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Therapist’s Approach Towards Complex
Regional Pain Syndrome (CRPS)
Punita V. Solanki
MSc (O.T.), YFT‐ISSA,
Level I PIA Trainer, ADCR‐ACE
Consultant Occupational Therapist, Mumbai
Mobile: +91‐9820621352
Email id: therapistindia@gmail.com
3rd Annual National Conference of Society for
Hand Therapy, India,
13th September 2014, Saturday
Thane, Mumbai
Table of Contents:
1. About Complex Regional Pain Syndrome (CRPS).
2. Scientific Basis of the Management of CRPS:
Preventive and Curative Aspects of Therapy.
3. Various Therapies on Evidence Based Practice Model
and a Case Study.
4. Quiz
Disclaimer:
The presentation is entirely the effort of the presenter,
based on the past and present clinical experiences;
academic training and from thorough literature search
on the related topic.
The company, organization and the hospitals where the
presenter is associated, has no bearing with the
presentation. It is entirely the view of the presenter
based on the existing evidence.
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Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Complex Regional Pain Syndrome is a chronic
pain disorder characterized by sensory, autonomic,
motor, and dystrophic signs and symptoms. CRPS
generally involves a dysfunctional response of the
nervous system and may develop after a traumatic
injury or a period of immobilization.
(First identified by Mitchell et al)
CRPS is divided into two categories:
Type I (formerly known as Reflex Sympathetic
Dystrophy).
Type II (formerly known as Causalgia).
(RSD renamed during the workshop for International experts for the
International Association for the Study of Pain in Orlando in 1993)
What is Complex Regional Pain Syndrome?
Source: Treating CRPS: A Guide for Therapy by Melanie E. Swan. Reflex
Sympathetic Dystrophy Syndrome Association. June 2004.
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Disproportionate pain to any inciting event.
Signs and Symptoms:
Sensory: Hyperesthesia, hyperalgesia (to pinprick)
or allodynia (to light touch);
Vasomotor: Temperature asymmetry and/or skin
colour changes and/or skin colour asymmetry;
Sudomotor/edema: Edema (with or without joint
stiffness) and/or sweating changes and/or sweating
asymmetry; or
Motor/trophic: Decreased range of motion and/or
motor dysfunction (weakness, tremor, dystonia)
and/or trophic changes (nails, hair, skin).
Personality Diathesis.
Diagnostic Criteria for Complex Regional Pain
Syndrome
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Complex Regional Pain Syndrome
Post K Wire and POP
Immobilization and Pre
Therapy
Post 2 Weeks of
Therapy
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Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Medical & Interventional Management of
Complex Regional Pain Syndrome
Preventive Approach: Vitamin C
Treatment Approach: Non Steroidal Anti‐
inflammatory Analgesics, morphine,
Bisphosphonates, calcitonin or a daily course of
intravenous ketamine, Neuromodulation drugs such
as gabapentin, pregabalin, Antidepressants such as
amitriptyline, duloxetine, Steroids, Lidocaine
patches.
Interventional Approach: Local anaesthetic
sympathetic blockade.
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Approach Towards Patients with Complex
Regional Pain Syndrome
Integrated Interdisciplinary Team Approach
where patient is the center of focus.
Multimodal Biopsychosocial Approach.
Client Centered Approach where patient’s
perspective is of prime importance.
Patient/Client takes precedence over the
Disease/Disorder.
Humanistic, Gentle, Comfortable, Patient Friendly
in a Non Distractive Environment and preferably
one‐on‐one settings.
Listen to the Patient/Client for a session; do the
talking or questioning in the subsequent sessions.
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Assessments of Patients with Complex
Regional Pain Syndrome
Detailed Careful Medical and Occupational History
from Medical Records, Interview and via Observation
Checklists.
Clinical Examination for signs and symptoms of
CRPS. Clinical Photographs Pre and Post Therapy.
Standardized Assessments: Pain VAS Score or
McGill Pain Questionnaire, Oedema Assessment,
AROM Vs PROM, Strength, Endurance, Functional
Scores e.g. DASH Score, Hamilton Inventory for
Complex Regional Pain Syndrome (Both Patient and
Clinician Based Multidisciplinary Assessment Tool)
etc
Functional Assessments: ADL Scales
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Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Occupational Therapy Preventive Approach
Primary Prevention: Avoid Prolonged
Immobilization, Avoid Tight Restrictive Bandages,
Avoid Vigorous Passive Stretching in the Initial and
Intermediate Phases of Rehabilitation.
