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CRPS and Graded Motor Imagery Programme Emma J Mair Emma. Mair@ggc. scot. nhs. uk CRPS and Graded Motor Imagery Programme Emma J Mair Emma. [email protected] scot. nhs. uk November 2012

Tonight- an overview Aetiology n Pathophysiology n UK Guidelines n Diagnosis n Treatment n Tonight- an overview Aetiology n Pathophysiology n UK Guidelines n Diagnosis n Treatment n Graded Motor Imagery programme n

European Incidence rate of 26/100, 000 person-years n Incidence with age till 70 n European Incidence rate of 26/100, 000 person-years n Incidence with age till 70 n 60% in upper limb, 40% in lower limb n Approximately 15% of sufferers will have unrelenting pain and physical impairment 2 years after CRPS onset n

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

CRPS-1 n Type 1: sympathetically maintained pain can start for no apparent reason but CRPS-1 n Type 1: sympathetically maintained pain can start for no apparent reason but most commonly follows distal radial fracture. n Characterised by pain which is disproportionate to inciting event, swelling, autonomic and motor disturbances, changes in skin blood flow

CRPS-2 n Type 2: Onset develops after injury to a major peripheral nerve. May CRPS-2 n Type 2: Onset develops after injury to a major peripheral nerve. May occur immediately or be delayed for several months n Most commonly involved are the median and sciatic nerves n Allodynia and hyperalgesia occur but not limited to the territory of one single peripheral nerve

1 + 2 = CRPS 1 + 2 = CRPS

Pathophysiology Multi-factorial n Other factors: environmental, genetic, psychological n The stereotyped stages are now Pathophysiology Multi-factorial n Other factors: environmental, genetic, psychological n The stereotyped stages are now obsolete n A definition of recovery has not yet been agreed n CRPS is not associated with a history of pain preceding psychological problems, or with somatisation or malingering n

Ipsilateral cortical changes ↓Inhibition and ↑excitation in M 1 Contralateral cortical changes Reorganisation of Ipsilateral cortical changes ↓Inhibition and ↑excitation in M 1 Contralateral cortical changes Reorganisation of sensory maps in S 1* Reorganisation of motor maps in M 1† ↓Inhibition and ↑excitation in M 1 and SMA ↓Endogenous pain control Pain Central sensitisation Allodynia, hyperalgesia, secondary hyperalgesia, and wind-up Sympathetic– afferent coupling Pain Peripheral sensitisation ↑IL-1β, IL-6, TNFα, NGF, CGRP, substance P, and bradykinin Pain, vasodilation of the skin, and oedema ↓Sympathetic outflow Vasodilation (early stage) Endothelial dysfunction ↓NO and ↑ET-1 Impaired circulation (chronic stage) • Swelling • Glossy skin • Increased nail and hair growth • Hyperaemia‡ • Sensory abnormalities • Autonomic dysfunction • Neurogenic inflammation • Motor abnormalities • Sensitisation • Central reorganisation

Risk Factors ACE inhibitors n Asthma n Migraine n Immobilisation n ? Genetic n Risk Factors ACE inhibitors n Asthma n Migraine n Immobilisation n ? Genetic n

UK Guidelines n n Published April 2012 Recommendations for assessment and management Speciality Guidelines: UK Guidelines n n 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 n Confirmation of Diagnosis Physio’s probably best equipped to identify a patient with CRPS n Confirmation of diagnosis based on Budapest guidelines n Confirmation with GP/cons n Differential diagnosis n Diagnosis tool: http: //www. trendconsortium. nl/diagnosis/ n

A The patient has continuing pain which is disproportionate to any inciting event B 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) 1. SENSORY Allodynia (to light touch and/or temp sensation and/or deep somatic pressure and /or joint movement) and/or hyperalgesia (to pinprick) 2. VASOMOTOR Temperature asymmetry and/or skin colour changes and/or skin colour asymmetry 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) Symptom (the patient reports a problem) Hyperesthesia does also qualify as a symptom Temp asymmetry must be >1°C All A-D must apply

Sensory n n n Alloydnia – pain due to a stimulus which does not Sensory n n n 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 n Skin colour changes n Vasomotor Temperature asymmetry n Skin colour changes n

Sudomotor / Oedema n Sweating changes or asymmetry n Sudomotor / Oedema n Sweating changes or asymmetry n

Motor / Trophic Decreased range of movement and/or n Motor dysfunction (weakness, tremor, dystonia) Motor / Trophic Decreased range of movement and/or n Motor dysfunction (weakness, tremor, dystonia) and/or n Trophic changes (hair, nails, skin) n

Body Perception Disturbance n n DISLIKE DISOWNERSHIP DESIRE TO AMPUTATE DISTORTED MENTAL VISUALISATION Body Perception Disturbance n n DISLIKE DISOWNERSHIP DESIRE TO AMPUTATE DISTORTED MENTAL VISUALISATION

