Complex Regional Pain Syndrome: CRPS Inhalt 1. Historical Review
Complex Regional Pain Syndrome: CRPS
2. Pain terms (Merskey; Pain 1979 /1994) Supplementary Notes: Pain 1982
3. Definition of CRPS (Merskey & Bogduk 1994) Taxonomy / Changing Concept
4. Diagnosis of CRPS (Harden / Bruehl 2005/06) New Empirically Derived Diagnostic Criteria „Four criterion factor“ Praxis für Handchirurgie, 8006 Zürich
Dr. med. Peter C. Butz
Complex Regional Pain Syndrome: CRPS 1. Historical Review 1872 Mitchell SW:
Injuries of nerves and their consequences „Causalgia“
1900 Sudeck P:
Über die acute entzündliche Knochenatrophie.
1942 Sudeck P:
Die sogennannte akute Knochenatrophie als Entzündungsvorgang.
1943 Livingstone WK: Pain mechanisms: a physiological interpretation of causalgia and its related states (increased sympathetic activity) 1944 Doupe J:
Posttraumatic pain and the causalgia syndrome.
1946 Evans JA:
Reflex Sympathetic Dystrophy (RSD)
1976 Sunderland S:
Pain mechanism in causalgia
1987 Procacci / Maresca: Neurodystrophy 1994 Merskey
and Reflex Dystrophy
IASP (J of Pain): Classification of chronic Pain (Taxonomy & Definition)
1995/96 Stanton Hicks and Jänig et al: RSD: Changing Concepts and Taxonomy „CRPS“ based on consensus workshops (Orlando 1993) 2005 Harden and Bruehl: (Consensus of Budapest 2004) Diagnostic Criteria: The Statistical Derivation of „the Four Criterion Factors“
Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
Complex Regional Pain Syndrome: CRPS PAIN ALLODYNIA
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage Pain due to a non-noxious stimulus
ANALGESIA
Absence of pain on noxious stimulation
ANAESTHESIA DOLOROSA
Pain in an area or region which is anaesthetic
CAUSALGIA
A syndrome of sustained burning pain after a traumatic nerve lesion combined with vasomotor and sudomotor dysfunction and Iater trophic changes
CENTRAL PAIN
Pain associated with a lesion of the central nervous system
DYSAESTHESIA
An unpleasant abnormal sensation, weather spontaneous or evoked
HYPERALGESIA
Increased sensitivity to noxious stimulation
HYPERAESTHESIA
Increased sensitivity to stimulation, excluding special senses
PARAESTHESIA HYPERPATHIA
An abnormal-sensation, whether spontaneous or evoked A painful syndrome, characterized by delay, over-reaction and after-sensation to a stimulus, especially a repetitive stimulus Diminished sensitivity to noxious stimulation Decreased sensitivity to stimulation, excluding special senses Pain in the distribution of a nerve or nerves Inflammation of a nerve or nerves A disturbance of function or pathological change in a nerve; in one nerve, monoreuropathy; in several nerves, mononeuropathy multiplex ; symmetrical and bilateral, polyneuropathy. A receptor preferentially sensitive to a noxious or potentially noxious stimulus A noxious stimulus is a tissue damaging stimulus
HYPOALGESIA HYPOAESTHESIA NEURALGIA NEURITIS NEUROPATHY NOCICEPTOR NOXIOUS Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
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Complex Regional Pain Syndrome: CRPS 2. Pain terms (Merskey; Pain 1979 /1994)
Complex Regional Pain Syndrome: CRPS PAIN THRESHOLD
Supplementary Notes Pain 1982
The least stimulus intensity at which a subject perceives pain
Note: The above has been the common usage for most pain research workers. In psychophysics, thresholds are
PAIN
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
defined as the level at which 50% of stimuli are recognized. In that case, the pain threshold would be the level at which 50% of stimuli would be recognized as painful: Pain here serves as a measure of the stimulus. The stimulus is not pain (q.v.)'and cannot be a measure of pain.
PAIN TOLERANCE LEVEL The greatest stimulus intensity causing pain that a subject is prepared to tolerate.
