What is complex regional pain syndrome (CRPS)
syndrome in which pain is out of proportion to the injury and the injury and the symptoms are characterized by autonomic dysregulation, such as swelling, vasomotor instability, abnormal sweating, trophic changes, and abnormal motor activity. CRPS I was formerly known as reflex sympathetic dystrophy, CRPS II was known as causalgia
Other terms for CRPS:
algodystrophy, sudeck's atrophy, bone loss dysfunction, reflex sympathetic dystrophy, causalgia, reflex neurovascular dystrophy, sympathalgia, neurodystrophy, traumatic arthritis, minor causalgia, posttraumatic osteoporosis, post traumatic pain syndrome, post traumatic edema, post traumatic angiospasm, shoulder-hand syndrome
Cardinal signs in CRPS:
- pain, burning type of pain. Distal part of the extremity in a nonsegmental distribution. Pain becomes more diffuse and may spread gradually to proximal limb. - Trophic change, edema often is the first notable change in the skin with gradual thickening and coarsening of the skin and wrinkle distribution changes or skin may become smooth and tight. Hair will become coarse, nails thicken and become ridged and brittle. Muscle shortening, atrophy, and weakness. - Autonomic instability, vasomotor instability indicates that the SNS is involved. Limb is cool, pale, and cyanotic with sweating changes. - sensory abnormalities, dysethesia and allodynia often occur.
Pain terms associated with CRPS:
allodynia: pain caused by a stimulus that does not normally provoke pain. ie cannot tolerate clothes or bed clothing on their injury - Hyperalgesia: stimulus that is more painful than normal or exaggerated to a normally painful stimulus - Hyperesthesia: unusual sensitivity to repetitive stimuli ie tapping on the skin becoming painful when it wasn't initially
Three stages of CRPS:
acute, dystrophic, atrophic
Describe the acute stage of CRPS:
Describe the dystropic stage of CRPS:
Describe the atrophic stage of CRPS:
List some of the percipitating events that cause CRPS I:
fracutres, soft tissue trauma, frostbite, burns, MS, wearing a tight cast, CVA, MI, crushing injury, amputations surgical procedures.
How common are CRPS I and II
Occurs most in women from the ages of 30-55,
Treatment for CRPS:
early recognition is most helpful utilizing a multidisciplinary approach: eliminate cause of pain to tx the interruption of the abnormal sympathetic response. Treat swelling, immobility, decreased wegith bearing. Surgical decompression, nerve blocks, ganglion blocks, and axillary blocks in conjunction with PT, OT, and psych
What is triple phase scintigrapy?
three phase bone scan to help rule out other Dx.
What should be seen in a three phase bone scan for the scan to be considered diagnostic of CRPS?
During the delayed phase 3-4 hours after the injuction and must show difficuta
How is radiography useful in dx of CRPS?
identifies patch demineralization in the late stages
Do children develop CRPS?
yes, there have been reports, most are adolescent girls
CRPS drugs used for tx:
Drug: Anticonvulsants (topamax, neurotin, keppra, trileptal) for neuropathic pain - action: change rate of nerve firing
Drug: Antidepressants (prozac, pomelor, paxil, zoloft) sleep problems and pain syndromes - action: block reuptake of serotonin and norepinephrine in descending pathway modulation
Second generation antidepressants: (seroquel, cymbalta) nerve pain - action: block selective serotonin reuptake
NSAIDs: inflammatory pain - action: decrease production of prostaglandins to reduce inflammatory mediators
Systemic cortiocosteriods: (medrol does pack) painful and edematous pain syndromes - action: antiinflammatory, reduce nerve firing
Calcintonin spray: bone pain - action: unknown
Opiods: (hydrocodone, vicodin, duragesic, kadian, avinza, kadian, aniza) extreme pain - action: interact with drug receptor
Antipsychotics: (zyprexa) pain caused by anxiety - action: serotonin and dopamine receptors to reduce anxiety
Capsaicin and clonide patches help with treating pain associated with CPRS by:
Capsaicin decrease the peptide substance P decreasing primary afferent neurons involved in pain transmission. Clonidine decreases sympathetic outflow by stimulating alpha adrenoreceptors
Outcomes associated with CRPS:
Therapy and mobilizations successful in wrist tendon lacerations and carpal fracture. exercise programs focused on compression and distraction improve function.
Is timing important in initiation of treatment in CPRS?
yes, 80% treated within 1 year show significant improvement, after 1 year only 50% show significant improvement
How does smoking aggravate CRPS symptoms?
sympathetic nervous system stimulated by products in cigarettes and increase plasma levels of epinephrine and norepinephrine; decreased blood flow in extremeties leading to ischemia.
Can CRPS be prevented?
- early recognition, appropriate meds, early PT and OT, avoiding unnecessary immobilization, avoid smoking and alcohol, avoid unnecessary surgery
What should nonaggresssive PT and OT programs s/p nerve block:
Exercise are best performed during this time because it will increase proprioception into the spinal cord, and may result in inhibition of overactive sympathetic nervous system. Additionally it will increase blood flow to the extremity and cause central inhibition of the sympathetic nervous system
delay of movement
reduced spontaneous movement
slowness of movement
small amplitude of movement
lack of awareness of a body part
Common types of neuropathic pain?
peripheral neuropathic pain: diabetic neuropathy, postherpetic neuralgia, complex regional pain syndrome, entrapment neuropathies, radiculopathy, phantom limb pain Central neuropathic pain: compressive myelopathy, poststroke pain, spinal cord injury pain, multiple sclerosis, parkinson's disease
When is surgery appropriate in CRPS II?
Although it was originally discouraged recent studies show positive electrophysiological testing with a pt who does not respond to conservative treatment that it is appropriate for a decompression to be performed. Positive EMG = improved result with surgery