HSS spring 2013 - CRPS

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HSS spring 2013 - CRPS
2013-04-26 14:57:52

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  1. Complex Regional Pain Syndrome (CRPS) basic def
    a chronic neurological pain disorder associated with autonomic dysfunction (involuntary activities in body - glands, cardiac, smooth muscle)
  2. precipitating event for CRPS?
    usually a traumatic or neurological insult - something like a bone break or a minor procedure - in 95% of the cases

    there's little rel btwn the severity of the CRPS and that of the original insult
  3. which body parts are vulnerable to CRPS?
    all of them!
  4. CRPS is associated with severe burning pain and what other symptoms?
    • basomotor instability
    • dystrophic changes (nail, hair, skin)
    • loss of function of an extremity
  5. approx how many americans get CRPS
    200,000 to 1.2 mil
  6. common age, gender, and race of CRPS pts?
    • middle age, but can appear in kids
    • 2-3x mor common in females than males
    • caucasians
  7. in what percent of cases do symptoms of CRPS radiate to the limb?
  8. What does CRPS look like?
    can be discolored, swollen, hairy, crazy nails, ulcerations, sore, wounds..... but usually looks normal
  9. CRPS types I and II
    • I: reflex sympathetic dystrophy (RDS) - not associated with classic nerve injury
    • II: causalgia - is associated w classic nerve injury
  10. effects of sympathetic stimulation
    • fight or flight 
    • increased HR, increased force of contraction
    • increased BP
    • increased RR
    • incrased alertness
    • decreased peristalsis
    • sweating 
    • dilated pupils
    • blood vessels contract to shift blood to vital muscles and organs
    • decreased supply of blood to skin to reduce blood loss
    • increased metabolism and heat production
    • increased sweat production to cool body

    SNS usually shuts down minutes/hours after injury, when pt feels safer

    in CRPS, the symp doesn't stop
  11. the sympathetic nervous system in CRPS
    so, an insult sends pain impulses to brain --> activates SNS-->SNS triggers inflammatory response --> blood gets shunted to or away from areas --> blood vessels spasm --> more pain and swelling .... repeat repeat repeat ... control of SNS is lost bc the brain receives constant pain signals
  12. pathophys of CRPS is poorly understood.... tell me about the theory involving substance P
    • there's the abnormaly increased resting discharge of the sympathetic nervous system
    • peripheral nociceptor sprouting secondary to local dmyelination
    • nociceptive C fibers increase substance P release at site of original injury
  13. what is substance P?
    a neurotransmitter that brings pain from area to area
  14. skin biopsies taken from CRPS pts revealed...(4)?
    • loss fo C and A type nerve fibers
    • reduced density of small fiber nerve endings
    • denervated sweat glands
    • decreased vascular innervation
  15. theories of CNS involvement in CRPS
    • neuroplastic alterations in somatosensory cortex --> trouble w how they receive and respond to pain
    • abnormal modulation of second order wide dynamic range tract cells
  16. predisposing factors to CRPS
    • (though this is debated)
    • inactivity
    • stressful events in preceding year
    • psych history (though the psych problems, like depression and helplessness, may be brought on by CRPS)
  17. 3 diagnostic criteria for CRPS
    • 1-noxious event and subsequent pain out of proportion to the event
    • 2- edema, changes in skin blood flow, abnormal sudomotor (sweat glands) activity, impaired motor function, or changes in tissue growth (dystrophy or atrophy) in region of pain
    • 3- no other conditions present that could account for the pain and dysfunction ("exclusion of other diagnoses")
  18. 6 ways the pain can present
    • severe, constant, burning or aching
    • allodynia - normal tactile stim is painful
    • hyperesthesia - increased sensitivity to stim
    • hyperpathia - repetitive tactile stim causing increase in pain and after-sensation
    • myofascial pain syndrome - diffuse tenderness due to muslce trigger points
    • paroxysmal dysethesia - spontaneous sharp jabs of pain
  19. paroxysmal dysesthesia
    spontaneous sharp jabs of pain
  20. myofascial pain syndrome
    diffuse tenderness due to muscle trigger points
  21. hyperpathia
    • repetitive tactile stim causing increasing pain and after-sensation 
    • ex: pat pt on back, stop patting, and the sensation persists for the pt and grows more painful
  22. hyperestesia vs allodenyia
    • hypersthesiaS: increased sensitivity to stim
    • allodynia; normal tactile stim is painful
  23. visible changes in CRPS
    • skin: dry, shiny, scaly, temp changes
    • edema: pitting or brawny
    • nail growth: faster, brittle
    • sweating: increased or decreased
    • skin color: "wide range"
    • hair growth: more hairy
  24. motor changes with CRPS
    • pain w movment
    • difficulty initiating movement (stiffness)
    • tremor and invol mvmnt
    • spasms
    • dystonia

