Reflex sympathetic dystrophy: a retrospective epidemiological study of 168 patients

Effect of an interdisciplinary inpatient program for patients with complex regional pain syndrome in reducing disease activity-a single-center prospective cohort study

OBJECTIVE

The aim of this study was to evaluate the benefit of inpatient treatment in reducing disease activity in patients with complex regional pain syndrome (CRPS) who have exhausted outpatient options. Furthermore, the study sought to identify patient-related outcome variables that predict a reduction in disease activity.

METHODS

The primary outcome was disease severity (CRPS Severity Score, range 0-16 points). Secondary outcomes included depression, anxiety, physical function, pain interference, fatigue, sleep disturbance, and the ability to participate in social roles and activities, all of which were assessed using the PROMIS-29. Furthermore, pain catastrophizing, neuropathic pain, quality of life, pain self-efficacy, medication intake, and the patient's global impression of change were examined in accordance with current international agreed recommendations, assessed at discharge, 3-month, and 6-month post-discharge. Mixed-effects models were conducted to identify baseline variables associated with CRPS severity.

RESULTS

Twenty-five patients completed the program (mean age 49.28 [SD 11.23] years, 92% females, mean symptom duration 8.5 [SD 6.5] months). Results showed a significant reduction between baseline and discharge of disease activity (CSS -2.36, P < .0001), pain (PROMIS-29 pain -0.88, P = .005), and emotional function (PROMIS-29 depression -5.05, P < .001; fatigue -4.63, P = .002). Moderate evidence for a reduction between baseline and discharge could be observed for pain interference (+2.27, P = .05), social participation (PROMIS-29 + 1.93, P = .05), anxiety (PROMIS-29 -3.32, P = .02) and physical function (PROMIS-29 + 1.3, P = .03). On discharge, 92% of patients (23 of 25) reported improvement in their overall condition. In the follow-up period, medication intake could be reduced after 3 (MQS -8.22, P = .002) and 6 months (MQS -8.69, P = .001), and there was further improvement in social participation after 3 months (PROMIS-29 + 1.72, 0.03) and sleep after 6 months (PROMIS-29 + 2.38, 0.008). In the mixed models, it was demonstrated that patients experiencing less pain at baseline also exhibited lower disease activity.

CONCLUSION

The results of this study confirm that inpatient interdisciplinary treatment of CRPS patients improves disease activity, pain, physical function, emotional function, and social participation. Most improvements were maintained for up to 6 months after discharge. The majority of patients reported that their overall condition had improved during the study period.

Quantitative Dynamic Allodynograph-A Standardized Measure for Testing Dynamic Mechanical Allodynia in Chronic Limb Pain

BACKGROUND

Dynamic mechanical allodynia (DMA) is both a symptom and a central sensitization sign, yet no standardized method for quantifying the DMA area has been reported. This study aimed to establish psychometric properties for Quantitative Dynamic Allodynography (QDA), a newly developed protocol measuring the DMA area as a percentage of the body surface.

METHODS

Seventy-eight patients aged 18-65 diagnosed with chronic complex regional pain syndrome (CRPS) participated in this study. Test-retest reliability was conducted twice, one week apart (N = 20), and inter-rater (N = 3) reliability was conducted on 10 participants. Disease severity (CRPS Severity Score, CSS), pain intensity (VAS), and quality of life (SF-36) measures were utilized to test construct validity.

RESULTS

High inter-rater reliability (intraclass correlation coefficient (ICC) = 0.96, p < 0.001) and test-retest reliability (r = 0.98, p < 0.001) were found. Furthermore, the QDA score was found to be correlated with the CSS (r = 0.47, p < 0.001), VAS (r = 0.37, p < 0.001), and the SF-36 physical health total (r = -0.47, p < 0.001) scores.

CONCLUSION

The QDA is the first developed reliable and valid protocol for measuring DMA in a clinical setting and may be used as a diagnostic and prognostic measure in clinics and in research, advancing the pain precision medicine approach.

