Post-stroke complex regional pain syndrome and related factors: Experiences from a tertiary rehabilitation center

https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104995Get rights and content

Abstract

Objective

In this study, it is aimed to determine the risk factors associated with CRPS after stroke and the clinical parameters of the patients and the treatment agents used for CPRS

Method

213 hemiplegic patients with CRPS diagnosed in Group 1 and 213 hemiplegic patients without CRPS in group 2 (control group) were included in the study designed retrospectively. Demographic data of the patients, Brunnstrom stage, Modified Ashworth scale, Barthel index were recorded from patients files. Associated risk faktors with CRPS such as Shoulder subluxation, adhesive capsulitis, fracture, deep vein thrombosis, spasticity, neglect, visual field defect, heterotopic ossification, entrapment neuropathies, brachial plexus damage, pressure wound, lower respiratory tract infection (LRTI), urinary tract infection, epilepsy, and depression were questioned. In addition, clinical findings, medical treatments, and physical therapy agents used were recorded.

Results

The average age of the participants was 67.9 ± 10.3 in group 1 and 66.1 ± 9.9 in group 2. According to the multivariate logistic regression analysis, the presence of the duration of hemiplegi, the duration of hospitalization, shoulder subluxation, soft tissue lesion, adhesive capsulitis, spasticity, entrapment neuropathy, brachial plexus ınjury, protein energy malnutrition, LRTI, urinary infection, depression, coronary artery disease were significantly increased the development of CRPS (p<0.05). As a clinical parameter, edema was present in 95.3% of the patients, while trophic change was the lowest in 1.9%. While sensory reeducation was used in all patients in physical therapy, ganglion blockade was the lowest with 0.9% of patients. In medical treatment, the use of oral paracetamol was 28.2%, while the use of gabapentin was the last with 8.9%.

Conclusions

In our study, the risk factors of CRPS after hemiplegia, which are as important as its treatment, as well as its diagnosis and prevention, are shown.

Introduction

Complex regional pain syndrome (CRPS) is a syndrome that is independent of the severity of the injury, and manifests itself with persistent severe pain with autonomic, sensory and motor abnormalities.1 The condition is classified as Type 1 and 2. Type 1 CRPS accounts for 90% of the cases, and the causative disease or injury is not accompanied by nerve damage. Type 2 CRPS (causalgia), on the other hand, occurs after serious nerve damage.2 Both types exhibit similar clinical symptoms; along with a burning pain, changes in the skin temperature and color, increased sensitivity, disruption of hair and nail growth, swelling affecting the joints, and motor dysfunction may be seen.3

Although the underlying pathophysiology is unclear, it has been reported that sympathetic nervous system dysfunction, which is thought to play an important role, occurs due to a microcirculatory disturbance in the sensory ganglion with peripheral nerves and noradrenergic sympathetic fibers.4 Somatic nervous system dysfunction, neurogenic inflammation, hypoxia and psychological factors are also effective in the progression of the clinical picture.5 The most common causes of CRPS are fractures (45%), followed by sprains and elective surgery. Inflammatory diseases, heart attacks, smoking, hereditary factors, and stroke are less common causes. The condition may develop regardless of a cause in less than 10% of the patients.57

Pain of the affected upper extremity is one of the most common complications in patients with stroke.8 Post-stroke CRPS is an important disabling complication in stroke survivors and the incidence was reported to range between 21% and 31%3 The precise pathophysiological mechanisms and predictive factors that underlie post-stroke CRPS remain unknown.9 While the risk factors in CRPS, which develop due to other reasons, have been shown in many studies, there aren't any studies that have identified the risk factors in post-stroke CRPS.6,10 In this study, we aimed to evaluate the risk factors for post-stroke CRPS. We also investigated the relationship between the incidence of CRPS and risk factors.

Section snippets

Participants

The files of the patients who were diagnosed with stroke and hospitalized for rehabilitation between June 1, 2014 and June 1, 2019 at the Ankara Physical Therapy and Rehabilitation Training & Research Hospital of Health Sciences University were retrospectively analyzed. Patients over 18 years of age and with CRPS Type 1, according to the Budapest clinical diagnostic criteria,11 were included in the study. In addition, hemiplegic patients without a CRPS diagnosis were included in the study as a

Results

The sociodemographic and clinical characteristics of the two groups and their comparisons are presented in Table 1. Risk factors of the patients and intergroup comparisons are shown in Table 2. Our multivariate logistic regression analysis showed that in patients with stroke, time of the incident, time to hospitalization, shoulder subluxation, soft tissue lesion, adhesive capsulitis, spasticity, entrapment neuropathy, brachial plexus injury, PEM, LRTI, urinary infection, depression, and CAD

Discussion

In this study, we tried to evaluate the risk factors of CRPS in patients with stroke. Our results have shown that time of the incident, time to hospitalization, shoulder subluxation, soft tissue lesion on the shoulder, adhesive capsulitis, spasticity, entrapment neuropathy, brachial plexus injury, LRTI, urinary infection, depression, PEM, and CAD were independent risk factors.

Although it has been reported that CRPS usually develops within two weeks to three months after the cerebrovascular

Conclusion

In conclusion, post-stroke CRPS is a complicated phenomenon encompassing both nociceptive and neuropathic pain etiologies. It is comprised by a variety of disorders, of which the most common include shoulder subluxation, soft tissue lesion on the shoulder, adhesive capsulitis, spasticity, entrapment neuropathy, brachial plexus injury, LRTI, urinary infection, depression, PEM, and CAD. The management and the treatment of these syndromes include pharmacological, orthotic, biomechanical, and

Declaration of Competing Interest

The authors state that the manuscript has not been published previously, and they have no conflict of interest.

No financial support was received for this project.

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