CRPS Bugle 10/10/13 | #CRPS

CRPS BugleWelcome to The CRPS Bugle–a selection of recent papers to peruse:

Clin J Pain. 2013 Nov;29(11):e33-e34.

Favorable Outcome of an Acute Complex Regional Pain Syndrome With Immunoglobulin Infusions.

Medlin F, Zekeridou A, Renaud S, Kuntzer T.



To emphasize that complex regional pain syndrome (CRPS), a disabling disorder with the implication of aberrant inflammation, vasomotor dysfunction, and maladaptive neuroplasticity, might be treated with a high dose of intravenous immunoglobulin infusions (IVIG).


We describe a patient who presented with CRPS in the acute phase of the disease.


The CRPS developed secondary to sciatic compression in a young patient and was treated within 10 days by high-dose IVIG (2 g/kg). It resolved completely within days after infusions.


This observational study emphasizes that high-dose IVIG may be a treatment option in the acute phase of CRPS

RS: Interesting but bear in mind that this is a case study with one patient


Ann Intern Med. 2010 Feb 2;152(3):152-8. doi: 10.7326/0003-4819-152-3-201002020-00006.

Intravenous immunoglobulin treatment of the complex regional pain syndrome: a randomized trial.

Goebel A, Baranowski A, Maurer K, Ghiai A, McCabe C, Ambler G.


University of Liverpool, Clinical Sciences Building, University Hospital Aintree, Liverpool L9 7AL, United Kingdom.



Treatment of long-standing complex regional pain syndrome (CRPS) is empirical and often of limited efficacy. Preliminary data suggest that the immune system is involved in sustaining this condition and that treatment with low-dose intravenous immunoglobulin (IVIG) may substantially reduce pain in some patients.


To evaluate the efficacy of IVIG in patients with longstanding CRPS under randomized, controlled conditions.


A randomized, double-blind, placebo-controlled crossover trial. (National Research Registry number: N0263177713; International Standard Randomised Controlled Trial Number Registry: 63918259)


University College London Hospitals Pain Management Centre.


Persons who had pain intensity greater than 4 on an 11-point (0 to 10) numerical rating scale and had CRPS for 6 to 30 months that was refractory to standard treatment.


IVIG, 0.5 g/kg, and normal saline in separate treatments, divided by a washout period of at least 28 days.


The primary outcome was pain intensity 6 to 19 days after the initial treatment and the crossover treatment.


13 eligible participants were randomly assigned between November 2005 and May 2008; 12 completed the trial. The average pain intensity was 1.55 units lower after IVIG treatment than after saline (95% CI, 1.29 to 1.82; P < 0.001). In 3 patients, pain intensity after IVIG was less than after saline by 50% or more. No serious adverse reactions were reported.


The trial was small, and recruitment bias and chance variation could have influenced results and their interpretation.


IVIG, 0.5 g/kg, can reduce pain in refractory CRPS. Studies are required to determine the best immunoglobulin dose, the duration of effect, and when repeated treatments are needed.

RS: this study from 2010 demonstrated reduced pain but in a small group


Arch Phys Med Rehabil. 2013 Sep 27

Complex regional pain syndrome type I. Incidence and risk factors in patients with fracture of the distal radius.

Jellad A, Salah S, Frih ZB.


University of Monastir Tunisia, Faculty of Medicine, Department of Physical Medicine and Rehabilitation. Electronic address:



To examine the incidence and predictors of complex regional pain syndrome type I (CRPS I) after fracture of the distal radius.


Prospective study SETTING: University hospital PARTICIPANTS: A consecutive sample of patients (N=90) with fracture of the distal radius treated by closed reduction and casting.


Not applicable MAIN OUTCOME MEASURES: Occurrence of CRPS I, pain, wrist and hand range of motion, radiographic measures, Patient-Rated Wrist Evaluation, Hospital Anxiety and Depression scale and The Short Form 36 at baseline and at 1, 3, 6 and 9 months follow-up.


CRPS I occurred in 29 patients (32.2%) with a mean delay of 21.7±23.7 days from cast removal. Univariate analyses found significant differences between patients with CRPS I and patients without CRPS I at baseline for gender (p=0.021), socio economic level (p=0.023), type of trauma (p=0.05), pain at rest and at activity (p=0.006 and p<0.001), wrist dorsiflexion and pronation (p=0.002 and p=0.001), fingers flexion (p=0.047), thumb opposition (p=0.002), function of the hand (p<0.001), and physical quality of life (p=0.013). Logistic regression showed that risk for CRPS I was higher in cases of female gender (OR:5.774;95%CI:1.391 to 23.966), medium and low energy trauma (OR:7.718;95% CI:1.136 to 52.44), physical quality of life of the short form 36 < 40 (OR:4.931;95%CI:1.428 to 17.025) and patient-rated wrist evaluation pain subscale >16 (OR:12.192;95%CI:4.484 to 43.478).


CRPS I occurs frequently during the third and fourth week after cast removal especially in women who report severe pain and impairment of their physical quality of life. Additional prospective studies are required to verify these findings in comminuted and operated fractures of the distal radius


J Pain. 2013 Sep 21. pii: S1526-5900(13)01130-9. 

Motor Dysfunction of Complex Regional Pain Syndrome Is Related to Impaired Central Processing of Proprioceptive Information.

Bank PJ, Peper CL, Marinus J, Beek PJ, van Hilten JJ.


Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Research Institute MOVE, Faculty of Human Movement Sciences, VU University Amsterdam, The Netherlands. Electronic address:


Our understanding of proprioceptive deficits in complex regional pain syndrome (CRPS) and its potential contribution to impaired motor function is still limited. To gain more insight into these issues, we evaluated accuracy and precision of joint position sense over a range of flexion-extension angles of the wrist of the affected and unaffected sides in 25 chronic CRPS patients and in 50 healthy controls. The results revealed proprioceptive impairment at both the patients’ affected and unaffected sides, characterized predominantly by overestimation of wrist extension angles. Precision of the position estimates was more prominently reduced at the affected side. Importantly, group differences in proprioceptive performance were observed not only for tests at identical percentages of each individual’s range of wrist motion but also when controls were tested at wrist angles that corresponded to those of the patient’s affected side. More severe motor impairment of the affected side was associated with poorer proprioceptive performance. Based on additional sensory tests, variations in proprioceptive performance over the range of wrist angles, and comparisons between active and passive displacements, the disturbances of proprioceptive performance most likely resulted from altered processing of afferent (and not efferent) information and its subsequent interpretation in the context of a distorted “body schema.”


The present results point at a significant role for impaired central processing of proprioceptive information in the motor dysfunction of CRPS and suggest that therapeutic strategies aimed at identification of proprioceptive impairments and their restoration may promote the recovery of motor function in CRPS patients.

RS: we know that in many persisting pain cases, especially those with a neuropathic pain mechanism, there is an altered body schema. This must be targeted within the treatment and training programme.

Visit our main clinic page here: Specialist Pain Physio Clinics for persisting pain and injury



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