therapist's approach towards complex regional pain syndrome - punita v. solanki

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Therapist’s Approach Towards ComplexRegional Pain Syndrome (CRPS)

Punita V. SolankiMSc (O.T.), YFT-ISSA,

Level I PIA Trainer, ADCR-ACEConsultant Occupational Therapist, Mumbai

Mobile: +91-9820621352Email id: [email protected]

3rd Annual National Conference of Society forHand Therapy, India,

13th September 2014, SaturdayThane, 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 Modeland 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 searchon the related topic.The company, organization and the hospitals where thepresenter is associated, has no bearing with thepresentation. It is entirely the view of the presenterbased on the existing evidence.

mailto:therapistindia:@gmail.com

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Punita V. SolankiConsultant

OccupationalTherapist

14th September 20143rd Annual NationalConference of SHT,

India

Complex Regional Pain Syndrome is a chronicpain disorder characterized by sensory, autonomic,motor, and dystrophic signs and symptoms. CRPSgenerally involves a dysfunctional response of thenervous system and may develop after a traumaticinjury or a period of immobilization.(First identified by Mitchell et al)

CRPS is divided into two categories:Type I (formerly known as Reflex SympatheticDystrophy).Type II (formerly known as Causalgia).(RSD renamed during the workshop for International experts for theInternational 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. ReflexSympathetic Dystrophy Syndrome Association. June 2004.




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Disproportionate pain to any inciting event.Signs and Symptoms:

Sensory: Hyperesthesia, hyperalgesia (to pinprick)or allodynia (to light touch);Vasomotor: Temperature asymmetry and/or skincolour changes and/or skin colour asymmetry;Sudomotor/edema: Edema (with or without jointstiffness) and/or sweating changes and/or sweatingasymmetry; orMotor/trophic: Decreased range of motion and/ormotor dysfunction (weakness, tremor, dystonia)and/or trophic changes (nails, hair, skin).

Personality Diathesis.

Diagnostic Criteria for Complex Regional PainSyndrome




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Complex Regional Pain Syndrome

Post K Wire and POPImmobilization and Pre

Therapy

Post 2 Weeks ofTherapy

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Complex Regional Pain SyndromePre Therapy Post Two Weeks of Therapy




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Medical & Interventional Management ofComplex Regional Pain Syndrome

Preventive Approach: Vitamin C

Treatment Approach: Non Steroidal Anti-inflammatory Analgesics, morphine,Bisphosphonates, calcitonin or a daily course ofintravenous ketamine, Neuromodulation drugs suchas gabapentin, pregabalin, Antidepressants such asamitriptyline, duloxetine, Steroids, Lidocainepatches.

Interventional Approach: Local anaestheticsympathetic blockade.




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Approach Towards Patients with ComplexRegional Pain Syndrome

Integrated Interdisciplinary Team Approachwhere patient is the center of focus.

Multimodal Biopsychosocial Approach.

Client Centered Approach where patient’sperspective is of prime importance.

Patient/Client takes precedence over theDisease/Disorder.

Humanistic, Gentle, Comfortable, Patient Friendlyin a Non Distractive Environment and preferablyone-on-one settings.

Listen to the Patient/Client for a session; do thetalking or questioning in the subsequent sessions.




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Assessments of Patients with ComplexRegional Pain Syndrome

Detailed Careful Medical and Occupational Historyfrom Medical Records, Interview and via ObservationChecklists.

Clinical Examination for signs and symptoms ofCRPS. Clinical Photographs Pre and Post Therapy.

Standardized Assessments: Pain VAS Score orMcGill Pain Questionnaire, Oedema Assessment,AROM Vs PROM, Strength, Endurance, FunctionalScores e.g. DASH Score, Hamilton Inventory forComplex Regional Pain Syndrome (Both Patient andClinician Based Multidisciplinary Assessment Tool)etc

Functional Assessments: ADL Scales

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Occupational Therapy Preventive ApproachPrimary Prevention: Avoid Prolonged

Immobilization, Avoid Tight Restrictive Bandages,Avoid Vigorous Passive Stretching in the Initial andIntermediate Phases of Rehabilitation.

Secondary Prevention: Avoid Static and PassiveApproaches to Rehabilitation; Avoid, acute problemfrom becoming chronic in nature: By FunctionalApproach, Multimodal Approach, InterdisciplinaryTeam Approach, & via Client Education.

Tertiary Prevention: Avoid mild joint stiffnessfrom becoming fixed non functional contractureswith timely optimal exercise regimen, functionalsplinting when need be, positioning and early returnto ADL, Work, Productive and Play/Leisure Activities.




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Occupational Therapy Pain Interventions

Level I & II: Client Education based onBehavioural Learning Approach:

Pain Health Literacy & Self ManagementPrograms.

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.




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Level I: Adjunctive Methods Based on SensoryMotor & Biomechanical Approaches:

Sensory Stimulations: Desensitization in CRPS: Toprogress from smooth to rough textures, objects,activities, as tolerable.

