Update on the diagnosis and management of CRPS

[Pages:56]Basiskurs Schmerztherapie, Poertschach, Juni 23?28, 2014

PresentacUip?dante on the diagnosis

and management of CRPS

Michael Stanton-Hicks

MB;BS Dr. med, FRCA, ABPM, FIPP, FCAI (Hon)

Department of Pain Management Institute for Neurological Restoration Shaker Pediatric Rehabilitation Program Cleveland Clinic

epidemiology

de Mos et Sandroni et Beerthhuizen et

al 2007* al 1998

al 2012

IR

26.2

5.46

7.0

Gender F:M

3:1

4:1

3:0

Age range 61-70 (R)

IE

F/S

50-70 F/S

22-82 (P)

F/S

Sandroni et al, Clin J Pain 1998: 14; 282

* per 100,000 (n=190,102)

deMos M, et al. Pain 2007; 129(1-2):12-20

Beerthuizen et al Pain 2012;153 (6): 1187-92

Less likely !

Cause(s) of CRPS?

Sprain/ fracture More likely !

"Budapest" Criteria

at least I SYMPTOM in 3 of 4 categories and 1 SIGN in 2 or more categories. (SENS. 0.99: SPEC. 0.68)

Harden et al. Pain (2010);150: 268-274

CATEGORY SENSORY

VASOMOTOR

SUDOMOTOR EDEMA MOTOR TROPHIC

SYMPTOM Hyperesthesia,

allodynia

skin / color temperature sweating / edema

motor dysfunction ROM

trophic

SIGN hyperalgesia (PP) allodynia ? mech. /

thermal / deep > 1? C / skin color

sweating / edema

motor function ROM (weak,

dystonia, tremor) / trophic

Inflammatory Aspects

Auton Neurosci. 2014 May;182:102-7. doi: 10.1016/j.autneu.2013.12.011. Epub 2013 Dec 22. Inflammation in CRPS: role of the sympathetic supply. Schlereth T1, Drummond PD2, Birklein F3

? Pro-inflammatory cytokines ? Adaptive immunity - autoantibodies to 2?adrenergic

and muscarinic 2 receptors ? Cold skin ? noradrenaline, endothelin/NO disturbance ? Neurogenic inflammation ? CGRP, NK1 ? Up-regulation of keratinocytes

Inflammatory Aspects

The first scintigraphic detection of tumor

necrosis factor-alpha in patients with

1. complex regional pain syndrome type I

Report of a preliminary discontinued double-blind, randomized, placebo-

controlled triBaleorfntaheteacnkti,-TMNFe-taclhAimneerisctmhoAnoncalolgna2l 0an1t0ib;o1d1y0in:fl2ix1im1-a5b in

complex regional pain syndrome.

Dirckx M, Groeneweg G, Wesseldijk F, Stronks DL, Huygen FJ.

TcP-laainbePlrlaecdt.a2n0t1i-3TNNoFv-;13a(8n)t:i6b3o3d-4y0.indfolii:x1im0.1a1b11w/paaspr.p1o20s7it8i.vEepiunb 2013

May 22.

early but not late CRPS I

...study terminated lacking statistical power; Trend that infliximab might reduce TNF-; No significant change in cytokine levels...

J Pain. 2014 May;15(5):485-95. doi: 10.1016/j.jpain.2014.01.490. Epub 2014 Jan 23.

Activation of cutaneous immune responses in complex regional pain syndrome. Birklein F1, Drummond PD2, Li W3, Schlereth T1, Albrecht N1, Finch PM2, Dawson LF2, Clark JD4, Kingery WS5. .

PERSPECTIVE: The results of this study support the hypotheses that CRPS involves activation the innate immune system, with keratinocyte and mast cell activation and proliferation, inflammatory mediator release, and pain.

?

TNF-a, IL-6 are elevated in skin blister fluid

?

tryptase (mast cells)

?

exaggerated sympathetic signaling

?

keratinocytes

1-adrenoceptors

Pain. 2014 Mar;155(3):606-16. doi: 10.1016/j.pain.2013.12.021. Epub 2013 Dec 14. Upregulation of 1-adrenoceptors on cutaneous nerve fibres after partial sciatic nerve ligation and in complex regional pain syndrome type II.

Drummond PD1, Drummond ES2, Dawson LF2, Mitchell V3, Finch PM2, Vaughan CW3, Phillips JK4

? Up-regulation of 1-AR's > in CRPS vs. contralateral side

? 1-AR's on non-peptidergic fibers, nerve bundles and papillary dermis

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download