Residual CRPS pain?

[lord_jeebus]

A hypothetical scenario based on a couple of recent cases I've seen.

Consider a patient who 10 years ago developed signs and symptoms of CRPS after an ankle injury, with good documentation in the medical records by a reputable pain physician of skin changes, temperature changes, edema, etc. Exam findings and diagnosis were verified by an independent medical examiner. Following PT and sympathetic blocks, physical exam signs of CRPS completely resolved at that time over a few months. However, pain has reportedly persisted in that area ever since. With 10 years of a normal-appearing leg and no symptoms other than pain itself, would you consider the patient to have CRPS pain at this point?

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[101N]

IASP-proposed revised CRPS clinical diagnostic criteria 2010

A clinical diagnosis of CRPS can be made when the following criteria are met:

1. Continuing pain that is disproportionate to any inciting event

2. Must report at least 1 symptom reported in at least 3 of the following categories:

a. Sensory: Hyperesthesia or allodynia
b. Vasomotor: Temperature asymmetry, skin color changes, skin color asymmetry
c. Sudomotor/edema: Edema, sweating changes, or sweating asymmetry
d. Motor/trophic: Decreased range of motion, motor dysfunction (eg, weakness, tremor, dystonia), or trophic changes (eg, hair, nail, skin)

3. Must display at least 1 sign at time of evaluation in at least 2 of the following categories:
a. Sensory: Evidence of hyperalgesia (to pinprick), allodynia (to light touch, temperature sensation, deep somatic pressure, or joint movement)
b. Vasomotor: Evidence of temperature asymmetry (>1°C), skin color changes or asymmetry
c. Sudomotor/edema: Evidence of edema, sweating changes, or sweating asymmetry
d. Motor/trophic: Evidence of decreased range of motion, motor dysfunction (eg, weakness, tremor, dystonia), or trophic changes (eg, hair, nail, skin)

No other diagnosis to better explaining the signs and symptoms.

REFERENCES:

Pain. 2010 Aug; 150(2): 268-274.Validation of proposed diagnostic criteria (the Budapest Criteria) for Complex Regional Pain Syndrome . Norman Harden,a,* Stephen Bruehl,b Roberto S.G.M. Perez,c,d Frank Birklein,e Johan Marinus,d,f Christian Maihofner,g Timothy Lubenow,h Asokumar Buvanendran,h Sean Mackey,i Joseph Graciosa,a Mila Mogilevski,a Christopher Ramsden,a Melissa Chont,b and Jean-Jacques Vatinej

 

[lord_jeebus]

Right, so I guess the question is, if a patient meets such criteria in the past, but not the present, and the "disproportionate" pain persists, do we stop thinking of it as CRPS? My thinking is, after 10 years of normal signs and symptoms, something else is going on. But if it was 6 months or so, I might think differently.

 

[101N]

I'd be very suspicious. If she no longer meets criteria, she no longer meets criteria.
You wouldn't know if from the patients WE see but CRPS is typically a time-limited
condition THAT IMPROVES. Given the patient demographics ALL studies should
control for CS, but they don't.

What you have here is a patient with symptoms disproportionate to the physical
findings and a history of CRPS. Look closely and it's CS, or secondary gain, or
opioid seeking, etc.

Pain. 2003 May;103(1-2):199-207.
Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study.
Sandroni P1, Benrud-Larson LM, McClelland RL, Low PA.
Author information

Abstract
The objective of this study is to undertake a population based study on the incidence, prevalence, natural history, and response to treatment of complex regional pain syndrome (CRPS). All Mayo Clinic and Olmsted Medical Group medical records with codes for reflex sympathetic dystrophy (RSD), CRPS, and compatible diagnoses in the period 1989-1999 were reviewed as part of the Rochester Epidemiology Project. We used IASP criteria for CRPS. The study population was in the Olmsted County, Minnesota (1990 population, 106,470). The main outcome measures were CRPS I incidence, prevalence, and outcome. Seventy-four cases of CRPS I were identified, resulting in an incidence rate of 5.46 per 100,000 person years at risk, and a period prevalence of 20.57 per 100,000. Female:male ratio was 4:1, with a median age of 46 years at onset. Upper limb was affected twice as commonly as lower limb. All cases reported an antecedent event and fracture was the most common trigger (46%). Excellent concordance was found between symptoms and signs and vasomotor symptoms were the most commonly present. Three phase bone scan and autonomic testing diagnosed the condition in >80% of cases. Seventy-four percent of patients underwent resolution, often spontaneously. CRPS I is of low prevalence, more commonly affects women than men, the upper more than the lower extremity, and three out of four cases undergo resolution. These results suggest that invasive treatment of CRPS may not be warranted in the majority of cases.

