CRPS and Graded Motor Imagery

Programme

Emma J MairEmma.Mair@ggc.scot.nhs.uk

November 2012

Tonight- an overview

Aetiology Pathophysiology UK Guidelines Diagnosis Treatment Graded Motor Imagery

programme

European Incidence rate of 26/100,000 person-years

Incidence with age till 70 60% in upper limb, 40% in lower limb Approximately 15% of sufferers will have

unrelenting pain and physical impairment 2 years after CRPS onset

Cause Unknown 45% following fracture 18% following sprains 12% following surgery <10% spontaneous

CRPS-1Type 1: sympathetically maintained pain

can start for no apparent reason but most commonly follows distal radial fracture.

Characterised by pain which is disproportionate to inciting event, swelling, autonomic and motor disturbances, changes in skin blood flow

CRPS-2Type 2: Onset develops after injury to a major

peripheral nerve. May occur immediately or be delayed for several months

Most commonly involved are the median and sciatic nerves

Allodynia and hyperalgesia occur but not limited to the territory of one single peripheral nerve

1 + 2 = CRPS

Pathophysiology

Multi-factorial Other factors: environmental, genetic,

psychological The stereotyped stages are now obsolete A definition of recovery has not yet been

agreed CRPS is not associated with a history of pain

preceding psychological problems, or with somatisation or malingering

• Swelling• Glossy skin• Increased nail andhair growth• Hyperaemia‡

Peripheral sensitisation↑IL-1β, IL-6, TNFα, NGF, CGRP,substance P, and bradykininPain, vasodilation of theskin, and oedema

Endothelial dysfunction↓NO and ↑ET-1Impaired circulation (chronic stage)

↓Sympathetic outflowVasodilation (early stage)

Sympathetic–afferent couplingPain

Contralateral cortical changesReorganisation of sensorymaps in S1*Reorganisation of motormaps in M1†↓Inhibition and ↑excitationin M1 and SMA

Ipsilateral cortical changes↓Inhibition and ↑excitation in M1

↓Endogenous pain controlPain

Central sensitisationAllodynia, hyperalgesia, secondaryhyperalgesia, and wind-up

•Sensory abnormalities•Autonomic dysfunction•Neurogenic inflammation•Motor abnormalities•Sensitisation•Central reorganisation

Risk Factors

ACE inhibitors Asthma Migraine Immobilisation ? Genetic

UK Guidelines Published April 2012 Recommendations for assessment and management Speciality Guidelines:

Primary Care Physio & OT Orthopaedic Practice Rheumatology, neurology and neurosurgery Dermatology Pain Medicine Rehabilitation Medicine Long-Term support in CRPS

Available from: http://www.rcplondon.ac.uk/resources/complex-regional-pain-syndrome-concise-guideline

Diagnosis

Physio’s probably best equipped to identify a patient with CRPS

Confirmation of diagnosis based on Budapest guidelines

Confirmation with GP/cons Differential diagnosis Diagnosis tool:

http://www.trendconsortium.nl/diagnosis/

A The patient has continuing pain which is disproportionate to any inciting event

B The patient has at least one sign in two or more of the categories

C The patient reports at least one symptom in three or more of the categories

D No other diagnosis can better explain the signs and symptoms

Category Sign (you can see or feel a problem)

Symptom (the patient reports a problem)

1. SENSORY Allodynia (to light touch and/or temp sensation and/or deep somatic pressure and /or joint movement) and/or hyperalgesia (to pinprick)

Hyperesthesia does also qualify as a symptom

2. VASOMOTOR Temperature asymmetry and/or skin colour changes and/or skin colour asymmetry

Temp asymmetry must be >1°C

3. SUDOMOTOR/ OEDEMA

Oedema and/or sweating changes and/or sweating asymmetry

4. MOTOR/ TROPHIC

Decreased range f motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair/nail/skin)

All A-D must apply

Sensory

Alloydnia – pain due to a stimulus which does not normally cause pain. E.g. touch and temperature

Hyperalgesia– increased response to stimulus that is normally painful

Hyperesthesia– increased sensitivity to stimulation Hyperpathia- a state of exaggerated and very painful

response to stimulation especially repetitive stimulus Hypoesthesia- a reduced sense of touch or sensation,

or a partial loss of sensitivity to sensory stimuli sensory.

