CRPS an enigmatic condition which often leads us to misdiagnose. In this lecture i tried to explain the diagnostic criteria and the clinical presentation and evidence on treatment methods based of physiotherapy management. Graded motor imagery is the best for long term goal but there is a research gap for indian context

1. COMPLEX REGIONAL PAIN SYNDROME
Nityal Kumar Alagingi M.P.T
Musculoskeletal and sports rehabilitation
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2. CONTENTS
 Definition
 Epidemiology
 Causes
 Clinical features
 Taxonomy
 Pathophysiology
 Diagnostic tests
 Management
Medical - pharmacology
Invasive - Spinal cord stimulation, Amputation
Allied - Physiotherapy, Occupational therapy,
Psychological therapy
Evidence of management
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3. DEFINITION
 A syndrome that usually develops after a noxious event is, is not
limited to the distribution of a single peripheral nerve and is
disproportionate to the inciting event.
 It is associated at some point with evidence of oedema, changes in
skin blood flow, abnormal sudomotor activity in the region of the
pain, or allodynia or hyperalgesia.
(Merskey and Bogduk, 1994)
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4. TYPES
 The International Association for the study of pain has proposed
CRPS into two types based on the presence of nerve lesion
following the injury.
 Type 1, formerly known as Reflex Sympathetic Dystrophy (RSD),
do not have a definitive nerve lesion.
 Type 2, formerly known as causalgia, has a definite nerve lesion
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5. SYNONYMS OF CRPS
RSD CAUSALGIA
SUDECK’S
ATROPHY
SHOULDER
HAND
SYNDROME
REGIONAL
MIGRATORY
OSTEOPOROSIS
Birklein F, O’Neill D, Schlereth T. Complex regional pain syndrome: An
optimistic perspective. Neurology. 2015;84(1):89–96.
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6. EPIDEMIOLOGY
 Incidence
• 5-26/100,000
 Some epimeological features
• Women affected more than men
• Incidence increases with age until 70
• Upper limbs (60%) vs. lower limbs (40%)
• CRPS -1 (90%)
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7. CAUSES
Peripheral
musculoskeletal
Fractures (45%), Sprains (18),
Other: dislocations, immobilisation, fasciitis,
tendonitis, arthritis, mastectomy, DVT
Peripheral nerves
and dorsal roots
Trauma and injury to brachial plexus and other
peripheral nerves
CNS CRPS can follow after stroke, tumours, Traumatic
Brain Injuries( TBI)
Viscera Can follow after myocardial infarction
Idiopathic Spontaneous ( <10%)
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8. CRPS – SIGNS AND SYMPTOMS
 Constant pain even at rest
 Area of pain larger than area of injury
 Limited range of motion
 Burning type of pain
 Nail growth changes
 Pain for non noxious stimuli
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9. CLINICAL FEATURES
 Negative symptoms
 Positive symptoms
 Automomic symptoms
Vasomotor- temp. color
Sudomotor- oedema, sweat
 Motor/trophic symptoms
Motor- ROM, dysfunction
Trophic changes
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10. 7/24/2019
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Oedema
Trophic
changes

11. NATURAL HISTORY( PHASES)
 Transition of CRPS are in three phases
 Acute/warm phase- oedema, warmth, red & glossy skin
 Intermediate/cold phase- cold, hyperhidrosis, cyanosis
 Chronic phase- severe motor and trophic changes
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12. TAXONOMY
CRPS-1 (Reflex Sympathetic
Dystrophy)
CRPS -2 (Causalgia)
1. Initiating noxious event or a cause of
immobilisation
The presence of a continuous pain,
allodynia or hypoalgesia after an nerve
injury, not necessarily limits to the
distribution of they injured nerve.
2. Continous pain, allodynia or
hyparalgesia & the pain disproportionate
to any inciting event.
Evidence at some time of oedema,
changes in skin blood flow or abnormal
sudomotor activity in the region of the
pain.
3. Evidence at some time of oedema,
changes in skin blood flow or abnormal
sudomotor activity in the region of the
pain.
The diagnosis is excluded by the existence
of conditions that would otherwise
account for the degree of pain and
dysfunction.
4. The diagnosis is excluded by the
existence of conditions that would
otherwise account for the degree of pain
and dysfunction.
Note : All three criteria must be satisfied
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13. BUDAPEST CRITERIA
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14. PATHOPHYSIOLOGY
 Neurogenic inflammation
 Altered cutenaous innervation
 Sensitization
 Brain plasticity( reorganise representation
 SNS
 Sympathetic – sensory coupling
 Genetics
 Psychology
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16. DIAGNOSTIC TESTS
 Imaging
 Autonomic function
 Others
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17. DIANOSTIC TESTS
 Radiographs (x-rays)
 Bone Scans
 MRI, fMRI, PET, and SPECT
 Infrared Thermometry, Laser Doppler Flowmetry, and Infrared
Thermography
 Resting Sweat Output (RSO) and Thermoregulatory Sweat Test
(TST)
 Quantitative Sudomotor Axon Reflex Test (QSART)
 Nerve Conduction Velocity (NCV)
 Somatosensory Evoked Potentials (SSEP)
 Quantitative Sensory Testing (QST)
 Sympathetic Nerve Blocks
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18. PILLARS OF PATIENT CARE IN CRPS
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20. TREATMENTSPharmacology
• NSAIDS
• Opiods
• Local
anaesthetics
• Antidepress
ents
• Botulinum
toxin
Invasive
• IV
sympathetic
blockade
• Other IV
treatments
• Percutaneou
s
sympathetic
blockade
• Spinal cord
stimulation
• Amputation
Allied
• Physiotherapy
• Occupational
therapy
• Psychological
treatments
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21. INVASIVE THERAPY
• Permanent implants placed in
spinal cord for continuous
stimulation of impulsesSpinal cord stimulation
• Surgical intervention of removal of
structure involved
Amputation
Percutaneous sympathetic
blockade
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22. PHYSIOTHERAPY MANAGEMENT
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23. ELECTRO MODALITIES
 TENS
 Ultrasound
 Interferential therapy
 Low level laser
There is a low quality evidence (RCT) that modalities used in physiotherapy are
effective in reducing pain except , TENS has moderate level of evidence in
CRPS only in short term less than 12 weeks.
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Effective
Not
effective

