CRPS

[pablo]

I'm interested in what others think the prognosis for a patient I saw recently is.

33 y.o. female
2 young children
recently separated from husband
eight year history of CRPS left upper limb
symptoms mostly confined to ulnar nerve territory
multitude of treatments in the past, including all types of medical interventions known for CRPS, with a few exceptions
still has pain, sweating, swelling at times and colour change (not very obvious)
unable to fully extend 4th and 5th digits
poor wrist extension (flexion was OK)
unable to fully make a fist
afraid of physiotherapist through past negative experiences
imagined movement (making a fist, which woul have been painful if she did it) causes pain
using a mirror for visual feedback feels "confusing" and also increases pain
has an increase in symptoms on neual stratching (active only)
further medical intervention not planned at present
injury occurred at work, compensation issues settled (financial settlement did not lead to an improvement in symptoms)

What do you think you would do, and what chances of success do you think you would have based on that approach?

Pablo

[rolf]

Hi pablo!

What do you know of her way of thinking/emotions(anxciety,anger,deprsession etc).what is her type of personality ?
Coping strategies,fear avoidens?
Here seems to be some yellow flags!?
"affraid of physiotherapy"!?
Hands on dosent seem sto be the right approach in this case!
It seem slike hard nut to break!
Have you considered any cind of cognitiv therapy?do you know anytrhing about " automatic negative thoughts"?
Left side problems like this one, is to me ,often mainly due to emotinal stress!(negative way of thinking)
Just some thoughts!

RIN :wink: :wink: :wink:

[pablo]

Hi Rolf,

Fear avoidance doesn't seem to be an issue. She has done a lot of work to improve function in the hand. She has taught herself to type with flexed fingers, so that she flicks the keys rather than push down on them. She was injured at work and has retrained and returned to full-time employment.
Her coping strategies at resent are quite reasonable. She is optimistic that she can do something to improve her situation. She presented as very pleasant and approachable. She has done a fair bit of research into the condition and understands very well the effects of emotions and thinking on her symptoms. Stress is a significant aggravating factor, and she recognises this. She has godd skills in place to manage this.
I wouldn't go as far as saying that the problem is "mailnly due to emotional stress" as that theory lacks evidence, and not for lack of trying. I agree that there is an influence, though.
She is frustrated. She was also assessed by a psychologist. There is significant anxiety, and depression. I will not be treating these, however.
She will participate in a CBT program next year, led by a psychologist.

OK, so what would you do and what odds do you give it of working?

Pablo

[bernard]

Hi Pablo,

Good to see you there!

This woman makes some troubles with my thoughts.
CRPS is known (?) to be related with centralization processes. Some scientists suppose that expectations, negative thoughts and lifestyle may compromise a well being.

You're saying she is afraid of physiotherapy but you're a physiotherapist anyway. You want to reverse this belief and show her that it is a false idea. I'll try a soft approach with minimal hands-on time/duration. I'll focus on a simple relaxation induced for an example by abdominal breathing. It will help to be aware that breathing may produce some cool changes in herself. I often/always begin my sessions with this. I tell patient to try to feel a starting state and then (after breathing) help them to understand that the previous state may be changed in a better way with simple things they can do at home or elsewhere. It is a beginning of a self-change. You can insist on the fact that she done the job alone.

I may add some passive neuromobs over the wrist, 10/15 repeats without any kind of pain.

[nari]

What's happening in her cervical spine? palpation? ROM?

Eight years' history does not sound promising - but one never knows.

ULNT4 -ve on PROM; +ve on AROM...fear++ of movement.
(I'm thinking aloud here)
What would happen if she performed the active ULNT4 on the other side?

What happens if she does SLR(L) , (L)UL in neutral, +/- slight LF of neck to the (R)?

What happens if the wrist is extended passively with everything else in neutral?

Contracture at all on medial aspect of the palm? (due to loss of ext?)

Slump?

I know you wanted some answers, but I think some more digging around (figuratively) is needed??....

Rolf:

I know that the (R) hemisphere is under suspicion, but it is established that with central pain both hemispheres are pretty equally involved.


