COMPLEX REGIONAL PAIN SYNDROME (crps)

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COMPLEX REGIONAL PAIN SYNDROME (crps)

• THE CIVIL WAR DISEASE

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COMPLEX REGIONAL PAIN SYNDROME HISTORY

• "Perhaps few persons who are not physicians can
  realize the influence of which long-continued and
  unendurable pain can have upon both body and
  mind".
• Silas Weir Mitchell, a Philadelphia neurologist
  treating causalgia in Civil War soldiers in 1864
• His observations

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SILAS WEIR MITCHELL 1864

• "its favorite site is the foot or hand...the palm
  of the hand or palmar face of the fingers, and on
  the dorsum of the foot scarcely ever on the sole
  of the foot or the back of the hand
• When it first existed in the whole foot or hand,
  it always remained last in the parts referred
  to...if it lasted long it was finally referred to
  the skin alone.
• The part itself is not alone subject to an
  intense burning sensation, but becomes
  exquisitely hyperaesthetic, so that a touch or a
  tap of the finger increases the pain."

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SILAS WEIR MITCHELL 1864

• "As the pain increases, the general sympathy
  becomes more marked. The temper changes and grows
  irritable, the face becomes anxious, and has a
  look of weariness and suffering.
• The sleep is restless, and the constitutional
  condition, reacting on the wounded limb,
  exasperates the hyperaesthetic state, so that the
  rattling of a newspaper, a breath of air...the
  vibrations caused by a military band, or the
  shock of the feet in walking, gives rise to
  increase of pain.

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SILAS WEIR MITCHELL 1864

• At last...the patient walks carefully, carries
  the limb with the sound hand, is tremulous,
  nervous, and has all kinds of expedients for
  lessening his pain."

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WHATS IN A NAME?
Algodystro-phy Mimo causalgia Sudecks atrophy Minor caus-algia
Major causalgia Reflex neurovas-cular dystrophy Post-traumatic dystrophy Post-traumatic algodystro-phy
Neurovas-cular dystrophy Morbus Sudeck Pourfour du Petit Syndrome Peripheral trophoneurosis
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RSD RENAMED

• Reflex Sympathetic Dystrophy renamed as Complex
  Regional Pain Syndrome in 1995
• CRPS type 1 is RSD
• CRPS type 2 is Causalgia (nerve lesion)
• Current evidence suggests CRPS 1 is minute nerve
  injury in C fibers (Oaklander AL MD PhD et al
  Pain 2006)

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CRPS TODAY

• Multi-system syndrome characterized by chronic
  pain usually affecting one limb
• Can begin/affect any part of the body
• Blood supply to the limb is affected
• Hand, knee, hip and shoulder most commonly
  affected
• Early diagnosis brings best prognosis

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WHAT CAUSES RSD/CRPS?

• 65 cases soft tissue injury e.g. sprain
• Fracture or surgery
• Back/neck disorders
• Cumulative strain injury, repetitive strain
• Other infection, stroke, heart attack,
  venipuncture

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SYMPTOMS

• PAIN in area other than primary site
• SWELLING
• SKIN CHANGES in temperature (hot/cold) and color
  (red, blue, mottled)
• MOVEMENT limited active range of motion
• INCREASE of complaints after exercise
• IASP criteria

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OTHER SYMPTOMS

• Motor dysfunction tremor, weakness, atrophy,
  myoclonus, dystonia
• Limbic system dysfunction insomnia, agitation,
  depression, memory loss, anxiety
• Hair, skin and nail changes
• Sweating (not in all cases)

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HOW IS IT DIAGNOSED?

• THERE IS NO SINGLE TEST
• Thorough medical history and examination by a
  qualified clinician
• Thermography may be helpful
• CT, MRI, bone scan may be normal
• X-ray may show osteoporosis (bone loss)

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TREATMENT OPTIONS

• Drugs
• Blocks
• Physical therapy aqua or physiotherapy
• Sympathectomy (rare cases)
• SCS, PNS, morphine pump
• Psychological support

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OTHER TREATMENT OPTIONS

• Cognitive behaviour therapy
• Relaxation techniques e.g. Qi Gong, biofeedback,
  progressive muscle relaxation, Tai Chi, guided
  imagery, Yoga
• Alternative medicine options chronic pain diet,
  naturopathy, homeopathy, massage, photon therapy,
  etc.
• TO IMPROVE, MOVE Exercise program

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WHEN TO SUSPECT CRPS

• Excruciating pain, stiffness, inflammation
  following a minor trauma
• .Persistent pain and swelling of unexplained
  origin aggravated by bed rest or upon awakening.
  .. Hooshmand , H MD CRPSDiagnosis and Therapy
  Spring Verlager 1999
• Injury that has not healed, (past normal healing
  time) and pain out of proportion to the injury.

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EARLY DIAGNOSIS CRITICAL

• Early diagnosis ( lt3 mo.) with PROPER treatment,
  success rate is highest, the best prognosis
• If left untreated, can lead to lifetime of
  severe, intractable, chronic pain
• First 3-6 months after onset 80-90 recovery
  rate
• 6 months to 2 years 70-80, after 2 years 20

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MC GILL PAIN INDEX

• cancer pain rated 28, CRPS pain rated 42

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RSDCANADA SURVEY 2006 PAIN SCALE RATING (0-10)
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SELF-MANAGEMENT OF CRPS

• MEDICAL SUPPORT
• CONTACT ORGANIZATION
• DEVELOP PLAN
• ALTERNATIVE THERAPIES
• WORK PIECES OF PUZZLE
• STAY POSITIVE

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PATIENT RESOURCES

• Build your medical support team
• Inform yourself VISIT www.rsdcanada.org
• Join P.A.R.C help promote awareness
• Educate yourself, your family/friends
• Develop your own support network of
  friends/family
• Use a combination of medical and alternative
  therapies, make a plan

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RSDCANADA SURVEY RESULTS

• Rating own success
• Progress over time
• Has your CRPS spread?

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OVERALL SUCCESS RATING
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PROGRESSION IS YOUR CRPS WORSE, BETTER OR SAME?
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HAS YOUR CRPS SPREAD?

• Most cases progress and travel through other body
  parts
• Progression causes systemic chronic problems
• Pain is hallmark feature

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RSDCANADA SURVEY CONCLUSIONS

• MUST educate medical profession about early
  recognition
• SUFFERING MUST BE recognized pain rating levels
  between 6-10 pain is grossly under-treated pain
  level as vital sign
• Low success ratings (10-50) show lack of
  effective treatments for CRPS

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CRPS FACTS

• When not caught early, CRPS can be progressive
  (70 of cases)
• NEED to find single diagnostic test
• Early recognition through education
• Early diagnosis equals BETTER prognosis
• Need more effective treatments for CRPS
• Research is desperately needed

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WHAT CAN A MEDICAL PROFESSIONAL DO?

• EARLY RECOGNITION IS ESSENTIAL TO PATIENT
  RECOVERY
• ATTEND CRPS INFORMATION SESSIONS
• IF YOU SUSPECT CRPS, REFER IMMEDIATELY FOR
  TREATMENT
• BELIEVE THE PATIENTS PAIN IT IS REAL
• LISTEN/SUPPORT PATIENT

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COMPLEX REGIONAL PAIN SYNDROME

• THANK YOU FOR INVITING ME!