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Complex Regional Pain Syndrome
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Complex Regional Pain Syndrome - May 14, 2005 5:36:00 PM
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pwrandall
Posts: 66
Joined: May 14, 2004
From: Elk Grove, CA
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Hello to the forum,
I'm looking for suggestions on how to handle a chronic CRPS case. The client is a 52 y/o female, s/p bunionectomy 2 years ago with hyperalgesia of the entire foot and ankle /c intermittent ache and pain into the calf. She demonstrates all of the classic CRPS signs and symptoms including impaired volitional motor control distal to the knee /c associated loss of A/PROM. She has had multiple failed spinal blocks, various medication trials, and prior PT /s relief.
At this time my intervention includes: texture desensitization /c various fabrics; use of various objects such as balls, foam roller rolled under the foot in a weekly progression from softer to firmer items; gentle soft-tissue mobilization using a mentholated/capascian lotion; and active ROM /c gentle stretching within tolerance of the patient. We have been working together now for 3 months and the only real help I've been is in getting her some temporary relief /c a TENS unit at home. Though she feels she is walking a little better, I have little objective data to support her report. Most of the time I find myself just happy my interventions aren't worsening her symptoms, but actually improving her function would be nice.
Her orthopedic surgeon just sent her back to me with a new prescription to continue PT and has the patient convinced I'm her best hope right now. Any help would be appreciated.
Thanks in advance.
PETE
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Re: Complex Regional Pain Syndrome - May 15, 2005 10:18:00 PM
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Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
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Pete,
I think there was another thread very similar to this not too long ago. Do a search on this website to find it. There may be some other information there as well.
I have had a few CRPS patients that I worked with and found that I had to almost force them to perform weight bearing strengthening activities (this may be a little easier for me in the military where I can use my rank to "encourage" movement). Contrast bath seemed to help with desensitizing the tissue and reduce pain although this procedure is not fun for the patient.
I think active weight bearing exercise is important but as you have pointed out, pain usually limits this. If TENS is helpful for pain control you could possibly try having the patient wear the unit while they perform the active exercises (leg presses, calf raises, single leg squats, etc.)
If all else fails, maybe you could contact Paula Abdul to see how she was "cured" of her CRPS.
Good luck.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Complex Regional Pain Syndrome - May 16, 2005 12:19:00 AM
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nari
Posts: 1568
Joined: November 14, 2003
From: Australia
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Pete
Chances are that weightbearing or even nonweightbearing will not be successful. Mirror therapy seems to work; I do not know much about the success rate but it is non-invasive, non-resistance and tricks the brain into thinking the limb is OK.
Place a mirror so her unaffected foot is in view, and not her painful one. Ask her to move the unaffected foot, in natural movements. The brain thinks it is her painful foot (reverse image) and learns to move it again. Start very slowly, or she may begin to feel pain in her unaffected foot and become confused. Worth a try.
Refer to V Ramachandran's work on mirror therapy.
It seems to be the only way to approach CRPS - by directly neuromodulating the brain.
Good luck
Nari
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Re: Complex Regional Pain Syndrome - May 16, 2005 4:33:00 AM
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JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
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Haven't seen mirror therapy in the literature for CRPS, though his (Ramachandran VS) citations for phantom limb pain and neglect s/p hemiplegia are interesting, with obvious correlates to CRPS.
Any other ideas about incorporating the mirror?
Does the affected limb need to remain out of sight?
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Complex Regional Pain Syndrome - May 16, 2005 5:48:00 PM
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pwrandall
Posts: 66
Joined: May 14, 2004
From: Elk Grove, CA
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Thanks for the replies. I've stumbled across the mirror therapy in the literature and was going to give it a try. Apparently some folks are trying a form a visual imaging (imagining?) technique as well. Thanks for the Ramachandran reference, I'll look it up.
Open chain exercise has been tolerable by the patient, but anything in weightbearing seems to flare up her signs and symptoms. Stationary cycling is just barely tolerable and she can't get all of the way around, just works her ankle back and forth.
I'll do a search to see if I can find the old thread on the forum.
Thanks again everyone.
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Re: Complex Regional Pain Syndrome - May 19, 2005 7:00:00 AM
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lesain
Posts: 24
Joined: November 21, 2003
From: MERCEDES, BUENOS AIRES, ARGENTINA
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Hello
I write from Argentina.
I have two patients with CRPS in the arm, post wrist´s fracture.
My treatment was very slow, with very slightly significant progresses. I used magnetic therapy, ultrasound, gentle stretching with active movement. All exercises were causing a lot of pain but the patients are very fearful and my work on the arms was very laborious.