Body Perception Disturbance n General Screening: ¨ Targeted questioning Emotions 2. Sense of belonging Body Perception Disturbance n General Screening: ¨ Targeted questioning Emotions 2. Sense of belonging 3. Perceived size 1. n Simple observation of position of limb The Bath CRPS Body Perception Disturbance Scale* Developed by Jennifer S. Lewis, The Royal National Hospital for Rheumatic Diseases Bath, England. v 2. © 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 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 ____________ 6 a) Have you ever had a desire to amputate the limb? Yes No 6 b) 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 n n n n Therapy environment – breezes, open windows, fans Lighting The Environment n n n n 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 n Aims of treatment: Treatment Prompt diagnosis and early treatment are considered best practice n Aims of treatment: n ¨ Reduce pain ¨ Preserve or restore function ¨ Enable patients to manage their condition ¨ Improve quality of life

Primary Care Physiotherapy & Occupational Therapy Primary Care Physiotherapy & Occupational Therapy

Best practice recommendations n n n Be aware of CRPS and identify the clinical Best practice recommendations n n n 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 Mild/Moderate symptoms Meet Budapest Rehabilitation Algorithm Identify CRPS signs and symptoms Consider Differential Diagnosis Mild/Moderate symptoms Meet Budapest criteria Consider yellow flags Confirm Diagnosis Via GP or consultant Moderate/ severe symptoms Educate, commence treatments Failing to respond to treatment in 4 weeks Noticeable response to Treatment within 4 weeks And ongoing improvement Educate, refer via GP To specialist pain clinic Pain Management programme

Pain Medicine and Interdisciplinary Specialist Rehabilitation Programmes Pain Medicine and Interdisciplinary Specialist Rehabilitation Programmes

Four Pillars of Treatment Physical and vocational rehabilitation Pain relief (medication and procedures) Psychological Four Pillars of Treatment Physical and vocational rehabilitation Pain relief (medication and procedures) Psychological interventions Patient information and education to support selfmanagement

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

Medical Management Investigation and confirmation of diagnosis n Pharmacological intervention to provide a window Medical Management Investigation and confirmation of diagnosis n Pharmacological intervention to provide a window of pain relief n Reassurance that PT and OT are safe and appropriate n Provide medical follow up n Support any litigation/ compensation claim n

Pain Medicine Guideline Recommendations n n n No drugs are licensed to treat CRPS Pain Medicine Guideline Recommendations n n n No drugs are licensed to treat CRPS in the UK Neuropathic drugs should be used in according to NICE & IASP guidelines Pamidronate (single 60 mg intravenous dose) should be considered in suitable patients with less than 6 mths 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 n n Psychological intervention is based on individualised assessment, to Psychosocial and behavioural management n n 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 n n Emphasis should be on restoration of normal function and activities Physical Management n n 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

n It may also include specialised techniques to address altered perception and awareness of n It may also include specialised techniques to address altered perception and awareness of the limb, for example: ¨ Self administered desensitisation with tactile and thermal stimuli ¨ Functional movement to improve motor control and limb position awareness ¨ Graded motor imagery, mirror visual feedback, mental visualisation ¨ Management of CRPS- dystonia

Activities of ADL and societal participation n n Support graded return to independence in Activities of ADL and societal participation n n 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 n Recognise n Prompt diagnosis n Educate n Early treatment n MDT Overview Understand n Recognise n Prompt diagnosis n Educate n Early treatment n MDT approach n

CRPS Treatment Explain & Educate Mindfulness / Awareness Problem Solving Reducing Threat CRPS Treatment Explain & Educate Mindfulness / Awareness Problem Solving Reducing Threat

Treatment- what are the options? n Based on evidence based practise, guidelines and innovative Treatment- what are the options? n Based on evidence based practise, guidelines and innovative clinicians n Good quality evidence for graded motor imagery(GMI) combined with pharmacological management is the most effective

Educate, educate n About CRPS n About Pain n n We do not know Educate, educate n About CRPS n About Pain n n 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 n Sensitisation of CNS n More Movement versus Pain Remember pain science and pathophysiology n Sensitisation of CNS n More harm than good? ! n

Desensitisation n Activities of daily living ¨Washing and dressing n Sensory Discrimination n Two-point Desensitisation n Activities of daily living ¨Washing and dressing n Sensory Discrimination n Two-point discrimination n Electrical Stimulation

Graded Motor Imagery Graded Motor Imagery

n n Sequential activation of cortical pre-motor and motor networks Laterality and Imagery = n n Sequential activation of cortical pre-motor and motor networks Laterality and Imagery = pre motor Mirror Therapy = Primary Motor Cortex and S 1 cortices ? reversal of cortical reorganisation

Limb Laterality Limb Laterality

What do you see? What do you see?