Therapeutic Touch.

Oedema Management.

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Level I: Adjunctive Methods Based onBiomechanical Approach:

Innovative Treatments: Stress Loading in CRPSexample: Improves Bone Mass and Prevents Disuseof Muscles and Bones.a. Carrying Light Weight Bags, Scrubbing with Brushor a Dystrophile, Light Joint Compression by WeightBearing Closed Kinematic Chain Exercisesb. Mirror Therapy.




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Positioning with Splinting & Functional Bracingin the management of fractures.

To Follow PRICE Principles during the initialphase of management of fractures.




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Therapeutic Exercises:

Six Pack Hand Exercises, Exercises for the Wrist,Forearm, Elbow, Shoulder and Shoulder Girdle.

Type: Uniplanar Exercises: initiate with GentleAROM, AAROM, PROM, and gradually move on toGentle, Slow, Sustained Passive Stretch, ProgressiveResistive Exercises as per tolerance [Goal: ROM,Strength, Endurance, Functional Strength andFunctional Endurance]

Dose: 1 Set of 10 Repetitions X 3 Times a Daywith adequate rest in between repetitions/sessions.

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Occupational Therapy Pain InterventionsTherapeutic Exercises:




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Occupational Therapy Pain InterventionsTherapeutic Exercises:




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Level II:Enabling Activities (Occupation-as-Means):To Hasten the recovery, to improve functional ROM, functionalStrength and Functional Endurance.

e.g. Transferring day to day different sized and shaped objects,dropping water with an ink dropper, putting cloth clips overthe line/ruler, clay modeling, gel press ball exercises etc.

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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 inSchools

Work & Productive Activities Adaptive Training &Adaptive Tools & Environment.

Play & Leisure Activities Training e.g. Arts, Crafts,Games, Sports.




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Evidence based guidelines for complex regional pain syndrometype 1: Roberto S Perez*, Paul E Zollinger, Pieter U Dijkstra, Ilona LThomassen-Hilgersom, Wouter W Zuurmond, Kitty CJ Rosenbrand, JanH Geertzenand the CRPS I task force. BMC Neurology 2010,10:20http://www.biomedcentral.com/1471-2377/10/20

Evidence Based Literature Review

Results: For pain treatment, the WHO analgesic ladder is advised withthe exception of strong opioids. For neuropathic pain, anticonvulsantsand tricyclic antidepressants may be considered. For inflammatorysymptoms, free-radical scavengers (dimethylsulphoxide or acetyl-cysteine) are advised. To promote peripheral blood flow, vasodilatorymedication may be considered. Percutaneus sympathetic blockades maybe used to increase blood flow in case vasodilatory medication hasinsufficient effect. To decrease functional limitations, standardizedphysiotherapy and occupational therapy are advised. To prevent theoccurrence of CRPS-I after wrist fractures, vitamin C is recommended.Adequate perioperative analgesia, limitation of operating time, limiteduse of tourniquet, and use of regional anaesthetic techniques arerecommended for secondary prevention of CRPS-I. Conclusions: Basedon the literature identified and the extent of evidence found fortherapeutic interventions for CRPS-I, we conclude that further researchis needed into each of the therapeutic modalities discussed in theguidelines.




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Evidence Based Literature ReviewO’Connell NE, Wand BM, McAuley J, Marston L, Moseley GL.Interventions for treating pain and disability in adults with complexregional 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 reviewswere included:

Graded motor imagery may be effective for pain and functionwhen compared with usual care; and that mirror therapy maybe effective for pain in post-stroke CRPS compared with a‘covered mirror’ control. This evidence should be interpretedwith caution.

Low quality evidence suggests that physiotherapy oroccupational therapy are associated with small positive effectsthat are unlikely to be clinically important at one year follow upwhen compared with a social work passive attention control.

http://www.biomedcentral.com/1471-2377/10/20

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Evidence Based Literature ReviewOriginal Article: Oerlemans H M, Oostendorp R A, de Boo T, van der LaanL, Severens J L, Goris J A. Adjuvant physical therapy versus occupationaltherapy in patients with reflex sympathetic dystrophy/complex regionalpain syndrome type I. Archives of Physical Medicine and Rehabilitation.2000;81(1):49-56.

Critically appraised economic evaluations. Published in Centre forReviews and Dissemination NHS Economic Evaluation Database(NHSEED) 2014 Issue 3. Copyright © 2014 University of York. Publishedby John Wiley & Sons, Ltd.

Clinical conclusions: The authors concluded that physical therapy, andto a lesser extent occupational therapy, had a clinically relevant effecton impairment. The physical therapy groups scored 6 points on theImpairment Level Sumscore (ISS), whilst the occupational therapygroup scored 4 points. On a disability level, a positive trend was foundin favour of occupational therapy. There were no differences betweenthe groups in terms of the level of handicap.

