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CRPS and the Anaesthetist – a problem all round! Dr Meredith Craigie

CRPS and the Anaesthetist – a problem all round! Dr Meredith Craigie Anaesthetist & Specialist Pain Medicine Physician Anaesthesia and Pain Management, Flinders Medical Centre Pain Management Unit, Royal Adelaide Hospital South Australia. Conflict of Interest.

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CRPS and the Anaesthetist – a problem all round! Dr Meredith Craigie

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  1. CRPS and the Anaesthetist – a problem all round! Dr Meredith Craigie Anaesthetist & Specialist Pain Medicine Physician Anaesthesia and Pain Management, Flinders Medical Centre Pain Management Unit, Royal Adelaide Hospital South Australia

  2. Conflict of Interest • Employed at FMC, RAH, Adelaide, South Australia • Private practice at Pelvic Pain SA • Affiliated with Faculty of Pain Medicine, ANZCA and Australian and New Zealand College of Anaesthetists

  3. Outline of the problems • What causes CRPS? • What are the diagnostic criteria for CRPS in children? • Psychological factors in CRPS – cause or effect? • How can we manage CRPS in children? • What is the role of the Anaesthetist? • Prognosis for children with CRPS?

  4. An Australian story of CRPS

  5. 3 months later……

  6. Pathophysiology of CRPS • Persistent inflammatory activity • Pathological vasospasm • fMRI changes – the “CRPS brain” • Visual distortion and changes in somatosensory cortex S1 • QST changes • Small fibre neuropathy Parkitny et al (2013) Neurology 80:106-117 Moseley, Pearson, Spence (2008) CurrBiol 18:R1048 Pistorius et al (2013) Angiology 59:301-5 Maihofner et al (2003) Neurology 61:1707-15 Lebel et al (2008) Brain 131:1854-79 Sethna et al (2007) Pain 131:153-61

  7. Budapest criteria for CRPS • Continuing pain disproportionate to the inciting event • Symptoms- at least 1 symptom in 4 categories • Sensory • hyperaesthesia • Vasomotor • temp asymmetry; colour changes and/or skin colour asymmetry • Sudomotor/oedema • oedema; sweating changes and/or sweating asymmetry • Motor/tropic • decreased ROM; motor dysfunction; hair, nail or skin changes Harden, Bruehl et al (2010) Pain 150:268-74

  8. Budapest criteria for CRPS • Signs: evidence of at least 1 sign in 2 or more categories • Sensory • hyperalgesia (pin prick) and/or allodynia (light touch) • Vasomotor • temp asymmetry; colour changes and/or skin colour asymmetry • Sudomotor • oedema; sweating changes and/or swearing asymmetry • Motor/tropic • decreased ROM; motor dysfunction; hair, nail or skin changes Harden, Bruehl et al (2010) Pain 150:268-74

  9. CRPS presentations • Epidemiology • Females : males 5-13:1 • Lower limb : upper limb 5-16:1 • Peak age 12-14 years • Triggers • Minor trauma to major surgery • Immunisation • None identified Murray et al (2000) Arch Dis Child 82:231-33 Wolter, Knoller, Rommel (2012) EurNeurol 68:52-58 Pearson, Bailey (2011) Military Medicine 176:876-8 Richards et al (2012) Arch Dis Child 97:913-5

  10. 1 week later….. • Hospital management • Bed rest/bed cradle • Morphine PCA • No progress after 1 wk • See PMU consultant • Get rid of PCA/opioids • See physiotherapist • See psychologist • Return to psychiatrist

  11. Psychological issues • Somatisation 60% • Mood disorders 29% • Anxiety 47% • Depression 27% • Peer/school problems 27/13% • Social isolation • Cognitive function generally intact • Impaired memory/working composite memory Ciccone, Bandilla, Wu (1997) Pain 71:323-33 Cruz, O’Reilly et al (2011) Clin J Pain 27:27-34

  12. Families • Genetic basis in some families • Family problems 40% • Impact on family members • Economic impact • 40% CRPS I • 2/3 not in full-time school • 68% parents took time off work • UK: direct and indirect costs ~ £ 8,000/yr • extrapolates to £ 3,840 million /yr Shirani et al (2010) Can J NeurolSci 37:389-94Sleed et al (2005) Pain 119:185-90 Pearson, Bailey (2011) Military Medicine 176:876-8

