporting evidence for the use of GMI however for other techniques higher quality studies might be required to generate further evidence
  • 88. Introduction • Graded motor imagery is a comprehensive program designed to sequentially activate cortical motor networks and improve cortical organization • Three stages – Limb laterality training, imagined hand movements and Mirror Visual Feedback
  • 89.
  • 90.
  • 91. Case study • 57 year old woman – 3 months post ORIF left distal radius fracture • Diagnosed as CRPS using IASP criteria • The hand was swollen with discoloration, stiff, and cooler to touch than the other hand
  • 92. • She had allodynia and experienced severe pain with a light breeze and light touch • She held it in a protective posture that included shoulder elevation, adduction, internal rotation, elbow flexion with slight finger, and wrist flexion • Patient’s pain score was 8 of 10
  • 93. • The patient’s chief complaints involved the extreme burning pain she experienced and her inability to move her hand and wrist (kinesiophobia), drive a car, and perform activities of daily living
  • 94. Treatment • The initial laterality training involved having the patient identify 20 nonthreatening pictures of the right and left hand in various positions • Both accuracy of pictures and the time it took to identify the pictures were recorded
  • 95. • The patient was instructed to perform the laterality training four times a day for 10 minutes • Additional exercises to perform at home were scapular strengthening, diaphragmatic breathing, and gentle no painful ROM along with edema control
  • 96. • The patient was instructed on positions of the wrist and forearm to reduce swelling and gentle wrapping of the extremity for edema control • At the second visit, the patient was able to progress to step 2, which consisted of visual imaging and mirror therapy without movement. It was reinforced to the patient to visualize specific hand postures without actually moving the hand
  • 97. • At the fourth visit, the patient was progressed to mirror visual therapy in which the patient was instructed to look at the unaffected hand in the mirror and then move the unaffected hand with hopes of not increasing pain in the involved hand • GMI for 4 weeks showed reduction in symptoms, thus GMI was discontinued
  • 98. • The patient continued treatment for two more months in therapy for desensitization and sensory reeducation, nervous system mobilization, cervical and thoracic mobilization, ROM, and scapular and upper extremity strengthening, along with functional activities for daily living
  • 99. Outcomes • At six months post injury, the patient showed decreasing pain and disability, improvement in ROM, and normalization of autonomic dysfunction • Kinesiophobia and allodynia were no longer present
  • 100. • The patient achieved her long-term goals of decreased pain (which occasionally fluctuated from 0 to 2) functional ROM of the left upper extremity, and strength gains sufficient to perform all activities of daily living, including driving and leisure activities
  • 101. Conclusion • The study demonstrates how GMI can be incorporated into a pain management program
  • 102. Physical therapy treatment for patients diagnosed with Complex Regional Pain Syndrome J. Connole 2015
  • 103. Objective • To analyze the effects of physical therapy interventions on a patient diagnosed with type 1 CRPS to determine the most beneficial treatments
  • 104. Case description • A 46-year-old female referred to physical therapy for post-op care of knee and foot surgery • She developed CRPS 1 of the left foot secondary to surgical trauma • Chevron osteotomy for left hallux valgus deformity
  • 105. Patient presentation • The patient complains of sharp stabbing pain and throbbing of ankle, foot, and calf of left lower extremity • Spasms approximately every 30 minutes in left plantar region and area of dorsal great toe
  • 106. • In the same region, she presents with sensitivity to touch and cold, swelling, change in temperature and color, change in skin texture, change in hair and nails, joint stiffness, and decreased motion below the ankle
  • 107. Examination • Foot/Ankle Disability Index – 52% • Pain VAS – 8/10 • Sensation diminished below the ankle • MMT - untestable due to pain • Reflexes – 2+ for Achilles, Hamstring, and Patellar • ROM – MTP extension L=7 R= 65, flexion L=22 R=55 • Pitting edema – lasted >30 sec. Circumference L=56cm R=49.5cm
  • 108.
  • 109. Intervention • Duration of intervention and re examination was decided to be one hour of therapy 3x/week for 4weeks • The main interventions provided during treatment consisted of: Patient related instructions, communication with other health professionals, direct interventions using specific therapeutic approaches and strategies
  • 110. • PROM/AROM, myofascial release, soft tissue and deep tissue massage, edema massage, TENS, low load long duration stretches, graded imagery, graded exposure, scar mobilization, post op knee rehab • Gait training, proprioception, compression stocking, great toe extension night splint use, and education • Home program was given
  • 111. Outcomes • Lack of extension was affecting her gait and was her chief complaint at the time • Her Foot and Ankle Disability Score improved to 14% and her pain VAS was 2/10 at its worst • Physiotherapy was decreased to 1x/week and was given a night splint for big toe extension
  • 112. Conclusions • An extensive approach including not just one but various adjunct treatment technique for better management of CRPS
  • 113. Using graded motor imagery for complex regional pain syndrome in clinical practice: Failure to improve Johnson et. al. 2011
  • 114. Objective • To establish whether GMI is effective in clinical practice or not
  • 115. Methods • Audit of GMI treatment at two UK centers with a special interest in the management of patients with CRPS • All patients received GMI, in conjunction with a range of other physical and psychological interventions
  • 116. Assessment • At baseline, at the start of each treatment stage and at the end of the programme, patients were asked to complete a Brief Pain Inventory (BPI) • Along with GMI other medical management and physical therapy interventions were continued as required
  • 117. Outcomes Primary outcomes Average pain intensity Secondary outcomes Worst pain intensity Accuracy of hand judgment before and after laterality training Mood
  • 119. Results • Average pain intensity: did not decrease than the baseline in either centers • Worst pain: At center 1, but not 2 there was decrease in the worst pain scores of the patients
  • 120. • Effects of limb laterality training: did not show any significant change • Function: Moderate to high pain interference at baseline, significant improvements noted • Increased pain: some patients experienced increment in pain
  • 121. Conclusion • GMI might be effective in reducing the worst pain experience and to improve pain experience but does not significantly improve average pain intensity which might be of more relevance
  • 122. Final conclusion • Physical and occupational therapy plays an important role in managing the symptoms of CRPS • Conventional physiotherapy in conjunction with other management (Sx or Pharmacological) can help in reduction of pain and improve function
  • 123. • Physiotherapy interventions targeting central mechanisms (GMI) have shown to be effective in managing pain and symptoms as an stand alone treatment when used appropriately especially in chronic cases • Virtual reality based treatments might be an upcoming therapeutic option in terms of patient adherence to therapy as the are more fun to perform for the patient
  • 124. • Special emphasis has to be paid on patient education and motivation for therapy as there has been reports of increment in the pain levels with interventions such as exposure therapy, mirror therapy as well as GMI • At the end a holistic approach is required for better management of CRPS