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CRPS

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by

Miyuki Yagisawa

on 11 July 2016

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Transcript of CRPS

Understanding Complex Regional Pain Syndrome
Definition:
(Merskey and Bogduk, 1994)

A syndrome that usually develops after a noxious event, is not limited to the distribution of a single peripheral nerve and is apparently disproportionate to the inciting event




Associated at some point with evidence of oedema, changes in skin blood flow, abnormal sudomotor activity in the region of the pain or allodynia or hyperalgesia
Revised Diagnostic Criteria



Sensory:
Symptoms:

-Hyperalgesia

-Allodynia

Signs:

-Hyperalgesia to pinprick

-Allodynia to light touch, deep somatic pressure or joint movement
Vasomotor:
Symptoms and /or Signs:

- Skin temperature asymmetries

- Skin colour changes

- Skin colour asymmetry
Sudomotor or Oedema:
Symptoms and/or Signs:

-Oedema

-Sweating changes

-Sweating asymmetry
Motor or Trophic:
The Budapest Criteria (Harden et al 2010)

1. Continuing pain which is disproportional to any inciting event

2. Must report at least one symptom in 3 or more of the following categories:
-sensory
-vasomotor
-sudomotor or oedema
-motor ot trophic

3. Must display at least one sign in 2 or more of the following categories:
-sensory
-vasomotor
-sudomotor or oedema
-motor or trophic

4. No other diagnosis better explains the signs and symtoms

Symptom and/or Signs:

-Decreased ROM

-Motor dysfuction (weakness, tremor, dystonia)

-Trophic changes (hair, nails, skin)


Pathophysiology:
Not totally understood...

Nociceptive sensitisation (central and peripheral, reduced endogenous pain control)

Neurogenic inflammation (reduced sympathetic outflow, peripheral cytokine and chemokine)

Vasomotor dysfuction (endothelial dysfunction)

Maladaptive neuroplasticity (ipsi and contralateral cortical changes, neural regeneration of C and A delta fibers)

Differential Dx:
Questions:

1. Has the extent of the primary pathology been recognised and managed? (carpel instability following colles # creating CTS)

2. Is a secondary pathology present? (nerve entrapment/thrombosis following #)

3. Are psychological/psychiatric symptoms present? (fear avoidance behaviour in the presence of pain)


Differential Dx:
Entrapment syndromes (e.g. carpel tunnel)
Compartment syndrome
Thrombosis
Disuse of nonuse of a limb
Lymphoedema
Infection
Conversion disorder
Self harm
Costo-clavicular compression syndrome
Evidence for Physiotherapy:
Stress loading

TENS

Exercise

Pain Mx

Graded motor imagery
Daly and Bialocercowski 2009 and 2012) - evidence still incomplete
GMI
(Moseley 2004)
Laterality (Left Right Discrimination)

Imagined Movements

Mirror Therapy

Explanation and Education
(remind me to show you Ken's Prezi on DVT!)
Some evidence from neuroimaging
(Di Pietro et al 2013)
Widely accepted that S1 reorganises with pain (smudging of S1)

This systematic review found;

1. consistent evidence that S1 representation of the affected CRPS hand smaller than the unaffected hand

2. Rx needs to target the brain

3. however the evidence isn’t as strong they thought it would be (few studies recruiting a low total number of subjects, and also a high risk of bias in their findings)



Researchers still not sure

- what the shrunken CRPS hand representation in S1 might mean

- if it causes pain or the other way around, or neither of these

- S1 enlargement of the healthy hand associated with increased compensatory use?

A lot more research required!
(while it is not known if cortical reorganisation is a potent contributor to chronic pain states, retraining for precision- reinhibition, does seem to work well with some people)
CRPS can be acquired from health professionals
Dx can be negative, very scary for patients

Make sure you are certain before making the Dx

CRPS can co-exist with other conditions
e.g. musculoskeletal, neurological, psychological


Clinical Management
http://painhealth.csse.uwa.edu.au/pain-management-CRPS.html
Great resource!
Full transcript