Complex Regional Pain Syndrome (CRPS) Exam 4 Flashcards
CRPS (Complex Regional Pain Syndrome)
Chronic pain syndrome - must be aware b/c any dx can slip into this and not easy to treat and very painful, the sooner it is caught the better the prognosis
Previously referred to as Shoulder Hand Syndrome and Reflex Sympathetic Dystrophy - name change b/c not all pt with CRPS have sympathetic symptoms
Involves several physiological and psychological systems
Process is progressive without intervention
Impacts women 4 x more than men of which 65% are btwn the ages of 30-50
Autonomic nervous system is not under voluntary control
Problem is not just reflexive, it is very complex physiological and psychological problem, gets worse if nothing is done
Really don’t know what causes it
Prevalence/Risk Factors
* Hx of distal radius fracture - docs prescribe 500mgs of Vitamin C (median nerve has a lot of autonomic fibers)
- Identifiable peripheral nerve - type II CRPS
Hypertrichosis
Abnormal hair growth that occurs in response to an irritated cutaneous nerve
This in itself does not mean person has CRPS but lets us know that the cutaneous nerve fibers were affected - compressed in a cast
Hair will eventually fall off and go back to normal
Prevalence/Risk Factors
Children can get CRPS (usually over 5 yrs old and LE more involved)
Children under 5 and elderly rarely get CRPS
General Symptoms
Vary from person to person
* Prolonged or excessive pain out of proportion to injury
* Continuous throbbing pain
* Sensation of burning, stinging, tingling, numbness,
squeezing
* Sensitivity to heat or cold
* Swelling
* Changes in skin temp - sweaty or cold at times and
temp variance. Extremities may be either hot or cold and
there is often a diff btwn involved and uninvolved extrem
* Atrophy
Fluidotherapy is good b/c you can adjust temp to provide
desensitization
Look at temp btwn each side
S/S - skin on back of hand is shiny
S/S - starts distal and climbs up and can cross
Sometimes they can have every other sign and no pain
Common S/S
- Inflammation
- Skin color changes
- Stiffness
- Abnormal hair growth
- Spasms in blood vessels and Mm of the extremities
- Osteopenia - bones will lose density as it progresses
- Insomnia/Emotional Disturbances
- Dystonia/motor planning difficulty
Additional Symptoms: Atrophy of hair and nails Hypertrophy of skin Spasms in blood vessels and Mm of the extremities Temp variance
**PAIN DEFINITIONS AND TERMS
Hyperpathia - Abnormal painful reactions to a stimulus (umbrella term)
Diff types of hyperpathis:
Allodynia - pain in specific dermatome distribution that is a result of a stimulus that is not normally painful
Hyperalgesia - an increased sensitivity to pain, may be caused by damage to nociceptors or peripheral nerves. More extreme pain than allodynia
Hyperesthesia - a condition that involves an abnormal increase in sensitive stimuli of the senses (hear, touch, taste, etc) Increased touch sensitivity - tactile
hyperesthesia
Increased sound sensitivity - auditory hyperesthesia
Autonomic Terms
Vasomotor - dilation and constriction of blood vessels
Sudomotor - autonomic function associated with the sweat
glands
Trophic - changes in tissues, due to loss/reduction of nerve and/or blood supply (muscle atrophy, increased nail growth , changes in nails, increased hair growth (hypertrichosis)
- Vasodilation - red swollen, as this progresses the vasodilation transitions to vasoconstriction - blue and stiff
- Typically sweating comes early and lack of sweat later
- Really dry skin and don’t sweat at all - they probably have a peripheral nerve issue (peripheral nerve autonomic role is to provide sweat in tissue)
Muscle atrophy occurs b/c of irritation but people who have this avoid movement
Body sends extra blood flow to nail and people don’t want to be touched so don’t cut nails
2 Types of CRPS
Type I: Occurs after an illness or injury that did not directly
damage the peripheral nerves of the affected limb
Type II: There is an identifiable peripheral nerve injury
Grades and Stages of CRPS
Grade 1: Algodystrophy (disruption of bone growth
combine with sympathetic symptoms).
Grade 2: Sympathetic dystrophy without pain
Grade 3: Sympathetic maintained pain
Stages - Time Frames:
Acute Phase: First 3 months (redness burning)
Subacute Phase: 3 more months (3-6 months)
Chronic Phase: 6 months onward (6-12 months)
Diagnostic Testing
Three phase bone scan to evaluate vascular profusion
Monitor digital pulp temp
X-Rays used to evaluate regional osteopenia
Infrared thermography imaging - diff in skin temp
Sympathetic Chain
Messages received from periphery are wrong - saying danger when there is not danger
Local issue but also brain is remapping and triggering fight or flight and brain shuts down area out of protection
Central sensitization - when threshold of the spinal cord in brain is lowered and takes less to fire pain receptors
Body can’t modulate for temperatures b/c they are not getting proper input so they can get frost bite in cold weather
Anxious person is at a higher risk
Evaluation and Identification of CRPS
- Early dx is of utmost importance - the sooner proper tx is delivered the better
- Mechanism of Injury - usually follows some type of trauma such as fx, sharp force injury, surgery, infections, heart problems and cumulative trauma disorders. Insult may be quite mild in nature.
