Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2nd ed.
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1 Kompleksni regionalni bolni sindrom, dijagnoza i novosti u liječenju Tamara Vukić, dr.med. Klinika za ortopediju Klinički bolnički centar Zagreb Medicinski fakultet Sveučilišta u Zagrebu
2 Kompleksni regionalni bolni sindrom(complex regional pain syndrome-crps CRPS) nastaje nakon precipitirajućeg oštećenja,a karakteriziraju ga bol, edem, vazomotorne i sudomotorne promjene autonomnog živčanog sustava i trofičke promjene koje rezultiraju funkcionalnom onesposobljenošću zahvaćenog dijela tijela.
3 Podjela: CRPS tip I (prijašnji naziv refleksna simpatička distrofija- RSD) bez kliničkih znakova ozljede perifernog živca CRPS tip II (prijašnji naziv kauzalgija) postoji dijagnosticirana ozljeda perifernog živca. Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain y g p Syndromes and Definitions of Pain Terms. 2nd ed. Seattle, Wash: IASP Press; 1994.
4 Prijašnji termini korišteni za označavanje CRPS: Refleksna simpatička distrofija- RSD Kauzalgija gj Algodistrofija Sudeckova atrofija Sindrom rame-šaka Traumatski vazospazam Posttraumatska osteoporoza
5 Etiologija: trauma u području ekstremiteta (mikro i makrotrauma) kirurški zahvati na lokomotornom sustavu ozljede i bolesti kralježnice neurološke bolesti i ozljede (CVI s posljedičnom hemiplegijom) gj kardiovaskularne bolesti (infarkt miokarda) jatrogeni uzroci(barbiturati, antituberkulotici)
6 Mehanizam nastanka Hettne KM, de Mos M, de Brujin AG et al. Applied information retrieval and multidisciplinary research: new mechanistic hypotheses in CRPS, J Biomed Discov Collab.2007 May 4;2:2
7 Osnovni simptomi i znakovi CRPS: Bol Trofičke promjene Poremećaj autonomnog živčanog sustava Senzorni poremećaji
8 Bol: neproporcionalna veličini ozljede najčešće žarećeg karaktera većinom počinje na distalnom dijelu ekstremiteta sa tendencijom širenja proksimalno često difuzna i ne slijedi distribuciju pojedinog živca
9 Trofičke promjene: edem najčešća vidljiva promjena koža s vremenom postaje tanka, glatka i čvrsta, nokti postaju stanjeni i izrazito sjajni, kosa suha atrofija u kasnom stadiju
10 Poremećaj autonomnog živčanog sustava: Vazomotorne promjene promjene u temperaturi i boji kože Sudomotorne promjene promjene znojenja (hiperhidroza ili anhidroza)
11 Senzorni poremećaji: Alodinija Hiperalgezija Hiperestezija Hipoestezija Hiperpatija Disestezija
12 Dijagnoza CRPS Dijagnoza se postavlja prvenstveno na temelju KLINIČKE SLIKE Dijagnostičke metode služe da bi dijagnozu opovrgnule ili potvrdile
13 Dijagnostičke metode: Laboratorij- većinom nespecifičan Rtg Troetapna scintigrafija Termografija
14 Rtg većinom uredan u ranim fazama bolesti u kasnijim fazama bolesti može se vidjeti karakteristična mrljasta osteoporoza
15 Troetapna scintigrafija Najosjetljivija metoda za CRPS Snimanje se vrši u tri etape Karakterističan scintigram je pozitivan u svim trima etapama snimanja
16 Prva etapa snimanja angioscintigram karakteristično je vidljiv brži dotok i viša krivulja protoka (arterijska i venska faza) zahvaćene strane.
