Complex Regional Pain Syndrome (CRPS): Difference between revisions

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== Examination  ==
== Examination  ==


No golden standard has been developed yet, but included here are the Budapest criteria.<ref name="art2" />


The following must be met<br>- Continuing pain, which is disproportionate to any inciting event<br>- Must report at least one symptom in three of the four following categories:<br>


*Sensory: reports of hypaesthesia and/or allodynia
The original International Association for the Study of Pain criteria required only history and subjective symptoms for a diagnosis of CRPS. But recent consensus guidelines developed by experts have argued for the inclusion of objective findings.
*Vasomotor: reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
<ref>PENTLAND, B., e.a., Parkinsonism and dystonia. Neurological Rehabilitation, 1997. (level of evidence 2C)</ref>
*Sudomotor/edema: reports of edema and/or sweating changes and/or sweating asymmetry <br>  
<br> <br>The examination of the affected limb should be done from the neck downwards. The examination should be carried out at rest, during activity, and during ambulation.
*Motor/trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
<ref>SANDEEP, J., Complex Regional Pain Syndrome. Indian Journal of Plastic Surgery, 2011. (level of evidence 2A )</ref>
<br> <br>During the physical examination, it is very important to investigate the sensory, motor and autonomic dysfunctions.
<ref>PENTLAND, B., e.a., Parkinsonism and dystonia. Neurological Rehabilitation, 1997. (level of evidence 2C)</ref><ref>ROMMEL, e.a., Quantitative sensory testing, neurophysiological and psychological examination in patients with complex regional pain syndrome and hemisensory deficits. Ruhr-University, 2000. (level of evidence 1B)</ref><ref>SANDEEP, J., Complex Regional Pain Syndrome. Indian Journal of Plastic Surgery, 2011. (level of evidence 2A )</ref>
<br> <br>1. Autonomic dysfunction<br>The majority of patients with CRPS have side-to-side differences in temperature of the limbs. The skin temperature depends of the chronicity of the disease. The temperature will increase in acute stages, this is most of the time in combination with a white or reddish skin with more swelling. The temperature will decrease in chronic stages. This is associated with bluish skin and more atrophy.
<ref>FRONTERA, W, e.a., Essentials of Physical Medicine and Rehabilitation - Musculoskeletal disorders, pain and rehabilitation. Saunders Elsevier, 2002. (level of evidence 5)</ref>
<br> <br>2. Motor dysfunction<br>Studies have shown that approximately 70% of the patients with CRPS show muscle weakness in the affected limb, exaggerated tendon reflexes or tremor, irregular myoclonic jerks, and dystonic muscle contractions. Muscle dysfunction often coincides with a loss of range of motion in the distal joints.
<ref>SANDEEP, J., Complex Regional Pain Syndrome. Indian Journal of Plastic Surgery, 2011. (level of evidence 2A )</ref>


- Must display at least one sign at time of evaluation in two or<br> more of the following categories:<br>


*Sensory: evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or temperature sensation and/or deep somatic pressure and/or joint movement)
*Vasomotor: evidence of temperature asymmetry (&gt;1°C) and/or skin color changes and/or asymmetry
*Sudomotor/edema: evidence of edema and/or sweating changes and/or sweating asymmetry
*Motor/trophic: evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)


