Complex Regional Pain Syndrome: Outcome Measures and ...

2021 Annual Ontario Chronic Pain Network Pediatric Virtual Education Workshop

Complex Regional Pain Syndrome: Outcome Measures

and Sensory InnovationsTara Packham, OTReg.(Ont), PhD

[email protected]

@TaraLPackham

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mailto:[email protected]

Presenter Disclosure

Presenter: Tara Packham

Relationships with commercial interests:

Grants/Research Support: none relevant to this talk

Speakers Bureau/Honoraria: American Society of Hand Therapists, Canadian Association of Occupational Therapists

Consulting Fees: none

Other: Publications with Elsevier and Springer Nature

This program has received financial support from the Ministry of Health and Long Term Care


Objectives

Measuring what matters

Plasticity in practice

Sensational suggestions


Complex Regional Pain Syndrome

May develop after injury (Type 1: formerly RSD) or be associated with a nerve injury (Type 2: formerly causalgia)

More often seen in upper limb and in women; increasing age and genetics may add to risk profile

(Bruehl, 2015)


May develop after injury (Type 1: formerly RSD) or be associated with a nerve injury (Type 2: formerly causalgia)

More often seen in lower limb and in girls; age and genetics may add to risk profile

(Mesaroli et al, 2019)


CRPS is characterized by disproportionate pain and: swelling and temperature changes

changes in colour and sweating

elevated sensory responses

changes in skin, hair growth, nails

weakness, incoordination, dystonia

changes in cortical representations

psychological features

Regional

not just local

Pain & other symptoms experienced throughout the affected limb

Sensory changes may not follow classic nerve distributions

Some persons will experience neuropathic pain features in other body regions … (Harden et al, 2013)

Pain

unpleasant sensory and emotional perception

Syndrome

a group of symptoms

Complex

mechanisms implicated

Mechanistic cascade (Gierthmühlen et al, 2014)

Increased circulating stress hormones (sensitive/irritable systems)

Focal osteopenia (bone loss)

Consequences of immobilization (muscle loss)

Body perception disturbance (limb feels foreign)

Dystonia (muscle cramps/spasms)

Inflammatory signs (colour, temperature, swelling)

Hyperalgesia, allodynia, spontaneous pain (hypersensitivity)

Kinesiophobia, guarding, altered movement patterns (fear of movement, freezing, motor extinction)

CRPS is NOT Chronic Regional Pain Syndrome because of PLASTICITY

If maladaptive plasticity and altered perception are core to our understanding of the symptom mechanisms…

…then adaptive plasticity (including graded stimuli and response training) should reduce symptoms by normalizing the perceptions

(Moseley & Flor, 2012; Mansour et al, 2014)

Assessment

Patient-reported core outcome measures set for research is in international validation process [COMPACT] (Grieve et al, 2017)

‘Objective’ core measures set for research is in development

** Persons with CRPS gauge recovery relative to pain (Llewellyn et al, 2018)

4 consensus meetings including international scholars, clinicians and patient representatives

COMPACT recommendations (Grieve et al, 2018)

DOMAIN MEASURE

Pain SF McGill Neuropathic scalePROMIS 29

Disease severity CRPS Severity Scale

Participation PROMIS 29EQ-5DPhysical function

Emotional and psychological functioning

PROMIS 29Single item on suicidal ideation

Self-efficacy Pain Self-Efficacy Questionnaire

Catastrophizing Pain Catastrophizing Scale

Self-perception of change GROC

COMPACT recommendations Pediatric versions

DOMAIN MEASURE

Pain SF McGill Neuropathic scalePROMIS 25

Disease severity CRPS Severity Scale

Participation PROMIS 25EQ-5DYPhysical function

Emotional and psychological functioning

PROMIS 25Single item on suicidal ideation

Self-efficacy Pain Self-Efficacy Questionnaire

Catastrophizing Pain Catastrophizing Scale

Self-perception of change GROC (?)

von Baeyer CL. Pain Res Manage 11(3) 2006

‘Describing pain only in terms of its intensity is like describing music only in terms of its loudness.’