Comment in

• Questions concerning the incidence and prevalence of complex regional pain syndrome type I (RSD). [Pain. 2003]

 

[lobelsteve]

101n is right.
Darn.

 

[willabeast]

most clinicians and researchers think the majority of "true" CRPS patients (in other words, the referrals who actually have CRPS ) have pain that usually does not remit with time. i suspect the ones that get much better with time did not have CRPS to begin with. see this article
The Natural History of Complex Regional Pain Syndrome
http://rsds.org/wp-content/uploads/2015/02/SchwartzmanRJ_ErwinKL_AlexanderGM.pdf

//Dynamic or static mechanoallodynia were present in more than 90% of patients by 5 years and in 96% of patients at 15 years. The severity of the pain and its maintenance in this group of patients may result from multiple mechanisms that include changes in the peripheral nervous system,22 active processes involving both the peripheral nervous system and the central nervous system2,23; or from a sickness like response involving interactions between the immune and nervous systems.3,4 These mechanisms are not mutually exclusive and may act individually or in concert.2//

 

[Ducttape]

no allodynia?

technically, the criteria does not change regardless of the passage of time. there is no caveat that CRPS is not CRPS after 5, or 10, or 15 years. the Budapest Criteria only states "at one point in time".

consider a bone scan if you think something else is contributing, in line with her CRPS.

 

[101N]

I'm not buying it. FMS is also a 'chronic' condition. You haven't convinced me that this patient -
or Schwartzman's - aren't just FMS patients that he doesn't screen for it or it's attendant
psychological distress. Most Rheums that see and treat FMS consider CRPS to be another
CS variant.

 

[willabeast]

I'm not buying it. FMS is also a 'chronic' condition. You haven't convinced me that this patient -
or Schwartzman's - aren't just FMS patients that he doesn't screen for it or it's attendant
psychological distress. Most Rheums that see and treat FMS consider CRPS to be another
CS variant.

in other words, it was never CRPS to begin with. based on 25 years of working with CRPS patients, i think most of the time you are correct.
CRPS is a very convenient diagnosis used for a whole bunch of problems that have nothing to do with CRPS. however - no way to know in this patient unless we were present 10 years ago.

 

[NJPAIN]

How many 60, 70, 80, 90 year olds with CRPS do all of you see? If this symptom complex does not get better with time then what eventually happens to the 20,30, 40 year old with CRPS? I have asked this numerous times but never get an answer.

 

[101N]

Every few years crazy, non-physiologic, pain takes on another name.
Ten yrs ago it was all CRPS. Now it's morphed into adult onset EDS.
Hopefully, the CS phenotype starts getting recognized sooner and
we break the silly cycle.

 

[101N]

How many 60, 70, 80, 90 year olds with CRPS do all of you see? If this symptom complex does not get better with time then what eventually happens to the 20,30, 40 year old with CRPS? I have asked this numerous times but never get an answer.

CS, catastrophizing, and mental illness in general tends to burn out with time.

 

[lord_jeebus]

no allodynia?

For the sake of this, ahem, hypothetical case, let's say that there is allodynia.

 

[willabeast]

How many 60, 70, 80, 90 year olds with CRPS do all of you see? If this symptom complex does not get better with time then what eventually happens to the 20,30, 40 year old with CRPS? I have asked this numerous times but never get an answer.

the average patient will see a doctor three times with the same complaint before giving up on doctors ever helping them. there is an enormous reservoir of people with problems that docs cannot help them with. the patients simply learn how to adapt and cope with their chronic unsolvable problem. just as an aside,
this is the key to making healthcare affordable. once everyone is covered under the same health plan, there will be no competition, and a whole raft of illness will no longer need to be treated. by the way, i am a little bit sympathetic to this viewpoint when it comes to chronic pain - the nervous system can adapt to almost anything, and i think pain docs get in the way of that sometimes.

 

[101N]

"there will be no competition, and a whole raft of illness will no longer need to be treated."

You can make a really strong argument that these 'illnesses' aren't being effectively treated
now anyway.

 

[willabeast]

"there will be no competition, and a whole raft of illness will no longer need to be treated."