- There is no other diagnosis that better explains the signs and symptoms<br>  
 
<br>3. Sensory dysfunction<br>The distal ends of the extremities require more attention when examining a patient with CRPS. However, common findings of regional neuropathic and motor dysfunction have shown us that it is important to broaden the examination both proximally and contra laterally.<ref>FRONTERA, W, e.a., Essentials of Physical Medicine and Rehabilitation - Musculoskeletal disorders, pain and rehabilitation. Saunders Elsevier, 2002. (level of evidence 5)</ref><br> <br>Light touch, pinprick, temperature and vibration sensation should be assessed to have a correct examination of CRPS.<ref>FRONTERA, W, e.a., Essentials of Physical Medicine and Rehabilitation - Musculoskeletal disorders, pain and rehabilitation. Saunders Elsevier, 2002. (level of evidence 5)</ref> Most assessments are linked with each other. This means that when for example vibration sensation is very positive, light touch should be positive too.<ref>FRONTERA, W, e.a., Essentials of Physical Medicine and Rehabilitation - Musculoskeletal disorders, pain and rehabilitation. Saunders Elsevier, 2002. (level of evidence 5)</ref><br> <br>To help distinguish the findings of a sensory dysfunction, you have to compare the affected area with an unaffected area. The findings should be clear and reliable.<ref>FRONTERA, W, e.a., Essentials of Physical Medicine and Rehabilitation - Musculoskeletal disorders, pain and rehabilitation. Saunders Elsevier, 2002. (level of evidence 5)</ref><ref>SANDEEP, J., Complex Regional Pain Syndrome. Indian Journal of Plastic Surgery, 2011. (level of evidence 2A )</ref><br>
 
<br>


== Medical Management <br>  ==
== Medical Management <br>  ==

Revision as of 12:52, 4 October 2015

Welcome to PPA Pain Project. This page is being reviewed and updated by participants of a project to populate the Pain section of Physiopedia.  The project is supervised and co-ordinated by the The Physiotherapy Pain Association.
  • Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!  
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Original Editors - Yves Hubar

Top Contributors - Katelyn Koeninger, Kristen Storrie, Laura Ritchie, Laure-Anne Callewaert, Yves Hubar, Angeliki Chorti, Admin, Melissa Coetsee, Evan Thomas, Scott Cornish, Elaine Lonnemann, Kim Jackson, Gayatri Jadav Upadhyay, Rachael Lowe, Habibu Salisu Badamasi, Gwen Wyns, Matthias Steenwerckx, Vidya Acharya, Lucinda hampton, Jo Etherton, Claire Knott, Lauren Lopez, Naomi O'Reilly, Maria Galve Villa, Michelle Lee, Richmond Stace, WikiSysop and Wendy Walker  

Search Strategy[edit | edit source]

Literature was found on pubmed and the vub v-spaces system.

Definition/Description[edit | edit source]

Complex regional pain syndrome (CRPS) is a term for a variety of clinical conditions characterized by chronic persistent pain. It is a disease that may develop after a limb trauma. [1] This appears mostly in 1 or more limbs, usually in the arms or legs. We can say a CRPS is a regional posttraumatic neuropathic pain problem. [2] Neuropathic pain disorders are a disproportionate consequence of painful trauma or nerve lesion. [3]


CRPS is subdivided into type I and type II CRPS.

In the literature, there are a lot of names used to describe this syndrome such as ‘‘Reflex Sympathetic Dystrophy’’, ‘‘causalgia’’, ‘‘algodystrophy’’, ‘‘Sudeck’s atrophy’’, ‘‘neurodystrophy’’, and ‘‘post-traumatic dystrophy’’. To standardize the nomenclature, the name ‘complex regional pain syndrome’ was adopted in 1995 by the ‘International Association for the Study of Pain’ (IASP).[4]


Clinically Relevant Anatomy[edit | edit source]

CRPS can take place in any body part, but the wrist is most frequently affected after fractures.


An important aspect of the disease is the occurance of vascular disturbances. Mostly affected are primary small vessels, causing an impact on microcirculation, skin temperature and clinical appearance of the limb.
A paper described the changes in microcirculation as an increase in the number of capillaries, endothelial swelling and changes in the vessel luminal wall.[5]
According to a review, the acute stage features inhibited sympathetic vasoconstriction and exaggerated neurogenic inflammation, whereas the cold stage features vasoconstriction and endothelial disfunction or vascular hyperreactivity while neurogenic inflammation is less severe.[6]

Epidemiology /Etiology[edit | edit source]

Complex regional pain syndrome can develop after different types of inciting injuries.
A few examples are:
● sprains and strains,
● post-surgical,
● fractures,
● contusions,
● crush injuries,
● nerve lesions,
● stroke.
Sometimes the inciting injury can occur spontaneously or can not be determined. [7][8][9][10][11][12]
Fifty-six percent of patients reported CRPS was due to an ‘on-the-job’ injury. The most common type of work-related injury occurred in service employments, such as in restaurants, bakeries and police offices.[13]

