Complex Regional Pain Syndrome Series: Peripheral Inflammation

Complex Regional Pain Syndrome (CRPS) is a complex and poorly understood problem. There have been several proposed interacting pathophysiological features of the condition including altered sympathetic nervous system function, central sensitisation, inflammatory factors, immune factors, genetic factors, brain changes and psychological factors (Bruehl, 2015; Marinus et al., 2011). Most diagnostic criteria come from clinical features of the condition and recent advances in understanding the pathophysiological aspects have provided a more comprehensive means to providing an accurate diagnosis (Birklein & Schlereth, 2015; Bruehl, 2015).

This second blog in my musings and understanding of CRPS looks at the peripheral inflammatory stages of CRPS. I apologise now for it may be heavy going.

CRPS is a chronic pain disorder characterised by sensory, autonomic features, motor disturbance and inflammatory changes in the region of the painful body part (Bruehl, 2015). CRPS is more prevalent with the hands or feet and can develop following any insult to tissue. It is sub-divided in two forms CRPS type 1 and CRPS type 2. Both occur because of injury to a body part with type 2 involving an identifiable nerve injury (Smart, Wand, & O’Connell, 2016)

CRPS has several pathophysiological features which may all (or not) be present. This can explain the clinical heterogeneity that is often faced with the condition. Furthermore, the heterogeneity of the condition presents as a complex and challenging problem for both clinician and patient. To discuss the extensive pathophysiological features of the condition is beyond the scope of this paper and the author refers readers to comprehensive texts for further reading (Birklein & Schlereth, 2015; Bruehl, 2015; Harden, Bruehl, Stanton-Hicks, & Wilson, 2007; Marinus et al., 2011; Smart et al., 2016).

As previously mentioned CRPS is more prevalent in the hands or feet and can develop following any insult to associated tissue. More common initiating events are fractures, crush injuries, sprains and surgery (Bruehl, 2010). These types of injuries can cause significant inflammatory responses which with any acute trauma lead to sensitisation of peripheral nociceptors (Marchand, Perretti, & Mcmahon, 2005). CRPS is a complex condition with a complicated pathophysiology and since the diagnostic criteria released in 1994 (Merskey & Bogduk, 1994) confusion for clinicians has resulted in non-CRPS conditions to be diagnosed as CRPS. The International Association­ for the Study of Pain (IASP) updated the 1994 diagnostic criteria to the Budapest criteria in 2007 with research validation in 2010 (Harden et al., 2010, 2007).

IASP Budapest criteria for CRPS

The update was required due to over-diagnosis of non-CRPS conditions including peripheral pain presentations such as peripheral neuropathy or even delayed healing following surgery (Birklein & Schlereth, 2015).

CRPS is associated with a multitude of interacting pathophysiological mechanisms that involve multiple systems from the peripheral tissue to the central nervous system and immune systems. It has been poorly understood due to the lack of animal models to provide measurable biomarkers and most diagnostic criteria come from clinical features of the condition. Recent advances in understanding the pathophysiological aspects have provided a more comprehensive means to providing an accurate diagnosis (Birklein & Schlereth, 2015). The remainder of this blog will briefly investigate the peripheral inflammatory mechanisms of CRPS.

Proposed pathophysiology of CRPS

Inflammatory mechanisms – peripheral

Peripheral sensitisation is activated by inflammatory mechanisms in several ways. As with all initiating injuries a local inflammatory response occurs in the tissues, a component of the tissue healing process. It also activates the process of transduction, the initial precursor to the afferent delivery of electrical activity in the nervous system, in the case of tissue insult, nociception (Dawes, Andersson, Bennett, Bevan, & Mcmahon, 2016). During this process, inflammatory mediators are released including Bradykinin, Prostaglandins, leukotrienes, substance P. This also includes the release of cytokines such as tumour necrosis factor, nerve growth factor, interleukin 1 & 6 (Meyer, Ringkamp, Campbell, & Raja, 2013).

Moreover, inflammatory mechanisms related to CRPS include the amplification of cytokines and nerve growth factor. These two chemical mediators are involved in exciting nociceptors and producing long-term peripheral sensitisation and have also been linked to enhancing the release of pro-inflammatory neuropeptides in primary sensory neurons (Marinus et al., 2011; Sommer & Kress, 2004). Peripheral sensitisation involves the activation of cutaneous nociceptors. The persistent stimulation of cutaneous nociceptors promotes the release of neuropeptides such as substance P and calcitonin gene related peptide (CGRP). These neuropeptides appear to mediate the pro-inflammatory changes that occur in CRPS. This includes inflammatory signs of redness, heat and oedema related to the process of neurogenic inflammation (Dawes et al., 2016; Marinus et al., 2011).