Secondary Prevention: Avoid Static and Passive
Approaches to Rehabilitation; Avoid, acute problem
from becoming chronic in nature: By Functional
Approach, Multimodal Approach, Interdisciplinary
Team Approach, & via Client Education.
Tertiary Prevention: Avoid mild joint stiffness
from becoming fixed non functional contractures
with timely optimal exercise regimen, functional
splinting when need be, positioning and early return
to ADL, Work, Productive and Play/Leisure Activities.
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Occupational Therapy Pain Interventions
Level I & II: Client Education based on
Behavioural Learning Approach:
Pain Health Literacy & Self Management
Programs.
Joint Protection Techniques.
Work Simplification & Energy Conservation
Techniques.
Time & Stress Management e.g. Relaxation
Techniques, Developing Coping Skills, CBT, Imagery,
Biofeedback, Hypnosis, Meditation, Pranayam etc.
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Occupational Therapy Pain Interventions
Level I: Adjunctive Methods Based on Sensory
Motor & Biomechanical Approaches:
Sensory Stimulations: Desensitization in CRPS: To
progress from smooth to rough textures, objects,
activities, as tolerable.
Therapeutic Touch.
Oedema Management.
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Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Occupational Therapy Pain Interventions
Level I: Adjunctive Methods Based on
Biomechanical Approach:
Innovative Treatments: Stress Loading in CRPS
example: Improves Bone Mass and Prevents Disuse
of Muscles and Bones.
a. Carrying Light Weight Bags, Scrubbing with Brush
or a Dystrophile, Light Joint Compression by Weight
Bearing Closed Kinematic Chain Exercises
b. Mirror Therapy.
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Occupational Therapy Pain Interventions
Level I: Adjunctive Methods Based on
Biomechanical Approach:
Positioning with Splinting & Functional Bracing
in the management of fractures.
To Follow PRICE Principles during the initial
phase of management of fractures.
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Occupational Therapy Pain Interventions
Level I: Adjunctive Methods Based on
Biomechanical Approach:
Therapeutic Exercises:
Six Pack Hand Exercises, Exercises for the Wrist,
Forearm, Elbow, Shoulder and Shoulder Girdle.
Type: Uniplanar Exercises: initiate with Gentle
AROM, AAROM, PROM, and gradually move on to
Gentle, Slow, Sustained Passive Stretch, Progressive
Resistive Exercises as per tolerance [Goal: ROM,
Strength, Endurance, Functional Strength and
Functional Endurance]
Dose: 1 Set of 10 Repetitions X 3 Times a Day
with adequate rest in between repetitions/sessions.
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Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Occupational Therapy Pain Interventions
Level III & IV: Purposeful (Occupation‐as‐End) &
Occupational Activities: Based on Rehabilitative
& Ergonomic Approach
Activities of Daily Living Adaptive Training &
Adaptive Equipments.
Educational Activities e.g. Modifications in
Schools
Work & Productive Activities Adaptive Training &
Adaptive Tools & Environment.
Play & Leisure Activities Training e.g. Arts, Crafts,
Games, Sports.
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Evidence based guidelines for complex regional pain syndrome
type 1: Roberto S Perez*, Paul E Zollinger, Pieter U Dijkstra, Ilona L
Thomassen‐Hilgersom, Wouter W Zuurmond, Kitty CJ Rosenbrand, Jan
H Geertzenand the CRPS I task force. BMC Neurology 2010,10:20
http://www.biomedcentral.com/1471‐2377/10/20
Evidence Based Literature Review
Results: For pain treatment, the WHO analgesic ladder is advised with
the exception of strong opioids. For neuropathic pain, anticonvulsants
and tricyclic antidepressants may be considered. For inflammatory
symptoms, free‐radical scavengers (dimethylsulphoxide or acetyl‐
cysteine) are advised. To promote peripheral blood flow, vasodilatory
medication may be considered. Percutaneus sympathetic blockades may
be used to increase blood flow in case vasodilatory medication has
insufficient effect. To decrease functional limitations, standardized
physiotherapy and occupational therapy are advised. To prevent the
occurrence of CRPS‐I after wrist fractures, vitamin C is recommended.
