Complex Regional Pain Syndrome - CRPS

Robert F. Valentz, MD, Alaska Spine Institute

Complex Regional Pain Syndrome (CRPS) is a syndrome that typically affects the hands or feet and is characterized by continuous pain, changes in skin temperature and increased or decreased sweating. This syndrome is often misdiagnosed initially because of its presentation. That’s unfortunate because early in the disease is the only time that its progression can effectively be halted. As the syndrome progresses, it becomes progressively more difficult to treat.

Most people who suffer from CRPS have experienced some type of traumatic event to a foot or hand. Sprains, contusions, crush injuries, fractures, lacerations, surgical procedures and venipunctures account for 94 percent of the inciting injury that occur in patients who develop CRPS.

Other types of disorders can mimic CRPS. These include unrecognized local injuries such as sprains, strains or fractures. Peripheral neuropathies, inflammatory conditions, infections and vascular disorders also can exhibit symptoms similar to CRPS.

The average age of a patient with CRPS is 42 years. The ratio female to males is 2.3:1. CRPS is usually causing pain in one extremity, with a 50-50 ratio between the upper and lower extremities. Of patients suffering from CRPS, the number of physician evaluations prior to a referral to a tertiary care center was found to be 4.8 in one study. The diagnosis of CRPS is based primarily on clinical findings after other conditions have been excluded. The patient with CRPS will have continuing pain, allodynia (perception of a noxious stimulus to something that is not), edema, changes in skin temperature and increased or decreased sweating. There are two types of CRPS - Type 1 and Type 2. Type 2 is differentiated from the Type 1 by a direct injury to a specific nerve. Both types have similar symptoms.

The cause of CRPS is unknown, but thought to be abnormalities in the peripheral and central nervous system. The sympathetic nervous system often mediates the pain in CRPS. Nerve blocks of the sympathetic nervous system early in the disease can often be curative. As the disease progresses, sympathetic blocks have a lesser effect.

Treatment of CRPS consists primarily of rehabilitation – mobilization of the affected extremity. This is accomplished through pain management and psychological interventions. Pain control is necessary to allow a patient to participate in physical therapy. Options for pain management include medications, nerve blocks, infusions of local anesthetic in epidural space and neurostimulation. Often, patients will develop anxiety and depression due to the frustration from their symptoms and the impairments that can develop. Antidepressants and psychological interventions can then be required. Biofeedback, relaxation techniques, coping techniques and education regarding CRPS have been shown to be helpful.

Neurostimulation has been shown to significantly reduce pain in CRPS. This involves implanting an electrode in the epidural space to control the pain in the affected area. The use of this device can reduce the amount pain medications used and increase functional activity. With the reduction in pain, patients are then able to participate more fully in the rehabilitation process.

Treatment for CRPS requires a multi-disciplinary approach involving anesthesiologists, physiatrists, psychologists and physical therapists. The Alaska Spine Institute has developed a comprehensive program for the treatment of CRPS. For more information, call (907) 563-8876.