Complex regional pain syndrome

The challenge of recognizing severe pain and autonomic abnormalities for early diagnosis of CRPS

OBJECTIVES

Complex regional pain syndrome (CRPS) is a disabling usually post-traumatic pain condition. International guidelines emphasize early diagnosis for treatment and improved outcome. Early intense and persistent pain along with features of autonomic dysfunction in the first week's post-injury are early warning signs for development of CRPS. We have previously reported a delayed diagnosis of CRPS. The main purpose of the present study was to investigate possible causes of a delayed diagnosis, with a special focus of recognition of risk factors.

METHODS

A total of 52 CRPS 1 (without detectable nerve damage) and CRPS 2 (with evidence of nerve lesion) patients were included in the study. When examined at OUS-Rikshospitalet, we retrospectively asked the patients on the development of pain and autonomic abnormalities from the time of the eliciting injury, performed a thorough clinical investigation with an emphasis on signs of autonomic failure and compared symptoms and clinical findings with such information in previous medical records. We also evaluated symptoms and signs according to the type of injury they had suffered.

RESULTS

Of a total of 52 patients (30 women and 22 men, mean age 39.0 years at the time of injury), 34 patients had CRPS type 1 (65.4%) and 18 CRPS type 2 (34.6%), 25 patients with pain in the upper and 27 in the lower extremity. A total of 35 patients (67.3%) were diagnosed with CRPS (following mean 2.1 years) prior to the investigation at OUS-Rikshospitalet (mean 4.86 years following injury). Mean time from injury to diagnosis was 33.5 months (SD 30.6) (2.8 years) for all patients. In retrospect, all 17 patients first diagnosed at OUS met the CRPS diagnosis at an earlier stage. All patients retrospectively reported intense pain (numeric rating scale > 7) from the time of injury with a large discrepancy to previous medical records which only stated intense pain in 29.4% of patients with CRPS type 1 and 44.4% of patients with CRPS type 2 within the first four months. While the patients reported an early onset of autonomic dysfunction, present in 67.3 and 94.2% of the patients within one week and one month, respectively, reports of autonomic abnormalities within the first four months was far less (maximum in 51.7% of patients with CRPS type 1 and in 60% in CRPS 2). In 10 patients with CRPS type 1, no symptom nor sign of autonomic abnormalities was reported.

CONCLUSIONS

We still find a significant delay in the diagnosis of CRPS. There is a large discrepancy between both self-reporting of intense, disproportionate pain, as well as symptoms of autonomic abnormalities from the time of injury, and documentation in previous medical records. Our findings suggest a lack of awareness of risk factors for the development of CRPS, such as early intense pain and autonomic abnormalities without recovery, contributing to delayed diagnosis. The present results suggest causes of delayed CRPS-diagnosis. An increased attention to early warning signs/risk factors may improve diagnosis of CRPS.

Complex regional pain syndrome

Practice development enables the practitioner to develop their knowledge and allow the application of evidence based care for patients. It happens within the practitioner's own clinical practice area and enhances personal and professional growth whilst focusing on patients' specific needs. This is important with a condition such as Complex Regional Pain Syndrome (CRPS), with patients seekingaccurate and timely diagnosis and coping strategies to support them in everyday activities. This article aims to provide the practitioner with an overview of CRPS, including some information that can be used in identifying signs and symptoms of the condition to support a diagnosis. There is also an introduction to brain retraining techniques which are used in CRPS rehabilitation to restore as much physical function to the patient as possible along with restoration of body perception and ownership of the limb.

An Integrative Neuroscience Framework for the Treatment of Chronic Pain: From Cellular Alterations to Behavior

