Assessment Of Complex Regional Pain Syndrome Dr Candy Mccabe

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Information about Assessment Of Complex Regional Pain Syndrome Dr Candy Mccabe

Published on August 16, 2008

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Lecture given to the North British Pain Association on 16th May 2008 by Dr Candy McCabe. In this talk, Dr McCabe discusses the mechanisms and assessment of patients with complex regional pain syndrome.

Assessment of Complex Regional Pain Syndrome Dr. Candy McCabe Consultant Nurse arc Senior Lecturer in Rheumatology Nursing Royal National Hospital for Rheumatic Diseases & School for Health, University of Bath, Bath The North British Pain Association 2008

Rene Descartes 1596-1650 “ I think therefore I am” Jean-Jacques Rousseau, 1712-1778 “ I FEEL therefore I am”

Silas Weir Mitchell 1829-1914 Turner’s Lane Hospital, Philadelphia

IASP Current diagnostic criteria Complex Regional Pain Syndrome Type I Follows an initiating noxious event Spontaneous pain and/or allodynia and hyperalegesia occur beyond area of a single peripheral nerve and disproportionate to the inciting event. Evidence or has been evidence of oedema, skin blood flow abnormality and sudomotor changes. CRPS Type II Follows nerve injury More regionally confined area Stanton-Hicks M, Janig W, et al. Pain, 1995; 63: 127-133 .

Complex Regional Pain Syndrome Type I

Follows an initiating noxious event

Spontaneous pain and/or allodynia and hyperalegesia occur beyond area of a single peripheral nerve and disproportionate to the inciting event.

Evidence or has been evidence of oedema, skin blood flow abnormality and sudomotor changes.

CRPS Type II

Follows nerve injury

More regionally confined area

IASP SIG proposed revised diagnostic criteria Hyperalagesia/ hyperaesthesia (sensory)‏ Temperature and colour changes (vasomotor)‏ Oedema and sweating (sudomotor)‏ Trophic and motor changes Clinical criteria: 2 signs and 3 symptoms Research criteria: 2 signs and 4 symptoms Galer et al., 1998. Pain; 14:48-54 Bruehl et al., 1999. Pain; 81:147-54

Hyperalagesia/ hyperaesthesia (sensory)‏

Temperature and colour changes (vasomotor)‏

Oedema and sweating (sudomotor)‏

Trophic and motor changes

Clinical criteria: 2 signs and 3 symptoms

Research criteria: 2 signs and 4 symptoms

Presentation of CRPS Incidence rates of 5.46 to 26.2 per 100,000 person years. UK incidence unknown. Sandroni et al Pain 2003 (Minnesota, USA); De Mos et al Pain 2007 (Netherlands)‏ Onset of symptoms may be immediate following trauma or within one month of limb immobilisation 50% go on to suffer chronic symptoms and long term physical impairment Field et al. Journal of hand Surgery 1992, Schasfoort et al. Arch. Physical Med. & rehab. 2004. Disturbance in sensory, motor and autonomic systems which may fluctuate over time and even over a single day. Diagnosis and therapy delayed by closeness in nomenclature between ‘Chronic’ and ‘Complex’ regional pain syndrome.

Incidence rates of 5.46 to 26.2 per 100,000 person years. UK incidence unknown.

Sandroni et al Pain 2003 (Minnesota, USA);

De Mos et al Pain 2007 (Netherlands)‏

Onset of symptoms may be immediate following trauma or within one month of limb immobilisation

50% go on to suffer chronic symptoms and long term physical impairment

Field et al. Journal of hand Surgery 1992,

Schasfoort et al. Arch. Physical Med. & rehab. 2004.

Disturbance in sensory, motor and autonomic systems which may fluctuate over time and even over a single day.

Diagnosis and therapy delayed by closeness in nomenclature between ‘Chronic’ and ‘Complex’ regional pain syndrome.