Targeted muscle reinnervation at the time of amputation in the management of complex regional pain syndrome of the lower extremity

BACKGROUND

Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined by severe pain and sensorimotor dysfunction. In cases of severe CRPS, patients request amputation, which may cause phantom limb pain (PLP) and residual limb pain (RLP). Targeted muscle reinnervation (TMR) reduces the risk of PLP and RLP. This report describes the use of TMR at the time of amputation in a series of patients with CRPS.

PATIENTS AND METHODS

Four patients (ages 38-71 years) underwent TMR at the time of amputation for CRPS between April 2018 and January 2019. Three patients had a history of trauma and surgery to the affected limb. All patients attempted pharmacologic and interventional treatments for 1-7 years before requesting amputation. Three patients underwent below-knee amputations (BKA) and one had an above-knee amputation (AKA). Target muscles included the soleus, gastrocnemius, and flexor hallucis longus (BKA), and semitendinosus, biceps femoris, and vastus medialis (AKA). Postoperative phantom and residual limb pain symptoms were collected via a telephone survey adapted from the Patient-Reported Outcomes Measurement Information System (PROMIS).

RESULTS

There were no complications related to the TMR procedure. Average follow-up time was 12.75 months. Patients reported varied outcomes: two had RLP and PLP, one had RLP only, and one had PLP only. All patients reported successful prosthetic use.

CONCLUSION

TMR may be performed at the time of amputation for CRPS. Further study is necessary to determine the effect of TMR on pain, pain medication use, prosthesis use, and other domains of function.

Direct Health Care Cost and Work Incapacity Related to Complex Regional Pain Syndrome in Switzerland: A Retrospective Analysis from 2008 to 2015

OBJECTIVE

First, to determine the number of accident-related complex regional pain syndrome (CRPS) cases from 2008 to 2015 and to identify factors associated with an increased risk for developing CRPS. Second, to analyze the duration of work incapacity and direct health care costs over follow-up periods of two and five years, respectively.

DESIGN

Retrospective data analysis.

SETTING

Database from the Statistical Service for the Swiss National Accident Insurances covering all accidents insured under the compulsory Swiss Accident Insurance Law.

SUBJECTS

Subjects were registered after an accident between 2008 and 2015.

METHODS

Cases were retrospectively retrieved from the Statistical Service for the Swiss National Accident Insurances. Cases were identified using the appropriate International Classification of Diseases, 10th Revision, codes.

RESULTS

CRPS accounted for 0.15% of all accident cases. Age, female gender (odds ratio [OR] = 1.53, 95% confidence interval [CI] = 1.47-1.60), and fracture of the forearm (OR = 38, 95% CI = 35-42) were related to an increased risk of developing CRPS. Over five years, one CRPS case accumulated average insurance costs of $86,900 USD and treatment costs of $23,300 USD. Insurance costs were 19 times and treatment costs 13 times the average costs of accidents without CPRS. Within the first two years after the accident, the number of days lost at work was 20 times higher in patients with CRPS (330 ± 7 days) than in patients without CRPS (16.1 ± 0.1 days). Two-thirds of all CRPS cases developed long-term work incapacity of more than 90 days.

CONCLUSION

CRPS is a relatively rare condition but is associated with high direct health care costs and work incapacity.

Clinical Course and Impact of Complex Regional Pain Syndrome Confined to the Knee

OBJECTIVE

Although complex regional pain syndrome (CRPS) of the knee is comparable to CRPS of the ankle/foot at time of diagnosis, no reports are available concerning the course of knee CRPS. Therefore, this study investigated the clinical course in terms of the symptoms and signs, health-related quality of life (HR-QoL), and work status of patients diagnosed with CRPS of the knee.

DESIGN

Observational, descriptive study.

SETTING

Single-center study.

SUBJECTS

Patients with CRPS of the knee.