The location of the CPRS varies from person to person. It often occurs in the extremities, a little bit more in the lower extremities (+/- 60%) than in the upper extremities (+/- 40%). It can also appear on the left and the right side and in both extremities.[14][15][16]

Complex regional pain syndrome occurs regularly in young adults. It is more frequent in females than males.[17][18]

The onset is mostly associated with a trauma in history, immobilization, injections or surgery. But there is no relation between the grade of severity of the initial injury and the following syndrome. A stressful life and other psychological factors may be potential risk factors that impact the severity of symptoms in CPRS.[19]



Characteristics/Clinical Presentation[edit | edit source]

The following symptoms have been found in literature:[20]
- Autonomic and trophic disorders:

  • Distal Edema in 80% of the patients
  • Skin temperature changes at the affected body part in 80% of the patients, initially warmer and in 40% of patients gradually cools down until colder in comparison to the rest of the body as the disease progresses. Another review mentioned that 30% of the patients start off from the primarily cold stage.3
  • In 40% of the patients skin at the affected body part starts showing redness, but becomes pale or livid in later stages
  • In 55% altered sweating takes place, with hyperhydrosis being more common than hypohydrosis.
  • Hair and nail growth possibly increase in early stages
  • Atrophy of skin and muscles in later stages, as well as contractures may severely restrict movement

- Sensory disturbances (90%) typically in a glove or stocking-like distribution

  • Spontaneous pain occurs in 75%, usually burning dragging or stinging
  • 68% felt in deep structures
  • 32% felt in skin
  • In 77% pain shows fluctuating intensity, lesser proportion shows shooting pain
  • Pain can be increased by orthostasis, anxiety, exercise or temperature changes.
  • In many cases, pain is more pronounced at night
  • Sensory gain (Mechanical hyperalgesia, allodynia, ...) or sensory loss (hypaesthesia, hypalgesia, …) may be present.

- Motor dysfunction

  • Motor weakness
  • Severe impairment of complex movements
  • Impairment of range of motion, initially by concomitant edema, later by contractures and fibroses
  • Neglect like symptoms have been found in some patiënts, described as the body part in question feeling foreign.
  • Enhanced physiological tremor in around 50%
  • Myoclonus or dystonia, especially in type II CRPS

Differential Diagnosis[edit | edit source]

The differential diagnosis includes the direct effects of [21][22]


● Bony or soft tissue injury
● Peripheral neuropathy, nerve lesions
● Arthritis
● Infection
● Compartment syndrome
● Arterial insufficiency
● Raynaud’s Disease
● Lymphatic or venous obstruction
● Thoracic outlet syndrome
● Gardner-Diamond Syndrome
● Erythromelalgia
● Self-harm or malingering
● Cellulitis
● Undiagnostic fracture

== Diagnostic Procedures == The diagnosis of CRPS requires a complicated process due to the absence of a golden standard test for diagnosis.[23][24][25][26] There are some criteria for diagnosis of CRPS, known as the Budapest criteria, and until there is a golden standard these criteria must suffice.[27] The Budapest criteria, also called the IASP clinical diagnostic criteria for complex regional pain syndrome are[28][29][30][31][32][33]:
● Constant pain, higher than the normally perceived pain
● Minimum one symptom in three of the following four symptom categories must be reported:
○ Vasomotor: temperature asymmetry and/or skin color changes/asymmetry
○ Sensory: hyperalgesia and/or allodynia
○ Sudomotor/edema: changes in sweating
○ Motor/trophic: smaller range of motion,motor dysfunction and/or changes in hair, nails and skin
● In addition to these symptoms the patient must also show signs that he will develop symptoms in at least two symptom categories
● No other illness could explain the set of symptoms the patient is showing.
CRPS diagnosis is mainly based on history, clinical examination, and some supportive investigations, just like:

