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!