Excessive pain in the presence of minor or no injury tends to be disbelieved

Excessive pain in the presence of minor or no injury tends to be disbelieved

Case study-limb perception Altered body perception with and without visual feedback Finger misidentification Forderreüther et al. Pain 2004 Referred sensations-face to wrist

Altered body perception with and without visual feedback

Finger misidentification

Forderreüther et al. Pain 2004

Referred sensations-face to wrist

McCabe et al. Rheumatology 2003 Referred Sensations in CRPS

Halligan PW et al. BMJ 1999 Referred Sensations in Amputees

Juottonen et al., Altered central sensorimotor processing in patients with CRPS. Pain 2002; 98:315-323. Maihöfner et al., Patterns of cortical reorganisation in CRPS Neurology 2003; 61:1707-1715. Neurology 2004, Pain 2005 Maihöfner et al.,The motor system shows adaptive changes in CRPS. Brain 2007;130:2671-87. Pleger et al., Sensorimotor returning in CRPS parallels pain reduction. Annals of Neurology 2005;57(3):425-429 Cortical reorganisation in CRPS

Juottonen et al., Altered central sensorimotor processing in patients with CRPS. Pain 2002; 98:315-323.

Maihöfner et al., Patterns of cortical reorganisation in CRPS Neurology 2003; 61:1707-1715. Neurology 2004, Pain 2005

Maihöfner et al.,The motor system shows adaptive changes in CRPS. Brain 2007;130:2671-87.

Pleger et al., Sensorimotor returning in CRPS parallels pain reduction. Annals of Neurology 2005;57(3):425-429

Wilder Penfield

Motor assessment Reduced grip strength and ROM Slow to ‘connect’ with affected limb when asked to move it Greater range with imagined movement Able to perform bilateral synchronised movements with mirror visual feedback

Reduced grip strength

and ROM

Slow to ‘connect’ with affected limb when asked to move it

Greater range with imagined movement

Able to perform bilateral synchronised movements with mirror visual feedback

Motor abnormalities in CRPS Slower response times in the affected limb with limb laterality tasks. Schwoebel et al Brain 2001 Increased pain and swelling with imagined movements . Moseley Neurology 2004 Weakness, Dystonias, Myoclonus, Tremor Slowness of repetitive movements (bradykinesia)‏ Frequency of motor disorders increases with disease duration Dysfunction of central neural networks involved with inhibition of movement. v an Hilten et al. IASP press 2005. Increased difficulty with motor tasks may link to autonomic changes via dorsal anterior cingulate cortex . Critchely et al. Brain 2003. Re-mapping in motor cortex with representation of painful area enlarged. Ma ïhöfner et al. Brain 2007.

Slower response times in the affected limb with limb laterality tasks. Schwoebel et al Brain 2001

Increased pain and swelling with imagined movements . Moseley Neurology 2004

Weakness, Dystonias, Myoclonus, Tremor

Slowness of repetitive movements (bradykinesia)‏

Frequency of motor disorders increases with disease duration

Dysfunction of central neural networks involved with inhibition of movement. v an Hilten et al. IASP press 2005.

Increased difficulty with motor tasks may link to autonomic changes via dorsal anterior cingulate cortex . Critchely et al. Brain 2003.

Re-mapping in motor cortex with representation of painful area enlarged. Ma ïhöfner et al. Brain 2007.

Summary CRPS Altered Perceptions Sensory Pain Altered body schema including macro- and microsomatognosis Reduced and heightened awareness of limb Increased peri-personal space Referred sensations Hostile feelings Motor Difficulty in locating limb prior to and on initiation of movement Poor motor control Dystonia Tremor Neglect of affected limb Altered posture and gait Galer & Jensen. J Pain Symptom Manage 1999. Forderreüther et al. Pain 2004. McCabe et al. Pain 2005; Lewis et al. Pain 2007, McCabe & Blake. Rheumatology in press