Note: Pain is always subjective. •Each individual learns the application of the word through experiences related to injury in early Iife. Biologists recognize that those stimuIi which cause pain are liable to damage tissue. Accordingly, pain is that experience which we associate with actual or potential tissue damage. It is unqueationably a sensation in a part or parts of the body but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain., e.g., pricking, but are not unpleasant, should not be called pain. Unpleasant abnormal experiences (dysaesthesiae) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain. Many people report pain in the absence of tissue damage or any Iikely pathophysiological cause; usually this happens for psychological reasons. There is no way to distinguish their experience from that due to tissue damage if we take the subjective report. If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain. This definition avoids tying pain to the stimulus. Activity induced in the nociceptor and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause. Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
1
Folie 5 pcb1
Diese Definition vermeidet bewusst eine Anbindung des begriffes Schmerz an den Begriff Stimulus (Reiz) peterbutz; 13.07.2010
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Complex Regional Pain Syndrome: CRPS
Complex Regional Pain Syndrome: CRPS
2. Pain terms (Merskey; Pain 1979 /1994)
Touch-Test Sensory EvaluatorsTM (Semmes-Weinstein Monofilaments)
Supplementary Notes Pain 1982
ALLODYNIA
Pain due to a non-noxious stimulus to normal skin
Note: (1979/1982) This is a new term which is intended to refer to the situa-tion where otherwise normal tissues which may have abnormal innervation or may be referral sites for other loci give rise to pain on stimulation by non-noxious means. „Allo“ means "other" in Greek and is a common prefix for medical conditions which diverge from the expected. "Odynia" is derived from the Greek word "odune" or "odyne", which is used in "pleurodynia" and in "coccydynia", and is similar in meaning to the root from which we derive words with -algia or -algesia in them. AlIodynia is suggested following discussions with Professor Paul Potter of the Department of the History of Medicine and Science at The University of Western Ontario.
Note: (1994) In the previous definition the words `to normal skin' completed the definition and have now been omitted. This is to remove any suggestion that allodynia applies only to referred pain. In regard to the purpose and function of the term please see the previous note.
Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
pcb5
Complex Regional Pain Syndrome: CRPS
Complex Regional Pain Syndrome: CRPS ALLODYNIA
normal Hand
Pain due to a non-noxious stimulus size 5.07 ≅ 10grams pcb7
ALLODYNIA →threshold for detection of touch →threshold for detection of pain
- localisation good - threshold normal - delay none - local pain 4-5mm - radiating none - duration 1-2sec. - after-sensation none
HYPERPATHIA Note: (1979/1982) This is a new term which is intended to refer to the situation where otherwise normal tissues which may have abnormal innervation or may be referral sites for other loci give rise to pain on stimulation by non-noxious means. „Allo“ means "other" in Greek and is a common prefix for medical conditions which diverge from the expected. "Odynia" is derived from the Greek word "odune" or "odyne", which is used in "pleurodynia" and in "coccydynia", and is similar in meaning to the root from which we derive words with -algia or -algesia in them. AlIodynia is suggested following discussions with Professor Paul Potter of the Department of the History of Medicine and Science at The University of Western Ontario. Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
increased response
lowered threshold
Note: (1982)This represents a lowered threshold to noxious stimulation or an increased response to suprathreshold stimulation. lt should not be used to refer to a response to nonnoxious stimulation. (The only change here is that it is now agreed that hyperalgesia covers two conditions, namely, increased response as well as lowered threshold to noxious stimulation. Previously, only the latter was included in the definition.) Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
A painful syndrome, characterized by delay, overreaction and after-sensation to a stimulus, especially a repetitive stimulus
delay, radiating sensation and after-sensation may be present, and the pain is often explosive in character.
Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
Complex Regional Pain Syndrome: CRPS 3. Definition of CRPS (Merskey & Bogduk 1994)
Increased sensitivity to noxious stimulation e.g. stimulation with pin → increased response to pain → lowered threshold → HYPERALGESIA
- localisation ?? -explosive in character - pain threshold low -hypo-/hyper- /dysaesthesia - radiating 10cm - duration 30-60 sec. - after-sensation 60-120s
Note: It may occur with hypo- or hyperaesthesia, or dysaesthesia. Faulty identification and localization of the stimulus,
Complex Regional Pain Syndrome: CRPS HYPERALGESIA
Hand with allodynia
Taxonomy / Changing Concept
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1. The presence of an initiating noxious event, or a cause of immobilization.
pcb10
2. Continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event.
p2
3. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain.
pcb12
4. This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction.
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Type I: without evidence of major nerve damage. Type II: with evidence of major nerve damage.
