Sometimes a patient comes to us at Summit Healthcare Pain Clinic complaining of chronic pain in their arm or leg. They’ve had an injury or surgery, but the level of pain they are describing doesn’t seem to match the actual injury. This could be a case of an uncommon condition known as complex regional pain syndrome (CRPS).
CRPS is most successfully treated if addressed early on. Dr. Trujillo has experience helping our patients get through CRPS.
What Is Complex Regional Pain Syndrome?
Complex regional pain syndrome (CRPS) is a somewhat mysterious form of chronic pain that usually affects an arm or a leg. The pain typically develops after an injury, a stroke or heart attack, or after surgery. But the level of pain is out of proportion with the severity of the actual injury. CRPS progresses to more serious stages.
Causes Of CRPS
Complex regional pain syndrome is thought to be caused by an injury or abnormality of the peripheral and central nervous systems, although the condition isn’t fully understood. CRPS typically arises after trauma or an injury.
There are two types CRPS. They both have similar symptoms, but different causes:
- Type 1 — This type of CRPS, also known as reflex sympathetic dystrophy syndrome (RSD), occurs after an illness or injury that did not damage the nerves in the affected limb. This is about 90 percent of CRPS cases. The injury was not serious, such as an ankle sprain.
- Type 2 — This type occurs following a definite nerve injury.
Types Of CRPS
There are two types of CRPS. Type I, also known as Reflex Sympathetic Dystrophy, develops without any obvious sign of direct nerve injury. It commonly develops after tissue trauma. Type II, which was once called causalgia, is related to direct injury of the nerves.
What are the Symptoms Of CRPS?
Complex regional pain syndrome has an assortment of symptoms. Some of these change over time and vary from person to person.
- Continuous burning or throbbing pain, usually in an arm, leg, hand, or foot
- Sensitivity to touch or cold
- Swelling of the painful area
- Changes in skin temperature, alternating between sweaty and cold
- Changes in skin color, ranging from white and mottled to red or blue
- Changes in skin texture, which may become tender, thin, or shiny in the affected area
- Changes in hair and nail growth
- Joint stiffness, swelling, and damage
- Muscle spasms, tremors, weakness, and atrophy
- Decreased ability to move the affected body part
Noticeable changes in temperature and hypersensitivity to cold and to touch usually occur first, along with pain, swelling, and redness. Over time, the affected limb can become cold and pale, and it may undergo skin and nail changes. Muscle spasms and overall tightness are common. Once these changes have occurred, CRPS is often irreversible.
How Is CRPS Diagnosed?
Diagnosing CRPS isn’t a cut and dried definitive answer. Dr. Trujillo uses a physical examination and your medical history to start. From there, he may use these tests for validation of CRPS:
- Bone scan — These tests can show demineralization in a bone. A radioactive substance is injected into a vein and it allows the bones to be seen with a special camera.
- Sympathetic nervous system tests — These tests look to show disturbances in the sympathetic nervous system. Thermography measures skin temperature and blood flow to both the affected and unaffected limbs. Other tests measure the amount of sweat on both limbs. If the production is uneven, this points to CRPS.
- X-rays — Loss of bone mass will show up in later stages of CRPS.
- MRIs — MRIs are good for showing tissue changes.
Stages Of CRPS
Although not all cases of CRPS follow the same path, the condition often follows three stages:
- Stage 1 — Following an injury, such as a fracture, the patient develops pain in the limb that exceeds what would normally be considered typical for the injury. This includes burning and throbbing pain, diffuse uncomfortable aching, sensitivity to touch or cold, and localized edema.
- Stage 2 — This stage is marked by a progression of the soft tissue edema, thickening of the skin and neighboring soft tissues, muscle wasting, and the development of brawny skin. This stage may last for 3-6 months.
- Stage 3 — This is the most severe stage. There is a limitation of movement in the limb, the skin becomes waxy, and the nails become brittle. Bones in the limb tend to demineralize.
Early treatment of CRPS is important to keep the symptoms from progressing. Dr. Trujillo uses a combination of therapies to treat patients:
- Pain relievers — From over-the-counter pain relievers to stronger short-term alternatives.
- Antidepressants and anticonvulsants — These drugs can be effective for pain that originates in a damaged nerve.
- Corticosteroids — Steroids can reduce inflammation and improve mobility in the affected limb.
- Bone-loss medications — Dr. Trujillo may prescribe drugs that prevent or slow bone loss.
- Sympathetic nerve-blocking medications — Anesthetic can be injected to block pain fibers in the affected nerves.
- Intravenous ketamine — Low does of this strong anesthetic can be delivered intravenously to alleviate pain.
- Heat therapy — When the skin feels cool, applying heat can relieve swelling and discomfort.
- Topical analgesics — Topical treatments such as lidocaine cream can reduce hypersensitivity.
- Physical therapy — With early diagnosis, physical therapy can help maintain range of motion and decrease pain.
- Transcutaneous electrical nerve stimulation (TENS) — This system delivers electrical impulses onto the skin, and it can ease pain in nerve endings.
- Mirror therapy — By sitting in front of a mirror and moving the unaffected limb, this can make the brain perceive it as the limb affected by CRPS. It has been shown to reduce pain and improve function.
- Biofeedback — This therapy teaches you how to consciously relax your body and relieve pain.
- Spinal cord stimulation — Delivering electrical stimulation along the spinal cord can reduce pain.
- Pain pumps — Pain medications can be pumped into the spinal cord fluid.
The Complications Involved With CRPS
If this condition isn’t diagnosed and treated early in its progression, symptoms can become more and more disabling. These may include:
- Tissue wasting (atrophy) — Your skin, bones, and muscles may begin to deteriorate and weaken. This is usually a direct result of either having difficulty moving the limb or avoiding movement to avoid pain.
- Muscle tightening (contracture) — The muscles may begin to tighten. This may end up in a condition where your hand and fingers or foot and toes contract into a fixed position.
Can CRPS Be Prevented?
CRPS is not fully understood, especially the type that develops without any nerve injury. There are thought to be two ways to potentially prevent CRPS onset:
Take vitamin C after a wrist fracture — Research has shown that if patients take a daily dose of at least 500 milligrams of vitamin C after a wrist fracture they have a lower risk of developing CRPS compared with those who don’t take the vitamin C.
Early mobilization after a stroke — Research also suggests that people who get out of bed and walk around soon after a stroke lower their risk of CRPS.