complex regional pain syndrome
TRANSCRIPT
ProfChris Oliver
COMPLEX REGIONAL PAIN SYNDROME
Complex regional pain syndromeReflex sympathetic dystrophySudeck’s atrophyCausalgiaMinor causalgiaMimo-causalgiaAlgodystrophyAlgoneurodystrophyPost-traumatic pain syndromePainful post-traumatic dystrophyPainful post-traumatic osteoporosisTransient migratory osteoporosis
SYNONYMS
hand or footkneeelbow rarely involvedshoulder common
frozen shoulder probably CRPShip in pregnancy
SITES OF PREDILECTION
I
II with obvious nerve lesion
CRPS TYPES
Preceding noxious event Spontaneous pain or
hyperalgesia/hyperesthesia not limited to a single nerve territory and disproportionate to the inciting event
Oedema, skin blood flow (temperature) or sudomotor abnormalities, motor symptoms or trophic changes are present on the affected limb, in particular at distal sites
Other diagnoses are excluded
DIAGNOSIS – IASP (1994)
Pain and hyperalgesia are the most important symptoms.
75% of patients had pain at rest Nearly all (100%) patients described hyperalgesia.
Mechanical hyperalgesia explains the motion-dependent amplification of pain in all CRPS patients.
Allodynia (brush-evoked pain)Record Pain 0-10 Scale
SENSORY DISTURBANCES
77% of CRPS patients have weakness.Range of motion is reduced by oedema in acute stages, in chronic stages contraction and fibrosis
50 % tremor can be seen 30% myoclonus or focal dystoniaAfter a nerve lesion 45% of the patients have exaggerated deep tendon reflexes
kinesiophobia
MOTOR DISTURBANCES
acute stages 81% patients have oedemafirst months of CRPS skin is red and hotchronic stages skin turns to bluish/cold20% of CRPS cases are primarily coldtemperature difference between sides is more than 1.0 °C
50% of the patients increased sweatingTest Tubes
AUTONOMIC DISTURBANCES
50% of CRPS patients.Increased hair-nail growth initiallyLater reduced hair-nail growthSevere cases atrophy of the muscles with fibrosis and contracture can occur
TROPHIC CHANGES
clinical examinationRadiography - spotty osteoporotic 4–8 weeks.
40% cases.Three phase bone scintigraphy - increased
bone metabolism.MRI - exclude other diseases. CRPS oedema in
deep tissuesAfter gadolinium injection subtle enhancement is
seen which points to an increased permeability of blood vessels but not really specific.
DIAGNOSTIC TOOLS
Chronic release of neuropeptides?central neuropeptide release facilitates nociceptive sensitization
Nerve lesionscould explain increased skin temperature,
oedema and trophic changesSympathetic nervous system failure?Sympathetico-afferent coupling?
NEUROGENIC INFLAMMATION, PAIN AND HYPERALGESIA
Chronic pain might effect cortical processing of touch in CRPS
LONG TERM ACTIVATION OF PRIMARY AFFERENTS TRIGGERS CORTICAL CHANGES
HLA-association?Genetic mechanism?
Psychosomatic background
WHY DO SOME PATIENTS DEVELOP CRPS AND OTHERS NOT?
Heterogeneous
1 Early
2 Middle
3 Late
STAGING
aims CRPS therapyrelief of painmaintenance or restitution of functiontherapy has to start ASAP
TREATMENT CRPS
Role limitedNot indicated to release contracturesAmputation of a limb affected by severe CRPS should be approached with great caution. Unpredictable
Surgery may exacerbate CRPS or precipitate a new attack
SURGERY AND CRPS
SteroidsSympathetic blocksRadical scavengersCalctionin – biphosphanatesAntidepressants, Antiepileptic'sGabapentin – pregabalinSpecialist Pain Clinic
DRUG TREATMENT CRPS
PhysiotherapyFunctional restorationDesensitisationTENS
Psychology Depression and anxietyPTSD
Occupational Therapy
NON-DRUG THERAPY
Self-mutilation
FACTITIOUS DISORDERS OF THE UPPER LIMB
Body identity disorder
FACTITIOUS DISORDERS OF THE UPPER LIMB
Non healing wounds
FACTITIOUS DISORDERS OF THE UPPER LIMB
Costs high. doctor/patient interface undermined by deception, risk of
litigation.high index of suspicion/adequate notes Knowledge of characteristic deformities useful.Potential gain has many different forms.CRPS Type 1 suspicion a full review of the hospital records
may indicate similar attendances to other specialities or previous psychiatric problems.
‘‘La belle indifference’’ Patients with factitious disorders are “ill”Psychology or Psychiatry
FACTITIOUS DISORDERS OF THE UPPER LIMB
