why isn’t your crps patient getting better · crps pain–central sensitization •persistent...
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WHY ISN’T YOUR CRPS PATIENT GETTING BETTER ?
SUSAN W. STRALKA PT,DPT,MS
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NEUROSCIENCE RESEARCH
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PERIPHERAL AND CENTRAL MECHANISMS
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SIGNS AND SYMPTOMS -CLINICAL PICTURE
•Sensory- abnormal sensations-allodynia and hyperalgesia
•Vasomotor- skin color changes and asymmetry, temperature changes
•Sudomotor- edema, hyperhidrosis or hypohidrosis( sweating )
•Motor/trophic- tremors, unusual movement, hair, nail changes
•Body disturbances-neglect, cognition, unable to determine body parts, larger or smaller limbs, dystonia
DID YOU FORGET TO TRAIN THE BRAIN?
•Treatment of brain down called Top-down treatment for CRPS
•Neuroscience education
•Graded and increasing exercise and activity to move forward for Functional Restoration not total pain relief
•Top-down is retraining the brain to reconnect body parts
•Treat central or top-down before or with the peripheral symptoms
• Hallmark of CRPS-disproportionate pain and abnormal sensations
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Pain is an output
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• Close allies – Brain and Body• Brain is Protector• Both depend on brain map of body• Thinking about movement can hurt
Moseley G.L. et al Arthritis Rheum; 2008; May 15:59 (5) 623-31
BRAIN IS THE BOSS
•Pain is an output of the brain
•Pain is just a sensation until it gets to the brain
•Brain decided is there is a threat and response at multiple brain areas
•Previous experience, knowledge, culture, beliefs all play a part
NEUROMATRIX AND NEUROSIGNATURES
•Melzack’s Neuromatrix- brain is a mass neural networks and when connected form an output
•Neurosigtnatures- network of neurons that are wired together ,fire together to cause an outputr
•The idea is to fire non-painful neurosignatures
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ACTIVATION OF NEUROTAGS
•Brains cells that make up the neurotag have to fire together.
•Other brain cells must be inhibited so they don’t fire.•So with pain neurotags keep them below activation level
•If pain persists neurotags become sensitized and disinhibited and fire whenever they want
•Example: thinking about movement causes pain
201. RETRAINING THE BRAIN BY UNDERSTANDING GRADED MOTOR IMAGERY. THIS INFORMATION IS THE PROPERTY OF SUSAN STRALKA AND
SHOULD NOT BE COPIED OR OTHERWISE USED WITHOUT EXPRESS WRITTEN PERMISSION OF THE AUTHOR.
BRAIN INVOLVEMENT
•Amygdala- fear, addiction and fear conditioning
•Sensory cortex-sensory discrimination
•Thalamus and Hypothalamus-stress response, autonomic and motivation
WHAT IS CRPS?
•Persistent debilitating condition
•Involves the peripheral and central nervous system as well as the autonomic nervous system.
•Somatosensory abnormalities-body perception disturbances
•Motor dysfunction
•Neuropathic and spreading pain
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INCITING EVENTS CAUSING CRPS
•Immobilization
•Fractures –distal radius fracture
•Surgery
• Sprains and strains
•Nerve entrapment or injury
•Neuroma
•Venipuncture
•No know cause
DEFINITION OF CRPS-1993•Complex-diverse symptoms such as pain, sensory-motor impairment ,autonomic dysfunction
•Regional-distribution is regional versus a dermatome/peripheral distribution
•Pain-though the symptoms are diverse pain is the most prominent and trouble
•Focusing only on peripheral and autonomic symptoms
International association for the study of pain 1995 diagnostic criteria
•CRPS 1(Reflex sympathetic Dystrophy)
•Noxious event
•Continued pain
•Changes blood flow, abnormal sudomotor activity
•CRPS 11- causalgia
•Continuing pain, allodynia or hyperalgesia caused by nerve injury
•Continued pain
•Changes in skin blood flow
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BUDAPEST CRITERIA
Following 3 criteria must be met for clinical diagnosis.
