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Vas, Lakshmi. "Complex Regional Pain Syndrome-Type 1 Presenting as deQuervain’s Stenosing Tenosynovitis." Pain Physician 1;19, no. 1;1 (January 14, 2016): E227—E234. http://dx.doi.org/10.36076/ppj/2016.19.e227.
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Aim: To report the presentation of complex regional pain syndrome-1 (CRPS-1) as deQuervain’s stenosing tenosynovitis (DQST). Case report: A 24-year-old woman presented with 3-year history of clinical diagnostic criteria (CDC) of CRPS-1. Conservative and surgical treatment for this as DQST had failed to relieve her. We diagnosed the problem as CRPS-1with CDC as inflammatory manifestations of a mechanical tendinoses of all her 5 digital tendons caused by movement of the fingers and hand tethered by agonist (flexor)/ antagonist (extensor) muscles in co-contraction. Ultrasound guided dry needling (USGDN) relaxed the muscles, replacing the abnormal agonist/antagonist co-contraction with normal agonist/antagonist coordination. Resolution of tendinoses reversed the inflammation causing the CDC. Six months later she leads normal personal and professional life, with reduction of scores of painDetect (from 21 to 5), Patient Health Questionnaire (from 13 to 4), Disability of arm, shoulder and hand from 70.8 to 25 and reversal of muscle abnormality characteristic of CRPS1 on Musculoskeletal Ultrasonography (MSKUSG). Conclusion: We believe the primary pathology of CRPS-1 to be co-contraction of agonist (flexor)/antagonist(extensor) muscles of digits resulting in tendinoses akin to DQST. CDC of CRPS are actually inflammatory manifestations of tendinoses amenable to reversal by USGDN which also addresses the disability, a hallmark of CRPS. Key words: Complex regional pain syndrome-1 (CRPS-1), deQuervain’s stenosing tenosynovitis (DQST), neuropathy, co-contraction, dry needling (DN), ultrasound guided dry needling (USGDN), musculoskeletal ultrasonography (MSKUSG)
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Kalita, Jayantee. "Long-term Prednisolone in Post-stroke Complex Regional Pain Syndrome." Pain Physician 8;19, no. 8;11 (November 14, 2016): 565–74. http://dx.doi.org/10.36076/ppj/2016.19.565.
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Background: There is no study on the long-term use of prednisolone in post-stroke complex regional pain syndrome-1 (CRPS1). Objective: To evaluate the efficacy and safety of long-term low dose prednisolone in post-stroke CRPS-I. Study Design: Open-labeled randomized controlled trial. Setting: Tertiary care teaching institute. Methods: Seventy-seven out of 396 (19.4%) patients with stroke had CRPS-1 and 58 met the inclusion criteria. Their clinical details and CRPS, Visual Analogue Scale (VAS), modified Rankin Scale (mRS), and Barthel Index (BI) scores were noted. The patients were prescribed 40 mg prednisolone for 2 weeks followed by tapering in the next 2 weeks. Patients who responded were randomly assigned prednisolone 10 mg daily (group I) or no prednisolone (group II). They were followed up for the first and second month of randomization and their CRPS, VAS, mRS, and BI scores were noted. The primary outcome was improvement in CRPS score and secondary outcomes were VAS, mRS, BI scores, and severe adverse events (SAE). Results: Fifty-six of fifty-eight (96.5%) patients responded to the initial high dose prednisolone and 26 each were assigned group I and group II treatment. Group I patients had further improvement in CRPS score. Fifty percent of patients in group II had deterioration at one month and needed reinstitution of prednisolone; following which 77% of them improved in the next month. The improvement in CRPS score paralleled the VAS score but not mRS and BI scores in the first and second months in group I compared to group II. There was no SAE necessitating withdrawal of prednisolone. Limitation: The design of the study is not double blind. Conclusion: In post-stroke CRPS-I, continuation of low dose prednisolone for 2 months is safe and effective. Key words: Shoulder hand syndrome, CRPS, corticosteroid, prednisolone, stroke, Visual Analogue Scale
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Barth, Robert J., and Tom W. Bohr. "Diagnostic Conceptualization for CRPS-1: Challenges in the IASP's Diagnostic Conceptualization for CRPS-1 (Formerly Conceptualized as RSD)." Guides Newsletter 11, no. 1 (January 1, 2006): 4–8. http://dx.doi.org/10.1001/amaguidesnewsletters.2006.janfeb02.
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Abstract Complex regional pain syndrome-type 1 (CRPS-1) is a problematic diagnosis of a characteristic burning pain that is present without stimulation or movement, occurs beyond the territory of a single peripheral nerve, and is disproportionate to the inciting event. This article highlights some challenging aspects of the diagnostic formulation for CRPS-1 by the International Association for the Study of Pain (IASP) and provides recommendations to address the issues. First, the terminology, CRPS-1, was created specifically to replace the previous term, “reflex sympathetic dystrophy.” Unfortunately, no gold standard diagnostic tests exist for CRPS-1, and the concept itself has a long and continuing history of controversy, not the least factor of which is the lack of reliable diagnostic schemes. Next, IASP's criteria for CRPS-1 do not standardize the diagnostic process and depart from epidemiologic guidelines, particularly regarding continuing pain, allodynia, or hyperalgesia disproportionate to any inciting event. Further, the IASP protocol overlaps diagnostic criteria for somatoform disorders, eg, those in the American Psychiatric Association's diagnostic manual, DSM-IV-TR. Finally, according to the IASP protocol, the majority of CRPS-1 patients present with symptoms that are indistinguishable from those in the DSM-IV-TR guidelines, and the majority of CRPS-1 cases are indistinguishable from the formal definition of malingering.
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Bernateck, M. "Anti-TNF-alpha-Therapie bei anderen Indikationen." Arthritis und Rheuma 29, no. 04 (2009): 223–29. http://dx.doi.org/10.1055/s-0037-1620168.
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ZusammenfassungDas Komplexe Regionale Schmerzsyndrom (CRPS) ist eine häufige Komplikation nach Traumen oder elektiven Eingriffen zumeist an der oberen Extremität mit einer Prävalenz von etwa 30 pro 100 000. Prospektive Studien von Patienten mit distaler Radiusfraktur ermittel-ten eine Inzidenz von mehr als 20 Prozent dieser Komplikation. Aktuell unterscheiden die Diagnose-Kriterien zwischen CRPS ohne (CRPS Typ 1) und CRPS mit Nervenläsion (CRPS Typ 2). Zytokine, wie z. B. Tumor-Nekrose-Faktor alpha (TNF-alpha) scheinen eine wichtige Rolle bei der Mediation von mechanischer Hyperalgesie und der Ödembildung in der akuten Phase des CRPS Typ 1 zu spielen. Die Erkenntnis dieser Zusammenhänge führte zu ersten erfolgreichen Einsätzen von Anti-TNF-alpha-Inhibitoren bei Patienten mit CRPS Typ 1.
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Tuinhout, Mirjam, and Jan Willem. "Multidisciplinaire Richtlijn CRPS-type 1." PodoSophia 23, no. 3 (May 2015): 18–20. http://dx.doi.org/10.1007/s12481-015-0051-z.
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Meier, Budak, and Brunner. "Komplexes regionales Schmerzsyndrom Typ 1 (CRPS 1)." Praxis 100, no. 4 (February 1, 2011): 191–200. http://dx.doi.org/10.1024/1661-8157/a000461.
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Devos, A., F. Claessens, P. Alen, J. Winderickx, W. Heyns, W. Rombauts, and B. Peeters. "Identification of a Functional Androgen-Response Element in the Exon 1-Coding Sequence of the Cystatin-Related Protein Gene crp2." Molecular Endocrinology 11, no. 8 (July 1, 1997): 1033–43. http://dx.doi.org/10.1210/mend.11.8.9961.
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Abstract Two hormone-responsive segments, one in the region of the promoter and one in intron 1, are identified in two homologous androgen-regulated and differentially expressed rat genes encoding the cystatin-related proteins (CRPs). Footprint analysis with the androgen receptor (AR) DNA-binding domain on the promoter-containing fragments reveals an AR-binding site downstream of the transcription start point in the crp2 gene (ARBSd/crp2,+ 40/+63). It displays an androgen response element-like sequence motif 5′-AGAAGAaaaTGTACA-3′ and overlaps with the ATG translation start codon. A double-stranded oligonucleotide containing this sequence forms a DNA-protein complex with the full-length AR synthesized by vaccinia, as seen in band shift assays. Additional AR-binding sites, ARBSu/crp1 and ARBSu/crp2, occur 5′ upstream of the transcription start point and are located at an identical position (−142/−120) in crp1 and crp2. The AR affinity for these two slightly different sequence motifs is relatively weak. The biological function of all three AR-binding sites as transcription control elements has been studied. The ARBSd/crp2 element clearly shows androgen-response element characteristics. The contribution of the common upstream element to the androgen-dependent control of reporter gene transcription is less clear. The transcription of a reporter gene construct containing the crp2 footprint fragment crp2F (−273/+88) is hormonally regulated as determined by transfection into the human breast cancer cell line T-47D. Androgens, but also glucocorticoids, efficiently stimulate steroid-dependent transcription of the chloramphenicol acetyltransferase gene. Mutation of the 5′-TGTACA-3′ sequence in ARBSd/crp2 destroys the AR binding and abolishes the androgen-dependent synthesis of chloramphenicol acetyltransferase. A large fragment derived from intron 1 of the crp1 and crp2 gene can also provide the androgen-dependent transcription of chimeric constructs in T-47D cells. However, the induction measured is less than the one observed with crp2F (−273/+88), and this activity seems to reside in several subfragments that each display a low but consistent androgen responsiveness.