Hamilton Inventory for CRPS

Clinician Based (CB-HI-CRPS)Sensory Autonomic Motor Trophic

14 items scored none/mild/moderate/severe (Packham et al, 2012)

Patient-Reported (PR-HI-CRPS)Physical symptoms

Daily functioning

Coping and social supports

40 items scored 0-6 using a mixture of agreement [Likert] and frequency scales

(Packham et al, 2018)

** Freely available in public domain

Sample question: CB-HI-CRPS

Testing: Touch test tube of cold water to skin for 3 seconds. Repeat over 3 different zones within affected area. Rate response as above.Instructions: I am going to touch you with this test tube of cold water; tell me how it feels to you. (Allow patient to respond then ask) Does it hurt?

Cold Allodynia / Hyperalgesia [sensory subscale]:Definition: an exaggerated painful sensation evoked by low-temperature stimulation Scoring:

0 = None - no complaints of pain; may report that tube feels cold.1 = Mild - patient reports discomfort with cold but no physical behaviours

evident2 = Moderate - patient reports pain, may show a behavioural response such as

flinching, grimacing, or vocalizing discomfort3 = Severe - patient reports pain and has a clear behavioural response; may

decline to be tested

Sample questions: PR-HI-CRPS

I need to concentrate in order to make my affected limbs move.

Pain prevents me from participating in activities throughout my day.

I still enjoy the things I used to enjoy

Always

6 5

Often

4 3

Some times

2 1

Never

0

Always

6 5

Often

4 3

Some times

2 1

Never

0

Strongly agree

0

Agree

1

Slightly agree

2

Neutral

3

Slightlydisagree

4

Disagree

5

Strongly disagree

6

Identification of CRPS using skin temperature asymmetry

Previous studies failed to find this to be useful, or used $$$ tools, but:

Didn’t account for innervation patterns

Didn’t account for warm/cold subtypes

Only compared to healthy volunteers, or other fracture patients

Pilot work demonstrated adding a cold pressor test for a consistent thermoregulatory stressor was safe, and inexpensive IR thermometers were reliable (Packham et al, 2012)

Can we correctly identify persons with CRPS vs. nerve injuries vs. post-traumatic inflammation vs. normal differences?

Copies of the Hamilton Inventories are freely available from [email protected]



Identification of CRPS using skin temperature asymmetry

Can we correctly identify persons with CRPS vs. nerve injuries vs. post-traumatic inflammation vs. normal differences?

Regression modelling of SkTA measures (n=378) supported diagnosis, post cold pressor test, and nerve distribution as significant predictors (p<0.001) explaining 94% of the variance.

ANOVA accounting for nested factors differentiated between diagnostic groups for the magnitude of SkTA at F[281, 378]=7.53, p<0.0001

Sensitivity [for a >1.0 oC SkTA]

Pre CPT = 85.1% Post CPT = 76.6% Rule in

Specificity [for a >1.0 oC SkTA]

Pre CPT = 43.8% Post CPT = 68.8% Rule out


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Allodynography

Standardized elements:

1) map created using 15g

(#5.18) monofilament

2) person identifies stimuli as

3/10 on NRS for pain [OR pain

at rest +1]**

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Allodynography

Start proximal to painful area

Apply monofilament for 2 seconds in 10 s intervals at 1 cm increments

Client indicates ‘STOP’ when stimulus becomes painful; this area is marked on map

Repeat procedure distally, and at end points of horizontal axis

Measure area using anatomical reference

1.2 cm proximal to wrist crease

3 cm distal to wrist crease

4 cm radial to scar

0.7 cm ulnar to scar

Reliability of Allodynography

Completed only in consenting participants demonstrating allodynia as defined by a painful response to a static touch with a 15g monofilament

Inter-rater reliability (n=12)ICC 2,1 = 0.97 [95%CI 0.90 - 0.99] single measures

Test-retest reliability (n=10) ICC 2,1 = 0.89 [95%CI=0.59-0.97] single measures

**p<0.001 for both(Packham et al, 2020)

Rainbow Pain Scale

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Colours represent the severity of allodynia as represented by

the smallest amount of pressure which elicits a painful

response (Spicher et al, 2015; similar to Keizer et al, 2007).