1. Disproportionate pain intensity to injury
2. Symptom cluster-( 1 symptom in 3 of the 4 categories)
Sensory-hyperalgesia ,hyperesthesia or allodynia
Vasomotor-temperature changes ,skin color changes or asymmetry
Sudomotor/edema –sweating changes or asymmetry and edema
Motor/trophic-hair,nail or skin , decreased ROM ,loss of motor dysfunction
BUDAPEST CRITERIA3. Sign Cluster- must display at least 1 sign at the time of evaluation in two of the four categories
Sensory-hyperesthesia to pinprick,allodynia,deep pressure
Vasomotor- temperatiure asymmetry,skin color changes
Sudomotor/Edema-evidence of edema ,sweating changes
Motor/trophic-decreased ROM, hair,nail,skin changes,motor
Dysfunction
4. No other diagnosis to explain this.
ACCURACY OF BUDAPEST CRITERIA
Decision rule for the Budapest criteria
Sensitivity Specificity
2+ signs and 2+ symptoms 0.94 0.36
3+ signs and 3+ symptoms 0.70 0.83
2+ signs and 4+ symptoms 0.70 0.94
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COLLES FRACTURE
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RESEARCH
Beyond the Joint: The Role of Central Nervous System Reorganization in Chronic Musculoskeletal Disorders. In JOSPT, volume 47, number 11;Sept 2017:817-821.
Jean Sebastien Roy, L Bouyer , P Langevin , and C Mercier
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SIGNS AND SYMPTOMS –Fukushima 2014
•Bizarre complaints – spreading, hot poker on skin
•Bizarre signs- blisters, skin lesions, dark spots
•Increased pain in all senses-ears, nose, eyes, body parts
•Neglect like symptoms
•Dystonia, tremors
CRPS PAIN–CENTRAL SENSITIZATION
•Persistent pain modifies CNS
•CNS becomes more sensitive and puts out more pain
•Takes less stimuli to intensify pain
•Hypersensitivity stays turned on – outlives being helpful
•Allodynia and hyperalgesia
•Remember - Central sensitization is an overreaction to threats in CNS. If if treatment is too intense we continue to trigger the brains alarm system now maladaptive neuroplasticity develops.
CENTRAL SENSITIZATION CHARACTERISTICS
•Disproportionate pain which is generalized
•Spreading of symptoms(-convergence at dorsal horn) abnormal pattern
•Increased response to multiple stimuli-mechanical, thermal or chemical
•Neurocognitive and neuroplastic brain changes
•Body disturbances and alienation
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WHAT HAPPENS IN CENTRAL SENSITIZATION
•Lower pain threshold due to central processing alterations
•Produces pain hypersensitivity by changing the sensory response to normal stimuli
•Loss of body schema by maladaptive changes in body map
•Unwiring in the dorsal horn – wrong neurons fire
•Inhibition of ascending pathways to block pain
GIERTHMUHLEN - 8 MECHANISMS FOR MANAGEMENT OF CRPS
•Inflammatory response-cardinal signs
•Neurogenic inflammatory-peripheral nerve sensitization
•Increased catecholamine circulation-stress hormones
•Peripheral sensitization – glial cell activity
•Sympatho-afferent coupling-autonomic and somatosensory cross talk
•Central sensitization – sensory and tactile changes
•Maladaptive neuroplasticity-body schema changes
•Psychological symptoms- kinesiophobia and muscleguarding
•TREATMENT IS MULTIDISCIPLINARY FOR BEST RESULTS
Mechanisms Based Treatment
•Inflammation - high level cytokines,glial cell activity
•Nociceptor sensitivity-peripheral and central
•Automatic Dysregulation
•Brain somato-trophic change-maladaptive neuroplasticity
•Immune system-increase in glial cells
Multiple interacting factors
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INFLAMMATION
NOCICEPTOR SENSITIVITY
AUTONOMIC DYSREGULATION
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SYMPATHETIC NERVOUS SYSTEM
BRAIN MAP CHANGES
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Smudging
Brain areas normally devoted to specific body parts or functions start to overlap. In themotor cortex this may make it more difficult to isolate and move that body part, in thesensory cortex too sensitive to move, perhaps as protective strategies.