Stage 1
Acute phase - beginning to 3 months
Clinical Presentation
- Increased hair and nail growth
- Changes in sweating
- Increased pain
- Skin becomes thin and dry
- Color change red, warm, and swollen but may quickly become cold (depending on activity)
- Can have swelling
- Allodynia - NON painful stimuli evokes pain
- Hyperalgesia - painful stimuli evokes more intense pain than usual
Stage 2
Sub-acute
- 3-6 months
- Decreased hair growth
- Swelling could spread (can start going up arm)
- Stiffness - even with PROM, changes process of tissue
- Appearance
- Joints thicken
- Mm atrophy
Stage 3
Chronic phase
* 6 or more months
* Changes are irreversible - can’t do anything
* Severely limited mobility of affected area - permanent
contractures
* Contractures of the muscle and tendons that flex the jts
* Muscle wasting occurs during this stage
Treatment
80% of those who receive treatment within the first year will have significant improvements
50% will improve if treatment is started within the second year
Good news we can help with this dx
No pain No gain does NOT work with CRPS
- Modalities
- Exercise
- Edema Control (Massage/garments)
- Stress Loading
- Desensitization
- Splinting is controversial
- Functional Activities
- Imagery and Relaxation
- Mirror box
- CPM
Need to move - usually short session of exercise thru day, if not moving it is the worst thing
Control Swelling - teach them how to do self retrograde massage and it gives them control (address it in mind and touch limb) b/c it can sometimes feel like the limb is not theirs
They don’t tolerate traction and stretch - splinting but flexion glove (isotoner glove with rubber bands) works better, traction on fingers can break up reflexive loop
Graded motor imagery - is wonderful
Continue passive motion machine - as long as they can tolerate it (moves the limb for them)
Grip usually sign affected due to proprioceptive dysfunction - can’t feel how hard they are gripping or weight bearing - can drop items often
MCP Squeeze Test
Grasp MCP and lightly squeeze - if can’t tolerate it is positive
Record as positive if pt pulls away
Drop and Swipe Test
Part 1: Alcohol swab package is opened and squeeze till alcohol drops on the affected limb. In 10-60 sec ask the pt what they feel. If pain is dramatically increased the pt is experiencing thermal hyperalgesia (positive - painful)
If cold/cool it is a normal response and not thermal hyperalgesia
Part 2: Swipe the alcohol pad lightly over the affected area If pt responds with increased pain or withdraws the limb or tells you to stop, they are experiencing mechanical hyperalgesia (positive - painful)
OT Goals
- Minimize edema
- Normalize sensation
- Increasing flexibility, ROM, coordination
- Promote normal positioning
- Decrease muscle guarding
- Increase functional use to increase independence
- Educate pt regarding the pain cycle, meds/pain management
- Normal use of the affected part
- Facilitate movement (cornerstone of treatment) - this is the main thing
Contraindicated in Most Cases
TEST!!!!
- PROM
- Joint Mobilization
- Splinting and casting to immobilize
- Not recommended to immobilize the extremity as
disuse and guarding exists with this condition
- Not recommended to immobilize the extremity as
PROM until they can tolerate it without being painful - we can easily push the into an inflammatory response
Need to focus on things that they have control over first
Once system is normalized we can progress
Patient Education
- Pain may not be giving an accurate account of their tissue status. No need to fear that they are causing damage
- Changes in the brain when subjects think differently about their pain
Watson Carlson Stress Loading
- Scrub and carry (compression and; distraction)
- Dystrophile - device used to measure amount of weight
bearing a person can perform - The goal is to bear as much weight as possible through
the affected arm. Common for the pain and swelling to
slightly increase 1st few days of the protocol, but positive
results usually observed within the 1st wk of tx - Begin with 3 min/ 3 times a day and progress to 10-15 min
3 times a day - Carry: The pt is asked to carry an object weighing 1-2 lbs
during the day. This causes a distraction force on the
limb
Active exercise requires stressful use of the UE without forcing joint motion
The results are based on the application of pressure or resistance to the hand
This increases the large fiber afferent impulses which in turn helps relieve pain
Stress loading may initially produce an increase in pain or swelling of the extremity after several days a decrease in symptoms will begin to be evident
Stress Loading Activities
- Scrubbing on a plywood board while in the quadruped position. Scrub every 2 hrs starting at 3-5 minutes and work up to 10 mins
- Carrying a weighted bag in the affected hand. Grade up the weight as quickly as possible according to tolerance
- Functional Activities: washing windows, wiping counters, ironing, scrubbing bath tile, carrying groceries, sanding wood
