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Physiotherapy is vital following diagnosis of Complex Regional Pain Syndrome (CRPS). To avoid further physical problems associated with disuse of the affected limb e.g. atrophy (wastage of the muscle of the affected limb).
Early diagnosis and a treatment plan that includes physio exercises can be key to managing CRPS.
Physiotherapy can improve the function of four major physical areas: musculoskeletal (muscles, bones, tendons, ligaments, joints etc.), cardiopulmonary (heart and lungs), integumentary (skin, nails, hair, glands and nerves of the skin) and neurological (brain, spine and nervous system).
There are a range of physical therapies for CRPS that may help to relieve pain and improve the movement of affected areas. We explore the most common below.
Most individuals with CRPS who have attended physiotherapy will know that desensitisation of the affected limb(s) plays a key role in managing a symptom known as allodynia. Allodynia is when the affected area of the body becomes hypersensitive causing a pain response to a sensation that would not typically cause pain e.g. a light breeze, water, sunlight etc.
The aim of desensitisation therapy is to retrain the brain and nerves affected also known as altering neuroplasticity. Neuroplasticity is an umbrella term referring to the ability of the nervous system to adapt in response to a range of experiences. With a focus on restoring normal function in the affected region, desensitisation therapy reintroduces a variety of textures in a gradual and deliberate manner. Textures are progressed in an order that you and the physiotherapist agree on, but generally it will start with the easiest to withstand.
Desensitisation therapy can be applied during physiotherapy sessions or at home as a self-management tool. You may even put together your own 'portable texture kit'. Some examples of different textures and materials include:
You should aim to practise little and often. St. George's University Hospitals (2022) recommend to "try two to three minutes every hour or even up to 10 minutes four to five times per day". However, the specific frequency is usually discussed with your physiotherapist to determine what is most suitable.
According to Chalmers et al. (2013) graded motor imagery (GMI) is "a 3-stage treatment that aims to gradually engage cortical motor networks without triggering the protective response of pain", meaning to activate the brain areas that control movement in a way that does not cause pain. This structure of understanding is derived from the fundamentals accepted in the physical therapies, of graded increase in activity. GMI was designed by Moseley et al. (2006) and the NOI Group with chronic CRPS patients in mind, but it has since been applied to other complex pain and movement disorders.
First stage – Left/right discrimination
The first stage is left/right discrimination e.g. is this a left/right movement, is this a left/right side. You will engage in mental visualisation and imagination to address pain, Left/right discrimination treatment aims to retrain the brain to be able to correctly recognise the affected limb. There are a variety of ways you can partake in this stage of the treatment. For example, readily accessible tools for training include Google images, personal photos, or magazines. Alternatively, the Recognise app and flashcards produced by the NOI Group are an excellent addition to a self-management toolkit.
Second stage – Motor imagery
The second stage is known as explicit motor imagery, which may involve considering how clothes feel on the skin, imagining moving, touching and feeling the affected limb. To do this you should imagine yourself moving rather than watching or imagining other people moving. By imagining movements, particular areas of the brain become active, similar to those areas that would be used if a movement was actually executed. This, in itself, is still hard work when in constant pain.
Explicit motor imagery is recommended to be practised in a quiet, calming environment to promote focus and avoid distraction.
It is often foreseen that imagining movement of the affected region can increase pain; therefore, it is often helpful to begin imagined movements on the opposite side, and gradually move toward the area of the pain.
Third stage – Mirror therapy
The third and final stage of GMI is mirror therapy. This involves putting the affected limb on the back of a mirror and the healthy limb in front of the mirror to do the exercises. You should be guided by a clinician who understands brain function; when practising this technique.
To perform this treatment, a mirror box or a fairly large mirror is required (especially if CRPS is experienced in the lower part of the body). Place the affected limb in the box or behind the mirror and concentrate on the image in the mirror.
This is often followed up with a couple of gentle exercises such as tapping each finger separately, or flexing of the ankle or wrist etc. However, specific exercises should be discussed with your physiotherapist to identify what is most appropriate for you.
Hydrotherapy is a form of physiotherapy that has been found to be effective for chronic pain. It works to simultaneously relieve multiple symptoms such as pain, stiffness, swelling, bruising etc. Moving in water provides a gentle resistance, which helps safe performance of physiotherapy exercises. Risk of injury and pain when attempting new exercises, is reduced as the water acts as a stabiliser. This is good for strengthening muscles and increasing muscle tone. Furthermore, using an array of aquatic equipment to help assist exercises, such as pool noodles, kickboards and aquatic hand bars, will increase buoyancy and allow for a more dynamic workout.
Hydrotherapy has several benefits specifically for people with CRPS. For example, those with CRPS of the foot/leg that cannot weight-bear on land will be able to take advantage of the buoyancy effect of the water. This allows them to be in an environment where they can re-educate and encourage normal movement of the affected limb. Another key benefit includes the heat that a hydrotherapy pool provides. According to BLB Solicitors (2017) "the typical temperature of a municipal pool is 29°C, as compared to the optimum temperature for hydrotherapy which is 35°C". This promotes pain relief by stimulating thermoreceptors (specialised nerve cell endings that detect temperature change) throughout the body.
Mayo Clinic (2023) defines isometric strengthening as the tightening of a specific muscle or group of muscles, and involves pushing against a fixed object. They state that since isometric exercises are performed in a static position, they won't help improve speed or athletic performance. However, they are beneficial for those with CRPS as isometric exercises are said to help prevent muscle atrophy (weakness) and maintain/regain strength without causing more pain.
An example of an isometric exercise is the flexing of the ankle, these exercises involve placing the foot/ankle with CRPS against a soft fixed object such as a sofa, and pushing inwards/outwards. Lower leg muscles should contract but the ankle joint should not move. An isometric exercise for those with CRPS of the hand/wrist is known as the isometric wrist extension, this involves making a fist with the CRPS hand/palm faced down, the opposite hand should resist against the symptomatic hand which should be moving upwards slightly. However, specific exercises should be discussed with your physiotherapist to identify what is most appropriate for you.
Occupational therapy focuses on the limitations someone may experience as a result of a disability or injury. An occupational therapist helps you to find practical solutions that can help improve independence and participation in daily life. These solutions might involve changing environment or using different techniques and mobility aids.
A method known as activity grading is utilised to help get involved in an activity. Activity grading is a technique where the activity is broken down into more manageable steps.
Another aspect of occupational therapy is workplace rehabilitation. This involves an occupational therapist assessing you in the workplace, assessing your ability to complete work activities, and finding ways you can be assisted.
Whilst these physiotherapy techniques are accessible to most with CRPS, you should keep in mind that they are not for everyone. These exercises are a case of trial and error - what may work for one person with CRPS, may not work for another. Additionally, you should always remember to pace yourself when doing exercises, by taking breaks and/or spacing the exercises throughout the day.
If you need any more support, Burning Nights are here for you:
Telephone/Helpline: 01663 795055 (UK) (Available Monday-Friday 10am-4pm, except Bank Holidays)
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