You can make a really strong argument that these 'illnesses' aren't being effectively treated
now anyway.

i think the book "House of God" ( Shem) made exactly this point over 30 years ago. i re-read it recently. amazing book.
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Struggling with grueling hours and sudden life-and-death responsibilities, Basch and his colleagues, under the leadership of their rule-breaking senior resident known only as the Fat Man, must learn not only how to be fine doctors but, eventually, good human beings.

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With an introduction by John Updike

 

[NJPAIN]

House of God was required reading when I started medical school 33 years ago. Very realistic representation of what it was like in training back then.


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[freddydpt]

For the sake of this, ahem, hypothetical case, let's say that there is allodynia.

MRI, look for edema - get a good MSK rad to read it. Pain follows edema on MRI. Inject the edematous soft tissue target. Tends to help. I've had a bunch of these types of patients this year. Pain didn't resolve all the way, but patients who I could have sworn were secondary gain, admitted relief after injection. I do believe there is a component of central sensitization to this as well.

 

[freddydpt]

House of God was required reading when I started medical school 33 years ago. Very realistic representation of what it was like in training back then.


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I was required to read it before med school. I personally hated it. It had such a doom and gloom outlook... depressing.

 

[Orin]

Sorry, what are you abbreviating as a CS?

 

[lord_jeebus]

Central Sensitization

 

[oreosandsake]

when I was in fellowship, we would see patients come in with diagnosis of CRPS. they didn't seem to satisfy criteria anymore, but would say, "when i first got this 15 years ago my leg was red, purple, blue and like a ballon, etc etc and my pain was 12/10. now it doesn't look so bad" they would commonly report mild swelling, or reduced rom, but otherwise that was it. then we'd refill their regimen of meds, possibly adjust their SCS programming, and they'd be off.

when I worked with Norm Harden, he would always say that you evaluate the person for what you see THAT day. Do they or do they not satisfy criteria at your evaluation. "yes, this person has signs and symptoms concordant with CRPS" you need to recognize the spectrum of CRPS, and what are classically described stages but the disease does not need to follow. Harden would always say something to the effect of, "'they start off hot, bloated, red, and end up cold clammy blue"

 

[NJPAIN]

Did anyone ever contemplate trying to taper the meds or turning the stim off or was the unwritten rule to just leave things be?


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[101N]

The idea of tapering the meds - opioids - is an interesting one. I wonder how many of us who refill opioids
for patients w/o aberrancy, high doses, or co-administered benzo's go to the trouble regularly asking patients
if they would like to taper off. Or how many of us recommend an opioid holiday, rather than a rotation, in
the face of tolerance.

 

[lobelsteve]

Rotation is reduction. Holiday is bunk.

 

[DOctorJay]

How long of a holiday are you recommending? Do you notice that prevents the development of tolerance and requests for endless increases in dose?


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[101N]

Roughly 4mo on COT followed by a 2mo holiday. Nuttin cures tolerance like a holiday

 

[Ducttape]

And nothing reveals those individuals with latent substance use disorder, opioid, than a holiday...

I rarely use these, except in the selected few that are very vested in limiting use, because the volume of phone calls and complaints up until the time they restart.


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[101N]

Unlearning COT as a measure of physician cognitive in-flexibility:http://shortcoatsinem.blogspot.com/2014/02/the-unlearning-process.html

 

[oreosandsake]

Did anyone ever contemplate trying to taper the meds or turning the stim off or was the unwritten rule to just leave things be?


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As a fellow, I found having a 20-30 min discussion on tapering their meds was like trying to convert them to another religion... I quickly found it to be a total waste of my time and hoped no one would decide to OD that month on the Rx I signed.

 

[freddydpt]

Converting them to another religion is probably the best analogy I've ever heard. I signed off on those kind of Rx's as a fellow, but have not and will not as an attending. "But Dr. my PCP told me you would prescribe these medications." "Your PCP was unfortunately mistaken."

 

[NJPAIN]

Converting them to another religion is probably the best analogy I've ever heard. I signed off on those kind of Rx's as a fellow, but have not and will not as an attending. "But Dr. my PCP told me you would prescribe these medications." "Your PCP was unfortunately mistaken."

Nothing infuriates me more than that statement from a patient as I am certain that is EXACTLY what the PCP said along with the statement that the law has changed and he doesn't have a license to prescribe these drugs for this long.

 

[Ducttape]

I love that statement.

cause that means that I can say "what did the PCP say that implied that I could?" and "well, since you wont get any more meds, here is what you can do to reduce the possibility of withdrawing".