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Assessment Of Complex Regional Pain Syndrome Dr Candy Mccabe


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Lecture given to the North British Pain Association on 16th May 2008 by Dr Candy McCabe. In this talk, Dr McCabe discusses the mechanisms and assessment of patients with complex regional pain syndrome.

Published in: Health & Medicine, Education
  • I have a number of health problems. I have severe arthritis in my right leg and hip. I use a cane or walker most of the time. I’m on oxygen 24 x 7 for C.O.P.D., and I have been fighting with depression for 20 years. And I’m in so much pain at night that I’m up and down all night. My doctor put me on morphine 12 hour caps. Any suggestions of a friend or doctor?

    Lindsay Hannover
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  • ive been to see dr candy mcabe as im a rsd suferer, this induction she had done is very intresting to those who have been dignosed with the condition its a brilliant peice she has done
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  • AMAZING she is an inspiration
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Assessment Of Complex Regional Pain Syndrome Dr Candy Mccabe

  1. 1. 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
  2. 2. Rene Descartes 1596-1650 “ I think therefore I am” Jean-Jacques Rousseau, 1712-1778 “ I FEEL therefore I am”
  3. 3. Silas Weir Mitchell 1829-1914 Turner’s Lane Hospital, Philadelphia
  4. 4. IASP Current diagnostic criteria <ul><li>Complex Regional Pain Syndrome Type I </li></ul><ul><li>Follows an initiating noxious event </li></ul><ul><li>Spontaneous pain and/or allodynia and hyperalegesia occur beyond area of a single peripheral nerve and disproportionate to the inciting event. </li></ul><ul><li>Evidence or has been evidence of oedema, skin blood flow abnormality and sudomotor changes. </li></ul><ul><li>CRPS Type II </li></ul><ul><li>Follows nerve injury </li></ul><ul><li>More regionally confined area </li></ul>Stanton-Hicks M, Janig W, et al. Pain, 1995; 63: 127-133 .
  5. 5. IASP SIG proposed revised diagnostic criteria <ul><li>Hyperalagesia/ hyperaesthesia (sensory)‏ </li></ul><ul><li>Temperature and colour changes (vasomotor)‏ </li></ul><ul><li>Oedema and sweating (sudomotor)‏ </li></ul><ul><li>Trophic and motor changes </li></ul><ul><li>Clinical criteria: 2 signs and 3 symptoms </li></ul><ul><li>Research criteria: 2 signs and 4 symptoms </li></ul>Galer et al., 1998. Pain; 14:48-54 Bruehl et al., 1999. Pain; 81:147-54
  6. 6. Presentation of CRPS <ul><li>Incidence rates of 5.46 to 26.2 per 100,000 person years. UK incidence unknown. </li></ul><ul><li>Sandroni et al Pain 2003 (Minnesota, USA); </li></ul><ul><li>De Mos et al Pain 2007 (Netherlands)‏ </li></ul><ul><li>Onset of symptoms may be immediate following trauma or within one month of limb immobilisation </li></ul><ul><li>50% go on to suffer chronic symptoms and long term physical impairment </li></ul><ul><li>Field et al. Journal of hand Surgery 1992, </li></ul><ul><li>Schasfoort et al. Arch. Physical Med. & rehab. 2004. </li></ul><ul><li>Disturbance in sensory, motor and autonomic systems which may fluctuate over time and even over a single day. </li></ul><ul><li>Diagnosis and therapy delayed by closeness in nomenclature between ‘Chronic’ and ‘Complex’ regional pain syndrome. </li></ul>
  7. 7. <ul><li>Excessive pain in the presence of minor or no injury tends to be disbelieved </li></ul>
  8. 8. Case study-limb perception <ul><li>Altered body perception with and without visual feedback </li></ul><ul><li>Finger misidentification </li></ul><ul><li>Forderreüther et al. Pain 2004 </li></ul><ul><li>Referred sensations-face to wrist </li></ul>
  9. 9. McCabe et al. Rheumatology 2003 Referred Sensations in CRPS
  10. 10. Halligan PW et al. BMJ 1999 Referred Sensations in Amputees
  11. 11. <ul><li>Juottonen et al., Altered central sensorimotor processing in patients with CRPS. Pain 2002; 98:315-323. </li></ul><ul><li>Maihöfner et al., Patterns of cortical reorganisation in CRPS Neurology 2003; 61:1707-1715. Neurology 2004, Pain 2005 </li></ul><ul><li>Maihöfner et al.,The motor system shows adaptive changes in CRPS. Brain 2007;130:2671-87. </li></ul><ul><li>Pleger et al., Sensorimotor returning in CRPS parallels pain reduction. Annals of Neurology 2005;57(3):425-429 </li></ul>Cortical reorganisation in CRPS
  12. 12. Wilder Penfield
  13. 13. Motor assessment <ul><li>Reduced grip strength </li></ul><ul><li>and ROM </li></ul><ul><li>Slow to ‘connect’ with affected limb when asked to move it </li></ul><ul><li>Greater range with imagined movement </li></ul><ul><li>Able to perform bilateral synchronised movements with mirror visual feedback </li></ul>
