Complex regional pain syndrome (CRPS) is probably one of the most challenging conditions that we see at Melbourne Hand Therapy. This is because the degree of pain suffered by a patient is not always obvious to the clinician involved. Also, the pain might not be proportional to the size of the injury. Often, a minor trauma can cause a higher-than-expected degree of pain.
Pain is the body’s way of protecting us and it is real. It is important our patients know this and know that at Melbourne Hand Therapy, we understand this. Pain is a necessary part of human development. It is an automatic reaction by the body to let us know we are doing something harmful and have to stop.
In the case of distal radius fractures – fractures of the wrist – the incidence of CRPS ranges from one to 37 per cent.
Melbourne Hand Therapy uses the Budapest Criteria to diagnose CRPS. This scale assesses the symptoms of CRPS based on several factors. Firstly, we assess symptoms based on sensory changes which relate to changes in pain sensitivity in the patient. Secondly, we evaluate vasomotor changes. This refers to the changes in the diameter of blood vessels during the natural processes of contraction and expansion of the blood vessels known as vasodilation and vasoconstriction. Thirdly, we look at the patient’s sudomotor reaction which refers mostly to the degree to which a patient is sweating even in the absence of exertion or intense physical activity. Finally, we look at the motor or trophic changes, or limitations of movement.
There are two types of CRPS. Type one occurs after trauma and causes sensory, motor, automatic and skin/bone changes. Type two includes all these changes plus the involvement of nerves.
Treatment for CRPS includes upper limb therapy often in conjunction with pharmacological treatment (such as pain medication). At Melbourne Hand Therapy, our treatment also involves patient education and a customised graded motor imagery program.
Graded motor imagery consists of laterality (left/right discrimination), imagined movements and mirror therapy. It is a well-researched field by Mr David Butler and Mr Lorimer Moseley etc al. We utilise this research in our clinical practice and often share textbooks, apps, mirrors and flashcards as part of our treatment approach.
When patients present at Melbourne Hand Therapy in a state of chronic pain, we know that in reality, they will only be with us for a very short period (0.1% of the time). In that short period, we endeavour to equip them with all the skills they need to become an integral part of the management of their own injury and recovery, and to enable them to have the confidence to be critical thinkers and problem-solvers in the treatment and healing process.
When attempting to diagnose the level of pain, Melbourne Hand Therapy uses the biopsychosocial model. This model has three interacting components – bio, psycho and social. The biological factors consider the patient’s genetics and the health of the tissue surrounding the injury. The psychosocial factors consider all that makes us human – such as our knowledge, thoughts and emotions. Lastly, we take into account social factors which include our relationships, communities and culture.
At Melbourne Hand Therapy, our focus is to provide pain biology education with a customised movement approach to increase our patient’s physical capacity, reduce their pain and improve their quality of life. It is important that our patients understand that movement is beneficial, but of course in a graded, gentle way. This is called graded exposure, also known as “pacing”.