Vasomotor

Temperature asymmetry Skin colour changes

Sudomotor / Oedema

Oedema Sweating changes or asymmetry

Motor / Trophic

Decreased range of movement and/or

Motor dysfunction (weakness, tremor, dystonia) and/or

Trophic changes (hair, nails, skin)

Body Perception Disturbance

DISLIKE DISOWNERSHIP DESIRE TO

AMPUTATE DISTORTED

MENTAL VISUALISATION

Body Perception Disturbance

General Screening: Targeted questioning

1. Emotions

2. Sense of belonging

3. Perceived size

Simple observation of position of limb

The Bath CRPS Body Perception Disturbance Scale*Developed by Jennifer S. Lewis, The Royal National Hospital for Rheumatic DiseasesBath, England. v2. ©2008. All rights reserved.Patient name ________________________ Date ________ Assessment no. 1 2 3 4 5 Diagnosis___________________________ Date of symptom onset____________ Body part affected: 1)_________________________ 2)_________________________ 3)_________________________ 1) On a scale of 0-10 how much a part of your body does the affected part feel? Very much a part = 0__1__2__3__4__5__6__7__8__9__10 = Completely detached 2) On a scale of 0-10 how aware are you of the physical position of your limb? Very aware = 0__ 1__2__3__4__5__6__7__8__9__10 = Completely unaware 3) On a scale of 0-10 how much attention do you pay to your limb in terms of looking at it and thinking about it? Full attention = 0__ 1__2__3__4__5__6__7__8__9__10 = No attention 4) On a scale of 0-10 how strong are the emotional feelings that you have about your limb? Strongly positive = 0__ 1__2__3__4__5__6__7__8__9__10 = Strongly negative 5) Is there a difference between how your affected limb looks or is on touch compared to how it feels to you in terms of the following: Size yes no Comment ________________________Temperature yes no Comment ________________________Pressure yes no Comment ________________________Weight yes no Comment ________________________6a) Have you ever had a desire to amputate the limb? Yes No 6b) If yes, how strong is that desire now? Not at all = 0__ 1__2__3__4__5__6__7__8__9__10 = Very strong Desired amputation site________________________________7) With eyes closed describe a mental image of your affected and unaffected body parts (drawn by assessor during patient description then verified by the patient)

This is an accurate account of my image of my affected body part. Signature __________________________________ Date____________________

The Environment Therapy environment – breezes, open windows,

fans Lighting Invasion of personal space Therapist movement and language (“your” vs

“it”) Other people nearby Noise Privacy

Treatment

Prompt diagnosis and early treatment are considered best practice

Aims of treatment:Reduce painPreserve or restore functionEnable patients to manage their

condition Improve quality of life

Primary Care Physiotherapy & Occupational Therapy

Best practice recommendations

Be aware of CRPS and identify the clinical signs Be aware of the Budapest criteria for diagnosing

CRPS Initiate treatment as early as possible Provide patient education about the condition Know of the nearest MDT pain service or CRPS

centre Recognising non-resolving or moderate symptoms for

onward referral

Rehabilitation Algorithm

Identify CRPS signs and symptoms

Consider Differential Diagnosis

Meet Budapest criteria

Confirm DiagnosisVia GP or consultant

Mild/Moderatesymptoms

Moderate/ severe symptoms

Educate, commence treatments

Educate, refer via GP To specialist pain clinic

Failing to respond to treatment in 4 weeks

Noticeable response to Treatment within 4 weeksAnd ongoing improvement

Pain Management programme

Consider yellow flags

Pain Medicine and Interdisciplinary Specialist Rehabilitation Programmes

Four Pillars of TreatmentPhysical and

vocational rehabilitation

Psychological interventions

Patient information and education to

support self- management

Pain relief (medication and procedures)

Engagement: education and information for the patient & family Understanding pain and CRPS Learning self management principles Self efficacy- the patient remains

responsible and involved Empowering the patient and the family

Medical Management

Investigation and confirmation of diagnosis Pharmacological intervention to provide a

window of pain relief Reassurance that PT and OT are safe and

appropriate Provide medical follow up Support any litigation/ compensation claim

Pain Medicine Guideline Recommendations No drugs are licensed to treat CRPS in the UK Neuropathic drugs should be used in according to NICE & IASP

guidelines Pamidronate (single 60mg intravenous dose) should be

considered in suitable patients with less than 6mths duration as a one off treatment

Intravenous regional sympathetic blocks with guanethidine should not be routinely used

Other additional drugs demonstrate efficacy but a lot of the evidence is still preliminary

Spinal Cord Stimulators

Psychosocial and behavioural management Psychological intervention is based on individualised

assessment, to identify and proactively manage any factors which may perpetuate pain or disability/ dependency including: Mood evaluation- management of anxiety and depression Internal factors, eg counter productive behaviour patterns Any external influences or perverse incentives

It usually follows principles of CBT delivering: Coping skills and positive thought patterns Support for family/carers

Physical Management Emphasis should be on restoration of normal function and

activities through acquisition of self management skills, with the patients actively engaged in goal setting

The programme may include elements of chronic pain management including: General body re-conditioning through graded exercise,

gait re-education, postural control Restoration of normal activities, including self care,

recreational physical exercise and social/ leisure activities Pacing and relaxation strategies Vocational support

