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• CRPS
• Dupuytren’s Contracture

CRPS

What is CRPS?

Complex Regional Pain Syndrome (CRPS) type 1 is a condition involving excessive pain following an injury that is out of proportion with the cause. It involves severe pain, swelling and skin, hair and nail growth changes (Merskey and Bogduk, 1994). Symptoms you may notice include pain that would be described as ‘burning’, ‘throbbing’, or ‘searing’ and does not respond to narcotics (Li et al, 2010), muscle and joint stiffness, oedema, osteopenia (decreased bone density), atrophy of hair and nails, excessive or lack of sweating, hot or cold limb, hypersensitivity (hyperalgesia), weakness, tremors or dystonia.

CRPS is thought to be a disease of the central nervous system rather than related to the physical trauma sustained at the time of original injury (Moseley, 2004). Our brain receives messages from the peripheral nervous system that it interprets as pain, as a protective mechanism against tissue damage, however, in patients with CRPS this feedback system is faulty and the pain is no longer protective.

CRPS is 3 to 4 times more common in women than men, most commonly occurs in people aged 40-60 although can occur at any age, and 44-48% of cases are reported as involving the upper limb (Aneja et al, 2006). Smokers are said to have a poorer prognosis than non-smokers (Li et al, 2010).

There is no pathognomonic marker for CRPS which means there are no definitive diagnostic tests that your doctor should perform to confirm a diagnosis of CRPS. Diagnosis is based on clinical assessment (Li et al, 2010).

Paths for intervention

Early intervention is reported to result in better prognosis for patients with CRPS (Chloros et al, 2009).

Traditionally treatment has involved the following algorithm:

Reactivation Contrast baths Desensitisation

Active range of movement Oedema control TENS Isometric strengthening Diagnosis and treatment of secondary myofascial pain

Passive range of movement (gentle) Stress loading Isotonic strengthening General aerobic conditioning Postural normalisation and balanced use

Ergonomics Movement therapies Normalisation of use Vocational and functional rehabilitation

(Adapted from Harden, 2009 and Stanton-Hicks et al, 2009)

More recent research advocates for the use of a graded motor imagery program as there is strong evidence to support its use in the treatment of complex regional pain syndrome (Moseley, 2004).

Prevention: recent studies have shown that high doses of vitamin C may have a role in preventing the development of complex regional pain syndrome in patients with wrist fractures (Zollinger et al, 2007). This study did not focus on other hand or upper limb trauma. The authors recommended the administration of 500mg of vitamin C daily for fifty days after wrist fracture for the prevention of complex regional pain syndrome.

Graded Motor Imagery

As CRPS is thought to be a disease of the central nervous system it is important that treatment targets the central processing of messages from the affected limb. Shrinkage of the cortical representation of the affected limb has been noted in patients with CRPS so treatment should be aimed at activation of the cortical areas related to the limb (Moseley et al, 2008). This is where graded motor imagery comes in.

A graded motor imagery program involves three stages: laterality, imagined movements and mirror therapy (Moseley, 2004).

Laterality is the identification of the left or right when images of hands are presented to a patient. During this activity the pre-motor cortex is stimulated. Studies have shown an intimate relationship between pain and motor output, this relationship is so intimate that even a movement execution command (or thinking about a movement) can cause pain. Completing the laterality program is a way of stimulating the pre-motor cortex in order to prepare your brain for activity. This is how we gradually introduce your limb to movement to reduce your pain experience.

The next step is imagined movements. Without moving the limb the patient is to imagine adopting the positions shown on the laterality cards with the affected limb. This then begins to stimulate the primary motor cortex.

The next step is mirror box therapy. The affected limb is placed in a box with a mirror mounted on the side and is instructed to watch the reflection of the unaffected hand in the mirror as a series of movements is completed.

The graded motor imagery program is most effective if implemented in the order stated above and it is recommended that you complete the program under the close supervision of your therapist (Daly, 2008).

Other treatment modalities:

While graded motor imagery is targeting the central nervous system the limb cannot be forgotten and kept still through the initial phases of treatment. This is because swelling and stiffness and associated tissue changes such as ligament and tendon shortening, joint capsule contracture and osteopenia will be occurring and will make return to normal use of the limb much more difficult and painful.

Your therapist will guide you through active exercises and other treatments such as heat treatments, desensitisation, massage, compression therapy and many more as indicated to address the symptoms of CRPS. Every patient will undergo an individualised treatment program based on the symptoms experienced and individual needs. Every patient’s experience of this condition is different and therefore so should their treatment be.

Aims of Therapy

• Reduce pain
• Increase functional use of the affected limb
• Minimise oedema
• Regain range of movement
• Normalise sensation
• Regain maximum function and strength

References

Dupuytren’s Contracture

What is Dupuytren’s Contracture?

Dupuytren’s contracture is a common and debilitating condition that presents in the palm of the hand(s). It can be unilateral or bilateral and most commonly affects men of advanced age (av 55 years). Early manifestation includes thickening and pitting of the skin on the palm of the hands, with nodules often present. Typically a cord will develop and over time, months or years, will gradually contract, forcing the MCP’s and PIP’s into a progressive flexion deformity. The ring and little ringers are most commonly affected, however any finger can be involved.

There are many risk factors associated with DD including, smoking, alcohol, diabetes mellitus, anticonvulsants, epilepsy, hypercholosterolacemia, manual labour and hand trauma, however a direct cause is still unknown.

There are many changes occurring at a cellular level including fibroblast proliferation, which clinically presents as the nodule. As proliferation reduces, connective tissue assembles and presents as the cord. There is evidence of collagen type III deposition and the presence of myofibroblast, which is possibly responsible for contracture.