Colour rating Purple Indigo Blue Green Yellow Orange Red

Pressure 15 g 8 g 4g 1.4g 0.6 0.16 0.04

Interpretation Discrete Significant Serious

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Rainbow Pain Scale

The area tested for the Rainbow pain scale is marked on the allodynography map with a star

‘Colour’ category is also recorded there Rainbow pain

scale: blue ( 4 g)

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Rainbow Pain Scale

Vision occluded for testing

Person instructed to indicate ‘Now or Ow’ when touched

Testing starts with a single touch of the smallest filament, then proceeds with remaining 6 (or until one is painful)

Rainbow pain scale: blue ( 4 g)

Rainbow Pain Scale: reliability

For this evaluation, we also evaluated the reliability of the screening (i.e. identified as having no allodynia)

Inter-rater reliability (n=24) ICC 2,1 = 0.79 [95%CI 0.57 - 0.90] single measures

Test-retest reliability (n=18)

ICC 2,1 = 0.82 [95%CI=0.60 - 0.93] single measures

p<0.001 for all


Somatosensory Rehabilitation

Conservative treatment for painful somatosensory disorders

Developed by an OT in Switzerland (Claude Spicher); therapists are trained and certified in method through U. of Brussels (CSTP©)

Key principle:

Reduce sensitization through comfortable sensory stimulation and sensory re-education

Basic tenets of the Somatosensory Rehabilitation Method (SRM)

1) Precise evaluation to define the territory that is painful to touch (allodynography & rainbow pain scale)

2) Formation of a plausible neuroanatomical hypothesis of the peripheral nerve branch(es) underlying the painful territory and contributing to peripheral sensitization

3) Avoid reinforcement of the sensitization mechanisms by minimizing evocation of pain by temporarily limiting touch (and consequently functional use) of the painful zone

4) Comfortable somatosensory ‘counter-stimulation’(tactile and/or vibratory) and sensory re-education

(Spicher et al, 2020)

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Home Program: working zones

Avoid touch and movement in the red zone (thumb and wrist)

Counterstimulation ONLY on the green zone

Sensory re-education starting on the green zone and progressing into the yellow zone but NEVER on the red zone

Always STOP if it is painful

Consider a soft wrist and thumb support if tolerated (minimize intermittent touch)

Example for allodynia in DRSB territory

Distant vibrotactile counterstimulation

Comfortable tactile stimulation 8 times daily for no longer than one minute

Working zone on a non-painful area of skin anatomically related to the painful zone

- as close as you can get, but as far away as you need to be for the signals to be experienced as NORMAL & COMFORTABLE- a proximal cutaneous area of the same branch OR - arising from the same cord of the plexus OR- entering the spinal cord above or below the painful signals

Microfleece, fur, silk, lotion; stroking or rubbing

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Sensory re-education strategies

Localization

Discrimination Direction of movementBig or smallLetter and shape recognitionHot and coldTextures

Mindful recognition (traditional re-education)

Tailored for maximum independence

NO desensitization! (Moseley et al, 2008; Lewis et al, 2011; Spicher et al, 2015)

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Typical SRM treatment session

Review of home program – how often, working zone, response

Review of activities and problem-solving for challenges

Demonstration of re-education activities

Modification of home program based on feedback

Monthly re-evaluation of allodynia

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Complimentary modalities in SRM

Gentle heat or TENS applied to working zone

Nerve glides through working zone

Gentle compression over allodynic territory to permit functional use (compression bandage, splinting, spandex undergarments) to minimize evoked pain from touch

Deep breathing and proximal massage for lymph drainage rather than local massage

Graded motor imagery for those with motor concerns; incorporate proprioceptive retraining in sensory re-education elements

Serial casting or low-load prolonged stretch static progressive splinting instead of PROM or CPM

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Show me the evidence!

To estimate effectiveness of the SRM for allodynia in CRPS

Retrospective cohort study based on chart review of all records by independent investigator

Chosen sample population: CRPS of one upper limb (n=48)


Pain improves but doesn’t always disappear

Results

Baseline tQDSA (x=51.4, SD=17.1) *n=58 maps from 48 persons

Final tQDSA (x=20.4, SD=20.0) t(57)=13.6, p< 0.001

Final tQDSA for subgroup (58%) who completed full treatment (x=12.3, SD 10.2, range 0-41)

Effect Size (Cohen’s d) = 1.64 *all subjects, accounting for paired samples

QDSA = Questionnaire Douleur St. Antoine


Limitations

No control group

Potential for bias (selection bias, response bias)

No long-term follow-up

Heterogenous severity and duration


Take aways

Validated pediatric evaluations for CRPS symptoms and pain qualia are lacking

‘New’ evaluations to consider:

Skin temperature asymmetry of >1 Co

Allodynography, allodynia severity (rainbow pain scale) using monofilaments

Somatosensory rehabilitation = sensory re-education principles applied in a new framework


References

Bruehl S. Complex regional pain syndrome. BMJ. 2015 Jul 29;351:h2730.