It may also include specialised techniques to address altered perception and awareness of the limb, for example:Self administered desensitisation with tactile

and thermal stimuliFunctional movement to improve motor

control and limb position awarenessGraded motor imagery, mirror visual

feedback, mental visualisationManagement of CRPS- dystonia

Activities of ADL and societal participation Support graded return to independence in ADLs

and clear functional goals Assessment and provision of appropriate

specialist equipment to support independence Adaptation of environment Extend social and recreational activities in and

outside the home Workplace assessment/ vocational re-training

Overview

Understand Recognise Prompt diagnosis Educate Early treatment MDT approach

CRPS Treatment

Explain & EducateMindfulness /

AwarenessProblem Solving Reducing Threat

Treatment- what are the options? Based on evidence based practise, guidelines

and innovative clinicians Good quality evidence for graded motor

imagery(GMI) combined with pharmacological management is the most effective

Educate, educate, educate

About CRPS About Pain

We do not know why some people get CRPS and others don’t

We DO know that it is not because of psychological frailty or abnormality

Several important changes in the brain seem to accompany CRPS

To normalise these changes, we have to identify ALL combinations to perceived threat and train the brain

Movement versus Pain

Remember pain science and pathophysiology

Sensitisation of CNS More harm than good?!

Desensitisation Activities of daily living

Washing and dressing

Sensory Discrimination

Two-point discrimination

Electrical Stimulation

Graded Motor Imagery

Sequential activation of cortical pre-motor and motor networks

Laterality and Imagery = pre motor

Mirror Therapy = Primary Motor Cortex and S1 cortices

?reversal of cortical reorganisation

Limb Laterality

What do you see?

Right or Left?

Right or Left?

Laterality Recognition Make a quick decision

about the laterality then you mentally rotate mental representation of the limb into the position viewed to confirm initial selection!

Limb Laterality Recognition

Pain affects the brains ability to recognise laterality of images of limbs

Information processing bias Working body Schema

“Normal Scores”

Accuracy of 80% and above Speed of hands and feet ~ 2 seconds Accuracies and RT should be equal

Differences in Speed Identifies problems with

Information processing

… but what does that mean?

Acute Pain

Acute LEFT hand injury looking at RIGHT hand

Difficult decision, safest to presume its LEFT hand because my LEFT hand is injured, chose LEFT hand.

Mentally move LEFT hand

X

Wrong choice,

start again

Mentally move

RIGHThand

correct

RT

R>L

Accuracy

L=R

Acute LEFT hand injury looking at LEFT hand

Difficult decision, safest to presume its LEFT hand because my LEFT hand is injured, chose LEFT hand.

Mentally move LEFT hand

correct

Chronic Pain

Chronic LEFT hand injury

looking at RIGHT hand

Difficult decision, safest to presume its RIGHT hand because my LEFT hand is in trouble and I’m protecting it by not focusing on it.

Mentally move

RIGHT

hand

X

Wrong choice,

start again

Mentally move LEFThand

correct

RT

L>R

Accuracy

L=R

Chronic LEFT hand injury

looking at RIGHT hand

Difficult decision, safest to presume its RIGHT hand because my LEFT hand is in trouble and I’m protecting it by not focusing on it.

Mentally move

RIGHT hand

correct

Why? Incorrect selection leads to longer

reaction time as need to repeat mental rotation of limb to confirm laterality choice

Pain & information processing, patients wrongly select

Differences in Accuracy Difference in accuracy

suggests issues with the working body schema

Why?

Cortical reorganisation Easier access to painful working body

schema?

Laterality Reconstruction Hands, Feet, Neck/Shoulder Vanilla, Abstract, Context Online and Flash cards Recognise Phone Apps Other methods:

Shadow Puppets Digital cameras Magazines

Recognise

Recognise online:

http://recognise.noigroup.com/recognise/

Motor Imagery

Motor Imagery

Sports Performance Neuro-Rehabilitation Cognitive Psychology Graded Motor Imagery

Motor Imagery Observing and

Imagining movements Imagining yourself

doing the movement not imagining observing themselves doing the movement

The Why? If you can’t feel it, how can

you use it?

The What?

Patient ExplanationFoodBack pain & bending

The How?

Prompts:ShapeSkinColourDigitsMovement

Motor Imagery Awareness of body

part Imagining movements Imagining functional

activities Flash cards and online

images can be used as prompts

Mirror Therapy

The Why?

Illusion Tricking the brain Motor Cortex / S1 Mirror Neurons

The How?

Observation De-sensitisation Movement Context- emotional, threat Weight bearing Functional rehab

Mirror Therapy

Practical:Try bilateral movements with the mirrorTry asynchronous movements whilst watching

your limb in the mirrorGet someone to tap or stroke the unaffected

limb whilst looking at the reflected limb

Mirror therapy for the 21st century?

Prism Glasses www.prismglasses.co.uk

Brain Training

Educate Desensitise Habituate Develop Function

Bilateral synchronised movements in a mirror

Mirror visual feedback

? Physical rehabilitation approaches

Rehearse motor imagery

Limb Laterality Limb Laterality programme

Sensory discrimination Electrical or manual

Concurrent medical and psychological support

Imagined movement of affected limb

Can’t Perform

Can’t Perform

Can’t Perform

Can’t Perform

Can’t Perform

Can’t Perform

Can’t Perform

Resources & Research

Questions from you and from me? How do we support

our primary & secondary care clinicians treating this condition?

Specialised Pathways and Clinics required?