Complex Regional Pain Syndrome (CRPS)
What is CRPS?
Complex Regional Pain Syndrome (CRPS) was originally known
as Causalgia, which was then re-named as Reflex Sympathetic Dystrophy (RSD) but
most recently the name for it is CRPS (complex regional pain syndrome).
It is characterised by chronic pain and it most often
affects one of the limbs. It usually comes on after an injury or trauma to that
limb but not always: Complex regional
pain syndrome develops after a traumatic event in 90% of patients and with 10%
of patients there is no traumatic event (Baykal et al 2013).
CRPS is believed to be caused by damage to, or malfunction
of, the peripheral and central nervous systems. CRPS is characterised by
prolonged or excessive pain, changes in skin colour, temperature and/or
swelling in the affected area.
The changes in the sympathetic nervous system and the immune
system contribute to CRPS. There are effects in the tissues such as altered
activity in the blood vessels and nerves that cause the signs and symptoms of
CRPS.
There are two types of CRPS:
Type I and II
Type I:
The presence of an initiating noxious event or a cause of
immobilisation.
Continuing pain, allodynia (perception of pain from a
nonpainful stimulus), or hyperalgesia disproportionate to the inciting event.
Evidence at some time of oedema, changes in skin blood flow,
or abnormal sudomotor activity in the area of pain.
The diagnosis is excluded by the existence of any condition
that would otherwise account for the degree of pain and dysfunction.
Type I has been found to affect brain structure in
prefrontal and motor cortex (Pleger et al 2014).
Type II:
The presence of continuing pain, allodynia, or hyperalgesia
after a nerve injury, not necessarily limited to the distribution of the
injured nerve.
Evidence at some time of oedema, changes in skin blood flow,
or abnormal sudomotor activity in the region of pain.
The diagnosis is excluded by the existence of any condition
that would otherwise account for the degree of pain and dysfunction
So the main difference is the identification of a nerve
injury.
What are the symptoms?
There are a range of signs and symptoms including:
Pain:
This can vary in severity, quality, location and pattern.
Altered sensation:
Numbness, pins & needles.
Temperature change:
Hot or cold.
Swelling:
This can vary. There can also be a sense of swelling that is
not apparent when compared to the other side, people often describe the feeling
of ‘sausage fingers’.
Stiffness:
Feeling tight in the soft tissues.
Sweating:
Clammy sensation (sudomotor)
Loss of function:
Reduced strength, position sense, control of movement.
Altered sense of self:
The limb feels detached, belonging to someone else.
Treatments:
Pharmacological treatments:
Non-steroidal anti-inflammatory drugs (NSAIDs):
NSAIDS have been shown to be very effective. They can also
help reduce any associated swelling.
Nerve blocks:
Used to provide short-term pain relief for people with CRPS.
This involves injecting local anaesthetic into a group of affected nerves, which prevents pain signals from reaching the brain. A reduction in pain often
continues even after the effect of the local anaesthetic has worn off.
Anticonvulsants:
Gabapentin is the most widely used anticonvulsant for
treating CRPS. However research shows that over half of those taking gabapentin
for neuropathic pain will not have good pain relief (Moore et al 2011).
Also 2/3rds of patients taking gabapentin experience dizziness,
somnolence (sleepiness), oedema (swelling), & gait disturbance (Moore et al
2011).
Tricyclic antidepressants (TCAs):
Amitriptyline is the most widely used TCA for treating CRPS.
Opiates
If you are experiencing severe pain, opiates such as codeine
and morphine can be used to provide short-term relief.
Long-term use of opiates is usually discouraged because of
potential side effects. There is a risk of addiction with opiates so your
dosage will be carefully monitored to reduce this risk as much as possible.
Physiotherapy:
Aimed at gradually developing healthy normal movement and
function, to increase the normal sense of the body and to reduce the pain and
sensitivity through range of motion and proprioceptive exercises.
Sensory training alongside movement and exercise therapies
with some hands-on treatments such as massage and mobilisation may
also be beneficial.
Therapeutic strategies aimed at restoration of
proprioceptive impairments, possibly using online visual feedback, may promote
the recovery of motor function in CRPS (Bank et al 2014). Exercise &
exercise therapies, regardless of their form, are recommended in the management
of patients with chronic pain (Colvin et al 2013).
Graded Motor Imagery programme:
Step one:
Testing your "laterality" (your ability to tell
left from right). This is where you teach your brain to recognise right and
left images, for example by correctly identifying a picture of a left hand or a
right hand.
Step two:
"Motor imagery" (imagining movements, or watching
other people move). As you watch other people move you imagine it is you doing
the movement.
Step three:
Mirror therapy (a mirror is used to reflect the
"good" limb). For example, if your left hand is causing you pain, it
is placed in a mirror box so that your right hand (the "good" hand)
is reflected. Your brain sees two "good" images and is tricked into
thinking that your left hand no longer hurts when it moves.
Occupational Therapy:
Help you work out practical solutions that will enable you
to remain independent.
They can teach you pacing strategies to help you to complete
your day to day activities by breaking it up into smaller manageable chunks or
teach you ways to get around the problems with specific techniques and
equipment to make life easier.
Psychological therapies:
To help you cope better with the symptoms of pain. Some
studies have shown that cognitive behavioural therapy (CBT) can help in the
management of chronic pain. Psychological therapies delivered via the Internet
reduced pain, disability, depression, & anxiety in chronic pain (Craig et
al 2014).
Electotherapy:
Spinal cord stimulation:
This produces mild electrical pulses that are sent to your
spinal cord. These pulses cause changes to how you feel pain.
A trial in people with type one CRPS found that, compared
with physical therapy alone, spinal cord stimulation was more effective at
reducing pain.
The National Institute for health and Clinical Excellence
(NICE) guidance states that spinal cord stimulation will only be considered if:
You are still experiencing pain after six months of trying
other treatments.
Or
You have had a successful trial of the stimulation.
Transcutaneous electrical nerve stimulation (TENS):
Reaseach states that TENS should be considered for the
relief of chronic pain (Colvin et al 2013).
Transcranial magnetic stimulation:
Single doses of high-frequency transcranial magnetic
stimulation of the motor cortex may have small short-term effects on chronic
pain (O'Connell et al 2014).
Recovery and prognosis:
Many CRPS patients recover within 6-13 months, but a
significant number experience some lasting symptoms, and some experience ongoing
chronic pain and disability (Bean et al 2014).
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