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| <div class="noeditbox">Welcome to [[ Vrije Universiteit Brussel Evidence-based Practice Project| Vrije Universiteit Brussel's Evidence-based Practice project]] . This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox"> | | [[Category:Bellarmine_Student_Project]]<div class="noeditbox">Welcome to [[ Pathophysiology of Complex Patient Problems| PT 635 Pathophysiology of Complex Patient Problems]] This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox"> |
| '''Original Editors ''' - [[User:Yves Hubar|Yves Hubar]] | | '''Original Editors '''- [[Pathophysiology of Complex Patient Problems|Students from Bellarmine University's Pathophysiology of Complex Patient Problems project.]] |
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| '''Lead Editors''' - Your name will be added here if you are a lead editor on this page. [[Physiopedia:Editors|Read more.]] | | '''Lead Editors''' - Your name will be added here if you are a lead editor on this page. [[Physiopedia:Editors|Read more.]] |
| </div> | | </div> |
| == Search Strategy ==
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| Literature was found on pubmed and the vub v-spaces system.<br>
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| == Definition/Description == | | == Definition/Description == |
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| The international association for the study of pain defines CRPS as a collection of locally occurring painful conditions, usually following traumatic injury, which tends to express itself distally and exceeds the expected pain of the original trauma and usually results in significant motor deficit. <ref name="reu1">L.Verbruggen. Reumatologie. Dienst Uitgaven VUB 2011</ref><br>
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| CRPS is subdivided into type I and type II CRPS. <br>Type I CRPS signifies that no peripheral nerve injury can be linked to the condition, while type II signifies that the condition results from a peripheral nerve injury. <ref name="art1">Groeneweg G, Huygen FJ, Coderre TJ, Zijlstra FJ. Regulation of peripheral blood flow in Complex Regional Pain Syndrome: clinical implication for symptomatic relief and pain management. BMC Musculoskelet Disord. 2009 Sep 23;10:116. (Level A1)</ref><br>
| | == Prevalence == |
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| == Clinically Relevant Anatomy ==
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| CRPS can take place in any body part, but the wrist is most frequently affected after fractures.
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| 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.<br>A paper described the changes in microcirculation as an increase in the number of capillaries, endothelial swelling and changes in the vessel luminal wall.<ref name="art1" /><br>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.<ref name="art2">Wasner G. Vasomotor Disturbances in Complex Regional Pain Syndrome—A Review. Pain Med. 2010 Aug;11(8):1267-73. (Level C)</ref><br>
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| == Epidemiology /Etiology ==
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| CRPS is found to result:<ref name="reu1" /><br>- After traumatic injury (65%)<br>
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| *1-2% of all fractures result in CRPS
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| *Largest risk of CRPS for fractures of the wrist
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| - After surgical intervention (19%)<br>- Infection (4%)<br>- Prior inflammation (2%)<br>- No clear cause (10%)
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| A review stated that women are predominantly affected, by a factor of 3,5 and a genetic predisposition has also been theorized.<br>The disease affects all ages, though most cases are between 50 and 70 years old, and it is generally believed to occur mainly in caucasian and Japanese people.<ref name="art4">de Mos M, Sturkenboom MC, Huygen FJ. Current Understandings on Complex Regional Pain Syndrome. Pain Pract. 2009 Mar-Apr;9(2):86-99. Epub 2008 Feb 9. (Level A1)</ref><br>
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| == Characteristics/Clinical Presentation == | | == Characteristics/Clinical Presentation == |
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| The following symptoms have been found in literature:<ref name="art3">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)</ref><br>- Autonomic and trophic disorders:
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| *Distal Edema in 80% of the patients
| | == Associated Co-morbidities == |
| *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
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| *In 40% of the patients skin at the affected body part starts showing redness, but becomes pale or livid in later stages
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| *In 55% altered sweating takes place, with hyperhydrosis being more common than hypohydrosis.
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| *Hair and nail growth possibly increase in early stages
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| *Atrophy of skin and muscles in later stages, as well as contractures may severely restrict movement
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| - Sensory disturbances (90%) typically in a glove or stocking-like distribution
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| *Spontaneous pain occurs in 75%, usually burning dragging or stinging
| | == Medications == |
| <blockquote>
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| *68% felt in deep structures
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| *32% felt in skin
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| *In 77% pain shows fluctuating intensity, lesser proportion shows shooting pain
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| *Pain can be increased by orthostasis, anxiety, exercise or temperature changes.
