CRPS 20 year history

Hi all,

I'v just had a patient present to me with CRPS on L side distal to the elbow. She has had this since 1988 - no injury, gradual onset through her work. in the 80's in NZ we didn't know much about CRPS aparently - she described the therapies she has received and they all seemed inappropriate to me. I'm contacting pain teams etc to try and get her some specialist treatment for her medications because she isn't on appropriate meds at present.

In the mean time what should I be trying - ultrasound causes her intense pain, I cannot touch the area or ask her to move it without alot of pain. I have her coming next week and I intend to work on her neck and see wether I can make a difference by mobilising there. I set up a mirror and spoke to her about mirror therapy today - she'd never heard of it, and liked the sound of it. So we did 10 minutes of it - she's sore now. I'm not surprised by this, but was bluffing my way through mirror therapy as haven't used it before.

Any advice?, any articles - I'm already researching and have read the ones mentioned under the other crps tags. Specifically any info about mirror therapy and how to perform it and not over do it etc.

Cheers

Try mirrorboxtherapy.com there are links to videos ect. or search youtube "mirror box therapy" Mirror therapy do not work for everyone but there is lots of medical evidence backing it up.
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Mirror Box Therapy is a therapy and like all therapies dose not always show immediate results. We note that you used the mirror box only once, with regular exercise and probably more important, the believe you can do it; the mirror box is one way towards recovery. The mirror box should be used as often and for as long as it is comfortable, but not turn it into a chore.

for lots of information have a look at:

Neuro Orthopaedic Institute, Noigroup Publications, Movement and education for pain, stress and performance

esther

Those are awesome referances, I checked out NOI group and found some fantastic video's with dave butler and laurimer mosely. so thanks for that.
I'v contacted a anathetist i know, and a few other physios who have sent me some fantastic research. I'll read it and post it if any of it is super good.

Apart from mirror box, US, joint mobs. anyone have another other ideas?

pleased to help....:D

The one thing that always worked well for me was bindegewebsmassage on the lower back area especially. (whatever and wherever the pain was)
The last 10-15 years I have used the oberflächige technique only , which is a very soft skin"scratch and it has worked very well for me.

You do need to know how though.....

Esther

Sounds very interesting... I'm unaware of anyone nearby that does that sort of massage to show me so I could experiment and research and see how I go.
The hand therapists have spoken to me about doing sesory input and slowly building it up, which i suspect sounds like it would work in a similar way. thanks for your input esther.

I'd glad for any and all suggestions, keep em coming.
Cheers

Think skin and autonomous nerve system.

For even more "nerve tickling" information go to
somasimple: the so simple body, a place for physical therapy (start with the discussion list) and become an active member of this group. Especially read everything concerning DNM by Diana who developed a skin stretch method.

As far as bindegewebsmassage is concerned, if you are going to do some skin kind of skin stimulation....
1, stay away from the affected limb,
2. only work on the lower trunk,
is my best advice

Esther

why avoid the affected limb and only go with lower trunk?

thanks

I will see if I can find some articles on the subject of BGM. We are in the middel of forming a special interest group.
This method is nothing like the normal massage of the connective tissue.
It consists of assessing the skin and organ zones. I'm sorry I cannot begin to tell you everything about how and why, this type of massage has to be learned hands-on.

Treatment always starts in the lumbar region, the influence is greatest there.
I will get back on this subject, cannot do so at the moment, am going off, have to teach this weekend.

Esther

Thanks esther, it sounds very intesting. If you do post articles and info about it lets make it it's own thread so people will be able to find it easier - sounds like it could be good information for the masses.

Have fun teaching this weekend.

Here is the research I have managed to accumulate regarding CRPS. The best evidence at the moment appears to be towards a Graded Motor Imagery program. I would suggest going to www.noigroup.com to see the video of david butler presenting a GMI lecture.

All the best to you all.

pudding bowl, why you term this clinical case as a relfex sympathetic dystrophy?? (in my country we call thet Sudeck syndrome!:D).....I believe the patientu mentioned has a possible history of neck pain which in fact start referring in the arm....And if u say that it is 20 years now is a definite CHRONIC PAIN status...Where exactly u conclude that it is CRPS??? Has your patient any history of injury???? As i see no....And besides this syndrome is establishing quickly after an injury there are some tell-tale symptoms which alert the clinician about sympathetic system involvement, which u didnt mention if there are at all, like sweating,increased temperature in skin etc.
Because your patient is in a CHRONICITY u should embark on self-therapy management with some form of exercises, not rely only on passive modalities....Remember that a chronic patient is in a vicious cycle of "kinesiophobia" that makes him more and more disabled resulting in more pain onwards

Thanks for your post... She definately has CRPS - the glossy skin appearance, difference in temperature, the pain out of proportion to the initial event (OOS with typing), the swelling after even the most mildly active movements is extreme hense why I'v gone with the GMI stuff. She isn't actually too kineseophobic - she continued to work and has never really given the limb a chance to be passive... she's a bit of a workaholic!

