Hanyang Med Rev.  2011 May;31(2):76-84. 10.7599/hmr.2011.31.2.76.

Diagnosis and Treatment of Complex Regional Pain Syndrome

• Shin JW

• KMID: 2168183
• DOI: http://doi.org/10.7599/hmr.2011.31.2.76

Abstract

Complex regional pain syndromes (CRPS) are neuropathic pain disorders of one or more extremities developing inadequately after trauma or lesions in the peripheral or central nervous system (CNS). However, CRPS may also develop spontaneously. CRPS are clinically characterized by sensory (pain, hyperalgesia, and allodynia), autonomic (disturbances of skin temperature, color change, and presence of sweating abnormalities), and motor (paresis, tremor, and dystonia) disturbances. There has been growing evidence claiming that CRPS is a systemic disease involving the CNS and peripheral nervous system. The diagnosis is mainly based on clinical symptoms and signs, so that it could be under or over diagnosed. However, careful clinical evaluation and additional tests should lead to an adequate diagnosis. The goal of treatment is to improve function, relieve pain, and achieve remission. The clinical management of CRPS involves pharmacotherapy, non pharmacological pain coping skills such as physical, psychological and interventional therapies. Timely diagnosis and validation of clinical presentation for CRPS may result in a better outcome.

Keyword

Complex Regional Pain Syndromes; Diagnosis; Therapeutics

MeSH Terms

Adaptation, Psychological
Central Nervous System
Complex Regional Pain Syndromes
Extremities
Hyperalgesia
Neuralgia
Peripheral Nervous System
Skin Temperature
Sweat
Sweating
Tremor

Reference

1. Galer BS, Bruehl S, Harden RN. International Association for the Study of Pain. IASP diagnostic criteria for complex regional pain syndrome: a preliminary empirical validation study. Clin J Pain. 1998. 14:48–54.

2. Harden R, Bruehl S. Wilson PR, Stanton-Hicks MA, Harden RN, editors. Diagnostic criteria: the statistical derivation of the four criterion factors. CRPS: Current Diagnosis and Therapy. 2005. Seattle: IASP Press;45–58.

3. Galer BS, Schwartz L, Allan RJ. Loeser JD, Butler SH, Chapman CR, Turk DC, editors. Complex regional pain syndromes-type I: reflex sympathetic dystrophy, and type II: causalgia. Bonica's management of pain. 2001. 3rd ed. Philadelphia: Lippincott Williams & Wilkins;388–411.

4. Bruehl S, Chung OY, Burns JW. Differential effects of expressive anger regulation on chronic pain intensity in CRPS and non-CRPS limb pain patients. Pain. 2003. 104:647–654.

5. Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet. 1993. 342:1012–1016.

6. Schwartzman RJ, Kerrigan J. The movement disorder of reflex sympathetic dystrophy. Neurology. 1990. 40:57–61.

7. Kozin F, Soin JS, Ryan LM, Carrera GF, Wortmann RL. Bone scintigraphy in the reflex sympathetic dystrophy syndrome. Radiology. 1981. 138:437–443.

8. Bekerman C, Genant HK, Hoffer PB, Kozin F, Ginsberg M. Radionuclide imaging of the bones and joints of the hand. A definition of normal and a comparison of sensitivity using 99mTc-pertechnetate and 99mTc-diphosphonate. Radiology. 1976. 118:653–659.

9. Kozin F, Genant HK, Bekerman C, McCarty DJ. The reflex sympathetic dystrophy syndrome. II Roentgenographic and scintigraphic evidence of bilaterality and of periarticular accentuation. Am J Med. 1976. 60:332–338.

10. Greyson ND, Tepperman PS. Three-phase bone studies in hemiplegia with reflex sympathetic dystrophy and the effect of disuse. J Nucl Med. 1984. 25:423–429.

11. Maurer AH, Holder LE, Espinola DA, Rupani HD, Wilgis EF. Three-phase radionuclide scintigraphy of the hand. Radiology. 1983. 146:761–775.

12. Davidoff G, Werner R, Cremer S, Jackson MD, Ventocilla C, Wolf L. Predictive value of the three-phase technetium bone scan in diagnosis of reflex sympathetic dystrophy syndrome. Arch Phys Med Rehabil. 1989. 70:135–137.

13. Allen G, Galer BS, Schwartz L. Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain. 1999. 80:539–544.

14. Bruehl S, Lubenow TR, Nath H, Ivankovich O. Validation of thermography in the diagnosis of reflex sympathetic dystrophy. Clin J Pain. 1996. 12:316–325.

15. Backonja MM. Reflex sympathetic dystrophy/sympathetically maintained pain/causalgia: the syndrome of neuropathic pain with dysautonomia. Semin Neurol. 1994. 14:263–271.

