CRPS and Chronic Pain Behviour Flashcards
Complex regional pain syndrome (CRPS)
Incompletely understood response of the body to an external stimulus
Results in non-anatomic pain that is disproportionate to the trauma or expected healing response
-best identified or diagnosed with thermography and bone scans
CRPS: epidemiology
Age 40-60
-younger pt’s have better prognosis
3 F : 2 M
8-10% pt’s with fracture develop CRPS
CRPS: diagnostic criteria
- follows noxious event/nerve injury
- spontaneous, prolonged pain out of proportion, not limited to a single peripheral nerve area
- edema or skin blood flow abnormality in area of pain since event
- ddx excluded
CRPS: chracteristic
- intense or unduly prolonged pain
- vasomotor disturbances
- delayed functional recovery
- trophic changes (skin, nails, hair): waxy/moist skin; hair loss, finger spindling (loss of knuckle creases)
- muscle contractures (e.g., dupuytren’s)
- decreased ROM
- common dystonic postures (shoulder adduction, flexion of elbow wrist finger), fine tremor)
Type 1 CRPS
develops following a noxious event (e.g. fracture(
Type 2 CRPS
secondary to nerve injury
-causalgia: cross-talk between nerves
cross-talk theory
short circuit in the reflex arc between somatic afferent sensory fibres and autonomic sympathetic efferent fibres, causing increased sympathetic stimulation
Bone scan and CRPS
the most reliable diagnostic tool (side from a physical examination)
three-phase bone scan has better specificity
periarticular accentuation is characteristic
Radiographs and CRPS
periarticular demineralization: requires 30-50% alteration in calcium content to show on a radiograph
also: look for bony trauma
Budapest Criteria (2010) for CRPS diagnosis
- continuing pain that’s disproportionate to event
- must have ONE SYMPTOM in 3-4 categories
- sensory: hyperesthesia and/or allodynia
- vasomotor: temp and/or colour changes or asymmetry
- sudomotor: edema and/or sweating
- motor/trophic: reduced ROM and/or dysfunction, trophic changes - must have ONE SIGN in 3-4 categories
- sensory: hyperalgesia to pinprick and/or allodynia to touch, pressure or joint motion
- vasomotor: temp asymmetry and/or skin colour change/asymmetry
- sudomotor: edema or sweating changes
- motor/trohpic: signs of reduced ROM, dysfunction
3 stages of CRPS
RED (acute): 0-3 months
-puffy, swelling, red/warm, hyperhidrosis, decreased ROM, normal x rays, positive bone scan
white (dystrophic): 3-6 month
-pain worsening, hard edema, dry/cyanotic skin, skin atrophy, osteopenia, dupuytren’s
blue (atrophic); >6-12 months
-pale/cool/dry/glossy skin, joint contracture, severe osteopenia, finger spindling, fragile hair and rigid nails, DECREASED PAIN
CRPS treatment
- reassurance
- analgesic: NSAIDS, gabapentin,
- intensive passive and active care
- avoid immobilization
- sympathetic block: BEST dx test, where 2/3 patients get significant relief
- surgery: last resort
tolerance
greatest level of discomfort a person is prepared to endure
person requires increased amount of substance/stimuli to acheive desired effect
pain threshold
least level of stimulus intensity perceived as painful
allodynia
pain caused by stimulus NOT NORMALLY causing pain
mechanical allodynia
static mechanical allodynia i pain in response to light touch/pressure
dynamic mechanical allodynia is pain response to brushing
thermal allodynia
hot or cold allodynia is pain in response to mild skin temperatures in affected area
four stage integrated model for chronic pain
stage 1: pain sensation
stage 2: immediate unpleasantness
stage 3: suffering (negative beliefs and emotions)
stage 4: illness behaviour
somatic pain
arises from skin, muscle, joint, connective tissue or bone
“som-“= body
som-BODY once told me
pre-operative neuroscience education tools (PNET)
pain communication tool that shows peripheral sensitization can be valuable for understanding if a patient udnertsand where the pain threshold is and if they feel alarmed
helps prevent overreacting to nociceptive stimuli before it truly becomes a painful entity
barriers to effective pain management
-attitudes/confusion from health care providers
-hidden biases and misconceptions about pain, anticipation of progress
=inadequate pain assessment
-failure to understand patient’s report of pain
-withholding pain-relieving meds
-exaggerated fears
-poor communication
-cost, time, other life activities
Chronic pain syndrome: the D’s
at least 4 of the following D’s need to be present to be diagnosed with CPS
- duration
- dramatization
- drugs
- despair
- disuse
- dysfunction
- diagnostic dilemma
- dependence on others/on passive physical therapy
chronic pain syndrome cycle
- pain catastrophizing: increased sense of helplessness, rumination and magnification of feelings toward painful situation
- kinesiophobia: fear of movement/activity–> vulnerability to injury-reinjure
- fear avoidance behaviours: pain perception with physiological repsonse
- emotional repsonse to pain
4.disability, disuse, depression, sick leave
