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WILDERMAN MEDICAL CLINIC

Complex Regional Pain Syndrome

Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD), is a chronic pain condition that usually affects a limb after an injury, surgery, or trauma.

The pain is typically disproportionate to the severity of the initial injury and can spread beyond the original site of injury.

According to NIH (National Institutes of Health, US), CRPS can affect anyone, regardless of age or gender. However, it is most commonly diagnosed in people between the ages of 20 and 40.

The exact incidence of CRPS is not well-established, but it is estimated to affect between 5 and 26 people per 100,000 individuals per year. It is more commonly diagnosed in women than in men.

While anyone can develop CRPS, some studies have suggested that there may be a genetic component to the condition, as it appears to run in some families (Harden and Bruehl, 2006).

Stages of CRPS

CRPS is typically divided into three stages, although not all individuals with CRPS will progress through each stage:

Stage 1: Acute stage or “warm” stage. This stage usually lasts for about three months and is characterized by severe pain, swelling, redness, and warmth in the affected limb.
Stage 2: Dystrophic stage or “cold” stage. This stage typically begins three to six months after the initial injury or trauma and is characterized by changes in skin texture and color, including thinning and shiny skin, and coldness or coolness in the affected limb. The affected limb may also become more sensitive to touch, and hair and nail growth may be affected.
Stage 3: Atrophic stage or “chronic” stage. This stage is characterized by marked atrophy or wasting of the muscles in the affected limb, decreased range of motion, and bone loss or osteoporosis. The affected limb may also become cool, pale, and dry.

Types of CPRS

CRPS is typically divided into two types:

CRPS type 1: This type was previously known as Reflex Sympathetic Dystrophy (RSD). It occurs after an injury or trauma that does not directly damage the nerves in the affected limb. Symptoms may include severe pain, swelling, changes in skin temperature and color, changes in skin texture, sweating, stiffness, and abnormal movement or tremors in the affected limb.
CRPS type 2: This type was previously known as Causalgia. It occurs after an injury or trauma that directly damages the nerves in the affected limb. Symptoms are similar to those of CRPS type 1 but may also include nerve-related symptoms such as weakness, numbness, or tingling in the affected limb.

What are the causes of CRPS?

The exact causes of CRPS are not fully understood, but it is thought to be caused by a combination of factors, including:

Injury or trauma: CRPS often develops following an injury or trauma to a limb, such as a fracture, sprain, or surgery. It is thought that the injury triggers an abnormal response in the nervous system, leading to the symptoms of CRPS.
Abnormal immune response: Some researchers believe that CRPS may be caused by an abnormal immune response, in which the immune system mistakenly attacks healthy tissue in the affected limb.
Nerve dysfunction: CRPS may be caused by dysfunction in the nerves that control sensation and movement in the affected limb.
Genetics: Some studies have suggested that there may be a genetic component to CRPS, as it appears to run in some families.
Psychological factors: While psychological factors do not cause CRPS, they may play a role in its development or maintenance. For example, stress, anxiety, and depression may exacerbate the symptoms of CRPS or make it more difficult to cope with the condition.

What are the symptoms of CRPS?

The exact causes of CRPS are not fully understood, but it is thought to be caused by a combination of factors, including:

Injury or trauma: CRPS often develops following an injury or trauma to a limb, such as a fracture, sprain, or surgery. It is thought that the injury triggers an abnormal response in the nervous system, leading to the symptoms of CRPS.
Abnormal immune response: Some researchers believe that CRPS may be caused by an abnormal immune response, in which the immune system mistakenly attacks healthy tissue in the affected limb.
Nerve dysfunction: CRPS may be caused by dysfunction in the nerves that control sensation and movement in the affected limb.
Genetics: Some studies have suggested that there may be a genetic component to CRPS, as it appears to run in some families.
Psychological factors: While psychological factors do not cause CRPS, they may play a role in its development or maintenance. For example, stress, anxiety, and depression may exacerbate the symptoms of CRPS or make it more difficult to cope with the condition.

The symptoms of CRPS can vary from person to person, but typically involve:

Severe pain: Pain is usually the most prominent symptom and may be described as burning, stabbing, or throbbing. The pain may be constant or intermittent and may worsen over time.
Changes in skin temperature and color: The affected limb may feel warmer or cooler than the other limb, and the skin may appear red or bluish.
Changes in skin texture: The skin in the affected area may become thin, shiny, or tight.
Swelling: The affected limb may become swollen or edematous.
Abnormal sweating: The affected area may sweat excessively or not at all.
Stiffness: The affected limb may become stiff and difficult to move.
Abnormal movement or tremors: The affected limb may exhibit abnormal movements, such as jerking or twitching.
Sensitivity to touch or cold: The affected area may be hypersensitive to touch or cold temperatures.
Muscle weakness or atrophy: In severe cases, the muscles in the affected limb may become weak or atrophied.