METHODS

Patients self-reported their past and current CRPS symptoms, HR-QoL, and work status; all underwent a physical examination. A comparison was made of changes in symptoms over time between patients with CRPS of the knee and those with CRPS of more distal locations.

RESULTS

In total, 32 patients were enrolled. The follow-up time was 11.5 ± 6.29 years since diagnosis, and symptoms and signs showed a significant decrease over time. Twelve patients (37.5%) rated their health as (generally) positive. Patients who were still able to work (31.3%) stated that their physical health gave them at least some problems in the performance of their job. A change in symptoms occurred significantly less often in CRPS of the knee.

CONCLUSIONS

CRPS of the knee changes in terms of symptoms over time, but significantly less than CRPS of other locations. A change in work status was reported in 82% of the patients due to their CRPS, and in 91%, the pain interfered with their daily life. CRPS of the knee is a painful condition with persistent symptoms causing a diminished HR-QoL.

Sensory modulation dysfunction is associated with Complex Regional Pain Syndrome

OBJECTIVE

Complex Regional Pain Syndrome (CRPS), a chronic pain condition, develops mainly after limb trauma and severely inhibits function. While early diagnosis is essential, factors for CRPS onset are elusive. Therefore, identifying those at risk is crucial. Sensory modulation dysfunction (SMD), affects the capacity to regulate responses to sensory input in a graded and adaptive manner and was found associated with hyperalgesia in otherwise healthy individuals, suggestive of altered pain processing.

AIM

To test SMD as a potential risk factor for CRPS.

METHODS

In this cross-sectional study, forty-four individuals with CRPS (29.9±11 years, 27 men) and 204 healthy controls (27.4±3.7 years, 105 men) completed the Sensory Responsiveness Questionnaire-Intensity Scale (SRQ-IS). A physician conducted the CRPS Severity Score (CSS), testing individuals with CRPS.

RESULTS

Thirty-four percent of the individuals with CRPS and twelve percent of the healthy individuals were identified to have SMD (χ2 (1) = 11.95; p<0.001). Logistic regression modeling revealed that the risk of CRPS is 2.68 and 8.21 times higher in individuals with sensory over- and sensory under-responsiveness, respectively, compared to non-SMD individuals (p = 0.03 and p = 0.01, respectively).

CONCLUSIONS

SMD, particularly sensory under-responsiveness, might serve as a potential risk factor for CRPS and therefore screening for SMD is recommended. This study provides the risk index probability clinical tool a simple evaluation to be applied by clinicians in order to identify those at risk for CRPS immediately after injury. Further research is needed.

Complex Regional Pain Syndrome Type 1: Diagnosis and Management

Diagnosis of Complex regional pain syndrome (CRPS) is made primarily on a clinical basis, and no specific test is known to confirm or exclude CRPS diagnosis. That is, there aren’t specific diagnostic tools and instrumental tests are made only for identifying an etiology at the basis of the CRPS. Numerous therapeutic methods have been introduced, but none have shown definitive results. When symptoms persist, patients experience permanent impairment and disability. Therefore, early recognition of CRPS, along with proper treatment, is important for minimizing permanent loss of function. As there is no gold standard test for CRPS, several clinical diagnostic criteria have been introduced and applied in various studies. However, to date, no formal or standardized diagnostic criteria for CRPS have been widely accepted. However, the Budapest diagnostic criteria have recently increased in popularity and are frequently used in scientific studies. The goal for management of CRPS is the return of normal limb function. No specific technique has been shown to prevent CRPS following surgery, but avoidance of prolonged immobilization may be important. Therefore, initiating early post-surgical rehabilitation, where possible, is important. A multidisciplinary approach would seem to be optimal, above all things objectives of physical and occupational therapy are fulfilled with combination pharmacotherapy due to provide pain relief to facilitate physical rehabilitation. Future research using large randomized controlled trials should focus on collecting strong evidence for the etiology of CRPS, testing pharmacological effects, and determining appropriate combination treatment strategies.

