COMPLEX REGIONAL PAIN SYNDROME

Definition Complex regional pain syndrome (CRPS) refers to a chronic condition affecting the nerves and blood vessels of one or more extremities. It is distinguished by extremely unpleasant burning sensations, swelling, sweating, color changes, and other distressing symptoms. There are two types of CRPS:

CRPS 1 (also called reflex sympathetic dystrophy or RSD) No nerve damage exists with this type.

CRPS 2 (also called causalgia)This produces similar symptoms after a nerve injury has occurred.

Causes The cause of CRPS is not known. The condition likely results from several factors. It may involve over activity of the sympathetic nervous system, which directs automatic body functions that a person cannot control. Inflammation also may play a role in the disorder. Risk Factors Minor or severe trauma increases the risk of CRPS, such as:

Trauma Fractures Lacerations Burns Frostbite Surgery Penetrating injury

Crush injury An injection into the muscle Blood draws Diabetic neuropathy Multiple sclerosis Stroke Carpal tunnel syndrome

Symptoms The upper extremities, particularly the hands, are most commonly affected. Symptoms progress and may vary during the course of the condition. Pain may spread from one side of the body to another. Many doctors describe symptoms in terms of stages. Within Hours or Days After Injury Symptoms may include:

Deep aching or burning pain, typically more severe than expected from the injury

Sensitivity to touch or even a light breeze Swelling in the arm or leg Unusual sweating Excessively warm or cool skin Hair and nails changes Symptoms may increase with stress and worsen over time.

3-6 Months After Injury Symptoms may include :

Burning pain moves to above and below the initial injury Swelling in the arm or leg hardens Muscle spasms or weakness develop Extremity becomes cold Hair growth slows Nails become brittle or crack

Six Months or Later After Injury Symptoms may include :

A pale, blue, and/or shiny appearance to the skin Limited joint movement Muscle loss

Diagnosis The doctor will ask about symptoms and medical history and perform a physical exam. To diagnose CRPS, the doctor uses four criteria:

An initial traumatic or painful event to a limb, or immobilization of the limb for a period of time

Continuing pain in the limb that is out of proportion to any stimulus (eg, pain with even light touch)

History of swelling, changes in skin blood flow, or temperature only in the affected limb

No other cause for the symptoms

Tests may be ordered to rule out other conditions. Your doctor may refer you to a pain specialist for further evaluation and management. Tests may include the following:

X-ray a test that uses radiation to take a picture of structures inside the body, especially bones Bone scan a special imaging test to check for early changes in bones

Thermogramto measure heat radiating from the body, which may be diminished in CRPS extremity

Quantitative sudomotor axon reflex test (QSART)a test that measures problems with the autonomic nervous system, like sweating Nerve conduction studies test that measures the speed and degree of electrical activity in a nerve to determine if it is functioning normally Electromyography measures and records the electrical activity that muscles generate at rest and in response to muscle contraction

Treatment Treatment aims to relieve pain and improve function. Visit the doctor as soon as possible. Early therapy may lead to better outcomes. In some cases, the condition goes away on its own; this is more common in children. Treatment options include:

Biofeedback Acupuncture Physical therapyActive and passive exercises help maintain function. Exercising in a warm pool may feel better than exercising on land.

Mirror box therapyWith this therapy, you place your affected hand or foot in a box, which has a mirror on one side. While moving your limb inside of the box, you move your unaffected limb in front of the mirror. To your brain, it appears that you are moving your painful limb easily and without discomfort. Mirror therapy may help to reduce pain and improve motor function in people who have CRPS due to stroke.

Nerve stimulation devices, such as:

Transcutaneous nerve stimulation (TENS)A device worn on the skin surface creates a tingling sensation and may relieve pain in some cases.

Implantable spinal cord stimulationmay be helpful for some patients

Medicines, such as:

Anti-anxiety medicines, low-dose antidepressants, and drugs used to treat epilepsy

Pain medicines (eg, narcotics)

Bisphosphonates (drugs used to treat osteoporosis ) Steroids Topical (applied to the skin) medicines (eg, Capsaicin,

dimethylsulfoxide)

Sympathetic nerve blockThe injection of drugs that prevent the transmission of signals along sympathetic nerves may temporarily relieve pain in some cases.

SympathectomyIf the nerve block is successful, a surgeon can permanently destroy sympathetic nerves. In some cases, surgery can worsen symptoms.

Psychological

support

Long-term

pain

often

leads

to depression or anxiety . Counseling is often required to help patients deal with chronic pain and loss of function. Prevention Quick mobilization after surgery or injury can help minimize the risk of CRPS in the affected extremity. Other steps that might be helpful include:

Early use of pain relievers after trauma Use of sympathetic nerve block after trauma Desensitization techniques (if needed) Use of vitamin C In a study, this was shown to reduce the risk of CRPS after a wrist fracture.

