CRPS and the Anaesthetist –
a problem all round!
Dr Meredith Craigie
Anaesthetist & Specialist Pain Medicine Physician
Anaesthesia and Pain Management, Flinders Medical Centre
Pain Management Unit, Royal Adelaide Hospital
South Australia
Conflict of Interest
• Employed at FMC, RAH, Adelaide,
South Australia
• Private practice at Pelvic Pain SA
• Affiliated with Faculty of Pain Medicine,
ANZCA and Australian and New Zealand
College of Anaesthetists
Outline of the problems
• What causes CRPS?
• What are the diagnostic criteria for CRPS
in children?
• Psychological factors in CRPS – cause or
effect?
• How can we manage CRPS in children?
• What is the role of the Anaesthetist?
• Prognosis for children with CRPS?
An Australian story of CRPS
3 months later……
Pathophysiology of CRPS
• Persistent inflammatory activity
• Pathological vasospasm
• fMRI changes – the “CRPS brain”
• Visual distortion and changes in
somatosensory cortex S1
• QST changes
• Small fibre neuropathy
Parkitny et al (2013) Neurology 80:106-117 Moseley, Pearson, Spence (2008) Curr Biol 18:R1048
Pistorius et al (2013) Angiology 59:301-5
Maihofner et al (2003) Neurology 61:1707-15
Lebel et al (2008) Brain 131:1854-79
Sethna et al (2007) Pain 131:153-61
Budapest criteria for CRPS
• Continuing pain disproportionate to the inciting
event
• Symptoms- at least 1 symptom in 4 categories
– Sensory
• hyperaesthesia
– Vasomotor
• temp asymmetry; colour changes and/or skin colour asymmetry
– Sudomotor/oedema
• oedema; sweating changes and/or sweating asymmetry
– Motor/tropic
• decreased ROM; motor dysfunction; hair, nail or skin changes
Harden, Bruehl et al (2010) Pain 150:268-74
Budapest criteria for CRPS
• Signs: evidence of at least 1 sign in 2 or more
categories
– Sensory
• hyperalgesia (pin prick) and/or allodynia (light touch)
– Vasomotor
• temp asymmetry; colour changes and/or skin colour asymmetry
– Sudomotor
• oedema; sweating changes and/or swearing asymmetry
– Motor/tropic
• decreased ROM; motor dysfunction; hair, nail or skin changes
Harden, Bruehl et al (2010) Pain 150:268-74
CRPS presentations
• Epidemiology
– Females : males
5-13:1
– Lower limb : upper limb
– Peak age
5-16:1
12-14 years
• Triggers
– Minor trauma to major surgery
– Immunisation
– None identified
Murray et al (2000) Arch Dis Child 82:231-33
Wolter, Knoller, Rommel (2012) Eur Neurol 68:52-58
Pearson, Bailey (2011) Military Medicine 176:876-8
Richards et al (2012) Arch Dis Child 97:913-5
1 week later…..
• Hospital management
– Bed rest/bed cradle
– Morphine PCA
– No progress after 1 wk
• See PMU consultant
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–
–
–
Get rid of PCA/opioids
See physiotherapist
See psychologist
Return to psychiatrist
Psychological issues
• Somatisation 60%
• Mood disorders 29%
– Anxiety 47%
– Depression 27%
• Peer/school problems 27/13%
– Social isolation
• Cognitive function generally intact
– Impaired memory/working composite memory
Ciccone, Bandilla, Wu (1997) Pain 71:323-33
Cruz, O’Reilly et al (2011) Clin J Pain 27:27-34
Families
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Genetic basis in some families
Family problems 40%
Impact on family members
Economic impact
• 40% CRPS I
• 2/3 not in full-time school
• 68% parents took time off work
• UK: direct and indirect costs ~ £ 8,000/yr
 extrapolates to £ 3,840 million /yr
Shirani et al (2010) Can J Neurol Sci 37:389-94
Pearson, Bailey (2011) Military Medicine 176:876-8
Sleed et al (2005) Pain 119:185-90
Treatment options
• Based on biopsychosocial model
– Multidisciplinary approach
• Physiotherapy
• Psychology
– Individual and family therapy
+/- psychiatry
• Medication
– Blocks
• Other novel treatments
What affects Rx choices for children?
