4.4 CRPS Flashcards
A 37-year-old female is referred to the pain clinic with a possible diagnosis of complex regional pain syndrome (CRPS). She had a right wrist fracture and was in a plaster cast for 6 weeks. She developed severe pain even on light touch as soon as the cast was removed.
a) What is CRPS?
Complex regional pain syndrome (CRPS)
is a post-traumatic disorder
consisting of a non-dermatomal distribution
of continuous and severe pain in the affected limb,
associated with varying combinations of
sensory,
motor,
vasomotor,
sudomotor,
and trophic disturbances
in the affected area
b) How is CRPS classified?
● CRPS type I — no demonstrable nerve lesion or damage.
● CRPS type II — nerve damage or lesion present.
c) List the symptoms and signs of CRPS from the Budapest
diagnostic criteria and explain these criteria.
Symptoms and signs from the Budapest criteria.
Symptoms
(must report at least one symptom
from three out of four categories):
1 ● Sensory —
suggestive of hyperalgesia and/or allodynia.
2 ● Vasomotor —
temperature asymmetry and/or
skin colour changes
and/or skin colour asymmetry.
3 ● Sudomotor/oedema —
oedema and/or sweating changes and/or
sweating asymmetry
4 ● Motor/trophic —
decreased range of motion and/or
motor dysfunction
(weakness, tremor, dystonia)
and/or trophic changes
(hair, nail, skin).
____________________________________________
Signs
(must have evidence of at least one sign from two out of four
categories):
● Sensory —
evidence of hyperalgesia (to pinprick) and/or
allodynia (to light touch and/or deep somatic pressure
and/or joint movement).
● Vasomotor —
evidence of temperature asymmetry
and/or skin colour changes and/or asymmetry.
● Sudomotor/oedema —
evidence of oedema and/or sweating changes
and/or sweating asymmetry.
● Motor/trophic —
evidence of a decreased range of motion
and/ or motor dysfunction
(weakness, tremors, dystonia)
and/or trophic changes (hair, nail, skin
Other needed criteria:
● Continuing pain that is disproportionate to the initiating event.
● No other diagnosis can explain the signs and symptoms.
d) How would you manage and treat this patient with CRPS?
● A multidisciplinary team approach,
using a biopsychosocial model.
● Treatments can be classified into
non-pharmacological,
pharmacological and interventional.
Non-pharmacological:
● Early physical rehabilitation and
early physiotherapy reduce pain and
improve function.
● Psychologist input for patients with psychological
issues such as an inability to cope or
chronic pain behaviour.
● Laterality recognition, mirror-box therapy.
● Complimentary therapies like
acupuncture and TENS
have limited evidence.
Pharmacological:
● Medications for neuropathic pain —
amitripytline (tricyclic),
gabapentin and pregabalin
(alpha-2 delta calcium channel ligand),
duloxetine (SNRI).
● Topical agents like lignocaine 5% plaster, capsaicin cream.
● N-acetyl cysteine intravenously.
● If vasomotor disturbance is prominent —
calcium channel blockers,
alpha-blockers or phosphodiesterase-5 inhibitors.
● If there is associated dystonia —
give a muscle relaxant, e.g. baclofen.
● Intractable pain —
low-dose IV ketamine, then converted to oral use.
● High-dose vitamin C — possible preventive role.
● Immunomodulators —
glucocorticoids, anti-TNF-alpha,
bisphosphonates
Interventional:
● Sympathetic blocks;
however, there is negative evidence published as per the updated EBGD (Evidence-based Guideline Development)
guidelines for CRPS 1 (2014).
● Spinal cord stimulation — evidence-based —
a positive effect on the
somatosensory system
and vasomotor disturbances.