What are the possible complications of CRPS?

CRPS can lead to a number of complications, including:

Chronic pain: The pain associated with CRPS can become chronic and long-lasting, even after the initial injury or trauma has healed.
Disability: Severe cases of CRPS can lead to disability and difficulty performing everyday tasks.
Muscle atrophy and weakness: CRPS can cause muscle atrophy and weakness in the affected limb.
Osteoporosis: CRPS can result in bone loss or osteoporosis in the affected limb, which can increase the risk of fractures.
Skin changes: The skin in the affected limb may become thin, shiny, and dry, and may develop ulcers or infections.
Psychological distress: Living with chronic pain and disability can lead to psychological distress, such as depression, anxiety, and social isolation.
Spread of symptoms: In some cases, CRPS can spread to other parts of the body, leading to the development of new symptoms in other limbs.

It is important to seek prompt treatment for CRPS to help prevent or minimize these complications.

How is CRPS diagnosed?

There are several methods used to diagnose CRPS, which may include:

Physical examination: A doctor will look for signs of CRPS, such as changes in skin color, temperature, and texture, as well as muscle weakness and limited range of motion.
Medical history: A doctor will ask about your symptoms and medical history, including any injuries or illnesses that may have triggered the onset of CRPS.
Imaging tests: X-rays, MRI scans, and bone scans may be used to detect changes in bone density or soft tissue damage that may indicate CRPS.
Nerve conduction/Electromyography studies: These tests measure the electrical activity of the nerves of the affected limbs, which may help to confirm a diagnosis of CRPS.
Pain tests: Various pain tests may be used to evaluate the severity and location of pain, such as applying pressure to the affected area or using a device to measure sensitivity to touch and temperature.

It is important to note that there is no single definitive test for CRPS; diagnosis is typically based on a combination of these methods and the presence of specific symptoms.

How is CRPS treated?

The treatment for CRPS generally involves a combination of therapies aimed at relieving pain, reducing inflammation, and restoring function. Some common treatments for CRPS may include:

Medications: Over-the-counter pain relievers, such as ibuprofen and acetaminophen, may help manage mild to moderate pain associated with CRPS. For more severe pain, prescription medications like opioids, anticonvulsants, and antidepressants may be prescribed. Topical creams and patches can also be used to deliver pain medication directly to the affected area.
Physical therapy: A physical therapist can do mirror therapy and also work with you to develop an exercise program that can help increase range of motion, reduce pain, and improve overall function. Exercises may include stretching, strengthening, and range-of-motion movements.
Sympathetic nerve block: This is a procedure in which an anesthetic is injected into the nerves that are believed to be contributing to your pain. The goal is to block the transmission of pain signals from the affected area to the brain.
Intravenous lidocaine infusion: Lidocaine is an anesthetic that can be given intravenously to help reduce pain and improve function.
Intravenous ketamine infusion: Ketamine is a potent and fast anesthetic that can be given intravenously to help reduce pain and improve function.
Spinal cord stimulation: This is a procedure in which an electrode is implanted in the spinal cord to deliver electrical stimulation to the nerves that are believed to be contributing to your pain. This can help disrupt the pain signals being sent to the brain and may provide relief.
Biofeedback: This is a technique that uses electronic monitoring to help you become more aware of your body’s responses to stress and pain. By learning to control certain physical responses, such as muscle tension and heart rate, you may be able to reduce your pain levels.
Cognitive behavioral therapy: This is a type of talk therapy that can help you learn coping strategies for managing pain and stress. It can also help address any negative thoughts or emotions that may be contributing to your pain.
Graded motor imagery: This therapy involves using mental imagery exercises to help retrain the brain to recognize and control movement in the affected limb.
Mirror therapy: Mirror therapy involves using a mirror to create the illusion of movement in the affected limb, which can help improve pain and function.
Surgery: In some cases, surgery may be recommended to remove damaged tissue or to correct an underlying problem that is contributing to your pain.
Psychological counseling: This can help patients to cope with the emotional and psychological aspects of chronic pain, which can be an important part of the overall treatment plan.

