BodyinMind.org. CRPS symposium June 2011

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1 BodyinMind.org CRPS symposium June 2011

2 Acute injury rehabilitation Chronic pain management Acute injury CRPS Chronic pain Injury 6 weeks 3 months Convention

3 Acute injury rehabilitation Chronic pain management Orthopaedic Rest Physiotherapy First line analgesia CRPS CBT pain program Spinal cord stimulator Brain stimulation Amputation Analgesia pump Injury 6 weeks 3 months Convention

4 1. Pharmacological Acute injury CRPS 6 weeks 3 months Current concepts

5 Anti-inflammatories Effective! O2 scavengers (dimethyl sulfoxide and N-acetylcysteine)! Goris et al (B); Geertzen et al (B);! Zuurmond et al (B); Perez et al 2003 (A2)! [level 2]!! Biphosphonates (clodronate and aledronate)! Forouzanfar et al (A1); Manicourt et al 2004 (A2) [level1]! 1.Pharmacological Acute injury CRPS Probably or definitely ineffective! Mannitol! Smeets et al (D) [level 4]!! Capsaicin! Expert opinion (D) [level 4]!! Calcitonin! Kingery et al (A1); Perez et al (A1); Forouzanfar et al (A1) van den Berg et al (A1) [level 1]! 6 weeks 3 months

6 Analgesics Effective! Ketamine iv?! Correl et al (C) [level 3]!!!!!!!!! Gabapentine! Serpell et al (B); van de Vusse et al (B) [level 2]! 1.Pharmacological Acute injury CRPS Probably or definitely ineffective! WHO ladder! Connely et al (C); Harke et al (B); Azad et al (C) Expert opinion (D)!![level 3-4]!!!!!! Local anaesthetics! Price et al (B); Azad et al (C); Cooper et al (C) [level 3]!! other anti-epileptics! Expert opinion (D) [level 4]!! 6 weeks 3 months

7 Vasodilatation therapies Effective! Ketanserin (serotonin receptor antagonist)! Kingery et al (A1); Hanna et al (B); Hord et al (B) [level 1]!! Not effective! Intravenous sympathetic blockade! Kingery et al, 1999 (A1); Forouzanfar et al (A1); Perez et al (A1) [level 1]!!! 1.Pharmacological Acute injury CRPS 6 weeks 3 months

8 2. Rehabilitation of chronic CRPS Acute injury CRPS Chronic pain 6 weeks 3 months Current concepts

9 Medical therapies Effective! Spinal cord stimulator (-2/10 pain; NNT for 50% decrease = 4.5)! Taylor et al 2006 (B)! Acute injury CRPS 6 weeks 3 months Rehabilitation Probably or definitely ineffective! WHO ladder! Connely et al (C); Harke et al (B); Azad et al (C) Expert opinion (D)!![level 3-4]!!!!! Ketamine infusion! Ralph-Thomas et al 2008 (C); Goldberg et al 2005 (C) [level 3]!! Local anaesthetics! Price et al (B); Azad et al (C); Cooper et al (C) [level 3]!! other anti-epileptics! Expert opinion (D) [level 4]!!

10 Non-medical therapies Effective!? CBT multidisciplinary pain management! Morley et al 1999; Guidelines Netherlands, UK, USA [level 3/4]!! Graded motor imagery! Moseley 2004 (B); Moseley 2005 (B); Moseley 2006 (A)! [level 1b]! Tactile discrimination training Moseley 2008 (C); Moseley 2009 (B) [level 3] Rehabilitation Probably or definitely ineffective! Scrub & carry! Forouzanfar et al. 2003; Daly 2008; Perez et al [level 3]!! Systematic desensitisation! Forouzanfar et al. 2003; Daly 2008; Marinus 2004 [evel 2]! Acute injury CRPS 6 weeks 3 months

11 Disinhibition & facilitation Based on idea that disinhibition & facilitation are problems and the observation that imagined movements can increase symptoms (Moseley et al Arth Care Res 2007) M1 neurons These are the ones you want to fire Movement

12 Disinhibition & facilitation M1 neurons Neurons in pain matrix These are the ones you want to fire This is what happens in a sensitised/disinhibited state... Pain Movement

13 Disinhibition & facilitation Using implicit motor imagery to promote inhibition & get under the radar Premotor M1 neurons neurons These are the ones you want to fire Subthreshold priming of target M1 cells L/R judgments of body parts

14 Graded motor imagery 1. Implicit motor imagery (left/right judgement task) Moseley (2004) Pain; 108: 192-8; Moseley (2005) Pain 114;54-61 Moseley (2006) Neurology

15 Is this a left or a right hand? One image is shown at a time Software is online and via CD Recognise Objectives: - Equal reaction times for left & right - >80% accuracy

16 Graded motor imagery Implicit motor imagery (left/right judgement task) Explicit motor imagery (imagined movements) Moseley (2004) Pain; 108: 192-8; Moseley (2005) Pain 114;54-61 Moseley (2006) Neurology

Imagined limb movements One image is shown at a time Software is online and via CD Recognise www.noigroup.

