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

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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

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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.

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Dr. med. Peter C. Butz, 8006 Zürich

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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

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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.

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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.

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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

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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

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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

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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

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24

7%

30%

**Source: Rommel O. (1999/2001) Dr. med. Peter C. Butz, 8006 Zürich

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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

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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

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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

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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

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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

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Dr. med. Peter C. Butz, 8006 Zürich

Complex Regional Pain Syndrome: CRPS Increased sensitivity to noxious stimulation 62

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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

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