Complex Regional Pain Syndrome (CRPS)

complex regional pain syndromeComplex Regional Pain Syndrome is a condition which usually occurs after musculoskeletal trauma, particularly surgery. It is estimated to affect between 1:100 to 1:1000 people who with suffer such trauma.

The term describes a group of symptoms occurring together in a painful part of the body. If there is NO associated nerve damage then the condition is called CRPS type1. If there IS associated nerve damage then it is CRPS2.

Both conditions give the same symptoms and both conditions more often than not affect a foot or hand, but any area of the body that has been injured in some way, may give rise to the condition. The condition can occur spontaneously, especially in children.

The Symptoms are:

  • Pain arising from a stimulus which is not normally painful
  • Excessive pain arising from a stimulus which is not normally that painful
  • Spontaneous, intermittent swelling
  • Spontaneous, intermittent skin colour changes

Diagnosis

The Budapest criteria are used to make the diagnosis.

There may be excessive hair growth and changes in nail quality and bone X-rays universally reveal some osteopenia or bone thinning. This is often seen around the joints or in a periarticular distribution. In chronic or long term cases there can be severe osteoporosis and there is withering of a limb with contractures around the joints.

It is very important to remember that painful movement in this condition is not causing damage to the affected area. The earlier the condition is recognised, the more likely it is to respond to treatment. Unfortunately not everyone responds and some people have life-long suffering.

Treatment

The treatment in children is basically education that pain is not damage, and maintenance of activity with graded physiotherapy. Psychotherapy is also often a key treatment. Pregabalin and Gabapentin are drugs which are licensed to treat this kind of pain. They are two of a range of such medications, but are generally the best tolerated of all of them and may also be useful.

In adults, the above is also true, where both pregabalin or gabapentin and physiotherapy can help and indeed physiotherapy is the only proven method to beat CRPS1.

In addition, however, a drug called Guanethidine can also be injected into the circulation in the affected area. This medication is now becoming obsolete and its use is decreasing in favour of other injections known as 'sympathetic nerve blocks'.

A treatment called lumbar chemical sympathectomy may be used for thigh and knee CRPS1.

Stellate Ganglion Block

A stellate ganglion block may be used for upper arm and shoulder CRPS1.

The details of such treatments with their associated chances of success and failure can be discussed in the clinic. These sympathectomy treatments are now the first line invasive treatments in patients with known CRPS. Simple injection with local anaesthetic and steroid around the sympathetic ganglion, is preferable to chemical sympathectomy with phenol, as this latter injection is not without its dangers.

The take home message is that successful treatment of CRPS1 depends on early presentation and adequate pain relief to allow intensive physiotherapy.

CRPS is a condition that is recognised to respond to dorsal column stimulation. This is however, a last-resort treatment once all other routes have been exhausted, and is not for everyone.

Budapest Criteria for diagnosing CRPS

General definition of the syndrome: CRPS describes an array of painful conditions that are characterized by a continuing, (spontaneous and/or evoked), regional pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion. The pain is regional, (not in a specific nerve territory or dermatome), and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or trophic findings. The syndrome shows variable progression over time.

To make the clinical diagnosis, the following criteria must be met:

  1. Continuing pain, which is disproportionate to any inciting event
  2. Must report at least one symptom in three of the four following categories:
    • Sensory: Reports of hyperesthesia and/or, allodynia
    • Vasomotor: Reports of temperature asymmetry and/or, skin color changes and/or, skin color asymmetry
    • Sudomotor/Edema: Reports of edema and/or, sweating changes and/or, sweating asymmetry
    • Motor/Trophic: Reports of decreased range of motion and/or, motor dysfunction (weakness, tremor, dystonia) and/or, trophic changes (hair, nail, skin)
  3. Must display at least one sign at time of evaluation in two or more of the following categories:
    • Sensory: Evidence of hyperalgesia (to pinprick) and/or, allodynia (to light touch and/or, temperature sensation and/or, deep somatic pressure and/or, joint movement)
    • Vasomotor: Evidence of temperature asymmetry (>1°C) and/or, skin color changes and/or, asymmetry
    • Sudomotor/Edema: Evidence of edema and/or, sweating changes and/or, sweating asymmetry
    • Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes(hair, nail, skin)
  4. There is no other diagnosis that better explains the signs and symptoms

How I Can Help

There is no need to suffer with debilitating pain; help is at hand! If you are suffering with pain and it will not go away despite the passage of time and using simple pain relieving medications, physiotherapy etc., then I can see you for a comprehensive evaluation of your problem. Sometimes I alone cannot help you and I work closely with colleagues – surgeons, physiotherapists and psychologists which is important in such care – the multidisciplinary team. Email enquiries@painmanagement.org.uk or call us on 020 7060 5109 for an appointment. Leave a message if you get through to a voicemail and you will be called back.

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