Usefulness of bone scintigraphy for the diagnosis of Complex Regional Pain Syndrome 1: A systematic review and Bayesian meta-analysis

BACKGROUND

Since 2007, the Budapest criteria are recommended for the diagnosis of Complex Regional Pain Syndrome (CRPS) 1. The usefulness of bone scintigraphy (BS, index test) for the diagnosis of CRPS 1 remains controversial. Imperfect reference tests (RT) result in underestimation of the diagnostic accuracy of BS. Further, biased results can occur when a dependency between the RT and BS exists. The objective was to assess the impact of different RTs, specifically the Budapest criteria, and the assumed imperfect nature of the RT on the diagnostic accuracy of BS. Further, we analyzed the association between baseline characteristics and positive BS in patients with CRPS 1.

METHODS

Systematic literature review and Bayesian meta-analysis to assess the test accuracy of BS with and without accounting for the imperfect nature of the RT. We examined correlations (Spearman correlation coefficients / Wilcoxon tests) between baseline characteristics and the proportion of positive BS in patients with CRPS 1.

RESULTS

The pooled sensitivity was 0.804 (95% credible interval (CI) 0.225-1.0, 21 studies) and specificity 0.853 (95%CI 0.278-1.00). Sensitivity and specificity of BS increased when accounting for the imperfect nature of the RT. However, in studies using Budapest criteria as reference, the sensitivity decreased (0.551; 95% CI 0.046-1) and the specificity increased (0.935; 95% CI 0.306-1). Shorter disease duration and a higher proportion of males were associated with a higher proportion of positive BS (27 studies, disease duration <52 weeks Wilcoxon test p = 0.047, female proportion Spearman correlation -0.63, p = 0.009).

CONCLUSION

Compared to the accepted Budapest diagnostic criteria BS cannot be used to rule-in the diagnosis of CRPS 1. In patients with negative BS CRPS 1 is less likely the underlying illness. Studies using older or no diagnostic criteria should not be used to evaluate the diagnostic accuracy of BS in CRPS 1.

Comparison of effects of seven treatment methods for distal radius fracture on minimizing complex regional pain syndrome

INTRODUCTION

Using network meta-analysis, we evaluated the adverse effects of the seven most common treatment methods, i.e., bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating, by their associated risk of developing complex regional pain syndrome (CRPS) in distal radius fracture (DRF) patients.

MATERIAL AND METHODS

Following an exhaustive search of scientific literature databases for high quality studies, randomized controlled trials (RCTs) related to our study topic were screened and selected based on stringent predefined inclusion and exclusion criteria. Data extracted from the selected studies were used for statistical analyses using Stata 12.0 software.

RESULTS

A total of 17 RCTs, including 1658 DRF patients, were enrolled in this network meta-analysis. Among the 1658 DRF patients, 452 received bridging external fixation, 525 received non-bridging external fixation, 154 received K-wire fixation, 84 received plaster fixation, 132 received dorsal plating, 123 received volar plating, and 188 received dorsal and volar plating. When compared to bridging external fixation patients, there was no marked difference in the CRPS risk in DRF patients receiving different treatments (all p > 0.05). However, the surface under the cumulative ranking curves (SUCRA) for plaster fixation (77.0%) and non-bridging external fixation (71.3%) were significantly higher compared with the other five methods.

CONCLUSIONS

Our findings suggest that compared with bridging external fixation, K-wire fixation, dorsal plating, volar plating, dorsal and volar plating, plaster fixation and non-bridging external fixation might be the better treatment methods to reduce the risk of CRPS in DRF patients.

A rare complication of total knee arthroplasty: Type l complex regional pain syndrome of the foot and ankle

Complex regional pain syndrome (CRPS) is a painful and disabling disorder that usually affects the extremities. This complication may affect the knee joint after total knee arthroplasty (TKA). We report a unique case of CRPS of the foot and ankle, which was an unusual involvement site for CRPS after TKA.

