CRPS Flashcards
What is hyperalgesia?
heightened response to pain due to a lowering of pain threshold
what is allodynia?
pain from a non-noxious stimulus on normal skin
what is the etiology of CRPS?
usually occurs after trauma- minor or major
*10% of cases have no traumatic or very minor event
what is the most significant risk factor for CRPS?
motor nerve injury
what are the characteristics of CRPS?
- pain out of proportion to injury
- hyperalgesia/allodynia
- vasomotor chgs- skin/temp abnormalities
- sudomotor chgs- edema or sweating abnormalities
- motor/trophic chgs- decreased ROM, weakness, tremor or neglect, changes to hair, nails, skin
pathophysiology of CRPS?
- not fully understood
- overactivity of SNS
- peripheral response to nerve injury
- central sensitization
what is aka “reflex sympathetic dystrophy?
CRPS 1
which type of CRPS develops after trauma without any definable nerve damage?
CRPS 1
what is the most common form of CRPS?
CRPS 1
what is aka “causalgia”?
CRPS 2
Which type of CRPS has an identifiable nerve injury?
CRPS 2
what were the limitations of the IASP diagnostic criteria of CRPS?
- doesn’t include motor changes
- sensitive but not specific
So, Budapest criteria was developed. What diagnostic criterai does this include?
at least 3 symptoms in each category
and 2 clinical sign categories
What are some DDx of CRPS?
DVT thrombophlebitis cellulitis lymphedema vascular insufficiency neuropathy thoracic outlet syndrome
what relationship do people with CRPS and psychological disorders have?
researched showed that there is no link with pre-existing psychological disorders
research has showed that there are possible links of ___ with CRPS
migraines osteoporosis preexisting neuropathy asthma recent menstrual disorders
how does patient with CRPS present?
- pain out of proportion
- allodynia and hyperesthesia
- pain that does NOT follow dermatome and spreads beyond area of injury
- severe, burning throbbing pain
what sympathetic changes are seen in patient with CRPS?
-skin can be red, hot, dry one second and then cold, blue, with mottling and hyperhydrosis the next
what trophic changes are seen in CRPS?
- hair and nail growth dec.
- skin thins
- fat atrophy
- adhesions and contractions of tendon and ligaments
what motor disturbances are seen in patients with CRPS?
stiffness tremor posturing exaggerated tendon reflex myoclonic jerks dystonia
describe stage 1 of CRPS.
(acute stage) : good prognosis
- skin warm, red, and dry then may become blue and cold
- hyperhydrosis, edema
- severe pain with allodynia and hyperalgesia
describe stage 2 of CRPS.
(dystrophic)
- X ray changes *
- muscle wasting begins*
- pain becomes more severe and diffuse
- edema becomes hardened
- hair and nail changes
describe stage 3 of CRPS.
(atrophic) -pain may start decreasing but motor and trophic changes increase
* tissue wasting occurs and can become permanent
in which stage does radiographic changes of Sudeck’s atrophy occur?
stage 2
*you start to see radiographic changes in stage 2
What radiographic changes are seen in sudeck’s atrophy?
- patchy osteoporosis
- accentuated joints
- subchondral bone resorption
- ground glass appearance
radiographic changes of Sudeck’s atrophy may also be seen in what diseases?
disuse atrophy or severe osteoporosis
What bone scan would you use to diagnose CRPS?
3 phase Technesium 99 bone scan
what would you see on a Tc-99 scan if sudeck’s atrophy was present?
increased periarticular uptake, esp in 3rd phase
what is sympathetic ganglion blocks used for?
useful for purely sympathetically mediated disease
What other additional tests can you use to diagnose CRPS?
infared thermography
sweat tests- sudomotor activity
what treatment steps do you have for CRPS?
- early diagnosis is key
- CONSULT (multi-disciplinary approach)
- no evidence-based treatment recommendations
what treatment options area available then?
physical therapy neuromodulation pharmacologic sympathetic blocks surgical neurolysis botulinum injections
what is the 1st line treatment for potential CRPS?
physical therapy
-start immediately!
what pharmacological approaches can you take?
corticosteroids
bisphosphonates
anticonvulsants
antidepressants
what is the MOA for corticosteroids in treating CRPS?
thought to inhibit inflammatory mediators and help degrade neuropeptides
what is usually 1st line drug treatment for CRPS?
corticosteroids
*not recommended for use over 1 month though
what is teh MOA by which bisphosphonates treats CRPS?
helps reduce bone remodeling and associated pain
How do anticonvulsants and antidepressants work to treat CRPS?
do not change the nerves themselves; but rather the abnormal signals they send
which topical agents can be used to treat CRPS?
EMLA
capsaicin
where are lumbar sympathetic blocks done?
T12- L1
*will see dilation of veins, dry skin, and increased limb temp
what is botox used for?
treat contractures and dystonia in late stages of CRPS
there is strong evidence for which treatment modalities?
#1 -rehab/ PT bisphosphonates
there is moderate evidence for which treatment modalities?
low-dose IV ketamine infusion
there is limited evidence for which treatment modalities?
oral tadalfil
low-dose IVIG
spinal cord stimulation
combined morphine and memantine
what are the treatment goals?
recovery of fxn and reduction of pain
how can you prevent against CRPS?
- careful surgical technique
- early active ROM
- vitamin C
- local anesthetic blocks pre-operative
what is the MOA for vitamin C in preventing CRPS?
antioxidant properties
~5 fold reduction in occurence of CRPS