17 Imagined limb movements One image is shown at a time Software is online and via CD Recognise Imagine adopting this posture with your own hand and then returning it to where it is. Imagine a pain-free, smooth movement. Objectives: - Little or no symptom provocation - Task is easy or boring

18 Graded motor imagery Implicit motor imagery (left/right judgement task) Explicit motor imagery (imagined movements) Mirror movements Moseley (2004) Pain; 108: 192-8; Moseley (2005) Pain 114;54-61 Moseley (2006) Neurology

Objectives: - Little or no symptom provocation - Movement is not

19 Mirror movements Gently adopt the posture shown with both hands, while watching the mirror image of your good hand. Objectives: - Little or no symptom provocation - Movement is not dystonic - Movement L & R similar in range and speed - Task is easy or boring

20 Single blind RCT MIP MIP 50 Neuropathic pain scale Crossed over Moseley(2004) Pain; 108: 192-8; Time (weeks)

21 CRPS of arm or leg years old No other diagnoses English-proficient Presented to GP, physiotherapy, Pain management or neurology Single blind RCT Moseley (2006) Neurology

22 Moseley (2006) Neurology Single blind RCT

23 Single blind RCT NNT to get a 50% reduction in pain Post-MIP = 3 (2-6) 6 months = 2 (1-5) NNT to get a 4/10 point increase in function Post-MIP = 4 (2-11) Moseley (2006) Neurology months = 3 (2-4)

24 Cognitive representation Sensory representation Motor representation Space Meaning Mood Explain pain Identify threats Nullify Gradually reexpose Sensory discrimination Graded motor imagery?motor discrimination? The future

25 Flor et al 2001 Lancet RCT Discriminate location & intensity between stimuli

26 Flor et al 2001 Lancet RCT Discriminate location & intensity between stimuli

27 Flor et al 2001 Lancet RCT Discriminate location & intensity between stimuli

28 Flor et al 2001 Lancet RCT Discriminate location & intensity between stimuli

29 Flor et al 2001 Lancet RCT Discriminate location & intensity between stimuli

30 Flor et al 2001 Lancet RCT Discriminate location & intensity between stimuli

31 Flor et al 2001 Lancet RCT Discriminate location & intensity between stimuli

32 Flor et al 2001 Lancet RCT Discriminate location & intensity between stimuli

33 Flor et al 2001 Lancet RCT Discriminate location & intensity between stimuli

34 Flor et al 2001 Lancet RCT Discriminate location & intensity between stimuli D

35 Flor et al 2001 Lancet RCT 6 Discriminate location & intensity between stimuli Phantom limb pain Pre Post 0 40 D 0 D

36 A. Stimulation Probes NO ATTENTION Screen mm 11 mm Stimulation sites Affected part ATTENTION Photograph of affected part, with stimulation sites marked. Moseley et al 2008 Pain 137(3) 600-8

37 8 Pain NRS TPD mm Screen NO ATTENTIO ATTENTION Task-specific NRS Wait No attention Attention Review Moseley et al 2008 Pain 137(3) 600-8

38 Tactile acuity Enhancing tactile acuity by seeing the skin Synchronous visual input of tactile stimulus Primary somatosensory cortex (S1) Thalamus Visual cortex cells Tactile input

39 Taylor-Clarke et al 2002 Curr Biol

40 Tactile acuity Spatial attention Attending to the location Primary somatosensory cortex (S1) Multisensory areas parietal cortex Thalamus Tactile input

41 Moseley & Wiech 2009 Pain 144(3) 314-9

42 Moseley & Wiech 2009 Pain 144(3) Two sessions of this per day for two weeks, reduced pain, increased tactile acuity and function.

43 Moseley & Wiech 2009 Pain 144(3) We hypothesise that one session of this will be better.

44 Moseley & Wiech 2009 Pain 144(3) 314-9

45 Fear exposure therapy replicated cases De Jong et al 2005 Pain

46 Walking for feet Radboud for arms 0 Radboud Pain exposure- Evidence from audit data 40 Radboud 3 4 month follow-up t =? N = 109 Ek et al 2009 Clinical Rehabilitation

47 Walking for feet Radboud for arms Evidence from audit data 0 Radboud 150 minutes walking 40 Radboud 0 minutes walking 3 4 month follow-up t =? N = 109 Ek et al 2009 Clinical Rehabilitation

48 Walking for feet Radboud for arms Evidence from audit data 0 Radboud 150 minutes walking pain Radboud 0 minutes walking pain month follow-up t =? N = 109 Ek et al 2009 Clinical Rehabilitation

49 Walking for feet Radboud for arms Evidence from audit data 0 Radboud 150 minutes walking pain Radboud 0 minutes walking pain month follow-up t =? N = 109 Ek et al 2009 Clinical Rehabilitation

50 Excellent Evidence base for rehab approaches Good Limited GMI Tactile training Fear exposure Mirror therapy Pain exposure therapy None Stress loading, scrub &carry Hydrotherapy, TENS (!), splints etc.

51 bodyinmind.org

Stanmore Therapy Service Approach to Management of Phantom Pain in the Post-operative Phase

Stanmore Therapy Service Approach to Management of Phantom Pain in the Post-operative Phase Jennifer Fulton Physiotherapy Clinical Specialist in Amputee Rehabilitation PHANTOM LIMB PHENOMENON Truly it