Complex Regional Pain Syndrome (original) (raw)

Complex regional pain syndrome: a comprehensive and critical review

Autoimmunity reviews, 2014

Complex regional pain syndrome (CRPS) is a term used to describe a variety of disorders characterized by spontaneous or stimulus-induced pain that is disproportional to the inciting event and accompanied by a myriad of autonomic and motor disturbances in highly variable combinations. There are no standards which can be applied to the diagnosis and would fulfill definitions of evidence-based medicine. Indeed, there are almost as many diagnostic criteria as there are names to this disorder. The umbrella term CRPS has been subdivided into type I and type II. CRPS I is intended to encompass reflex sympathetic dystrophy and similar disorders without a nerve injury; while CRPS II occurs after damage to a peripheral nerve. There are numerous etiological pathophysiological events that have been incriminated in development of CRPS, including inflammation, autoimmune responses, abnormal cytokine production, sympathetic-sensory disorders, altered blood flow and central cortical reorganization....

VIEWS & REVIEWS Complex regional pain syndrome An optimistic perspective

Complex regional pain syndrome (CRPS) presents with clinical symptoms that can no longer be explained by the initial trauma, including pain, sensory, motor, and trophic symptoms, and impairment of autonomic control of the limb. These symptoms spread distally and go beyond single nerve innervation territories. Typically, the symptoms change through the course of CRPS as a result of the varying pathophysiology. Diagnosis is made clinically after the rigorous elimination of other possible causes, and 3-phase bone scintigraphy can be a useful tool for confirming CRPS. In acute stages, inflammatory symptoms prevail and should be treated with anti-inflammatory agents (steroids), bisphosphonates, or topical application of dimethyl sulfoxide. In chronic stages, many symptoms are related to so-called central neuroplasticity; these include hyperalgesia, sensory loss, motor symptoms, body perception disturbance, autonomic symptoms, and learned incorrect behavior such as nonuse. At this stage, the only medical treatment that is effective against pain without improving the function is ketamine infusions, but this has side effects. Physical therapy, graded motor imagery, and pain exposure/graded exposure in vivo therapy can help to overcome central reorganization. If a relevant mental comorbidity is present, the patient should be referred for psychotherapeutic treatment. Invasive treatment should be restricted to special cases and only offered after psychosomatic assessment. If these recommendations are followed, CRPS prognosis is not as poor as commonly assumed. Whether the patients can return to their previous life depends on particular individual factors. Neurology ® 2015;84:89–96 GLOSSARY CGRP 5 calcitonin gene-related peptide; CRPS 5 complex regional pain syndrome; GEXP 5 graded exposure in vivo; HLA 5 human leukocyte antigen; IL 5 interleukin; PEPT 5 pain-exposure physical therapy; SNS 5 sympathetic nervous system; SP 5 substance P; TNF 5 tumor necrosis factor. Complex regional pain syndrome (CRPS) develops as a localized pain disorder within 4–6 weeks following a trauma to an extremity. The latency between the trauma and the earliest possible diagnosis depends on the expected recovery period. Directly after a fracture, many injured limbs appear to exhibit CRPS but symptoms often resolve spontaneously. It is estimated that approximately 3%–5% of patients who have had a distal radial fracture subsequently develop definite CRPS. 1 CRPS diagnoses made months or years after the initial trauma due to persistent pain and limb nonuse should be questioned. The epidemiologic data suggest that the CRPS incidence lies between 5.5 2 and 26.2 3 in 100,000 per year. The mean age is between 50 and 60 years, and women are 2 times more frequently affected. Assessing the prognosis is difficult, but in the absence of confounding factors, the rate of substantial recovery exceeds 50%. 4 Late diagnosis, incorrect treatment, or failure to consider complicating factors can lead to chronic CRPS with serious disability and significant sociomedical and welfare consequences. CLASSIFICATION AND DIAGNOSIS OF CRPS The diagnosis of CRPS is made using clinical criteria, 5 as shown in the figure. It should be noted that the specificity of these criteria is limited. In particular, if criterion 4 is omitted (" exclusion of other reasons "), overdiagnosis of CRPS may result. Just the persistence of pain and nonuse of the limb is not sufficient for making a CRPS diagnosis. In unclear cases, detailed medical reports or photographs must be requested. Typically, symptoms are preceded by a trauma. There are reports of Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Complex regional pain syndrome: Literature review as a guide for the practicing clinician