Can we reduce the incidence of complex regional pain syndrome type I in distal radius fractures? The Liverpool experience

Introduction

Complex regional pain syndrome is a multifaceted condition, which is relatively common after distal radius fracture.

Method

A series of audits and service evaluations were conducted from 2004 to 2013 to investigate the incidence of complex regional pain syndrome type I and any correlation to tight, restrictive, over-flexed casts. Simple subsequent clinical and patient management changes were implemented and impact re-evaluated.

Results

These audits have contributed to organisational learning and a subsequent reduction in the incidence of complex regional pain syndrome type I in non-operatively managed distal radius fracture from 25%, in keeping with expected incidence in the relevant literature, to a rare event (<1%).

Conclusion

The authors suggest that careful attention to the prevention of complex regional pain syndrome through staff and patient awareness, vigilance for warning signs and minor modifications to the traditional management of distal radius fractures can significantly reduce the incidence of complex regional pain syndrome type I after distal radius fracture.

Work-Related Complex Regional Pain Syndrome: Diagnosis and Treatment

Complex regional pain syndrome can be a debilitating disorder, which, in its earliest stages, can be prevented by aggressive rehabilitation based on reactivation. It is critical to follow international criteria on making the diagnosis; overdiagnosis can lead to inappropriate interventions and further disability. When present, early recognition with reactivation is the cornerstone of treatment. This article presents a phased approach to treatment that suggests movements of nonresponders quickly to more integrated levels of care. Some commonly used invasive interventions, such as sympathectomy and spinal cord stimulation, have not been proved effective; these unproven and potentially harmful therapies should be avoided.

Potential risk factors for the onset of complex regional pain syndrome type 1: a systematic literature review

Anaesthetists in the acute and chronic pain teams are often involved in treating Complex Regional Pain Syndromes. Current literature about the risk factors for the onset of Complex Regional Pain Syndrome Type 1 (CRPS 1) remains sparse. This syndrome has a low prevalence, a highly variable presentation, and no gold standard for diagnosis. In the research setting, the pathogenesis of the syndrome continues to be elusive. There is a growing body of literature that addresses efficacy of a wide range of interventions as well as the likely mechanisms that contribute to the onset of CRPS 1. The objective for this systematic search of the literature focuses on determining the potential risk factors for the onset of CRPS 1. Eligible articles were analysed, dated 1996 to April 2014, and potential risk factors for the onset of CRPS 1 were identified from 10 prospective and 6 retrospective studies. Potential risk factors for the onset of CRPS 1 were found to include being female, particularly postmenopausal female, ankle dislocation or intra-articular fracture, immobilisation, and a report of higher than usual levels of pain in the early phases of trauma. It is not possible to draw definite conclusions as this evidence is heterogeneous and of mixed quality, relevance, and weighting strength against bias and has not been confirmed across multiple trials or in homogenous studies.

Complex regional pain syndrome: a review

Complex regional pain syndrome, formally known as reflex sympathetic dystrophy, is a poorly understood condition that describes a collection of clinical symptoms and signs occurring in the peripheries most commonly after trauma. Pain is the main problem. It is generally out of proportion to the degree of injury and can be unresponsive to narcotics. In addition joint stiffness, temperature and colour changes, and swelling occur. The diagnosis and treatment are challenging for any clinician and a multidisciplinary approach is often necessary with physiotherapy, occupational therapy, and the pain team. The hand surgeon is involved for two reasons, firstly as the upper limb is the most frequently involved, and secondly because the condition may be a complication of the patient's surgery and result in a much prolonged recovery. This review elucidates the recent advances in the knowledge of the aetiology, classification and treatment of this fascinating condition.

