Komplekst regionalt smertesyndrom

CRPS - Complex regional pain

syndrome

Bergenskurset 07. november 2017

Sara Maria Allen Spesialfysioterapeut, MSc

Avd for nevrologi, Nevroklinikken

Oslo Universitetssykehus

Innhold

• Bakgrunn

• Hva vi vet i dag

• Behandling

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To hovedtyper

CRPS type I:erstatter begrepet refleksdystrofi (RSD- reflexsympathetic dystrophy)

CRPS type II: har en påvist nerveskade, men øvrige symptomer er like og behandlingen ens. Erstatter begrepet causalgia

Diagnostisering

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• Vedvarende smerte som er uforholdsmessig sterk eller langvarig i forhold til traumet.

Budapest CRPS Criteria

Årsaker:• Alle former for kirurgi i

ekstremitetene kan for-årsake CRPS.

• Hjerneslag

• Ryggoperasjoner (prolaps, avstivning o.a)

• Mindre operasjoner synes mer risikabelt enn større.

• Spontan start. Oftest barn.

NB: Ny kirurgi kan forverre tilstanden.

Problem: blanding av smertekvaliteter

13.11.2017Lunden m fl 2016

Budapest diagnostic criteria (Harden et al 2007)

(adopted as IASP’s criteria 2012)

>2>3

All 4

For research purposes,

diagnostic decision rule

should be at least one

symptom in all four

symptom categories and

at least one sign

(observed at evaluation)

in two or more sign

categories

Vasomotoriske forandringer Motoriske forandringer

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Motor/trofiske/sudomotoriske forandringer

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2010 Budapest Validation Study

Diagnostic Criteria Sensitivity Specificity

1994 IASP 1.00 0.41

Budapest Criteria 0.99 0.68

Harden et al., 2010

Overdiagnostisering

N=596

• 49% diagnostisert med CRPS i henhold til tidligere IASP kriterier (Velden m fl 1993)

• 7% ved bruk av gjeldende Budapest kriterier

(Harden m fl 2010)

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Bedre CRPS diagnostisering?

• Forlanger nærvær av objektive tegn i tilegg til selvrapporterte symptomer.

• Inkluderer motor/trofiske forandringer

• Beskriver vasomotoriske tegn og ødem/sudomotoriske tegn som to separate diagnosekriterier.

Bruehl et al, 1999; Harden et al., 1999

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Our results indicate that although patients with CRPS1 are stigmatized with a specific psychological profile, psychological problems are not likely to contribute to the prediction of the development of CRPS1.

No empirical evidence supports a diagnosis of CRPS1 patients as psychologically different, and the current results indicate that there is no association between psychological factors and CRPS1.

Few psychological differences between CRPS and other

chronic pain patients

• Forekomst av angst og depresjon hos CRPS pasienter 24-65%

• Langvarige CRPS pasienter scorer lavere på ”health related quality of life” tester sammenlignet med andre kroniske lidelser

• Scorer høyt på somatisering, katastrofetanker og bevegelsefrykt.

(Bruehl et al. 1996, 2001)

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Fear and catastrophizing

• TAMPA Scale for Kinesiophobia

• Pain CatastrophizingScale, PCS

• Fear avoidance BeliefFABQ

(de Jong 2005, 2010)

Psychotherapy. Not every CRPS patient needs an

extensive psychological assessment. However, when

there are existing psychological factors or insufficient

improvement under somatic-oriented therapy, psychotherapeutic

approaches should be initiated early.

Neurology 84 January 6, 2015

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UMC St Radboud 2013

• Neglekt-like

symptoms (Galer

1995,1998), Reinersmann 2010)

• (Test laterality, Recognise program, neglect score)

• Body perception

disturbance (Lewis 2012,

Peltz 2011, Moseley 2015)

(Test two-point-discrimination-thresholds. Ask the patient to draw the affected limb)

Epidemiologi

Epidemiologi

Insidensen av CRPS blant befolkningen:

• 5.5 new CRPS-I cases per 100,000 annually (Sandroni et al., 2003)

• 26.2 new CRPS cases per 100,000 annually (de Mos et al., 2007)

Kvinner 2 ganger vanligere en men.

Acute CRPS

Remissionsraten kan være høy

74% - 87% av CRPS blir bra i løpet av et år.

