CRPS, type I

1. What is the most common cause of hemiplegic shoulder pain?
2. What is Complex Regional Pain Syndrome (CRPS)? What is the most common subtype?
3. What are the stages of CRPS?
4. How is CRPS diagnosed?
5. What are the physical exam findings of Shoulder-hand syndrome?
6. What is the treatment for CRPS?

Answers:
1. CRPS, soft tissue lesions (including plexopathy).
2. CRPS is characterized by sympathetic mediated pain and related sensory abnormalities, abnormal blood flow, abnormalities in motor system, and changes in superficial and deep structures. Most common subtype is shoulder-hand syndrome.
3. Stage 1 (acute) lasts 3-6 months, involving burning pain, swelling.edema, exquisite tenderness, vasomotor changes. Stage 2 (dystrophic) lasts 3-6 months and involves more intense pain that spreads proximally, with skin/muscle/nail atrophy, edema, cold insensitivity. Stage 3 (atrophic) involves decreased pain with pale cyanotic skin, smooth and shiny appearance, cool and dry, with weakness/atrophy, contractures/flexion deformities.
4. X-rays may show periarticular osteopenia. Bone scan showing diffusely increased juxta-articular tracer activity on delayed images. EMG showing spontaneous activity predicts eventual development of CRPS. Stellate ganglion block that alleviates pain is the gold standard.
5. Shoulder pain with ROM, lack of elbow pain, no pain with pronation/supination, wrist dorsiflexion pain, pain with MCP/PIP flexion, PIP edema, MCP tenderness, pain out of proportion to clinical findings.
6. ROM exercises, corticosteroids, intra-articular corticosteroid injection, NSAIDs, tricyclics, diphosphonates, calcitonin, anticonvulsants, alpha-blockers, beta-blockers, Ca-blockers, topical capsaicin, TENS, contrast bath, edema control, desensitization, US, sympathetic ganglion blocks, local injections, sympathectomy.