The nociceptor in peripheral sensitisation alters its receptor bioavailability, thus increasing the opportunity for chemical mediator binding. Therefore, due to the increase in receptor numbers there is an increased affinity for binding and nerve depolarisation. Furthermore, studies have shown the impact of prolonged substance P release on keratinocytes (skin cells). An increase in receptor availability on Keratinocytes increases the release of cytokines and neuropeptides and compounds the familiar signs associated with CRPS – limb oedema, redness, heat – a perpetuating cycle (Dallos et al., 2006; Kingery, 2010).

Due to the ongoing inflammatory process, the process of nociception and resultant central sensitisation changes that can occur, a perpetuating cycle of swelling, redness and oedema is maintained.  This is particularly evident in the mechanism of mechanical hyperalgesia, which has been directly related to central sensitisation. Mechanical hyperalgesia refers to an amplified response to some form of deformation of the tissue that normally provokes pain (Woolf, 2011). Maihöfner, Handwerker, Neundörfer, & Birklein, (2005) identified that more than half of CRPS patients presented with pin-prick hyperalgesia. Moreover, sensory neurons involved in the transmission of nociception (A-delta and C-fibers) are responsible for peripheral sensitisation and central sensitisation respectively.

As previously mentioned the pathophysiology of CRPS is a complex one, with the inflammatory component being one part of a multi-factorial aetiology. Inflammation does not primarily involve peripheral tissue it is also postulated to be prevalent in the spinal cord sensitising second order nociceptors. Moreover, additional factors such as glial-neuronal interactions are also likely to occur (Marinus et al., 2011).

People living with CRPS face a turbulent and challenging life due to the multi-factorial pathophysiological features of the condition.  Many personal accounts from patients refer to CRPS as the ‘suicide disease’. Due to the intense levels of pain experienced, patients are prepared to take their own life. The case study in this assignment displayed psychological features of depression, anxiety, stress, severe levels of catastrophic thought and low self-efficacy. Therefore due to the associated psychosocial factors with chronic pain conditions it would seem pertinent that psychological approaches are implemented as part of a management approach for CRPS (Bean, Johnson, Heiss-Dunlop, Lee, & Kydd, 2015). CRPS is not a condition that can be treated via a single interventional approach, with low quality evidence to support several single and combined approach interventions (O’Connell et al., 2013). Complex pathophysiological and psychosocial factors are associated with the condition and so further high quality research is urgently needed for more effective treatment.

If you have gotten this far, thanks so much for reading. In time I aim to release future blogs on the other aspects of CRPS with the aim of looking at interventions more closely.

Your comments are always welcome

TNP

 

 

References:

Bean, D. J., Johnson, M. H., Heiss-Dunlop, W., Lee, A. C., & Kydd, R. R. (2015). Do psychological factors influence recovery from complex regional pain syndrome type 1? A prospective study. Pain, 156(11), 2310–8. http://doi.org/10.1097/j.pain.0000000000000282

Beerthuizen, A., van ’t Spijker, A., Huygen, F. J. P. M., Klein, J., & de Wit, R. (2009). Is there an association between psychological factors and the Complex Regional Pain Syndrome type 1 (CRPS1) in adults? A systematic review. Pain, 145(1–2), 52–59. http://doi.org/10.1016/j.pain.2009.05.003

Birklein, F., & Schlereth, T. (2015). Complex regional pain syndrome-significant progress in understanding. Pain, 156 Suppl, S94-103. http://doi.org/10.1097/01.j.pain.0000460344.54470.20

Bruehl, S. (2010). An update on the pathophysiology of complex regional pain syndrome. Anesthesiology, 113(3), 713–725. http://doi.org/10.1097/ALN.0b013e3181e3db38

Bruehl, S. (2015). Complex regional pain syndrome. British Medical Journal, 350. http://doi.org/10.1136/bmj.h2730