Thats my fault for not fully giving a patient history... thanks for your reply.
You raise a valid point though and I will look at her neck, it's something I haven't done, and as you never know it may be a neck based problem that i'v missed. thanks again.

yep.....This is the Cyriax's heritage mate.....Always check the spine on a peripheral joint problem because the first can easily refer pain
Some beliefs like above are so strong even though that they are almost 30-40 years old.....:)
Take care anyway

WOW - so I saw her 2 days ago and thought, ok lets do the spinal thing!
She was so positive - really painful with gentle mobilisations of the neck
She just came to see me and said after leaving she had to go home and have a diazepam because the pain was so bad and her sister feared she was having a stroke. She won't let me mobilise her spine again... but it shows there was a huge spinal component to her pain.

it had happened that to me mate too....I was moblising a 75 year male's neck (NO MANIPULATION i swear loool:D) and 1 day after the session he had Vertebral artery signs like blurred vision,dizziness and drop attacks....I t was a huge pitfall for me, because when i first took his history he denied any symptoms like that in the past....Then i thought,that we really must be cautious when we "generate" FORCES(simple mobilisation and overpressures to manipulation and thrusts) to the patient....Its always better for the patient to start with his own FORCES (self-mobilisation), and then consider further progression

Yea, I mean it was all just assessment grade 2 to 3 to feel the movement, I didn't work on any of the levels because I figured she'd be quite sore and wouldn't take it well. how annoying though... I finish this job tomorow so I suppose I don't have to worry about it anymore, but would love to be able to dig into the Tx and see if we could make a difference. One of my favourite parts of my job is when people come in with 20 year history's and you rapidly improve them (usually it's McKenzie principals that acheieve this though).

dear Puddingbowl,


Still thinking autonomic nerves, I would say it is possible you have irritated the vagal nerve in your enthousiasm.
I will get back to how to treat patients with this bindegewebsmassage in a while.
Still afraid you cannot learn this online though.
AND I am an old bird, and Cyriax trained but NEVER EVER do I mobilise or passively "treat" the cervical spine anymore;certainly not using the old Cyriax´s "techniques".

Esther

yep, even though u cant see so easily "centralisation" phenomena in Chronic PAtients...But i dont really think that McKenzie method works a lot because of "disc pathology"....If u estimate that over 30-40 per cent of spinal mechanical pain is from FACETS (there is an up-to-date study on that...) and in clinic we see the majority of patients to responding well in McKenzie priniciples, i firmly believe that u DONT moblise only a disc, even though that u will see both symptomatic-mechanical improvement and of course CENTRANISATION...It is much more than this

Yes theres no doubt doing McKenzie exercises works far more than just a disc... The theoretical model is great for explaining to patients but doesn't satisfy me as I'm aware of all the other structures that we affect during the movements.

Esther - What do you feel is the best way to assess and treat the neck, how do you mobilise the joints? - I'd appreciate your thoughts, as I feel I should be better at this.

dear Quorthon,

Would you be so kind as to tell us which study you are referring to?.... we can look it up.....

dear Puddingbowl,
If anything, I do skin "stretching" (DNM) or the slightest of intermittent piccolo traction. This as an instrument to let people feel what I mean by stretching their necks. Personally I prefer teaching patients how to put their spine back into its (their own) normal position and letting them feel this helps a lot and often relieves a lot of the pain; the slighter the touch, the better the reaction.
The exercises you advocate are too "general" for me.
Look up the forum somasimple: the so simple body, a place for physical therapy for more info on the DNM
I wouldn´t be surprised if you really like what you see there....:D
lots of discussion and critical collegeaus sharing information.

Esther

of course i will be kind:) and the referrence from i was saying that are:
1) Prevalence of facet joint pain in chronic spinal p... [BMC Musculoskelet Disord. 2004] - PubMed result
2)Age-related prevalence of facet-joint involvement ... [Pain Physician. 2008] - PubMed result

The first article is the original survey collecting patients from ALL spine-related problems (instead on focusing on one particular area of the spine) and the second is a secondary-retrospective analysis of the first article...few studies compare simultaneously the 3 specific areas of the spine namely cervical,thoracic,lumbar....The only critisism on these studies is that there was no comparative evaluation of other possible pain-generated structures like the disc,through a discogram, and despite the authors have mentioned the FALSE-POSITIVE rate of a facet-joint block injection we cannot rule out other potential causes of pain....
The only safe conclusion is that CERVICAL SPINE has much more FACET- joint pain than LUMBAR SPINE and this is more obvious in younger ages which can be explained by the fact that Cervical disc is almost fibrosous by the age of early adulthood and not acting as its lumbar counterpart...Its my explanation why facet joint-pain is more often in neck area......
But we should never in clinical practice trying to diagnose patients as "discogenic" ,"facet-joint" pain or whatever....When u get patients in a self-mobilisation programm (adding clinician forces where NECESSARY, see one of my older posts,where i didnt follow this LAW,not just a rule) u surely get good results,no matter if the pain comes from disc,facet,ligaments and muscles!!!

Thank you both for your replies thats fantastic of you to take the time to educate me :)
quorthon - Thanks for the articles, and I'm with you... I'v always believed that the mckenzie exercises don't act on 1 area but if they work then I'm all for them, and following the force progression pathway is a brilliant way to keep it safe.

esther - Your a wealth of information. I will look at the somasimple website thanks for that link. I searched for intermittant piccollo traction and couldn't find anything - do you have a link for that. And by teaching people to put their own spine back into place are you referring to posture exercises that are unique to the patient? how do you acheieve this?

Thanks to you both.

i must admit though that it seems a little bizarre to me the phrase "put their own spine back"....By NO generated applied forces could this possibly happen, especially if the patients tries so...i agree that the patient should have control of his situation but there are more efficient ways to do so.....