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Re: Complex Regional Pain Syndrome
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Re: Complex Regional Pain Syndrome - July 8, 2005 1:49:00 AM
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pablo w
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This is also very enlightening:
Impaired self-perception of the hand in complex regional pain syndrome (CRPS). Forderreuther, S and Straube, U. Pain 110 (2004) 756-761.
Many patients with CRPS experience their affected limb as “foreign”, an important sign indicating a dysfunction of the parietal cortex. This has been referred to as a “neglect-like syndrome”.
114 patients with CRPS (upper limb) with average symptom duration of 183 days were examined. All patients had:
An inciting or noxious event or a cause of immobilisation,
Continuing pain, allodynia, or hyperalgesia disproportionate to the inciting event,
Evidence of oedema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain at some time, and,
No other conditions that would otherwise account for the degree of pain and dysfunction.
Sensory abnormalities were identified in 86% of patients, mostly localised in 40 patients but showing an at least stocking-like spread in 58. In 41 patients, the whole arm or the ipsilateral half of the body was affected. There was isolated allodynia or hyperalgesia in 34, isolated hypoaesthesia in 16, and a combination in 48.
All patients had weakness of the affecdted hand that caused motor dysfunction. Even in patients with CRPS 2 the weakness was greater than could be explained by the peresis of an individual nerve root or peripheral nerve. 51 patients had a tremor. 20 patients had exaggerated tendon reflexes, 3 had diminished reflexes.
54.4% reported to find their hand as “foreign” or “strange”. Forty patients spontaneously gave this answer. This was independent to the side of the symptoms.
“This is not my hand”
“This hand feels like the hand of another person”
“This hand feels as though it is not part of the rest of my body”
“This hand feels as if someone had sewed on a foreign hand”
This was slightly more common in more chronic patients, and patients with this feeling reported higher pain intensities (5.9 vs 3.8 on a VAS). It was more common in patients with “glove and stocking” type sensory abnormalities.
48% of patients had an impaired ability to identify fingers of the affected hand. This difference was highly significant (p<0.0001). A subgroup found it harder to identify fingers in the affected side, taking longer to do so, even though they could feel the cotton swab.
Patients may hesitate to mention these symptoms for fear of being considered a psychiatric case.
There are differences between neglect and the current findings, in that neglect occurs with right hemispheric lesions, while it was independent of side in the study. Furthermore patients did not show typical signs of neglect on a line division task. The results do not support the hypothesis that the feeling of foreignness is caused by neglect. In the acute phase of neglect, patients are unaware of the deficit. CRPS patients are quite aware of the feeling of foreignness.
The researchers cannot rule out the possibility of the foreignness being a mild case of anosognosia, or alien hand syndrome. Likewise for a somatoform or psychiatric disorder, although the evidence for this is not supportive. There are more arguments against than for the presence of a psychiatric disorder.
The authors suggest than simply focusing of ROM and function, physiotherapy should also focus on higher sensory processing.
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Re: Complex Regional Pain Syndrome - July 8, 2005 1:49:00 AM
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pablo w
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From: Canberra
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Why do people with complex regional pain syndrome take longer to recognise their affected hand? Moseley, GL. Neurology 62, June (2 of 2) 2004. 2182-2186.
To recognise whether a pictured hand is either a left or a right hand, we mentally maneuver our own “virtual hand” to match the position of the hand in the picture.
18 patients with CRPS 1.
Pictures of a right hand were taken and mirrored to give left hand images also. The length of time it took normal subjects to adopt these hand positions gave a measure of “awkwardness”. Patients predicted how much pain they would have when adopting each position.
It was found that the mean reaction time to identify the laterality of a pictured hand varied according to the duration of symptoms independent of pain intensity, and the RT for each picture varies primarily according to the pain that would be evoked by executing the mental movements rather than simply as a function of the awkwardness of the movement.
The delayed RT may be due to long term changes in S1 and primary motor cortices (as in other pain conditions), but the hand laterality recognition task does not consistently activate the primary motor or sensory areas but is thought to primarily affect the dorsolateral frontal and posterior parietal cortex, which supposedly holds the neural substrate for the body schema. Reorganisation of the neural correlates for the body schema seem s feasible.
The fact that the pain associated with hand positions was more strongly correlated with RT than awkwardness per se, suggests that guarding-type processes occur at an intention to move level, which involves the planning of movements and predictions of their sensory consequences. The current data for the first time suggests that the impact of predicted pain may occur upstream from the primary motor cortex at a motor planning level.
This is helpful information when looking at studies on mirror therapy
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Re: Complex Regional Pain Syndrome - July 8, 2005 1:51:00 AM
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pablo w
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From: Canberra
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A few more, still not fully summarised but good for the references:
Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Moseley, GL, Pain 108 (2004) 192-198.