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PUCHALSKI, P., and A. ZYLUK. "Complex Regional Pain Syndrome Type 1 after Fractures of the Distal Radius: A Prospective Study of the Role of Psychological Factors." Journal of Hand Surgery 30, no. 6 (December 2005): 574–80. http://dx.doi.org/10.1016/j.jhsb.2005.06.023.
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A prospective study was designed to investigate the question “Do patients who develop Complex Regional Pain Syndrome Type 1 (CRPS Type 1) after fracture of the distal radius display different psychological behaviour patterns and/or are more depressive than those who recover uneventfully after this fracture?” Sixty-two patients of mean age 56 years with displaced distal radius fractures were operated on by closed reduction and percutaneous fixation with K-wires. All these patients were examined psychologically on the day after the operation. A series of standardized, self-administered questionnaires was used to assess personality and depression. Fifty of the 62 patients were reassessed at 2 months for symptoms and signs of CRPS Type 1 and a diagnosis of this condition made on clinical grounds. Nine patients (18%) were diagnosed as having CRPS Type 1. There were no significant differences in scores on any of the personality and depression scales between CRPS Type 1 and non-CRPS Type 1 patients. Therefore, patients who eventually developed CRPS Type 1 after radial forearm fracture had neither a unique psychological pattern nor displayed more symptoms of depression than those who recovered uneventfully.
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van Eijs, Frank, José Geurts, Maarten van Kleef, Catharina G. Faber, Roberto S. Perez, Alfons G. H. Kessels, and Jan Van Zundert. "Predictors of Pain Relieving Response to Sympathetic Blockade in Complex Regional Pain Syndrome Type 1." Anesthesiology 116, no. 1 (January 1, 2012): 113–21. http://dx.doi.org/10.1097/aln.0b013e31823da45f.
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Background Sympathetic blockade with local anesthetics is used frequently in the management of complex regional pain syndrome type 1(CRPS-1), with variable degrees of success in pain relief. The current study investigated which signs or symptoms of CRPS-1 could be predictive of outcome. The incidence of side effects and complications of sympathetic blockade also were determined prospectively. Methods A prospective observational study was done of 49 patients with CRPS-1 in one extremity only and for less than 1-yr duration who had severe pain and persistent functional impairment with no response to standard treatment with medication and physical therapy. Results Fifteen (31%) patients had good or moderate response. The response rate was not different in patient groups with cold or warm type CRPS-1 or in those with more or less than 1.5°C differential increase in skin temperature after sympathetic blockade. Allodynia and hypoesthesia were negative predictors for treatment success in CRPS-1. There were no symptoms or signs of CRPS-1 that positively predicted treatment success. A majority of patients (84%) experienced transient side effects such as headache, dysphagia, increased pain, backache, nausea, blurred vision, groin pain, hoarseness, and hematoma at the puncture site. No major complications were reported. Conclusions The presence of allodynia and hypoesthesia are negative predictors for treatment success. The selection of sympathetic blockade as treatment for CRPS-1 should be balanced carefully between potential success and side effect ratio. The procedure is as likely to cause a transient increase in pain as a decrease in pain. Patients should be informed accordingly.
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Helyes, Zsuzsanna, Valéria Tékus, Nikolett Szentes, Krisztina Pohóczky, Bálint Botz, Tamás Kiss, Ágnes Kemény, et al. "Transfer of complex regional pain syndrome to mice via human autoantibodies is mediated by interleukin-1–induced mechanisms." Proceedings of the National Academy of Sciences 116, no. 26 (June 10, 2019): 13067–76. http://dx.doi.org/10.1073/pnas.1820168116.
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Neuroimmune interactions may contribute to severe pain and regional inflammatory and autonomic signs in complex regional pain syndrome (CRPS), a posttraumatic pain disorder. Here, we investigated peripheral and central immune mechanisms in a translational passive transfer trauma mouse model of CRPS. Small plantar skin–muscle incision was performed in female C57BL/6 mice treated daily with purified serum immunoglobulin G (IgG) from patients with longstanding CRPS or healthy volunteers followed by assessment of paw edema, hyperalgesia, inflammation, and central glial activation. CRPS IgG significantly increased and prolonged swelling and induced stable hyperalgesia of the incised paw compared with IgG from healthy controls. After a short-lasting paw inflammatory response in all groups, CRPS IgG-injected mice displayed sustained, profound microglia and astrocyte activation in the dorsal horn of the spinal cord and pain-related brain regions, indicating central sensitization. Genetic deletion of interleukin-1 (IL-1) using IL-1αβ knockout (KO) mice and perioperative IL-1 receptor type 1 (IL-1R1) blockade with the drug anakinra, but not treatment with the glucocorticoid prednisolone, prevented these changes. Anakinra treatment also reversed the established sensitization phenotype when initiated 8 days after incision. Furthermore, with the generation of an IL-1β floxed(fl/fl)mouse line, we demonstrated that CRPS IgG-induced changes are in part mediated by microglia-derived IL-1β, suggesting that both peripheral and central inflammatory mechanisms contribute to the transferred disease phenotype. These results indicate that persistent CRPS is often contributed to by autoantibodies and highlight a potential therapeutic use for clinically licensed antagonists, such as anakinra, to prevent or treat CRPS via blocking IL-1 actions.
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Baron, Ralf. "Can we model CRPS type 1?" Pain 112, no. 1 (November 2004): 8–9. http://dx.doi.org/10.1016/j.pain.2004.09.001.
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Lunden, Lars K., Inge P. Kleggetveit, and Ellen Jørum. "Delayed diagnosis and worsening of pain following orthopedic surgery in patients with complex regional pain syndrome (CRPS)." Scandinavian Journal of Pain 11, no. 1 (April 1, 2016): 27–33. http://dx.doi.org/10.1016/j.sjpain.2015.11.004.
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Abstract Background and aims Complex regional pain syndrome (CRPS) is a serious and disabling chronic pain condition, usually occurring in a limb. There are two main types, CRPS 1 with no definite nerve lesion and CRPS 2 with an identified nerve lesion. CRPS 1 and 2 may occur following an injury (frequently following fractures), surgery or without known cause. An early diagnosis and start of adequate treatment is considered desirable for patients with CRPS. From the clinical experience of the principal investigator, it became apparent that CRPS often remained undiagnosed and that the clinical conditions of many patients seemed to be worsened following orthopedic surgery subsequent to the initial eliciting event. The aim of the present retrospective study of 55 patients, all diagnosed with either CRPS 1 or 2, was to evaluate the time from injury until diagnosis of CRPS and the effect on pain of orthopedic surgical intervention subsequent to the original injury/surgery. Methods Clinical symptoms with an emphasis on pain were assessed by going through the patients’ records and by information given during the investigation at Oslo University Hospital, where the patients also were examined clinically and with EMG/neurography. Alteration in pain was evaluated in 27 patients who underwent orthopedic surgery subsequent to the eliciting injury. Results Of a total of 55 patients, 28 women and 27 men (mean age 38.7 (SD 12.3), 38 patients were diagnosed with CRPS type 1, and 17 with CRPS type 2. Mean time before diagnosis was confirmed was 3.9 years (SD1.42, range 6 months-10 years). The eliciting injuries for both CRPS type 1 and type 2 were fractures, squeeze injuries, blunt injuries, stretch accidents and surgery. A total of 27 patients (14 men and 13 women) were operated from one to 12 times at a later stage (from 6 months to several years) following the initial injury or any primary operation because of fracture. A total of 22 patients reported a worsening of pain following secondary surgical events, while four patients found no alteration and one patient experienced an improvement of pain. None of the 22 patients reporting worsening, were diagnosed with CRPS prior to surgery, while retrospectively, a certain or probable diagnosis of CRPS had been present in 17/22 (77%) patients before their first post-injury surgical event. Conclusions and implications A mean time delay of 3.9 years before diagnosis of CRPS is unacceptable. A lack of attention to more subtle signs of autonomic dysfunction may be an important contributing factor for the missing CRPS diagnosis, in particular serious in patients reporting worsening of pain following subsequent orthopedic surgery. It is strongly recommended to consider the diagnosis of CRPS in all patients with a long-lasting pain condition. We emphasize that the present report is not meant as criticism to orthopedic surgical practice, but as a discussion for a hopefully increased awareness and understanding of this disabling pain condition.
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Dimova, Violeta, Myriam Selma Herrnberger, Fabiola Escolano-Lozano, Heike Lydia Rittner, Eva Vlckova, Claudia Sommer, Christian Maihöfner, and Frank Birklein. "Clinical phenotypes and classification algorithm for complex regional pain syndrome." Neurology 94, no. 4 (December 24, 2019): e357-e367. http://dx.doi.org/10.1212/wnl.0000000000008736.
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ObjectiveWe pursued the hypothesis that complex regional pain syndrome (CRPS) signs observed by neurologic examination display a structure allowing for alignment of patients to particular phenotype clusters.MethodsClinical examination data were obtained from 3 independent samples of 444, 391, and 202 patients with CRPS. The structure among CRPS signs was analyzed in sample 1 and validated with sample 2 using hierarchical clustering. For patients with CRPS in sample 3, an individual phenotype score was submitted to k-means clustering. Pain characteristics, quantitative sensory testing, and psychological data were tested in this sample as descriptors for phenotypes.ResultsA 2-cluster structure emerged in sample 1 and was replicated in sample 2. Cluster 1 comprised minor injury eliciting CRPS, motor signs, allodynia, and glove/stocking-like sensory deficits, resembling a CRPS phenotype most likely reflecting a CNS pathophysiology (the central phenotype). Cluster 2, which consisted of edema, skin color changes, skin temperature changes, sweating, and trophic changes, probably represents peripheral inflammation, the peripheral phenotype. In sample 3, individual phenotype scores were calculated as the sum of the mean values of signs from each cluster, where signs from cluster 1 were coded with 1 and from cluster 2 with −1. A k-means algorithm separated groups with 78, 36, and 88 members resembling the peripheral, central, and mixed phenotypes, respectively. The central phenotype was characterized by cold hyperalgesia at the affected limb.ConclusionsStatistically determined CRPS phenotypes may reflect major pathophysiologic mechanisms of peripheral inflammation and central reorganization.