Chronic pain can result from many pain syndromes including complex regional pain syndrome (CRPS), phantom limb pain and chronic low back pain, among others. On a molecular level, chronic pain syndromes arise from hypersensitization within the dorsal horn of the spinal cord, a process known as central sensitization. Central sensitization involves an upregulation of ionotropic and metabotropic glutamate receptors (mGluRs) similar to that of long-term potentiation (LTP). Regions of the brain in which LTP occurs, such as the amygdala and hippocampus, are implicated in fear- and memory-related brain circuity. Chronic pain dramatically influences patient quality of life. Individuals with chronic pain may develop pain-related anxiety and pain-related fear. The syndrome also alters functional connectivity in the default-mode network (DMN) and salience network. On a cellular/molecular level, central sensitization may be reversed through degradative glutamate receptor pathways. This, however, rarely happens. Instead, cortical brain regions may serve in a top-down regulatory capacity for the maintenance or alleviation of pain. Specifically, the medial prefrontal cortex (mPFC), which plays a critical role in fear-related brain circuits, the DMN, and salience network may be the driving forces in this process. On a cellular level, the mPFC may form new neural circuits through LTP that may cause extinction of pre-existing pain pathways found within fear-related brain circuits, the DMN, and salience network. In order to promote new LTP connections between the mPFC and other key brain structures, such as the amygdala and insula, we propose a holistic rehabilitation program including cognitive behavioral therapy (CBT) and revolving around: (1) cognitive reappraisals; (2) mindfulness meditation; and (3) functional rehabilitation. Unlike current medical interventions focusing upon pain-relieving medications, we do not believe that chronic pain treatment should focus on reversing the effects of central sensitization. Instead, we propose here that it is critical to focus on non-invasive efforts to promote new neural circuits originating from the mPFC.

Complex regional pain syndrome acute care pathways in England: Do they exist and what do they look like?

Introduction

Complex Regional Pain Syndrome is a condition with a high degree of morbidity and health costs to the National Health Service (NHS), characterised by persistent pain, sensory, motor, trophic and autonomic signs and symptoms. The British Orthopaedic Association (BOA) and the Royal College of Physicians (RCP) have recommended treatment guidelines and care pathways for the management of acute Complex Regional Pain Syndrome. The objective of this scoping exercise was to use Freedom of Information (FOI) requests to ascertain whether NHS Trusts in England had such pathways and what they looked like.

Methods

FOI requests were sent to 126 English NHS Trusts on 9 March 2017 on behalf of the Complex Regional Pain Syndrome Clinical and Research Network UK, asking: “What does your acute Complex Regional Pain Care Syndrome pathway look like?”

Results

Replies were received by 95 NHS Trusts and of these 84 had relevant services but (82%) had no pathway or agreed initial management.

Conclusions

It appears to be common for no acute care pathway to exist for CRPS in NHS Trusts in England despite it being a domain in BOA national guidelines. The Royal College of Physicians guidelines also recommend integrated MDT care. Consequentially, BOA and Royal College of Physicians standards in acute CRPS management are not yet being followed in most acute NHS Trusts in England providing trauma care. Where there is a pathway agreed, it is rarely integrated and truly multidisciplinary.

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.

Coping with chronic complex regional pain syndrome: advice from patients for patients

OBJECTIVE

To explore what advice people currently living with chronic complex regional pain syndrome would offer to another person coming to terms with a diagnosis of chronic complex regional pain syndrome.

METHODS

Semi-structured interviews with 21 adults (5 male) living with chronic complex regional pain syndrome who had completed a complex regional pain syndrome rehabilitation programme were conducted.

RESULTS

Effectively self-managing complex regional pain syndrome required individuals to play an active role. This could only be achieved if they felt they had sufficient control. Means of attaining control involved attaining a level of acceptance, becoming well-informed and accessing the right kind of support. The advice offered by patients for patients largely reflected that offered by healthcare professionals. One area where there was a conflict concerned sleep hygiene.

CONCLUSIONS

Our study provides support both for the argument put forward by Redman that without appropriate preparation and support, self-management is ineffective, and that by Skuladottir and Hallsdottir that the main challenge of the chronic pain trajectory is that of retaining a sense of control. The clinical implications of this are discussed.

Finger Stiffness Measured by Goniometry Method—A Simple useful Tool for Early Diagnosis of Reflex Sympathetic Dystrophy after Colles’ Fracture

We assess the finger joint stiffness by measuring the active range of motion of all metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints of the involved hand with a hand goniometer. It is then compared with the normal hand for the effective range of total motion and thereby using it as a quantitative, qualitative, and reproducible method for early diagnosis of reflex sympathetic dystrophy after Colles’ fracture. It is sensitive and specific.