Understanding Complex Regional Pain Syndrome (CRPS)

Understanding Complex Regional Pain Syndrome (CRPS)

Mat Foreman, Physiotherapist

Complex Regional Pain Syndrome (CRPS) is a chronic pain condition that typically affects a limb following an injury. Characterized by prolonged or excessive pain and changes in skin colour, temperature, and swelling, CRPS is believed to result from dysfunction of the nervous system. CRPS can significantly impact a person's quality of life, making early diagnosis and treatment crucial.

Prognosis of CRPS

The prognosis for CRPS varies widely among individuals. While some people recover gradually over time, others may experience long-term or permanent symptoms. Early intervention is key to improving outcomes.

Symptoms and Diagnosis of CRPS

Diagnosing CRPS relies on clinical evaluation and patient history, as there is no definitive test for the condition. The Valencia Criteria is widely used for diagnosis.

Valencia Criteria

The Valencia Criteria require the presence of continuous pain that is disproportionate to any inciting event, along with specific symptoms and signs in five categories (Goebel et al., 2021):

  1. Sensory: Excessive sensitivity to touch, heat or cold. This could be noticeable with lightly touching the area, clothing rubbing or bedclothes rubbing on the area, warm or cool water may feel hotter or colder than it usually does or may be painful.

  1. Vasomotor: The skin may feel hotter or colder to touch than it usually does or when compared to the other side. The skin may show a change in colour compared to normal or the other side, this can commonly be red, purple, white or darker pigmentation depending on the persons natural skin tone but importantly it is a change in colour and different to the opposite limb.

  2. Sudomotor/Oedema: The limb may be swollen, or the person may notice changes in the amount of sweating of the injured side compared to the uninjured side.

  3. Motor/Trophic: There may be difficulty with movement or weakness of the affected side or changes to the skin, hair or nails such as dryer or rashie skin, brittle nails or reduced hair growth on the affected side.

  4. Emotional distress or reduced social participation: There may be feelings of lower mood or feeling more emotional than usual and the pain/ injury may prevent the participation in normal social activities.

A diagnosis of CRPS can be made if the patient has symptoms (things that the patient has noticed) in three of categories 1-4 and objective signs (things that the treating healthcare professional has noticed in their examination) in two of categories 1-4 and at least one symptom in category 5.

Evidence-Based Treatments for CRPS

There are several treatments that can help manage symptoms and improve quality of life. A multidisciplinary approach, including medications, physical therapy, and psychological support is often most effective.

Multidisciplinary Pain Management

A multidisciplinary approach involves a team of healthcare professionals working together to manage CRPS. This often includes pain specialist physicians, physiotherapists and psychologists. The focus is on improving function and quality of life through coordinated care that addresses physical, emotional, and psychological aspects of the condition.

Medications

Complex Regional Pain Syndrome is often managed by specialist pain physicians. Several types of medications are used to manage CRPS symptoms:

  1. Pain Relievers: Over-the-counter pain medications like ibuprofen or naproxen can help manage mild pain and assist with flare ups.

  2. Antidepressants and Anticonvulsants: Medications like amitriptyline, nortriptyline and gabapentin, used for nerve pain, can be effective in CRPS.

  3. Corticosteroids: These can reduce inflammation and swelling in the early stages of CRPS.

  4. Sympathetic Nervous System Blocks: Injections of anaesthetic agents near the spine can block pain signals and can be beneficial in some cases (Bruehl, 2015).

Physiotherapy

Physiotherapy plays a crucial role in managing CRPS. Techniques include:

  1. Graded exercise: Exercises to improve movement, strength or function are applied in a carefully graded manor.

  2. Desensitization Therapy: Gradual exposure to various textures and sensations can help reduce hypersensitivity. Graded increase in activity and movement can help reduce hypersensitivity to movement.

  3. Graded functional restoration: Activities and exercises designed to improve the use of the affected limb in daily tasks.

  4. Graded Motor Imagery (GMI)

Mirror exercises help retrain the nervous system in CRPS.

Graded Motor Imagery is an evidence-based therapeutic approach often used in the early stages of rehabilitation with rehabilitation then progressing to graded exercise, activity and functional restoration. Graded Motor Imagery involves three stages:

  1. Laterality training: Patients recognize left and right images of their affected limb, retraining the brain’s understanding of limb position.

  2. Imagined Movements: Patients visualize movements of the affected limb without moving it, which helps reduce pain and improve motor function.

  3. Mirror Therapy: Patients perform movements with the unaffected limb while watching its reflection, creating the illusion that the affected limb is moving pain-free (Moseley, 2004).

Identifying right vs left images helps retrain the nervous system in CRPS.

Psychological Support

Chronic pain can lead to anxiety, depression, and other psychological issues. Cognitive-behavioural therapy (CBT), mindfulness and other forms of psychological counselling can help patients cope with the emotional aspects of CRPS. Psychological support is integral to a multidisciplinary approach.

Conclusion

Complex Regional Pain Syndrome is a challenging condition that requires a comprehensive and multidisciplinary approach for effective management. Early diagnosis and intervention are crucial in preventing the progression of symptoms and improving the quality of life for those affected. Through a combination of medications, physical therapy, psychological support, and emerging treatments like Graded Motor Imagery, many patients can find relief from the debilitating symptoms of CRPS.

References

Bruehl, S. (2015). Complex regional pain syndrome. BMJ, 351, h2730.

Goebel, A., Birklein, F., Brunner, F., Clark, J. D., Gierthmühlen, J., Harden, N., ... & Bruehl, S. (2021). The Valencia consensus-based adaptation of the IASP complex regional pain syndrome diagnostic criteria. Pain, 162(9), 2346-2348.

Moseley, G. L. (2004). Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain, 108(1-2), 192-198.

Turner-Stokes, L., Goebel, A., Beyer, F., & Wiedemann, B. (2016). Complex regional pain syndrome in adults: UK guidelines for diagnosis, referral and management in primary and secondary care. BMJ Open, 6(12), e013200.

Mathew became a qualified physiotherapist after completing his undergraduate studies in 2011. He has worked in private practice in Melbourne treating a variety of musculoskeletal and sports injury conditions since then. Mathew completed post graduate studies in musculoskeletal physiotherapy in 2016 and has developed a keen interest in the evidence based treatment of low back pain, neck pain and headaches.