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Zollinger, Paul E., Robert W. Kreis, Hub G. van der Meulen, Maarten van der Elst, Roelf S. Breederveld, and Wim E. Tuinebreijer. "No Higher Risk of CRPS After External Fixation of Distal Radial Fractures – Subgroup Analysis Under Randomised Vitamin C Prophylaxis§." Open Orthopaedics Journal 4, no. 1 (February 17, 2010): 71–75. http://dx.doi.org/10.2174/1874325001004010071.
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Operative and conservative treatment of wrist fractures might lead to complex regional pain syndrome (CRPS) type I.In our multicenter dose response study in which patients with distal radial fractures were randomly allocated to placebo or vitamin C in a daily dose of 200mg, 500mg or 1500mg during 50 days, an operated subgroup was analyzed.48 (of 427) fractures) were operated (11.2%). Twenty-nine patients (60%) were treated with external fixation, 14 patients (29%) with K-wiring according to Kapandji and five patients (10%) with internal plate fixation. The 379 remaining patients were treated with a plaster.In the operated group of patients who received vitamin C no CRPS (0/37) was seen in comparison with one case of CRPS (Kapandji technique) in the operated group who received placebo (1/11 = 9%, p=.23). There was no CRPS after external fixation.In the conservatively treated group 17 cases of CRPS (17/379 = 4.5%) occurred in comparison with one in case of CRPS in the operated group (1/48 = 2.1%, p=.71).External fixation doesn’t necessarily lead to a higher incidence of CRPS in distal radial fractures. Vitamin C may also play a role in this. This subgroup analysis in operated distal radial fractures showed no CRPS occurrence with vitamin C prophylaxis.
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Meenan, Daniel R. "The Use of Sub-Anesthetic Intravenous Ketamine and Adjuvant Dexmedetomidine when Treating Acute Pain from CRPS." Pain Physician 4;13, no. 4;7 (July 14, 2010): 365–68. http://dx.doi.org/10.36076/ppj.2010/13/365.
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Complex regional pain syndrome (CRPS) is a pain condition of the extremities that presents with pain and allodynia, decreased range of motion, swelling and skin changes. There are 2 forms of CRPS — Type I which does not have demonstrable nerve lesions and Type 2, which has evidence of obvious nerve damage. Management of refractory CRPS has been challenging. Some studies have revealed that the Nmethyl-D-aspartic acid receptor (NMDAR) may be involved in the etiology of the pain in CRPS and perhaps that a NMDA receptor antagonist like Ketamine is a potential treatment for CRPS. However, the side effect profile of ketamine is concerning, and limiting the adverse effects of the drug is beneficial. Dexmedetomidine is an alpha 2 agonist similar to clonidine with analgesic properties that can be used in combination with ketamine to provide additional analgesia in CRPS. This case describes the treatment of acute pain symptoms from Chronic Regional Pain Syndrome-Type 1 (CRPS-1) with sub-anesthetic intravenous infusion of ketamine with adjunct dexmedetomidine. A 47-year-old female patient presented with severe pain, burning and allodynia from CRPS-1 refractory to conventional therapy. She was then admitted to a monitored bed, received a sub-anesthetic intravenous infusion of ketamine with adjunct dexmedetomidine for 19 hours and subsequently discharged with complete resolution of her pain and associated symptoms. Here, the synergistic effect of the ketamine and dexmedetomidine together is shown to provide excellent symptom relief while decreasing the total ketamine administered. The combination minimized unwanted side effects and eliminated the need for intensive care unit admission secondary to anesthetic doses of ketamine. Key words: CRPS; ketamine; dexmedetomidine; NMDA receptor; alpha 2 agonist; analgesia.
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ZYLUK, A., and P. PUCHALSKI. "Treatment of Early Complex Regional Pain Syndrome Type 1 by A Combination of Mannitol and Dexamethasone." Journal of Hand Surgery (European Volume) 33, no. 2 (April 2008): 130–36. http://dx.doi.org/10.1177/1753193408087034.
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A total of 75 patients, 68 women (91%) and seven men (9%), with a mean age of 58 (range 38–82) years with early Complex Regional Pain Syndrome Type 1 (CRPS Type 1), present for less than 4 months, were given in-patient treatment with 10% mannitol 2 × 250 ml per day and 8 mg dexamethasone per day for 1 week. Measurements assessed included the pain, the range of finger movements, grip strength and our own clinical severity scoring system for CRPS Type 1 (CRPS score). The results were assessed at 1 week and, finally, at a mean of 9 (range 8–12) months. At 1-week assessment, all variables decreased significantly: pain from a mean Visual Analogue Scale (VAS) of 6.7 to 2.3, loss of finger flexion (6–0.3 cm) and the CRPS score (7.6–2.2 points). Total grip strength did not improve. At the final assessment of 70 patients, the VAS score was a mean of 1.8, loss of finger flexion a mean of 0.1 cm, the CRPS score was a mean of 1.6 and grip strength a mean of 34% of the strength of the unaffected hand. All these variables showed statistically significant improvement.
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Hájek, Michal, Dittmar Chmelař, Jakub Tlapák, František Novomeský, Veronika Rybárová, and Miloslav Klugar. "Hyperbaric oxygen treatment in recurrent development of complex regional pain syndrome: A case report." Diving and Hyperbaric Medicine Journal 51, no. 1 (March 31, 2021): 107–10. http://dx.doi.org/10.28920/dhm51.1.107-110.
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A broad spectrum of conditions including neuropathic pain, complex regional pain syndrome (CRPS) and fibromyalgia, have been implicated as causes of chronic pain. There is a need for new and effective treatments that patients can tolerate without significant adverse effects. One potential intervention is hyperbaric oxygen treatment (HBOT). The case reported here is unique in describing repeated HBOT in a patient who developed recurrent post-traumatic CRPS of the lower as well as the upper limbs. In the first event, two months after distortion and abruption of the external right ankle, the patient suffered leg pain, oedema formation, mild hyperaemia, limited mobility of the ankle and CRPS Type 1. In the second event, the same patient suffered fracture-dislocation of the distal radius 1.5 years after the first injury. After the plaster cast was removed the patient developed pain, warmth, colour changes, oedema formation and limited wrist mobility with CRPS Type 1. Pharmacological treatment as well as HBOT were used with significant improvement of functional outcome in both cases. Some studies suggest that patients with a history of CRPS are more likely to develop secondary CRPS compared to the rates reported in the literature among the general population. Patients with a history of CRPS should be counselled that they may be at risk for developing secondary CRPS if they undergo surgery or sustain trauma to another extremity.
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Truffyn, Emma E., Massieh Moayedi, Stephen C. Brown, Danielle Ruskin, and Emma G. Duerden. "Sensory Function and Psychological Factors in Children With Complex Regional Pain Syndrome Type 1." Journal of Child Neurology 36, no. 10 (April 21, 2021): 823–30. http://dx.doi.org/10.1177/08830738211007685.
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Objective: To assess thermal-sensory thresholds and psychosocial factors in children with Complex Regional Pain Syndrome Type 1 (CRPS-I) compared to healthy children. Methods: We conducted quantitative sensory testing on 34 children with CRPS-I and 56 pain-free children. Warm, cool, heat, and cold stimuli were applied to the forearm. Children with CRPS-I had the protocol administered to the pain site and the contralateral-pain site. Participants completed the self-report Behavior Assessment System for Children. Results: Longer pain durations (>5.1 months) were associated with decreased sensitivity to cold pain on the pain site ( P = .04). Higher pain-intensity ratings were associated with elevated anxiety scores ( P = .03). Anxiety and social stress were associated with warmth sensitivity (both P < .05) on the contralateral-pain site. Conclusions: Pain duration is an important factor in assessing pediatric CRPS-I. Hyposensitivity in the affected limb may emerge due to degeneration of nociceptive nerves. Anxiety may contribute to thermal-sensory perception in childhood CRPS-I.
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Carpenter, Daniel, and Reid Draeger. "Neurogenic Edema from Complex Regional Pain Syndrome Resulting in Fulminant Infection Necessitating Below Elbow Amputation." Journal of Hand and Microsurgery 09, no. 03 (November 29, 2017): 159–62. http://dx.doi.org/10.1055/s-0037-1608694.
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AbstractWe report a case of severe upper extremity complex regional pain syndrome type 1 (CRPS-1) and neurogenic edema that ultimately led to a medically necessary below-elbow amputation. The patient presented with a history of remote bilateral carpal tunnel release complicated by debilitating and recalcitrant bilateral CRPS-1. Following years of severe neurogenic edema of the left upper extremity, the patient had full-thickness skin sloughing on the dorsum of her hand due to massive edema. This subsequently led to maggot infestation of the soft tissues of the left hand ultimately necessitating amputation. We present the case as an illustration of an extreme case of neurogenic edema, a potential physical manifestation of CRPS-1. The case presented discusses upper extremity amputation as an end treatment option for CRPS-1, though in this case amputation was primarily indicated secondary to medical necessity.
