Complex Regional Pain Syndrome Flashcards
1
Q
What is CRPS?
A
- A type of chronic pain syndrome previously referred to as Shoulder Hand Syndrome and Reflex Sympathetic Dystrophy
- In 1993 the International Association for the Study of Pain proposed a name change to CRPS
- Name change suggested because the term Reflex Sympathetic Dystrophy implied that the sympathetic nervous system was the primary cause. But not all patients with CRPS have sympathetic symptoms
- Involves several physiological and psychological systems
- Process is progressive without intervention
- Impacts women 3x more than men of which 65% are between ages of 30-55 - average age is 40. Smokers are at higher risk
- Autonomic Nervous System is not under voluntary control
2
Q
What is the prevalence and risk factors for CRPS?
A
- Hx of distal radius fracture. Taking 500 mgs of vitamin C a day could reduce chances
- Hx of peripheral nerve injury (Type 2)
- Individuals with other inflammatory disorders including DM, RA, fibromyalgia
- CRPS in UE is more common than in LE
- In 90% of the cases there was some sort of trauma that occurred that triggered a response
- The median nerve has a lot of autonomic fibers and is more prone to develop CRPS
- 10% unknown etiology
- Children can get CRPS (usually over the age of 5) and it is more common in the LE
- Children under the age of 5 and the elderly rarely get CRPS
3
Q
What is hypertrichosis?
A
- Abnormal hair growth that occurs in response to an irritated cutaneous nerve
- This response alone does not mean a person has CRPS but signals that a nerve was compressed and there might be sensitivity and numbness
- Hair will eventually fall off
4
Q
What are the general symptoms of CRPS?
A
- Symptoms vary from person to person
- Prolonged or excessive pain out of proportion to injury
- Continuous throbbing pain
- Sensation of burning, stinging, tingling, numbness, squeezing
- Sensitivity to heat or cold
- Swelling
- Changes in skin temperature - sweaty or cold at times and temperature varies. Extremities may be either hot or cold and there is often a difference between involved and uninvolved extremities
- Changes in skin texture, which may become tender, thin or shiny in the affected area
- Atrophy
- CRPS starts distally and can cross and migrate
- Some people might not experience pain
5
Q
What are common symptoms of CRPS?
A
- Inflammation that is usually associated with stiffness
- Skin color changes
- Abnormal hair growth or atrophy of hair and nails
- Spasms in blood vessels and muscles of extremities
- Osteopenia
- Insomnia/emotional disturbance
- Dystonia/motor planning difficulty
6
Q
What is hyperpathia?
A
- An umbrella term for abnormal painful reactions to a stimulus
7
Q
What is allodynia?
A
- Pain in specific dermatome distribution that is a result of a stimulus that is not normally painful. Pain with touch and movement
8
Q
What is hyperaglesia?
A
- An increased sensitivity to pain that may be caused by damage to nociceptors or peripheral nerves. More extreme than allodynia
9
Q
What is hyperesthesia?
A
- A condition that involves an abnormal increase in sensitive stimuli of the senses (hearing, touch, taste, etc.). Increased touch sensitivity is known as tactile hyperesthesia and an increased sound sensitivity is known as auditory hyperesthesia
10
Q
What is the autonomic term vasomotor?
A
- Dilation (red and swollen) and constriction of blood vessels (blue and stiff)
- As CRPS progresses, vasodilation turns to vasoconstriction
11
Q
What is the autonomic term sudomotor?
A
- Autonomic function associated with the sweat glands
- Lotion is important for people who do not sweat
12
Q
What is the autonomic term trophic?
A
- Changes in tissues, due to loss/reduction of nerve and/or blood supply (muscle atrophy, increased nail growth - hypertrichosis, changes in nails, increased hair growth)
- Muscle atrophy generally results because people do not want to move if they are in pain
13
Q
What is the role of the parasympathetic system?
A
- Rest and digest
14
Q
What is the role of the sympathetic system?
A
- Fight or flight
- Increase in blood flow, heightened sensitivity, dilation of pupils, sweating
- We are preparing to engage in a fight or flight or run away
- Not all people with CRPS have sympathetic components
- Old theory was that the sympathetic nervous system would kick into overdrive and not calm down. We now know that it is much more complicated than that and not all individuals have a sympathetic component
15
Q
What are the two types of CRPS?
A
- Type I: Occurs after an illness or injury that did not directly damage the peripheral nerves of the affected limb. Ex: CRPS can occur with removal of gall bladder
- Type II: there is an identifiable peripheral nerve injury
*both types have phases
16
Q
What are the grades/stages of CRPS?
A
- Grade 1: algodystrophy (disruption of bone growth combined with sympathetic symptoms)
- Grade 2: sympathetic dystrophy without pain
- Grade 3: sympathetic maintained pain
17
Q
What are the time frames/stages of CRPS?
A
- Acute Phase: first 3 months
- Subacute Phase: 3 more months
- Chronic Phase: 6 months and onward
18
Q
How is CRPS evaluated and identified?
A
- Early dx of CRPS is of utmost importance. The sooner proper treatment is delivered, the better the outcome
- The medical community is not often trained to spot early signs of CRPS
- Patient often gets “labeled” as being a malingerer, magnifier, or having psychological issues
- Mechanism of injury: usually follows some type of trauma such as a fracture, sharp force injury, surgery, infections, heart problems, and cumulative trauma disorders. Insult may be quite mild in nature
- May spread in 70%, only 8% are systemic
19
Q
What are the International Association for The Study of Pain (IASP) criteria for evaluating CRPS?
A
- Presence of inciting noxious event or prolonged immobilization
- Continuing pain, allodynia, or hyperaglesia which is disproportionate to any inciting event
- Edema, changes in the skin, blood flow or abnormal sudomotor activity in the region of pain
- The diagnosis is excluded by the existence of a condition that would otherwise account for the degree of pain and dysfunction
20
Q
What are therapeutic ways to identify CRPS?
A
- Through history of health, mechanism of injury, and post injury care
- Pain threshold evaluation: McGill Pain Questionnaire and Visual Analog Scale
- Clinical observations including movement and assessment of skin color, nails, and possible atrophy
- Semmes Weinstein Monofilament testing because light touch can be perceived as being painful
- The presence of pain associated with light touch (2.83) is abnormal
- Neuromusculoskeletal evaluation including: ROM, sensation, fine/gross motor control. Muscle testing if pain is limited or not present
- Bone scans can also detect osteopenia
- Comparing the temperature of one extremity to another
21
Q
What are diagnostic tests that can detect CRPS?
A
- 3 phase bone scan to evaluate vascular profusion
- Monitoring digital pulp temperature
- X-rays used to evaluate regional osteopenia - intervenous contrast is used. Regular radio graphs are usually only 60% accurate
- Thermography is imaging that can be useful in diagnosing CRPS. CRPS can be associated with abnormal skin temperature regulation, often described as a “hot” or “cold” feeling of the skin
