18.8 CRPS

Question 1

a) List the symptoms of complex regional pain syndrome (CRPS). (9 marks)

Answer 1

Symptoms

Sensory:

• Hyperaesethesia.

• Allodynia.

Vasomotor:
• Temperature asymmetry.

• Skin colour changes.

• Skin colour asymmetry.

Sudomotor/Oedema:
• Oedema.

• Sweating changes.

• Sweating asymmetry.

Motor/trophic:
• Decreased range of motion.

• Motor dysfunction
(weakness, tremor, dystonia).

• Trophic changes
(hair, nail, skin).

Question 2

a) List the signs of complex regional pain syndrome (CRPS). (9 marks)

Answer 2

Sensory:
• Hyperalgesia (to pinprick).

• Allodynia
(to light touch or deep somatic
pressure or joint. movement).

Vasomotor:
• Temperature asymmetry.

• Skin colour changes.

• Skin colour asymmetry.

Sudomotor/Oedema:
• Oedema.

• Sweating changes.

• Sweating asymmetry.

Motor/trophic:
• Decreased range of motion.

• Motor dysfunction (weakness, tremor,
dystonia).
• Trophic changes (hair, nail, skin).

Question 3

b) What other features, apart from signs and symptoms, are essential for the diagnosis of CRPS?
(2 marks)

Answer 3

According to the Budapest criteria,
there are four criteria that
need to be satisfied for diagnosis.
The first two are:
» At least one symptom in at least three
of the four symptom categories.

> > At least one sign in at least
two of the four sign categories.

The remaining two criteria are the answers to
section (b) of this question:

> > Continuing pain disproportionate to inciting event.

> > No other diagnosis that can
explain symptoms and signs.

Question 4

c) What are the available
treatments for CRPS? (9 marks)

Answer 4

Prevention is ideal:

there is evidence to suggest that good early pain control
after injury may reduce incidence of CRPS.

Also, a single, prospective,
double-blinded study of vitamin C
(an oxygen free radical antagonist)
after wrist fracture (500 mg od, 50 days)
showed reduced incidence of CRPS

Question 5

c) What are the available treatments for CRPS? (9 marks)

Answer 5

1. Patient information and education:
2. Physical and vocational rehabilitation:
3. Pain relief (medication and procedures):
4. Psychological interventions:

Question 6

c) What are the available treatments for CRPS? (9 marks)

Answer 6

There are four management ‘pillars’; start early
and aggressively for best outcome:

1. Patient information and education:

Outcome may be improved by
full patient education about what
CRPS is and how it is to be managed.

2. Physical and vocational rehabilitation:
   • Physiotherapy: desensitisation,
   gradual weight bearing, fine motor exercises,
   aerobic conditioning, TENS, hydrotherapy.

• Oedema control strategies.

• Occupational therapy:
pacing prioritising planning, vocational
support, relaxation techniques.

• Multidisciplinary pain management.

• Motor therapy: mirror visual feedback.

3. Pain relief (medication and procedures):
   • Start with amitryptiline, move on if not effective or not tolerated to duloxetine, gabapentin or pregabalin.

• Tramadol for rescue only, not long term.

• Consider capsacin cream for
localised neuropathic pain or to avoid
oral treatments.

• Bisphosphonates:
pamidronate 60 mg single intravenous dose for
patients with CRPS less than six months’ duration to help maintain bone integrity and function.

• Spinal cord stimulation:
NICE approved for pain persisting greater
than six months.

4. Psychological interventions:
   • Cognitive behavioural therapy:
   ensure that fear does not reduce
   limb movement and use which
   can exacerbate disuse atrophy.

• Possible psychiatric issues and
other life stressors should be
sought and dealt with.