1. Infrared thermography
Infrared thermography (IRT) is an effective mechanism to find significant asymmetry in temperature between both limbs by determining if the affected side of the body shows vasomotor differences in comparison to the other side. It is reported having a sensitivity of 93% and a specificity of 89%.[34] This test is hard to obtain so it is not often used for diagnosis of CRPS.[35][36][37]

2. Sweat Testing
To determine if the patient sweats abnormally the amount of sweat that he produces can be measured. Q-sweat is an adequate instrument to measure sweat production. The sweat samples should be taken from both sides of the body at the same time.[38][39][40]

3. Radiographic Testing
Irregularities in the bone structure of the affected side of the body can become visible with the use of X-rays. If the X-ray shows no sign of osteoporosis, CRPS can be excluded if the patient is an adult.[41][42][43] 4. Three-phase bone scan
With the use of technetium Tc 99m-labeled bisophosphonates increase in bone metabolism can be shown. Higher uptake of the substance means increased bone metabolism which means the body part could be affected.[44][45]

5. Bone densitometry
An affected limb often shows less bone mineral density and a change in the content of the bone mineral. During treatment of the CPRS the state of the bone mineral will improve. So this test can also be used to determine if the patient’s treatment is effective.[46]

6. Magnetic resonance imaging (MRI)
MRIs are useful to detect periarticular marrow edema, soft tissue swelling and joint effusions. And in a later stage atrophy and fibrosis of periarticular structures can be detected. But these symptoms are not exclusively signs of CRPS.[47][48][49]

7. Sympathetic Blocks
If the patient shows vasomotor or sudomotor dysfunction and severe pain, blocking the sympathetic nerves proves to be an effective technique to evaluate if the sympathetic nervous system is causing the pain to remain. This technique requires local anesthetic or ablation and is successful if at least 50% of the pain is reduced.[50]

Outcome Measures[edit | edit source]

add links to outcome measures here (also see Outcome Measures Database)

Examination[edit | edit source]

The original International Association for the Study of Pain criteria required only history and subjective symptoms for a diagnosis of CRPS. But recent consensus guidelines developed by experts have argued for the inclusion of objective findings. [51]

The examination of the affected limb should be done from the neck downwards. The examination should be carried out at rest, during activity, and during ambulation. [52]

During the physical examination, it is very important to investigate the sensory, motor and autonomic dysfunctions. [53][54][55]

1. Autonomic dysfunction
The majority of patients with CRPS have side-to-side differences in temperature of the limbs. The skin temperature depends of the chronicity of the disease. The temperature will increase in acute stages, this is most of the time in combination with a white or reddish skin with more swelling. The temperature will decrease in chronic stages. This is associated with bluish skin and more atrophy. [56]

2. Motor dysfunction
Studies have shown that approximately 70% of the patients with CRPS show muscle weakness in the affected limb, exaggerated tendon reflexes or tremor, irregular myoclonic jerks, and dystonic muscle contractions. Muscle dysfunction often coincides with a loss of range of motion in the distal joints. [57]




3. Sensory dysfunction
The distal ends of the extremities require more attention when examining a patient with CRPS. However, common findings of regional neuropathic and motor dysfunction have shown us that it is important to broaden the examination both proximally and contra laterally.[58]

Light touch, pinprick, temperature and vibration sensation should be assessed to have a correct examination of CRPS.[59] Most assessments are linked with each other. This means that when for example vibration sensation is very positive, light touch should be positive too.[60]

To help distinguish the findings of a sensory dysfunction, you have to compare the affected area with an unaffected area. The findings should be clear and reliable.[61][62]


Medical Management
[edit | edit source]

Concerning pharmacogenic treatment:

- Pathophysiologically oriented pharmacogenic treatment include application of glucocorticoids, tnf-alpha antibodies, free radical scavengers and sympathic blockade.
- Symptomatically oriented pharmacogens include opioids, gabapentin, NSAIDs and baclofen.
- To inhibit osteoclastic activity calcitonin, bisphosphonates and mannitol and vasodilating drugs may be given.


