26. Complex regional pain syndrome

Question 1

What do you understand by the term ‘complex regional pain syndrome’?

Answer 1

Diagnostic criteria for CRPS

According to the Budapest criteria, there are four criteria that
need to be satisfied for diagnosis.

The first two are:
» At least one symptom in at least three of the four symptom categories.

> > At least one sign in at least two of the four sign categories.

The remaining two criteria are the

> > Continuing pain disproportionate to inciting event.

> > No other diagnosis that can explain symptoms and signs

CRPS II
1. Continuing pain, allodynia or hyperalgesia following a nerve injury, not
necessarily limited to the distribution of the nerve.

Question 2

What are the symptoms

Answer 2

Sensory:

• Hyperaesethesia.
• Allodynia.

Vasomotor:
* Temperature asymmetry.

• Skin colour changes.
• Skin colour asymmetry.

Sudomotor/Oedema:
* Oedema.

• Sweating changes.
• Sweating asymmetry.

Motor/trophic:
* Decreased range of motion.

• Motor dysfunction
  (weakness, tremor, dystonia).
• Trophic changes
  (hair, nail, skin).

Question 3

List the signs of complex regional pain syndrome (CRPS)

Answer 3

Sensory:
* Hyperalgesia (to pinprick).

• Allodynia
  (to light touch or deep somatic pressure or joint. movement).

Vasomotor:
* Temperature asymmetry.

• Skin colour changes.
• Skin colour asymmetry.

Sudomotor/Oedema:
* Oedema.

• Sweating changes.
• Sweating asymmetry.

Motor/trophic:
* Decreased range of motion.

• Motor dysfunction (weakness, tremor, dystonia).
• Trophic changes (hair, nail, skin).

Question 4

Allodynia

Answer 4

Pain from a stimulus that does not normally cause pain.

Question 5

Hyperalgesia

Answer 5

A heightened response to a stimulus, which is normally
painful.

Question 6

Hyperpathia

Answer 6

Severe pain in an area of numbness.

Question 7

What are the available treatments for CRPS?

Answer 7

1. Patient information and education:
2. Physical and vocational rehabilitation:
3. Pain relief (medication and procedures):
4. Psychological interventions:

Question 8

1. Patient information and education:

Answer 8

There are four management ‘pillars’; start early and aggressively for best outcome:

Outcome may be improved by full patient education about what
CRPS is and how it is to be managed.

Question 9

2. Physical and vocational rehabilitation:

Answer 9

• Physiotherapy: desensitisation,
  gradual weight bearing, fine motor exercises,
  aerobic conditioning, TENS, hydrotherapy.
• Oedema control strategies.
• Occupational therapy:
  pacing prioritising planning, vocational
  support, relaxation techniques.
• Multidisciplinary pain management.
• Motor therapy: mirror visual feedback.

Question 10

3. Pain relief (medication and procedures):

Answer 10

• Start with amitryptiline, move on if not effective or not tolerated to duloxetine, gabapentin or pregabalin.
• Tramadol for rescue only, not long term.
• Consider capsacin cream for
  localised neuropathic pain or to avoid
  oral treatments.
• Bisphosphonates:
  pamidronate 60 mg single intravenous dose for
  patients with CRPS less than six months’ duration to help maintain bone integrity and function.
• Spinal cord stimulation:
  NICE approved for pain persisting greater
  than six months.

Question 11

4. Psychological interventions:

Answer 11

• Cognitive behavioural therapy:
  ensure that fear does not reduce
  limb movement and use which
  can exacerbate disuse atrophy.
• Possible psychiatric issues and
  other life stressors should be
  sought and dealt with.