MANAGEMENT OF CRPS Paradoxical Hypoaesthetic Skin, Painful to Touch: A Target to relieve Neuropathic Pain Spicher, C.J. et al. (2010) Paris: Sauramps medical Paradoxical Hypoaesthetic Skin, Painful to Touch Hypersensibility NEUROMA Hypoaesthetic SKIN HyperSENSIBILITY Claude Spicher, BSc OT, Swiss certified HT, Editor in Chief University Scientific Collaborator Director, 2011 Combined Meeting of CSSH & CSHT - Vancouver 1 2 Brachial Neuralgia n = 81 patients 81 Patients CRPS type II n = 126 patients 126 patients 41 Patients 50 % 40 Patients 50 % 49 patients 39 % 77 patients 61 % Hypoaesthetic Painful to touch Hypoaesthetic Painful to touch Spicher (European Vol. 2008) - J Hand Surg, 33E (suppl. 1), 201-202 3 CRPS-SYMPOSIUM - MÜNCHEN, 19 th of September 2009 4 CONTENTS Introduction Neuropathic Pain Definitions Testing Rehabilitation Pain arising as a direct consequence of a lesion or disease affecting the somatosensory system. Conclusion Mechanisms 5 Treede et al. (2007) -Eur J Pain, (2008) - Neurology 6 1
Mechanical Hyperaesthetic Neuropathic Pain Painful to touch When a non-noxious stimulus causes Pain due to a stimulus the sensation of pain which does not normally provoke pain the area will be termed hyperaesthetic. Noordenbos Merskey (1959) & Bogduk Pain. (1979, Amsterdam: 1994) IASP Elsevier 7 Spicher (2011) - e- News for Somotosens Rehab 8(1) 8 CONTENTS Definitions Introduction Anamnesis 1 st session: 23 rd of February 2010 Testing Rehabilitation Mechanisms Conclusion 9 Mrs T., 56 year old female, Caucasian, house wife Status one month post osteosynthesis (distal radius fracture) Case Report (April 2011) CSHT & CSSH Vancouver 10 1 st session: 23 rd of February 2010 Throbbing 4, Flashing 5, Wrenching 4, Burning 5, Tingling 3, Heavy 4, Tender 3, Radiating 4, Numb 1, Pressing 5 Sub-total of sensory pains : 39 / 65 X 100 = 61 points : 1 st session 3 / 3 / 2010 Sub-total of affective pains : 14 / 35 X 100 = 39 points Total of pains: 39 + 14 = 53 points Case Report (April 2011) CSHT & CSSH Vancouver 11 Palmar cutaneous branch of ulnar nerve 12 2
MECHANICAL ALLODYNIA TESTING STIMULUS IMPORTANCE Pain due to a stimulus which does not normally provoke pain Stimulus Importance Pain Intensity Site of Stimulus Application 15 grams [ mark: 5.18 ] VAS 3 / 10 cm THIS IS THE VARIABLE 13 TO MAP Tenderness to touch 15 grams 1500 grams / cm 2 Spicher C.J. (2006) Handbook for Somatosens Rehab Painful Tenderness 4 kilograms 4000 grams / cm 2 / cm 2 Criteria of fibromyalgia (1990) Arthritis Rheum Palpable Tenderness 2 kilograms 2000 grams / cm 2 14 Neck / Shoulder Pain (2011) Pain Spicher (2006) Handbook for Somatosensory Rehabilitation CRPS of a priori Palmar cutaneous branch of ulnar nerve with mechanical allodynia 1 st session: 3 rd of March 2010 Throbbing 4, Flashing 5, Wrenching 4, Burning 5, Tingling 3, Heavy 4, Tender 3, Radiating 4, Numb 1, Pressing 5 Sub-total of sensory pains : 39 / 65 X 100 = 61 points Sub-total of affective pains : 14 / 35 X 100 = 39 points Total of pains: 39 + 14 = 53 points 15 Case Report (April 2011) CSHT & CSSH Vancouver 16 BURNING SENSATIOIN BOILING SENSATION 1 st session: 3 rd of March 2010 Throbbing 4, Flashing 5, Wrenching 4, Burning 5, Tingling 3, Heavy 4, Tender 3, Radiating 4, Numb 1, Pressing 5 Sub-total of sensory pains : 39 / 65 X 100 = 61 points Sub-total of affective pains : 14 / 35 X 100 = 39 points Total of pains: 39 + 14 = 53 points Palmar cutaneous branch of ulnar nerve 17 Case Report (April 2011) CSHT & CSSH Vancouver 18 3