Definite reports on the efficacy of sympathectomy are currently lacking and there is a risk of developing post sympathectomy pain syndrome.[6]

A review has been found, describing the positive effects of Spinal Cord Stimulation and several theories regarding its effectiveness.[63]

Physical Therapy Management
[edit | edit source]

The following interventions were found in literature: [6]

  • Lymphatic drainage to facilitate regression of edema
  • Mirror Therapy
  • Graded motor learning
  • TENS (Unless patient cannot tolerate the therapy due to allodynia or hyperalgesia)

A paper on movement disorders in CRPS stated that splints or plaster casts are often ineffective and might even worsen dystonic postures related to CRPS. [64]

Key Research[edit | edit source]

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Resources
[edit | edit source]

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Clinical Bottom Line[edit | edit source]

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Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

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  1. ↑ O’CONNEL, N.E., e.a., Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews (Review). The Cochrane Collaboration, 2013. (level of evidence 3A)
  2. ↑ RHO, R. e.a., Concise Review for Clinicians: Complex Regional Pain Syndrome. Mayo Foundation for Medical Education and Research, 2002. (level of evidence 3A)
  3. ↑ WASNER, G., e.a., Vascular abnormalities in reflex sympathetic dystrophy (CRPS I): mechanisms and diagnostic value. Oxford University Press, 2001. (level of evidence 3A)
  4. ↑ TRAN, Q., e.a., Treatment of complex regional pain syndrome: a review of the evidence. Canadian Anesthesiologists’ Society, 2010. (level of evidence 1A)
  5. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named art1
  6. ↑ 6.0 6.1 6.2 Wasner G. Vasomotor Disturbances in Complex Regional Pain Syndrome—A Review. Pain Med. 2010 Aug;11(8):1267-73. (Level C)
  7. ↑ ROSS A.H. et al., The Theoretical Basis for and Treatment of Complex Regional Pain Syndrome with Prolotherapy. Journal of Prolotherapy, 2010. (level of evidence 2C)
  8. ↑ BARON, et al., Complex regional pain syndrome: mystery explained? The Lancet Neurology, 2003. (level of evidence 3B)
  9. ↑ ALLEN, G., et al., Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain,1999. (level of evidence 2B)
  10. ↑ SUMITANI M., et al., Complex regional pain syndrome. Rheumatology, 2014. (level of evidence 2C)
  11. ↑ JUOTTONEN, K., et al., Altered central sensorimotor processing in patients with complex regional pain syndrome. Pain, 2002. (level of evidence 5)
  12. ↑ ATALA, N.S., et al., Prednisolone in Complex Regional Pain Syndrome. Pain Physician, 2014. (level of evidence 2B)
  13. ↑ ALLEN, G., et al., Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain,1999. (level of evidence 2B)
  14. ↑ ROSS A.H. et al., The Theoretical Basis for and Treatment of Complex Regional Pain Syndrome with Prolotherapy. Journal of Prolotherapy, 2010. (level of evidence 2C)
  15. ↑ ALLEN, G., et al., Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain,1999. (level of evidence 2B)
  16. ↑ SUMITANI M., et al., Complex regional pain syndrome. Rheumatology, 2014. (level of evidence 2C)
  17. ↑ SRINIVASA N. et al., Complex Regional Pain Syndrome I (Reflex Sympathetic Dystrophy). American Society of Anesthesiologists, 2002. (level of evidence 3B)
  18. ↑ SANDRONI, P., et al., Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Pain, 2003. (level of evidence 2B)