Chien, C. W., Bagraith, K. S., Khan, A., Deen, M., & Strong, J. (2013). Comparative responsiveness of verbal and numerical rating scales to measure pain intensity in patients with chronic pain. Journal of Pain, 14(12), 1653–1662. http://doi.org/10.1016/j.jpain.2013.08.006

Dallos, A., Kiss, M., Polyánka, H., Dobozy, A., Kemény, L., & Husz, S. (2006). neuropeptides substance P, calcitonin gene-related peptide, vasoactive intestinal polypeptide and galanin on the production of nerve growth factor and inflammatory. Neuropeptides, 40(4), 251–263. http://doi.org/10.1016/j.npep.2006.06.002

Dawes, J. M., Andersson, D. a, Bennett, D. L. H., Bevan, S., & Mcmahon, S. B. (2016). Chapter  3 – Inflammatory Mediators and Modulators of Pain. Wall & Melzack’s Textbook of Pain (Sixth Edit). Elsevier Ltd. http://doi.org/10.1016/B978-0-7020-4059-7.00003-6

Harden, R. N., Bruehl, S., Perez, R. S. G. M., Birklein, F., Marinus, J., Maihofner, C., … Vatine, J. J. (2010). Validation of proposed diagnostic criteria (the “budapest Criteria”) for Complex Regional Pain Syndrome. Pain, 150(2), 268–274. http://doi.org/10.1016/j.pain.2010.04.030

Harden, R. N., Bruehl, S., Stanton-Hicks, M., & Wilson, P. R. (2007). Proposed new diagnostic criteria for complex regional pain syndrome. Pain Medicine, 8(4), 326–331. http://doi.org/10.1111/j.1526-4637.2006.00169.x

Kendall, N. A, Linton, S.J, Main, C. J. (2004). New Zealand Acute Low Back Pain Guide. New Zealand Guidelines Group.

Kingery, W. S. (2010). Role of neuropeptide, cytokine, and growth factor signaling in complex regional pain syndrome. Pain Med, 11(8), 1239–1250. http://doi.org/PME913 [pii]\r10.1111/j.1526-4637.2010.00913.x

Lovibond, S.H. & Lovibond, P.F. (1995).  Manual for the Depression Anxiety Stress Scales(2nd. Ed.) Sydney: Psychology Foundation.  ISBN 7334-1423-0.

Maihöfner, C., Handwerker, H. O., Neundörfer, B., & Birklein, F. (2005). Mechanical hyperalgesia in complex regional pain syndrome: A role for TNF-α? Neurology, 65(2 SUPPL. 1), 311–313. Retrieved from http://www.scopus.com/inward/record.url?eid=2-s2.0-22544481453&partnerID=40&md5=b3441df586d2ed585f73e883ded30ca2

Marchand, F., Perretti, M., & Mcmahon, S. B. (2005). ROLE OF THE IMMUNE SYSTEM IN CHRONIC PAIN. Nature Neuroscience, 6, 521–532. http://doi.org/10.1038/nrn1700

Marinus, J., Moseley, G. L., Birklein, F., Baron, R., Maihöfner, C., Kingery, W. S., & van Hilten, J. J. (2011). Clinical features and pathophysiology of complex regional pain syndrome. The Lancet Neurology, 10(7), 637–648. http://doi.org/10.1016/S1474-4422(11)70106-5

Merskey, H., & Bogduk (Eds), N. (1994). Classification of Chronic Pain. Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. IASP Press, i–xvi. http://doi.org/10.1002/ana.20394

Meyer, R. a, Ringkamp, M., Campbell, J. N., & Raja, S. (2013). Peripheral mechanisms of cutaneous nociception. Wall and Melzack’s Textbook of Pain (Sixth Edit). Elsevier Ltd. http://doi.org/10.1016/B978-0-7020-4059-7.00001-2

Moseley, G. L. (2004). Why do people with complex regional pain syndrome take longer to recognize their affected hand? Neurology, 62(12), 2182–2186. http://doi.org/10.1212/01.WNL.0000130156.05828.43

Moseley, G. L., & Gandevia, S. C. (2005). Sensory-motor incongruence and reports of “pain.” Rheumatology, 44(9), 1083–1085. http://doi.org/10.1093/rheumatology/keh631

Moseley, G. L., Zalucki, N. M., & Wiech, K. (2008). Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain. Pain, 137(3), 600–608. http://doi.org/10.1016/j.pain.2007.10.021