16. Low PA, Caskey PE, Tuck RR, Fealey RD, Dyck PJ. Quantitative sudomotor axon reflex test in normal and neuropathic subjects. Ann Neurol. 1983. 14:573–580.

17. Bianchi C, Rossi S, Turi S, Brambilla A, Felisari G, Mascheri D. Long-term functional outcome measures in corticosteroid-treated complex regional pain syndrome. Eura Medicophys. 2006. 42:103–111.

18. Hsu ES. Practical management of complex regional pain syndrome. Am J Ther. 2009. 16:147–154.

19. Rowbotham MC, Reisner-Keller LA, Fields HL. Both intravenous lidocaine and morphine reduce the pain of postherpetic neuralgia. Neurology. 1991. 41:1024–1028.

20. Portenoy RK, Foley KM, Inturrisi CE. The nature of opioid responsiveness and its implications for neuropathic pain: new hypotheses derived from studies of opioid infusions. Pain. 1990. 43:273–286.

21. Tan AK, Duman I, Taskaynatan MA, Hazneci B, Kalyon TA. The effect of gabapentin in earlier stage of reflex sympathetic dystrophy. Clin Rheumatol. 2007. 26:561–565.

22. van de Vusse AC, Stomp-van den Berg SG, Kessels AH, Weber WE. Randomised controlled trial of gabapentin in Complex Regional Pain Syndrome type 1 [ISRCTN84121379]. BMC Neurol. 2004. 4:13.

23. Finnerup NB, Otto M, McQuay HJ, Jensen TS, Sindrup SH. Algorithm for neuropathic pain treatment: an evidence based proposal. Pain. 2005. 118:289–305.

24. Wallace MS, Ridgeway BM, Leung AY, Gerayli A, Yaksh TL. Concentration-effect relationship of intravenous lidocaine on the allodynia of complex regional pain syndrome types I and II. Anesthesiology. 2000. 92:75–83.

25. Robinson JN, Sandom J, Chapman PT. Efficacy of pamidronate in complex regional pain syndrome type I. Pain Med. 2004. 5:276–280.

26. Sahin F, Yilmaz F, Kotevoglu N, Kuran B. Efficacy of salmon calcitonin in complex regional pain syndrome (type 1) in addition to physical therapy. Clin Rheumatol. 2006. 25:143–148.

27. Perez RS, Zuurmond WW, Bezemer PD, Kuik DJ, van Loenen AC, de Lange JJ, Zuidhof AJ. The treatment of complex regional pain syndrome type I with free radical scavengers: a randomized controlled study. Pain. 2003. 102:297–307.

28. Zollinger PE, Tuinebreijer WE, Kreis RW, Breederveld RS. Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: a randomised trial. Lancet. 1999. 354:2025–2028.

29. Krystal JH, Karper LP, Seibyl JP, Freeman GK, Delaney R, Bremner JD, Heninger GR, Bowers MB Jr, Charney DS. Subanesthetic effects of the noncompetitive NMDA antagonist, ketamine, in humans. Psychotomimetic, perceptual, cognitive, and neuroendocrine responses. Arch Gen Psychiatry. 1994. 51:199–214.

30. Jevtovic-Todorovic V, Carter LB. The anesthetics nitrous oxide and ketamine are more neurotoxic to old than to young rat brain. Neurobiol Aging. 2005. 26:947–956.

31. Young C, Jevtovic-Todorovic V, Qin YQ, Tenkova T, Wang H, Labruyere J, Olney JW. Potential of ketamine and midazolam, individually or in combination, to induce apoptotic neurodegeneration in the infant mouse brain. Br J Pharmacol. 2005. 146:189–197.

32. Olney JW, Labruyere J, Price MT. Pathological changes induced in cerebrocortical neurons by phencyclidine and related drugs. Science. 1989. 244:1360–1362.

33. Cepeda MS, Lau J, Carr DB. Defining the therapeutic role of local anesthetic sympathetic blockade in complex regional pain syndrome: a narrative and systematic review. Clin J Pain. 2002. 18:216–233.

34. Harke H, Gretenkort P, Ladleif HU, Rahman S. Spinal cord stimulation in sympathetically maintained complex regional pain syndrome type I with severe disability. A prospective clinical study. Eur J Pain. 2005. 9:363–373.

35. van Rijn MA, Munts AG, Marinus J, Voormolen JH, de Boer KS, Teepe-Twiss IM, van Dasselaar NT, Delhaas EM, van Hilten JJ. Intrathecal baclofen for dystonia of complex regional pain syndrome. Pain. 2009. 143:41–47.