    and all of these can lead to disuse atrophy
  25. location patterns for CRPS
    • initially localized to site of injury, then become more diffuse. 3 known patterns --
    • 1) spread distal to prox from initial site
    • 2) mirror image on opp limb
    • 3) spread to a separate, distant region
  26. psych features of CRPS
    • suffering
    • fear
    • anxiety
    • anger
    • depression
    • failure to cope
    • behavioral illness
    • (av go to 4.8 diff docs before getting referred to a pain specialist)
  27. 3 stages of CRPS - just names
    • acute
    • dystrophic
    • atrophic
  28. describe the first stage of CRPS
    • ACUTE
    • onset: 3 days -3 weeks
    • duration: 1-3 months
    • skin changes
    • pain
    • decreased ROM
    • pitting edema 
  29. describe phase 2 of CRPS
    • onset: 3-7 months
    • duration: 3-6 months
    • skin changes
    • brawny (hard) edema
    • pain - decreased sensitivity, but bitter aera
    • further ROM reduction
    • diffuse osteoporosis
  30. dif btwn skin changes in stages 1 and 2
    • acute: glossy, increased/decreased sweating, hair growth, color changes
    • dystrophic: taut, shiny, decreased sweating, cool/cyantotic, thinning, loss of landmarks, coarser hair/nail growth
  31. which stage has diffuse osteoporosis, pain that's decreased but over a wider area, and cool/cyanotic skin?
    2: dystrophic
  32. stage 3 of CRPS
    • onset: 6-9 months
    • skin: irriversible trophic changes, smooth glassy skin, cyanotic/cool, hair follicles large and brittle, nails brittle and grooved
    • atrophy: muscle and bone
    • fascia: thickening
    • pain: disseminating
    • joints: contractures
    • IRREVERSIBLE, not much we can do now
  33. how's a bone scan as a diagnostic tool for CRPS?
    gives earlier diagnosis, but variable sensitivity/specificity in lit
  34. how's a x-ray as a diagnostic tool for CRPS?
    not pos til 6 weeks-3 months after onset
  35. how's a thermogram as a diagnostic tool for CRPS?
    shows skin temp changes
  36. how's a laser doppler imaging as a diagnostic tool for CRPS?
    shows skin blood flow changes (very diminished flow in CRPS)
  37. how's a quantitatve sensory test (QST) as a diagnostic tool for CRPS?
    it assesses sensation
  38. how's electrodiagnostic (EMG/NCV) as a diagnostic tool for CRPS?
    unable to diagnose CRPS I
  39. how's MRI/diagnostic arthrorscopy as a diagnostic tool for CRPS?
    can find presence of lesion
  40. how's sympathetic blockade as a diagnostic tool for CRPS?
    • most reliable!!
    • can be intravenous or spinal
    • not part of diagnostic criteria
    • you put a sympathetic block (an anasthetic) in the ganglia, and it shuts down the symp n. --> quick release -- lets the nervous system reset
  41. differential diagnoses
    • post-traumatic peripheral nerve pain
    • inflammatory soft tissue lesions
    • myofascial pain
    • vascular disease
    • connective tissue disease (like lupus or RA)
    • psychiatric (somatoform disorder, hysterical conversion disorder ((both of those are symptoms w/o found physical or medical cause)), malingering)
  42. prognosis info
    • poor when symptoms are chronic (atrophic phase)
    • better luck if treatment starts early
    • CRPS can result in markedly limited function and even amputation
  43. 5 yr follow up study of pts w upper extremity CRPS revealed that...?
    • pts continued having impairments and disabiities in ADL
    • 28% had to stop working for >1yr
  44. tx goals with CRPS
    • reduce pain
    • reduce edema
    • restore bilat symmetry 
    • restore normal movement and wt bearing
    • restore limb's normal participation in ADL
    • increase QOL and improve psychosocial functioning
  45. meds for CRPS
    • corticosteroids
    • antiepileptic - gabapentin
    • anti-depressants - elavil
    • systemic alpha-blockers -- phenoxybenzamine
    • cacitonin
    • topical mes - DMSO cream
    • intravenous biphosphonates - fosamax
    • NSAIDS
    • narcotics - not recommended, but may be used
  46. sympathetic nerve blocks tx
    • sympathetic blocking agents are injected into extremity
    • 50-90% cure or remission success rate
    • helps determine what portion of pain is caused by SNS
    • often a series of blocks (3) is required for full effect, usually bupivacaine
    • success varies based on stage, skill of technician, completeness of block
  47. spinal cord stim for CRPS tx
    electrode is implanted in dorsal horn of the spinal cord at level of pain -- this is super invasive - y're havign a TENS unit inserted in spine
  48. sympathectomy
    sympathetic nerves are disolved to treat CRPS -- super invasive

