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Complex Regional Pain Syndrome Dr Jason Brooks Consultant Anaesthesia and Pain Medicine Belfast Trust Orthopaedic Update June 2013.

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Presentation on theme: "Complex Regional Pain Syndrome Dr Jason Brooks Consultant Anaesthesia and Pain Medicine Belfast Trust Orthopaedic Update June 2013."— Presentation transcript:

1 Complex Regional Pain Syndrome Dr Jason Brooks Consultant Anaesthesia and Pain Medicine Belfast Trust Orthopaedic Update June 2013

2 CRPS What is it? Diagnosis Treatment – general principles Pain Clinic treatment Dr Brooks

3 Key Messages Clinical Diagnosis of exclusion Uncertain cause No specific treatment Rehabilitation key treatment Other treatments aimed to facilitate above Dr Brooks

4 Health-care services involved in the care of patients with CRPS. Goebel A Rheumatology 2011

5 In 1993, the IASP introduced the term Complex regional pain syndrome to describe all pain states that previously would have been diagnosed as RSD or causalgia-like syndromes Posttraumatic dystrophy Causalgia Minor causalagia Sudek atrophy Shoulder-hand syndrome Reflex sympathetic dystrophy

6 CRPS Dr Brooks Complex : Varied and dynamic clinical presentation Regional: Non-dermatomal distribution of symptoms Pain: Out of proportion to the inciting events Syndrome: Constellation of symptoms and signs

7 The term sympathetic was avoided in the revised definition because its contribution is not constant across patients CRPS pain may be sympathetically maintained pain (SMP) or sympathetically independent pain (SIP) Dr Brooks

8 CRPS can be separated into two types based on the presence or absence of a nerve injury CRPS type I: A syndrome that develops after an initiating noxious event that may or may not be associated with a period of immobilization CRPS type II: Differs from CRPS type I by the presence of a known injury to a nerve or nerves

9 Incidence: 26/100,000 life years Hip OA = 88 per 100,000 person years Female:Male ratio: 3-4: % have experienced preceding trauma (fractures, surgery) How common is CRPS? deMos et al 2007 ? 1-2% following # 7-35% following colles 2-5% following nerve injury Veldman et al 1993

10 Natural History Natural history uncertain 30% consider resolved by 6yrs 50% disease stable 15% no improvement Later improvement less common with time Dr Brooks deMos etal 2009

11 Signs%Symptoms% Burning pain80 Hyperethesia65 Temperature diff5578 Colour changes6685 Sweating2452 Oedma5621 Nail Changes924 Hair changes818 Weakness2075 Tremor923 Dystonia1420 Reduced ROM7080 Hyperalgesia63 Allodynia74 Features - Harden 2001 Dr Brooks

12 Early CRPS of the right hand; clearly visible signs include swelling, red colour and a shiny skin. Goebel A Rheumatology 2011

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15 Dr Brooks

16 Budapest Diagnostic criteria A) Continuing pain disproportionate to initiating event B) At least 1 sign in 2 or more categories C) The patient symptoms in 3 or more categories D) No other diagnosis can better explain the signs and symptoms

17 Sign >2 Symptom >3 1) Sensory Allodynia (to light tough or temperature deep somatic pressure or hyperalgesia to pinprick 2) Vasomotor Temperature asymmetry and or skin colour changes and or skin colour asymmetry Must be > 1C 3) Sudomotor/ Vasomotor Oedema and or sweating and or sweating asymmetry 4) Motor/Trophic Decreased range of motion and or motor dysfunction

18 Features PAIN Spontaneous Disproportionate to initiating event Allodynia / Hyperalgesia (variability in reported prevalence) Dr Brooks

19 WHAT IS PAIN ?

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22 This artwork represents my daily struggle with constant pain. The only part of my body that does not hurt yet is still reaching out for help because I am not giving up. The artwork also glows in the dark representing the relentless nature of my pain 24/7 The Eradicator – Consumed by Chronic Pain

23 A Definition an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage International Association for the Study of Pain

24 A Definition an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage International Association for the Study of Pain

25 A Definition an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage International Association for the Study of Pain

26 A Definition an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage International Association for the Study of Pain

27 Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does McCaffery

28 Disease Model Pain Pain = tissue injury Tissue damage = impairment = disability = incapacity work Cure pain – disability will recover Problem Pain tissue injury Pain, disability and work incapacity not same thing Different people respond very differently Social issues profound influence

29 Biopsychosocial Model Pain Culture Social interactions Sick role Illness behaviour Beliefs, coping strategies Emotions distress Neurophysiology Physiologic dysfunction (Tissue damage?) SOCIAL PSYCHO BIO-

30 BIOLOGICAL Psyc Social Pain Experience Biopsychosocial Model Pain

31 Social Psychological Pain Experience Bio Biopsychosocial Model Pain

32 Sympathetically Maintained Pain Proportion of CRPS symptoms improved with sympathetic blockade If symp outflow to limb stimulus evoked pain in those who responded to block Proposed coupling between sympathetic NS and afferent neurones Peripheral coupling Indirect via vascular bed Via adrenal medulla

33 Vasomotor changes Colour – red, cyanotic or pale Typically temp in acute stages < 6mths in chronic state ? Reliability of HISTORY Often difficult to examine / variable Thermography Difference 0.6 Sens & Spec 67% (Bruehl 1996) Difference 2 Sens 32 % spec 100% (Wasner 2002) Diagnostic value increases if multiple sites Very dynamic measures Not a reliable clinical test

34 Sudomotor & Oedma Increased or decreased sweat production ? Reliability of history ? Clinical assessment Sweat testing – research setting Resting sweat output Dr Brooks

35 Trophic –Advanced – atrophy skin/ nails –Demineralisation bone –7% develop severe changes / refractory Motor –Weakness, poor coordination, tremor and myoclonus –? Related to disuse / neglect Dr Brooks

36 Other Investigations QST –Not specific –No additional diagnostic information Neurophysiological procedures –CRPS - borderline delay NCV / distal motor latency > 20% suggest underlying peripheral nerve lesion –Useful to distinguish between CRPS & –Is that important??