Source: Modified from Merskey and Bogduk (1994). Dr. med. Peter C. Butz
Praxis für Handchirurgie, 8006 Zürich
2
Folie 7 pcb3
peterbutz 13.07.2010 Änderung-- damit keine Zweifel mehr bestehen, dass der Begriff Allodynie nur Anwendung findet in Bezug zum Begriff Schmerz. peterbutz; 13.07.2010
Folie 9 pcb5
Mit einem solchen Aesthesiometer ermitteln Sie nicht nur die Schmerzschwelle sondern auch den Schwellenwert für die Oberflächenwahrnehmung; die Wahrnehmungsschwelle (threshold )
- Ermittlung der - Schwellenwerte für Schmerz (pain) _ Schmwwellenwerte für Berührung (touch) -- mapping. peterbutz; 16.07.2010
pcb7
quantitatie Ermittlung der Schmerz-Schwelle bei der Allodynie: v.a. vorgehen bei Gutachten. Claude Spicher aus Freiburg hat diesbezüglich eine in 7 Stufen aufgegliederte sogen. "Regenbogenskala" kreiert um die Allodynie in 7 Schweregrade einzuteilen. peterbutz; 14.07.2010
Folie 12 pcb9
Faktor 1: Nachweis eines schädigenden initialen Ereignisses oder Grund für eine Ruhigstellung peterbutz; 14.07.2010
pcb10
Faktor 2: ein anhaltender Schmerz, eine Allodynie oder eine Hyperalgesie bei welchen der Schmerz unverhältnismässig zu jeglichem Ereignis ist. peterbutz; 14.07.2010
pcb12
Fakor4: diese Diagnose ist auszuschliessen bei Vorhandensein von Bedingungen, welche auf andere Weise die vorhandenen Schmerzen und Störungen erklären könnten. peterbutz; 14.07.2010
pcb13
Typ I und II: Es werden 2 Typen unterschieden. Mit und ohne Verletzung eines peripheren Nervs. Über die Grösse oder Lokalisation eines solchen Nerven ist nicht ausgesagt. peterbutz; 14.07.2010
p2
Faktor3: Zu irgend einem Zeitpunkt Nachweis von Oedem, Veränderungen in der Hautdurchblutung oder abnormale Schweissbildung in der Region des Schmerzes. pcb-Tessin; 23.08.2010
pcb39
4. Diagnosis of CRPS (Harden / Bruehl 2005) 4 criterion factor
Sensory: Reports of hyperesthesia and/or allodynia. Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry. pcb15 Sudomotor/Edema: Reports of edema and/or sweating changes and/or sweating asymmetry. Motor/Trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor,dystonia) and/or trophic changes (hair, nails, skin).
Color changes Color asymetry
Temperature
3. Must display at least one sign at time of evaluation in two or more of the following categories:
Edema
Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement).
Vasomotor: Evidence of temperature asymmetry and/or skin color changes and/or skin color asymmetry. Sudomotor/Edema: Evidence of edema and/or sweating changes and/or sweating asymmetry. Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nails, skin)
Sweating
• • • • • • • • • • • Sudeck ? ? • • • • • • • • •
1. Continuing pain, which is disproportionate to any inciting event.
Continuing / intermittent pain
• • • • • • • • • • • Sudeck ? • • • • • • • • •
• • • • • • • • postop. reaction ? • • • • • •
Initial pain
2. Must report at least one symptom in three of the four following categories:
Sensory:
Complex Regional Pain Syndrome: CRPS
VAS 10
Praxis für Handchirurgie, 8006 Zürich
month
3
6
Source: Rommel O. (2001)
