CRPS Bugle | April 2014 | All your research updates #CRPS

Welcome to the April update — click on ‘abstract’ for link to Pubmed

Dermatological Findings in Early Detection of Complex Regional Pain Syndrome.
Kabani R, Brassard A.

IMPORTANCE Complex regional pain syndrome (CRPS) is a chronic pain condition usually affecting the extremities. It mostly occurs in 3 distinct stages with intense pain being the hallmark feature in every stage. Skin abnormalities are common, and often necessary, in the clinical findings required to diagnose CRPS. OBSERVATIONS A man in his 30s presented to the dermatology clinic with complaints of recurrent redness, swelling, and burning pain in his left arm. Based on this clinical presentation with normal findings from a neurological examination and unremarkable findings on diagnostic imaging, the diagnosis of CRPS was made. CONCLUSIONS AND RELEVANCE It is important for dermatologists to understand and recognize CRPS as a neurological disorder with major dermatologic implications. The ability of dermatologists to identify and direct patients with this syndrome is a critical factor in determining the likelihood of favorable outcomes following diagnosis of CRPS. This report outlines and reviews a neurological condition presenting with clinically significant cutaneous changes. We illustrate the bias that dermatologists may have in exclusively associating patient complaints with dermatological implications. This stresses the necessity for dermatologists to perform comprehensive medical histories and physical examinations to minimize diagnostic error and improve patient care.


Complex regional pain syndrome in a 15-year-old girl successfully treated with continuous epidural anesthesia.
Saito Y1, Baba S2, Takahashi A3, Sone D4, Akashi N5, Koichihara R2, Ishiyama A2, Saito T2, Komaki H2, Nakagawa E2, Sugai K2, Sasaki M2, Otsuki T3.

A 15-year-old girl developed severe pain in her right upper limb within a few days after she experienced an astatic epileptic seizure accompanied by falling on her right side. She was treated with fluid infusion through a cannula into her right hand. Swelling, mild flaring, and muscle weakness of the right arm subsequently appeared. Pharmacotherapy and stellate ganglion block were ineffective, and continuous epidural anesthesia was commenced 14days after the falling event. The pain and accompanying symptoms completely disappeared within 5days. Early treatment with continuous epidural anesthesia may be a promising option for the management of complex regional pain syndrome during childhood.

RS: Interesting but remember this is a case study!


Case report: Long-standing complex regional pain syndrome relieved by a cephalosporin antibiotic.
Ware MA1, Bennett GJ2.

We describe a young woman who had had treatment-refractory complex regional pain syndrome (CRPS) for 6years before receiving antibiotic treatment with cefadroxil (a cephalosporin derivative) for a minor infection. Cefadroxil reduced the patient’s pain and motor dysfunction (dystonia and impaired voluntary movement) within days; the pain and motor disorder returned when cefadroxil was discontinued; and both again abated when cefadroxil was re-instituted. The patient has now had symptom relief for more than 3years on continuing cefadroxil therapy. We discuss this case in the context of previous reports of antibiotic treatment relieving neuropathic pain in experimental animals.

RS: Again interesting but a case study.


Complex Regional Pain Syndrome in a Young Athlete with Von Willebrand Disease.
Khadavi MJ1, Alm JC, Emerson JA.

A 17-year-old female with type 1 Von Willebrand Disease (vWD) developed left medial calf pain while running track. Over the next 6 months, orthopedic surgery, sports medicine, vascular surgery, and neurology treated her under various working diagnoses; however, the pain, allodynia, coldness, and pale skin color worsened. She was admitted to a tertiary pediatric hospital for intractable pain where PM&R diagnosed her with complex regional pain syndrome (CRPS) type 1, began gabapentin, and initiated an aggressive inpatient rehabilitation program. During her 3 weeks of inpatient rehabilitation, passive range of motion of knee extension improved from 40° from extension to full extension, and ankle dorsiflexion improved from 15° from neutral to a consistent range of motion beyond neutral. Additional outcome measures were distance of ambulation and assistive device usage; from admission to inpatient rehabilitation to 2 months postdischarge, her weight-bearing tolerance progressed from nonweight-bearing to partial weight-bearing, and ambulation improved from 20 feet with a three-point crutch gait to unlimited distances with a four-point crutch gait. This is the first known case of a bleeding disorder as the likely underlying microvascular pathology associated with CRPS, a theory exposed in 2010.


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The Inner Voice — what is it saying? Do you respond?

We all know the little voice that chunters away at us whilst we are awake, often influencing our choices and behaviours. This inner dialogue structures our thoughts that emerge from our belief system, a system that has evolved since we started interacting with the world. That combination of our genetic blueprint and experience grooves the way we see ourselves and experience our lives. 



The Inner Voice – do you listen?

The inner voice impacts enormously; can’t live with it, can’t live without it. Both our brilliant thoughts and destructive thoughts come from this dialogue, the balance of the two driving our behaviours at any given moment. So are we passively subject to the words uttered in our head or can we choose whether we listen or ignore?

I would argue that we can choose how we respond to the inner voice. We are not always very good at it, but we can improve. The thoughts that I refer to are those known as automatic thoughts. They just pop in there, frequently come in waves and can if not checked, habitually trigger emotional and physical responses. These responses are both positive and negative, although it seems we err towards the latter. Perhaps this is a survival instinct to tend toward cautionary options. 

A negative thought that is ‘lived’, either dragging us back to an event in the past or one that exists in a future, is one we embody. We play it out via our physical existence. To the brain it is very real hence the feelings noted in the body. The brain does not differentiate between a thought and reality, the responses are similar. This leads to the question, how true are our thoughts? How close are they to reality? One could argue that if it is a thought about the past or the future, this cannot be reality because neither exist except in our heads. The past has gone. The future never comes.

To practice mindfulness means that we are paying attention to the present moment without judgement. For our thoughts that we cannot stop, we can be observant of the train that trundles through our head. But instead of letting it stop at every station and allowing a hullabaloo of passengers on an off, the train rolls on through with no or minimal impact. Thoughts come and thoughts go. It is only when we grab hold and play with them do the effects kick in. This sounds very simple and in practice, mindfulness is a simple concept. The truth is that it takes practice, although even after a few weeks of dedicated training, the effects are noticed.

The effects of mindful practice are far reaching in our body systems: for example, reduced muscle tension, clearer thinking, less pain, increased happiness, reduced inflammation, reduced rumination, increased energy, increased awareness, better relationships — sounds good doesn’t it? And the reason for these feel good factors? By and large we can say that it is due to reducing the threats in life that are consistently triggering protective responses in the body that include pain, tension, deteriorating performance at work and unhappiness. All the time that we are associating ourselves with our thoughts, defining ourselves with our thinking and letting the body systems protect in response to thoughts, we will be affecting our physical and mental health, and our ability to live — the essence of suffering.

I use mindfulness training as part of the comprehensive treatment and training programmes for chronic pain for the reasons outlined above. There is no mystery, no religious or spiritual connotation, but rather a simple way of training the mind to focus upon what you want to focus upon and not passively following the wandering mind. Remember that you cannot stop thinking and thoughts arising, that is the mind’s job. But you can become skilled at deciding whether to respond or just let it go, hence minimising the body’s responses and feelings of anxiety, stress and pain. It is important to point out that feelings of stress and anxiety are normal and actually desirable survival mechanisms that prepare us and motivate us for the right action, but in the short term and not in a prolonged manner that causes distress, suffering and an amplification of pain. So, take action, learn how to hear the voice but decide whether to respond or let it go.

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