It is important to note that treatment for CRPS is highly individualized and may vary depending on the severity of the condition, the individual patient’s needs and preferences, and the presence of any underlying medical conditions.

Prevention

There is no known way to prevent CRPS from developing. However, early diagnosis and treatment may help to prevent the condition from worsening and limit its impact on an individual’s quality of life.

If you have experienced an injury or surgery that puts you at risk for developing CRPS, it is important to closely monitor the affected area for signs and symptoms of the condition, such as persistent pain, swelling, or changes in skin color or temperature.

If you notice any of these symptoms, you should seek medical attention as soon as possible to determine the underlying cause and receive prompt treatment.

Additionally, maintaining a healthy lifestyle, managing stress, and following recommended safety precautions when participating in sports or other physical activities may help to reduce the risk of injury and minimize the chances of developing CRPS.

Other factors that may support faster recovery from CRPS

Certain lifestyle changes can help in faster recovery:

Quitting smoking: Smoking greatly interferes with nerve regeneration.
Managing existing health conditions: Poor management of diabetes and other conditions that can affect circulation, inflammation, and nerve health can make recovery more difficult.
• Keeping the affected limb elevated when resting or sleeping can help excess fluid return to the heart.
• Exercising every day is critical to improving circulation to the damaged nerves.
• Wearing compression stockings or sleeves may help limit swelling, particularly when standing.

What do we do at WMC?

At the Wilderman Medical Clinic, we offer a variety of interventional and non-interventional pain management options, including:

Interventional pain management for CRPS:

• Medication
• Lidocaine infusions for CRPS
• Ketamine infusions for CRPS
• Nerve block injections for CRPS

Non-interventional pain management for CRPS:

• Psychotherapy
• Kinesiology education sessions

Works Cited

Bruehl, S., & Schwartzman, R. (2006). Complex Regional Pain Syndrome (CRPS) – Understanding, Diagnosis and Treatment. Informa Healthcare. ISBN-10: 0824729045, ISBN-13: 978-0824729048.

Icon Health Publications. (2004). Complex Regional Pain Syndrome – A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. ICON Health Publications. ISBN-10: 0597840931, ISBN-13: 978-0597840939.

Harden, R. N., Oaklander, A. L., Burton, A. W., Perez, R. S., Richardson, K., Swan, M., & Barthel, J. (2013). Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. Pain Medicine, 14(2), 180-229.

Harden RN, Bruehl SP. Complex Regional Pain Syndrome: Epidemiology, Pathophysiology, and Treatment. Clin J Pain. 2006;22(4): 387-397. doi:10.1097/01.ajp.0000180279.36320.32

Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Complex Regional Pain Syndrome: A Review. J Hand Surg Am. 2011;36(4): 635-646. doi:10.1016/j.jhsa.2011.01.002

Mayo Clinic. CRPS (Complex Regional Pain Syndrome). Accessed April 18, 2023. https://www.mayoclinic.org/diseases-conditions/crps-complex-regional-pain-syndrome/symptoms-causes/syc-20371151.

Cleveland Clinic. Complex Regional Pain Syndrome (CRPS). Accessed April 18, 2023. https://my.clevelandclinic.org/health/diseases/12085-complex-regional-pain-syndrome-crps.

National Health Service. Complex Regional Pain Syndrome. Accessed April 18, 2023. https://www.nhs.uk/conditions/complex-regional-pain-syndrome/.

American Academy of Orthopaedic Surgeons. Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy). Accessed April 18, 2023. https://orthoinfo.aaos.org/en/diseases–conditions/complex-regional-pain-syndrome-reflex-sympathetic-dystrophy/.

National Organization for Rare Disorders. Complex Regional Pain Syndrome. Accessed April 23, 2023. https://rarediseases.org/rare-diseases/complex-regional-pain-syndrome/.

International Association for the Study of Pain. Complex Regional Pain Syndrome. Accessed April 23, 2023.https://www.iasppain.org/ClinicalResources/PainTaxonomy/Content.aspx?ItemNumber=1698#ComplexRegionalPainSyndrome.

Author

Niharika Mandal

Niharika Mandal has a Ph.D. in Biotechnology and over four years of experience as a medical writer. Her expertise includes writing and editing clinical documents such as protocols, clinical study reports, patient narratives, and manuscripts, in compliance with regulatory guidelines. She has authored a book and published several articles in international journals in the field of biotechnology. Niharika’s passion for healthcare is evident in her work, as she is dedicated to positively impacting people’s lives through her contributions to the medical field.