NEW RESEARCHES ABOUT:

Chronic Care on Patients with Complex Regional Pain Syndrome Nursing Considerations 1. Skin care Skin characteristics alternate between warm, swollen and red to cool, clammy and bluish. Elevation of the affected extremity offers some pain relief. White patchy areas may develop. Temperature changes, especially cold, may trigger additional changes in the skin. The nurse should assist in providing gentle skin care with minimal stimulation, although one source suggested towel rubs to the affected area. Keep diaphoretic skin dry. An emollient may help dry, scaly skin. Avoid trauma to affected areas, i.e., give injections or start IVs in the unaffected arm. 2. Sleep deprivation Often accompanies and potentiates pain. Severe pain may allow only a few hours of sleep each night. Encouraging the patient to avoid nicotine, caffeine and alcohol may be helpful. Physical activities and exercises should be performed early in the day. Encourage the patient to avoid naps, which initially may be difficult due to the severe fatigue of unremitting pain. The goal is the naps will decrease and nightly sleep increase as interventions bring about pain relief.

3. Adjustments in ADL/mobility Depending on the degree of motor impairment a3nd the extremity involved, the atient will need to adapt ADL. Shopping, cleaning and meal preparation may need to be delegated to other family members. Adaptive clothing with Velcro, long-handled shoehorns, elastic or Velcro shoelaces, reachers/grabbers, long-handled sponges, shower chairs, grab bars, raised toilet seats, blanket support frames (bed cradles) for allodynia or wheelchairs may be needed as the disorder progresses.

4. Osteoporosis prevention This is an important part of patient education. Calcium intake of 1-1.5 g daily is recommended. Biophosphonates such as alendronate (Fosamax), etidronate (Didronel), zoledronate (Zometa) and pamidronate (Aredia) may be

prescribed. If there is lower-extremity involvement present, walking may be restricted; however, light resistance training, such as swimming or upper body cycling, may be used.

5. Long-term care This option must be considered. Pain may lead to a sedentary lifestyle, placing the patient at risk for obesity, osteoporosis, diabetes, atherosclerotic disease and cancers. Healthy, prudent lifestyle management such as smoking cessation, weight control, diet and exercise should be encouraged.

6. Grief and loss CRPS-1 is a chronic, lifelong disorder where symptoms may be controlled but not cured. Ninety-seven percent of patients reported pain interfered with general activity, enjoyment of life, mood, work, and ability to concentrate, eat or sleep. Ninety-three percent felt pain interfered with their relationships with others. Over half of individuals were unable to work. Expect these patients to experience the grieving process in multiple phases and varying degrees over time. Miller describes four stages of dealing with chronic pain. 9 In stage I, the patient seeks a cure and hopes the pain will go away. In stage II, the patient wonders if inappropriate or harmful treatment was received. During stage III, the patient realizes the pain is permanent, and anger, resentment and depression are triggered. The patient will need to go through the grief process. Stage IV finds the patient accepting the pain is permanent and considers lifestyle changes.

Depending on the patient's occupation, adjustments or career changes may need to be made. In one case, a client worked in construction and was unable to make plans to return due to severe lower-extremity muscle weakness and pain. Denial, anger and frustration are not uncommon with this and other chronic illnesses.

Patients may fear pain cannot be managed. They may be frustrated and discouraged by the lack of answers as to what is wrong with them or by lengthy diagnostic workups. Patients may feel abandoned by healthcare providers and left to deal with the increasing pain and spreading sequelae on their own. To develop a context for care and understanding of the condition, the nurse should ask the patient to describe their pain

in detail as well as past procedures and treatments. Some patients may express a fear of addiction and prefer to avoid narcotics due to side effects, but are lost as to how to manage the pain without them. Pain management specialists or clinics are helpful during this time.

Some patients may believe they need to be "good" patients, friends or spouses. This results in avoiding discussions about pain and/or feelings of grief and loss. Frustration of holding in feelings, the lack of sleep and insensitive comments may build up even as the pain intensifies.9 Patients may also crave intimacy, but fear something as simple as a hug can turn into a painful encounter. Reassure patients their anxiety, frustration and anger are expected. Encourage them to discuss their concerns with people who are respectful of their feelings or professionals and to use all available resources, including support groups.

7. Financial concerns Medications, equipment, home modifications, surgeries and loss of income with loss of insurance coverage may impact the patient and family. 8. Avoiding Isolation Living with a chronic, painful condition can be challenging, not only for patients, but for their families and friends. Pain, loss of sleep and fatigue may become debilitating. The nurse can encourage patients to take care of their physical, emotional and spiritual health by maintaining ADLs, hobbies and interests, and work as close to normal as possible, getting sufficient rest and pacing themselves.

Lastly, the nurse's compassion and understanding of the patient's experience can provide hope and renewal.

