Complex Regional Pain Syndrome (Crps)

(Reflex sympathetic dystrophy and causalgia)

Complex regional pain syndrome (CRPS) is a chronic neuropathic pain that a soft tissue or bone injury (Type I) or nerve damage (type II) is followed, lasts longer and is more than would be expected from the original tissue damage. Other manifestations involve changes in the autonomic nervous system (eg. As sweating, vasomotor disorders), motor changes (weakness, dystonia) and trophic changes (skin or bone atrophy, hair loss, joint contractures). The diagnosis is made clinically. Treatment includes medication, physical therapy and sympathetic.

CRPS type I was formerly known as reflex sympathetic dystrophy known (see. Also Clinical practice guideline [third edition] for the diagnosis, treatment, and management of reflex sympathetic dystrophy / complex regional pain syndrome [RSD / CRPS] the Reflex Sympathetic Dystrophy Syndrome Association) type II as causalgia. Both types are most common in young adults and up to 3 times more common in women 2.

Complex regional pain syndrome (CRPS) is a chronic neuropathic pain that a soft tissue or bone injury (Type I) or nerve damage (type II) is followed, lasts longer and is more than would be expected from the original tissue damage. Other manifestations involve changes in the autonomic nervous system (eg. As sweating, vasomotor disorders), motor changes (weakness, dystonia) and trophic changes (skin or bone atrophy, hair loss, joint contractures). The diagnosis is made clinically. Treatment includes medication, physical therapy and sympathetic. CRPS type I was formerly known as reflex sympathetic dystrophy known (see. Also Clinical practice guideline [third edition] for the diagnosis, treatment, and management of reflex sympathetic dystrophy / complex regional pain syndrome [RSD / CRPS] the Reflex Sympathetic Dystrophy Syndrome Association) type II as causalgia. Both types are most common in young adults and up to 3 times more common in women 2. Etiology CRPS type I (usually of the hand or foot) typically occurs after injury to, most often after crushing, v. a. the lower limb. It may be followed by amputation, acute myocardial infarction, stroke, or cancer (lung, breast, ovaries, central nervous system); at about 10% of patients, no cause can be seen. CRPS type II type I like, but is also a flagrant violation of the peripheral nervous before. Pathophysiology The pathophysiology is unclear, but peripheral nociceptors and central sensitization and the release of neuropeptides (substance P, calcitonin-gene-related peptide) contribute to maintaining the pain and inflammation. The sympathetic nervous system is involved at CRPS more than other neuropathic pain syndromes: the central sympathetic activity is increased and the peripheral nociceptors are (a sympathetic neurotransmitter) sensitized to norepinephrine. These changes can lead to perspiration disorders and poor circulation by vasoconstriction. Nevertheless, some patients respond to the sympathetic influence of (z. B. by central or peripheral sympathetic). Symptoms and signs The symptoms vary widely and do not follow a pattern; they include sensory, autonomous focal (or vaso sudomotor) and motor disturbances. Burning or dull-aching pains are widespread. He does not follow the coverage area of ??a single peripheral nerve; also it can be stronger by changes in the environment or emotional stress. Allodynia and hyperalgesia can occur. The pain is killing patients often to limit the use of a limb. It can vasomotor skin changes (eg red, speckled and gray;. Increased or decreased temperature) and perspiration disorders (dry or hyper antiperspirant skin) occur. Edema can be significant and locally limited. Other symptoms may include trophic disorders include (z. B. shiny, atrophic skin, splinters or excessive growth of the nails, bone atrophy, hair loss) and motor dysfunction (weakness, tremors, spasms, dystonia with flexion fixation of the fingers or development of Spitz clubfoot). The range of motion is often limited, sometimes leading to joint contractures. The symptoms can overlap with complaints by tight-fitting prostheses after amputation. Mental stress (eg., Depression, anxiety, anger) are often favored by the little-understood reasons, the absence of effective therapy and long-lasting history. Diagnosis Clinical examination The following clinical criteria must be met in order to make the diagnosis CRPS: onset of pain (usually burning) allodynia and hyperalgesia Focal autonomous dysregulation (vaso or sudomotor anomalies) No evidence