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Hand Therapy; Complex Regional Pain Syndrome

A Guide for Student Occupational Therapists; raising awareness and mirror therapy
by

Becky Robertson-Bown

on 17 June 2013

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Transcript of Hand Therapy; Complex Regional Pain Syndrome

Complex Regional Pain Syndrome
By Becky Robertson-Bown
Occupational Therapy Level 5
A Guide For Student Occupational Therapists
What is CRPS?
Impact on
Function

Assessments & Outcome-measures
Interventions
Severe, unrelenting, disproportionate pain
Causes
Symptoms
Usually occurs after an injury or operation
Type 1;
no nerve injury
Type 2;
nerve injury
However, it is unknown exactly why this happens
Linked to the pain matrix
Pro-longed pain alters antinociception mechanisms
Disruption between motor planning and sensory feedback pathways
Between 5.4 - 26.2 per 100,000 will have CRPS
Upper limb is twice as likely to be affected
Women more likely to be affected than men
It can occur in any age
Changes to peripheral and central nervous systems
Vasomotor
Oedema
Motor
Inflammation
Sensory
Temperature
Colour
Hair growth
Hyperalgesia
Allodynia
Hyperesthesia
Guarding
Neglect
Avoidance
Distress
Depression
Anxiety
Loss of roles
and identity
Pain
Observation
Visual analogue
pain scale
Multi-disciplinary Approach
Medical
Physical
Sensation
Two-point discrimination test
Oedema
Figure-8 measurement
Volumeter
Range of
movement
Goniometer
Functioning
Observation
Activity analysis
Coordination
Dexterity
Proprioception
Functional
Psychological
Early intervention is paramount
Restore function
Avoid contractures and atrophy
Desensitisation
Neural retraining of sensory pathways
Graded stereognosis
Dystonia
Pain
Burning
Electric
Barbed-wire
Challenges relationships
Cognitive
Behavioural Therapy
Coping strategies
Relaxation training
Splinting
Can inhibit recovery
Should only be used for chronic CRPS
Education
Support
Advice
Planning
Prioritising
Pacing
Shooting
Key Resources
HUGE, V. et al. (2011). Complex interaction of sensory and motor signs and symptoms in chronic CRPS. PLOS ONE, 6 (4), 1-13.

MCCABE, C. et al. (2003). A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology, 42, 97-101.

MOS, M. et al. (2007). The incidence of complex regional pain syndrome: a population based survey. Pain, 129, 12-20.

MOSELEY, G. (2004). Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain, 108, 192-8.

MOSELEY, G. et al. (2008). Thinking about movement hurts: the effect of motor imagery on pain and swelling in people with chronic arm pain. American College of Rheumatology, 59 (5), 623-31.

MOSELEY, G. and WIECH, K. (2009). The effect of tactile discrimination training is enhanced when patients watch the reflected image of their unaffected limb during training. Pain, 144 (3), 314-19.

NATUSCH, D. (2012). Complex regional pain syndrome. Orthopaedics and trauma, 26 (6), 405-9.

ROYAL COLLEGE OF PHYSICIANS (2012). Complex regional pain syndrome in adults: UK guidelines for diagnosis, referral management in primary and secondary care. London, Royal College of Physicians.

SANDORINI, P. et al. (2003). Complex regional pain syndrome type 1: incidence and prevalence in Olmstead county: a population based survey. Pain, 103, 199-207.

TURNER-STOKES, L. and GOEBEL, A. (2011). Complex regional pain syndrome in adults: concise guidance. Clinical Medicine, 11, 596-600.
Follow-up sessions to ensure results are long-lasting
Goals
Disabilities of the Arm Shoulder and Hand (DASH)
Canadian Outcome Performance Measure (COPM)
It is a neurological condition
NOT
a psychological condition
Chronic CRPS
Imagined imagery can activate primary motor area
Challenge neglect
Mirror Therapy
Severely affects occupational performance
Attention
Concentration
Sleep
Alienated
Powerless
The importance of rapport
Patient experiences and narratives
Activities of daily living
Leisure
Productivity
Antinocicpetion Mechanism
Controls pain suppression
Heightened pain
Normal sensations are painful
Sensitive skin
50% will develop long-term symptoms
Measure perceived pain levels
Measure changes in hand functioning and somatosensory ability
Stereognosis
Measure changes in swelling
Dynomometer
Measure changes in movement and function
Strength
Quantifiable
Evaluation
Evidence-based practice
Effectiveness
Decreases pain
Increases range of motion
Improve somatosensory ability
Reconcile motor output and sensory feedback
By utilising visual feedback
Manipulate meaningful objects
Occupation-based
Patient facilitation at home
Opens-up practice constraint boundaries
First developed by Ramachandran
Effective treatment for stroke and phantom limb pain
Can incorporate tactile discrimination training and stereognosis
Hand Therapy Groups
Intense
Peer-support
Self-esteem
Empowerment
Motivation
Usually affects localised areas of the limbs
However, some patients report pain across their whole bodies
Causing damage to the peripheral and central nervous system
It can occur without trauma
Shiny
Swollen
Contractures
Colour change
However, emerging research suggests that Type 1 could also involve nerve injuries
There have only been two studies which have explored the prevalence of CRPS
Symptoms are split into
Fire-works
Some people have had the condition for 10 years
Thick finger-nails
Hair growth
Identify personalised goals and meaningful interventions
The patient can practice this at home
Touching different textures, shapes and objects on the hand
Prevent contractures,
provide pain relief and
maintain functional position
Reflect the unaffected arm onto the painful arm
Important for the patient to maintain a good position and posture
Remove all jewellery and watches
Place a mirror vertically down the mid-plane of the body
The painful arm is covered
Disordered movement caused by repetitive muscle contractions, twisting movements and abnormal posture
Dystonia
Wearing jewellery and clothing can be unbearable
Bathing can be agonising
It can impact upon everything
Identify treatment priorities
Watches should be removed
Focus on the reflected hand
Manipulate something meaningful
Mirror placed centrally
Client-centred
Enables further rehabilitation opportunities
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