Background & Aims

Complex Regional Pain Syndrome (CRPS) is a challenging diagnosis for both patients and clinicians and leads to continuing pain, usually disproportionate to any inciting event and significant disability. CRPS is a chronic pain condition underpinned by a multifactorial origin, involving sensory, vasomotor, edema and trophic symptoms. Patients often present neuropsychological changes, such as reduced attention or neglection of the affected extremity. Yet, there is an “evidence vacuum” once the available and relevant literature remains low and the recent advancements are quite modest. Without great evidence, healthcare professionals must use the available data and embrace the complexity and try to offer a personalized and tailored treatment for each patient that suffers from this syndrome. This work aimed to report the case and share the experience of a multidisciplinary care of a patient with CRPS via telehealth, showing that distance is not an impediment to pain management.

Methods

This a case report about a patient with the diagnosis of CRPS type I that was treated via telehealth by both pain management clinician and physical therapist. Patient was geographically located In England, pain management doctor in The Netherlands and the physical therapist in Brazil. Treatment was offered via online synchronous sessions. The clinical diagnosis was made by Budapest Criteria and did not receive any interventional procedure but was advised about the origin of her pain and multiple therapeutic possibilities. Physical therapy consisted in desensitization, mirror visual feedback, graded motor imagery, exposure therapy, edema control, isometric strengthening, gentle restauration of range of movement, postural normalization and balance and gait training. Patient also was encouraged to return to work and attend social activities gradually and with its necessary adaptations. Patient also received an online exercise program and its adherence and pain intensity were telemonitored

Results

The outcome measures assessed included pain intensity (numeric rating scale), disability (patient-specific functional scale), and levels of depression, anxiety, and stress (measured using DASS). The pharmacological intervention commenced with the initiation of amitriptyline at 10mg/day by the local general practitioner, and a supplementary low dose of CBD was prescribed by the Netherlands-based physician. Following medical consultation and engagement in physical therapy rehabilitation, the patient progressively reintegrated into her daily life, exhibiting pain scores ranging between 0 and 4/10 on the Numeric Rating Scale (NRS). The patient experienced occasional flare-ups, promptly resolving without the necessity of interventional procedures.

Conclusions

Despite the lack of face-to-face consultations and the therapeutic touch, it was possible to offer the patient adequate diagnosis and treatment for her condition. Patient education, respecting the patient’s sociocultural background played a major role on her positive outcome. We concluded that telehealth is a promising and possible tool to be used in the treatment of patients with such a complex syndrome and to improve a better quality of life.

References

Dey S, Guthmiller KB, Varacallo M. Complex Regional Pain Syndrome. 2023 Aug 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 28613470.

Goebel A, Barker CH, Turner-Stokes L. Complex Regional Pain Syndrome in Adults: UK Guidelines for Diagnosis, Referral and Management in Primary and Secondary Care. 2nd edition. London: Royal College of Physicians, 2018. [Available from: https://www.rcplondon.ac.uk/guidelines-policy/complex-regional-pain-syndrome-adults]

Halicka M, Vittersø AD, Proulx MJ, Bultitude JH. Neuropsychological Changes in Complex Regional Pain Syndrome (CRPS). Behav Neurol. 2020 Jan 14;2020:4561831. doi: 10.1155/2020/4561831. PMID: 32399082; PMCID: PMC7201816.

Harden RN, Bruehl S, Perez RSGM, Birklein F, Marinus J, Maihofner C, et al. Validation of proposed diagnostic criteria (the “Budapest criteria”) for complex regional pain syndrome. Pain 2010;150(2):268-74

Harden RN, McCabe CS, Goebel A, Massey M, Suvar T, Grieve S, Bruehl S. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. Pain Med. 2022 Jun 10;23(Suppl 1):S1-S53. doi: 10.1093/pm/pnac046. PMID: 35687369; PMCID: PMC9186375.

Lloyd ECO, Dempsey B, Romero L. Complex Regional Pain Syndrome. Am Fam Physician. 2021 Jul 1;104(1):49-55. PMID: 34264598.

Misidou C, Papagoras C. Complex Regional Pain Syndrome: An update. Mediterr J Rheumatol. 2019 Mar 28;30(1):16-25. doi: 10.31138/mjr.30.1.16. PMID: 32185338; PMCID: PMC7045919.

Shim H, Rose J, Halle S, Shekane P. Complex regional pain syndrome: a narrative review for the practising clinician. Br J Anaesth. 2019 Aug;123(2):e424-e433. doi: 10.1016/j.bja.2019.03.030. Epub 2019 May 2. PMID: 31056241; PMCID: PMC6676230.

Smart KM, Ferraro MC, Wand BM, O’Connell NE. Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Database Syst Rev. 2022 May 17;5(5):CD010853. doi: 10.1002/14651858.CD010853.pub3. PMID: 35579382; PMCID: PMC9112661.

Taylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, Carlson T, Myrcik D, Varrassi G, Viswanath O. Complex Regional Pain Syndrome: A Comprehensive Review. Pain Ther. 2021 Dec;10(2):875-892. doi: 10.1007/s40122-021-00279-4. Epub 2021 Jun 24. Erratum in: Pain Ther. 2021 Jul 26;: PMID: 34165690; PMCID: PMC8586273.

Fukushima F B, Bezerra D M, Villas Boas P J F, Valle A P, Vidal E I O. Complex regional pain syndrome BMJ 2014; 348 :g3683 doi:10.1136/bmj.g3683

Presenting Author

Jessica Fernandez

Poster Authors

Fernanda Fukushima

MD, PhD

UNESP

Lead Author

Jessica Fernandez

UNISUAM

Lead Author

Marcia Porto Rovina

Lead Author

Topics

  • Access to Care