Complex Regional Pain Syndrome

This assignment will help students integrate knowledge and skills developed in this course as well as previous courses.  Specifically, analysis of the case study will help prepare students to perform the following:   engage in problem-solving related to assigned interventions, respond to changes in client status,consider the impact of determinants of health on client well-being, collaborate with other team members, and communicate effectively and sensitively with clients.

 

Assignment steps

1.       This assignment must be completed individually.
2.      Read the case study carefully.
3.      Answer the questions using the textbook and previous course materials as a resource.
4.      Your answers should be typed, with each question clearly labeled.  You may answer in point form, as long as your provide your instructor with enough detail to follow your train of thought, and you use correct spelling and punctuation.

 

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Case Study: Complex Regional Pain Syndrome

 

You are the PTA/OTA in a multidisciplinary private clinic that is located in a large medical building with family physicians, specialists, a medical lab, and a pharmacy.  The clinic includes two full-time physiotherapists, two chiropractors, a massage therapist, and a part-time occupational therapist.  The clinic has a full range of therapeutic modalities including TENS, IFC, Laser, ultrasound, and basic exercise equipment such as a stationary bike, a treadmill, free weights and balance training equipment.

 

You are working with Keith Riverside, a sixteen-year-old high school student who has been diagnosed with complex regional pain syndrome (CRPS), a severe chronic pain syndrome that involves the sensory, motor and autonomic nervous systems.  He has no other medical concerns.

 

Four months ago, Keith twisted his right ankle playing basketball, and was treated immediately with ice and elevation.  In the emergency rooms, x-rays failed to reveal a fracture.  Keith was sent home with a diagnosis of a grade II ankle sprain and  instructions to continue icing, wrapping the ankle with a tensor bandage, and using crutches for NWB ambulation.

 

Two months later, the pain was continuing to get worse instead of better, so his family physician requested an MRI, which revealed a stress fracture of the calcaneus.  Keith was given a hard cast for one month.  His pain continued to increase, so his family physician removed the cast.  At that time, the physician noted persistent edema, sweating, allodynia (pain from stimuli that are not usually painful) in the foot and ankle and increased temperature in the lower leg and foot. He sent Keith for a bone scan which revealed a decrease in bone density.  The physician diagnosed Keith with complex regional pain syndrome, prescribed Percocet and referred him to your clinic.

 

Prior to his injury Keith was active in sports at school, including basketball, volleyball and downhill skiing.  He has not been able to participate in sports since then.  He dropped his physical education class, but has been able to continue with his other courses.  He has also limited his time socializing with his friends, because he finds it embarrassing when he can’t keep up.

 

Keith lives with his mother, stepfather and ten year-old half-sister in a townhouse with several flights of stairs.  He has a good relationship with all of his family members, including his father, who lives out of town but speaks regularly with him on Skype.  Because of his age, Keith qualifies for publicly-funded physiotherapy services, which is fortunate because Keith’s stepfather was laid off from his construction company, so money has been tight, despite financial support from Keith’s father.

 

Significant Findings from the Physiotherapy Assessment (chart # 2355):

Impairments:

  • Severe ankle and foot pain with an average pain rating of 10/10 in the previous 24 hours
  • Decreased AROM right ankle dorsiflexion/plantarflexion and inversion/eversion with active ankle dorsiflexion 0⁰ as compared to 15⁰ on the left, and ankle plantarflexion of 30⁰ compared to 60⁰ on the left side
  • Minimal swelling noted right ankle and foot with difference in volumetric water displacement right leg from knee to toes 35 mL greater than left

 

  • Decreased strength all ankle movements with an MMT of 3/5 and decreased strength knee flexion and extension with an MMT of 4/5
  • Severe pain and withdrawal reflex when client asked to weight bear in single-leg stance on the right leg
  • Pain with sensory stimuli of the ankle and foot including cold and light touch and deep pressure

Activity Limitations:

  • Ambulates with an antalgic gait pattern using toe-touch weight-bearing and axillary crutches short distances indoors independently
  • Able to ascend/descend 1 flight stairs with crutches and railing using toe-touch weight-bearing independently
  • Requires a wheelchair for outdoor mobility, propels independently

Participation Restrictions:

  • Inability to participate in sports
  • Inability to participate fully in schoolwork
  • Inability to socialize fully with friends

Current Role of the Physiotherapist:

Keith and the physiotherapist have established the following short term goals:

Impairments:

  1. Average pain rating will decrease from 10/10 in the previous 24 hours to 8/10 in the previous 24 hours in two weeks.
  2. AROM in right ankle plantarflexion will increase from 30⁰ to 40⁰ in two weeks
  3. AROM in right ankle dorsiflexion will increase from 0⁰ to 5⁰ in two weeks
  4. Swelling in right ankle will decrease to difference in volumetric water displacement of 20 mL as compared to left side in two weeks
  5. Strength in ankle movements will increased to MMT 3+/5 in three weeks
  6. Client will tolerate change in temperature when ankle and foot immersed in water from 38⁰C to 34⁰C in three weeks
  7. Client will tolerate sensory stimulation with wool on right leg in four weeks

Activity Limitations:

  1. Client will ambulate with normal gait pattern with partial weight bearing (40%) and axillary crutches X 50 m indoors in 3 weeks independently
  2. Client will ambulate with normal gait pattern with partial weight bearing (40%) and axillary crutches X 20 m outdoors independently in 3 weeks
  3. Client will ascend and descend 2 flights of stairs with partial weight bearing (40%) and axillary crutches independently in 3 weeks

 

Participation Restrictions:

  1. In three weeks, client will be able to socialize once per week for 2-3 hours

The physiotherapist is currently seeing Keith three times per week after school.  The treatment session with the physiotherapist consists of manual therapy, acupuncture, desensitization to touch using textured cloth, and gait training with manual assistance inside and outside of the parallel bars.

