CRPS 2

[nari]

I thought we might restart a thread on this condition.

Given what is known about CRPS and its manifestations, I am interested to promote a discussion on:

How much is known of the condition itself? (neurophysiology)

and

given the highly variable history of patients with CRPS, is there any suggestion or trend towards certain risk factors for developing the condition?

Nari 8)

[bernard]

CRPS Complex Regional Pain Syndrome is certainly a useful label for many patients when Medicine seem to fail to care them.

Complex => unknown origins (or all in your head!!!)
Regional => located in some areas.
Pain Syndrome => Pain Syndrome??? what a definition!

In France, we are seeing the term only for some years, before and for many old therapists (I'm a old one), it is called algoneurodystrophy or pain dystrophy of neuropathic origin. These terms fit better the regional definition but discard the central component of CRPS. The French Medicine is so cartesian but many are too.

Here is a little summary about CRPS (with an animation).
http://www.stoppain.org/pain_medicine/crps.html#

[nari]

Thanks for the link, Bernard.

What do you find most helpful with these patients?


Nari

[bernard]

Two things are very helpful in CRPS.

The first one is listening and we can learn a full story about the problem. CRPS seems to me a way of communication for patients?
In the same tune, advices on patience.
I use neurodynamics and it reduces the pain/inflammation component more quickly than before (3/4 weeks vs months).

NSAIDs does nothing or quite!

[nari]

Bernard,

I agree that neurodynamics is probably the best way to go-but the choice of doing what movement and where is the crunch.

It varies so much from one person to another, and I have not had much experience with CRPS. The last occasion was a forty-something woman who had ceased using her (L) arm (due to intense pain)10 weeks after a fall which sprained her wrist. All the signs were there, including fear and marked allodynia, but after a month of contralateral and then ipsilateral neurodynamic stuff, she had full function.

I am sure there would be many who would take much longer. Unfortunately we see them too late, again after the doctors have filled them with rather useless drugs.

I agree about NSAIDS, and am starting to think they aren't much use for anything, except for the very acute tissue injury.


Nari

[bernard]

Nari,

The last guy I seen with a CRPS was in December. He had a wrist fracture with a plaster which was too tighten/constricted. He saw him after 45 days of strict immobilization and constant pain.

I was not sure to get a fine success since these silly things were done but this morning after 1 month of 3/week sessions, the man is able to move quite normally his hand and wrist. He got a little pain at end of day but is a computer programmer!

As you did, I focused the action on breathing, firstly, to show him the control it gives over pain and then used neurodynamics on the whole right upper side.

The man fits perfectly the socio-emotional component of CRPS with a past of Patriarch (he took the role long time ago when his father had had a hard depression!!!). He did not really accepted to play it but was obliged (his thoughts) and he ruled the six brothers and sisters. He did not realize that something was able to compromise his job and the worst for him was an eventual comment from his family: him, who never failed before! And was not permitted to have pain.

[nari]

This guy's reaction is interesting, for the more cynical would read his pain as an avoidance mechanism, keeping him away from his onerous task of managing siblings, and so on.

Yet that is not the case - he was more likely concerned he could not cope with both jobs, and I presume anxiety prevailed. And the yellow flag of his father in a state of depression did the rest..


Nari

[emad]

Hi Bernard ;
You are right , currently , we as physiotherapists advise the consumer to take rest and perfrom certain movements .

But , seems employers do not like our advices .

cheers
Emad

[nari]

It also seems that most patients fall onto either side of the road - either they do not want to move, or do not want to rest. Not many, in consistent pain, have the wherewithal to sail along down the road.

How much rest is appropriate?

One day? a week? What do we call rest. anyway?

I generally advise those with severe shoulder pain and all sorts of compensatory actions, use a sling for a few hours am and pm, over 2-3 days.
I never advise rest in bed - (invalid image) but often in a recliner, particularly at night when pain increases.

However, I recommend rest only as very temporary..and usually warn about what may occur if there is too much rest. The patients usually take it on board very well.

Back to CRPS in particular - usually they 'rest' to much, methinks.
I wonder if restraint of the unaffected arm would serve any purpose???
Sounds brutal, but if the principle is explained, it would be quite acceptable to many; and may serveto promote movement in the way the practice does after stroke.


nari

[emad]

Hi Nari :

When I mentioned rest in the last post , I meant taking rest /being free/ stopping the flaring up activities , because I believe most of CRPS are workers /females/housewives who perform over activities daily and vigrously .

So that stopping these activities will give the chance to skip over neural both central and peripheral sensitivities .

Regarding rest periods , usually I advise few periods 2/3 days only particulraly if the consumer ,before i see him/her, was practising flaring up motions.

Cheers
Emad

[EricM]

Nerve Damage May Underlie Mysterious Pain Syndrome (http://www.medscape.com/viewarticle/523736)

I'll just tack this on to the end of this older thread.

NEW YORK (Reuters Health) Feb 15 - The findings from a new study lend support to the hypothesis that complex regional pain syndrome is a bona fide neurologic disorder caused by persistent minimal distal nerve injury affecting nociceptive small fibers.

Complex regional pain syndrome involves post-traumatic limb pain and autonomic disturbances that continue even though the inciting injury seems to have healed. The etiology of the symptoms is unknown and because there are few objective findings, diagnosis and treatment is difficult. Some have even questioned whether complex regional pain syndrome has a real biologic basis or is a psychosomatic illness.

In the current study, reported in the February issue of Pain, Dr. Anne Louise Oaklander and colleagues, from Harvard Medical School in Boston, performed sensory testing and quantitative nerve assessment of affected and unaffected sites on 18 patients with complex regional pain syndrome. Seven subjects without complex regional pain syndrome, but with similar symptoms served as additional controls.

The complex regional pain syndrome patients had classic histories and symptoms for the disorder. Unexpectedly, the researchers found that complex regional pain syndrome onset was often associated with medical procedures.

Sensory testing showed mechanical allodynia and heat-pain hyperalgesia at complex regional pain syndrome-affected sites, the report indicates. Compared with unaffected sites, those with complex regional pain syndrome showed decreased axonal densities (p < 0.01). By contrast, control subjects did not display these reductions at their pain sites, "suggesting that pain, disuse, or prior surgeries alone do not explain complex regional pain syndrome-associated neurite losses," the authors state.

"The fact that complex regional pain syndrome now has an identified cause takes it out of the realm of so-called 'psychosomatic illness'," Dr. Oaklander said in a statement. "Our results suggest that complex regional pain syndrome patients should be evaluated by neurologists who specialize in nerve injury and be treated with medications or procedures that have proven effective for other nerve-injury pain syndromes."

Pain 2006;120:235-243.