  19. ↑ SRINIVASA N. et al., Complex Regional Pain Syndrome I (Reflex Sympathetic Dystrophy). American Society of Anesthesiologists, 2002. (level of evidence 3B)
  20. ↑ Maihöfner C, Seifert F, Markovic K. Complex regional pain syndromes: new pathophysiological concepts and therapies. Eur J Neurol. 2010 May;17(5):649-60. Epub 2010 Feb 18. (Level A1)
  21. ↑ TURNER-STOKES, L., e.a., Complex regional pain syndrome in adults: concise guidance. Clinical Med, 2011. (level of evidence 5)
  22. ↑ MCBRIDE, A., e.a., Complex Regional Pain Syndrome, Current Orthopaedics, 2005. (level of evidence 3A)
  23. ↑ PEREZ, R., et al., Diagnostic criteria for CRPS I: Differences between patient profiles using three different diagnostic sets. European Journal of Pain, 2007. (level of evidence 2A)
  24. ↑ ALBAZAZ, R. N., et al., Complex Regional Pain Syndrome: A review. Annals of Vascular Surgery Inc., 2008. (level of evidence 2A)
  25. ↑ HARDEN, R. N., et al., Validation of proposed diagnostic criteria (the ‘‘Budapest Criteria”) for Complex Regional Pain Syndrome. International Association for the Study of Pain, 2010. (level of evidence 1C)
  26. ↑ CHOI, E., et al., Interexaminer reliability of infrared thermography for the diagnosis of complex regional pain syndrome. Skin Research and Technology, 2013. (level of evidence 2B)
  27. ↑ HARDEN, R. N., Commentary: The Diagnosis of CRPS: Are we there yet?. International Association for the Study of Pain, 2012. (level of evidence 1B)
  28. ↑ PEREZ, R., et al., Diagnostic criteria for CRPS I: Differences between patient profiles using three different diagnostic sets. European Journal of Pain, 2007. (level of evidence 2A)
  29. ↑ ALBAZAZ, R. N., et al., Complex Regional Pain Syndrome: A review. Annals of Vascular Surgery Inc., 2008. (level of evidence 2A)
  30. ↑ HARDEN, R. N., et al., Validation of proposed diagnostic criteria (the ‘‘Budapest Criteria”) for Complex Regional Pain Syndrome. International Association for the Study of Pain, 2010. (level of evidence 1C)
  31. ↑ HARDEN, R. N., Commentary: The Diagnosis of CRPS: Are we there yet?. International Association for the Study of Pain, 2012. (level of evidence 1B)
  32. ↑ WASNER, G., et al., Complex regional pain syndrome - diagnostic, mechanisms, CNS involvement and therapy. International Spinal Cord Society, 2003. (level of evidence 2A)
  33. ↑ HODGE, S., et al., Complex Regional Pain Syndrome: The Anatomy Of A Controversy. Anatomy For Litigators: complex regional pain syndrome, p. 163-167. (level of evidence 2A)
  34. ↑ ALBAZAZ, R. N., et al., Complex Regional Pain Syndrome: A review. Annals of Vascular Surgery Inc., 2008. (level of evidence 2A)
  35. ↑ PEREZ, R., et al., Diagnostic criteria for CRPS I: Differences between patient profiles using three different diagnostic sets. European Journal of Pain, 2007. (level of evidence 2A)
  36. ↑ ALBAZAZ, R. N., et al., Complex Regional Pain Syndrome: A review. Annals of Vascular Surgery Inc., 2008. (level of evidence 2A)
  37. ↑ CHOI, E., et al., Interexaminer reliability of infrared thermography for the diagnosis of complex regional pain syndrome. Skin Research and Technology, 2013. (level of evidence 2B)
  38. ↑ BARON, R., Complex regional pain syndromes. Curr Pain Headache Rep., 2001. (level of evidence 2A)
  39. ↑ ALBAZAZ, R. N., et al., Complex Regional Pain Syndrome: A review. Annals of Vascular Surgery Inc., 2008. (level of evidence 2A)
  40. ↑ CHEMALI, K., et al., α-adrenergic supersensitivity of the sudomotor nerve in complex regional pain syndrome. Annals of Neurology, 2001. (level of evidence 2B)