Gierthmühlen J, Binder A, Baron R. Mechanism-based treatment in complex regional pain syndromes. Nat Rev Neurol. 2014;10(9):1-11.

Grieve S, Perez RS, Birklein F, Brunner F, Bruehl S, Harden RN, et al. Recommendations for a first Core Outcome Measurement set for complex regional PAin syndrome Clinical sTudies (COMPACT). Pain. 2017;158(6):1083–90.

Harden RN, Maihofner C, Abousaad E, et al. A prospective, multisite, international validation of the Complex Regional Pain Syndrome Severity Score. Pain. 2017;158(8):1430-1436.

Lewis JS, Coales K, Hall J, McCabe CS. “Now you see it, now you do not”: sensory-motor re-education in complex regional pain syndrome. Hand Ther. 2011;16(2):29-38.

Llewellyn A, McCabe CS, Hibberd Y, et al. Are you better? A multi-centre study of patient-defined recovery from Complex Regional Pain Syndrome. Eur J Pain (United Kingdom). 2018;22(3):551–64.

Mansour AR, Farmer MA, Baliki MN, Apkarian AV. Chronic pain: the role of learning and brain plasticity. Restor Neurol Neurosci. 2014;32(1):129–39.

References

Mesaroli G, Ruskin D, Campbell F, et al. Clinical Features of Pediatric Complex Regional Pain Syndrome. Clin J Pain. 2019;35(12):1.

Moseley GL, Flor H. Targeting cortical representations in the treatment of chronic pain: A review. Neurorehabil Neural Repair. 2012;26(6):646-652.

Packham T, Holly J. Mechanism-specific rehabilitation management of complex regional pain syndrome: Proposed recommendations from evidence synthesis. J Hand Ther. 2018;31(1):10-19.

Packham T, Holly J. Therapists’ management of complex regional pain syndrome. In Skirven et al (eds) Rehabilitation of the Hand (8th ed.) Elsevier, 2020.

Packham T, Spicher CJ, MacDermid JC et al. Somatosensory rehabilitation for allodynia in complex regional pain syndrome of the upper limb: A retrospective cohort study. J Hand Ther. 2018;31(1):1-9.

Packham T, MacDermid JC, Henry J, Bain JR. The Hamilton Inventory for Complex Regional Pain Syndrome: A cognitive debriefing study of the clinician-based component. J Hand Ther. 2012;25(1):97-112.

Packham TL, MacDermid JC, Michlovitz SL, Buckley N. Content validation of the Patient-ReportedHamilton Inventory for Complex Regional Pain Syndrome. Can J Occup Ther. 2018. Apr;85(2):99-105.

Packham T, Spicher C, MacDermid J, Quintal I, Buckley N. Evaluating a sensitive issue: reliability of a clinical evaluation for allodynia severity. Somatosensory & Motor Research. 2020 Mar;37(1):22-27.

References

Packham T, Spicher CJ, MacDermid JC, Buckley DN. Allodynography: Reliability of a New Procedure for Objective Clinical Examination of Static Mechanical Allodynia. Pain Medicine.2020; 21(1), 2020, 101–108.

Packham T, MacDermid JC, Bain J, Buckley DN. Cold-pressor stimulated skin temperature asymmetries for the identification of CRPS. Canadian Journal of Pain 2018. 2(1). doi:10.1080/24740527.2018.1504283

Spicher C, Quintal I, Vittaz M. Reeducation Sensitive Des Douleurs Neuropathiques. (3rd ed). Montpellier, France: Sauramps Medical, 2015.

Spicher CJ, Packham TL, Buchet N, Quintal I, Sprumont P. Atlas of cutaneous branch territories for the diagnosis of neuropathic pain [1st ed. English]. Switzerland: Springer Nature. 2020.

Questions?

@TaraLPackham

[email protected]


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