More later

Nari

[rolf]

Hi pablo!
If she has problems with abdominal breathing i would consentrate ,as bernard wrote,on this in the first place! and vcognitiv therapy if i considered it nesessary!
Looking at her pousture in standing and sitting is there any difference between the two sholders?
What about her body awareness?Is she able to relax any part of her body if you ask her to ?Does she elevate her shoulder girdle uncounesessly?What about her left m.scalenii compared to the right one?
How are her "tunnels"?Carpal,pronator,pectoralis min and scalenii ?
Does she bite her teeth or press her tounge without beeing aware of it?
RIN

[pablo]

Lots of questions!

I did not do any palpation, and I explained to her the reason: her previous experience with physiotherapy. She was appreciative of that. Likewise, I did not do any ULNT or SLR or any other test which required me to place my hands on the patient. What am I, some kind of sadist?!? She saw a fellow member of staff after seeing me (a nurse, who also did not do any palpation, etc.) and I know that after she saw me her pain had already increased considerably.

On active movements simulating ULNT's, she had an increase in pain. Her breathing I didn't assess, but I would suspect she has some difficulties. She is highly anxious. The significance of the left side vs the right is lost on me. She injured the left wrist, not because of any differential effect of the right brain on emotions, but because she had trauma to the left wrist. I suspect that if she had injured her right little toe she would have right sided symptoms.

I didn't get the impression that fear of movement was an issue. She has done a lot of movemets and exercises and has shown determination in the past.

Does she clench her teeth? No idea. She probably does. She did not report an ncrease in pain when just talking to me, so I don't suspect jaw movement per se has much influence here. Her voice was fine, not strained. She cried later, but not when I saw her. Does she elevate the shoulder unconsciously? I admit I was paying more attention to her story than other factors, but she moved her left arm and shoulder freely.

Contractures? I don't know. She could achieve almost full passive extension of the fingers when she did this herself. Wrist extension was very limited, and I didn't test passively.

I don't think passive anything would help. Just a hunch, and previous experience with similar patients has dampened my enthusiasm for hands-on work. She has an unpleasant past history. I have only managed to make such patients worse in the past with hands-on passive approaches. I now take that into account. I don't need her fear of physio to be reinforced.

Imagined movements caused increase pain. I don't think what her muscles are doing, or what position her joints are in, matter very much at this stage.

Anyone seen this report?

Moseley GL. Imagined movements cause pain and swelling in a patient with complex regional pain syndrome. Neurology 62, May (1of 2) 2004, page 1644.

Pablo

[nari]

Ooops...

sorry

nari

[pablo]

Sorry, not having a good day today.

Pablo

[nari]

That's OK


Nari

[bernard]

Hi All,

Anyone seen this report?

Moseley GL. Imagined movements cause pain and swelling in a patient with complex regional pain syndrome. Neurology 62, May (1of 2) 2004, page 1644.

Not for the moment, none abstract is available but many related papers are, so I'll take a look at these ones.

I clearly understand your position with the patient and sometimes we are in front of a door and we know something about the room behind it, but the room remains strange and it seems quite preferable to stay in our comfortable place which was polished and arranged over years.

When we're facing with a patient who do not want physiotherapy for many reasons/beliefs, we haven't several alternatives in our hands/skills. Our physical approach is our major one but it may fail in that case => the patient is already rejecting it!

The second way is more psychological and one must admit that our knowledge is a bit thin when we leave the university. We have to make it bigger with long years of practice and post-uni trainings.

My uncle was a general practitioner and I ever respected his clinical skills. He ever amazed me. Since he is retired, we had time to push discussion about this mystery.

'Here my nephew, listening is often the key of a good diagnose, the exams will only confirm your intuition. But your intuition is nothing more than a good examination and listening. While patients are telling their stories, listen to their voices and gesture. Listen to the body and search what is going wrong...'

So Pablo, you are on the right track, and I was saying that it was a good thing to stay aside of her, helping the woman discovering that a body is also obeying to brain.

[pablo]

Long time since I posted!
I have seen the patient in question a couple more times, in the context of a pain management program. My input into the program was to include some education about pain neurophysiology. Then the plan was to follow this up with some appropriate graded exposure, starting with imagined movements, then progressing to mirror work, and gradually progressing to graded exposure of previously painful activities. We even made an appointment, but the patient cancelled it! I didn't get my chance to play!

However...