RADIATING 1 st session: 3 rd of March 2010 Throbbing 4, Flashing 5, Wrenching 4, Burning 5, Tingling 3, Heavy 4, Tender 3, Radiating 4, Numb 1, Pressing 5 Sub-total of sensory pains : 39 / 65 X 100 = 61 points Sub-total of affective pains : 14 / 35 X 100 = 39 points Total of pains: 39 + 14 = 53 points Palmar cutaneous branch of ulnar nerve 19 Case Report (April 2011) CSHT & CSSH Vancouver 20 MECHANICAL CLINICAL EXAMINATION ALLODYNIA TESTING SIGNS Aesthesiography Allodynography Rainbow Pain Scale SYNDROMES Peripheral Neuropathic Pain Syndrome, Complex Regional Pain Syndrome type II With Hypoaesthesia (Stimulus Independent Pain) With Mechanical (Stimulus Evoked Pain) Spicher, Desfoux & Sprumont (2010) Atlas des territoires cutanés 21 Woolf & Manion (1999) Lancet 22 RAINBOW PAIN SCALE Rainbow Pain Scale V. A. S : 3 / 10 cm 8.7 grams 1.5 grams 3.6 23 Case Report (April 2011) CSHT & CSSH Vancouver 24 4
MECHANICAL ALLODYNIA PROGNOSIS: 1 st session MECHANICAL ALLODYNIA PROGNOSIS: 1 st session 60 60 Mea an Time (days) 50 40 30 20 49.9 33.7 23.1 15.8 Mea an Time (days) 50 40 30 20 49.9 33.7 23.1 15.8 10 10 0 0 1 2 3 4 5 Static mechanical-induced pain threshold 0 0 1 2 3 4 5 Static mechanical-induced pain threshold 1.5 g (n = 19). 3.6 g (n = 35). 8.7 g (n = 41). 15 g (n = 63) 1.5 g (n = 19). 3.6 g (n = 35). 8.7 g (n = 41). 15 g (n = 63) Spicher et al. (2008) Somato Mot Res 25 Spicher et al. (2009) e-news for Somatosens 26 Definitions Testing CONTENTS Introduction Conclusion Rehabilitation Mechanisms 27 MECHANICAL ALLODYNIA REHABILITATION Distant vibrotactile counter stimulation (DVCS) is at the opposite of desensitization. Objective: to progressively re-educate the patient to perceive a comfortable stimulus in a non-nociceptive manner on a territory more and more vast Tactile (at home): silk, alcantara leather, rabbit fur, Vibrotary (during therapy): Frequency 100 Hz, Amplitude 0.06mm Pharmacological: Lidocaïne (plaster or gel), Bipuvacaïne infiltration Spicher et al. (2008) Somato Mot Res 28 A Therapeutic Management b CRPS type II n = 126 patients 126 patients Distant Vibrotactile Counter Stimulation Rehabilitation of hyposensitivity 49 patients 39 % 77 patients 61 % Hypoaesthetic Mechanical Painful to touch 29 CRPS-SYMPOSIUM - MÜNCHEN, 19 th of September 2009 30 5
MECHANICAL ALLODYNIA REHABILITATION COMFORTABLE Distant Counter Stimulation on: Lower Work Zone 1 st session: 23 rd of February 2010 The proximal part of the territory of cutaneous distribution The territory of a «cousin» nerve and not a «neighbour» nerve The upper and/or lower segmentary level Noël & Spicher (2007) Eur Congres Paris 31 Case Report (April 2011) CSHT & CSSH Vancouver 32 MECHANICAL ALLODYNIA REHABILITATION Cousin Work Zone 2 nd session: 2 nd of March 2010 COMFORTABLE Distant Counter Stimulation on: The proximal part of the territory of cutaneous distribution The territory of a «cousin» nerve and not a «neighbour» nerve The upper and/or lower segmentary level Noël & Spicher (2007) Eur Congres Paris 33 Medial brachial cutaneous nerve territory 34 4 th session: 16 th of March 2010 5 th session: 29 th of March 2010 CRPS of CRPS of Palmar cutaneous branch of ulnar nerve 35 Palmar cutaneous branch of ulnar nerve 36 6