  41. ↑ BARON, R., Complex regional pain syndromes. Curr Pain Headache Rep., 2001. (level of evidence 2A)
  42. ↑ ALBAZAZ, R. N., et al., Complex Regional Pain Syndrome: A review. Annals of Vascular Surgery Inc., 2008. (level of evidence 2A)
  43. ↑ HODGE, S., et al., Complex Regional Pain Syndrome: The Anatomy Of A Controversy. Anatomy For Litigators: complex regional pain syndrome, p. 163-167. (level of evidence 2A)
  44. ↑ ALBAZAZ, R. N., et al., Complex Regional Pain Syndrome: A review. Annals of Vascular Surgery Inc., 2008. (level of evidence 2A)
  45. ↑ HODGE, S., et al., Complex Regional Pain Syndrome: The Anatomy Of A Controversy. Anatomy For Litigators: complex regional pain syndrome, p. 163-167. (level of evidence 2A)
  46. ↑ ALBAZAZ, R. N., et al., Complex Regional Pain Syndrome: A review. Annals of Vascular Surgery Inc., 2008. (level of evidence 2A)
  47. ↑ BARON, R., Complex regional pain syndromes. Curr Pain Headache Rep., 2001. (level of evidence 2A)
  48. ↑ ALBAZAZ, R. N., et al., Complex Regional Pain Syndrome: A review. Annals of Vascular Surgery Inc., 2008. (level of evidence 2A)
  49. ↑ HODGE, S., et al., Complex Regional Pain Syndrome: The Anatomy Of A Controversy. Anatomy For Litigators: complex regional pain syndrome, p. 163-167. (level of evidence 2A)
  50. ↑ ALBAZAZ, R. N., et al., Complex Regional Pain Syndrome: A review. Annals of Vascular Surgery Inc., 2008. (level of evidence 2A)
  51. ↑ PENTLAND, B., e.a., Parkinsonism and dystonia. Neurological Rehabilitation, 1997. (level of evidence 2C)
  52. ↑ SANDEEP, J., Complex Regional Pain Syndrome. Indian Journal of Plastic Surgery, 2011. (level of evidence 2A )
  53. ↑ PENTLAND, B., e.a., Parkinsonism and dystonia. Neurological Rehabilitation, 1997. (level of evidence 2C)
  54. ↑ ROMMEL, e.a., Quantitative sensory testing, neurophysiological and psychological examination in patients with complex regional pain syndrome and hemisensory deficits. Ruhr-University, 2000. (level of evidence 1B)
  55. ↑ SANDEEP, J., Complex Regional Pain Syndrome. Indian Journal of Plastic Surgery, 2011. (level of evidence 2A )
  56. ↑ FRONTERA, W, e.a., Essentials of Physical Medicine and Rehabilitation - Musculoskeletal disorders, pain and rehabilitation. Saunders Elsevier, 2002. (level of evidence 5)
  57. ↑ SANDEEP, J., Complex Regional Pain Syndrome. Indian Journal of Plastic Surgery, 2011. (level of evidence 2A )
  58. ↑ FRONTERA, W, e.a., Essentials of Physical Medicine and Rehabilitation - Musculoskeletal disorders, pain and rehabilitation. Saunders Elsevier, 2002. (level of evidence 5)
  59. ↑ FRONTERA, W, e.a., Essentials of Physical Medicine and Rehabilitation - Musculoskeletal disorders, pain and rehabilitation. Saunders Elsevier, 2002. (level of evidence 5)
  60. ↑ FRONTERA, W, e.a., Essentials of Physical Medicine and Rehabilitation - Musculoskeletal disorders, pain and rehabilitation. Saunders Elsevier, 2002. (level of evidence 5)
  61. ↑ FRONTERA, W, e.a., Essentials of Physical Medicine and Rehabilitation - Musculoskeletal disorders, pain and rehabilitation. Saunders Elsevier, 2002. (level of evidence 5)
  62. ↑ SANDEEP, J., Complex Regional Pain Syndrome. Indian Journal of Plastic Surgery, 2011. (level of evidence 2A )
  63. ↑ Prager JP. What Does the Mechanism of Spinal Cord Stimulation Tell Us about Complex Regional Pain Syndrome? Pain Med. 2010 Aug;11(8):1278-83. (Level C)
  64. ↑ de Mos M, Sturkenboom MC, Huygen FJ. Movement Disorders in Complex Regional Pain Syndrome. Pain Pract. 2009 Mar-Apr;9(2):86-99. Epub 2008 Feb 9. (Level D)
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