I saw young girl (about 17) with acute onset CRPS after a wrist strain. Initially referred from the emergency department to physiotherapy, with a diagnosis of "wrist injury" and querying carpal tunnel syndrome. It was impossible to assess her as she was very distressed and had allodynia and hyperpathia. Everything hurt. Seeing the other hand move in a mirror also hurt! Then a good explanation and three sessions of graded mirror exercises, and she is back at work! She has not kept her last appointment and has not returned despite me chasing this up, so I have assumed that she no longer feels she needs treatment. I was hoping a similar approach with the patient in question, but have not had the chance to try it!

Pablo

[nari]

Pablo

As the 17 yo did not return, can you assume that your pain education was the main factor in her improvement? Did she respond well to each of the mirror exercises/movements with significant and progressive improvement each time, or did she plateau towards the end of the third session?

It would have been good if she had returned to give this feedback!


Nari

[pablo]

I have tried to get her to come back but she is not returning my calls! Maybe she thought I was crazy and decided to avoid physiotherapy altogether.

When I first saw her it was with a couple of students. Their first patient for the unit, no less! She was in extreme distress, couldn't move the hand, couldn't be tested passively bacause of pain, light touch with a tissue caused pain, she had non-anatomical (in terms of dermatomes or peripheral nerve distribution) pain, of a type consistent with CRPS. She also had some colour changes and her hand was much colder than the other. Spontaneous pain extending from the hand to the shoulder. I figured it was CRPS, I hope I was right!

On her first session, I took her to the emergency department and spoke to the doctor there, and suggetsed an X-ray to rule out bony pathology. These were normal as I had suspected, but I felt it was quite reassuring for the patient. The doctors were also kind enough to give her some stronger analgesic medication than at the initial visit, and supplemented this with Naprosyn. From then on the pain started to ease. We also used a tubular elastic bandage.

The next session was all about education and testing, and reassurance. We also started mirror exercises. It was amazing to see the range of pain-free motion of the affected arm increase as she watched an image of the other hand in the mirror. She was able to make a fist and move her wrist quite a lot after only a few minutes, all without increasing her pain. She was sent home with instructions to practice more of the same at home.

The third session was the same, with further progress. She was going to put ina a worker's compensation claim but was able to return to work after that. I know she was managing at work because whenever I called her her parents said she was at work and back to her usual activities. And that she was busy doing teenager stuff so they didn't see much of her! I took the fact that she didn't follow up with treatment to be a good sign in this case. She cencelled her last booked appointment because she was at work.

I was hoping to present it as a case study, so I was hoping to see her at least one more time for review...

Pablo

[nari]

Sounds great - hope the students were suitably impressed, too. Good learning experience; they won't forget about mirrors now....

You should do a case study. Other PTs need to know about the wonderful world of mirrors........

nari

[pablo]

The message is getting there! A colleague at work is treating a patient who underwent a nerve graft (sural nerve) to treat a brachial plexus injury. So far has had very good results, and is recovering some control of almost all muscle groups. Mind you, only a slight flicker in deltoids and triceps, but this actually imprved during testing. And based on some discussion about the hypothetical use of mirror therapy, the patieng has incorporated this into his daily routine, as well as some mental practice. Pain has not been a major issue, although he has the occasional burning pain in his arm this doesn't last long. He is also doing some mental practice to supplement his mirror exercises. I will hear more about this case, no doubt!

I just managed to ride home in record time! (under 35 minutes from the hospital side of Yamba drive to my door). I was quite proud of that, I thought I'd share it!

Pablo

[nari]

Good work on mirror osmosis.

Sounds like great going on the bike but you will have lost the nonACT folk!

You may have had a tailwind - funny weather this afternoon with the smoke cumulus cloud.

nari

[pablo]

No, I swear it was all self propulsion! But you are probably right, it was probably a tail wind. I just slouched imperceptibly with the realisation that you were probably right.

[nari]

Nah...let's call it self propulsion, perhaps imperceptibly assisted by a smoke-enhanced tailwind.

[pablo]

Yeah, that feels better already! :D

[emad]

Hi Pab:

Good work .Well done .

Why do you use the non affected in mirro ex , after she got confidence Did not you perform on the affected mirroring ?


Regards

Emad