Economic Evaluation conclusions: Physical therapy was shown tohave an advantage over occupational therapy with regards to thecost-effectiveness ratio.




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Evidence Based Literature ReviewFunctional restoration and complex regional pain syndrome.Steven D. Feinberg and Rachel M. Feinberg. Practical PainManagement, September 2008.

“Functional restoration involves multiple disciplines workingtogether in a coordinated fashion and is focused on maximizingfunction, returning as close as possible to pre-injuryproductivity.. While preventing needless disability, unnecessarymedical and surgical care, and avoiding iatrogenic healthcarerelated complications.

They found that a carefully selected combination of therapies -including medications, interventions, rehabilitation therapies, andpsychological treatment approaches in the context of a functionalrestoration model of care - provides the best hope for treatingCRPS




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Importance of Integrated Interdisciplinary Team Approach

Of all approaches to the treatment of chronicpain, none has a stronger evidence basis forefficacy, cost-effectiveness & lack of iatrogeniccomplications than interdisciplinary care.

Most critical is the understanding that chronicpain is a disease of the person, and that atraditional biomedical approach cannot adequatelyaddress all of the pain-related problems of thispatient population.

Reference: 1. Interdisciplinary Chronic Pain Management: InternationalPerspectives. Pain Clinical Updates by International Association for the Studyof Pain. December 2012. Vol. XX, Issue 7.2. Ludeke C Lambeek et. al. Randomised controlled trial of integrated care toreduce disability from chronic low back pain in working and private life. BMJ2010;340:c1035. doi:10.1136/bmj.c1035

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Occupational Therapists are important Team Members in anIntegrated, Interdisciplinary Team Approach towards CRPSManagement. (~ International Association for the Study ofPain)

Integrated Interdisciplinary Care has a stronger evidencebasis for efficacy, cost-effectiveness & lack of iatrogeniccomplications in the management of Chronic Pain thanTraditional Biomedical approaches.

Primary Preventive Approach helps prevent development ofsigns and symptoms of CRPS

Secondary & Tertiary Preventive Approach & Timely returnto everyday activities helps prevent acute/sub-acute painbecoming chronic in nature.

Do not treat the pain alone but treat the person sufferingfrom pain {Physical, Psychological, Social & Emotional Care}

Take Home Message:




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Quiz:1. A three component Active Stress Loading Program in themanagement of Chronic Regional Pain Syndrome wasestablished and reported to be a successful treatment methodbya. D. Butlerb. L. Lankfordc. ED Peacock and Van Winkle Wd. H Watson and L Carlson

Key Answer: d

2. Pain from sources that do not typically cause pain isknown asa. Hyperalgiab. Allodyniac. Hyperpathiad. Causalgia

Key Answer: b




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Quiz:3. A commercial scrub brush with a light and a timer that areactivated when the user reaches a preset load, which can helpimprove compliance in stress loading program in ChronicRegional Pain Syndrome clients, is known asa. Dystrophileb. Vigorimeterc. Hydrostat Scrubd. Vibrometer

Key Answer: a

4. An Evidence of Level II was found in the literature on the roleof following vitamin in primary prevention of Chronic RegionalPain Syndrome (CRPS) type I in patients with wrist fractures.a. Ab. Bc. Cd. D

Key Answer: c

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References:

1. Treating CRPS: A Guide for Therapy by Melanie E. Swan. Reflex SympatheticDystrophy Syndrome Association. June 2004. www.rsds.org2. The Canadian Association of Occupational Therapists (CAOT) Position Statement:Pain Management and Occupational Therapy. 2012.3. Interdisciplinary Chronic Pain Management: International Perspectives. Pain ClinicalUpdates by International Association for the Study of Pain. December 2012. Vol. XX,Issue 7.4. World Federation of Occupational Therapists (WFOT): http://www.wfot.org5. Occupational Therapy and Pain Management: Occupational therapy - Helping peopleto live life their way. By College of Occupational Therapists: www.COT.org.uk6. Recommended guidelines for Pain Management Programmes for adults. A consensusstatement prepared on behalf of the British Pain Society. April 2007.7. Watson HK, Carlson L. Treatment of reflex sympathetic dystrophy of the hand with anactive "stress loading" program. J Hand Surg [Am]. 1987;12(5 Pt 1):779-7858. Carlson LK, Watson HK. Treatment of reflex sympathetic dystrophy using the stress-loading program. J Hand Ther. 1988;1:149-1549. Oerlemans H, Goris J, de Boo T, Oostendorp R. Do physical therapy and occupationaltherapy reduce the impairment percentage in reflex sympathetic dystrophy? Am J PhysMed Rehabil. 1999;78:533-539

Occupational Therapy adds life to years.The best kind of work can be to get others back to theirs.

Time Duration of Presentation: 30 minutes

http://www.rsds.org/

http://www.wfot.org/

http://www.COT.org.uk/

therapist's approach towards complex regional pain syndrome - punita v. solanki

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