37 Radiography –Demineralisation –? Related to disuse –Considered non-specific & late –Not part of screening procedure

38 Three-phase bone scintigraphy Dr Brooks Unilateral Uptake tracer High sensitivity Low Specificity Not useful in the work –up of patients Neither makes or excludes the diagnosis

39 Integrative conceptual model of CRPS Central Sensitisation Driver CRPS Dynamic changes in spinal cord increasing transmission of pain signal Central Sensitisation Driver CRPS Dynamic changes in spinal cord increasing transmission of pain signal Inflammatory Process inflammatory agents Neurogenic inflammation Skin reddening / oedma Inflammatory Process inflammatory agents Neurogenic inflammation Skin reddening / oedma Cortical Reorganisation Reduced sensory representation in homouculus altered. Improves with Rx Mirror Therapy / GMI Cortical Reorganisation Reduced sensory representation in homouculus altered. Improves with Rx Mirror Therapy / GMI Autoimmune Condition Novel concept Evidence antineuronal Abs IVIG effective in reducing pain short term Autoimmune Condition Novel concept Evidence antineuronal Abs IVIG effective in reducing pain short term Ischaemia reperfusion injury Some evidence for low oxygen tension in peripheral tissues Ischaemia reperfusion injury Some evidence for low oxygen tension in peripheral tissues Goebel A Rheumatology 2011 Sympathetic Dysfunction

40 Management

41 The Four Pillars of Treatment in CRPS. Goebel A Rheumatology 2011;rheumatology.ker202

42 CRPS Pain Mx oral/topical meds Psychological Rx with focus on Education Interventional Pain Mx SNB IVRA Somatic Epidural/Plexus Neurostim Intrathecal Surgical / Rehab Reactivation Desensitisation Isometric Flexibility Oedma control ROM, Stress Load Isotonic Aerobic conditioning Other Psychological Assess for axis 1 Pain coping Biofeed/Relax CBT Freq or psycotherapy Failure to Progress

43 Medication Very little good data for CRPS Initial - Codeine / Paracetamol / NSAIDS Next Step – Antiepileptics / Antidepressants used in Neuropathic pain conditions Anticonvulsants Pregabalin/ Gabapentin Antidepressants Amitriptyline

44 Dr Brooks Opiates – Care with prescribing especially doses Not increase above equivalent 60 mg morphine per 24 hrs No short acting

45 Medication Second / Third Line Therapies Lidocaine patches NMDA antagonist Ketamine iv infusion 5 days Topical capsaicinNo evidence in trials but still used Cannabinoids Nabilone

46 Other Medications Iv palmidronate Early CRPS Vit C Steroids Dr Brooks

47 Psychological interventions All pain conditions complex biopsychosocial disorder Pain Disuse/Emotional arousal Several case reports / series reporting benefits RCTs contain psychological therapy as part physical/medical therapy Dr Brooks

48 In general: – Relaxation therapy –Coping skills –Behavioural intervention to address disuse –CBT –Active participant in therapy –Potentially as part of more formal Pain Management Programme Dr Brooks

49 Physiotherapy / Rehabilitation See Louis Talk!

50 Interventional therapies Stellate ganglion block Lumbar sympathetic chain Intravenous Regional anaesthesia –Guanethidine –Bretyllium Sympathetic Block Dr Brooks

51 Stellate Ganglion Block Upper Limb Chronic Regional Pain Syndrome Type I (CRPS I) Sympathetic supply to the ipsilateral arm / hemi- face

52 Lumbar Sympathetic Block sympathetic chains –overlying anterior portion of vertebral bodies posterior to aorta/IVC anteromedial to kidneys/ureter

53 LSB Needle Insertion Dr Brooks

54 Intravenous Regional Sympathetic Block Depletion of norepinephrine in sympathetic nerve terminals guanethidine bretylium

55 IVRA –Guanethidine – essentially little evidence efficacy BUT ALL THE STUDIES– entry criteria / all included Dr Brooks

56 Sympathetic nerve blocks Very little evidence benefit or evidence to base judgement Still used routinely ? role Dr Brooks

57 Titrate to response Allow Physio therapy 3 studies demonstrated improvements Epidural Infusions

58 StudyNo. PtsInfusionResults Complications Cooper Bupiv-opioid 4 days Improved pain/ROM 13/14 none Konnig Bupiv 7 days 83% improved pain Infection catheter site Rauck Clonidine 3 days Improved pain Infections Nausea Dizziness Dr Brooks

59 Brachial Plexus Catheter Several Case reports (level 4 evidence) 1-3 weeks Allow physiotherapy Even less evidence Dr Brooks

60 Spinal Cord Stimulation Meta-analysis Grabow studies 1 RCT / 14 observational case series Only 1 RCT – 50% response ( 50% relief) Kemler MA 2000 Suggest benefit still questions re efficacy Use if other Rx failed NICE approved

61 Take Home Message Clinical Diagnosis Uncertain cause No specific treatment Rehabilitation key treatment Moderate/Severe CRPS needs multidisciplinary team management! Dr Brooks

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63 NHS Website CRPS

64 Useful links


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