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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
RSDCANADA SURVEY 2006: PAIN SCALE RATING (0-10)
0
5
10
15
20
25 1
2
3
4
5
6
7
8
9
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
0
2
4
6
8
10
12
14
16
18 10%
20
30
40
50
60
70
80
90
100
No rating
PROGRESSION: IS YOUR CRPS WORSE, BETTER OR SAME?
0
10
20
30
40
50
60
70
WORSE
BETTER
SAME
HAS YOUR CRPS SPREAD?
0
10
20
30
40
50
60
70
YES
NO
UN-KNOWN
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!