Page 263 Guide to Pain Management in Low-Resource Settings

Complex Regional Pain Syndrome 251

What are Dr. Ndungu’s options What are the clinical
for further diagnostic procedures?
symptoms of CRPS?
Based on the diagnostic criteria defi ned by IASP (see
below) and the course of the disease, Dr. Ndungu diag- Th e clinical pattern of CRPS is characterized by sen-
nosed a complex regional pain syndrome. Upon start of sory, motor, and autonomic impairment. Additionally,
the treatment at the pain center, he explained to Etta patients with CRPS often feel as if the hand or the foot
the disease pattern and the principles of therapy, which does not belong to them anymore or as if it is not per-
require her active cooperation, understanding, and pa- ceptible or controllable; movements can only be per-
tience because progress may be slow, with relapses and formed under direct visual control (“neglect-like syn-
periods of stagnation. He prescribed Etta a splint and drome”). Furthermore, the following features occur in
recommended that she position the hand and the fore- almost all cases:
arm higher than the heart, until the edema is reduced. • Th e impairment due to CRPS is disproportionate
Coxibs (celecoxib) and anticonvulsants (gabapentin) to the inciting event.
were prescribed as pain medications. Physical and occu- • Th ere is a tendency for a distal generalization
pational therapy was started one week after the decrease for all symptoms, i.e., not a single fi nger, but the
of the edema and the pain at rest. whole hand is aff ected, and the hand is more
strongly aff ected than the forearm.
Are there any other therapeutic options? • Th e joint and soft tissue structures are also aff ect-
What are the main rules for therapy? ed, with according mobility impairment.
At the beginning of physical therapy, focus was put on • An edema, depending on position and physi-
the shoulder, and 2 weeks later, normal mobility was re- cal activity, usually occurs, especially in the early
gained. Th e progress of improvement in hand function stages of the disease.
was much slower. As soon as Etta exercised too strongly Sensory impairment: Spontaneous pain and hy-
with her hand or used it for household tasks, the edema peralgesia in the hand or foot, which is not restricted to
developed again and the pain became stronger. After ap- the supply area of a single peripheral nerve, are main
proximately 3 months, with physical and occupational characteristics of the clinical pattern of CRPS. Th e pain
therapy, Etta was able to achieve an improvement in is described as burning and is felt in the deep tissues;
hand function and a reduction in pain. It took 6 more additionally, sudden pain attacks, described like electri-
months before she was able to return to her offi ce and op- cal shocks, are often present. A periarticular pressure
erate her computer with her left hand. pain of the fi nger joints is almost always present. As a
rule, strong hypersensitivity to mild painful stimuli (hy-
Was this a typical course of CRPS? peralgesia) or pain following usually nonpainful stimuli

Th is case exemplifi es a typical course of CRPS with re- (allodynia) can be observed.
spect to sex, age, injury, and symptoms. However, espe- Motor impairment: In 90% of all cases, the vol-
cially in the early stages of the disease, it is often diffi - untary motor function of all distal muscles is impaired.
cult to diff erentiate between the symptoms of CRPS and Complex movements, such as fi st closure or fi nger-
the normal or slightly delayed fracture healing. Th e di- thumb opposition, are restricted. Th ese movements are
agnosis of CRPS is possible only after the development only possible under visual control. Approximately 50%
of typical symptoms, such as an impairment of sensory, of patients with involvement of the upper limb develop
vasomotor, motor, and sudomotor function. In Etta’s a tremor; dystonia or spasticity is seldom found.
case, attention should be focused on two typical clini- Autonomic impairment: Skin temperature dif-
cal phenomena: fi rst, the negative infl uence of forced ferences of more than 2°C between the aff ected and
physical exercises on the further course of the disease, the unaff ected extremity are often present (the aff ected
and second, the commonly observed involvement of the side is warmer in about 75% of cases), and they corre-
shoulder during the course of the disease. Th e mobility spond to an altered skin blood fl ow. About 60% of pa-
of the elbow joint is mostly unaff ected, whereas abduc- tients have hyperhidrosis, and 20% have hypohidrosis.
tion and rotation of the shoulder joint are often dis- In the early stages, hair and nail growth on the aff ected
abled. Patience and individually adjusted physical activ- extremity is often increased, in the further course of the
ity are essential requirements for patients. disease it is often decreased. Dystrophic symptoms (i.e.,