Both patients have psychic disorders, they are depressive and when the doctor give they AMITRIPTILINA X 25mg. and PAMIDRONATO DISODICO they had more significant progresses because I can work without so much resistance.
From now I´m going to use the mirror, then I was tell you that result I had.
Thanks everyone and excuse me for my English.
Regards
_____________________________
LEANDRO ESAIN, PT.
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Re: Complex Regional Pain Syndrome - May 19, 2005 2:07:00 PM
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rickpt
Posts: 13
Joined: May 18, 2005
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Pete! We should've connected at the Simple Contact Seminar. I remember you because Barrett pointed you out. I was the guy who asked about the use of his technique for spinal fusion patients. Anyway, in my clinic I have seen about 8 CRPS patients just in the past year alone. From this experience, you must emphasize distraction in whatever exercise you employ. It is a disease of the sympathetic nervous system and only focused concentration on parasympathetic activities will allow increased motion without excessive pain. The greatest exercise you can achieve is diaphragmatic breathing which activates parasympathetic flow. Yoga moves, Tai Chi, relaxation, meditational movements are so far my other best tools for these patients. Why? because they all distract them from the obvious movement - somewhat similar to mirror work. I will now attempt to add simple contact methods to my arsenal. If you want to contact me I am at the Functional Restoration Center in Sacramento.
Good luck
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Re: Complex Regional Pain Syndrome - May 19, 2005 6:31:00 PM
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pwrandall
Posts: 66
Joined: May 14, 2004
From: Elk Grove, CA
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Thanks everyone, I now have several new ideas to work with, I'm planning on trying some mirror work with the patient tomorrow.
PETE
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Re: Complex Regional Pain Syndrome - May 20, 2005 7:30:00 PM
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Geert Jeuring
Posts: 92
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From: Möhnesee, Germany
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Hello Pete, I posted a couple of weeks ago on CRPS. I had a patient (42, female, a medical dr. herself) and I was unsure of the actual goldstandard in treatment. I came across these guidelines: http://www.worksafebc.com/for_health_care_providers/Assets/PDF/CRPS.pdf
and I´ve tried to build my therapy on these standards.
I´ve started with three weeks of Cycle training (very little weightbearing but causing a cardiovascular adaptation, starting with a pulse of 120, rising up to 140). Over the three weeks I´ve increased the resistance. After three weeks I´ve started with the crosstrainer, again at 120 pulse and rising. The next level will be Running on the "tapis roulant", again starting with a low pulse and slowly increasing. Up till now things are functioning as planned.
Geert
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Re: Complex Regional Pain Syndrome - May 25, 2005 8:19:00 AM
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rickpt
Posts: 13
Joined: May 18, 2005
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Geert,
I just checked out your other post on this topic. I am assuming that your patient is still in the acute phase of the disease because they can tolerate some of that activity. However, if Pete's patient is in the chronic phase I would reccomend only progressive activity in the upper extremities, such as a UBE and avoid lower extremity as that most likely will cause the patient to fail given her past history. Most of the guidelines refer to psychologic assistance. This is in part why I advocate parasympathetic activities.
Welcoming your comments,
Rick
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Re: Complex Regional Pain Syndrome - May 25, 2005 9:11:00 AM
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Geert Jeuring
Posts: 92
Joined: June 26, 2002
From: Möhnesee, Germany
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Hello Rick, I think, but then again I don´t have too much experience with this kind of Patient, that part of the problem is disuse syndrom as in chronic LBP and Fibromyalgia (I´m not certain if that is the correct englisch translation). Training the cardiovascular system first and afterwards increase bodyweight still seems a good idea to me. We have another rather simple trick to train this. It takes an old mechanic scale (no electronics). You let the patient take weight on the limb causing the problems and measure at what kind of pressure she has pain (say 20 Kg). You take half of that (10Kg) and let her perform 10 - 20 Weightbearing exercises. The important thing is no pain. In time you progress the weight and the repetition. Normally the tissue/ nervous system adapts. Another tip can be progressive adaptationprocesses with the use of a pedometer.
Geert
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Re: Complex Regional Pain Syndrome - June 6, 2005 9:23:00 PM
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Ann McChesney
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Joined: August 25, 2004
From: New Zealand
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I would suggest you re educate the normal gait pattern first if weight bearing is too difficult. For example normal heel strike / toe push off / stride length etc, and then add more weight bearing as tolerated. You could also work on sit - stand. I think these people need normal functional movements feeding into the brain. Parallel bars are great for this, to ease the weightbearing.