17 Druga etapa snimanja rani statički scintigram prikazuje tkz. krvni postor ili tkivnu fazu karakteristično kt tič je vidljiv difuzno intenzivan prikaz zahvaćenog dijela tijela
18 Treća etapa snimanja najosjetljivija kasni statički scintigram karakteristično je vidljiv difuzno intenzivniji i iji prikaz zahvaćenog ć dijela tijela s posebice pojačanim nakupljanjem u periartikularnim dijelovima. ima
19 Termografija Metoda grafičkog prikaza uzorka lokalnog zračenja tjelesne topline Detektira se područje lokalizirane topline ili hladnoće na zahvaćenom dijelu tijela Neinvazivna metoda i nema izloženosti bolesnika zračenju Korisna u postavljanju j dijagnoze bolesti, a prvenstveno u praćenju tijeka bolesti
20 IASP(Orlando) dijagnostički kriteriji za CRPS: 1.Postojanje određenog precipitirajućeg oštećenja 2.Kontinuirana bol, alodinija ili hiperalgezija gdje bolni podražaj nije proporcionalan s veličinom ozljede. Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain y g p Syndromes and Definitions of Pain Terms. 2nd ed. Seattle, Wash: IASP Press; 1994.
21 IASP(Orlando) dijagnostički kriteriji za CRPS: 3.Postojanje edema, promjene krvnog protoka kože ili sudomotorne promjene u regiji boli. 4.Dijagnoza je isključena postojanjem drugih stanja koja inače uzrokuju ovakav stupanj boli i disfunkciju. Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain y g p Syndromes and Definitions of Pain Terms. 2nd ed. Seattle, Wash: IASP Press; 1994.
22 Predloženi modificirani klinički ički dijagnostički kriteriji iji za CRPS (Budimpešta) 1.Kontinuirana bol koja je neproporcionalna veličini ozljede. 2.Bolesnik mora imati barem jedan simptom u tri od navedene četiri kategorije: a) Senzorni: pojava hiperestezije i/ili alodinije b) Vazomotorni: pojava asimetrije u temp. i/ili promjene boje kože i/ili asimetrija boje kože Harden RN, Bruehl SP. Diagnostic criteria: the statistical derivation of the four criterion factors. In: Harden RN, Bruehl SP. Diagnostic criteria: the statistical derivation of the four criterion factors. In: Wilson P, Stanton-Hicks M, Harden R, editor. CRPS: Current Diagnosis and Therapy. Seattle, WA: IASP Press; pp
23 Predloženi modificirani klinički ički dijagnostički kriteriji iji za CRPS (Budimpešta) c) Sudomotorni/Edem: pojava edema i/ili promjene znojenja i/ili asimetrija znojenja d) Motorički/Trofički: pojava smanjenog opsega pokreta i/ili motorička disf.(slabost, tremor, distonija) i/ili trofičke promjene(koža, nokti, kosa). Harden RN, Bruehl SP. Diagnostic criteria: the statistical derivation of the four criterion factors. In: Harden RN, Bruehl SP. Diagnostic criteria: the statistical derivation of the four criterion factors. In: Wilson P, Stanton-Hicks M, Harden R, editor. CRPS: Current Diagnosis and Therapy. Seattle, WA: IASP Press; pp
24 Predloženi modificirani klinički ički dijagnostički kriteriji iji za CRPS (Budimpešta) 3) Bolesnik mora imati barem jedan znak u vrijeme pregleda u dvije ili više od navedenih kategorija: a)senzorni: pojava hiperalgezije (pinprick test) i/ili alodinije (na lagan dodir i/ili pritisak i/ili pokret zglobom). b) Vazomotorni: pojava asimetrije u temp. i/ili promjene boje kože, i/ili asimetrije ij boje kože Harden RN, Bruehl SP. Diagnostic criteria: the statistical derivation of the four criterion factors. In: Wilson P, Stanton-Hicks M, Harden R, editor. CRPS: Current Diagnosis and Therapy. Seattle, WA: IASP Press; pp
25 Predloženi modificirani klinički ički dijagnostički kriteriji iji za CRPS (Budimpešta) c) Sudomotorni/Edem: pojava edema i/ili promjene znojenja i/ili asimetrija znojenja d) Motorički/Trofički: pojava smanjenog opsega pokreta i/ili motorička disf.(slabost, tremor, distonija) i/ili trofičke promjene (koža, nokti, kosa). 4) Druga dijagnoza ne može bolje objasniti ove simptome i znakove. Harden RN, Bruehl SP. Diagnostic criteria: the statistical derivation of the four criterion factors. In: Wilson P, Stanton-Hicks M, Harden R, editor. CRPS: Current Diagnosis and Therapy. Seattle, WA: IASP Press; pp
26 Liječenje- multidisciplinarni pristup Medikamentozna terapija Fizikalna terapija pj Intervencijski oblici liječenja
27 Medikamentozna terapija: NSAR Antiepileptici/ neuromodulatori Antidepresivi Kalcitonin Kortikosteroidi Alfa blokatori Blokatori Ca-kanala Bifosfonati
28 Antiepileptici u liječenju CRPS GABAPENTIN osim u liječenju epilepsija i neuropatske boli pokazao se efektivnim i u liječenju CRPS mehanizam djelovanja nije u potpunosti razjašnjen (suprimira ekscitatorne aminokiseline kao glutamat i transmisiju Ca+?) doziranje- postupno povećanje doze, max. doza 1.8 g na dan nuspojave- somnolencija, vrtoglavica, umor Mellick GA, Mellick LB. Reflex sympathetic dystrophy treated with gabapentin. Arch Phys Med Rehabil. 1997;78: Harden RN. Gabapentin: a new tool in the treatment of neuropathic pain. Acta Neurol Scan. 1999;173(Suppl):43-47.
