My Pain Clinic - Complex Regional Pain Syndrome

Introduction

Complex regional pain syndrome (CRPS) is an uncommon, chronic condition that usually affects your arm or leg. Rarely, the disease can affect other parts of your body. The key symptom of CRPS is continuous, intense pain out of proportion to the severity of the injury, which gets worse rather than better over time. You may experience intense burning or aching pain along with swelling, skin discoloration, altered temperature, abnormal sweating and hypersensitivity in the affected area.

The nature of complex regional pain syndrome is puzzling, and the cause isn't clearly understood.

Women are more likely to be affected by complex regional pain syndrome than men are. Although complex regional pain syndrome is most common in people between the ages of 40 and 60, it can occur at any age. Treatment for complex regional pain syndrome is most effective when started early in the course of the syndrome.

What Causes CRPS?

Complex regional pain syndrome occurs in two types with similar signs and symptoms, but different causes:

Type I. Previously known as reflex sympathetic dystrophy syndrome, this type occurs after an illness or injury that didn't directly damage the nerves in your affected limb. About 90 percent of people with complex regional pain syndrome have type I.
Type II. Once referred to as causalgia, this type follows a distinct nerve injury.

Many cases of complex regional pain syndrome occur after a forceful trauma to an arm or a leg, such as a gunshot wound or shrapnel blast. Other major and minor traumas — surgery, heart attacks, infections, fractures and even sprained ankles — also can lead to complex regional pain syndrome. It's not well understood why these injuries sometimes trigger complex regional pain syndrome.

The syndrome was first described after the U.S. Civil War when soldiers continued to report severe pain after their wounds had healed. It was often referred to as "hot pain" during that period.

Signs and symptoms

The main symptom of complex regional pain syndrome is intense pain, often described as "burning." Additional signs and symptoms include:

		Skin sensitivity.
		Changes in skin temperature color and texture. At times your skin may be sweaty; at other times it may be cold. Skin color can range from white and mottled to red or blue. Skin may become tender, thin or shiny in the affected area.
		Changes in hair and nail growth.
		Joint stiffness, swelling and damage.
		Muscle spasms, weakness and loss (atrophy).
		Decreased ability to move the affected body part.

Complex regional pain syndrome typically has three stages, though not everyone progresses through these phases at the same pace:

Stage 1. Severe pain develops in one of your limbs. Swelling, sensitivity to touch or to cold, and skin changes, such as drying or thinning, begin to appear. This stage usually lasts one to three months.

Stage 2. Changes to the color and texture of your skin become increasingly obvious, and the swelling spreads. You may begin to feel stiffness in your muscles and joints. This stage may last three to six months.

Stage 3. Severe damage is evident, such as limited movement in your affected limb, irreversible skin damage, muscle atrophy and contractures in nearby digits.

When to seek medical advice?

If you experience constant, severe pain that affects a single limb and makes touching or movement of that limb seem intolerable, see your doctor to determine the cause. It's important to treat complex regional pain syndrome early.

How Is CRPS Diagnosed?

A physiatrist will conduct an interview and physical exam. He may ask questions about how you would describe your pain, when the pain occurs, or whether anything specific triggers the pain.

Review of your medical history. The onset of complex regional pain syndrome symptoms can often be traced back to an accident, illness or injury.

Physical examination. An examination of your skin, muscles and joints may reveal information about the source of your tenderness and pain. There may be changes in the normal texture and color of your skin, and you may have problems with range of motion of one or more of your joints.

Bone scan. A radioactive substance injected into one of your veins permits viewing of your bones with a special camera. This procedure may show increased circulation to the joints in the affected area.

Sympathetic nervous system tests. These tests look for disturbances in your sympathetic nervous system. For example, thermography measures the skin temperature and blood flow of your affected and unaffected limbs. Other tests can measure the amount of sweat on both limbs. Dissimilar results can indicate complex regional pain syndrome.

X-rays. Loss of minerals from your bones may show up on an X-ray in later stages of the disease.

Magnetic resonance imaging (MRI). Images captured by an MRI device may show a number of tissue changes, such as skin thinning and muscle atrophy, that may help your doctor determine the stage of your disease.

How Is CRPS Treated?

Because there is no cure for CRPS, treatment is aimed at relieving painful symptoms. Dramatic improvement and even remission of complex regional pain syndrome is possible if treatment begins within a few months of your first symptoms. Treatment options include:

Medications. Doctors use various medications to treat the symptoms of complex regional pain syndrome. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve), may ease pain and inflammation. In some cases, doctors may recommend prescription medications. For example, antidepressants such as amitriptyline and anticonvulsants such as gabapentin (Neurontin) are used to treat pain that originates from a damaged nerve (neuropathic pain). Corticosteroids, such as prednisone, may reduce inflammation. Your doctor may suggest bone-loss medications, such as alendronate (Fosamax) and calcitonin (Miacalcin). Opioid medications may be another option. Taken in appropriate doses, they may provide acceptable control of pain. However, they may not be appropriate if you have a history of substance abuse or lung disease. Some pain medications, such as COX-2 inhibitors (Celebrex), may increase your risk of heart attack and stroke. It's wise to discuss your individual risk profile with your doctor.

Applying heat and cold. Applying cold may relieve swelling and sweating. If the affected area is cool, applying heat may offer relief.

Capsaicin. This cream, made from the seeds of hot chili peppers, may relieve pain caused by nerve damage in early-stage complex regional pain syndrome. Your doctor may recommend applying the cream to the affected area several times daily. Capsaicin cream can be very irritating if rubbed on nonaffected parts of your body. Follow the application instructions carefully. You should be able to tell within a week whether the treatment is effective and tolerable.

Physical therapy. Gentle, guided exercising of the affected limbs may improve range of motion and strength. The earlier the disease is diagnosed, the more effective exercises may be.

Sympathetic nerve-blocking medication. Injection of an anesthetic to block pain fibers in your affected nerves may relieve pain in some people.

Transcutaneous electrical nerve stimulation (TENS). Chronic pain is sometimes eased by applying electrical impulses to nerve endings.

Biofeedback. In some cases, learning biofeedback techniques may help. In biofeedback, you learn to become more aware of your body so that you can relax your body and relieve pain.

Spinal cord stimulation. Your doctor inserts tiny electrodes along your spinal cord. A small electrical current delivered to the spinal cord sometimes results in pain relief.

What is the prognosis?

The prognosis for CRPS varies from person to person. Spontaneous remission from symptoms occurs in certain individuals. Others can have unremitting pain and crippling, irreversible changes in spite of treatment.

Coping skills

Living with a chronic, painful condition can be challenging, especially when — as is often the case with complex regional pain syndrome — your friends and family don't believe you could be feeling as much pain as you describe. Share information from reliable sources about complex regional pain syndrome with those close to you to help them understand what you're experiencing.

Take care of your physical and mental health by following these suggestions:

		Maintain normal daily activities as best you can.
		Pace yourself and be sure to get the rest that you need.
		Stay connected with friends and family.
		Continue to pursue hobbies that you enjoy and are able to do.

If complex regional pain syndrome makes it difficult for you to do things you enjoy, ask your doctor about ways to get around the obstacles.

Keep in mind that your physical health can directly affect your mental health. Denial, anger and frustration are common with chronic illnesses.

At times, you may need more tools to deal with your emotions. Professionals such as therapists or behavioral psychologists may be able to help you put things in perspective. They can also teach you coping skills that may help you, including relaxation techniques.

Sometimes, joining a support group, where you can share experiences and feelings with other people, is a good approach. Ask your doctor what support groups are available in your community.