COMPLEX REGIONAL PAIN SYNDROME (crps)

1. COMPLEX REGIONAL PAIN SYNDROME (crps) THE CIVIL WAR DISEASE

2. 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…

3. 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."

4. "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

5. 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."

6. WHAT’S IN A NAME?

7. 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)

8. 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

9. 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

10. 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

11. 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)

12. 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)

13. TREATMENT OPTIONS • Drugs • Blocks • Physical therapy: aqua or physiotherapy • Sympathectomy: (rare cases) • SCS, PNS, morphine pump • Psychological support

14. 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

15. 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”.

16. 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%

17. MC GILL PAIN INDEX • cancer pain rated 28, CRPS pain rated 42

18. RSDCANADA SURVEY 2006: PAIN SCALE RATING (0-10)

19. SELF-MANAGEMENT OF CRPS • MEDICAL SUPPORT • CONTACT ORGANIZATION • DEVELOP PLAN • ALTERNATIVE THERAPIES • WORK PIECES OF PUZZLE • STAY POSITIVE

20. 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

21. RSDCANADA SURVEY RESULTS • Rating own success • Progress over time • Has your CRPS spread?

22. OVERALL SUCCESS RATING

23. PROGRESSION: IS YOUR CRPS WORSE, BETTER OR SAME?

24. HAS YOUR CRPS SPREAD? • Most cases progress and travel through other body parts • Progression causes systemic chronic problems • Pain is hallmark feature

25. 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

26. 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

27. 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

28. COMPLEX REGIONAL PAIN SYNDROME… THANK YOU FOR INVITING ME!