Neurology. 2006 Dec 26;67(12):2129-34. Epub 2006 Nov 2.
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MULTIPLE SYSTEM INVOLEMENT-IMMUNE RESPONSE
RETRAINING THE BRAIN
PACKMAN T, HOLLY J-MECHANISM BASED REHAB FOR CRPS-2018 JOUR HAND THERAPY
•Help with decision making ( informed ) for individual clients
•Start with comprehensive assessment signs and symptoms
•Listen to your patient
•Participation in therapy should be graded to promote progress
•Individually tailored client intervention
•Activity modification,adaptive equipment, functional splinting and retraining
•DON’T WORSEN THEIR SIGNS AND SYMPTOM
•Healthy sleep habits, nutrition, hydration, relaxation
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THERAPIST MUST USE HOMUNCULUS TO YOUR ADVANTAGE WITH CRPS
If the patient can’t find the body part how can we train it.
•Loss of body schema
•Denial of part
•Size difference
•Loss of tactile sensation
REMAPPING OF THE BRAIN
•Non threatening rehabilitation
•Do not CRANK on anything
•Fire good neurotags or neurosignatures and inhibit others
•Do not increase Pain
•Identify and start early-short periods but, often
THIS IS GUIDED NEUROPLASTICITY-Lundborg and Rosen 2010
CRPS TREATMENT GUIDED PLASTICITY IN THERAPY
•Goal - uncover silent synapses
•Form new axon connections by guided neuroplasticity
•Correct the maladaptive neuroplasticity caused by immobilization, inflammation, catasrophizing, fear of moving and lack of understanding neuroscience
•Decreasing pain assists in establishing correct motor units firing
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CRPS RED FLAGS –REMEMBER TO REFER OUT
•Early life stressors-emotional and sexual abuse
•Post Traumatic Stress Disorders
BRAIN CHANGES
•Following injuries-any type
•Persistent pain
•Immobilization
•Inflammation
•Amputation
CORTICAL REORGANIZATION
FOUNDATION FOR TOP_DOWN TREATMENT
•Evaluation for meeting the Budapest criteria for CRPS
•Neuroscience education-treat Biopsychosocial model
•Identify all mechanisms causing CRPS
•Start treatment for central sensitization and plan ahead for peripheral symptoms
•Calm the nervous system
•Test for loss of body schema-Graded motor imagery
•Start somatosensory reeducation
•Normal movement exercise patterns
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PAIN REACTION•Sensation to peripheral pain input
•Reaction is Physical, Cognitive and Emotional
•No control over the onset of unpleasant sensations but we do have control of our responses to the sensation
•Our reaction is a choice and mindful awareness can assist in helping our reaction
•BRAIN IS THE BOSS
Mismatch between Motor Output
and Visual Feedback
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BIOPSYCHOSOCIAL MODEL-REFRAMING
•Neuroscience education changes misperception of pain
•This changes the pain, attitude, beliefs, and fears-these affect the bioplastic changes in PNS,CNS, ANS
•Gives the patient a sense of control instead of uncertainty
•Cognitive restructuring and pacing must happen for a movement approach with therapeutic exercise
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PAIN-EMPOWER THE PATIENT
•PAIN IS A MULTIDIMENSIONAL EXPERIENCE
•SENSORY AND AFFECTIVE COMPONENTS
•PAIN IS REAL AND PERCEIVED ONLY BY THE INDIVIDUAL
•COGNITIVE COMPONENT HOW PATIENT PERCEIVES IT
•REDUCTION OF SYMPTOMS
•BIOPSYCHOSOCIAL
THERAPIST TREAT THE BRAIN PLASTICITY
•Targeted plasticity or guided plasticity in rehab
•Prevent maladaptive plasticity-EINSTEN THEORY
•Early intervention
•Use all senses
•Substitute senses
•Observation and tactile stimulation
•Graded motor imagery or mirror therapy
EVALUATION FOR CRPS
•Good history and clinical evaluation
•Budapest criteria
•Identify both peripheral and central symptoms
•Neuroscience education – make patient safe
•Calm the nervous systems
•Empower the patient
•Aerobic exercise
•Reevaluate for mechanism changes
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Abnormal Pain States
