Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD) or causalgia, is a severe pain condition, considered by some to be the most painful medical condition in the world. CRPS is thought to be an injury or malfunction of the peripheral and central nervous systems that manifests itself as extreme pain and other physiologic symptoms in one or more limbs of the body. These symptoms can last for months to years, and if untreated can become permanent. For treatment, there are multiple options, including physical therapy treatment options.
What causes CRPS?
The central nervous system consists of the brain and spinal cord. The peripheral nervous system consists of all the other nerves in the body minus the brain and spinal cord. The peripheral nerves deliver signals to and from the brain and spinal cord to the different parts of the body. It is believed that an injury to one of the peripheral nerves is the initial start to CRPS. An injury such as a fracture of a bone, a strain or sprain, burn, cut, surgery, or something as minor as a needle stick can be the initial start of CRPS. In some cases, infection or blood vessel issues can start the cascade toward CRPS as well.
Once an initial injury occurs, the signals going from the peripheral nerves to the brain tell a person they are hurt. The brain then sends signals to various parts of the body telling them to start releasing chemicals that will cause many physiological responses in the body needed to begin the healing process. Some of the first things a body does to protect and heal itself is sending chemicals and nerve signals that cause swelling, increased blood flow to the injured area, and pain. These are normal parts of the healing process.
In CRPS, the major problem is that the signals from the brain causing pain, swelling, and increased blood flow never turn off, even after the injury is fully healed. The brain then tricks the body into believing it is still injured even though it is not. As this goes on, the signals can become stronger and stronger to the point where constant, extreme pain persists for months to years, and even permanently.
There is no clear reason for why someone who, for example, breaks their arm gets CRPS when many others who break their arm do not. They have found, however, that CRPS happens more frequently to women than men and has a peak likelihood of occurring during a person’s 40’s. However, it can happen to either gender at any age. Some studies have seen a correlation showing that people with severe allergies or hypersensitivity reactions have a higher likelihood to develop CRPS.
What are the signs and symptoms of CRPS?
Signs and symptoms of CRPS can vary slightly from person to person depending on what stage of the condition they are in at the time. Some patients can have all of the symptoms listed or only a few. Also, symptoms can change over time depending on how long since the CRPS started.
- Extreme pain – burning, pins and needles, and/or crushing/squeezing pain
- Changes in skin color – skin can turn more pink, red, purple, or blue compared to the other limb
- Changes in hair or nail growth in the limb – brittle nails and increased or decreased hair growth depending on the person
- Skin changes – skin becomes shiny and thin
- Sweat changes – either excessive sweating or decreased sweating compared to the other limb
- Skin temperature – although people feel like their leg is burning, when they touch the limb it is actually very cool to the touch.
- Increased joint stiffness and decreased motion in the joint
- Increased muscle tightness and spasms in limb
- Osteoporosis – shown on x-ray
- Allodynia – severe sensitivity to normal touch of the skin, like being touched after getting sunburned
As the condition progresses and lasts longer people may also experience:
- Atrophy of muscles in the limb due to decreased use
- Short-term memory issues
- Difficulty coming up with words when speaking
- Increased swelling in the limb
- Sensitivity to noise and vibration
Additionally, research has also found that persons in pain have a hard time distinguishing the right vs. left limb that is injured when looking at a picture of the same body part. Many with CRPS have this same issue, being unable to determine whether it is a right or left hand or leg when looking at a picture.
How is CRPS treated?
There are many forms of treatment for CRPS, though for each person treatment will be individualized depending on their signs and symptoms. What works for one CRPS patient may not work for another and a combination of treatments might be necessary as well.
- Physical Therapy
- Biphosphonates – to prevent bone reabsorption, helps with osteoporosis
- Corticosteroids – to prevent inflammation and swelling
- Botox – for muscle spasms and tightness
- Drugs for nerve pain – Gabapentin, Amitriptyline, etc.