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Herschkowitz, Daniel, and Jana Kubias. "A case report of wireless peripheral nerve stimulation for complex regional pain syndrome type-I of the upper extremity: 1 year follow up." Scandinavian Journal of Pain 19, no. 4 (October 25, 2019): 829–35. http://dx.doi.org/10.1515/sjpain-2019-0071.
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Abstract Background Complex regional pain syndrome (CRPS) is a chronic disabling painful disorder with limited options to achieve therapeutic relief. CRPS type I which follows trauma, may not show obvious damage to the nervous structures and remains dubious in its pathophysiology and also its response to conservative treatment or interventional pain management is elusive. Spinal cord and dorsal root ganglion stimulation (SCS, DRGS) provide good relief, mainly for causalgia or CRPS I of lower extremities but not very encouraging for upper extremity CRPS I. we reported earlier, a case of CRPS I of right arm treated successfully by wireless peripheral nerve stimulation (WPNS) with short term follow up. Here we present 1-year follow-up of this patient. Objective To present the first case of WPNS for CRPS I with a year follow up. The patient had minimally invasive peripheral nerve stimulation (PNS), without implantable pulse generator (IPG) or its accessories. Case report This was a case of refractory CRPS I after blunt trauma to the right forearm of a young female. She underwent placement of two Stimwave electrodes (Leads: FR4A-RCV-A0 with tines, Generation 1 and FR4A-RCV-B0 with tines, Generation 1) in her forearm under intraoperative electrophysiological and ultrasound guidance along radial and median nerves. This WPNS required no IPG. At high frequency (HF) stimulation (HF 10 kHz/32 μs, 2.0 mA), patient had shown remarkable relief in pain, allodynia and temperature impairment. At 5 months she started driving without opioid consumption, while allodynia disappeared. At 1 year follow up she was relieved of pain [visual analogue scale (VAS) score of 4 from 7] and Kapanji Index (Score) improved to 7–8. Both hands look similar in color and temperature. She never made unscheduled visits to the clinic or visited emergency room for any complications related to the WPNS. Conclusions CRPS I involving upper extremity remain difficult to manage with conventional SCS or DRGS because of equipment related adverse events. Minimally invasive WPNS in this case had shown consistent relief without any complications or side effects related to the wireless technology or the technique at the end of 1 year. Implications This is the first case illustration of WPNS for CRPS I, successfully treated and followed up for 1 year.
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Mertz, Kevin, Jeremy Trunzter, Edward Wu, James Barnes, Sara L. Eppler, and Robin N. Kamal. "National Trends in the Diagnosis of CRPS after Open and Endoscopic Carpal Tunnel Release." Journal of Wrist Surgery 08, no. 03 (February 27, 2019): 209–14. http://dx.doi.org/10.1055/s-0039-1678674.
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Background Complex regional pain syndrome (CRPS) occurs in 2 to 8% of patients that receive open or endoscopic carpal tunnel release (CTR). Because CRPS is difficult to treat after onset, identifying risk factors can inform prevention. We determined the incidence of CRPS following open and endoscopic CTR using a national claims database. We also examined whether psychosocial conditions were associated with CRPS after CTR. Methods We accessed insurance claims using diagnostic and procedural codes. We calculated the incidence of CRPS following open carpal tunnel release and endoscopic carpal tunnel release within 1 year. The response variable was the presence of CRPS after CTR. Explanatory variables included procedure type, age, gender, and preoperative diagnosis of anxiety or depression. Results The number of open CTRs (85% of total) outweighs the number of endoscopic procedures. In younger patients, the percentage of endoscopic CTRs is increasing. Rates of CRPS are nearly identical between surgery types for both privately insured (0.3%) and Medicare patients (0.1%). Middle aged (range: 40–64 years) and female patients had significantly higher rates of CRPS than did the general population. Preoperative psychosocial conditions did not correlate with the presence of CRPS in surgical patients. Clinical Relevance The decision between endoscopic and open CTR should not be made out of concern for development of CRPS postsurgery, as rates are low and similar for both procedures. Rates of CRPS found in this study are much lower than rates found in previous studies, indicating inconsistency in diagnosis and reporting or generalizability of prior work. Preoperative psychosocial disorders and CRPS are unrelated.
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Barth, Robert J. "Special Feature: Complex Regional Pain Syndrome (CRPS): Unratable Through the Pain Chapter." Guides Newsletter 11, no. 4 (July 1, 2006): 4–8. http://dx.doi.org/10.1001/amaguidesnewsletters.2006.julaug02.
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Abstract A sidebar titled “Rating Impairment for [complex regional pain syndrome] CRPS Type 1” in the March/April issue of The Guides Newsletter states: “Do NOT use the pain chapter to rate CRPS” because there is no well-defined pathophysiologic basis. That conclusion is contradicted by the pain chapter, which lists CRPS among conditions considered ratable, but accompanying text provides no explanation how this determination was made. This article attempts to resolve the conflict between the sidebar in The Guides Newsletter and the pain chapter. The lack of a well-defined pathophysiologic basis for CRPS is the reason for the position stated in the sidebar, and a review of the relevant professional literature confirms this reasoning. Further, the concept of CRPS itself is ambiguous and was intentionally designed to be “general” and “descriptive” and historically has been diagnosed using nonstandardized, idiosyncratic, or incompatible diagnostic systems. The AMA Guides to the Evaluation of Permanent Impairment is self-contradictory regarding diagnostic criteria and terminology (eg, is CRPS-1 synonymous with RSD, causalgia, or neither?). CRPS lacks any well-defined pathophysiology, is highly ambiguous and controversial, involves characteristics that compromise the credibility of any examinee making such a presentation, and is a good example of a condition that should be evaluated using the mental and behavioral disorders chapter.
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Bello-Perez, Melissa, Mikolaj Adamek, Julio Coll, Antonio Figueras, Beatriz Novoa, and Alberto Falco. "Modulation of the Tissue Expression Pattern of Zebrafish CRP-Like Molecules Suggests a Relevant Antiviral Role in Fish Skin." Biology 10, no. 2 (January 22, 2021): 78. http://dx.doi.org/10.3390/biology10020078.
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Recent studies suggest that short pentraxins in fish might serve as biomarkers for not only bacterial infections, as in higher vertebrates including humans, but also for viral ones. These fish orthologs of mammalian short pentraxins are currently attracting interest because of their newly discovered antiviral activity. In the present work, the modulation of the gene expression of all zebrafish short pentraxins (CRP-like proteins, CRP1-7) was extensively analyzed by quantitative polymerase chain reaction. Initially, the tissue distribution of crp1-7 transcripts and how the transcripts varied in response to a bath infection with the spring viremia of carp virus, were determined. The expression of crp1-7 was widely distributed and generally increased after infection (mostly at 5 days post infection), except for crp1 (downregulated). Interestingly, several crp transcription levels significantly increased in skin. Further assays in mutant zebrafish of recombinant activation gene 1 (rag1) showed that all crps (except for crp2, downregulated) were already constitutively highly expressed in skin from rag1 knockouts and only increased moderately after viral infection. Similar results were obtained for most mx isoforms (a reporter gene of the interferon response), suggesting a general overcompensation of the innate immunity in the absence of the adaptive one.
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Benchouk, Samy, Pierre-Alain Buchard, and François Luthi. "Complex regional pain syndrome and bone marrow oedema syndrome: family ties potentially closer than expected." BMJ Case Reports 13, no. 8 (August 2020): e234600. http://dx.doi.org/10.1136/bcr-2020-234600.
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Complex regional pain syndrome (CRPS) and bone marrow edema syndrome (BMES) are two rare conditions that are still being discussed. They are generally considered as two distinct entities, yet they share similarities such as a homogeneous bone marrow edema is also often found in the early phase of CRPS. We present the case of a 41-year-old man with CRPS after a foot fracture followed by the development of painful BMES of the ipsilateral knee and hip a few weeks later. The search for another pathology was negative. After pamidronate infusions, the evolution was spectacular: the disappearance of hip pain at 1 month and more than 50% reduction in knee and foot pain at 2 months. At final follow-up (1 year), the patient was asymptomatic. This case reinforces the idea of a possible link between CRPS and BMES probably through similar trabecular bone involvement. Imaging remains useful in diagnosis of CRPS.
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Baronio, Manuela, Hajra Sadia, Stefano Paolacci, Domenico Prestamburgo, Danilo Miotti, Vittorio A. Guardamagna, Giuseppe Natalini, Stephanie G. B. Sullivan, and Matteo Bertelli. "Molecular Aspects of Regional Pain Syndrome." Pain Research and Management 2020 (April 11, 2020): 1–10. http://dx.doi.org/10.1155/2020/7697214.
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The purpose of this review is to summarize the pathophysiology of complex regional pain syndrome (CRPS), the underlying molecular mechanisms, and potential treatment options for its management. CRPS is a multifactorial pain condition. CRPS is characterized by prolonged or excessive pain and changes in skin color and temperature, and/or swelling in the affected area, and is generally caused by stimuli that lead to tissue damage. An inflammatory response involving various cytokines and autoantibodies is generated in response to acute trauma/stress. Chronic phase pathophysiology is more complex, involving the central and peripheral nervous systems. Various genetic factors involved in the chronicity of pain have been identified in CRPS patients. As with other diseases of complex pathology, CRPS is difficult to treat and no single treatment regimen is the same for two patients. Stimulation of the vagus nerve is a promising technique being tested for different gastrointestinal and inflammatory diseases. CRPS is more frequent in individuals of 61–70 years of age with a female to male ratio of 3 : 1. Menopause, migraine, osteoporosis, and asthma all represent risk factors for CRPS and in smokers the prognosis appears to be more severe. The pathophysiological mechanisms underlying CRPS involve both inflammatory and neurological pathways. Understanding the molecular basis of CRPS is important for its diagnosis, management, and treatment. For instance, vagal nerve stimulation might have the potential for treating CRPS through the cholinergic anti-inflammatory pathway.
