CRPS and Chronic Pain Behviour

Question 1

Complex regional pain syndrome (CRPS)

Answer 1

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

Question 2

CRPS: epidemiology

Answer 2

Age 40-60
-younger pt’s have better prognosis

3 F : 2 M

8-10% pt’s with fracture develop CRPS

Question 3

CRPS: diagnostic criteria

Answer 3

• 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

Question 4

CRPS: chracteristic

Answer 4

• 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)

Question 5

Type 1 CRPS

Answer 5

develops following a noxious event (e.g. fracture(

Question 6

Type 2 CRPS

Answer 6

secondary to nerve injury

-causalgia: cross-talk between nerves

Question 7

cross-talk theory

Answer 7

short circuit in the reflex arc between somatic afferent sensory fibres and autonomic sympathetic efferent fibres, causing increased sympathetic stimulation

Question 8

Bone scan and CRPS

Answer 8

the most reliable diagnostic tool (side from a physical examination)

three-phase bone scan has better specificity

periarticular accentuation is characteristic

Question 9

Radiographs and CRPS

Answer 9

periarticular demineralization: requires 30-50% alteration in calcium content to show on a radiograph

also: look for bony trauma

Question 10

Budapest Criteria (2010) for CRPS diagnosis

Answer 10

1. continuing pain that’s disproportionate to event
2. 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
3. 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

Question 11

3 stages of CRPS

Answer 11

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

Question 12

CRPS treatment

Answer 12

• 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

Question 13

tolerance

Answer 13

greatest level of discomfort a person is prepared to endure

person requires increased amount of substance/stimuli to acheive desired effect

Question 14

pain threshold

Answer 14

least level of stimulus intensity perceived as painful

Question 15

allodynia

Answer 15

pain caused by stimulus NOT NORMALLY causing pain

Question 16

mechanical allodynia

Answer 16

static mechanical allodynia i pain in response to light touch/pressure

dynamic mechanical allodynia is pain response to brushing

Question 17

thermal allodynia

Answer 17

hot or cold allodynia is pain in response to mild skin temperatures in affected area

Question 18

four stage integrated model for chronic pain

Answer 18

stage 1: pain sensation

stage 2: immediate unpleasantness

stage 3: suffering (negative beliefs and emotions)

stage 4: illness behaviour

Question 19

somatic pain

Answer 19

arises from skin, muscle, joint, connective tissue or bone

“som-“= body

som-BODY once told me

Question 20

pre-operative neuroscience education tools (PNET)

Answer 20

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

Question 21

barriers to effective pain management

Answer 21

-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

Question 22

Chronic pain syndrome: the D’s

Answer 22

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

Question 23

chronic pain syndrome cycle

Answer 23

1. pain catastrophizing: increased sense of helplessness, rumination and magnification of feelings toward painful situation
2. kinesiophobia: fear of movement/activity–> vulnerability to injury-reinjure
3. fear avoidance behaviours: pain perception with physiological repsonse
   - emotional repsonse to pain

4.disability, disuse, depression, sick leave