29 Kalcitonin osim CRPS koristi se i u liječenju hiperkalcijemije, Pagetove bolesti, osteoporoze ima analgetski učinak i utječe na razgradnju kosti (blokator osteoklastične resorpcije u kostima) doziranje i.j. na dan kroz 6-8 tj. nuspojave- mučnina i povraćanje Gobelet C, Waldburger M, Meier JL. The effect of adding calcitonin to physical treatment on reflex sympathetic dystrophy. Pain.1992;48: Perez R, Kwakkel G, Zuurmond W, de Lange J. Treatment of reflex sympathetic dystrophy (CRPS type I.): A research synthesis of 21 randomized clinical trials. J Pain Sympt Manage. 2001;21:
30 Bifosfonati prvenstveno se koriste u prevenciji i liječenju osteoporoze pojedine studije su dokazale značajnu redukciju boli kod bolesnika sa CRPS alendronat i klodronat su se u otvorenim studijama pokazali najefektivnijima potrebne su daljne studije i daljne praćenje da bi se pokazala konačna efikasnost u liječenju CRPS Varenna M, Zucchi F, Ghiringhelli D, et al. Intravenous clodronate in the tratment of reflex sympathetic dystrophy syndrome. A randomized, d double blind, placebo controlled study. J Rheumatol. 2000;37: Adami S, Fossaluzza V, Gatti D, Fracassi E, Braga V. Bisphosphonate therapy of reflex sympathetic dystrophy syndrome. Ann Rheum Dis. 1997;56: Manicourt DH, Brasseur JP, Boutsen Y, Depreseux G, Devogelaer JP. Role of alendronate in therapy for postraumatic CRPS ty I of the lower extremity. Arthritis Rheum. 2004;50:
31 Fizikalna terapija Rana mobilizacija može se prevenirati pojava CRPS Dijadinamičke struje- blokada na određeni ganglij (ganglion stellatum-za gornje udove) TENS Krioterapija (kriooblozi, kriomasaža)- topla koža i vazodilatcija
32
33 Fizikalna terapija Desenzitizacija- dodirna stimulacija s pomoću različite kvalitete materijala Vježbe opsega pokreta, vježbe snaženja Hidroterapija Sherry DD, Wallace CA, Kelley C, Kidder M, Sapp L, Short- and long- term outcomes of y y pp g children with complex regional pain syndrome type I treated with exercise therapy. Clin J Pain. 1999;15:
34 Intervencijski postupci: na gornjim ekstremitetima blokada ganglion stellatum (SGB) i Bier - blok na donjim ekstremitetima blokada lumbalnog simpatičkog lanca (LSB) i epiduralni blok neurostimulacija kralježnične moždine Kemler MA, Barend se GAM, van Kleef M et al. Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med. 2000;343:
35 CRPS u djece Epidemiološki najčešći udjevojčica u adolescentnoj dobi Donji ekstremitet je češće zahvaćen od gornjeg ekstremiteta Troetapni scintigram je manje osjetljivosti nego u odraslih Prognoza je povoljnija nego u odraslih
36 Zaključak Potrebno je što ranije postaviti točnu dijagnozu Dijagnoza se postavlja prvenstveno na temelju kliničke slike Multidisciplinaran pristup jedini je izbor u liječenju CRPS Cilj nam je spriječiti funkcionalnu onesposobljenost i trajni hendikep
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