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Pons, Tracey, Edward A. Shipton, Jonathan Williman, and Roger T. Mulder. "Potential Risk Factors for the Onset of Complex Regional Pain Syndrome Type 1: A Systematic Literature Review." Anesthesiology Research and Practice 2015 (2015): 1–15. http://dx.doi.org/10.1155/2015/956539.
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Anaesthetists in the acute and chronic pain teams are often involved in treating Complex Regional Pain Syndromes. Current literature about the risk factors for the onset of Complex Regional Pain Syndrome Type 1 (CRPS 1) remains sparse. This syndrome has a low prevalence, a highly variable presentation, and no gold standard for diagnosis. In the research setting, the pathogenesis of the syndrome continues to be elusive. There is a growing body of literature that addresses efficacy of a wide range of interventions as well as the likely mechanisms that contribute to the onset of CRPS 1. The objective for this systematic search of the literature focuses on determining the potential risk factors for the onset of CRPS 1. Eligible articles were analysed, dated 1996 to April 2014, and potential risk factors for the onset of CRPS 1 were identified from 10 prospective and 6 retrospective studies. Potential risk factors for the onset of CRPS 1 were found to include being female, particularly postmenopausal female, ankle dislocation or intra-articular fracture, immobilisation, and a report of higher than usual levels of pain in the early phases of trauma. It is not possible to draw definite conclusions as this evidence is heterogeneous and of mixed quality, relevance, and weighting strength against bias and has not been confirmed across multiple trials or in homogenous studies.
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Tan, ECTH, MH de Keijzer, and RJA Goris. "Capillary blood gas analysis in complex regional pain syndrome: a pilot study." Annals of Clinical Biochemistry: International Journal of Laboratory Medicine 40, no. 5 (September 1, 2003): 569–71. http://dx.doi.org/10.1258/000456303322326524.
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Background: The pathophysiology of complex regional pain syndrome type 1 (CRPS 1) is still a matter of debate. An inflammatory reaction may cause the syndrome. Increasing evidence points to a role for impairment of oxygen metabolism in the affected limb. Methods: In this pilot study (16 patients) we performed capillary blood gas analysis in extremities with acute CRPS 1, in order to assess oxygen saturation and lactate concentrations. Comparison was made with the unaffected limb for capillary blood pH, pO2, SaO2, and lactate and glucose concentrations. Results: No statistically significant differences could be found. Conclusions: Capillary blood gas analysis is not useful to detect changes in oxygen saturation and lactate concentrations in CRPS 1.
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Jia, Siming, Chuan Ren, Xiaoying Shi, Tailong Shi, Dacheng Sun, Yuqin Zhang, Kai Ding, Hao Du, Yanbin Zhu, and Wei Chen. "Relative Prevalence and Associated Factors of Complex Regional Pain Syndrome Type I in Patients with Radial Head Fractures Treated with Open Reduction and Internal Fixation: A Cross-Sectional Study." Pain Research and Management 2022 (May 19, 2022): 1–8. http://dx.doi.org/10.1155/2022/9214404.
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Objective. This cross-sectional study aimed to examine the incidence and associated factors of complex regional pain syndrome type I (CRPS I) in patients who underwent open reduction and internal fixation (ORIF) for radial head fractures. Methods. The study enrolled 601 radial head fracture patients treated with ORIF, 523 of which completed the 1-year follow-up. The incidence of CRPS I in those patients was assessed using the Budapest criteria. Patients were then divided into 2 groups: patients with CRPS I (n = 28) and patients without CRPS I (n = 495). The patients’ demographic and clinical data before the operation were prospectively collected by our team. Independent t-tests and χ2 tests were used as univariate analyses to compare the demographic and clinical data between the two groups. Meanwhile, multivariate regression analysis was conducted to identify the associated risk factors for CRPS I. Results. The incidence of CRPS I in patients with radial head fractures treated with ORIF was 5.5% during the first year following surgery. Significant differences were observed in age, gender, type of trauma, modified Mason Classification, and depressive personality disorders. The logistic regression analysis revealed that the female gender, modified Mason type III fractures, and depressive patients were significantly more likely to develop CRPS I ( p = 0.021 , 0.023, and 0.025, respectively). Conclusions. The incidence of CRPS I among radial head fracture patients undergoing ORIF was 5.5%. In addition, early detection of CRPS I and providing adequate intervention will likely result in greater benefits for those patients.
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Abu-Arafeh, Hashem, and Ishaq Abu-Arafeh. "Complex regional pain syndrome in children: incidence and clinical characteristics." Archives of Disease in Childhood 101, no. 8 (March 22, 2016): 719–23. http://dx.doi.org/10.1136/archdischild-2015-310233.
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ObjectiveTo study the clinical and epidemiological characteristics of complex regional pain syndrome (CRPS) in children.Patients and methodsAll children and adolescents under 16 years of age with a new diagnosis of CRPS who were reported to the Scottish Paediatric Surveillance Unit were included. Patients’ recruitment ran between 1 November 2011 and 31 October 2015. Information was collected on patients’ demography, clinical features, investigations, management and impact of disease on child and family. The diagnosis of CRPS was made on fulfilling the clinical criteria of the International Association for the Study of Pain.Results26 cases of CRPS were reported over 4 years, giving a minimum estimated incidence of 1.16/100 000 (95% CI 0.87 to 1.44/100 000) children 5–15 years of age. Nineteen patients were female (73%) and mean age at diagnosis was 11.9 (range 5.5–15.4 years). The median interval between onset of symptoms and diagnosis was 2 months (range 1–12). The majority of children have single site involvement, with legs been more often affected than arms and the right side is more often affected than the left. There was a clear trauma at onset of the illness in 19 children and possible nerve injury in one. All investigations were normal and several treatment modalities were used with variable success. The disease had significant impacts on the patients’ education and family lives.ConclusionsThe estimated incidence of CRPS is 1.2/100 000 children 5–15 years old. The diagnosis of CRPS is often delayed. CRPS has a significant impact on children and their families.
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Petchkrua, Wannapha, David J. Weiss, and Rakesh R. Patel. "Reassessment of the Incidence of Complex Regional Pain Syndrome Type 1 Following Stroke." Neurorehabilitation and Neural Repair 14, no. 1 (March 2000): 59–63. http://dx.doi.org/10.1177/154596830001400107.
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Previous literature has suggested that reflex sympathetic dystrophy, also known as complex regional pain syndrome (CRPS) type 1, is a relatively common finding after a stroke. However, much of this data was obtained before patients routinely re ceived early intensive inpatient rehabilitation. The purpose of this study is to reeval uate the incidence of CRPS type 1 following an acute first stroke. Subjects admitted to an acute rehabilitation setting for stroke with no other concomitant neurologic or orthopedic injuries between October 1, 1996, and May 31, 1997, were studied. At admission and once a week until discharge, subjects were evaluated for shoulder pain, decreased passive range of motion of the shoulder, wrist/hand pain, edema, and skin changes. If three of these five criteria were positive, the subjects underwent a triple- phase bone scan (TPBS). Bone scan findings consistent with CRPS type 1 were taken as confirming the diagnosis. Of 64 subjects, 13 underwent bone scans, with only one positive result. Thus our study revealed a 1.56 percent incidence of CRPS type 1 fol lowing a first stroke. This incidence is much lower than the historically accepted 12.5 percent. We speculate that this low figure is related to early comprehensive rehabili tation that included proper upper extremity positioning and early mobilization with sensory stimulation.
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Buset, C., P. Dziunycz, N. Gräni, F. Kaufmann, N. Jaberg-Bentele, C. Luder, M. T. Mohanna, et al. "Complex regional pain syndrome (CRPS)." Phlebologie 43, no. 06 (November 2014): 312–16. http://dx.doi.org/10.12687/phleb2240-6-2014.
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Summary Introduction: Complex regional pain syndrome (CRPS) is a relatively rare disorder, but one that is extremely serious for the affected patient. It usually occurs in the area distal to a primary limb injury. The clinical symptoms and the pain are out of all proportion to the inciting event and in approximately 10 % of CRPS patients, there is no triggering event at all. CRPS leads to long-term disability and high treatment and follow-up costs In about half of those affected.Clinical symptoms: Two forms exist. In CRPS type 1, no nerve lesions are present, whereas in CRPS type 2, injury has occurred to a nerve or the main branch of a nerve. However, in terms of their clinical course, there is no difference between the two forms. Approximately 90 % of all cases involve CRPS type 1, formerly known as “Sudeck’s atrophy”. The cardinal symptom is pain. In addition, trophic disturbances, such as swelling, local skin discolouration or asymmetric skin temperatures, can also occur. Impaired mobility and function of the affected limb also occur frequently and are very difficult to treat. Diagnosis: Initially, it can be difficult to distinguish between CRPS and a normal post-traumatic course. Subsequently, the severe symptoms are out of all proportion to the inciting event. The diagnosis of CRPS is based mainly on the clinical symptoms. The Budapest criteria help to confirm the diagnosis. Therapy: Early and interdisciplinary rehabilitation is of crucial importance in CRPS treatment. Occupational therapy and physiotherapy are supplemented by good analgesic management and psychological support, if required. Analgesia should be based on the WHO pain ladder. Methadone is of proven efficacy in cases of severe hyperalgesia and gabapentin or pregabalin are used to treat refractory pain. Bisphosphonates have shown a good analgesic effect, particularly in patients with confirmed bone lesions. Chronic oedema and inflammation may require short-term steroid administration. A further clinical goal is the avoidance of sequelae, such as osteoporosis. Patients with suspected CRPS should be referred to a multidisciplinary treatment team, preferably one with considerable experience in treating this clinical presentation. One physician should coordinate the patient’s treatment. The earlier the treatment is started, the better the prognosis.