Edema / Sweating
p1
Complex Regional Pain Syndrome: CRPS
pcb29
65/32%
Range of motion / Dysfunction 9
12
15
18
21
24
Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
Complex Regional Pain Syndrome: CRPS
Factor I: Pain continuing, intermittent, spontaneous, evoked
Factor II: category: sensory
9
spontaneous pain wave 8
Sensory: allodynia
Motor: 0
Dr. med. Peter C. Butz
Sensory: hypohypo-/hyperaesthesia
Color/Temperature
4. There is no other diagnosis that better explains the signs and symptoms.
pcb14 Source: Harden and Bruehl IASP press 2005
• • • • • • • • • • •Causalgia ? • • • • • • • • •
Complex Regional Pain Syndrome: CRPS
Somatosensory abnormalities are the defining feature of the CRPS: 93%**
evoked pain wave
7 6
Distribution of sensory disturbances:**
5
Amplification of pain CRPS I / CRPSII 94%* / 96% / Hyperalgesia: by lowering/striking/physical effort/night/upset/warm/cold
4 3 2 1
Location of pain: CRPS I deep in the limb 63% Superficial 30% None 7%
0 00Day time 0300
0600
Dr. med. Peter C. Butz, 8006 Zürich
→glove/stocking-like → palms / soles → dorsum of hand/foot → cuff-like
/ CRPSII / 65% / 30% / 5%
0900
1200
56%* 1500
1800
2100
Praxis für handchirurgische Gutachten & Expertisen
24
7%
30%
**Source: Rommel O. (1999/2001) Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
CMC-I: Resektions-Interpositions-Arthroplastik unter Verwendung von Rippenknorpel
CMC-I: Resektions-Interpositions-Arthroplastik unter Verwendung von Rippenknorpel
Das CRPS ist keine psychiatrische Diagnose
Das CRPS ist keine psychiatrische Diagnose
Danke für Ihre Aufmerksamkeit
Dr. med. Peter C. Butz
Praxis für Handchirurgie, 8006 Zürich
Dr. med. Peter C. Butz
Praxis für Handchirurgie, 8006 Zürich
3
Folie 13 pcb4
aus früherer Definition verschmelzen noxious event und continuous pain zu Faktor 1. Hauptthema ist der Schmerz als Dauerschmerz (VAS-Skala) Faktor 2 + 3 wird eingeteilt in 4 identische Kategorien Faktor 2 betrifft nur die Anamnese Faktor 3 betrifft ausschliesslich den aktuellen Untersuchungsbefund. Faktor4 betrifft die Ausschlussklausel. darunter fallen beispielsweise alle psychiatrischen Diagnosen. peterbutz; 14.07.2010
pcb14
diese klinische Definition nach IASP kennt keine Stadieneinteilung wie sie bei der RSD bekannt waren sondern unterscheidet generell nur 2 Typen: Typ I für RSD und Typ II für Causalgie. peterbutz; 14.07.2010
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Neu hinzugekommen sind die motorischen Störungen gruppiert mit den trophischen Störungen als statistisches Cluster, damit wurde die diagnostische Treffsicherheit erhöht. peterbutz; 14.07.2010
Folie 14 pcb39
Studien, welche den Langzeitverlauf beim CRPS zu Inhalt haben gibt es leider sehr wenige. peterbutz; 15.07.2010
Folie 15 p1
Studien, welche den Langzeitverlauf beim CRPS zum Inhalt haben gibt es leider sehr wenige. Dies Graphik zeigt den Tagesverlauf. Rommel stellte in seiner Studie 2001 bei CRPS Patienten bei 85 % einen permanenten Schmerz und bei 15 % einen intermittierenden Schmerz fest. Sie sehen ein Profil eines Durchschnitts-Patientnen. Diese Schmerzcharakteristik entspricht niemals einer Arthrose, einer Arthritis, einer frischen Fraktur oder sonstigen Weichteilverletzung, schon gar nicht nach 6 oder 12 oder 18 Monaten.