Puchalski & Zyluk, 2005; Herlyn et al., 2010

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Langvarig CRPS

• Blant CRPS pasienter med >1 års varighet,

6 års follow-up indikerer:

• 30% “selvrestitusjon” (selvrapportert)

• 54% “stabil”

• 16% “progressiv forverring”

De Mos et al., 2009

• 48% of sample of 185 CRPS patients displayed

spreading of CRPS to second limb or more

• 49% Contralateral Spread

• 30% Ipsilateral Spread

• 14% Diagonal Spread

• Spread triggered by additional trauma in 37-91%

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Prognose

• Høy smerte i forbindelse med kirurgi øker risikoen for CRPS

• Angst og frykt kan hindre progresjon i rehabiliteringen ved CRPS

(Birklein 2015)

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Patofysiologi

• Mulig genetisk disposisjon usikkert

• Posttraumatisk inflammasjon, i akutt fase

• Plastiske forandringer i SNS, i kronisk fase

• Sympatiske nervesystemets rolle usikker

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Behandling og smertelindring ved CRPS

Lite evidens

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«Physical therapy is the cornerstone and first line treatment for CRPS»

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•Authors’ conclusions

The best available data show that GMI and mirror therapy may provide clinically meaningful improvements in pain and function in people with CRPS I although the quality of the supporting evidence is very low. Evidence of the effectiveness of multimodal physiotherapy, electrotherapy and manual lymphatic drainage for treating people with CRPS types I and II is generally absent or unclear. Large scale, high quality RCTs are required to test the effectiveness of physiotherapy-based interventions for treating pain and disability of people with CRPS I and II. Implications for clinical practice and future research are considered.

(Smart KM, Wand BM, O’Connell NE. 2016, Issue 2.)

• Noen får mer smerter

Eur J Pain 16 (2012) 550–561

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• Systematiske oversikter - 6 Cochrane og 13 andre.

• Effekt på smerte og/eller funksjon

• Intravenøs Ketamine, daglig, kan gi effektiv smertelindring men ofte uakseptable bivirkninger

- Lav grad av evidens

• Bisphosphonater, Calcitonin og Graded Motor Imagery(GMI) kan ha effekt på CRPS og at annen speilbehandling kan ha effekt på CRPS etter hjerneslag

-Lav kvalitet på evidens

• Lav kvalitet på evidens for at fysio- eller ergoterapi ikke har klinisk nyttig effekt ved ett års oppfølging og at sympatiske nerveblokader med lokal anestesi ikke har effekt.

• Moderat kvalitet på evidens for at intravenøse regionale blokader (guanethidine) ikke har effekt og at det kan medføre komplikasjoner.

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MAIN RESULTS:

We included an additional 10 studies (combined n = 363) in this update. Overall we include 12 studies (combined n = 386). All included studies were assessed to be at high or unclear risk of bias. Three small studies compared LASB to placebo/sham. We were able to pool the results from two of these trials (intervention n = 23). Pooling did not demonstrate significant short-term benefit for LASB (in terms of the risk of a 50% reduction of pain scores).Of two studies that investigated LASB as an addition to rehabilitation treatment, the only study that reported pain outcomes demonstrated no additional benefit from LASB. Eight small randomised studies compared sympathetic blockade to another active intervention. Most studies found no difference in pain outcomes between sympathetic block and other active treatments. Only five studies reported adverse effects, all with minor effects reported.

AUTHORS' CONCLUSIONS:

This update has found similar results to the original systematic review. There remains a scarcity of published evidence to support the use of local anaesthetic sympathetic blockade for CRPS. From the existing evidence it is not possible to draw firm conclusions regarding the efficacy or safety of this intervention but the limited data available do not suggest that LASB is effective for reducing pain in CRPS.

Intravenøs regional guanetidin (Ismelin) blokade

Translatoriske problem eller muligheter?

• Hva kan vi bruke av kunnskap i klinikken.

• Hva vet vi?

Inflammatoriske prosesser, Smerte, Redsel, Immobilitet

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Immobilisering

Friske forsøkspersoner: 28 dagers immobilisering i gips gav signifikant økning av:

• Leddsmerte ved bevegelse

• Kuldehyperalgesi

• Asymetrisk hudtemperatur

• Redusert lokal smerteterskel

Alle symptomer foruten smerte hadde gått tilbake 28 dager etter at gipset var fjernet.