    (can also get acupuncture as tx, but he's not a big fan it seemed)
  49. ketamine and CRPS
    • IV anesthetic with disassociative, analgesic, sedative, and amnesic properties
    • has shown to provide significant pain relief and increased mobility to CRPS pts
  50. side effects of ketamine
    • hallucinations, wt loss, abnormal appetite and sweating
    • infusion lasts 3-5 days
  51. 4 general steps of PT for CRPS
    • 1) desensitization of the affected area (get it used to soap, cotton,... building up to things like velcro)
    • 2) mobilization, edema control, isometric strengthening
    • 3) stress loading, isotonic strengthening, ROM, postural normalization, aerobic conditioning
    • 4) vocational/functional rehab, ergonomic reconditioning
  52. objective measures looked at in PT for CRPS
    • edema
    • ASROM
    • strenght
    • coordination
    • dexterity
    • skin/vasomotor changes
    • sensation
    • functional use of extremity
  53. tips for edema management
    • garments
    • cotnrast baths
    • retrograde massage
    • stress loading
    • AROM exercises
    • elevation (as long as it doesn't become incorporated into muscle guarding and disuse)
  54. PT tx, 2 words, for CRPS
    scrub & carry
  55. idea behind scrub and carry
    promotes active movement and compression of affected jts
  56. scrubbing, in the scrub and carry model
    move the extremity back and forth while wt bearing thru it
  57. carrying, in the scrub and carry model
    • loading the joint
    • for UE - hold a weighted object
    • for LE - amb, wt bear thru limb, wt shift, load/unload jot (vs scrubbing - walking and dancing)
  58. mirror box w chronic cases?
    no improvements
  59. list of PT techniques
    • gentle active stretchign
    • continuous passive motion machines
    • myofacial release
    • splinting/positioning
    • aquatic therapy
    • TENS
    • US
    • promote proper posture using mirrors, biofeedback, balance control

    exercises should be performed in short, frequent sessions throughout day
  60. pt edu... what he had in bold...
    must learn to functionally reuse limb (functional improvement, PEPT)
  61. how's about exercise as tx for CRPS
    one study of 103 13y/o kids w CRPS exercise 4 hrs/day for 6-14 days and found 92% relief
  62. psychotherapy?
    should get a psych eval after 2 moths of CRPS pain

    and you should slip imagery, self-hypnosis, biofeedback, relaxion, behavioral modification counseling into PT
  63. what about operating on a limb with CRPS?
    • most surgeons wait 5-12 months after remission
    • pts might get a series of sympathetic nervous blocks before surgery
    • early functional mobilization post0op goodf or edema control
    • take high-dose vitamin C (500mg for 50 days)