a chronic neurological pain disorder associated with autonomic dysfunction (involuntary activities in body - glands, cardiac, smooth muscle)
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
which body parts are vulnerable to CRPS?
all of them!
CRPS is associated with severe burning pain and what other symptoms?
dystrophic changes (nail, hair, skin)
loss of function of an extremity
approx how many americans get CRPS
200,000 to 1.2 mil
common age, gender, and race of CRPS pts?
middle age, but can appear in kids
2-3x mor common in females than males
in what percent of cases do symptoms of CRPS radiate to the limb?
What does CRPS look like?
can be discolored, swollen, hairy, crazy nails, ulcerations, sore, wounds..... but usually looks normal
CRPS types I and II
I: reflex sympathetic dystrophy (RDS) - not associated with classic nerve injury
II: causalgia - is associated w classic nerve injury
effects of sympathetic stimulation
fight or flight
increased HR, increased force of contraction
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
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
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
what is substance P?
a neurotransmitter that brings pain from area to area
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
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
predisposing factors to CRPS
(though this is debated)
stressful events in preceding year
psych history (though the psych problems, like depression and helplessness, may be brought on by CRPS)
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")
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
spontaneous sharp jabs of pain
myofascial pain syndrome
diffuse tenderness due to muscle trigger points
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
hyperestesia vs allodenyia
hypersthesiaS: increased sensitivity to stim
allodynia; normal tactile stim is painful
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
motor changes with CRPS
pain w movment
difficulty initiating movement (stiffness)
tremor and invol mvmnt
and all of these can lead to disuse atrophy
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
psych features of CRPS
failure to cope
(av go to 4.8 diff docs before getting referred to a pain specialist)
3 stages of CRPS - just names
describe the first stage of CRPS
onset: 3 days -3 weeks
duration: 1-3 months
describe phase 2 of CRPS
onset: 3-7 months
duration: 3-6 months
brawny (hard) edema
pain - decreased sensitivity, but bitter aera
further ROM reduction
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
which stage has diffuse osteoporosis, pain that's decreased but over a wider area, and cool/cyanotic skin?
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
IRREVERSIBLE, not much we can do now
how's a bone scan as a diagnostic tool for CRPS?
gives earlier diagnosis, but variable sensitivity/specificity in lit
how's a x-ray as a diagnostic tool for CRPS?
not pos til 6 weeks-3 months after onset
how's a thermogram as a diagnostic tool for CRPS?
shows skin temp changes
how's a laser doppler imaging as a diagnostic tool for CRPS?
shows skin blood flow changes (very diminished flow in CRPS)
how's a quantitatve sensory test (QST) as a diagnostic tool for CRPS?
it assesses sensation
how's electrodiagnostic (EMG/NCV) as a diagnostic tool for CRPS?
unable to diagnose CRPS I
how's MRI/diagnostic arthrorscopy as a diagnostic tool for CRPS?
can find presence of lesion
how's sympathetic blockade as a diagnostic tool for CRPS?
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
post-traumatic peripheral nerve pain
inflammatory soft tissue lesions
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)
poor when symptoms are chronic (atrophic phase)
better luck if treatment starts early
CRPS can result in markedly limited function and even amputation
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
tx goals with CRPS
restore bilat symmetry
restore normal movement and wt bearing
restore limb's normal participation in ADL
increase QOL and improve psychosocial functioning
meds for CRPS
antiepileptic - gabapentin
anti-depressants - elavil
systemic alpha-blockers -- phenoxybenzamine
topical mes - DMSO cream
intravenous biphosphonates - fosamax
narcotics - not recommended, but may be used
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
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
sympathetic nerves are disolved to treat CRPS -- super invasive
(can also get acupuncture as tx, but he's not a big fan it seemed)
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
side effects of ketamine
hallucinations, wt loss, abnormal appetite and sweating
infusion lasts 3-5 days
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)