Symptom validity testing in medically unexplained pain: a chronic regional pain syndrome type 1 case series

This study examines validity findings in a particular behavioral pain disorder. We examined two types of validity scores in 73 participants with a primary diagnosis of the controversial Complex Regional Pain Syndrome Type I (CRPS-1). All participants were incentivized by a disability-seeking context. Failure rates on performance validity tests ranged from 23% (Test of Memory Malingering) to 50% (Reliable Digit Span). Positive findings on symptom validity tests (MMPI-2 or MMPI-2-RF) ranged from 15% to 50% of subsamples. At least 75% of the sample failed one performance validity indicator and over half showed at least one positive symptom validity score. This initial study suggests that CRPS-1 could serve as a good patient model for studying the role of simulation in pain-related disability.

Complex regional pain syndrome of the pediatric lower extremity: a retrospective review

BACKGROUND

Complex regional pain syndrome (CRPS) type 1 is a disorder of the extremities characterized by pain, edema, limited range of motion, integument changes, and vasomotor instability often after an inciting event. In the pediatric population, CRPS may be misdiagnosed, or missed entirely, as CRPS literature for this patient population is lacking.

METHODS

Twenty-seven pediatric patient medical records with the diagnosis of CRPS type 1 from the institutional and private practices of the principal investigator (E.J.H.) were reviewed for demographics, inciting event, lower-extremity clinical examination, ancillary testing, previous treatments, time to diagnosis, treatment after diagnosis, and time to resolution of symptoms.

RESULTS

Females composed 85.2% of the patient population (n = 23) (mean age of females, 11.11 years). An inciting event preceded pain in 74.1% of patients (n = 20). On physical examination, more than 50% of patients were identified as having changes in skin color and temperature, edema to the affected lower extremity, painful or decreased range of motion in affected joints, and intact lower-extremity motor function. The average time to resolution of symptoms was 6.8 weeks for the entire population.

CONCLUSIONS

Diagnosis of CRPS type 1 should be considered in a preadolescent female complaining of pain out of proportion after an inciting event with a physical examination demonstrating change in skin color, decrease in skin temperature, edema, and painful or diminished range of motion in affected joints. Prompt diagnosis can decrease the time to resolution of symptoms.

Relationship between complex regional pain syndrome and working life: a Korean study

Complex regional pain syndrome affects the quality of life of the patient. The aim of this study was to investigate the epidemiological features of this syndrome and evaluate its effect on the patient's working life. We demonstrated that the disease has a male preponderance and is 3 times more likely to affect the lower extremities. In this study, 11 participants (20%) retained their employment, whereas 44 (80%) became unemployed. Mean age and pain score were lower in the employment group than in the unemployment group (29.1 ± 16.8 yr vs 40.1 ± 12.6 yr, P = 0.021, and 4.5 ± 2.9 vs 7.0 ± 2.0, P = 0.002, respectively). Subjects diagnosed within 8 months (P = 0.044), those who had achieved higher levels of education (P = 0.028), and those working in white-collar jobs (P = 0.011) had higher employment-retention rates. Therefore, patients must manage their jobs (lower physical demand and decrease the number of working hours) if they are to improve their occupational life. To achieve satisfactory outcomes and a high employment-retention rate, clinicians must be aware of the importance of an early diagnosis (within 8 months), appropriate treatment, and a reduction in the patient's pain score.

Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures?

BACKGROUND

In the treatment of distal radial fractures, physicians often advocate internal fixation over cast treatment for potentially unstable fracture patterns, citing the difficulties of successful nonoperative treatment and a decrease in patient tolerance for functional deficiencies. This study was performed to evaluate whether early internal fixation or nonoperative treatment would be preferred for displaced, potentially unstable distal radial fractures that initially had an adequate reduction.