Patients with long-standing CRPS were treated with a motor-imagery program of hand laterality recognition, followed by imagined hand movements, and then mirror therapy. The NNT for a 50% reduction in Neuropathic Pain Score was 2. The effect of Rx was replicated in the cross-over control group (who continued with usual management).
Is successful rehabilitation of complex regional pain syndrome due to sustained attention to the affected limb? A randomised controlled trial. Moseley, GL. Pain 2005, 1-8 (in press at the time I printed this).
Why do people with complex regional pain syndrome take longer to recognise their affected hand? Moseley, GL. Neurology 62, June (2 of 2) 2004. 2182-2186.
To recognise whether a pictured hand is either a left or a right hand, we mentally maneuver our own “virtual hand” to match the position of the hand in the picture.
18 patients with CRPS 1.
Pictures of a right hand were taken and mirrored to give left hand images also. The length of time it took normal subjects to adopt these hand positions gave a measure of “awkwardness”. Patients predicted how much pain they would have when adopting each position.
It was found that the mean reaction time to identify the laterality of a pictured hand varied according to the duration of symptoms independent of pain intensity, and the RT for each picture varies primarily according to the pain that would be evoked by executing the mental movements rather than simply as a function of the awkwardness of the movement.
The delayed RT may be due to long term changes in S1 and primary motor cortices (as in other pain conditions), but the hand laterality recognition task does not consistently activate the primary motor or sensory areas but is thought to primarily affect the dorsolateral frontal and posterior parietal cortex, which supposedly holds the neural substrate for the body schema. Reorganisation of the neural correlates for the body schema seem s feasible.
The fact that the pain associated with hand positions was more strongly correlated with RT than awkwardness per se, suggests that guarding-type processes occur at an intention to move level, which involves the planning of movements and predictions of their sensory consequences. The current data for the first time suggests that the impact of predicted pain may occur upstream from the primary motor cortex at a motor planning level.
This is helpful information when looking at studies on mirror therapy.
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Re: Complex Regional Pain Syndrome - July 8, 2005 1:52:00 AM
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pablo w
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From: Canberra
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That's all I have! A few other articles to summarise, and hopefully some more info from the upcoming IASP conference in Sydney next month. If anyone is attending, hope to see you there!
Pablo
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Re: Complex Regional Pain Syndrome - July 8, 2005 2:25:00 AM
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SJBird55
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From: Michigan
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Pablo... you get the "fast typer" award! Do you know how many words per minute you just posted??? ;) I know, I know... you're gonna tell me to READ the words instead of COUNT the words...
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Re: Complex Regional Pain Syndrome - July 8, 2005 3:59:00 AM
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pablo w
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From: Canberra
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Thanks, I cheated! Cut and paste is a wonderful thing. And I just counted over 4195 words excluding some of my comments!
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Re: Complex Regional Pain Syndrome - July 8, 2005 5:28:00 AM
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dragonfire
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From: usa
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Went to APTEI and found this:
"An Impressive Treatment Option for CRPS!
Reference: Cleland J, McRae M 2002 Complex Regional Pain Syndrome I: Management through the use of vertebral and sympathetic trunk mobilization. The Journal of Manual & Manipulative Therapy 10(4): 188-199
This single case study supports my own positive clinical experience with using the Slump Long Sitting with Sympathetic Emphasis (SLSSE) mobilization technique on patients presenting with signs & symptoms of CRPS.
A 50 year-old female 8-weeks following a fracture of her right tibia and femur was diagnosed with right lower leg CRPS.
The patient had immediate improvements in her symptoms following the SLSSE mobilizations.
After 10 treatments sessions using the SLSSE mobilization and of course other functional exercises, she had dramatic improvements in her symptoms and function.
Posted on: April 03, 2003 "
Illustration of said SLSSE mobilization is on the website.
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Re: Complex Regional Pain Syndrome - July 8, 2005 4:08:00 PM
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pablo w
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From: Canberra
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Not having read the above article, I could be biased, but here are my thoughts:
With a case study, it is never possible to compare the treatment to a different approach, so attributing effects to the particular treatment (unless it is known to work) is difficult.
The patient had a fracture. I suppose he was immobilised for some time. Immobilisation per se can give rise to features of CRPS, which reverse with mobilisation.
Was it the sympathetic mobilisation that achieved the results or the exercises? For a good review of the role of the sympathetic nervous system and CRPS, have a look at "Topical Issues in Pain 3" Edited by Louis Gifford, publisjed by the Physiotherapy Pain Association [URL=http://www.ppaonline.com]www.ppaonline.com[/URL] for more details.