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Re: Complex Regional Pain Syndrome - June 7, 2005 12:25:00 AM
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nari
Posts: 1568
Joined: November 14, 2003
From: Australia
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I would like to add that we are not talking about distraction here. Just thinking about something else doesn't work too well long term.
What we are doing with the mirror is tricking the brain into thinking everything is OK. The brain notes that movement is occurring in the 'affected part' normally; and decides there is no point pouring out pain.
it is a clever trick, and movement can be restored quite quickly, provided the CRPS effect is not widespread. The lower limb would present more of a need to restore functioning through a rehab process.
I did have one person recently with signs of CRPS due to her fear of using her sprained wrist.
She was OK after about two sessions with a mirror. I can't say what would have happened if she had CRPS in a Gr3 sprain of the ankle!
Nari
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Re: Complex Regional Pain Syndrome - June 8, 2005 11:38:00 AM
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rickpt
Posts: 13
Joined: May 18, 2005
Status: offline
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Gert,
Yes! It is definitely a syndrome of disuse, so actions away from kenisiophobia are advised. However, the progressive weight bearing is most likely effective in the more acute phase of this disease. It sounds to me that Pete's patient may be in or entering a chronic condition (past 6 months post injury). In that case, progressive weight bearing must be extremely slow, because many of these patients hurt when the wind blows on the affected area.
Thoughts anyone?
Rick
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Re: Complex Regional Pain Syndrome - June 9, 2005 8:42:00 AM
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Geert Jeuring
Posts: 92
Joined: June 26, 2002
From: Möhnesee, Germany
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Hello Rick, in the guidelines I mentioned above, the weightbearing ist combined with anaesthetic measures. That may be a way to go round that problem.
Geert
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Re: Complex Regional Pain Syndrome - June 10, 2005 8:09:00 PM
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rickpt
Posts: 13
Joined: May 18, 2005
Status: offline
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Gert,
What type of anaesthesia are you suggesting? It is my experience with this diagnosis (3 years and about 25 cases) that narcotics don't work, ice is absolutely forbidden, heat increases inflammation, electrical stimulation creates "burning" pain, etc. Have you been able to reduce some of the pain even temporarily?
Rick
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Re: Complex Regional Pain Syndrome - June 11, 2005 8:58:00 AM
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Geert Jeuring
Posts: 92
Joined: June 26, 2002
From: Möhnesee, Germany
Status: offline
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Hello Rick I´m not suggesting anything. The guideline mentioned above is. I´ve copied and pasted it for you. :
1. Conservative care:
• The goal of the treatment is physical restoration and pain control;
• Early, aggressive care is encouraged; and
• Emphasis should be on improved functioning of the symptomatic
limb.
2. First 6 weeks of care:
• Physical/occupational therapy should be focused on increasing
functional level;
• Sympathetic or somatic blocks, maximum of five. Each block
should be followed by physical/occupational therapy; and
• Other medications are at MD's discretion as long as it promotes
improved function.
3. After the 1st six weeks of care:
• Strongly consider psychiatric or psychological consultation if
disability has extended beyond 3 months;
• Continued physical/occupational therapy based on documented
progress toward goals established during the first 6 weeks (Item 2
above); and
• Sympathetic or somatic blocks only if response to previous blocks
has been positive, maximum of 3 every six weeks for a maximum
of 12 weeks (a maximum of 11 blocks can be delivered over the
total 18 week period).
4. Sympathectomy is not the treatment of choice for CRPS :
• Sympathectomy should only be contemplated in highly unusual and
extraordinary cases.
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Re: Complex Regional Pain Syndrome - June 13, 2005 12:59:00 PM
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rickpt
Posts: 13
Joined: May 18, 2005
Status: offline
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Gert,
Thanks for providing those highlights again, however, Pete's patient is in the chronic phase ( 2 years post injury)as he stated in his opening. Therefore, the guidelines no longer apply. I work with these type of people and, to my dismay, have yet to find physical measures to assist other than sympatheticly dominant therapeutics (Tai Chi, Yoga, Meditation, etc.) And even then it simply increases ROM a little and assists in temporarily distracting them from the pain. There is no significant increase in function. If anyone out there knows of protocols for chronic RSD/CRPS please help!
Rick
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Re: Complex Regional Pain Syndrome - June 13, 2005 4:00:00 PM
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nari
Posts: 1568
Joined: November 14, 2003
From: Australia
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I did suggest on May 16 that mirror work could resolve dysfunction, but nobody took much notice.
There are no protocols that I know of because management of CRPS has only recently been studied in the light of improved pain knowledge.
Mirrors are worth a try. All the other orhtopaedic stuff can be tried after the pain is reduced...
Just a suggestion.
Nari
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