SECUNDARY AESTHESIOGRAPHY 5 th session Detection 0.7 gram 5 / 3 / 2010 DIAGNOSTIC TESTING OF AXONAL LESIONS CRPS of a posteriori Palmar cutaneous branch ulnar nerve with mechanical allodynia Detection VAS: 0.7 gram 3 / 10 cm 5 / 3 / 2010 CRPS of Palmar cutaneous branch of ulnar nerve 37 38 Paradoxical Hypoaesthetic Skin, Painful to Touch Aβ pain Devor (2009) Exp Brain Res is a paradoxical painful hypo-aesthesia Hypoaesthetic SKIN HyperSENSIBILITY 39 Spicher et al. (2008) Somatosensory & Motor Research 40 Throbbing 4, [0], Flashing 5 [0], Wrenching 4 [0], Burning 5 [0], Tingling 3 [0], Heavy 4 [0], Tender 3 [0], Radiating 4 [0], Numb 1 [0], Pressing 5 [1] Sub-total of sensory pains : 39 [1] / 65 X 100 = 61 points [0-3 points] Sub-total of affective pains : 14 [0] / 35 X 100 = 39 points [0 point] Total of pains: 39 [2] + 14 [0] = 53 points [2 points] PRE : 23 rd of February 2010 POST : 6 th of July 2010 41 Date t Sensory pains Affective pains Total of pains 23 rd of February 2010 13 th of April 2010 25 th of May 2010 15 th of June 2010 6 th of July 2010 t 0 14 to 61 pts. 0 to 39 pts. 8 to 53 pts. t 48 6 to 47 pts. 11 to 32 pts. 8to41pts. t 90 0 to 19 pts. 6 to 21 pts. 0 to 20 pts. t 111 0 to 8 pts. 0 to 11 pts 0 to 9 pts t 132 0 to 3 pts. 0 pt. 0 to 2 pts Case Report (April 2011) CSHT & CSSH Vancouver 42 7
Definitions Testing CONTENTS Introduction Conclusion Rehabilitation Mechanisms 43 Pathophysiology: Mechanisms ACTIVATION Transduction Transmission Use-dependent augmentation Autosensitization and Wind-up Altered gene regulation MODULATION Phosphorylation of receptors/ion channels Peripheral and Central Sensitization MODIFICATION Altered connectivity Persistent Pathological Wool & Salter (2000) Science Cell death 44 Pathophysiology: Mechanisms Dorsal Horn Activation Modulation Modification Woolf & Salter (2000) Science 45 46 Pathophysiology: Modification Pathophysiology: Mechanisms Activation Befo ore ter Af Modulation Modification Kohama et al. (2000) J Neurosci 47 Woolf & Salter (2000) Science 48 8
A Therapeutic Management b CONCLUSION Distant Vibrotactile Counter Stimulation Rehabilitation of hyposensitivity 49 50 CAUSALGIA - CRPS II CAUSALGIA - CRPS II There is an unanimity of opinion, that the injury is a partial one. ( ) The damage of the nerve is always partial. Noordenbos, W. (1959) - PAIN Problems pertaining to the transmission of nerve impulses which give rise to pain. Amsterdam: Elsevier 51 These causalgias were certainely major by the importance of the symptoms, but stemmed from minor neurological lesions. Mitchell, S.W. (1872) - Injuries of Nerves and their Consequences. Philadelphia: JB Lippincott Co 52 Tactile sensory abnormalities in patients with CRSP can basically be classified in two types: Therapists in Somatosensory Rehabilitation of Pain in the World n = 594 CRPS with Hypoaesthesia CRPS with Mechanical CRPS-SYMPOSIUM - MÜNCHEN, 19 th of September 2009 53 54 9