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Buller, Mitchell, Steven Schulz, Morton Kasdan, and Bradon J. Wilhelmi. "The Incidence of Complex Regional Pain Syndrome in Simultaneous Surgical Treatment of Carpal Tunnel Syndrome and Dupuytren Contracture." HAND 13, no. 4 (July 8, 2017): 391–94. http://dx.doi.org/10.1177/1558944717718345.
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Background: To determine the incidence of complex regional pain syndrome (CRPS) in the concurrent surgical treatment of Dupuytren contracture (DC) and carpal tunnel syndrome (CTS) through a thorough review of evidence available in the literature. Methods: The indices of 260 hand surgery books and PubMed were searched for concomitant references to DC and CTS. Studies were eligible for inclusion if they evaluated the outcome of patients treated with simultaneous fasciectomy or fasciotomy for DC and carpal tunnel release using CRPS as a complication of treatment. Of the literature reviewed, only 4 studies met the defined criteria for use in the study. Data from the 4 studies were pooled, and the incidence of recurrence and complications, specifically CRPS, was noted. Results: The rate of CRPS was found to be 10.4% in the simultaneous treatment group versus 4.1% in the fasciectomy-only group. This rate is nearly half the 8.3% rate of CRPS found in a randomized trial of patients undergoing carpal tunnel release. Conclusions: Our analysis demonstrates a marginal increase in the occurrence of CRPS by adding the carpal tunnel release to patients in need of fasciectomy, contradicting the original reports demonstrating a much higher rate of CRPS. This indicates that no clear clinical risk is associated with simultaneous surgical treatment of DC and CTS. In some patients, simultaneous surgical management of DC and CTS can be accomplished safely with minimal increased risk of CRPS type 1.
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Merkulov, V. N., A. I. Dorokhin, A. I. Krupatkin, M. V. Merkulov, and M. A. Avakova. "Treatment of Type 1 Complex Regional Pain Syndrome in 14 Years Old Child." Vestnik travmatologii i ortopedii imeni N.N. Priorova, no. 4 (December 30, 2014): 79–82. http://dx.doi.org/10.32414/0869-8678-2014-4-79-82.
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Case report on 14 years old girl with type 1 complex regional pain syndrome (CRPS) is presented. At first admission in 5.5 months after right hand injury and development of type 1 CRPS, paravasal sympathectomy on the right upper extremity was performed. Complete elimination of pain syndrome and restoration of the extremity function was achieved. Five and a half months after discharge the left foot and in 3 weeks later the right hand were injured. In both cases injuries were accompanied by pronounced CRPS clinical picture. At second admission in 6 weeks after foot injury interventional treatment with placement of catheters next to nerve trunks and bolus administration of antibiotics was performed for 1 week and enabled to achieve remission of the disease. It was noted that not only hypersymphaticotony but also psychological status of a patient were important for the disease development.
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Merkulov, V. N., A. I. Dorokhin, A. I. Krupatkin, M. V. Merkulov, and M. A. Avakova. "Treatment of Type 1 Complex Regional Pain Syndrome in 14 Years Old Child." N.N. Priorov Journal of Traumatology and Orthopedics 21, no. 4 (December 15, 2014): 79–82. http://dx.doi.org/10.17816/vto20140479-82.
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Case report on 14 years old girl with type 1 complex regional pain syndrome (CRPS) is presented. At first admission in 5.5 months after right hand injury and development of type 1 CRPS, paravasal sympathectomy on the right upper extremity was performed. Complete elimination of pain syndrome and restoration of the extremity function was achieved. Five and a half months after discharge the left foot and in 3 weeks later the right hand were injured. In both cases injuries were accompanied by pronounced CRPS clinical picture. At second admission in 6 weeks after foot injury interventional treatment with placement of catheters next to nerve trunks and bolus administration of antibiotics was performed for 1 week and enabled to achieve remission of the disease. It was noted that not only hypersymphaticotony but also psychological status of a patient were important for the disease development.
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Vas, Lakshmi. "Musculoskeletal Ultrasonography in CRPS: Assessment of Muscles Before and After Motor Function Recovery with Dry Needling as the Sole Treatment." Pain Physician 1;19, no. 1;1 (January 14, 2016): E163—E179. http://dx.doi.org/10.36076/ppj/2016.19.e163.
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Background: Motor impairment is an important criterion in the Clinical Diagnostic Criteria (CDC) of Complex Regional Pain Syndrome type-1 (CRPS-1) as defined by International Association for Study of Pain (IASP). Objective: To describe the changes in musculoskeletal ultrasonography (MSKUSG) in CRPS-1 before and after treatment with ultrasound-guided dry needling (USGDN) in retrospective data from 44 patients. Study Design: Patients irrespective of age, gender, or cause of CRPS were included in this retrospective data analysis; the Budapest criteria for the diagnosis of CRPS were stringently adhered to. Setting: The analysis was done at Ashirvad Institute for Pain Management and Research with the database of CRPS patients who were treated between December 2005 and December 2014. Methods: The CDC, range of motion at upper extremity joints, dynamometry, Disability of arm, shoulder and hand score (DASH) and ultrasonography were documented on days one, 15, and 45. MSKUSG demonstrated loss of myoarchitecture and reduced bulk. Results: All 44 patients received USGDN as the sole intervention with medications and physiotherapy. MSKUSG at 15 and 45 days after starting USGDN showed a return of normalcy to the myoarchitecture and muscle bulk increase that coincided with the disappearance of CDC and a progressive and predictable improvement of the DASH scores in all the 44 patients. Limitation: The analysis focuses on only 2 parameters: the musculoskeletal changes of the forearm flexors and extensors on ultrasound guidance and the efficacy of the dry needling treatment. It is not a comparative study with another accepted form of treatment or intervention. We have not looked into the age and gender predilection of the condition owing to the small sample size of the study. Analysis of long term maintenance of relief and rehabilitation of the disability were limited to one year. Conclusion: Myofascial pathology of co-contraction appears to cause CDC of CRPS and probable ischemic loss of myoarchitecture. Relief of co-contraction with USGDN allowed resolution of tenosynovitis causing the CDC and return of normal myoarchitecture. Key words: CRPS-1, co-contraction, motor impairment, disability, dry needling, musculoskeletal ultrasonography
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Breivik, Harald, and Audun Stubhaug. "Importance of early diagnosis of complex regional pain syndrome (CRPS-1 and CRPS-2): Delayed diagnosis of CRPS is a major problem." Scandinavian Journal of Pain 11, no. 1 (April 1, 2016): 49–51. http://dx.doi.org/10.1016/j.sjpain.2015.11.009.
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Richards, Stephanie, George Chalkiadis, Raman Lakshman, Jim P. Buttery, and Nigel W. Crawford. "Complex regional pain syndrome following immunisation." Archives of Disease in Childhood 97, no. 10 (August 1, 2012): 913–15. http://dx.doi.org/10.1136/archdischild-2011-301307.
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Complex regional pain syndrome type 1 (CRPS-1) is a clinical syndrome that affects one or more extremities and is characterised by persistent pain disproportionate to any inciting event, and at least one sign of autonomic dysfunction in the affected limb(s). The pathogenesis of this syndrome is poorly understood, but its onset is often precipitated by a physical injury, such as minor trauma, fracture, infection or a surgical procedure. In the literature, there are reports of CRPS-1 following immunisation with rubella and hepatitis B vaccines. Here we present a case series of CRPS-1 following immunisation in adolescents, with either diphtheria-tetanus-acellular pertussis (1 case), or human papillomavirus vaccines (4 cases). Enhanced awareness of this syndrome and its potential to occur following immunisation in the paediatric population is vital to the prompt and effective management of this condition.
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Huygen, Frank J. P. M., Anke G. J. de Bruijn, Martha T. de Bruin, J. George Groeneweg, Jan Klein, and Freek J. Zijlstra. "Evidence for local inflammation in complex regional pain syndrome type 1." Mediators of Inflammation 11, no. 1 (2002): 47–51. http://dx.doi.org/10.1080/09629350210307.
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Background: The pathophysiology of complex regional pain syndrome type 1 (CRPS 1) is still a matter of debate. Peripheral afferent, efferent and central mechanisms are supposed. Based on clinical signs and symptoms (e.g. oedema, local temperature changes and chronic pain) local inflammation is suspected.Aim: To determine the involvement of neuropetides, cytokines and eicosanoids as locally formed mediators of inflammation.Methods: In this study, nine patients with proven CRPS 1 were included. Disease activity and impairment was determined by means of a Visual Analogue Scale, the McGill Pain Questionnaire, the difference in volume and temperature between involved and uninvolved extremities, and the reduction in active range of motion of the involved extremity. Venous blood was sampled from and suction blisters made on the involved and uninvolved extremities for measurement of cytokines interleukin (IL)-6, IL-1β and tumour necrosis factor-α (TNF-α), the neuropetides NPY and CRGP, and prostaglandin E2.Results: The patients included in this study did have a moderate to serious disease activity and impairment. In plasma, no changes of mediators of inflammation were observed. In blister fluid, however, significantly higher levels of IL-6 and TNF-α in the involved extremity were observed in comparison with the uninvolved extremity.Conclusions: This is the first time that involvement of mediators of inflammation in CRPS 1 has been so clearly and directly demonstrated. This observation opens new approaches for the succesful use and development of immunosuppressives in CRPS 1.