pcb-Tessin; 23.08.2010
Folie 16 pcb29
Veränderungen der sensiblen Qualitäten sind ein Kardinalsymptom des CRPS. peterbutz; 15.07.2010
Complex Regional Pain Syndrome: CRPS
pcb46 pcb47
Factor II: category: vasomotor abnormalities
Factor II: category: sensory Somatosensory abnormalities are the defining feature of the CRPS: 96%* Bedside investigations: CRPS-I CRPS-II 1. brush-evoked pain: → allodynia 26.2% 26.1%** 2. distribution of sensory→ glove/stocking-like 36.8% 30.4% disturbances: → palms / soles 30.3% 52.2% → dorsum of hand/foot only 13.9% 8.7% → cuff-like 6.5% 0% 3. pinprick testing: → hypoalgesia 41.8% 60.1% → hyperalgesia 39.3% 21.7% → no side-to-side-diff. 18.9% 13% 4. touch: → hypoalgesia 50% 69.6% → hyperalgesia 18% 18.7% Laboratory investigations: 5. quant.sens. Testing (QST) →threshold for perception of touch/cold/warm *Source: Oaklander and Birklein; IASP Press 2005 Dr. med. Peter C. Butz, 8006 Zürich
Complex Regional Pain Syndrome: CRPS
Praxis für handchirurgische Gutachten & Expertisen
Bedside investigations: Skin colour differences: → vasoconstriction (paler) or → vasodilatatation (redder) → orthostatic effect
65%* 59.8%**
Laboratory investigations: Skin temperature side differences: infrared-thermometry (> 1.4°C) Quantitative thermotesting → threshold for perception of cold (Peltier-Element) → threshold for perception of warm Measurement of skin perfusion: (Laser-Doppler-flowmetry)
32%*
Source: *Rommel O. (2001) ** Oaklander and Birklein IASP Press 2005 Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
pcb49
pcb48
Complex Regional Pain Syndrome: CRPS
Complex Regional Pain Syndrome: CRPS
Factor II: category: sudomotor / edema
Factor II: category: motor / trophic *
Sweating (altered sudomotor function) palms hairy skin spontaneously oder induced by sensory stimuli/ physical activity/psychological stress. Quantitative sudomotor reflex test (QSART)
Edema 43% difficult to quantitate clinically (volumetric/circumference) Rommel (2001): peripheral sympathetic tone altered in Patients with CRPS I: → none oder gentle 60% → moderate 40% → severe 0% Source: *Rommel O. (2001)
„Why have the movement disorders of CRPS been neglected as a relevant part of the syndrome?“ (Hilten/Blumberg/Schwartzmann) Psychogenic origin goes back to the writings of Charcot, who designated the abnormal postures of CRPS as a “hysterical contracture of traumatic origin“ (Charcot 1889) *(Hilten/Blumberg/Schwartzmann IASP Press 2005)
Dr. med. Peter C. Butz, 8006 Zürich
pcb50
.
18%*
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Complex Regional Pain Syndrome: CRPS Factor II: category: motor / trophic
Motor dysfunctions*: 1. Movement disorders: 2. Weakness 3. Tremor (3-7 Hz frequency) (descritive yes / no)
→ scale 0-5 → scale 0-5 → relaxed position → maintaining a posture → making a movement 4. Dystonia (descriptive yes / no) → triggered by movement, cold 5. Myoclonus/Spasm (descriptive yes / no) 6. Muscle reflex The suggest: Are the movement disorders the interplay of different mechanisms at the peripheral, spinal and supraspinal level ? The consequence: To reestablish the congruence of motor and sensory information the CRPS patients are trained in the use of mirror visual feedback.
pcb51
Praxis für handchirurgische Gutachten & Expertisen
Complex Regional Pain Syndrome: CRPS Factor II: category: motor / trophic
Trophic changes*: 1. Skin: texture, structure → 13% 2. Nail: growth 3. Hair: pigmentation, thikness, length, density,
*Source: Rommel O. 2001
*Source: Hilten et al: IASP Press 2005 / Rommel 2001 Dr. med. Peter C. Butz, 8006 Zürich
Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
4
Folie 19 pcb44
Veränderungen der sensiblen Qualitäten sind ein Kardinalsymptom des CRPS. peterbutz; 15.07.2010
Folie 20 pcb46