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| *In many cases, pain is more pronounced at night
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| </blockquote>
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| *Sensory gain (Mechanical hyperalgesia, allodynia, ...) or sensory loss (hypaesthesia, hypalgesia, …) may be present.
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| - Motor dysfunction
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| *Motor weakness
| | == Diagnostic Tests/Lab Tests/Lab Values == |
| *Severe impairment of complex movements
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| *Impairment of range of motion, initially by concomitant edema, later by contractures and fibroses
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| *Neglect like symptoms have been found in some patiënts, described as the body part in question feeling foreign.
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| *Enhanced physiological tremor in around 50%
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| *Myoclonus or dystonia, especially in type II CRPS<br>
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| == Differential Diagnosis ==
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| The differential diagnostic consists of:<ref name="art2" /><br>
| | == Etiology/Causes == |
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| *[[Rheumatology|Rheumatic conditions]]
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| *Inflammatory conditions (infections following bone surgery, neuritides)
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| *Thromboembolic conditions
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| *[[Compartment_Syndrome|Compartment syndrome]]<br>
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| *Peripheral neuropathy (mainly for type II CRPS)
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| == Diagnostic Procedures == | | == Systemic Involvement == |
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| add text here related to medical diagnostic procedures | | add text here |
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| == Outcome Measures == | | == Medical Management (current best evidence) == |
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| add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]]) | | add text here |
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| == Examination == | | == Physical Therapy Management (current best evidence) == |
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| No golden standard has been developed yet, but included here are the Budapest criteria.<ref name="art2" />
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| 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>
| | == Alternative/Holistic Management (current best evidence) == |
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| *Sensory: reports of hypaesthesia and/or allodynia
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| *Vasomotor: reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
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| *Sudomotor/edema: reports of edema and/or sweating changes and/or sweating asymmetry <br>
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| *Motor/trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
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| - Must display at least one sign at time of evaluation in two or<br> more of the following categories:<br>
| | == Differential Diagnosis == |
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| *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)
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| *Vasomotor: evidence of temperature asymmetry (>1°C) and/or skin color changes and/or asymmetry
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| *Sudomotor/edema: evidence of edema and/or sweating changes and/or sweating asymmetry
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| *Motor/trophic: evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)
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| - There is no other diagnosis that better explains the signs and symptoms<br>
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| == Medical Management <br> == | |
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| Concerning pharmacogenic treatment:
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| - Pathophysiologically oriented pharmacogenic treatment include application of glucocorticoids, tnf-alpha antibodies, free radical scavengers and sympathic blockade.<br>- Symptomatically oriented pharmacogens include opioids, gabapentin, NSAIDs and baclofen.<br>- To inhibit osteoclastic activity calcitonin, bisphosphonates and mannitol and vasodilating drugs may be given.
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| Definite reports on the efficacy of sympathectomy are currently lacking and there is a risk of developing post sympathectomy pain syndrome.<ref name="art2" />
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| A review has been found, describing the positive effects of Spinal Cord Stimulation and several theories regarding its effectiveness.<ref name="art5">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)</ref><br>
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| == Physical Therapy Management <br> ==
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| The following interventions were found in literature:
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| <ref name="art2" />
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| *Lymphatic drainage to facilitate regression of edema
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| *Mirror therapy
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| *Graded motor learning
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| *TENS (Unless patient cannot tolerate the therapy due to allodynia or hyperalgesia)
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| 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.
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| <ref name="art6">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)</ref>
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| == Key Research == | | == Case Reports/ Case Studies == |
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| add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br> | | add links to case studies here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br> |
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| == Resources <br> == | | == Resources <br> == |
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| add appropriate resources here <br> | | add appropriate resources here |
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| == Clinical Bottom Line ==
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| == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | | == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == |
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| see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]] | | see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]] |
| <div class="researchbox"> | | <div class="researchbox"> |
| <rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1P7PR1QO6IS9xQ724YOoSHF8On2gkKwiE3UGU6x5C6gE847gBI|charset=UTF-8|short|max=10</rss> | | <rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1NGmwZeh8JwVIzrKgHG1LrDm0izTr7ViJiDkSYAY2BW5hiXsx0|charset=UTF-8|short|max=10</rss> |
| </div> | | </div> |
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| see [[Adding References|adding references tutorial]]. | | see [[Adding References|adding references tutorial]]. |
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| <references /> | | <references /> |
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| [[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]]
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