CRPS

1. Complex Regional Pain Syndrome (CRPS)
ADE WIJAYA, MD
NOVEMBER 2017

2. Outline:
 Introduction
 Epidemiology
 Pathophysiology
 Diagnosis criteria
 Diagnostic procedures
 Precipitating events
 Clinical presentation
 Differential diagnosis
 Treatment
 Prevention
 Prognosis
 Summary

3. Introduction
• CRPS is a term coined by IASP
• Spontaneous or stimulus-induced pain that is disproportionate to the inciting event and
accompanied by a wide variety of autonomic and motor disturbances
• Causalgia
Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review.Autoimmunity reviews, 13(3), 242-265.

4. Epidemiology
Annual Incidence:
CRPS I : 5,46 / 100.000
CRPS II : 0,82 / 100.000
Mean or median age at onset varies from ~37–52 years
Woman > Man
Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review.Autoimmunity reviews, 13(3), 242-265.

5. Pathophysiology
1. Psychological factor
2. Immobilization
3. Sympathetic nervous system (vasomotor disturbances and pain)
4. Neurogenic inflammation
5. The deep tissue microvascular pathology hypothesis
6. The small fiber neuropathy hypothesis
7. Central processes (cortical reorganization, central changes in pain processing)
8. Genetic predisposition
9. Autoimmunity
Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review.Autoimmunity reviews, 13(3), 242-265.
Bruehl, S., & Chung, O. Y. (2015). Complex regional pain syndrome. Bmj, 351(h2730).

6. Bruehl, S., & Chung, O. Y. (2015). Complex regional pain syndrome. Bmj, 351(h2730).

7. Diagnostic Criteria
Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle, WA: IASP Press; 1994
International Association for the Study of Pain. Classification of chronic pain. 2nd edition (revised). www.iasp-pain.org/files/Content/ ContentFolders/Publications2/ClassificationofChronicPain/Part_II-A.pdf

8. Diagnostic Procedures
• EMG / NCV  to detect nerve dysfunction
• Sensory testing, QST, SSEP
• TMS
• MRI, PET, SPECT
• Bone scintigraphy
Harden, R. N., Oaklander, A. L., Burton, A. W., Perez, R. S., Richardson, K., Swan, M., ... & Bruehl, S. (2013). Complex regional pain syndrome: practical diagnostic and treatment guidelines. Pain Medicine, 14(2), 180-229.
Ringer R, Wertli M, Bachmann LM, Buck FM, Brunner F. Concordance of qualitative bone scintigraphy results with presence of clinical complex regional pain syndrome 1: meta-analysis of test accuracy studies. Eur J Pain 2012;16:1347–56

9. Precipitating Events
• Sprains
• Fractures
• Surgery
• Injections
• Local infections
• Burns
• Frostbytes
• Pregnancy
• Stroke
• Myocardial infarction
Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review.Autoimmunity reviews, 13(3), 242-265.

10. Clinical Presentation
Sensoric
Autonom
Motoric
Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review.Autoimmunity reviews, 13(3), 242-265.

11. Sensory Disturbances
• Burning
• Dull, aching, tearing
• Allodynia, hyperalgeusia, hypoalgeusia
Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review.Autoimmunity reviews, 13(3), 242-265.

12. Clinical Presentation
AUTONOM
Temperature asymmetry
MOTORIC
Weakness
Limited ROM
Slower inaccurate movement
Rarely movement disorders
Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review.Autoimmunity reviews, 13(3), 242-265.

13. CRPS Phases
Acute
• Pain
• Sensory
symptoms
• Edema
• Sudomotor
• Sometimes
motoric
Dystrophic
• Pain and sensory
more prominent
• Vasomotor
Atrophic
• Vasomotor
• Motor
• Trophic
Bruehl S, Harden RN, Galer BS, Saltz S, Backonja M, Stanton-Hicks M. Complex regional pain syndrome: are there distinct subtypes and sequential stages of the syndrome? Pain 2002;95:119–24

14. Differential Diagnosis
Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review.Autoimmunity reviews, 13(3), 242-265.

15. Treatment
Bruehl, S., & Chung, O. Y. (2015). Complex regional pain syndrome. Bmj, 351(h2730).
Surgery and amputation
Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review.Autoimmunity reviews, 13(3), 242-265.

16. Prevention
Vitamin C
Ischaemic reperfusion injury
Bruehl S, Harden RN, Galer BS, Saltz S, Backonja M, Stanton-Hicks M. Complex regional pain syndrome: are there distinct subtypes and sequential stages of the syndrome? Pain 2002;95:119–24

17. Prognosis
Symptoms resolution: 7 months – several years
CRPS following fracture was found to be associated with a higher resolution rate and better
outcome, while involvement of an upper extremity, and cold CRPS were associated with worse
outcome in the Netherlands.
A colder skin temperature of the affected limb at the onset of symptoms was associated with
the recurrence of RSD in, or spreading of RSD to, a second limb, and the development of
dystonia, other severe complications, and possibly the requirement for amputation.
Unlike overall outcome, severe complications were also associated with involvement of a lower
extremity in addition to younger age and female gender.
Borchers, A. T., & Gershwin, M. E. (2014). Complex regional pain syndrome: a comprehensive and critical review.Autoimmunity reviews, 13(3), 242-265.

18. Summary
• CRPS is uncommon but affect QOL
• Multiple mechanisms underlie CRPS, both peripheral and central, and these may differ across
patients and even within patients over time
• Multidisciplinary approach to manage CRPS

19. THANK YOU