Definition
Complex regional pain syndrome (CRPS) is a chronic pain condition, usually associated with stiffness, swelling and discolouration that most often affects the hand. Arm, legs and feet can also be affected. The pain may be out of the proportion to the injury that triggered it.CRPS was previously known as Reflex Sympathetic Dystrophy (RSD), Sudeck’s atrophy, shoulder hand syndrome and causalgia. There are two types of CRPS: Type 1 – caused by injury to the tissues and type 2 – caused by damage to a nerve. The symptoms and treatments of the both types are very similar.
Symptoms
The symptoms you will encounter in CRPS include:
- Burning or aching pain.
- Skin changes: discolouration – blotchy, purple or red.
- Skin texture: sweaty, thin and shiny.
- Increase in skin sensitivity.
- Swelling and stiffness in affected joint.
- Changes in nail and hair growth pattern.
- Reduced ability to move a body part.
The course of CRPS is usually divided into 3 stages,
- 1st stage: may last up to 3 months. Increased sensitivity and burning pain are the most common early symptom of CRPS. The affected area is usually swollen and warm. Also, sweating and discolouration are evident.
- 2nd stage: can last 3 to 12 months. Skin temperature becomes cooler. Swelling is more constant. Pain is more severe, widespread and the area is more sensitive to touch.
- 3rd stage: occurs after 1 year. Pain is worsened by any kind of movement or touch of the affected limb. Skin becomes dry, pale, shiny and stretched. This condition may affect other parts of the body.
Causes
CRPS can begin after a minor injury, such as sprain or minor laceration. Other times, it may be result of a more significant injury, such as fracture, surgery, immobilisation with cast, or the result from stroke. Other causes include: pressure on a nerve, cancer, infection, neck problems and heart attack.
It’s not really well understood why these injuries could trigger CRPS. This may be due to a dysfunctional connection between the central and peripheral nervous system and inappropriate inflammatory responses.
Risk Factors
Risk factors for developing CRPS may include:
- Immobilisation of the injured limb in a cast or splint.
- Genetics.
- Smoking.
- Psychological factors such as emotional stress.
Investigations
Your doctor may perform a thorough history and physical examination.
History: Your doctor will ask questions about any previous trauma and period of immobilisation that may have caused your symptoms.
Physical Examination: Your doctor will examine your skin for any changes in colour, texture and the presence of swelling. Range of motion of the affected area will also be assessed. Others include temperature, hair and nails growth will also be examined.
There is no single test that can diagnose CRPS. Your doctor may perform the following tests:
- Sympathetic nervous system test: Local anaesthetic is injected into the neck (stellate ganglion) when treating the upper extremity. This should numb the area, and if there is a relief in pain and increase in temperature, this indicates positive diagnostic test.
- Blood flow measurement: Thermograph measures the skin temperature and blood flow of the affected and blood flow of the affected area.
- X-rays: Show problems with loss of minerals from the bone. This is usually seen as the disease progresses.
- Bone scan: May be helpful in detecting bone changes. It involves radioactive tracers injecting into your blood stream. The bone scan is usually normal in the early stage. If CRPS is present, the uptake will be greater around the joints.
- MRI: May show tissue changes or nerve compression at the spine or other larger nerves.
Complications
Failure to diagnose and treat this condition will result in more severe and disabling problems.
These may include:
- Surrounding tissue wasting (atrophy): If you avoid moving your affected hands, arms or legs due to pain, the surrounding tissues such as skin, bones and muscles will begin to deteriorate.
- Muscle tightening (contracture): As the condition progresses, you may complain of muscle tightening and this may affect the position of your fingers or foot – which is usually flexed.
- May affect a person’s psychosocial behaviour due to self limitation of activities of daily living.
Treatment
The earlier the diagnosis of CRPS is made and treatment started, the better the chance of recovery. Often, a combination of various therapies is necessary.
Medications:
- Pain relievers: Over the counter medications such as aspirin, ibuprofen or naproxen may reduce pain and inflammation. Your doctor may prescribe stronger pain killers such as opiod if over the counter medications are not helpful. This should be taken in an appropriate dose as they can provide an acceptable control of pain.
- Steroids: Can be beneficial as they reduce swelling and improve the mobility in the affected arm or limb.
- Antidepressants and anticonvulsants: Amitriptylline and Gabapentin are occasionally used to treat pain – neuropathic pain.
- Bone loss medications: Alendronate (Fosamax) can be used to prevent or halt the loss of calcium from the bone.
- Anesthetic intervention: Injection of an anesthetic into the affected nerves. This includes sympathetic ganglion blocks (arm + hand), lumbar ganglion blocks (leg or foot) and regional sympathetic block.
Therapy:
- Topical analgesics: Various creams, such as lidocaine are available to reduce hypersensitivity of the affected area.
- Applying heat and cold: If the area is swollen and sweating, cold can be applied. If the affected area is cold, then applying heat may offer relief.
- Physical therapy: Active exercise of the affected limb is imperative to reduce the pain. Physical or occupational therapy is important to help patients regain their function and mobility.
- Biofeedback: Relaxation techniques and increased body awareness may help with pain relief.
- Trancutaneous electrical nerve stimulation (TENS): Electrical impulses are applied on the affected area to relieve pain.
- Spinal cord stimulation: It involves implanting wires near the spinal cord to an electrical device. This helps to “short-circuit” the pain pathway to the brain.
Results from some methods may be poor. Many patients with chronic CRPS benefit from psychological counselling and evaluation.
Seeking Advice
Your Family Doctor (GP)
Your Family Doctor will be able to diagnose and help treat your problem. He or she will be able to
- tell you about your problem
- advise you of the best treatment methods
- prescribe you medications
- and if necessary, refer you to Specialists (Consultants) for further treatment
Prevention
Taking daily vitamin C will reduce the risk of developing complex regional pain syndrome.
Early mobilisation – people who get out of bed and walk around after a stroke will reduce the risk of developing CRPS.
F.A.Q. | Frequently Asked Questions
What is my prognosis?
Each patient with CRPS responds differently to treatment. Some symptoms may resolve spontaneously while some may experience debilitating irreversible symptoms. As a general rule, the earlier the diagnosis of CRPS, the better the treatment outcome.
Rehabilitation
Physical therapy should be started as soon as possible. Early movement of the joint and weight bearing exercises to prevent bone density loss are important. Alternating hot and cold soaks and massage to the affected area to control inflammation can help. You may also be started on a desensitisation program. Initially, you may start rubbing the affected area with a washcloth, and gradually rubbing and tapping with various pressures. Physical therapy can be painful but it is essential as it prevents the condition from progressing into unrelieved pain, disability and deformity.