Investigations to identify factors for a poor prognosis and to evaluate new therapeutic interventions regarding the complex regional pain syndrome (crps/M.Sudeck)

Status:

completed 09/2010

Aims:

Early identification of difficult recovery processes as well as clinical efficiency evaluation of new therapeutic interventions.
Complex regional pain syndrome (CRPS) is a condition resulting from a complication of fractures and lesions of the upper extremities, which, albeit rare, will often lead to permanent disability. The pathological mechanism of the condition is as yet unknown.

Activities/Methods:

Here we present the first extensive, prospective and controlled study to use a combination of clinical, neurophysiological, electrophysiological, immunological and imaging methods on the one hand and psychological exploration methods on the other.

Results:

Patients with complex regional pain syndrome (CRPS) showed a significantly stronger impediment of joint function, compared to a control group reporting comparable pain intensities. In measurements of skin exudates we found increased levels of proinflammatory and reduced levels of anti-inflammatory cytokine concentrations. Moreover, the CRPS group exhibitied significantly more prominent neglect-like symptoms, together with disturbances of their body representation and of unilateral sensorimotor inhibition, combined with static hyperalgesia.
60% of CRPS patients - significantly more than in the control group - benefitted from a multimodal therapy as revealed by improvements in all parameters investigated in this study. Normalization of inflammation parameters was independent of therapeutic success. Changes in the central nervous system, however, correlated closely with the pain reduction achieved in therapy. The outcome of the six months multimodal therapy was related to the pre-existing psychological stress level. Those patients with lower psychological stress levels showed the strongest pain reduction in combination with the most prominent improvement of function.
The findings in this study underline that the particulars of the CRPS syndrome result from an interplay of psychological and physical - specifically central nervous - changes, associated with disturbances of the body representation and distorted processing of sensory and motor stimuli. This explains why monodisciplinary therapies regularly failed. For the first time, we could show that a multimodal therapy approach did not only achieve pain reduction, but in 48% of cases also restored the patient's ability to work within six months. Here, the recovery of joint movability seems to be the key factor. We did not find a single prognostic factor which prohibited therapy success. Those favourable findings show how important it is to start a specialized therapy in an early stage of CRPS.
A consequence for therapies of the Social Accident Insurance is to enforce a systematic, early coordination and implementation of a therapy in qualified treatment centers of the Social Accident Insurances. Therapeutic efficacy of the non-invasive mirror therapy was demonstrated in a separate study on amputees suffering from neuropathic pain. Thus, within the framework of a multimodal approach, the controlled use of innovative therapy methods should be encouraged in qualified competency centers of the Social Accident Insurance.
More research is needed with regard to how therapeutic efficacy can be further improved by means of individualizing and thus optimizing various therapy components, while taking into account identified pathogenetic factors.

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