Article

Widespread Pain in Patients with Complex Regional Pain Syndrome

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Abstract

Our goal was to ascertain the prevalence of widespread pain in our cohort of patients with complex regional pain syndrome (CRPS). We conducted a retrospective analysis of clinical letters and notes. We assessed data from consecutive patients diagnosed with CRPS according to the Budapest criteria, after a referral to one consultant at a tertiary Pain Medicine referral center. Between July 2007 and September 2012, 190 patients (149 females) received a diagnosis of CRPS according to the Budapest criteria, and an additional 26 patients received the diagnosis of CRPS NOS (not otherwise specified). The CRPS patients were an average of 44 years of age, and had a median disease duration of 18 months. Before the CRPS incident trigger, a third had already experienced other than everyday pains in the now CRPS-affected limb. Twenty-one patients (11.1%) experienced widespread pain in clinic, which was often not communicated in the referral letters. The types of triggering traumata and frequencies of Budapest signs and symptoms did not differ between patients with or without widespread pain. All patients considered their widespread pain as an important factor affecting their quality of life; for the majority it was of similar severity to the CRPS pain. Additional patients reported CRPS-concomitant regional pains, most commonly headaches/migraines, lower back pain, and irritable bowel syndrome. In this systematic assessment of the incidence of widespread pain in a large cohort of patients with CRPS, important widespread pain affected > 10% of patients. Our data support the inclusion of routine enquiries about additional pains in the clinical assessment of patients with CRPS.

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... [24][25][26] IBS is common in CRPS although the relationship has hitherto not been elucidated. 27 In multiple studies, SIBO was found to be present in up to 50% of IBS-d patients. 21 Treatment of both SIBO and IBS with rifaximin, a nonabsorbed, gut-directed antibiotic, has been extensively studied, and use of rifaximin for IBS-d was approved by the U.S. Food and Drug Administration in May 2015. ...
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Article
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Article
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... Research shows that some people with CRPS experience widespread pain [7], which could confound the assessment of CRPS related pain. For this reason, the individual will be asked to consider and report only the pain related to the CRPS when completing the instrument. ...
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Article
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Article
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Chapter
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The pathogenesis of reflex sympathetic dystrophy--variously known as Sudeck's atrophy, causalgia, algodystrophy, and peripheral trophoneurosis--is not yet understood, and diagnosing and treating patients is difficult. We have prospectively studied 829 patients, paying particular attention to early signs and symptoms. In its early phase, reflex sympathetic dystrophy is characterised by regional inflammation, which increases after muscular exercise. Pain was present in 93% of patients, and hypoaesthesia and hyperpathy were present in 69% and 75% respectively. With time, tissue atrophy may occur as well as involuntary movements, muscle spasms, or pseudoparalysis. Tremor was found in 49% and muscular incoordination in 54% of patients. Sympathetic signs such as hyperhidrosis are infrequent and therefore have no diagnostic value. We found no evidence consistent with the presence of three consecutive phases of the disease. Early symptoms are those of an inflammatory reaction and not of a disturbance of the sympathetic nervous system. These data support the concept of an exaggerated regional inflammatory response to injury or operation in reflex sympathetic dystrophy.
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Many aspects of bilateral presentation or recurrence of reflex sympathetic dystrophy (RSD) are unknown. For this reason 1183 consecutive patients with RSD were analyzed. In 10 patients RSD started in symmetrical limbs. In 34 patients RSD recurred in the same limb after a period of no or few complaints and in 76 patients RSD recurred in one or more limbs other than the first limb. Compared to 1065 patients with RSD without these features, these patients were younger (P < 0.01) and RSD started more frequently with a cold skin temperature (P = 0.02). Patients did not differ in gender or primary localization of RSD. Involvement of a second limb concerned in 47% the symmetrical limb. Recurrences were in 53% of spontaneous origin and often characterized by few signs and symptoms. The incidence of a recurrence was 1.8% per patient per year. No measures are known to prevent recurrence. Reflex sympathetic dystrophy may recur in the same or in another limb, although only in a minority of patients. Recurrences occur especially in younger patients and in the symmetrical limb. Diagnosis of a recurrence is difficult, for often the recurrence is spontaneous and presents with few signs and symptoms.