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Re: Complex Regional Pain Syndrome - July 8, 2005 4:10:00 PM
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pablo w
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From: Canberra
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sorry, wrong link! I will post the correct one unless someone beats me to it.
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Re: Complex Regional Pain Syndrome - July 8, 2005 5:27:00 PM
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nari
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From: Australia
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I found the paper by Forderreuther and Straube interesting , with over 50% of the CRPS subjects noting that the hand was 'foreign'.
AHS, or Alien Hand Syndrome (also called ALS - alien limb syndrome) is well documented, and occurs chiefly in epileptic and CJD patients. It is thought, though not certainly, that it is a disorder of the corpus callosum, and is definitely not the same as neglect.
Neglect can occur on (R)or (L)sides, but is more common on the (L) side, which indicates a(R)hemisphere lesion. The person is indifferent to the limb.
With AHS, the person is acutely aware of this alien bit of body; I remember one guy post-(L)CVA who had the (R) arm voluntarily tethered at night because it would 'wander' around and often close down on his throat, somewhat waking him up in a fright.
He did recover fully, and the hand came back under voluntary control. He also could not count his fingers - ended up with anything from 3-6.
Another person, who had quite a severe SDH, experienced AHS on one side, (once she was able to be cognisant of anything)but I cannot remember the pathology of the SDH. She too recovered, but required sedation because she was so upset by this ugly thing hanging around her shoulder area; she pleaded for amputation. Of course there was no psych history of any kind.
Nari
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Re: Complex Regional Pain Syndrome - July 8, 2005 6:10:00 PM
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Diane
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From: Vancouver, B.C., Canada
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Pablo, I think you meant [URL=http://www.achesandpainsonline.com]www.achesandpainsonline.com[/URL]
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Re: Complex Regional Pain Syndrome - July 8, 2005 8:36:00 PM
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pablo w
Posts: 88
Joined: November 13, 2002
From: Canberra
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Thanks Diane, I knew you would know!
There are lots of good articles on CRPS.
A current patient has a long history of CRPS (about 18 years). When I discussed some of Moseley's research with her, she said she has always had trouble telling left from right. I took pictures of hands similar to what is described in Moseley's article. When asked to tell me whether they were pictures of a left hand or right hand, she often got it wrong despite knowing that the pictures were all of a left hand! She had a lot of trouble with the task. Currently gathering a collection of hand pictures to use in treatment (and have recruited my father to develop an appropriate computer program to select images at random and time people's responses). I hope it works!
Nari, the similarities with Alien Hand Syndrome are interesting. That's why I like to read authors such as Oliver Sacks and Ramachandran, who explore these seemingly bizarre conditions with a great deal of insight.
Pablo
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Re: Complex Regional Pain Syndrome - July 9, 2005 1:47:00 AM
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SJBird55
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Oliver Sacks rocks...
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Re: Complex Regional Pain Syndrome - July 9, 2005 1:50:00 PM
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Randy Dixon
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That sounds like a tongue twiest, Oliver sacks rocks, Oliver sacks rocks, Oliver sacks rocks.
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Re: Complex Regional Pain Syndrome - July 9, 2005 1:56:00 PM
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srcase
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From: Michigan
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That he does. I've been reading "The Man Who Mistook His Wife for a Hat". Excellent book. It really gets one thinking about how much we take for granted....not to get off topic.
Sarah
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Re: Complex Regional Pain Syndrome - July 11, 2005 6:10:00 PM
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pwrandall
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From: Elk Grove, CA
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Wow, popular topic after all.
I recently discontinued therapy with the patient that started this thread and sadly I have very little to report in the way of objective changes. However, mirror therapy and guided mental imagery did have a significant effect on the ability of the patient to voluntarily complete the limited ROM availiable at her knee ankle and toes. Interestingly, mirror therapy frequently caused report of a flare up of symptoms early on in the treatment, despite the fact that no physical motion was occuring in the effected lower extremity.
TENS still provides relief when pain is severe; walking is tolerable, but not comfortable; and she now has a much better understanding of her condition--as she states, she knows it is all in her head, just not in a crazy way. I shared the information from the NPR piece Randy mentions and she was very relieved by the knowledge that something really is going on in there, and someone has seen it.
Anyway, thanks everyone for the great discussion and all of your assistance.
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Re: Complex Regional Pain Syndrome - July 12, 2005 12:56:00 AM
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pablo w
Posts: 88
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From: Canberra
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PTPete,
If she has had symptoms for a long time, mirror therapy may not be the starting point (and it obviously sets up pain and reinforces the pain neuromatrix). The trick in theaory is to find something that doesn't increase symptoms but that still has some use. Seeing the limb move may be enough to cause pain. Maye staring with imagined movements may yield different results. A lot of this wors much better early on...
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