Srpski medicinski casopis Lekarske komore

Complex regional pain syndrome (CRPS) is a chronic complex disorder that significantly affects the quality of life of the people suffering from it. This syndrome affects the extremities after trauma or nerve injury. Hyperalgesia and allodynia of the extremities often accompany this condition. Diagnosing and treating this disease is very complex. The Budapest criteria are currently the most widely accepted diagnostic criteria. Early diagnosis and treatment are essential for a favorable outcome in CRPS. Therapeutic modalities available for the treatment of CRPS include physical therapy, pharmacotherapy, and interventional techniques. Additional high-quality studies are needed to determine the best therapeutic option.

Complex Regional Pain Syndrome: A Review

Annals of Vascular Surgery, 2008

Complex regional pain syndrome (CRPS) is a challenging neuropathic pain state, quite difficult to comprehend and treat. Its pathophysiological mechanisms are unclear and its treatment is difficult. Multiple factors play a role in the generation and maintenance of CRPS. A close interdisciplinary collaboration amongst the psychologist, physical and occupational therapists, neurologist and pain medicine consultants is necessary to achieve optimal treatment effects. The primary goals of managing patients with this syndrome are to: 1) perform a comprehensive diagnostic evaluation, 2) be prompt and aggressive in treatment interventions, 3) assess and reassess the patient's clinical and psychological status, 4) be consistently supportive, and 5) strive for the maximal amount of pain relief and functional improvement. This article reviews the different aspects of CRPS including definition, classification, epidemiology and natural history, clinical presentation, pathophysiology and management.

Complex regional pain syndrome—1: history, diagnostic criteria and etiology

Journal of Bodywork and Movement Therapies, 2004

Physical therapists and other health care providers frequently evaluate and treat patients with complex regional pain syndrome (CRPS). The term CRPS replaces the previous terms reflex sympathetic dystrophy (now referred to as CRPS Type I) and causalgia (CRPS Type II). Part 1 of this paper describes the diagnostic criteria for CRPS and the clinical features and etiology of both CRPS Types I and II. CRPS is a multifactorial syndrome with overlapping symptoms. Although much progress has been made in the understanding of CRPS, many questions remain unanswered. CRPS is probably a disease of the central nervous system. Yet, peripheral inflammatory processes, abnormal sympathetic-afferent coupling, and adrenoreceptor pathology may also be part of the picture. It is likely that in the near future the current concepts of CRPS will be replaced by a new mechanism-based term or group of terms leading to improved clinical guidelines. Part 2 in this series reviews the physical therapy management of patients with CRPS.

A medical mystery of complex regional pain syndrome

A B S T R A C T Complex regional pain syndrome (CRPS) is a condition of neuropathic pain, which is characterized by significant autonomic and inflammatory features. CRPS occurs in patients who have limb surgery, limb fractures, or trauma. Many patients may have pain resolve within twelve months of the inciting incident; however, a small subset progresses to the chronic form. This transitional process often happens by changing from warm CRPS with dominant inflammatory phase to cold CRPS, in which autonomic characteristics or manifestations dominate. Several peripheral and central mechanisms are involved, which might vary among individuals over a period of time. Other contributors include peripheral and central sensitization, autonomic alterations, inflammatory and immune changes, neurochemical changes, and psychological and genetic factors. Although effective management of the chronic CRPS form is often challenging, there are a few high quality randomized controlled trials that support the efficacy of the most commonly used therapeutic approaches.