Right or Left? Right or Left?

Right or Left? Right or Left?

Laterality Recognition n Make a quick decision about the laterality then you mentally rotate Laterality Recognition n 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 Limb Laterality Recognition Pain affects the brains ability to recognise laterality of images of limbs n Information processing bias n Working body Schema n

“Normal Scores” Accuracy of 80% and above n Speed of hands and feet ~ “Normal Scores” Accuracy of 80% and above n Speed of hands and feet ~ 2 seconds n Accuracies and RT should be equal n

Differences in Speed n Identifies problems with Information processing … but what does that Differences in Speed n Identifies problems with Information processing … but what does that mean?

Mentally move LEFT hand Acute LEFT hand injury looking at RIGHT hand Difficult decision, Mentally move LEFT hand 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 RIGHT hand X RT R>L correct Wrong choice, start again 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 Acute Pain

Mentally move RIGHT Chronic LEFT hand injury looking at RIGHT hand Difficult decision, safest Mentally move RIGHT 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 LEFT hand X RT L>R correct Wrong choice, start again 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 Chronic Pain

Why? n Incorrect selection leads to longer reaction time as need to repeat mental Why? n Incorrect selection leads to longer reaction time as need to repeat mental rotation of limb to confirm laterality choice n Pain & information processing, patients wrongly select

Differences in Accuracy n Difference in accuracy suggests issues with the working body schema Differences in Accuracy n Difference in accuracy suggests issues with the working body schema

Why? Cortical reorganisation n Easier access to painful working body schema? n Why? Cortical reorganisation n Easier access to painful working body schema? n

Laterality Reconstruction n n Hands, Feet, Neck/Shoulder Vanilla, Abstract, Context Online and Flash cards Laterality Reconstruction n n Hands, Feet, Neck/Shoulder Vanilla, Abstract, Context Online and Flash cards Recognise Phone Apps Other methods: ¨ Shadow Puppets ¨ Digital cameras ¨ Magazines

Recognise online: http: //recognise. noigroup. com/recognise/ Recognise online: http: //recognise. noigroup. com/recognise/

Motor Imagery Motor Imagery

Motor Imagery Sports Performance n Neuro-Rehabilitation n Cognitive Psychology n Graded Motor Imagery n Motor Imagery Sports Performance n Neuro-Rehabilitation n Cognitive Psychology n Graded Motor Imagery n

Motor Imagery n n Observing and Imagining movements Imagining yourself doing the movement not Motor Imagery n n Observing and Imagining movements Imagining yourself doing the movement not imagining observing themselves doing the movement

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

The What? n Patient Explanation ¨ Food ¨ Back pain & bending The What? n Patient Explanation ¨ Food ¨ Back pain & bending

The How? n Prompts: ¨ Shape ¨ Skin ¨ Colour ¨ Digits ¨ Movement The How? n Prompts: ¨ Shape ¨ Skin ¨ Colour ¨ Digits ¨ Movement

Motor Imagery n n Awareness of body part Imagining movements Imagining functional activities Flash Motor Imagery n n Awareness of body part Imagining movements Imagining functional activities Flash cards and online images can be used as prompts

Mirror Therapy Mirror Therapy

The Why? Illusion n Tricking the brain n Motor Cortex / S 1 n The Why? Illusion n Tricking the brain n Motor Cortex / S 1 n Mirror Neurons n

The How? Observation n De-sensitisation n Movement n Context- emotional, threat n Weight bearing The How? Observation n De-sensitisation n Movement n Context- emotional, threat n Weight bearing n Functional rehab n

Mirror Therapy n Practical: ¨ Try bilateral movements with the mirror ¨ Try asynchronous Mirror Therapy n Practical: ¨ Try bilateral movements with the mirror ¨ Try asynchronous movements whilst watching your limb in the mirror ¨ Get someone to tap or stroke the unaffected limb whilst looking at the reflected limb

Mirror therapy for the 21 st century? Prism Glasses n www. prismglasses. co. uk Mirror therapy for the 21 st century? Prism Glasses n www. prismglasses. co. uk n

Brain Training Educate n Desensitise n Habituate n Develop Function n Brain Training Educate n Desensitise n Habituate n Develop Function n

Can’t Perform Bilateral synchronised movements in a mirror Mirror visual feedback ? Physical rehabilitation Can’t Perform Bilateral synchronised movements in a mirror Mirror visual feedback ? Physical rehabilitation approaches Can’t Perform Imagined movement of affected limb Can’t Perform Rehearse motor imagery Can’t Perform Limb Laterality programme Can’t Perform Sensory discrimination Electrical or manual Concurrent medical and psychological support

Resources & Research Resources & Research

Questions from you and from me? n n How do we support our primary Questions from you and from me? n n How do we support our primary & secondary care clinicians treating this condition? Specialised Pathways and Clinics required?