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Complex regional pain syndrome (CRPS) remains a poorly understood chronic pain disorder. Little data has been published assessing the epidemiology of CRPS (and reflex sympathetic dystrophy, RSD). This study assessed epidemiological variables in 134 CRPS patients evaluated at a tertiary chronic pain clinic in the US, including demographic, health care utilization and legal/workman's compensation measures. In addition, the frequency of physician-imposed immobilization of the CRPS limb was assessed, as was physical examination evidence of myofascial dysfunction. This study found that these patients had seen on average 4.8 different physicians before referral to the pain center and had received an average of five different kinds of treatments both prior to and during pain clinic treatment. The mean duration of CRPS symptoms prior to pain center evaluation was 30 months. Seventeen percent had a lawsuit and 54% had a worker compensation claim related to the CRPS. Fifty-one patients received a bone scan, but only 53% of which were interpreted as consistent with the diagnosis of RSD/CRPS. Forty-seven percent had a history of physician-imposed immobilization, and 56% had a myofascial component present at evaluation. The duration of CRPS symptoms and the involvement of the upper extremity was significantly associated with the presence of myofascial dysfunction. Thus, this study found that most CRPS patients are referred to a pain specialty clinic after several years of symptoms and many failed therapies. The data also suggest the lack of utility of a diagnostic bone scan and highlight the prominence of myofascial dysfunction in a majority of CRPS patients.
Article
Early diagnosis is a prerequisite for a successful treatment of complex regional pain syndrome (CRPS). In order to describe neurological symptoms which characterize CRPS, we evaluated 145 patients prospectively. Two-thirds of these were women, the mean age at time of investigation was 50.4 years. CRPS followed limb trauma, surgery and nerve lesion. Employing the current IASP criteria 122 patients were classified as CRPS I and 23 as CRPS II. All patients were assessed clinically pain was quantified using the McGill pain questionnaire, skin temperature was measured by an infrared thermometer and a subgroup of 57 patients was retested in order to determine thermal thresholds (QST). Of our patients 42% reported stressful life events in a close relationship to the onset of CRPS and 41% had a history of chronic pain before CRPS. The latter group of patients gave a higher rating of CRPS pain (P<0.05). The major symptoms were pain at rest in 77% and hyperalgesia in 94%. Typical pain was deep in the limb having a tearing character. Patients getting physical therapy had significantly less pain than those without (P<0.04). Autonomic signs were frequent (98%) and often changed with the duration of CRPS. Skin temperature was warmer in acute and colder in chronic stages (P<0.001). Likewise edema had a higher incidence in acute stages (P<0.001). We found no correlation between pain and autonomic dysfunction. Motor dysfunction (present in 97%) included weakness, tremor, exaggerated tendon reflexes, dystonia or myoclonic jerks. QST revealed increased warm perception thresholds (P<0.02) and decreased cold pain thresholds (P<0.03) of the affected limb. The detailed knowledge of clinical features of CRPS could help physicians early to recognize the disease and thus to improve therapy outcome.
Article
There are reports that complex regional pain syndrome, type I (reflex sympathetic dystrophy; CRPS-I/RSD) can spread from the initial site of presentation, but there are no detailed descriptions of the pattern(s) of such spread. We describe a retrospective analysis of 27 CRPS-I/RSD patients who experienced a significant spread of pain. Three patterns of spread were identified. 'Contiguous spread (CS)' was noted in all 27 cases and was characterized by a gradual and significant enlargement of the area affected initially. 'Independent spread (IS)' was noted in 19 patients (70%) and was characterized by the appearance of CRPS-I in a location that was distant and non-contiguous with the initial site (e.g. CRPS-I/RSD appearing first in a foot, then in a hand). 'Mirror-image spread (MS)' was noted in four patients (15%) and was characterized by the appearance of symptoms on the opposite side in an area that closely matched in size and location the site of initial presentation. Only five patients (19%) suffered from CS alone; 70% also had IS, 11% also had MS, and one patient had all three kinds of spread. Our results suggest that CRPS-I/RSD spread may not be a unitary phenomenon. In some it may be due to a local spread of pathology (CS); in others it may be a consequence of a generalized susceptibility (IS). In the MS case, spread may be due to abnormal neural functioning spreading via commissural pathways. Alternatively, we discuss the possibility that all three kinds of spread may be due to aberrant CNS regulation of neurogenic inflammation.
