1. Amanda Nowak OT/s

2.  Pain is a signal that the body has been
damaged or something is wrong
 Reaction designed to protect you (makes you
stop what you are doing what caused it
 Pain can either be acute or chronic

3. The Process
of Pain
Stimulus  Pain
receptors  Spinal
cord  Thalamus 
Cerebral cortex 
“OUCH”

4.  Abnormality of the processing of pain by the
neurologic system
 CRPS can be either type I (RSD) or type II
(causalgia)
 Pain is disproportionate to the initial event
 An official diagnosis must first rule out any
alternative diagnosis
 Frequently diagnosed associated with mild
severe injuries/surgeries (commonly carpal tunnel
release, Dupuytren’s release, and distal radial
fracture)
 Can occur either before or after therapy referral

5.  Allodynia
 Hyperalgia
 Hyperpathia
 Swelling
 Stiffness
 Discoloration
 Abnormal hair/
nail growth
 Hyperhydrosis
 Motor Dysfunction
 Bone Degeneration

7. CRPS Pain rated a 42
Most painful form of chronic pain

8.  Ask which areas are
hypersensitive BEFORE
touching the patient
 Pain assessment is
important to determine
client’s tolerance
 Postpone unnecessary
tests to a time when they
are not swollen, painful,
and stiff
 Measuring edema: use
warm water and as
quickly as you can
 Phych eval

9.  Pain  Stress Loading
 Modalities (moist heat,  “load and carry”
fluidotherapy, contrast  Joint Protection
baths)  Patient Education
 Edema  “To Improve, Move”
 Elevation with AROM,
manual edema mobilization,
compression, massage
 Sensation
 Desensitization
 Range of Motion
 PROM, stretching, blocking,
tendon gliding, PNF patterns
 Splinting
 Resting position

10. No protocol works for all patients
with CRPS. It is dependent on
current pain level, symptoms,
and tolerance (see handout)

11. OCCUPATIONAL THERAPY PHYSICAL THERAPY
i) to reduce clinical symptoms, i) Increasing the degree of
and protect and support the control over the pain and
affected limb in the most improving the way the patient
functional and comfortable copes with the syndrome
position by means of a splint. ii) Extinguishing the source of
ii) to normalize sensitivity by pain and treating any
carrying out an extensive dysregulation
desensitization program iii) Improving skills
iii) to encourage the functional
use of the limb within the pain
threshold.
iv) to encourage independence

12.  Communicate regarding progress/lack of progress
 Monitor symptoms and adjust treatment
accordingly
 Communicate with therapist regarding goals
 Discuss maximal pain limits and which pain
reduction techniques are most effective
 Record progress of home exercise program
 Provide adaptations and assistive devices for
ADL’s and work related activities
 Modify/Adjust splints

13. Shows a trend that mirror therapy is effective with
CRPS. Mirror therapy was shown to be effective in
CRPS patients in Stage I and II but not effective in
Stage III patients. It had an immediate analgesic
effect with a reduction in stiffness. In those patients
which mirror therapy was not effective, all were
lower extremity affected. 17 different outcome
measures were used measuring symptoms,
functional levels, and the treatment itself. It is noted
that Mirror therapy in CRPS II patients is worth
further exploration.
Results of these studies were not statistically analyzed

14. May be safe and effective
186 Patients
Assumes that avoiding use of a limb Referred
due to pain will result in loss of
function
“Graded exposure”
Discussion of possible pain increase
Traction & translation of joints 106 Patients Included
80 Patients 4 Patients Stopped 2
Passive Stretching Excluded Male 2Female
Functional use immediately after 2 arm/hand
2 leg/foot
Desensitization
Max of 5 45 min sessions over 3
months with evaluation of
Arm/hand 39 Leg/foot 63
treatment 3 months after last patients patients
treatment 18 full recovery 31 full recovery
19 partial recovery 27 partial recovery
Focuses on FUNCTIONAL 2 patients lost to 5 no change
improvement only follow-up

15.  Completely individual
 The sooner treatment begins, the quicker
improvements are noted
 The longer treatment is delayed, the more
likely it is to require long-term treatment

16. No, there is a lack of evidence in all areas of
CRPS and more research needs to be done
to find the most effective treatments for
these patients.

18.  Cooper, C. (2007). Fundamentals of hand therapy. Mosby-Elsevier: St. Louis, MO.
 Ek, J., Gijn, J., Samwel, H., Egmond, J., Klomp, F., & Dongen, R. (2009). Pain exposure
physical therapy may be a safe and effective treatment for longstanding complex regional
pain syndrome type 1: a case series. Clinical Rehabilitation, 23, 1059–1066. doi:
10.1177/0269215509339875
 Ezendam, D., Bongers, R. & Jannik, M. (2009). Systematic review of the effectiveness of
mirror therapy in upper extremity function. Disability and Rehabilitation, 31(26), 2135–
2149. doi: 10.3109/09638280902887768
 Geertzen, J. & Harden, R. (2006). Physical and Occupational Therapies in Complex Regional
Pain Syndrome Type I. Joumal of Neuropathic Pain & Symptom Palliation, 2(3), 51-55. doi:
doi:10.1300/J426v02n03_11
 Kishner, S., Rothaermel, B., Munshi, S., Malalis, J. & Gunduz, O. (2011). Complex regional
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10.4274/tftr.09327
 Maihofer, C., Seifert, F., & Markovic, K. (2010). Complex regional pain syndromes: new
pathophysiological concepts and therapies. European Journal of Neurology, 17, 649–660.
doi: doi:10.1111/j.1468-1331.2010.02947.x
 Mos, M., Sturkenboom, M., & Huygen, F. (2009). Current understandings of complex
regional pain syndrome. Pain Practice, 9(2), 86-99. doi: 10.1111/j.1533-2500.2009.00262.x
 Perez, R., Zollinger, P., Dijkstra, P., Thomassen-Hilgersom, I., Zuurmond, W., Rosenbrand,
K. & Geertzen, J. (2010). REevseiadrche anrticclee based guidelines for complex regional
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