METHODS

A decision analytic model was created to compare early internal fixation with use of a volar plate and nonoperative management of a displaced, potentially unstable distal radial fracture with an acceptable closed reduction. To identify the optimal treatment, quality-adjusted life expectancy was estimated for each management approach. Data from the literature were used to estimate rates of treatment complications (e.g., fracture redisplacement with nonoperative treatment) and of treatment outcomes. Mean health-state utilities for treatment outcomes of painless malunion, functional deficit, and painful malunion were derived by surveying fifty-one adult volunteers with use of the time trade-off method. Sensitivity analysis was used to determine which model parameters would change the treatment decision over a plausible range of values.

RESULTS

Early internal fixation with volar plating was the preferred strategy in most scenarios over the ranges of parameters available, but the margins were small. The older patient (mean age, 57.8 years) who sustains a distal radial fracture can expect 0.08 more quality-adjusted life years (29.2 days) with internal fixation compared with nonoperative treatment. Sensitivity analysis revealed no single factor that changed the preferred option within the reported ranges in the base case. However, the group of patients sixty-five years or older, who had lower disutility for painful malunion, derived a very small benefit from operative treatment (0.01 quality-adjusted life year or 3.7 days) and would prefer cast treatment in some scenarios.

CONCLUSIONS

Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature. This long-term gain in quality-adjusted life years outweighed the short-term risks of surgical complications, making early internal fixation the preferred treatment in most cases. However, the difference was quite small. Patients, especially those over sixty-four years old, who have lower disutility for the malunion and painful malunion outcome states may prefer nonoperative treatment.

Complex regional pain syndrome 1--the Swiss cohort study

BACKGROUND

Little is known about the course of Complex Regional Pain Syndrome 1 and potential factors influencing the course of this disorder over time. The goal of this study is a) to set up a database with patients suffering from suspected CRPS 1 in an initial stadium, b) to perform investigations on epidemiology, diagnosis, prognosis, and socioeconomics within the database and c) to develop a prognostic risk assessment tool for patients with CRPS 1 taking into account symptomatology and specific therapies.

METHODS/DESIGN

Prospective cohort study. Patients suffering from a painful swelling of the hand or foot which appeared within 8 weeks after a trauma or a surgery and which cannot be explained by conditions that would otherwise account for the degree of pain and dysfunction will be included. In accordance with the recommendations of International Classification of Functioning, Disability and Health (ICF model), standardised and validated questionnaires will be used. Patients will be monitored over a period of 2 years at 6 scheduled visits (0 and 6 weeks, 3, 6, 12, and 24 months). Each visit involves a physical examination, registration of therapeutic interventions, and completion of the various study questionnaires. Outcomes involve changes in health status, quality of life and costs/utility.

DISCUSSION

This paper describes the rationale and design of patients with CRPS 1. Ideally, potential risk factors may be identified at an early stage in order to initiate an early and adequate treatment in patients with increased risk for delayed recovery.

Unusual case of camptocormia triggered by lumbar-disc herniation

A 21-year-old male patient with low back pain and marked forward bending was presented. The exaggerated lumbar flexion was preventing him to stand in erect posture but disappeared while lying. The symptoms had begun after he had lifted a heavy object. Straight-leg-raising test could not be performed properly because of the exaggerated pain. The light-touch sense was decreased on L5 and S1 dermatomes. There was no loss of muscle strength. The deep-tendon reflexes were normal. Plain graph showed mild narrowing in the L4-5 and L5-S1 intervertebral spaces. Lumbar magnetic resonance imaging revealed disc protrusions in L4-5 and L5-S1 levels. During his stay in the department, the patient was given tizanidine and tramadol, and physical therapy was performed. A paravertebral intramuscular injection with lidocaine was applied. Moreover, the patient was referred to psychiatrist for evaluation regarding his medical history of conversive seizures and possible efforts for secondary gain. No response was obtained from all the treatments. The final diagnosis was camptocormia triggered by lumbar-disc herniation. He was applied supportive psychotherapy, psychoeducation regarding secondary gain, strong suggestions to improve posture, positive reinforcement, and behavioral therapy. His postural abnormality resolved and disappeared completely with mild pain.