Adequate perioperative analgesia, limitation of operating time, limited
use of tourniquet, and use of regional anaesthetic techniques are
recommended for secondary prevention of CRPS‐I. Conclusions: Based
on the literature identified and the extent of evidence found for
therapeutic interventions for CRPS‐I, we conclude that further research
is needed into each of the therapeutic modalities discussed in the
guidelines.
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Evidence Based Literature Review
O’Connell NE, Wand BM, McAuley J, Marston L, Moseley GL.
Interventions for treating pain and disability in adults with complex
regional pain syndrome‐ an overview of systematic reviews.
Cochrane Database of Systematic Reviews 2013, Issue 4. Art.
No.:CD009416. DOI:10.1002/14651858.CD009416.pub2. Copyright ©
2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Six Cochrane reviews and 13 non‐Cochrane systematic reviews
were included:
Graded motor imagery may be effective for pain and function
when compared with usual care; and that mirror therapy may
be effective for pain in post‐stroke CRPS compared with a
‘covered mirror’ control. This evidence should be interpreted
with caution.
Low quality evidence suggests that physiotherapy or
occupational therapy are associated with small positive effects
that are unlikely to be clinically important at one year follow up
when compared with a social work passive attention control.
9. 02/01/2016
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Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Evidence Based Literature Review
Original Article: Oerlemans H M, Oostendorp R A, de Boo T, van der Laan
L, Severens J L, Goris J A. Adjuvant physical therapy versus occupational
therapy in patients with reflex sympathetic dystrophy/complex regional
pain syndrome type I. Archives of Physical Medicine and Rehabilitation.
2000;81(1):49‐56.
Critically appraised economic evaluations. Published in Centre for
Reviews and Dissemination NHS Economic Evaluation Database
(NHSEED) 2014 Issue 3. Copyright © 2014 University of York. Published
by John Wiley & Sons, Ltd.
Clinical conclusions: The authors concluded that physical therapy, and
to a lesser extent occupational therapy, had a clinically relevant effect
on impairment. The physical therapy groups scored 6 points on the
Impairment Level Sumscore (ISS), whilst the occupational therapy
group scored 4 points. On a disability level, a positive trend was found
in favour of occupational therapy. There were no differences between
the groups in terms of the level of handicap.
Economic Evaluation conclusions: Physical therapy was shown to
have an advantage over occupational therapy with regards to the
cost‐effectiveness ratio.
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Evidence Based Literature Review
Functional restoration and complex regional pain syndrome.
Steven D. Feinberg and Rachel M. Feinberg. Practical Pain
Management, September 2008.
“Functional restoration involves multiple disciplines working
together in a coordinated fashion and is focused on maximizing
function, returning as close as possible to pre‐injury
productivity.. While preventing needless disability, unnecessary
medical and surgical care, and avoiding iatrogenic healthcare
related complications.
They found that a carefully selected combination of therapies ‐
including medications, interventions, rehabilitation therapies, and
psychological treatment approaches in the context of a functional
restoration model of care ‐ provides the best hope for treating
CRPS
Punita V. Solanki
Consultant
Occupational
Therapist
14th September 2014
3rd Annual National
Conference of SHT,
India
Importance of Integrated Interdisciplinary Team Approach
Of all approaches to the treatment of chronic
pain, none has a stronger evidence basis for
efficacy, cost‐effectiveness & lack of iatrogenic
complications than interdisciplinary care.
Most critical is the understanding that chronic
pain is a disease of the person, and that a
traditional biomedical approach cannot adequately
address all of the pain‐related problems of this
patient population.
Reference: 1. Interdisciplinary Chronic Pain Management: International
Perspectives. Pain Clinical Updates by International Association for the Study
of Pain. December 2012. Vol. XX, Issue 7.
2. Ludeke C Lambeek et. al. Randomised controlled trial of integrated care to
reduce disability from chronic low back pain in working and private life. BMJ
2010;340:c1035. doi:10.1136/bmj.c1035
