26. Complex regional pain syndrome Flashcards
What do you understand by the term ‘complex regional pain syndrome’?
Diagnostic criteria for CRPS
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
> > Continuing pain disproportionate to inciting event.
> > No other diagnosis that can explain symptoms and signs
CRPS II
1. Continuing pain, allodynia or hyperalgesia following a nerve injury, not
necessarily limited to the distribution of the nerve.
What are the 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).
List the signs of complex regional pain syndrome (CRPS)
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).
Allodynia
Pain from a stimulus that does not normally cause pain.
Hyperalgesia
A heightened response to a stimulus, which is normally
painful.
Hyperpathia
Severe pain in an area of numbness.
What are the available treatments for CRPS?
- Patient information and education:
- Physical and vocational rehabilitation:
- Pain relief (medication and procedures):
- Psychological interventions:
- Patient information and education:
There are four management ‘pillars’; start early and aggressively for best outcome:
Outcome may be improved by full patient education about what
CRPS is and how it is to be managed.
- 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.
- 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.
- 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.