Complex regional pain syndrome (CRPS), a review

Medicina Universitaria, 2015

Complex regional pain syndrome is a chronic and painful condition that affects the quality of life of patients. It is usually triggered by a traumatic event of the soft tissues involving the nervous tissue. Although the factors that cause the syndrome are varied and not well known, different etiopathologic concepts have been proposed to explain the presence of this syndrome, such as autonomic dysfunction and changes in CNS plasticity, among others. The patient characteristically presents pain, sensory abnormalities, vasomotor disturbances in the skin, edema, changes in sweating, and motor alterations. The pain is associated with changes in the autonomic nervous system and has a distal predominance. Since there is no definitive diagnostic test, diagnosis is mainly based on a complete medical history and physical examination. Treatment is multidisciplinary and based on pain relief. Although in most cases evolution is favorable, rapid diagnosis and treatment are recommended to avoid dystrophic stage as much as possible.

Complex regional pain syndrome-up-to-date

Complex regional pain syndrome (CRPS) was described for the first time in the 19th century by Silas Weir Mitchell. After the exclusion of other causes, CRPS is characterised by a typical clinical constellation of pain, sensory, autonomic, motor, or trophic symptoms which can no longer be explained by the initial trauma. These symptoms spread distally and are not limited to innervation territories. If CRPS is not improved in the acute phase and becomes chronic, the visible symptoms change throughout because of the changing pathophysiology; the pain, however, remains. The diagnosis is primarily clinical, although in complex cases further technical examination mainly for exclusion of alternative diagnoses is warranted. In the initial phase, the pathophysiology is dominated by a posttraumatic inflammatory reaction by the activation of the innate and adaptive immune system. In particular, without adequate treatment, central nociceptive sensitization, reorganisation, and implicit learning processes develop, whereas the inflammation moderates. The main symptoms then include movement disorders, alternating skin temperature, sensory loss, hyperalgesia, and body perception disturbances. Psychological factors such as posttraumatic stress or pain-related fear may impact the course and the treatability of CRPS. The treatment should be ideally adjusted to the pathophysiology. Pharmacological treatment maybe particularly effective in acute stages and includes steroids, bisphosphonates, and dimethylsulfoxide cream. Common anti-neuropathic pain drugs can be recommended empirically. Intravenous long-term ketamine administration has shown efficacy in randomised controlled trials, but its repeated application is demanding and has side effects. Important components of the treatment include physio-and occupational therapy including behavioural therapy (eg, graded exposure in vivo and graded motor imaging). If psychosocial comorbidities exist, patients should be appropriately treated and supported. Invasive methods should only be used in specialised centres and in carefully evaluated cases. Considering these fundamentals, CRPS often remains a chronic pain disorder but the devastating cases should become rare.

Diagnosis, mechanisms and treatment of complex regional pain syndrome

Current Opinion in Anesthesiology, 2014

Purpose of review The incidence and disease course of complex regional pain syndrome (CRPS) has been unclear until recently. This was due to inconsistent diagnostic criteria used in previous studies and a lack of large-scale prospective datasets. Multiple mechanisms of CRPS have been suggested, and recent research has begun to explain how inflammation, the immune system and the autonomic nervous system may interact with aberrant central neuroplasticity to produce the clinical picture. This review summarizes progress in these fields. Recent findings National registries of patients with CRPS have provided us with an invaluable insight into the epidemiology of the disorder. We now have a better understanding of the disease course and expected outcome. Widespread sensory abnormalities, not limited to the CRPS limb, have been found suggesting that systemic changes may occur. Parietal lobe dysfunction and problems with sensory-motor integration have also been revealed. Abnormalities in the immune system in CRPS have also been demonstrated. Summary Recent findings in diverse research fields suggest novel treatment options for CRPS: from targeting autoimmunity to correcting abnormal body image. Many of the advances in our understanding of CRPS have arisen from the development of collaborative research efforts, such as the TREND group in the Netherlands.