24. CORTICALLY DIRECTED SENSORY MOTOR
REHABILITATION STRATEGIES
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25. GRADED MOTOR IMAGERY
NOIGROUP – MOSELEY & DAVID BUTLER
 A series of intervention strategies aimed at the
treatment of people with complex pain problems.
 Patients with – Neuropathic pain problems
■ Central sensitization
■ Peripheral sensitization –
High fear-avoidance – An inability to move or touch
affected region
As a prophylactic intervention
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27. GRADED MOTOR IMAGERY
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28. STEPS
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29.  Left/Right discrimination
• It involves implicit training by given cards/orientate software
and patients identifies whether it is left/right.
• The accuracy of the identifying side of the body must be
above 80%, 24 cards and time must be less than 2 sec/image
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30.  Explicit Motor Imagery (imagined movements)
• Normally active movements send afferent impulses to the cortex
which are programmed and stored in neural engrams but in
pathology they get altered in quantity and quality.
• It was said that 25% of neurons of brain starts firing while
observing/ imaging movements. In this training patient will be asked
to imagine themselves doing the activity.
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31.  Mirror therapy
• Based on visual stimulation.
• In this therapy, a mirror is placed in patients mid sagittal plane thus
reflecting the non-affected side as if it was affected.
• During this practice start exercising little movements of the fingers
and gradually progressing to complex activities.
• The process involves accommodating and adapting ultimately luring
brain into illusion.
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32.  The first level involve moving the limb outside mirror.
 Further progression of moving the limb inside the mirror at baseline.
 Then to both limbs equally
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33. DOSAGE OF GMI
 The dosage of GMI depends on severity of the condition and
patients understanding of the program.
 A study conducted by Cacchio et al, 2009, showed that 4 weeks of
GMI, 7 days a week , 5 times of 30 min sessions have an effect on
pain and disability.
 Moseley et al, 2006 , suggested that 12 weeks of GMI 6 days a week
for 15 minutes session 5 times a day found to be effective.
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34.  Challenges for GMI
 Difficult to understand
 Requires lot of practice
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35.  Quality of evidence
 There is a low quality(RCT) in treating people with
CRPS, but this was highly recommended first line
of choice in managing pain in CRPS 1 & 2
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36. VIRTUAL BODY SWAPPING
 There was a low quality evidence (RCT) on virtual
reality training in people with CRPS and they found
that mental rehearsal does not reduce pain in
CRPS-1.
 Virtual software will be used in this which swap
patient body
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37. TACTILE LOCALISATION THERAPY
 Tactile discrimination technique encourage patients
to concentrate on the delivered stimuli- improve
tactile aquity and reduce pain ( via improvements in
cortical reorganisation)
 Involving active participation from the patients to
distinguish type and location of the stimuli shows
better results in improving tactile aquity and pain
than passive stimulation( touching the affected limb
without conscious thought)
(Moseley,2008)
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38. MINIMISING BODY PERCEPTION
DISTURBANCES
 CRPS patients exhibit perception disturbance.
 In order to move the affected limb, people
frequently comment on their need to consciously
focus their mental and visual attention to the limb
leading to pain
 often describing as ‘’not belonging to me.’’
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39. PRISM GLASS
 Principles of mirror therapy
 They utilise a wedge to add visual distortion toward
the affected side while blocking the vision of the
other eye.
 Moving the unaffected limb will give a perception of
moving the affected side.
 Use of 20 degree deviated prism glass for 2 weeks
have cause alleviation of pain and improved
function in patients with CRPS.
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41. OTHER INTERVENTIONS
• Low
quality
evidenceManual
lymphatic
drainage
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42. PSYCHOLOGICAL THERAPIES
COGNITIVE BEHAVIOURAL
THERAPY
COGNITIVE FUNCTIONAL
THERAPY
COUNCELLING
OPERANT CONDITIONING
PAIN EDUCATION
RELAXATION TECHNIQUE
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43. CBT
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44. DISCUSSION?
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45. THANK YOU
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