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Diagnosis and Management of Complex Regional Pain Syndrome (CRPS) after Stroke

Leonard S.W. LiHonorary Clinical Professor,Department of Medicine, The University of Hong KongDirector, Neurological Rehabilitation CentreVirtus Medical Group, Hong Kong

Pain Syndromes after stroke

• Central Pain (CPSP) 2–8%

• Nociceptive (Hemiplegic shoulder) Pain 38%-84%.

• Complex Regional Pain Syndrome CRPS 20-70%

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Complex Regional Pain Syndrome (CRPS)

• The physiopathology of the disease is still not known.

• Hypothesis: a localized neurogenic inflammation is at the basis of oedema, vasodilation and hyperhidrosis that are present in the initial phases of CRPS.

• The repeated discharge of the C fibres causes an increased medullary excitability (central sensitization).

• Another important factor is the reorganisation of the central nervous system, and in particular this appears to affect the primary somatosensory cortex.

CRPS Diagnosis (Clinical)

Color, edema Temperature

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CRPSProposed Diagnostic Criteria (symptoms)

1. Continuing pain, which is disproportionate to any inciting events.

2. Report of at least one symptom in three of the four following categories:• Sensory: reports of hyperesthesia• Vasomotor: reports of temperature asymmetry and/or skin color

changes and/or skin colour asymmetry• Sudomotor/edema: reports of edema (with or without joint stiffness)

and/or sweating changes and/or sweating asymmetry; or • Motor/trophic: reports of decreased range of motion and/or motor

dysfunction (weakness, tremor, dystonia) and/or trophic changes (nails, hair, skin).

Budapest IASP consensus group

CRPS:Proposed Diagnostic Criteria (Signs)

3. At least one sign in two or more of the following categories:• Sensory: evidence of hyperalgesia (to pinprick) or allodynia (to

light touch• Vasomotor: evidence of temperature asymmetry and/or skin

color changes and/or asymmetry• Sudomotor/edema: objective evidence of edema (with or

without joint stiffness) and/or sweating changes and/or sweating asymmetry; or

• Motor/trophic: evidence of decreased range of motion (including joint stiffness) and/or motor dysfunction and/or trophic changes

4. No other potential cause of pain is identified

Budapest IASP consensus group

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Differential Diagnosis

Post Stroke Central Pain

Investigation

• Plain X-ray or MRI: patchy osteoporosis

• Three phases of bone scan

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SSR (Sympathetic Skin Response) and Post Stroke CRPS

Sympathetic Skin Response study:

Increase in amplitude in Post

Stroke CRPS

Clinchot DM,et al. Am J Phys Med Rehabil. 1996 Jul-Aug;75(4):252-6

Selçuk et al.: Neurology India | September 2006 | Vol 54 | Issue 3

SSSR (Sympathetic Skin Response) and Post Stroke CRPS

Obstacles in application of clinical use:

• May be absence in age >70

• Criteria of abnormality varied

• Variable increase in amplitude observed

in CRPS

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Application of SSR in the diagnosis of Post Stroke CPRS

Amplitude: Ratio between paretic and normal hands

，

Data not published yet

Treatment Objectives

Conservative care:•The goal of the treatment is physical restoration and pain

control; • Early, aggressive care is encouraged; • Emphasis should be on improved functioning of the

symptomatic limb. •Physical/occupational therapy should be focused on

increasing functional level; • Other medications: as long as it promotes improved

function.

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Quality of Evidence

• High

• Moderate

– intravenous regional blockade with guanethidine is not effective

Quality of Evidence

• Low

– Gabapentine, ketamine, bisphosphonates and calcitonin may effectively reduce pain when compared with placebo at least in the short term

– local anaesthetic sympathetic blockade is not effective

– passive attention vs. control are associated with small positive effects at one year follow up that are unlikely to be clinically important

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Quality of Evidence

• Very Low

– compared with placebo, oral corticosteroids reduce pain

– compared with placebo, epidural clonidine reduced pain

– intravenous regional block (IVRB) ketanserin and IVRB bretylium may be effective;

– sympathetic blockade with botulinum toxin A(BTX) may deliver a longer duration of pain relief than local anaesthetic sympathetic blockade

Quality of Evidence

• Very Low– physiotherapy and occupational therapy improve pain more than a passive attention

social work control for up to six months and that physiotherapy but not occupation therapy improves impairment for up to four months compared to the same control be effective versus sham Qigong therapy

– acupuncture may offer short-term improvement in pain when added to rehabilitation compared with rehabilitation alone

– in post-stroke CRPS and that electro-acupuncture plus rehabilitation therapies (details not specified) might be more effective than lidocaine, triamcinolone acetonide and vitamin B12

– acupuncture is not superior to sham

• No Evidence– efficacy of surgical sympathectomy

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Mirror therapy and CRPS I

De Blass et al. NEJM 361;6,Aug 6, 2009

Graded Motor Imagery

VAS

Functional

Scale

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Mechanism ??

Occipital Cortex

Somatosensory Cortex

Motor Cortex

Damaged

hemisphere

Damaged

hemisphere

Mirror Therapy and Interhemispheric Interaction

H.E. Rossiter, M. R. Borrelli, R. J. Borchert1 D.Bradbury, N. S. Ward,

Neurorehab and Neural Repair 2015, Vol. 29(5) 444–452

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Intervention Strategies

Evaluation

TARGET: Functional Restoration

Pharmacological intervention

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Functional Restoration : A Gradual Approach

1. Mirror therapy, Reactivation, Contrast Baths, Desensitization, Exposure Therapy

2. Edema Control, Flexibility (active), Isometric Strengthening, Treatment of 2nd Myofascial Pain

3. Stress Loading, Isotonic Strengthening ROM (gentle, passive)

4. Ergonomics, Movement Therapies, Normalization of Use, Functional Rehabilitation

fMRI and imagined allodynia

Heidrun H. Krämer, The Journal of Pain, Vol 9, No 6 (June), 2008: pp 543-551

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PsychologicalIntervention

Coping skills for Chronic Pain

• disturbed sleep, fatigue, diminished capacity, mood changes, and stress in relationships.

• Different coping strategies– making the pain comprehensible,

– planning of activities,

– taking medications,

– Communicating, and

– Distractions.

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Interventional Treatment

• negative recommendation – Sympathetic blocks,

• stellate ganglion blocks,

• Spinal cord stimulation (SCS) may be considered if – do not respond to pharmacological treatments or

rehabilitation therapies.• a positive effect on both the somatosensory system and the

vasomotor disturbances

Kemler MA et al. N Engl J Med 2000; 343: 618–24

Key word to prevent and manage Poststroke Pain

• Appropriate and Proper mobilization of paretic limbs early

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Thank You

End of

Presentation