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Beales, Darren, David Carolan, Joshua Chuah-Choong, Sarah Hammond, Eimear O’Brien, Eileen Boyle, Sonia Ranelli, David Holthouse, Tim Mitchell, and Helen Slater. "Exploring peoples’ lived experience of complex regional pain syndrome in Australia: a qualitative study." Scandinavian Journal of Pain 21, no. 2 (January 6, 2021): 393–405. http://dx.doi.org/10.1515/sjpain-2020-0142.
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Abstract Objectives Complex regional pain syndrome (CRPS) is a persistent pain condition which is often misunderstood and poorly managed. Qualitative studies are needed to explore the lived experience of the condition and to better understand patient perspectives on their management experiences and needs. The aim of this study was to explore the lived experience of CRPS in Australia, including exploration of their perceptions of care and advice received from healthcare professionals. Methods A qualitative study with individual in-depth semi-structured, face-to-face interviews was performed (n=15, 80% female, average time elapsed since diagnosis 3.8 years). Qualitative data were analysed using an inductive thematic analysis approach. Results Four main themes with associated subthemes were identified, representing the participants’ journey: (1) Life Changing Impact of CRPS (Subthemes: Impact on self, Impact on others); (2) Variable Experiences of Care (Subthemes: Helpful experiences of care, Unhelpful experiences of care); (3) Making Sense of CRPS (Subthemes: Knowledge and understanding, Dealing with unpredictability); and (4) Perceptions on Lessons Learned from Living with CRPS (Subthemes: Acceptance was an important part of the journey, Trial and error was necessary to find an individual way forward, Coping strategies). Conclusions The themes identified align to and expand on prior qualitative research findings in people with CRPS. It highlights the challenges people face related to their personal self, their close relationships and their social and work roles. It highlights the difficulties these people have in finding reliable, trust-worthy information. These findings suggest that healthcare professionals may benefit from education about how to better support people with CRPS, including helping people to navigate to the right care. Engaging people with CRPS in the development of educational resources should be a future research goal. It is recommended that patient perspectives are incorporated into the development of care pathways for CRPS.
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LIBON, DAVID J., ROBERT J. SCHWARTZMAN, JOEL EPPIG, DENENE WAMBACH, ERIC BRAHIN, B. LEE PETERLIN, GUILLERMO ALEXANDER, and ATUL KALANURIA. "Neuropsychological deficits associated with Complex Regional Pain Syndrome." Journal of the International Neuropsychological Society 16, no. 3 (March 19, 2010): 566–73. http://dx.doi.org/10.1017/s1355617710000214.
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AbstractWe sought to elucidate the existence of neuropsychological subtypes in Complex Regional Pain Syndrome (CRPS). One hundred thirty seven patients with CRPS were administered tests that assess executive control, naming/lexical retrieval, and declarative memory. A 2-step cluster analysis that does not require any a priori specification regarding the number of clusters, classified patients into three groups. Group 1 obtained scores that were in the average range on all tests (n = 48; normal CRSP group). Group 2 (n = 58; dysexecutive CRSP group) presented with mild impairment or statistically low average test performance on working memory/verbal fluency tests. Group 3 (n = 31; global CRSP group) produced scores in the statistically low average/borderline range on all tests with particularly reduced scores on naming/declarative memory tests. Between-group analyses found that the CRPS group 1 obtained higher scores than CRPS groups 2 and 3 on all tests. However, groups 2 and 3 were equally impaired on executive tests. CRPS group 3 was impaired on tests of naming/memory tests compared to the other groups. Significant neuropsychological deficits are present in 65% of patients, with many patients presenting with elements of a dysexecutive syndrome and some patients presenting with global cognitive impairment. (JINS, 2010, 16, 566–573.)
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Pons, Tracey, Edward Shipton, Jonathan Williman, and Roger Mulder. "Physiotherapy Interventions and the Outcomes for Complex Regional Pain Syndrome (CRPS) Type 1 on the South Island of New Zealand – A Longitudinal, Prospective Case Series." Open Pain Journal 10, no. 1 (March 23, 2017): 5–13. http://dx.doi.org/10.2174/1876386301710010005.
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Physiotherapy is considered in pain medicine to be a key element in the management of Complex Regional Pain Syndrome (CRPS). This is the first paper to document and categorise all physiotherapy intervention methods used as well as evaluate the outcomes of a case series of 18 CRPS patients attending physiotherapy in a prospective, longitudinal study across a region. Outcomes were measured across the region of the South Island of New Zealand over 1 year through independent telephonic interviewing of the pain experience with the McGill Pain Questionnaire-short form, function with Foot Function Index for the lower limb or Disability of the Arm Shoulder and Hand for the upper limb, and quality of life with the World Health Organisation Disability Schedule. Clinical records were accessed for each CRPS participant following discharge from physiotherapy to categorise the intervention methods used. Seventeen participants received intervention for both functional restoration with pain modulation and only one participant received functional restoration with no pain modulation; 12 also received immobilisation with 10 receiving passive interventions. All outcome measures improved significantly by 6 months and were maintained at 1 year. Eighty five percent had their diagnosis of CRPS confirmed within 3 months of their injury; half had fracture as the precipitating injury for their onset of CRPS with a third following soft tissue injury and 11% following surgery. Physiotherapists showed a high variation with the intervention methods used and showed a greater proportion of intervention methods focusing on functional restoration followed by pain modulating interventions. Future research is necessary to define what physiotherapy interventions are efficacious in the management of CRPS.
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Bass, Christopher, and Gregory Yates. "Complex regional pain syndrome type 1 in the medico-legal setting: High rates of somatoform disorders, opiate use and diagnostic uncertainty." Medicine, Science and the Law 58, no. 3 (June 4, 2018): 147–55. http://dx.doi.org/10.1177/0025802418779934.
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Objective The aim of this study was to review demographic and clinical characteristics of patients with complex regional pain syndrome type 1 (CRPS) seen in a UK medico-legal setting – particularly the relationship between CRPS and somatoform disorders. Methods Fifty consecutive cases of CRPS (interviewed 2005–2016) undergoing psychiatric assessment were reviewed. A systematic assessment of mental states was conducted via interview and examination of medical/psychiatric records. Thirty patients also completed the Brief Illness Perception Questionnaire (BIPQ). Results Sixty per cent of patients ( n = 30) were female, and the mean age was 43 years. Twenty-two per cent ( n = 11) were employed, and 60% ( n = 30) received disability benefits. Symptoms were reported in the upper limb (62%; n = 31), lower limb (30%; n = 15), both (6%; n = 3) or elsewhere (2%; n = 1). Eighty-four per cent ( n = 42) satisfied DSM-5 criteria for current somatoform disorder. A history of more than two pain-related functional somatic syndromes (e.g. non-cardiac chest pain) was found in 42% ( n = 21) and functional neurological symptoms (e.g. ‘claw-hand’) in 42% ( n = 21). BIPQ scores resembled those associated with somatoform disorders and disorders mediated by psychological factors (e.g. irritable bowel syndrome). In 38% ( n = 19), the CRPS diagnosis was disputed among experts. A history of depression was noted in 60% ( n = 30), panic attacks in 20% ( n = 10) and alcohol/substance misuse in 18% ( n = 9). Opiates were prescribed to 64% ( n = 32). Conclusions Patients diagnosed with CRPS involved in litigation have high rates of prior psychopathology (mainly somatoform disorders) and pain-related disability for which opiate use is common. They risk an adverse reaction to limb pain ‘shaped’ by maladaptive illness beliefs. The CRPS diagnosis lacks reliability in medico-legal settings and may cause iatrogenic harm
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Perez, Roberto S. G. M., Gert Kwakkel, Wouter W. A. Zuurmond, and Jaap J. de Lange. "Treatment of Reflex Sympathetic Dystrophy (CRPS Type 1)." Journal of Pain and Symptom Management 21, no. 6 (June 2001): 511–26. http://dx.doi.org/10.1016/s0885-3924(01)00282-2.
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Huygen, Frank J. P. M., Sjoerd Niehof, Freek J. Zijlstra, P. Martin van Hagen, and Paul L. A. van Daele. "Successful treatment of CRPS 1 with anti-TNF." Journal of Pain and Symptom Management 27, no. 2 (February 2004): 101–3. http://dx.doi.org/10.1016/j.jpainsymman.2003.12.006.
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Cheon, Miju, Hyo Jung Kang, Kyung Hee Do, Hee Seung Yang, Eul Joo Han, and Jang Yoo. "Diagnostic Performance of Three-Phase Bone Scintigraphy and Digital Infrared Thermography Imaging for Chronic Post-Traumatic Complex Regional Pain Syndrome." Diagnostics 11, no. 8 (August 12, 2021): 1459. http://dx.doi.org/10.3390/diagnostics11081459.
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This study aimed to evaluate the diagnostic performance of three-phase bone scintigraphy (TPBS) and digital infrared thermography imaging (DITI) in the chronic post-traumatic CRPS and propose new imaging diagnostic criteria that combine the two tests. We retrospectively enrolled 44 patients with suspected symptoms of CRPS from various injuries during obligatory military service. We analyzed the following findings: (1) uptake pattern on TPBS, (2) uptake ratios of affected and unaffected sides in each phase of TPBS, (3) difference in body skin temperature on DITI. New criteria combining the above findings were also evaluated. Eighteen patients were finally defined as CRPS according to the Budapest criteria. Uptake pattern and uptake ratio in blood pool phase on the TPBS were significantly different between CRPS and non-CRPS groups (both p < 0.05). The DITI could not discriminate significantly between the groups (p = 0.334). The diagnostic criteria considering both the pattern analysis and quantitative analysis in TPBS exhibited the highest positive likelihood ratio. On the other hand, the diagnostic criteria combining DITI and TPBS showed the lowest negative likelihood ratio value. TPBS can be useful in diagnosing chronic post-traumatic CRPS. Moreover, we can suggest that different diagnostic criteria be applied depending on the purpose.
