1. COMPLEX REGIONAL PAIN SYNDROME (crps)
THE CIVIL WAR DISEASE

2. 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…

3. 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."

4. 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.

5. 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."

6. WHAT’S IN A NAME? Algodystro-phy Mimo causalgia Sudeck’s 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

7. 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)

8. 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

9. 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

10. 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

11. 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)

12. 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)

13. TREATMENT OPTIONS Drugs Blocks Physical therapy: aqua or physiotherapy
Sympathectomy: (rare cases)
SCS, PNS, morphine pump
Psychological support

14. 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

15. 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 CRPS:Diagnosis and Therapy Spring Verlager 1999
“Injury that has not healed, (past normal healing time) and pain out of proportion to the injury”.

16. EARLY DIAGNOSIS CRITICAL
Early diagnosis ( <3 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%

17. MC GILL PAIN INDEX cancer pain rated 28, CRPS pain rated 42
Causalgia is rated higher than cancer pain.

18. RSDCANADA SURVEY 2006: PAIN SCALE RATING (0-10)

19. SELF-MANAGEMENT OF CRPS
MEDICAL SUPPORT
CONTACT ORGANIZATION
DEVELOP PLAN
ALTERNATIVE THERAPIES
WORK PIECES OF PUZZLE
STAY POSITIVE

20. PATIENT RESOURCES Build your medical support team
Inform yourself: VISIT:
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

21. RSDCANADA SURVEY RESULTS
Rating own success
Progress over time
Has your CRPS spread?

22. OVERALL SUCCESS RATING

23. PROGRESSION: IS YOUR CRPS WORSE, BETTER OR SAME?

24. HAS YOUR CRPS SPREAD?
Most cases progress and travel through other body parts
Progression causes systemic chronic problems
Pain is hallmark feature

25. 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

26. 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

27. 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 PATIENT’S PAIN: IT IS REAL
LISTEN/SUPPORT PATIENT

28. COMPLEX REGIONAL PAIN SYNDROME…
THANK YOU FOR INVITING ME!