The Severity Spectrum in Persistent Complex Regional Pain Syndrome (CRPS), Palliation with Ongoing Hyperbaric Oxygen Therapy (HBOT), and the Role of Serial Photo-Documentation (P6.271)

Abstract

OBJECTIVE: To document the clinical spectrum of severity observed in persistent CRPS, the stabilizing palliative effect of HBOT in severe CRPS and the role of serial photo-documentation in CRPS management. BACKGROUND: CRPS is a neuropathic, non-malignant pain syndrome. Prior literature suggested a fixed relentless three stage course predicting muscle atrophy, thin shiny skin and involvement limiting joint mobility after one year (stage III). In early CRPS (within three months), subjective findings (burning/aching pain) dominate; objective features (swelling, sweating, color, temperature changes) fluctuate (posture, activity, ambient conditions, stress). Prognosis and resolution are dependent upon prompt diagnosis and early mobilization, often difficult due to pain. Later (after one year), variable-severity CRPS (pain/limited-signs ranging to pain/severe-signs) can become more treatment-resistant, potentially limb-threatening. However, HBOT is safe, non-invasive, underutilized and palliative. DESIGN/METHODS: Validated CRPS diagnostic criteria were met. CRPS patients with duration over one year (persistent) were evaluated regarding symptoms (pain) and signs (swelling, sweating, color, temperature, trophic and movement) in dependent portions of affected and unaffected limbs. HBOT was utilized for potentially limb-threatening weeping/inflammatory lesions. Serial photo-documentation chronicled care. RESULTS: Persistent CRPS varies greatly in appearance and severity. Although pain is universal, objective features varied independently of duration. Pain is influenced by prior comorbid conditions (entrapment, radiculopathy, etc.) and secondary compensatory changes reflecting altered posture(s) adopted to limit pain. Objective early CRPS manifestations were usually less evident, possibly reflecting treatment efforts. Limb-threatening severe skin manifestations (ulceration, weeping, cellulitis) responded to cycles of HBOT, avoiding amputation. HBOT also restricted worsening following post-CRPS injuries. Serial photo-documentation of CRPS contemporaneously with treatment afforded guidance/assurance in treatment-selection and response-assessment. CONCLUSIONS: Persistent CRPS severity is defined on a spectrum reflecting degree of tissue changes, not by duration alone. Limb threatening skin ulceration, weeping wounds and cellulitis responded to HBOT, avoiding amputation. Serial photo-documentation facilitated management by chronicling therapeutic-effectiveness.

Disclosure: Dr. Knobler has received personal compensation for activities with Teva Neurosciences and Mallinckrodt Pharmaceuticals as a speaker.