Article
To evaluate the economic aspects of treatment of chronic reflex sympathetic dystrophy (RSD) with spinal cord stimulation (SCS), using outcomes and costs of care before and after the start of treatment. Fifty-four patients with chronic RSD were randomized to receive either SCS together with physical therapy (SCS+PT; n = 36) or physical therapy alone (PT; n = 18). Twenty-four SCS+PT patients responded positively to trial stimulation and underwent SCS implantation. During 12 months of follow-up, costs (routine RSD costs, SCS costs, out-of-pocket costs) and effects (pain relief by visual analogue scale, health-related quality of life [HRQL] improvement by EQ-5D) were assessed in both groups. Analyses were carried out up to 1 year and up to the expected time of death. SCS was both more effective and less costly than the standard treatment protocol. As a result of high initial costs of SCS, in the first year, the treatment per patient is $4,000 more than control therapy. However, in the lifetime analysis, SCS per patient is $60,000 cheaper than control therapy. In addition, at 12 months, SCS resulted in pain relief (SCS+PT [-2.7] vs PT [0.4] [p < 0.001]) and improved HRQL (SCS+PT [0.22] vs PT [0.03] [p = 0.004]). The authors found SCS to be both more effective and less expensive as compared with the standard treatment protocol for chronic RSD.
Article
To systematically evaluate and compare the clinical manifestations, disease course, risk factors and demographic characteristics of Complex Regional Pain Syndrome type 1 (CRPS), fibromyalgia (FM) and a-specific Repetitive Strain Injury (RSI). A literature search was performed using terms related to the aforementioned topics and diseases. Only original clinical studies that included at least 20 subjects were eligible. Fifty-nine studies on CRPS, 73 on FM and 7 on a-specific RSI were identified. The diseases show similarities in age distribution, male-female ratio, pain characteristics and sensory signs and symptoms. Motor, autonomic and trophic changes are frequently reported in CRPS, but only occasionally in FM and RSI. Systemic symptoms are found in patients with CRPS and FM, and in a subgroup of patients with RSI. In all three disorders, symptoms usually start locally, but may spread to other body regions later, which, in the case of FM, is a prerequisite for diagnosis. Disease onset is always, usually, or occasionally of traumatic origin in RSI, CRPS and FM, respectively. Anxiety and depression are more frequent in patients compared to controls, but probably not very different from patients with other pain conditions or chronic diseases. Apart from some obvious differences between CRPS, FM and RSI, the similarities are conspicuous. The common features of CRPS, FM and a-specific RSI may suggest that a common pathway is involved, but until patients with these type of symptoms are assessed with a uniform assessment procedure, a thorough comparison cannot be made. A systematic evaluation of patients with a suspected diagnosis of CRPS, FM or RSI, may lead to a better appreciation of the differences and similarities in these diseases and help to unravel the underlying mechanisms.
Article
The aim of this study was to investigate involvement of central mechanisms in complex regional pain syndrome (CRPS). In particular, we wished to determine whether hyperalgesia extends ipsilaterally from the affected limb to the forehead. The heat-pain threshold, pressure-pain threshold, and ratings of cold and sharpness were investigated on each side of the forehead and in the affected and unaffected limbs of 38 patients with features of CRPS. In addition, touch thresholds were investigated in the limbs. The pressure-pain threshold was lower on the ipsilateral forehead than contralaterally, consistent with the presence of static mechanical hyperalgesia. Although the heat-pain threshold and ratings of sharpness and cold did not differ between the two sides of the forehead in the group as a whole, the sharpness of pinprick sensations in the affected limb was mirrored by similar sensations in the ipsilateral forehead. Conversely, diminished sensitivity to light touch in the affected limb was associated with diminished sensitivity to sharpness, cold and heat-pain in the ipsilateral forehead. These findings suggest that central nociceptive processing is disrupted in CRPS, possibly due to disturbances in the thalamus or higher cortical centres.
Article
The complex regional pain syndrome (CRPS) is a painful disorder that can occur in an extremity after any type of injury, or even spontaneously. Data on the incidence of CRPS are scarce and mostly hospital based. Therefore the size of the problem and its burden on health care and society are unknown. The objective of the present study was to estimate the incidence of CRPS in the general population. A retrospective cohort study was conducted during 1996-2005 in the Integrated Primary Care Information (IPCI) project, a general practice research database with electronic patient record data from 600,000 patients throughout The Netherlands. Potential CRPS cases were identified by a sensitive search algorithm including synonyms and abbreviations for CRPS. Subsequently, cases were validated by electronic record review, supplemented with original specialist letters and information from an enquiry of general practitioners. The estimated overall incidence rate of CRPS was 26.2 per 100,000 person years (95% CI: 23.0-29.7). Females were affected at least three times more often than males (ratio: 3.4). The highest incidence occurred in females in the age category of 61-70 years. The upper extremity was affected more frequently than the lower extremity and a fracture was the most common precipitating event (44%). The observed incidence rate of CRPS is more as four times higher than the incidence rate observed in the only other population-based study, performed in Olmsted County, USA. Postmenopausal woman appeared to be at the highest risk for the development of CRPS.