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Lipman, Marc D., Daniel E. Hess, Brian C. Werner, and D. Nicole Deal. "Fibromyalgia as a Predictor of Complex Regional Pain Syndrome After Distal Radius Fracture." HAND 14, no. 4 (October 11, 2017): 516–22. http://dx.doi.org/10.1177/1558944717735949.
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Background: Complex regional pain syndrome (CRPS) can be a devastating complication following extremity injury, but risk factors are not well understood. The purpose of this study was to investigate the association between fibromyalgia and the development of CRPS after distal radius fracture. Methods: The PearlDiver Medicare database was queried using International Classification of Diseases, 9th Revision (ICD-9) and Current Procedural Terminology (CPT) codes for diagnoses and treatments of distal radius fractures. Patients were separated into fibromyalgia and control cohorts, and the prevalence of CRPS was measured at 3, 6, 9, and 12 months from the date of injury or procedure. Demographic factors, treatment modality, and comorbid conditions were analyzed by multivariable logistic regression to reduce confounding and identify additional risk factors. Results: Database queries yielded 853 186 patients diagnosed or treated for distal radius fracture, with 6% having previous diagnosis of fibromyalgia. The prevalence of CRPS following distal radius fracture was increased at 3, 6, 9, and 12 months in the fibromyalgia cohort compared with the control c, with a 1-year incidence of 0.51% compared with 0.20% (odds ratio [OR], 2.54, P < .001). Multivariable logistic regression supported the association, with estimated OR of 2.0 ( P < .001). In addition, female gender, surgical or manipulative treatment, and anxiety were positively associated with CRPS, and age >65, diabetes, and heart failure were negatively associated. Conclusions: While the basis of the association between fibromyalgia and CRPS is unknown, our data suggest that it could serve as a useful predictor of CRPS risk, promoting increased vigilance for CRPS symptoms and earlier recognition and treatment, thereby improving patient outcomes.
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Ryskalin, Larisa, Giulia Ghelarducci, Chiara Marinelli, Gabriele Morucci, Paola Soldani, Nicolò Bertozzi, Paolo Annoscia, Andrea Poggetti, and Marco Gesi. "Effectiveness of Decision Support to Treat Complex Regional Pain Syndrome." Applied Sciences 12, no. 18 (September 7, 2022): 8979. http://dx.doi.org/10.3390/app12188979.
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Background: Complex regional pain syndrome (CRPS) type 1 is a rare but disabling pain condition, usually involving distal extremities such as the wrist, hand, ankle, and foot due to either direct or indirect traumas. CRPS type 1 is characterized by a complex set of symptoms where no correlation can be identified between the severity of the initial injury and the ensuing painful syndrome. Over the years, numerous treatment strategies have been proposed for CRPS management, but therapies remain controversial. At present, no successful therapeutic intervention exists for this condition. The aim of the present study was to propose and assess the effectiveness of a rehabilitative treatment algorithm for CRPS, which is actually in use at our institution. Methods: We retrospectively reviewed all the patients that underwent physical rehabilitative treatment algorithm for hand CRPS between 2011 and 2017 at our Institution. Results: All the parameters taken into consideration, namely the Purdue Pegboard Test (PPT), Disability of the Arm, Shoulder and Hand (DASH), Visual Analog Scale (VAS), as well hand edema, were significantly improved at the end of the rehabilitation protocol. Conclusions: The results obtained in the present study demonstrated that our rehabilitation protocol was able to achieve substantial improvement in pain and quality of life scores. Thus, an early and skillful rehabilitation intervention is of paramount importance for CPRS type 1 management to achieve a stable and optimal functional recovery while preventing the onset of deformities.
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Moretti, Antimo, Angela Palomba, Marco Paoletta, Sara Liguori, Giuseppe Toro, and Giovanni Iolascon. "Complex Regional Pain Syndrome in Athletes: Scoping Review." Medicina 57, no. 11 (November 17, 2021): 1262. http://dx.doi.org/10.3390/medicina57111262.
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Background and Objectives: Complex regional pain syndrome (CRPS) is a chronic condition characterized by disproportionate regional pain, usually affecting distal limbs, that follows trauma or surgery. Athletes may develop CRPS because of exposure to traumatic or overuse injuries. The aim of the present study is to review the available literature about CRPS type 1 in athletes. Materials and Methods: We searched two online databases (PubMed and Web of Science), selecting papers aiming at investigating CRPS type 1 (algodystrophy) in athletes. The analysis of databases was made considering original articles published until 30 June 2021, written in English. Results: Fifteen papers (12 case reports, 3 case series) were selected for a total of 20 clinical cases (15 females, 5 males), aged between 10 and 46 years (mean age 18.4 ± 9.8 standard deviation years). Patients included practiced different types of sport (soccer, athletics, gymnastics, basketball). The most involved anatomical sites were lower limbs, and time to diagnosis ranged from 2 days to 4 years. The most used treatments were pharmacological and physical therapies, but sometimes invasive approaches, as regional nerve, or lumbar sympathetic blocks, were provided. The main assessed outcomes were return to activity and pain. Conclusions: Our review suggests a higher prevalence of CRPS type 1 in younger people and in lower limbs than in general population but confirms the higher prevalence in females. However, the number of studies addressing CRPS in athletes is limited, as well as the number of involved patients, considering that only few and heterogeneous case reports were published about this topic. Moreover, the high prevalence of old studies (only 5 available studies in the last 10 years) might have influenced the choice of both assessment tools and management strategies. Despite these limitations, athletes showing disproportionate pain after sport-related injury should be promptly evaluated and treated through a multidimensional approach to avoid long-term consequences of algodystrophy.
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Lee, Byung Joo, Jun Young Kim, Hyung-jung Cho, and Donghwi Park. "Sphingosine 1-phosphate receptor modulation attenuate mechanical allodynia in mouse model of chronic complex regional pain syndrome by suppressing pathogenic astrocyte activation." Regional Anesthesia & Pain Medicine 45, no. 3 (January 21, 2020): 230–38. http://dx.doi.org/10.1136/rapm-2019-100801.
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Background and objectivesFTY720 ((2-amino-2-)2-[4-octylphenyl]ethyl)-1,3-propanediol) is an Food and Drug Administration (FDA)-approved immunomodulatory drug for treating multiple sclerosis. It inhibits lymphocyte egression from lymphoid tissues by downregulating sphingosine-1 phosphate receptor (S1PR). To date, there has been no study on the effects of FTY720 on the chronic stage of the complex regional pain syndrome (CRPS) rodent model, despite its antiallodynic effect in previous studies. Thus, the aim of this study is to investigate the effect of FTY720 in a chronic stage of the CRPS mouse model.MethodThe authors used a mouse model of CRPS, involving tibia fracture/cast immobilization, to test the efficacy of intrathecal FTY720 (2.5 or 25 ng daily; 6 days) or vehicle during the chronic (7 weeks after fracture) stage of CRPS.ResultsIntrathecal recombinant FTY720 administration was antiallodynic in the chronic stage of the CRPS mouse model, and such an effect of FTY720 developed by modulating astrocyte activation in the spinal cord. Additionally, according to the in vitro data, the FTY720 treatment inhibited S1P-induced increase in the nitric oxide production and suppression of the NF-κB pathway, by inhibiting the phosphorylation of NF-κB/p65 in astrocytes without toxic effect on astrocytes.ConclusionCollectively, these results demonstrate that intrathecally administered FTY720 attenuates mechanical allodynia in the chronic stage of the CRPS mouse model.
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Barth, Robert J., and Tom W. Bohr. "Challenges in the Diagnostic Conceptualization of CRPS-1 (Formerly Conceptualized as RSD)." Guides Newsletter 11, no. 2 (March 1, 2006): 1–3. http://dx.doi.org/10.1001/amaguidesnewsletters.2006.marapr01.
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Abstract From the previous issue, this article continues a discussion of the potentially confusing aspects of the diagnostic formulation for complex regional pain syndrome type 1 (CRPS-1) proposed by the International Association for the Study of Pain (IASP), the relevance of these issues for a proposed future protocol, and recommendations for clinical practice. IASP is working to resolve the contradictions in its approach to CRPS-1 diagnosis, but it continues to include the following criterion: “[c]ontinuing pain, which is disproportionate to any inciting event.” This language only perpetuates existing issues with current definitions, specifically the overlap between the IASP criteria for CRPS-1 and somatoform disorders, overlap with the guidelines for malingering, and self-contradiction with respect to the suggestion of injury-relatedness. The authors propose to overcome the last of these by revising the criterion: “[c]omplaints of pain in the absence of any identifiable injury that could credibly account for the complaints.” Similarly, the overlap with somatoform disorders could be reworded: “The possibility of a somatoform disorder has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a somatoform scenario.” The overlap with malingering could be addressed in this manner: “The possibility of malingering has been thoroughly assessed, with the results of that assessment failing to produce any consistencies with a malingering scenario.” The article concludes with six recommendations, and a sidebar discusses rating impairment for CRPS-1 (with explicit instructions not to use the pain chapter for this purpose).