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Allodynia: Pain response to non-noxious
stimuli
Hyperalgesia
Exaggerated or spontaneous response to noxious stimuli
Both associated with Central Pain
Mechanisms
ALLODYNIA AND HYPERPATHIA
• Somatosensory symptoms
• Limits functional outcomes if not addressed early on
• Ideas on desensitization-tactile discrimination training at painful area and comfortable vibrotactile stimulation in a related skin area
INTEGRATIVE TREATMENT FOR THE BRAIN- CALM IT DOWN
•Improve breathing
•Mindfulness-makes life safer, less stress and allows self to be kinder. Non-judgmental attention to present moment experience
•Yoga
•Relaxation
•Feldenkrais
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NURTURING OF THE MIND and BODY
•Sleep
•Water
•Healthy eating habits
•Relaxation
•Creativity
•Exercise
•Pacing
• Family
•Religious beliefs
Fear Avoidance Model
•Mind – Body Connection
•Pain causes altered motor control which leads to development of dysfunctional movement patterns
•Developing of protective movement and fear of movement causes musculoskeletal impairment
•Central sensitization
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GMIP Sequential ProcessConvince patients in a non-threatening
201. RETRAINING THE BRAIN BY UNDERSTANDING GRADED MOTOR IMAGERY. THIS INFORMATION IS THE PROPERTY OF SUSAN STRALKA AND
SHOULD NOT BE COPIED OR OTHERWISE USED WITHOUT EXPRESS WRITTEN PERMISSION OF THE AUTHOR.
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201. RETRAINING THE BRAIN BY UNDERSTANDING GRADED MOTOR IMAGERY. THIS INFORMATION
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Laterality Reconstruction
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Mental Imagery
Capacity to imagine objects or events that are not there
Motor Imagery
Covert Cognitive
Process of imagining a movement of your own body without actually moving your body
Movement Observation
Perception of action of others
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Mirror Therapy
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Progression
•When doing laterality if symptoms increase. STOP revisit later on
•When doing imagery if symptoms increase STOP and go back to laterality
•When doing mirror therapy when symptoms increase STOP and go back to imagery
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NEW TREATMENT STRATEGIES OR WHAT CAN WE DO AS THERAPIST
•No immobilization or rapid mobilization
•Treat the brain changes during immobilization
•Immediate identify CRPS (treatment after immobilization for both peripheral and central symptoms
•Educate our patients /referring Physicians
FUNCTIONAL OUTCOMES•Calm the brain then start retraining
•Change the cognitive perception of the experience of pain
•Tools of ownership – mindfulness, relaxation, yoga, breathing
•Educate constantly
•Reduce medications especially opiates
•Reduce the cost of the burden on patient and society
RESET YOUR BRAIN AND BODY
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NOT EVERYONE BENEFITS, BUT SOME DO
•KETAMINE INFUSION
•BIER BLOCKS -Veins stay empty, blood is exsanguated use blood
pressure cuff
•STEM CELLS-
•SCRAMBLER STIMULATION - with action potential stimulation-(Italian)
you confuse CNS uses 16 action potentials and continuously changes
•SYMPATHETIC BLOCKS
•SPINAL STIMULATION
Why Patients Don’t Get Well
Signs: abnormality of the normal homuncular organization of the representation in primary somatosensory cortex
◦ Chronic pain, intermittent and vague symptoms, control problems or somatosensory dysfunction may be early signs of
focal dystonia
◦ Treatment must consist of discriminative sensory motor skills
◦ Top down treatment is necessary GMIP
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TREATMENT SUCCESS•Bio-Psycho-Social Approach- educate on neuroscience
•Central and Peripheral Nervous system
•Nerve mobilizations but gentle
•Normalize movement- aerobic exercise
•Support the patient
•Refer out
