COMPLEX REGIONAL PAIN SYNDROME (CRPS)
WHAT IS CRPS?
Complex regional pain syndrome (CRPS) is a common and debilitating chronic neuropathic (nerve) pain disorder that usually occurs after a minor injury to the hand or foot. It can also occur after more significant traumas, for example surgery to the hands, feet or to other parts of the body like the knees or shoulders. It has previously also been called Causalgia, Reflex Sympathetic Dystrophy (RSD), and Reflex Neurovascular Dystrophy (RND). It is still not entirely certain why and how CRPS occurs, but we do know that it can be a disabling and excruciatingly painful condition that in some cases can last a long time.
CRPS is a devastating neuropathic (nerve) pain disorder.
CRPS is characterised by certain changes to the painful area which might include exquisitely sensitive skin (where even a light brush could be painful), swelling, redness, warmth, and changes to the way the hair and nails grow. The hand or foot may not function correctly, and cramps can occur. Later on, the area can look mottled and feel cold.
The mainstays of CRPS treatment are making an early diagnosis and starting multimodal treatments by pain specialists.
CRPS CAUSES AND MECHANISMS
The exact cause of CRPS remains unclear. However, it’s believed to involve abnormal nerve function and a heightened response to pain following a triggering event like a sprain, laceration, or surgical procedure.
There must first be a triggering injury like a ligament strain, sprain, laceration, or surgery. The injury does not need to be severe to trigger CRPS.
Once triggered, changes in the function of the nerves and immune system occur. Nerves carry sensation (feeling and touch), motor information (telling muscles how to move) and other functions like blood flow, which affects sweatiness and colour changes within the skin. This can lead to stiffness and weakness too.
The Devastating Pain of Complex Regional Pain Syndrome (CRPS): Causes and Mechanisms Explained
WHO GETS CRPS?
Anyone can get CRPS after an injury to their arm or leg or other part of the body.
If someone has already had CRPS they are more likely to get it again with another injury. There may also be a genetic link and CRPS can occur in families.
CRPS occurs in about 5:100,000 people and affects females about 4 times more than males. The upper limbs are generally more affected than lower limbs. The arm is affected in 60% of cases and the leg in 40%. It can affect more than one limb and can even appear on the opposite limb.
CRPS SYMPTOMS
CRPS is characterised by a number of symptoms:
PAIN AND MOVEMENTS
People with CRPS pain report severe pain, muscle spasms, and difficulty with movement. Pain may affect the arm and shoulder, leg, knee, foot, or hand.
SENSORY CHANGES
People with CRPS report changes in the sensation of the skin. Heightened sensitivity, or numbness in the affected area are common complaints.
SKIN, HAIR AND NAIL CHANGES
People with CRPS notice swelling, altered hair and nail growth, and changes in skin colour or temperature.
CRPS DIAGNOSIS
Diagnosing CRPS involves a thorough evaluation by a pain specialist using the Budapest Criteria. This set of guidelines considers pain intensity and the presence of symptoms like changes in sensation, skin appearance, and movement restrictions.
Complex Regional Pain Syndrome (CRPS) is Overwhelming: How Experts Diagnose it
HOW DO PAIN SPECIALISTS TREAT CRPS?
When CRPS is suspected by a treating team the most important thing is to pay attention to the symptoms and to never assume they will resolve on their own. Although it does happen in some patients, the most basic rule of pain management is to manage pain early and aggressively using many different modalities. This is to prevent acute pain becoming chronic pain and for the best chance of a total recovery. Early referral to a pain specialist is a vital step for getting the right treatment started as quickly as possible.
PHYSIOTHERAPY AND OCCUPATIONAL THERAPY
Patients with CRPS require early assistance from specialist therapists with expertise in physiotherapy and occupational therapy. These therapists use a host of techniques to improve the motor functions of the affected part of the body, aid with reduction in swelling and skin sensitivity and should be a part of management throughout treatment. This is a vital step in recovery.
Complex Regional Pain Syndrome (CRPS) is Exhausting: Early Treatments
MEDICATIONS AND INTERVENTIONAL TREATMENTS
Medication combinations targeting the pain system, the immune system and inflammation are a vital step in early treatment of this condition. Medications may include steroids, anti-inflammatories, antineuropathics, muscle relaxants and even opioids.
There are a number of different pain injection treatments (interventions) that aid patients with CRPS. These include nerve block treatments that target nerves that cover the affected limb. Nerve blocks might be stellate blocks, sympathetic blocks, nerve root blocks and sometimes even pulsed radiofrequency ablation of nerves. These treatments should be used in conjunction with medications and physiotherapy and psychological therapy.
Complex Regional Pain Syndrome (CRPS) is Devastating: Medications & Interventional Treatments
PSYCHOLOGY
Chronic pain is an exhausting condition that understandably leads to poor sleep, mood disturbance like anxiety and depression, and reduced function. It is imperative that people struggling with chronic pain are frank and open about the distress they experience. Trained pain specialist psychologists are invaluable in helping patients manage these situations and cope with the pain. Sometimes patients require a more formalised cognitive behavioural therapy (CBT).
ADVANCED TREATMENT OPTIONS
Most patients report significant improvement with the treatment options listed above, but this is not always the case. It is important that symptoms are not ignored and that referral to a pain specialist occurs early and quickly.
For severe cases of CRPS, advanced therapies such as ketamine infusions or neuromodulation strategies like spinal cord stimulation may be recommended. These treatments aim to provide greater pain relief and improved function when conventional methods have not been effective, however they may carry some risks.
Ketamine is a strong pain-relieving medication, given as an infusion during a hospital admission. This gives better control, allowing intensive physical therapy with the aim of improved function and pain relief.
Spinal cord stimulation involves an implanted device to suppress pain nerves and can be profoundly effective for CRPS that has not responded to more conservative treatments. Spinal cord stimulation involves a trial phase, so before anything permanent is considered the treatment can be trialled to indicate how successful it might be. It has been suggested that spinal cord stimulation should be used early in the treatment of some forms of CRPS.
For further information on spinal cord stimulation, please refer to our ebook.
HOW DO YOU PREVENT CRPS?
Taking Vitamin C (500mg daily for two months) after an injury may help prevent CRPS in some individuals. Early intervention by a pain specialist is key to managing symptoms effectively.
CRPS (Complex Regional Pain Syndrome) is devastating: Can it be prevented?
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