Terskelsen m fl 2008

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4 ukers immobilisering av uskadet håndledd

hos 21 frivillige

• Alle 21 hadde temperatur-forskjell sml. med ikke-mobilisert håndledd (0,5-2,7°). Hos tre varte forskjellen mer enn 2 uker

• Øket generell leddstivhet: 18 (Tommel spesielt: 14)

• Neglectlignende tilstand: 14

• Endret følsomhet ved sensorisk testing: 12

• Smerter: 12 (hvorav 2 med brennende smerter)

• Unormal svetting: 6

• Trofiske forandringer: 7 (hud, negl og/eller hår)

Butler SH (2000): ”Immobility in volunteers transiently producessigns and symtoms of CRPS”

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• Pain is typically the leading symptom of CRPS and is often associated with limb dysfunction and psychological distress. For those in whom pain persists, psychological symptoms (anxiety, depression), and loss of sleep are likely to develop, even if they are not prominent at the outset.

Interdisciplinary treatment approach is recommended, tailored to the individual patient. The primary aims are to reduce pain, preserve or restore function, and enable patients to manage their condition and improve their quality of life.

Royal College of Physicians 2011

Behandlingsalgoritme for fysio- og

ergoterapeuter (ref. Guidelines fra Royal college of Physicians, London

2012)

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Behandling

Medikamentell behandling:

- I akutt fase: Kortikosteroider

- Senere i forløpet, kronisk fase: Tricyclisk antidepressiva, Gabapentin

• Blokader? I akutt fase?

• Nevromodulerende behandling:

- Transkutan elektrisk nervestimulering (TENS)

- Nevrokirurgisk behandling med ryggmargssstimulering (SCS)

• Eksponering til aktivitet

• Speilbehandling

• Kognitiv behandling

(Harden, N m fl 2013)

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• Få studier

• Kan være vanskelig ved allodyni

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Pain exposure physical therapy may be

a safe and effective treatment for

longstanding complex regional pain

syndrome type 1: a case series

After 3 months of observation, an improvement in function and in pain was found in the majority of

patientsJan-Willem Ek mfl. Clinical Rehabilitation 2009;23:1059-66

“Emphasis is placed on positive developments. In chronic CRPS, the worry of causing damage through movement is a predictor for functional derogation, more so than pain itself.”. (Birklein 2015)

Safety of ‘‘pain exposure’’ physical

therapy in patients with complex

regional pain syndrome type 1

Only if patients understand the reasoning and long-term

goals will they be motivated; otherwise they will give up.

Henk van de Meent m fl. Pain 2011 (52);6:1431-1438

Disuse

PAO CRPS bijscholing maart 2013

Central sensitisation

Cortical re-organisation

Trofic changes

Limited/ changed movement

Pain Avoidance Behaviour

(Kinesiophobia/catastrophizi

ng)

Pain

Disuse

PAO CRPS bijscholing maart 2013

Central sensitisation

Cortical reorganisation

Trofic changes

Limited/ altered movement

Pain avoidance

(Kinesiophobia/catastrophiz

ng)

Pain PEPT

PEPT PROTOCOL

1. Explain pain

2. Reduction and cessation of analgesics and CRPS related

medication

3. Progressive excercise and stress-loading;

treatment of kinesiofobia:

Improve function and activity; no pain treatment.

PAO CRPS bijscholing maart 2013

If the treating physician

bears in mind that patients should understand

the reasoning underlying the prescribed therapy,

actively motivates the patient to use the painful limb,

and avoids unjustified interventions, then the chance

of successful treatment is reasonable.

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Oppsummering 1• Dysfunksjonell interaksjon mellom det sentrale og det perifere

nervesystemet og en uhensiktsmessig inflammatorisk respons.

• Frykt og angst, et hinder for fremgang.

• Trygg behandlere og pasient. Samforstand mellom lege, fysioterapeut og pasient om behandlingen.

• Tilpass behandlingen til den enkelte pasient.

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Oppsummering 2

- I akutt (varm fase) fase: Kortikosteroider

- Senere i forløpet, kronisk fase: Som ved nevropatiske smerter. Tricyklisk antidepressiva, Antieptileptikum

• Eksponering til aktivitet

• Speilbehandling

• Kognitiv behandling

• Nevrokirurgisk behandling med ryggmargssstimulering (SCS)

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