Management

Intervention stage 1 (box 13-10)

CRPS is a progressive disorder unless vigorous intervention is used during the acute
stage. The best intervention is prevention when it is recognized that development of
this condition is a possibility, such as when there has been trauma to the extremity or
when the extremity is immobilized. It requires that the therapist motivate the patient
to move the entire extremity safely, minimize edema and vascular stasis with
elevation and activity of the distal segments (squeeze and open hand with upper
extremity lesions, or ankle pumping and toe curls with lower extremity lesions), and
be alert to the development of adverse symptomatology.
Medical intervention is necessity to manage this syndrome. The physician may choose
to utilize analgesics sympatholytic drugs, local anesthetic blocks, stellate ganglion
blocks, spinal cord stimulation, or upper thoracic sympathectomy or may use oral
steroids or intramuscular medication. Because there is often an emotional or
psychological component, medical intervention includes therapies to manage this area
(antidepressant). This is done in conjunction with active exercise (including exercise
in warm water) to manage physical impairments and functional limitations
Pain and edema control. Use modalities such as ultrasound, vibration,
transcutaneous electrical nerve stimulation (TENS), or ice . Utilize not undergoing
pneumatic compression treatment.
Mobility. In the early stages, use gentle, active exercises to manage the increasing
stiffness. Have the patient actively contract the musculature while the part is held near
the end of the pain-free range. It is important to avoid increasing painful reactions that
would decrease mobility. Support and have the patient actively move each joint for a
short period of time. They should follow this program of brief motion frequently
throughout the day.
In the hand, include tendon glide exercises
butler suggested that there may be adverse tension in the sympathetic trunk
influencing sympathetic activity and therefore suggested mobilization of the nervous
system, as descrilbed earlier in this chapter. Avoid vigorous stretching.

Muscle performance. Facilitate active muscle contractions. Include joints proximal to

the symptoms:
They often develop restrictions due to pain or lack of use. Use both dynamic and
isometric exercise and alternating controlled stress loading (compressive loading)
with distraction activities for neuromuscular control as well as afferent fiber
stimulation. The objective is to provide tissue stress with minimal joint motion.
Suggested exercise include
-stress load the upper extremity by scrubbing with a brush in the quadruped position,
begining at 3 minutes and incrementally increasing to 10 minutes three times a day.
For the lower extremity, utilize progressive weight bearing activities
-distraction by carrying 1 to 5 pounds up to 10 minutes at time frequently throughout
the day.
Total body circulation and cardiac output. Initiate a program of low-impact aerobic
exercise
Desensitization. Utilize desensitization techniques for brief periods five times per
day, such as having the patient work with various textures the patient to wear a
protective glove during activities of daily living (described earlier in the chapter)
Patient education. Emphasize the importance of following the program of increased
activity. Teach the patient interventions that deal with the variable vasomotor
responses with the use of gentle heat, gentle exercises for short periods throughout the
day, and use associated parts of the extremity.
CLINICAL TIP
Its important not to exacerbate the patients pain and underlying phatology.if
there is increased sensitivity, use caution when touching sensitive areas. Maintain
continuous contact to avoid the irritation of make-and-break contact over the
sensitive area, especially if untilizing massage for endema control. When the patient
presents with hypersensitivity, painful stretching or manipulations exacerbate the
symptoms. Untilize gentle active exercises and light massage, for short periods,
throughout the day.

 CLINICAL TIP
Pain continues to be variable during stages II and III, and therefore, the initiation of
any therapeutic exercise or manual therapy technique should be carefully monitored
and adapted to the patient at each visit to minimize exacerbation of symptoms

Intervention : Stages II and III

Pain management. Modalities ara often used as palliative interventions

prior to or in conjuction with exercise to minimize pain.

Desensitization. Progress the desensitization techniques to increase the

patients tolerance to various textures.

Mobility. Use joint mobilization, neuromobilization, and stretching
techniques to address tissue limiting mobility. Use caution since
osteoporosis is frequent complication

FOCUS ON EVIDENCE
Evidence supports effective use of physical therapy with early intervention
(acute stage), but there is contradictory evidence forits effectiveness during the
later stages. In one study, the primary predictors for success and statisfaction
with patients during the chronic phase after 6 months of therapy (evaluated at 12
months) was with the patient group that began therapy at a higher baseline of
function, higher baseline ROM and strength, and less baseline pain.

INDEPENDENT LEARNING ACTIVITIES

Critical Thinking and Discussion
1. Your patient describes intermittent sensory changes in the index and
middle finger. What are the possible causes? What tests would you use to
examine this patient? What results would lead you to determine nerve
mobility restrictions?
2. You have a new client who describes intermittent tingling and sensations
of heaviness in his hands whenever working with his hands in overhead
position. He is an auto mechanic and frequently has to work this way.
Identify possible causes of these symptoms. What is usually the source of
tingling sensations? What may be the source of the heaviness feelings?
Why would the the overhead position cause both vascular and neurological
symptoms? Identify possible sites that could cause these symptoms. What
tests would you use to confirm or rule out your hypotheses?

3. A 19-year-old patient presents with the medical diagnosis of complex

regional pain syndrome type I (RSD) and the following history.
Three month history of midfoot pain that increases with standing more
than 5 minutes or running. Symptoms have increased over the past 3

weeks.
Stress fracture to the navicular was setected on radiography, so

patientwas placed in BK nonweight-bearing cast.

Foot discomfort increased and became more diffuse, radiating into the

lateral forefoot and digits even after pain medications were prescribed.
Symptoms increased with burning or stinging pain, edema, and

discoloration of the digits.

Examination 3 weeks after cast apllied : digits cool, edematous,
hyperesthetic, and hyperhidrotic. Passive and active motions of ankle
and toes modeeately painful. Radiographs showed diffuse osteoporosis.

What would be your goals for this patient? Develop a program of interventions.
4.

Identify and describe everyday activities and/or positions that mimic the
nerve tension test positions. These activities/positions may be patient
complaints that indicate further nerve tension testing. For example, getting
into a cat by straightening the leg and ducking the head mimics the
slump position.

Laboratory Practice
1. With your laboratory partner, practice each of the nervetension positions.
Demonstrate how you would mobilize restrictions for each of the nerves.
2. Practice each of the thoracic outlet tests and describe the mechanics of each
test. Identify and practice techniques you could use to increase mobility or
reduce compression on the brachial plexus at each of the sites where
compression or tension might occur. Design an exercise program and
progression for managing impairments that could cause TOS symptoms.
3. Practice sensory stimulation and reintegration techniques by doing each of the
following.

Gather 10 pieces of material of various textures. Place them in order of least

irritating to most irritating. Practice sensory stimulation techniques by gently
rubbing each material across your fingers

Use five plastics tubs or buckets. Place each of the following in a

container: dry peas or beans, spiral macaroni, sand, fine gravel, seeds.
Practice sensory stimulation by moving your hand (or foot) through each

of the textures.
Have your laboratory partner place several familiar household items in a
bag (e.g., key, dime, penny, can opener). Without looking, attempt to
identify each one.