• Beliefs concerning causes of pain
• Knowledge and preferences for pain Rx
• Expectations of outcome of pain Rx
• Reduction in pain required for patient to
resume ‘reasonable activities’
• Typical coping response for stress or pain
• Family expectations & beliefs
Physiotherapy key to recovery
• Goal: functional restoration
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Desensitisation
Hydrotherapy
Land exercises
Mirror box therapy
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•
Lee et al (2002) 141:135-40
Logan et al (2012) Clin J Pain 28:766-74
Wilder (2006) Clin J Pain 22:443-8
Role of the Anaesthetist in CRPS
• Interventionist only?
• Clinical team leader
• Requirements:
– Understand pathophysiological aetiologies
– Understand key management principles
– Understand role of medication in managing CRPS
– Understand evidence for regional blockade and
other invasive techniques
Acute noci
mild
Paracetamol
NSAIDs
Codeine
+++
++
++
Tramadol
Morphine
Amitriptyline
Anticonvulsants
-
Acute noci
Acute
Chronic
severe
neuropathic non-cancer
++
++
+
++
+++
-
Wheeler, Vaux, Tam (2000) Ped Neurol 22:220-1
+
+
+
+
++
++
++
++
++
++
+
Regional blockade
• IV regional blockade
– Guanethidine
– Lignocaine
– Ketorolac
• Catheter techniques
– Major nerve plexus
– Epidural
– Intrathecal
Kaplan, Claudio, Kepes, Gu (1996) 40:1216-22
Suresh, Wheeler, Patel (2003) Anesth Analg 96:694-5
Cepeda, Carr, Lau (2005) Cochrane Database of Systematic Review CD004598
Dadure et al (2005) Anesth 102:387-91
Other invasive treatments
• Intravenous lignocaine infusion
• Spinal cord stimulation
• Novel treatments
– IV pamidronate
– IV Iloprost (prostaglandin analog)
– Intrathecal ziconamide
Wallace et al (2000) Anesthesiol 92:75-83
Petje et al (2005) Clin Ortho & Rel Res433:178-82
Stanton-Hicks, Kapural (2006) J Pain Sympt Manage 32:509-11
Olssen, Meyerson, Linderoth (2008) Eur J Pain 12:53-9 Simm, Briody et al (2010) 46:885-88
Role of psychologist
• Assessment of child
• Based on CBT, ACT
– Challenge thoughts
• Biobehavioural techniques
– Breathing techniques
– Meditation
– Self-hypnosis
• Facilitate physical therapy
Psychiatrist
• Controversial area
– At risk of anxiety or depression
67%
– At risk of anxiety, depression
and somatisation 47%
• Family therapy
• Medication if necessary
Cruz et al (2011) Clin J Pain 27:27-34
Progressing recovery
Child taking charge of own management
– Willingness to self-manage pain
– Active coping strategies
• Support team
• Return to school
Logan et al (2012) 153:1863-70
Prognosis
• Overall outcomes better in children
– Highly variable recovery time
• Morbidity
• Relapse rates high - 50%-79%
– 10% symptoms persist > 1yr
• Future treatment options
– Immunomodulatory agents
Sherry et al (1999) Clin j Pain 15:218-22
Lee et al (2002) J Pediatr 141:135-40
Murray et al (2000) Arch Dis Child 82:231-33
Logan et al (2012) Clin J Pain 28:766-74
Resources
My Pain Toolkit www.paintoolkit.org
“Good practice in postoperative and procedural pain”
-APAGBI
www.apagbi.org.uk/docs/APA_Guidelines_on_Pain
_ Management.pdf
Acute Pain Management: Scientific Evidence 3rd Ed.
ANZCA and FPM www.anzca.edu.au/resources/
Book “Pain Pain Go Away Helping Children with Pain”
download at www.rch.org.au
Summary
• Outlined potential causes CRPS
• Diagnostic criteria for CRPS in children
• Psychological factors in CRPS
• Management options for CRPS in children
• The role of the Anaesthetist
• Relatively good prognosis for children with
CRPS
Thank you
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THE TEAM
Dr Bruce Foster, Orthopaedic surgeon
Dr Penny Briscoe, Pain Medicine
Physician
Ms Helen Burgan, Physiotherapist
Ms Lindy Peterson, Clinical
Psychologist
Dr John Govan, Psychiatrist
Pembroke School
Catherine’s family and friends