  13. Treatment options • Based on biopsychosocial model • Multidisciplinary approach • Physiotherapy • Psychology • Individual and family therapy +/- psychiatry • Medication • Blocks • Other novel treatments

  14. What affects Rx choices for children? • Beliefs concerning causes of pain • Knowledge and preferences for pain Rx • Expectations of outcome of pain Rx • Reduction in pain required for patient to resume ‘reasonable activities’ • Typical coping response for stress or pain • Family expectations & beliefs

  15. Physiotherapy key to recovery • Goal: functional restoration • Desensitisation • Hydrotherapy • Land exercises • Mirror box therapy • Lee et al (2002) 141:135-40 Wilder (2006) Clin J Pain 22:443-8 • Logan et al (2012) Clin J Pain 28:766-74

  16. Role of the Anaesthetist in CRPS • Interventionist only? • Clinical team leader • Requirements: • Understand pathophysiological aetiologies • Understand key management principles • Understand role of medication in managing CRPS • Understand evidence for regional blockade and other invasive techniques

  17. Wheeler, Vaux, Tam (2000) PedNeurol 22:220-1

  18. Regional blockade • IV regional blockade • Guanethidine • Lignocaine • Ketorolac • Catheter techniques • Major nerve plexus • Epidural • Intrathecal Kaplan, Claudio, Kepes, Gu (1996) 40:1216-22 Suresh, Wheeler, Patel (2003) AnesthAnalg 96:694-5 Cepeda, Carr, Lau (2005) Cochrane Database of Systematic Review CD004598 Dadure et al (2005) Anesth 102:387-91

  19. Other invasive treatments • Intravenous lignocaine infusion • Spinal cord stimulation • Novel treatments • IV pamidronate • IV Iloprost (prostaglandin analog) • Intrathecalziconamide Wallace et al (2000) Anesthesiol 92:75-83 Petje et al (2005) Clin Ortho & Rel Res433:178-82 Stanton-Hicks, Kapural (2006) J Pain Sympt Manage 32:509-11 Olssen, Meyerson, Linderoth (2008) Eur J Pain 12:53-9 Simm, Briody et al (2010) 46:885-88

  20. Role of psychologist • Assessment of child • Based on CBT, ACT • Challenge thoughts • Biobehavioural techniques • Breathing techniques • Meditation • Self-hypnosis • Facilitate physical therapy

  21. Psychiatrist • Controversial area • At risk of anxiety or depression 67% • At risk of anxiety, depression and somatisation 47% • Family therapy • Medication if necessary Cruz et al (2011) Clin J Pain 27:27-34

  22. Progressing recovery Child taking charge of own management • Willingness to self-manage pain • Active coping strategies • Support team • Return to school Logan et al (2012) 153:1863-70

  23. Prognosis • Overall outcomes better in children • Highly variable recovery time • Morbidity • Relapse rates high - 50%-79% • 10% symptoms persist > 1yr • Future treatment options • Immunomodulatory agents Sherry et al (1999) Clin j Pain 15:218-22 Murray et al (2000) Arch Dis Child 82:231-33 Lee et al (2002) J Pediatr 141:135-40 Logan et al (2012) Clin J Pain 28:766-74

  24. Resources • My Pain Toolkit www.paintoolkit.org • “Good practice in postoperative and procedural pain” -APAGBI • www.apagbi.org.uk/docs/APA_Guidelines_on_Pain_ Management.pdf • Acute Pain Management: Scientific Evidence 3rd Ed. ANZCA and FPM www.anzca.edu.au/resources/ • Book “Pain Pain Go Away Helping Children with Pain” download at www.rch.org.au

  25. Summary • Outlined potential causes CRPS • Diagnostic criteria for CRPS in children • Psychological factors in CRPS • Management options for CRPS in children • The role of the Anaesthetist • Relatively good prognosis for children with CRPS

  26. Thank you • THE TEAM • Dr Bruce Foster, Orthopaedic surgeon • Dr Penny Briscoe, Pain Medicine Physician • Ms Helen Burgan, Physiotherapist • Ms Lindy Peterson, Clinical Psychologist • Dr John Govan, Psychiatrist • Pembroke School • Catherine’s family and friends

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