Chronic Regional Pain Syndrome Flashcards
What is the main characteristic of CRPS?
Severe pain disproportionate to coinciding event
What are the symptoms for CRPS?
Sensory disturbances Temperature changes Abnormal sweating patterns Swelling and oedema Reduced ROM Movement abnormalities Trophic changes Localised OP changes and body perceptions
How do patients with CRPS describe pain?
Continuous most severe pain
- Intensity high
- Painful response from non-painful stimulus
- Hyper pain response
How do we diagnose CRPS?
Assessment of sensory motor autonomic skin and bone abnormalities in affected limb
History: No correlation between symptoms and cause of injury
Present with mixed pain
Which group is more likely to have CRPS?
Women 3-4x more
What happens when a tissue is injured?
- Activate release of neurotransmitter from primary neuron
- Release from the immune cells of inflammatory mediators
- Vasodilation response at nerve endings
What is the process that causes pain?
- Peripheral activation of primary neurons
- Sensory signals travel by primary afferent fibres into dorsal horn
- Synapses with intrinsic spinal horn neurons - 2nd order neurons
- Signals to many areas of the brain
- Down modulation of signals
What are the 4 pain mechanisms of CRPS?
- Aberrant (neurogenic) inflammation
- Vasomotor dysfunction
- Nociceptive sensitization
- Maladaptive neuroplasticity
What is Aberrant Inflammation?
- Reduced sympathetic outflow causing vasodilation
- Increased peripheral cytokine and chemokine leading to activation of nociceptive sensory neurons, proinflammatory
What is vasomotor dysfunction?
- Endothelial dysfuncton/damage –> vasoconstriction
- Peripheral cytokine and chemokine
What is nociceptive sensitisation?
- Central and peripheral
- Reduced endogenous pain control –> allodynia, hyperalgesia, motor dysfunction, disruption in perception
Maladaptive neuroplasticity
- Ipsi and contralateral cortical changes
- Neural degeneration of C and A-d fibres –> allodynia, hyperalgesia, motor dysfunction, disruption in perception
What are the immune alterations associated with CRPS?
- Systemic- anti autonomic immunoglobulin G autoantibodies high prevalent
- Mild pro-inflammatory states in affected skin, muscle, bone and peripheral blood
- No systemic inflammatory signs (blood)
What are 3 subtypes of CRPS?
- not useful much anymore
I - no nerve damage
II - nerve damange
NOS - Not useful, as it is being defined around mechanisms
Cold Vs Warm models
Cold: Cold, blue, dry, less oedematous
Warm: Warm, red, sweaty, oedematous
What is the way to measure subsets of CRPS?
Severity
CRPS score, clusters in CSS may represent subsets such as autonomic dysfunction subset
Refer to CRPS severity score
What are the risk factors?
Demographic and trauma RF
- Unusually high level of pain during week of trauma
- Female?
- Fracture, surgery, soft tissue injury
Psychological risk factors
- Alexithymia (differentiation between emotion and bodily sensations
- PTSD
What does the subjective assessment for CRPS consist of?
- Same MS questions
- Chronic pain questions
- Budapest criteria
- Questioning regarding body schema e.g. body perception
What makes up the physical examination for CRPS?
Budapest criteria
Clinical sensory testing
Balance, coordination, gait, weightbearing
Body schema testing
Category 1: sensory
What are the signs and symptoms and clinical diagnosis?
Symptoms: Hyperaesthesia, allodynia
Signs: Hyperalgesia to pinprick, allodynia to light touch, deep somatic pressure or joint movement
Clinical diagnosis: 1+ symptoms in 3 categories, 1+ signs in 2 categories
Category 2: Vasomotor
What are the signs and symptoms and clinical diagnosis?
Symptoms/signs:
- skin temperature asymmetries
- skin colour changes
- skin colour asymmetry
Clinical diagnosis same as sensory
Category 3: Sudomotor or Oedema
What are the signs and symptoms and clinical diagnosis?
Symptoms/signs
- Oedema
- Sweating changes
- Sweating asymmetry
Same clinical diagnosis numbers
Category 4: Motor or Trophic
What are the signs and symptoms and clinical diagnosis?
Symptoms/signs
- Decreased ROM
- Motor dysfunction: weakness, tremor, dystonia
- Trophc: hair, nails, skin
What are differences in S/s of CRPS vs non CRPS?
Allodynia: 83% vs 44%
Pinprick hyperalgesia: 89% vs 37%
1.5deg temp diff: 59% vs 15%
What are questions that are helpful for differential diagnosis?
- Has extent of primary pathology been recognized and managed (carpal instability following Colles fracture)
- Secondary pathology present?
- Psychological/psychiatric symptoms present?
What are the 5 stages to multidisciplinary treatment?
Engagement Education Activation Body perception Psychological practice
What are the factors of early diagnosis?
Pain reduction Oedema reduction Fear reduction Sensory motor reintegration Address impairments
What makes up education in treatment for CRPS?
Suited to person Multimodal Analogies Reassurance Realistic journey
What makes up activation in treatment for CRPS?
Graded exposure
Pacing
Patient led
Specific –> Functional
What makes up body perception in treatment for CRPS?
Graded motor imagery: laterality, imagine movements, mirror therapy
Mindful movement
Movement with relaxation
Desesnitisation
What makes up body perception in treatment for CRPS?
Graded motor imagery: laterality, imagine movements, mirror therapy
Mindful movement
Movement with relaxation
Desesnitisation
How to conduct psychological practice for CRPS?
- Communication and language
- Address fear avoidance/catastrophising
- Belief system
- CBT
- motivational interviewing
- Patient led goals
- Sense of self