Paths for intervention

If the condition requires intervention, intervention is almost exclusively surgery. If surgery is not possible, an extension splint may be used to assist with straightening the fingers. This type of treatment is also often used prior to surgery to help reduce some complications associated with surgery. Other non-surgical interventions such as radiotherapy, steroids and topical vitamin A have been tried but there is little evidence regarding their effectiveness.

Enzyme injections have shown encouraging results however small sample sizes reduce the generalization of the studies to the wider population – further research is required.

A minimally invasive treatment, known as needle aponeurotomy, was developed by Dr Lermusiaux in Paris and has shown encouraging results for individuals with MCP joint contractures, however less so for PIP joint contractures. The procedure is performed under a local anaesthetic, taking approximately 15-20 minutes. The contracted tissue is transected and/or lengthened by shearing and perforation via a fine needle. This technique is used widely in Europe and Russia and is now being used more in the US.

Surgery

Early surgical intervention is preferable to reduce secondary changes occurring to the joint – particularly the PIP joint. Namely degeneration of the volar plate, tight volar collateral ligament structures, digital fascia attaching to the volar skin and attenuated extensor mechanism over the PIP joint with adherence to the dorsal capsule. This can result in a fixed flexion contracture, or bent finger.

Fasciectomy and dermofasciectomy are the most common surgical techniques used to remove diseased tissue. In combination with this a surgeon may perform a PIP joint release, advancement of flaps or open palm wounds. The incision and wound closure most commonly used in surgery is in a Z formation (Z-plasty) to reduce the risk of further contracture. Surgical intervention is generally indicated when MCPJ contracture exceeds 30º and/or any PIPJ contracture is evident.

Complications

Timing of complication	Common complications
Intra-operative:	Nerve injury (in all PIPJ contractures)
	Digital artery injury (in all PIPJ contractures)
Early post-operative:	Infection (highest complication)
	Haematoma (digits only)
	Neuropraxia
	CRPS Type 1
	Skin slough
Late post-operative:	Tendon tethering
	PIP joint contracture
	DIP joint limited movement
	Scar shortening
	Central slip attenuation
	Recurrence of disease
	Carpal tunnel syndrome

Post surgical intervention procedure

There is conflicting evidence in the literature regarding protocol for post-operative therapeutic intervention for dupuytren’s disease with many different regimes and procedures being used. Most therapists and surgeons use splinting however the design of the splint and the wearing regimes vary greatly. Evans (1997) argued that there is an increase in odema, thereby prolonging the initial inflammatory phase, if aggressive splinting or therapy is used three to five days post-operatively. Saar & Crothaus (2000) and Azad et al (1990) backed this theory up with their findings that applying excessive tension or aggravating tissue within this post-operative period can increase scar formation and the recurrence of the disease is inferred. Gupta et al (1998) discovered changes at a cellular level when shear stress is applied to fibroblasts derived from Dupuytren’s tissue. Many authors agree that tension on the hand should be reduced within the splint 5-7 days post-operatively (Evans et al, 2002 and Mullins, 1999).

While valid points are made within the Evans et al (2002) article there are many limitations that reduce the transferability of the results. Despite the large sample size there was no randomisation into groups with some retrospective aspects and some prospective aspects increasing the potential variance. Changes to surgical techniques, instruments and equipment used over 2 decades would have changed and the 49 different surgeons operating would have again varied the results. The author was not blinded to the study and therefore may affect the outcomes. Also, non-standardised assessments and protocol were used, thereby reducing the reliability and validity.

The article does, however, clearly state the theoretical and pathological reasoning for the benefit of the non-tension applied splint being used initially post-operatively. This is confirmed by a number of other studies.

Authors have shown that non-compliance with splint wearing regime and therapy has resulted in poor outcomes and PIPJ contracture (Mullins, 1999). Rives et al (1992) showed that splinting in extension over a long period of time has a beneficial effect on the PIPJ contracture. Similarly dynamic or serial splinting can gain extension beyond that achieved by surgery (Mullens, 1999 and Saar and Grothaus, 2000).

While there is conflicting evidence regarding the benefits of splinting for MCP contractures, the effect is confirmed where PIP joint is involved, with splinting for 8-12 weeks and an active exercise regime (Saar & Grothaus 2000, Mullins 1999, McGrouther 2005 and McFarlane & McDermid 2002). This is possibly due to secondary changes occurring to the volar plate, ligaments and tendons at the PIPJ (Mee 2007).

Aims of Therapy

•  Maintain extension gained in surgery
•  Protect wound site from infection
•  Minimise odema
•  Regain flexion
•  Encourage tendon gliding
•  Minimise impact of scarring
•  Normalise sensation
•  Regain maximum function and strength

Rehabilitation

•  Begins 3-5 days post-operatively
•  Focus on PIPJ management
•  Odema management including elevation, exercises, coban and odema gloves
•  Splint considerations:
  •  pre-op contracture and extension gained in surgery
  •  PIPJ involvement (if PIPJ involved splinting is priority)
  •  maintain extension gained in surgery
  •  dynamic v’s passive
  •  decrease wound tension 3-5 days (MCP flexion, PIP extension)
  •  gentle tension over an extended period (3-6 months)
•  Exercises – 3-5 days post-op tendon gliding exercises for FDP, FDS & central slip, if long term PIPJ contracture work on intrinsic strengthening/function
•  Scar management – massage, silicone gel, elastomers
•  Sensation – desensitisation, sensory feedback, cortical mapping

References