CRPS for all of us. MC Chu Anaesthesia and Intensive Care, PWH. 7th November 2007
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1 CRPS for all of us MC Chu Anaesthesia and Intensive Care, PWH 7th November 2007
2 Agenda What is CRPS Physiotherapy for CRPS Other interventions for CRPS Optimizing outcome
3 Before CRPS Reflex sympathetic dystrophy
4 Beginning of CRPS First described in 1995
5 Beginning of CRPS
6 Beginning of CRPS Descriptive classification, no implications on pathophysiology send basic scientist back to the laboratories Incoporated into IASP classification Allows for future sub-typing Stanton-Hicks Pain 1995
7 Evolution of CRPS High sensitivity (98%) but low specificity (36%) Overdiagnosis Bruehl Pain 1999
8 Evolution of CRPS New diagnostic criteria in 2003
9 Evolution of CRPS
10 Evolution of CRPS Clinical Research Harden Pain Medicine 2007
11 Evolution of CRPS Bonica stages I) Sensory / vasomotor / sudomotor II) onset of motor / trophic changes III) atrophic stage with reduced pain Bonica Management of Pain 1990 Sequential changes? Clinical entities?
12 Evolution of CRPS Cluster analysis of all symptoms and signs 3 subgroups
13 Evolution of CRPS Sensory Vasomotor Sudomotor Motor / trophic Subgroup 1 Subgroup 2 Subgroup 3 Subgroup 2 Subgroup 1 All groups similar in pain duration & demographics Subgroup 3
14 Evolution of CRPS EMG/NCV changes: 2 > 1 > 3 Bone scan changes: 3 > 2 > 1? clinical significance? evidence against Bonica s sequence Bruehl Pain 2002
15 Treating CRPS The most important persons are YOU and the PATIENT
16 Physiotherapy for CRPS Stanton-Hicks Clin. J. Pain 1998
17 Physiotherapy for CRPS Sensory training Proprioception, thermal, touch Motor training Range, strength, posture / gait Psychotherapy Empathy, education, cognitive-behavioral training
18 Physiotherapy for CRPS
19 Physiotherapy for CRPS Hydrotherapy Oedema control, strength, thermal conditioning Recreational therapy
20 Physiotherapy for CRPS Less useful ones: Contrast bath, ultrasound, electrostimulation, massage
21 Anaesthesiology for CRPS
22 Medications for CRPS Very few data Poorly defined Mix with other neuropathies Exclusion upon injury litigations
23 Anti-inflammatory for CRPS Topicals 2 studies with Dimethyl Sulphoxide (DMSO) - similar to N-acetylcystine - similar to placebo 1 study with Lignocaine - uncontrolled, open label
24 Anti-inflammatory for CRPS NSAID 1 study with regional Parecoxib - modest analgesia for 2 weeks - on top of regional blocks
25 Anti-inflammatory for CRPS Steroids 1 study with shoulder-hand syndrome -? Peripheral injuries / central pain - not controlled 1 study with RSD, n=16 - Prednisolone 10 mg tds - marked improvement c/w placebo
26 Systemic analgesics for CRPS Anti-convulsants & antidepressants No controlled studies Opioids (full or partial agonists) no data at all!
27 Calcitonin for CRPS Ca lowering hormone from thyroid Anti-nociceptive mechanism unclear 5 studies - conflicting results ~ $1,000 per month
28 Bisphosphonates for CRPS Similar actions with Calcitonin 4 studies - all positive RCTs Promising
29 Other drugs for CRPS Thalidomide Innovative chemotherapeutic Development limited by bitter history Same for ketamine?
30 Anaesthesiology for CRPS Regional sympatholytics Anecdotal therapy 1 review - no benefit over placebo Largely abandoned
31 Anaesthesiology for CRPS Sympathetic nerve blockade Stellate / lumbar sympathetomy
32 Anaesthesiology for CRPS Sympathetic nerve blockade 1 review of lumbar sympathetomy - RR 1.17 (short term relief) - same as placebo (long term) - samples too small to be conclusive
33 Anaesthesiology for CRPS Spinal Cord Stimulation (SCS) Mechanism unknown
34 Anaesthesiology for CRPS Spinal Cord Stimulation (SCS) Latest review in 2006 grade A evidence
35 Anaesthesiology for CRPS Intrathecal drug pumps Deep brain stimulation Epidural medications Transcranial magnetic stimulation etc.
36 Anaesthesiology for CRPS Is it preventable? 1 review Regional anaesthesia for limb surgery - less CRPS than general anaesthesia Multimodal analgesia - less CRPS after knee surgery
37 Psychology for CRPS Education Right dose, right way How they behave Feedback, homework, relaxation How they believe Thought challenge, group dynamics
38 Psychology for CRPS Cognitive-behavioral therapy
39 In summary Long name versus no name complexregionalpainsyndrome 27 characters Ill-defined pathophysiology, subtyping, clinical aspect Treatment is chaotic Any perceivable remedy, minimal outcome data
40 In summary Best evidence on outcome 1. Physiotherapy 2. Bisphosphonates 3. Spinal cord stimulation It might be preventable
41 What shall one do? Get the direction correct Unified approach (but be ready to change)
42 What shall one do? Something is better than nothing Act according to data Act according to resources available Act according to what you think is right
43 What shall one do? Tips to motivate patients Explain rationale Overcome fear - gradual exposure - reward Active vs. passive treatment
44 The end
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