Mit einem solchen Aesthesiometer ermitteln Sie nicht nur die Schmerzschwelle sondern auch den Schwellenwert für die Oberflächenwahrnehmung; die Wahrnehmungsschwelle (threshold ) peterbutz; 14.07.2010
pcb47
Vasomotorisch Abnormitäten stellen eine eigene unabhängige Gruppe dar und erhöhen damit die Sensitivität und Spezifität der Diagnostik. Diese quantitativ klinisch zu ermitteln ist aber nicht einfach. peterbutz; 17.07.2010
Folie 21 pcb48
Schwitzen und Odeme korrelieren miteinander und bilden ein statistisches Cluster. eine globale vegetative Beeinträchtigung mittelschweren Grades fand Rommel nur bei 40% der Patienten, bei 60 % keine oder nur eine leichte. Eine schwere liess sich nicht nachweisen, wobei zu erwähnen ist, dass die mittlere Krankheitsdauer der 44 Patienten mit CRPS 20.5 Monate betrug. peterbutz; 17.07.2010
Folie 22 pcb49
Mit einem solchen Aesthesiometer ermitteln Sie nicht nur die Schmerzschwelle sondern auch den Schwellenwert für die Oberflächenwahrnehmung; die Wahrnehmungsschwelle (threshold ) peterbutz; 14.07.2010
Folie 23 pcb50
Die Beurteilung der globalen motorischen Beeinträchtigungen beruht auf folgenden Kriterien entnommen Hilten et al , modifiziert nach Rommel 2001 Zunehmend setzt sich auf Grund klinischer Erkenntnisse und Experimente die Meinung durch, das die motorischen Beeinträchtigungen nicht nur eine simple Folge einer Schutzfunktion und einer willentlichen Abwehr- und Schutzfunktion sind, sondern dass diese Störungen durch bestimmte Mechanismen verursacht werden. Diese sind weiter zu erforschen. Die Autoren Hilten/Blumberg und Schwartzmann vertreten die Meinung, dass überwiegend supraspinale Mechanismen verantwortlich sind für die vielfältigen senso-motorischen Störungen. Funktionelle bild gebende Verahren wie PET (Positron emission tomography) so Galer und Jensen 1999 und SPECT (single photon emission computed tomography) so Fukumoto et al 1999 und Fukui et al 2002 zeigten signifikante Signalveränderungen im kontralateralen Thalamus, im frontalen und motorischen Cortex. peterbutz; 18.07.2010
Folie 24 pcb51
Die Beurteilung der globalen motorischen Beeinträchtigungen beruht auf folgenden Kriterien entnommen Hilten et al , modifiziert nach Rommel 2001 Zunehmend setzt sich auf Grund klinischer Erkenntnisse und Experimente die Meinung durch, das die motorischen Beeinträchtigungen nicht nur eine simple Folge einer Schutzfunktion und einer willentlichen Abwehr- und Schutzfunktion sind, sondern dass diese Störungen durch bestimmte Mechanismen verursacht werden. Diese sind weiter zu erforschen. Die Autoren Hilten/Blumberg und Schwartzmann vertreten die Meinung, dass überwiegend
Folie 24 (Fortsetzung) supraspinale Mechanismen verantwortlich sind für die vielfältigen senso-motorischen Störungen. Funktionelle bild gebende Verahren wie PET (Positron emission tomography) so Galer und Jensen 1999 und SPECT (single photon emission computed tomography) so Fukumoto et al 1999 und Fukui et al 2002 zeigten signifikante Signalveränderungen im kontralateralen Thalamus, im frontalen und motorischen Cortex. peterbutz; 18.07.2010
Complex Regional Pain Syndrome: CRPS
Complex Regional Pain Syndrome: CRPS
Psychological Factors
The need to revise pain diagnosis in ICD-11
Gener. sens. def. n=24
Local sens. def. n=13
Totals N=37
minor oder major depression after the trauma (CRPS)
73%
59%
65%
healthy patients
20%
23%
22% (n=8)
Table 1 Examples of pain diagnoses in ICD-10. • Migraine (G43), other headaches (tension-type headache, cluster headache, vasomotor headache G44) • Trigeminal neuralgia, atypical facial pain (G5) • Phantom pain (G54) • Neuropathic pain (several G-diagnoses and others) • Dental pain (K08) • Back pain (M54) • Fibromyalgia (M79.4) F-diagnoses (psychiatric diagnoses):
Preexistant deficencies