Sensory

Pain

Altered body schema

including macro- and microsomatognosis

Reduced and heightened awareness of limb

Increased peri-personal space

Referred sensations

Hostile feelings

Motor

Difficulty in locating limb prior to and on initiation of movement

Poor motor control

Dystonia

Tremor

Neglect of affected limb

Altered posture and gait

Summary Both motor and sensory perceptions are altered in CRPS Distressing and often disbelieved Only careful history taking will elicit these descriptions Clinical and imaging evidence of central reorganisation in motor and sensory cortices

Both motor and sensory perceptions are altered in CRPS

Distressing and often disbelieved

Only careful history taking will elicit these descriptions

Clinical and imaging evidence of central reorganisation in motor and sensory cortices

Sensory events are analysed in terms of appropriate motor response. Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000 Baseline information

Motor simulation network and motor planning Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000 Baseline information MSN

Altered sensory and motor perceptions are generated Thermal Body perception Reduced and heightened awareness of limb Pain, stiffness, pins and needles Difficulty in locating limb prior to, and on initiation of movement Poor motor control When sensory input and motor output conflict? McCabe et al Rheumatology 2005 Sensorimotor conflict

Altered sensory and motor perceptions are generated

Thermal

Body perception

Reduced and heightened awareness of limb

Pain, stiffness, pins and needles

Difficulty in locating limb prior to, and on initiation of movement

Poor motor control

CRPS and sensory-motor conflict Baseline information MSN Corrupted Imagined or actual movements will cause a range of sensory/motor disturbances

Access to the basic building blocks Snyder AW, Mitchell DJ. Proc.R.Soc. Lond. 1999;2666:587-592.

Link to current clinical signs? Foreshortened limbs/ Altered body perception? Autotomy/ desire for amputation?

Link to current clinical signs? Increased peri-personal space Farné A, Làdavas E. Neuropreport 2000; 85:1645-1649.

Correcting motor sensory mismatch – 3 potential target areas Von Holst & Mittelstaedt; 1950. Wolpert et al.; 1995, Frith et al.; 2000 Baseline information MSN

Sensorimotor integration Sensory and motor systems work in partnership When discordance occurs altered sensory and motor perceptions are generated Therapies designed to target this discrepancy appear effective.

Sensory and motor systems work in partnership

When discordance occurs altered sensory and motor perceptions are generated

Therapies designed to target this discrepancy appear effective.

Multidisciplinary inpatient and outpatient service at the RNHRD National referral centre Mobilisation of limb priority Physiotherapy twice daily (land based and hydrotherapy)‏ Occupational therapy Mirror visual feedback and motor imagery programme Enable above activities by providing pharmacological and psychological support Education, education, education! 2006 Established UK CRPS Clinical & Research Network

National referral centre

Mobilisation of limb priority

Physiotherapy twice daily (land based and hydrotherapy)‏

Occupational therapy

Mirror visual feedback and motor imagery programme

Enable above activities by providing pharmacological and psychological support

Education, education, education!

2006 Established UK CRPS Clinical & Research Network

Acknowledgements Funding Bodies & Other Partners Arthritis Research Campaign Gwen Bush Foundation Remedi RSD-UK Pfizer Pharmaceuticals Royal National Hospital for Rheumatic Diseases Donated Funds Wiltshire College of Higher Education Email: c.mccabe@bath.ac.uk CRPS Clinical Research Team Professor David Blake Dr. Helen Cohen Dr. Jane Hall Dr. Nigel Harris Ms Keri Johnson Ms. Jenny Lewis Dr. Karen Rodham

Funding Bodies & Other Partners

Arthritis Research Campaign

Gwen Bush Foundation

Remedi

RSD-UK

Pfizer Pharmaceuticals

Royal National Hospital for Rheumatic Diseases Donated Funds

Wiltshire College of Higher Education

CRPS Clinical Research Team

Professor David Blake

Dr. Helen Cohen

Dr. Jane Hall

Dr. Nigel Harris

Ms Keri Johnson

Ms. Jenny Lewis

Dr. Karen Rodham

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