Moseley, L. G. (2008). I can’t find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain, 140(1), 239–243. http://doi.org/10.1016/j.pain.2008.08.001

Nicholas, M. K. (2007). The pain self-efficacy questionnaire: Taking pain into account. European Journal of Pain, 11(2), 153–163. http://doi.org/10.1016/j.ejpain.2005.12.008

O’Connell, N. E., Wand, B. M., Mcauley, J., Marston, L., & Moseley, G. L. (2013). Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews ( Review ). The Cochrane Library, (4), 1–68. http://doi.org/10.1002/14651858.CD009416.pub2.www.cochranelibrary.com

Smart, K. M., Wand, B. M., & O’Connell, N. E. (2016). Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Database of Systematic Reviews, 2016(2). http://doi.org/10.1002/14651858.CD010853.pub2

Sommer, C., & Kress, M. (2004). Recent findings on how proinflammatory cytokines cause pain: Peripheral mechanisms in inflammatory and neuropathic hyperalgesia. Neuroscience Letters. http://doi.org/10.1016/j.neulet.2003.12.007

Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995). The Pain Catastrophizing Scale: Development and validation, 7(4), 524–532. Retrieved from http://www.scopus.com/inward/record.url?eid=2-s2.0-0029584617&partnerID=40&md5=7f8615d1b52cbabde152c2e9b9683fff

Tan, G., Jensen, M. P., Thornby, J. I., & Shanti, B. F. (2004). Validation of the brief pain inventory for chronic nonmalignant pain. Journal of Pain, 5(2), 133–137. http://doi.org/10.1016/j.jpain.2003.12.005

Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152(SUPPL.3), S2–S15. http://doi.org/10.1016/j.pain.2010.09.030

Advertisements

6 thoughts on “Complex Regional Pain Syndrome Series: Peripheral Inflammation

      1. Hi NP. Yes, it has helped me to understand how many different path-physiological aspects there are to CRPS. I am a qualified and practicing Physiotherapist who left Physiotherapy many years ago to study Psychotherapy as I felt that I needed to understand the mind to understand the whole. Since I have returned to Physio, I feel a little bit on the ‘out-side edge’ as it were, since my opinion differs from most. I believe that medicine in general has become overcomplicated and over-medicalized and that we should be taking a simpler more holistic view. I appreciate that you make reference to the psychological within this blog. I haven’t had a huge amount of experience with CRPS but I find sometimes that when I have found a simple and effective solution for a patient that they DNA the next time and I can only consider that this is because on some level, they don’t want the simple solution, they want the long drawn out solution that involves much investigation and furrowed brows. The patient that comes to mind is one who presented with CRPS and following a long and detailed history taking and some objective measures, I proposed a treatment of ice and it’s wonderful, natural anti-inflammatory properties, thinking that if the patient understood inflammation that this would help, but she did not return. In summary, I am most interested to hear how you treat these patients. I still struggle to understand how understanding the whole physiological processes helps and how this relates to practice. In my mind, it’s simple, if it’s hot, cool it down, if it’s weak, strengthen it, if there is excessive muscle tone then relax it, in the most natural way possible ie without meds! Thank you

        Like

  1. @louisebernard
    Hold Up! You “haven’t had a huge amount of experience with CRPS but” you still “find sometimes that when you have found a simple and effective solution for a patient that they DNA the next time” and its got to be only “because on some level, they don’t want the simple solution.” Did you pass the medical board all on your own? If so, the only other explanation, then you must be criminally insane! Because only a maniac wants to torture another living and breathing creature or a woman in your case, since you only prescribed an ice pack to a CRPS Patient and a side dish of “no chance in HELL” now at a quality of life! You just inflicted a great deal and unnecessary amount of pain, as well as a whole lot of damage onto your patient! Which of course she should’ve sued you for malpractice… I really hope someone does soon for the sake of man-kind! You are what is wrong with the medical profession and community. You are also why people like myself have developed this horrifically painful incurable chronic disease/condition, known as CRPS. You need to find a different profession because you are not living up to the Hippocratic Oath: do no harm, Louise Bernard!

    Like

    1. Oh never mind! I just realized you’re British so physiotherapist is the same as an American physical therapist, neither are an actual physician but regardless even American PTs know not to put ice packs on their CRPS patients! Education is Key…. Power… So learn about CRPS before judging a patient who has it!

      Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s