Graded Motor Imagery

The Graded Motor Imagery (GMI) programme is an evidence based therapeutic approach that falls under the brain training umbrella. This is because the treatment targets changes that have occurred in the brain. We know about these changes from a number of brain scanning studies in recent years. The actual programme has been developed largely through the brilliant work of Lorimer Moseley, so for this we are truly grateful. The programme runs through three sequential stages, laterality (recognising left and right), imagined movements and mirror therapy. In essence this is graded progression, working the brain to desensitise, habituate and develop function. These areas of the brain are part of the pain matrix which means that they have a role in pain production as well as other functions that are non-nociceptive (nothing to do with danger). We know that pain is a brain experience influenced by physical, psychological and social factors, hence the biopsychosocial model. Targeting the brain with clinical treatments is offering a very modern approach to pain and chronic pain in particular. Mirror therapy using a mirror box or standing mirror was initially used for stroke rehabilitation and for phantom limb pain but in fact it can be used for a range of nasty pains and functional problems. The brain sees a normally functioning hand, foot or other body part as the affected area is hidden and the unaffected side is moved. Observing the reelection of the unaffected side, the brain thinks that the affected side is working well and looking normal. As the brain uses visual information over and above information from the tissues, it will prioritise what it sees compared to what it feels. At Specialist Pain Physio we use this programme in its entirety but also the different components. We also integrate the techniques with others to optimise the learning process and changes in the nervous system that lead to pain relief and improved ability. Rehabilitation is learning and the underlying process is similar to learning a language or a musical instrument. It takes time, practice, motivation and perseverance. Give the brain and the nervous system the opportunity and it can change for the better. We commonly use GMI for complex regional pain syndrome (CRPS), arthritis, tendon pain and injury, sports injuries and repetitive strain injury (RSI). The principles can be applied in a range of other conditions to provide a more complete bodywide rehabilitation programme.

NURSING STANDARD OF PRACTICE PROTOCOL: PAIN MANAGEMENT IN OLDER ADULTS A. General Approach 1. Pain management requires an individualized approach. 2. Older adults with pain require comprehensive, individualized plans that incorporate personal goals, specify treatments, and address strategies to minimize the pain and its consequences on functioning, sleep, mood, and behavior. B. Pain Prevention 1. Develop a written pain treatment plan upon admission to the hospital, or prior to surgery or treatments. Help the patient to set realistic pain treatment goals, and document the goals and plan. 2. Assess pain regularly and frequently to facilitate appropriate treatment. 3. Anticipate and aggressively treat for pain before, during, and after painful diagnostic and/or therapeutic treatments. Administer analgesics 30 minutes prior to activities. 4. Educate patients, families, and other clinicians to use analgesic medications prophylactically prior to and after painful procedures. 5. Educate patients and families about pain medications and their side effects; adverse effects; and issues of addiction, dependence, and tolerance. 6. Educate patients to take medications for pain on a regular basis and to avoid allowing pain to escalate. 7. Educate patients, families, and other clinicians to use nonpharmacological strategies to manage pain, such as relaxation, massage, and heat/cold. C. Treatment Guidelines 1. Pharmacologic a. Administer pain drugs on a regular basis to maintain therapeutic levels. Use PRN (as needed) medications for breakthrough pain. b. Document treatment plan to maintain consistency across shifts and with other care providers. c. Use equianalgesic dosing and the WHO three-step ladder to obtain optimal pain relief with fewer side effects. d. For postoperative pain, choose the least invasive route. Intravenous analgesics are the first choice after major surgery. Avoid intramuscular injections. Transition from parenteral medications to oral analgesics when the patient has oral intake. e. Choose the correct type of analgesic. Use opoids for treating moderateto-severe pain and nonopoids for mild-to-moderate pain. Select the

analgesic based on thorough medical history, comorbidities, other medications, and history of drug reactions. f. Among nonopoid medications, acetaminophen is the preferred drug for treating mild-to-moderate pain. Guidelines recommend not exceeding 4 g per day (maximum 3 g/day in frail elders). The maximum dose should be reduced to 50%-75% in adults with reduced hepatic function or history of alcohol abuse. g. The other major class of nonopoid medications, nonsteroidal antiinflammatory drugs (NSAIDs), should be used with caution in older adults. Monitor for gastrointestinal (GI) bleeding and consider giving with a proton pump inhibitor to reduce gastric irritation. Also monitor for bleeding, nephrotoxicity, and delirium. h. Older adults are at increased risk for adverse drug reactions due to ageand disease-related Monitor changes medication in pharmacokinetics closely to and avoid

pharmacodynamics.

effects

overmedication or undermedication and to detect adverse effects. Assess hepatic and renal functioning. 2. Nonpharmacologic a. Investigate older patients' attitudes and beliefs about, preference for, and experience with nonpharmacological pain-treatment strategies. b. Tailor nonpharmacologic techniques to the individual. c. Cognitive-behavioral strategies focus on changing the person's perception of pain (e.g., relaxation therapy, education, and distraction) and may not be appropriate for cognitively impaired persons. d. Physical pain relief strategies focus on promoting comfort and altering physiologic responses to pain (e.g., heat, cold, TENS units) and are generally safe and effective. 3. Combination approaches that include both pharmacological and

nonpharmacological pain treatments are often the most effective. D. Follow-up Assessment 1. Monitor treatment effects within 1 hour of administration and at least every 4 hours. 2. Evaluate patient for pain relief and side effects of treatment. 3. Document patient's response to treatment effects. 4. Document treatment regimen in patient care plan to facilitate consistent implementation.