of another condition that could explain the symptoms If another malfunction, CRPS should be considered a possible or probable. Other symptoms and findings can support the diagnosis: edema, trophic disorders, or a temperature change in the affected area. To document the change in temperature, a thermal imaging can be used when the clinical examination is doubtful and this finding would confirm the diagnosis. Changes in the bone (eg. As demineralization radiographically, increased uptake at a Dreiphasenradionukliduntersuchung the bone) can be found. These findings are only applicable as a rule, if the diagnosis is in doubt. However Imaging tests can fail without pathological CRPS after an injury in patients. (Stellate ganglion blockade of the cervical or lumbar) sympathetic blockade can be used diagnostically and therapeutically. However, false-positive and false-negative results are common because not all CRPS pain be entertained sympathetic and a nerve block can also meet not sympathetic fibers. In another test, an involvement of the sympathetic nervous system of the patient will receive i.v. infusions of saline (placebo) or phentolamine 1 mg / kg over 10 min, while the pain intensity is detected. A pain reduction after phentolamine but not by placebo, indicates a sympathetic maintained pain. Prognosis The prognosis varies and can be difficult to predict. CRPS may regress or persist for years; in some patients it progresses and spreads to other areas of the body. Multimodal therapy therapy (eg. As drugs, physical therapy, sympathetic, psychological treatment, Neuromodulation, mirror box). The treatment is complex and often unsatisfactory, especially when they started late. It includes drugs, physical therapy, sympathetic blocks, psychological treatment and neuromodulation. So far, only a few controlled treatment studies have been conducted. Many of the drugs used in neuropathic pain such. B. tricyclic antidepressants, anticonvulsants, and corticosteroids (see Table: pharmacotherapy in neuropathic pain), can be tried; none is recognized as superior. Long-term treatment with opioid analgesics may be useful in selected patients. In some patients with sympathetically maintained pain a regional sympathetic blockade eases the pain, allowing for physical therapy. Oral analgesics (NSAIDs, opioids, and various co-analgesics) may also ease the pain to the point that rehabilitation is possible. For Neuromodulation Implantable Spinal cord stimulators are increasingly used. The transcutaneous electrical nerve stimulation (TENS) should be tried for a long time and in different locations with different stimulation parameters. Implanted stimulation systems, aimed at the peripheral nerves (z. B. occipital nerve stimulation in some headache syndromes) may be beneficial. Other methods of neuromodulation include a vigorous rubbing of the affected part (counter-irritation), and acupuncture. In any form of neuromodulation is known that they would be more effective than another, a small answer to a form does not mean a bad answer to a different form of neuromodulation. Neuraxial infusion of opioids, anesthetics and clonidine can help and intrathecal Baclofengabe has in a few patients reduces dystonia. Physical therapy is essential. It aims to strengthen, improve mobility and vocational rehabilitation. From the mirror box has been reported that patients benefit with CRPS type 1 phantom pain or stroke. Patients span a large mirror between her legs. the impression of the mirror reflects the image of the non-affected limb and hides the (painful or missing) affected limb, then the patient is given that it has 2 normal limb. Patients are instructed to move their painful or missing links while viewing the mirror image of their normal limb, trying to make the same move. Most patients who perform this exercise for 4 weeks for 30 min / day, reported a significant reduction in pain. Important points CRPS may be due to injury (soft tissue, bone or nerve), amputation, acute myocardial infarction, stroke or cancer arise or has no apparent underlying cause. CRPS should be diagnosed when patients have neuropathic pain, allodynia or hyperalgesia and focal autonomic dysregulation, when no other cause is identified. The prognosis is not predictable, and the treatment is often unsatisfactory. Treatment as early as possible using multiple modalities (eg. As drugs for neuropathic pain, physical therapy, sympathetic, psychological treatment, neuromodulation, mirror box).

Health Life Media Team

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