COMPLEX REGIONAL PAIN SYNDROME (crps) THE CIVIL WAR DISEASE

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…

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."

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.

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."

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

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)

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

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

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

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)

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)

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

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

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”.

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%

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

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

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

PATIENT RESOURCES Build your medical support team Inform yourself: VISIT: www.rsdcanada.org 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

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

OVERALL SUCCESS RATING

PROGRESSION: IS YOUR CRPS WORSE, BETTER OR SAME?

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

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

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

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

COMPLEX REGIONAL PAIN SYNDROME… THANK YOU FOR INVITING ME!