Page 264 Guide to Pain Management in Low-Resource Settings

252 Andreas Schwarzer and Christoph Maier

skin and muscle atrophy, connective tissue fi brosis) are What is the diff erential
typical for the later stages of the disease; however, they diagnosis for CRPS?
are not always found.
In the clinical routine, it is most essential to diff erenti-
What are the diagnostic ate between CRPS and a delayed healing of a trauma
or complaints after long-term immobilization. In the
criteria for CRPS?
case of CRPS, not only an increase in pain intensity,
CRPS is a clinical diagnosis. Th ere are no laboratory but also a change in the characteristics of pain usually
parameters that confi rm the presence or absence of the occurs. Diff erential diagnosis is nerve or plexus injury,
disease. Patchy demineralization especially in the peri- especially after an operation to treat nerve entrapment
articular regions appears in the radiography some weeks syndromes (carpal tunnel syndrome). However, in these
or months after the disease begins, but it can be seen in cases, the symptoms are limited to the area supplied
less than 50% of patients with CRPS. CT and MRI ex- by the injured nerve. Autonomic impairment does not
aminations are not specifi c for the diagnosis of CRPS. prove the diagnosis of CRPS. Furthermore, self-injuri-
However, triple-phase bone scintigraphy plays an im- ous behavior is another diff erential diagnosis to CRPS.
portant role for the diagnosis of CRPS during the fi rst
year after trauma. Band-shaped increased radionuclide What are the treatment
accumulation in the metacarpophalangeal and interpha- options for CRPS?
langeal joints of the aff ected extremity during the min-
eralization phase is a very specifi c diagnostic criterion. Th e treatment of CRPS should be based on a multidisci-
Th e current diagnostic criteria are listed below plinary approach. Next to pain treatment, the recovery
according to Harden and Bruehl [3]. Aside from diff er- of limb function should play an important role.
entiation between sensory, vasomotor, sudomotor, and Pharmacological options: Traditional NSAIDs
motor impairment, the physician should discriminate (ibuprofen 3 × 600 mg) or COX-2 inhibitors (celecox-
between anamnestic hints (symptoms) and current clin- ib 2 × 200 mg) can be taken temporarily for treatment
ical signs during the physical examination. of CRPS pain. Additionally, metamizol (4 × 1000 mg)

Table 1
Diagnostic criteria for CRPS (according to Harden and Bruehl [3])
1 Persistent pain, which is disproportionate to any known inciting event
2 Th e patient must report at least one symptom in three of the following categories (anamnestic hints):
2.1 Sensory Reports of hyperesthesia and/or allodynia
2.2 Vasomotor Reports of temperature asymmetry and/or skin color changes and/or skin
color asymmetry
2.3 Sudomotor/edema Reports of edema and/or sweating changes and/or sweating asymmetry
2.4 Motor/trophic Reports of decreased range of motion and/or motor dysfunction (weakness,
tremor, dystonia) and/or trophic changes (hair, nails, skin)
3 Th e patient must display at least one sign in two or more of the following categories during the current
physical examination:
3.1 Sensory Evidence of hyperesthesia and/or allodynia
3.2 Vasomotor Evidence of temperature asymmetry and/or skin color changes and/or skin
color asymmetry
3.3 Sudomotor/edema Evidence of edema and/or sweating changes and/or sweating asymmetry
3.4 Motor/trophic Evidence of decreased range of motion and/or motor dysfunction (weakness,
tremor, dystonia) and/or trophic changes (hair, nails, skin)
4 Th ere is no other diagnosis that would otherwise account for the signs and symptoms and the degree of
pain and dysfunction.