- Over the counter drugs for pain/inflammation – ibuprofen, aspirin, naproxen
- Topical creams for pain – lidocaine usually
- Intravenous immunoglobulin and ketamine – both are undergoing research for CRPS treatment but have shown good results in decreasing pain in early research trials.*
- Sympathetic nerve block – have been shown to help in short-term but long-term benefits are usually not seen
- Spinal cord stimulator – this is a surgical procedure where a stim unit is placed directly into the spine to control the signals going from the brain to the body using electrical stimulation.
- Surgical sympathectomy- A procedure where sympathetic nerves going from the brain to the affected limb are surgically cut to stop the pain signals from getting to the limb. This is a controversial surgery because some doctors think it makes CRPS
- Many people with CRPS develop anxiety, depression, and even PTSD. Visiting a psychiatrist or psychologist for help is a highly encouraged treatment strategy.
- Maintaining a well-balanced diet has been shown to reduce symptoms of CRPS
- Maintaining a consistent sleep-wake cycle has been shown to reduce symptoms of CRPS due to the body regulating hormones such as cortisol that can make pain and sympathetic nerve symptoms worse.
* These drugs are still in a research phase and considered experimental
**It is recommended that non-procedural treatments are attempted before procedural treatments due to decreased risks and possible complications of the treatment itself.
How can physical therapy help those with CPRS?
Physical Therapy (PT) has been shown to be one of the best treatments for CRPS due to its ability to maintain function in the limb. Physical therapy will focus primarily on maintaining function in the limb by using stretches and exercises to keep the muscles loose and strong, and the joint moving. Beyond that, PT can also help with pain management and edema/swelling. There are many types of physical therapy treatments shown to be helpful.
- Desensitization therapy – a treatment that focuses on reducing allodynia
- In this treatment, different types of textured objects are lightly brushed across the either the affected or non-affected limb to retrain the pain receptors in the area. The goal is to tell the pain receptors that light touch should not cause pain in a limb and to stop sending pain signals to the brain.
- Graded Motor Imagery (GMI)- a treatment that focuses on retraining right v. left limb distinction and restoring function while reducing pain to the limb
- This treatment style uses pictures of right and left arms or legs in different positions.
- In stage one, the patient only has to determine if a limb is a right or left limb
- For stage two the patient has to only think about moving the same-sided limb into the position seen in the picture, no movement actually occurs. This is turning on the premotor cortex areas of the brain.
- During stage three, the patient actually moves the same-sided limb into the position scene in the picture.
- The goal is that all stages are done pain-free and that the next stage is not started until the stage before it is performed pain-free with 100% accuracy
- Mirror box therapy- This treatment is used to restore function and reduce pain in the effected limb
- The affected limb is placed into a box where is unable to be seen by the patient
- A mirror attached to the box is aimed toward the unaffected limb. This causes a mirror image of the unaffected limb to be seen by the patient. For example, if the left hand is in the box and mirror is aimed at the right hand the image seen in the mirror will look as if it is your left hand when really it is the mirror image of the right hand.
- The mirror image tricks the brain visually into believing it is the affected limb.
- The patient then performs exercises, stretches, desensitization therapy, graded motor imagery, etc. with their unaffected limb, however, the whole time they are looking into the mirror tricking their brain into believing the affected limb is performing all the motions or treatments pain-free.
- Edema Massage/Edema Taping
- This treatment focuses on managing swelling and edema in the area
- Different massage and taping techniques promote swelling and edema to leave an area. This usually decreases pain, restores normal blood flow, and increases mobility and strength in an area
What is the take-home message?
CRPS is a very serious and extreme pain condition that can be debilitating. Physical therapy treatments are the best treatment strategies to maintain function and offer pain relief. Physical therapy for improved function and decreased pain combined with other medical treatments, to address the signs and symptoms of CRPS, can make CRPS manageable and even cause it to go into remission.
If you believe you have CRPS based on the information above, talk to your doctor immediately. The sooner a diagnosis is made the better chances you have of going into remission for CRPS. Once you’re ready to visit a physical therapist, make an appointment with us.