Current Role of the PTA:

Your role with the client is to administer contrast baths for desensitization to cold, teach Keith AROM exercises of the ankle, gentle strengthening exercises of the knee and practice ascending and descending stairs.

Questions (50 marks – 15% of final TecMod mark):

  1. Identify two determinants of health that may affect Keith’s rehabilitation and overall health and describe their potential impacts (refer to the IntRh student workbook and www.thecanadianfacts.org). (4 marks)
  2. Aside from the Numeric Rating Scale, what is another method of pain assessment that could be used with Keith? Give a rationale for your answer.(2 marks)
  3. Today is Keith’s first session with the contrast baths. What temperatures would you use for the warm and cool water?  Why?(4 marks)
  4. It is February, the temperature is well below zero degrees and there is a lot of ice and snow. What advice would you give Keith about going outdoors?(2 marks)
  5. The physiotherapist would like you to teach Keith long arc quads with an 8 lbs weight, but he cannot tolerate the ankle weight around his ankle because of his hypersensitivity to touch. How would you modify the exercise?(2 marks)
  6. Today the physiotherapist has inserted 5 acupuncture needles in Keith’s lower extremity and one in his hand. He is sitting in a chair in a treatment room.  There is a plinth next to him. You go in to check on him and notice he looks pale.  He tells you he feels like he is about to pass out.  What would you do?(3 marks)
  7. The physiotherapist has decided to refer Keith to the occupational therapist. What do you think the OT’s role would be with this client?(3 marks)
  8. Three weeks have passed and Keith’s pain and allodynia have decreased, although he still has trouble tolerating a lot of touch on his foot and ankle. He doesn’t want to take Percocets anymore because they make him “feel weird”.  The physiotherapist consults with the physician, and the physician prescribes a gradual decrease in medications.  The physiotherapist tries TENS at a frequency of 2 Hz and finds it is effective in helping Keith manage his pain.
    1. What type of pain relief can Keith expect with this type of TENS? (2 marks)
    2. He found the physiotherapist’s explanation about TENS was too complicated. He asks you to explain how the TENS works again. How would you put it into everyday words he can understand?(2 marks)

 

 

 

  1. Where do you feel the electrodes should be placed? Provide a rationale for your answer.(2 marks)
  2. The physiotherapist would like Keith to have a TENS unit to use at home, but his family cannot afford to purchase one at this time, and there are not enough units at the clinic to lend him one. Research potential affordable options in your community, and describe at least one.  Include a website or phone number.(2 marks)
  1. Charting:

 

Today is 8 days after the initial assessment.  Keith reports that his pain has decreased to an average of 8/10 in the previous 24 hours and is currently 7/10.  You measure the active range of motion in his right ankle and find that he is able to dorsiflex to 10⁰ and plantarflex to 50⁰.  You practice crutch walking and find he is able to ambulate with a normal gait pattern X70 m with partial weight bearing independently.  You practice stairs with him and find he is able to ascend and descend 2 flights independently with crutches and no railing with partial weight bearing.  You feel that Keith is doing so well; it might be time for the physiotherapist to conduct a full reassessment.

 

Document today’s session with Keith using SOAP format.  Be sure to include information about Keith’s progress towards his short term goals.(12 marks)

 

  1. Keith used to chat with you about hockey and other sports, but over the last few sessions, you’ve noticed that Keith has become more and more withdrawn. He doesn’t seem to want to chat anymore.  He also seems to be neglecting his appearance.  You are concerned about his mental health.  You have mentioned it to the physiotherapist and she has asked you to broach the subject with him, as you have developed a good relationship with him.
    1. What differences exist between you and Keith in terms of age, gender and culture? How will these differences influence the way you approach this sensitive topic? (3 marks)
    2. Describe how you would approach Keith. How would you prepare yourself for this conversation? Where would you talk to him? (2 marks)
    3. Today when Keith comes into the clinic, you notice that he is showing very little emotion and it looks like he hasn’t washed his hair or changed clothes. When you approach him about his mental health he admits that he has been feeling depressed, but denies thoughts of suicide.  He says “I just feel so hopeless.  This is never going to get better, what’s the point?”  He tells you that he has not talked to anyone else about his mental health.  He says his family has a lot to worry about right now and doesn’t want to add to their problems.  How will you respond to this information?  List at least three specific actions you will take.(3 marks)

 

 

 

 

  1. Six weeks have passed and Keith is still working with you as a client, but his ankle pain has decreased significantly and his level of function has improved. In addition, because of your intervention regarding Keith’s mental health, he approached his family about his feelings, and they made sure he received the medical help he needed.  His mental health has improved dramatically.  His family is so grateful to you; they have asked you to dinner in their home to thank you.  Will you accept their invitation?Why or why not? (2 marks)

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