• Persistent somatoform pain disorder (F45.4) • Chronic pain disorder with somatic and psychological factors (F45.41 German Edition) • Enduring personality change due to chronic pain (F62.8)
54% (n=20)
R-diagnoses: symptoms, not otherwise specified (NOS):
• • • • •
*Source: Rommel O. (2001)
*Source: Rommel O. (2001) Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
Dr. med. Peter C. Butz, 8006 Zürich
Complex Regional Pain Syndrome: CRPS ICD-10 (1989) english
german
F45.0
Somatoform disorders
Somatisierungsstörung
F45.4
Persistent somatoform pain disorders
Anhaltende somatoforme Schmerzstörung
F45.8
Other somatoform disorders
Sonstige somatoforme Störungen
F68.0
Symptom magnification syndrome
Symptomausweitung
F43.ff
Adjustment disorders
Anpassungsstörungen
F43.2
with depression
mit depressiver Verstimmung
Praxis für handchirurgische Gutachten & Expertisen
Dr. med. Peter C. Butz, 8006 Zürich
Complex Regional Pain Syndrome: CRPS Increased sensitivity to noxious stimulation 62
Praxis für handchirurgische Gutachten & Expertisen
Complex Regional Pain Syndrome: CRPS
The need to revise pain diagnosis in ICD-11 Codes
HYPERALGESIA
Chest pain, NCCP, precordial chest pain R07 Abdominal pain, pelvic pain R10 Pain while urinating 830.9 Headache NOS R51 Pain, not elsewhere specified R52
The need to revise pain diagnosis in ICD-11 Codes
ICD-10 (1989) english
Symptoms, not otherwise specified R20-R23 (NOS)
german Sensibilitätsstörungen R20 Hypaesthesie der Haut R 20.1 Hyperaesthesie der Haut R 20.3
Other nonorganic psychotic disorders
Sons.Symp. Des NS/Muskel-Skelett-Syst.
Pain, not elsewhere classified
Schmerzen andernorts n. klassifiziert, keiner best. Region zugeord.
R52.0
Acut pain
Akuter Schmerz
R52.1
Chronic intractable pain
Chron. Nicht beeinflussb. Sz
R52.2
Other chronic pain
Sonstiger chron. Sz
R52.9
Pain, unspecified / gen. Pain NOS
Sz nicht näher bezeichnet
R29 R52
G50-G59 Nerve, nerve root and plexus disorders
Krankh. v. Nerven u. Nervenplexus
G56.4
Kausalgie
Causalgia
Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
Complex Regional Pain Syndrome: CRPS ALLODYNIA Pain due to a non-noxious stimulus
A.L. OAKLANDER AND F. BIRKLEIN
Table I Incidence of pain, hyperalgesia, and sensory symptoms in CRPS CRPS-I CRPS-II (n = 122 Patients) (n = 23 Patients) Symptoms Spontaneous Pain Hyperalgesia, Amplification of Pain
by lowering striking physical effort night upset temperature: cold temperature: warm Quality of Pain
tearing burning stinging squeezing pulsating could not describe none
Location of Pain
deep in the limb superficial none
Duration of Pain
permanent/most the time lancinating on movement only
Dysesthetic Pain Allodynia (Brush-Evoked Pain) Distribution of Sensory Disturbances
91 114 73 74 53 53 20 39 26
74.6 93.4 59.8 60.7 43.4 43.4 16.4 32.0 21.3
21 22 13 12 14 13 6 14 3
91.3 95.7 56.5 52.2 60.9 56.5 26.1 60.9* 13.0
31 20 21 14 12 16 8
25.4 16.4 17.2 11.5 9.8 13.1 6.6
7 6 5 2 1 1 1
30.4 26.1 21.7 8.7 4.3 4.3 4.3
77 37 8
63.1 30.3 6.6
15 7 1
65.2 30.4 4.3
72 33 9 34 32
59.0 27.0 7.4 27.9 26.2
18 4 0 12 6
78.3 17.4 0 52.2* 26.1 30.4 52.2 8.7 0 8.7
45 37 17 8 15
36.8 30.3 13.9 6.5 12.3
7 12 2 0 2
hypoalgesia
51
41.8
14
60.1
hyperalgesia no side-to-side difference
48 23
39.3 18.9
glove/stocking-like palms/soles only dorsum of hand/foot only cuff-like none Pinprick Testing
Touch
hypoesthesia hyperesthesia no side-to-side difference
5 3
21.7 13
61
50
16
69.6
22 39
18 32
2 5
8.7 21.7
Source: Modified from Birklein et al. (2000a), with permission. Note: Descriptors
of pain and hyperalgesia indicated by 145 CRPS patients. Incidence of each pain descriptor is given separately for CRPS-I and CRPS-II (significant differences: *P < 0.05). Further, sensory symptoms on the affected limb as established by neurological bedside examination are listed.
Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
e.g. lifting of the skin: → Pain → ALLODYNIA
pcb40
Note: (1979/1982) This is a new term which is intended to refer to the situation where otherwise normal tissues which may have abnormal innervation or may be referral sites for other loci give rise to pain on stimulation by non-noxious means. „Allo“ means "other" in Greek and is a common prefix for medical conditions which diverge from the expected. "Odynia" is derived from the Greek word "odune" or "odyne", which is used in "pleurodynia" and in "coccydynia", and is similar in meaning to the root from which we derive words with -algia or -algesia in them. AlIodynia is suggested following discussions with Professor Paul Potter of the Department of the History of Medicine and Science at The University of Western Ontario. Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
5
Folie 25 pcb52 Rommel fand bei 65 % aller Patienten nach Durchführung eines strukturierten klinischen Interviews nach DSM IV (SKID) Kriterien einer psychischen Erkrankung, welche sich erst nach dem Trauma entwickelten und in Zusammenhang stehen mit dem CRPS. Dabei war die minor oder major Depression die häufigste Störung. peterbutz; 18.07.2010
Folie 26 pcb53 Rommel fand bei 65 % aller Patienten nach Durchführung eines strukturierten klinischen Interviews nach DSM IV (SKID) Kriterien einer psychischen Erkrankung, welche sich erst nach dem Trauma entwickelten und in Zusammenhang stehen mit dem CRPS. Dabei war die minor oder major Depression die häufigste Störung. peterbutz; 18.07.2010
Folie 27 pcb54 Rommel fand bei 65 % aller Patienten nach Durchführung eines strukturierten klinischen Interviews nach DSM IV (SKID) Kriterien einer psychischen Erkrankung, welche sich erst nach dem Trauma entwickelten und in Zusammenhang stehen mit dem CRPS. Dabei war die minor oder major Depression die häufigste Störung. peterbutz; 18.07.2010
Folie 28 pcb55 Rommel fand bei 65 % aller Patienten nach Durchführung eines strukturierten klinischen Interviews nach DSM IV (SKID) Kriterien einer psychischen Erkrankung, welche sich erst nach dem Trauma entwickelten und in Zusammenhang stehen mit dem CRPS. Dabei war die minor oder major Depression die häufigste Störung. peterbutz; 18.07.2010
Folie 30 pcb40 schon einfaches Anheben der Haut löst einen inadäquaten Schmerz aus. Der Schmerz kann zudem ausstrahlen dauert übherdurchschnittlich lang an und klingt nur langsam ab (nacheffekt) peterbutz; 14.07.2010
Complex Regional Pain Syndrome: CRPS ALLODYNIA
Pain due to a non-noxious stimulus
Complex Regional Pain Syndrome: CRPS HYPERALGESIA
Increased sensitivity to noxious stimulation
e.g.: simple pressure: → Pain:burning/tearing/stinging. → radiating/lancinating → duration of time → after sensation → no relation to structures → deep in the limb/superficial → ALLODYNIA
e.g. stimulation with pin → increased response to pain → lowered threshold → HYPERALGESIA
increased response Note: (1979/1982) This is a new term which is intended to refer to the situation where otherwise normal tissues which may have abnormal innervation or may be referral sites for other loci give rise to pain on stimulation by non-noxious means. „Allo“ means "other" in Greek and is a common prefix for medical conditions which diverge from the expected. "Odynia" is derived from the Greek word "odune" or "odyne", which is used in "pleurodynia" and in "coccydynia", and is similar in meaning to the root from which we derive words with -algia or -algesia in them. AlIodynia is suggested following discussions with Professor Paul Potter of the Department of the History of Medicine and Science at The University of Western Ontario. Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
lowered threshold
Note: (1982)This represents a lowered threshold to noxious stimulation or an increased response to suprathreshold stimulation. lt should not be used to refer to a response to nonnoxious stimulation. (The only change here is that it is now agreed that hyperalgesia covers two conditions, namely, increased response as well as lowered threshold to noxious stimulation. Previously, only the latter was included in the definition.) Dr. med. Peter C. Butz, 8006 Zürich
Praxis für handchirurgische Gutachten & Expertisen
6