complex regional pain syndrome

YouTube Mirror Box videos

I was just looking for a quick video on using mirror box for CRPS (Complex regional pain syndrome) – well I couldn’t find any on YouTube, but I did find a good few on use for stroke.

Take a look at these and let me know what you think!  BTW If you’ve made a video on mirror box therapy in CRPS, or phantom, let me know and I’ll link to it.

This link takes you to jeisea’s blog where she has posted an extensive range of articles and links on using mirror box therapy for CRPS. Thanks jeisea!

BTW you don’t always need the box – you can simply use a mirror…

Here’s another – this time from Australian physiotherapist David Butler

Another recent one from Jeisea.

This is a series of four videos of mirrorbox therapy including history – it’s by Dr Ilan Lieberman, and at a commercial website (note I don’t endorse any specific products)  but it is clear, and a great watch!

Welcome to Monday!

It’s not yet Monday here, it’s Sunday evening and I’m putting a quick post up now because Very Early In the Morning I’m going off to see the sunrise! Mad I know, but this is what happens in our household – the camera will be packed and I can almost taste the bacon and eggs on the beach now!

So…I scoped out some things on Slideshare, and came up with this presentation on Complex Regional Pain Syndrome. It’s not overly technical, but summarises some of the newer material available on this very challenging pain problem.

Enjoy – and have a wonderful day!

Case formulation: A simplified example

Over the past few days I’ve been posting about case formulation. While I’ve presented the abductive theory of method (ATOM) which is a process of inferring from phenomena to underlying causal mechanisms, it’s not the only way to develop a formulation.  I posted on some of the other ways formulations can be developed, and today I’m going to describe a simplified formulation to show how it can work in practice. Don’t forget that when I write about patients I make sure details that can identify the individual are changed – or I describe a composite of several patients.

Robert is a 39 year old previously self-employed electrician who sustained a fracture of a his nondominant hand when he fell from a ladder two years ago.  This fracture developed into a complex regional pain disorder type i which had been slowly resolving with the use of medication, functional restoration (graded daily use of the hand), and mirrorbox therapy.  Robert presented for pain management assessment when his progress plateaued, and he became increasingly distressed.

He was assessed in a three-part comprehensive pain assessment in which he was seen by a pain management medical specialist, a functional assessor and a psychosocial assessor.  He completed a set of questionnaires prior to the assessment which were used to ‘flag’ areas for closer investigation.  Information was made available from the referrer (the GP), the case manager (clinical notes from the orthopaedic surgeon and initial physiotherapy treatment provider), and an initial workplace assessment which provided details of his work demands.

The medical assessment consists of reviewing his previous medical history, a full musculoskeletal examination, general ‘systems’ examination, current and past medications used for pain management, and pain specific examination.  The purpose is to identify whether all the appropriate investigations have been completed, the appropriate medical treatments have been pursued, and the medication regime is rationalised. (more…)

A man with a lot on his mind

For over two years, Joe (definitely not his real name!) was waiting for someone to tell him that his pain could be cured, or not. One way or another he’d have liked to know. In the meantime he looked everywhere for things to fix his pain.

He’d, in his words ‘smashed’ his hand up in a crush injury, and developed what seemed to be complex regional pain syndrome in his non-dominant hand, which would have been fine if he had a pen and paper job. Joe didn’t, he worked as a joiner, a craftsman. What’s worse, he was self-employed, and during that two years his business went under, and his future as a skilled craftsman looked bleak.

Yes, he had compensation – 80% of the income he’d declared for tax purposes, which was nothing like what he’d actually made because much of his income had been plowed back into his business. And with compensation came a whole lot of requirements: to attend various people for assessments (he worked out he’d had 9 different assessments just for the medical or treatment part of his rehabilitation, a further 4 for vocational rehabilitation, and several for necessary equipment and support for home); to attend treatments (none of which had resolved his pain); to tell people about his distress and worries about his future; his life which had been very private, was now an open book to more people than he wanted to think.

Joe was asked to see me because he had refused to consider any of the options that his vocational assessment had come up with, and because when he had started to think about work, he became depressed and anxious. He told me he threw the vocational assessment in the bin because the suggestions were, in his words, ‘insulting’. He told me the assessor had no idea what a craftsman joiner actually did, and the list of potential jobs included ‘retail assistant’, ‘carpenter’, ‘builder’, ‘courier driver’.

When I reviewed the concerns Joe had about work, it’s no wonder he was stressed. I used a work self efficacy assessment to identify the areas he felt confident about, and those he didn’t. The areas he felt fine about were his ability to work out ways to keep himself safe at work, to let people know what he needed, and to be ‘a good employee’ – but he had very low confidence in these areas:
(1) ability to work a full day
(2) ability to meet quality requirements
(3) ability to tell others about his pain
(4) ability to obtain support and assistance from others
(5) ability to work in a way that used his skills

He told me the work was important because ‘it is who I am’. And who he was was a very capable, highly skilled man with an 18 year history of work as a joiner who produced quality goods that he could be proud of. He said he felt ashamed of his pain, and that he couldn’t be a ‘real man’ because his pain hadn’t resolved. And what’s more, he felt frustrated that the job options he’d been given were of such a low skill level. He’d put a huge investment of himself and his time and energy to develop a high level of technical skill into being a hands-on craftsman.

A couple of interesting things about this case – first of all, although details have been changed, this is a real situation. His angst is real, and his concerns about his future – and his response to his situation – are real.

He’d waited two years to hear that his pain was either going to go, or not. No-one had been clear with him that pain can become chronic, and that this is neither a death sentence, nor a life sentence. Life is possible with persistent pain. Instead he’d been held in stasis for that time, being uncertain which way to turn, and consequently he lost his business. Once he’d received the diagnosis and prognosis, he was able to confront his future – and yes, admittedly for a while he has become very distressed, but he told me that at last he could make clear choices.

What do we learn from that? Don’t fudge! If the chances of pain resolving are slim, let the person know so they can start to live.

The second point is that work is so much more than a way to earn a living.
I don’t know whether this particularly applies to men, but it certainly applies to tradesmen – their work is part of their identity, it carries more emotional significance than the pay-packet, it represents years of skill development, and no, suggesting that someone like this consider a job that is a step down is just not going to sit well!
I don’t know whether Joe will return to his previous work. He won’t be able to return to his business.

I do know that he now has a sense of hope as I’ve started to help him review his situation and see that what he views as a liability (ie his functional limitations) can be turned into an asset – he’s much more likely to be careful, safety-conscious, and efficient at his work because it matters to him if he hurts himself.

It will be a long road for Joe, he has a lot of pain management to develop, as well as addressing his lack of confidence and the mismatch between his expectations of himself and his current abilities. But this is pain management at the coalface – this is what I love.


Just included in this blog – my brief description of hypnosis and imagery in pain management! This is located in the ‘Coping Skills’ section – either click on the header above, or on the title on the link to the right.

If you have any questions or experiences using hypnosis, drop me a comment! I’ll be publishing a brief case study of hypnosis in complex regional pain syndrome soon, and a more detailed version of this study will be published in Ngau Mamae, the NZ Pain Society journal in March/Aril 2008.