  14. 14. Motor abnormalities in CRPS <ul><li>Slower response times in the affected limb with limb laterality tasks. Schwoebel et al Brain 2001 </li></ul><ul><li>Increased pain and swelling with imagined movements . Moseley Neurology 2004 </li></ul><ul><li>Weakness, Dystonias, Myoclonus, Tremor </li></ul><ul><li>Slowness of repetitive movements (bradykinesia)‏ </li></ul><ul><li>Frequency of motor disorders increases with disease duration </li></ul><ul><li>Dysfunction of central neural networks involved with inhibition of movement. v an Hilten et al. IASP press 2005. </li></ul><ul><li>Increased difficulty with motor tasks may link to autonomic changes via dorsal anterior cingulate cortex . Critchely et al. Brain 2003. </li></ul><ul><li>Re-mapping in motor cortex with representation of painful area enlarged. Ma ïhöfner et al. Brain 2007. </li></ul>
  15. 15. Summary CRPS Altered Perceptions <ul><li>Sensory </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Altered body schema </li></ul></ul><ul><ul><li>including macro- and microsomatognosis </li></ul></ul><ul><ul><li>Reduced and heightened awareness of limb </li></ul></ul><ul><ul><li>Increased peri-personal space </li></ul></ul><ul><ul><li>Referred sensations </li></ul></ul><ul><ul><li>Hostile feelings </li></ul></ul><ul><li>Motor </li></ul><ul><ul><li>Difficulty in locating limb prior to and on initiation of movement </li></ul></ul><ul><ul><li>Poor motor control </li></ul></ul><ul><ul><li>Dystonia </li></ul></ul><ul><ul><li>Tremor </li></ul></ul><ul><ul><li>Neglect of affected limb </li></ul></ul><ul><ul><li>Altered posture and gait </li></ul></ul>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
  16. 16. Summary <ul><li>Both motor and sensory perceptions are altered in CRPS </li></ul><ul><li>Distressing and often disbelieved </li></ul><ul><li>Only careful history taking will elicit these descriptions </li></ul><ul><li>Clinical and imaging evidence of central reorganisation in motor and sensory cortices </li></ul>
  17. 17. Sensory events are analysed in terms of appropriate motor response. Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000 Baseline information
  18. 18. Motor simulation network and motor planning Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000 Baseline information MSN
  19. 19. <ul><li>Altered sensory and motor perceptions are generated </li></ul><ul><ul><li>Thermal </li></ul></ul><ul><ul><li>Body perception </li></ul></ul><ul><ul><li>Reduced and heightened awareness of limb </li></ul></ul><ul><ul><li>Pain, stiffness, pins and needles </li></ul></ul><ul><ul><li>Difficulty in locating limb prior to, and on initiation of movement </li></ul></ul><ul><ul><li>Poor motor control </li></ul></ul>When sensory input and motor output conflict? McCabe et al Rheumatology 2005 Sensorimotor conflict
  20. 20. CRPS and sensory-motor conflict Baseline information MSN Corrupted Imagined or actual movements will cause a range of sensory/motor disturbances
  21. 21. Access to the basic building blocks Snyder AW, Mitchell DJ. Proc.R.Soc. Lond. 1999;2666:587-592.
  22. 22. Link to current clinical signs? Foreshortened limbs/ Altered body perception? Autotomy/ desire for amputation?
  23. 23. Link to current clinical signs? Increased peri-personal space Farné A, Làdavas E. Neuropreport 2000; 85:1645-1649.
  24. 24. Correcting motor sensory mismatch – 3 potential target areas Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000 Baseline information MSN
  25. 25. Sensorimotor integration <ul><li>Sensory and motor systems work in partnership </li></ul><ul><li>When discordance occurs altered sensory and motor perceptions are generated </li></ul><ul><li>Therapies designed to target this discrepancy appear effective. </li></ul>
  26. 26. Multidisciplinary inpatient and outpatient service at the RNHRD <ul><li>National referral centre </li></ul><ul><li>Mobilisation of limb priority </li></ul><ul><li>Physiotherapy twice daily (land based and hydrotherapy)‏ </li></ul><ul><li>Occupational therapy </li></ul><ul><li>Mirror visual feedback and motor imagery programme </li></ul><ul><li>Enable above activities by providing pharmacological and psychological support </li></ul><ul><li>Education, education, education! </li></ul><ul><li>2006 Established UK CRPS Clinical & Research Network </li></ul>
  27. 27. Acknowledgements <ul><li>Funding Bodies & Other Partners </li></ul><ul><li>Arthritis Research Campaign </li></ul><ul><li>Gwen Bush Foundation </li></ul><ul><li>Remedi </li></ul><ul><li>RSD-UK </li></ul><ul><li>Pfizer Pharmaceuticals </li></ul><ul><li>Royal National Hospital for Rheumatic Diseases Donated Funds </li></ul><ul><li>Wiltshire College of Higher Education </li></ul>Email: <ul><li>CRPS Clinical Research Team </li></ul><ul><li>Professor David Blake </li></ul><ul><li>Dr. Helen Cohen </li></ul><ul><li>Dr. Jane Hall </li></ul><ul><li>Dr. Nigel Harris </li></ul><ul><li>Ms Keri Johnson </li></ul><ul><li>Ms. Jenny Lewis </li></ul><ul><li>Dr. Karen Rodham </li></ul>