Complex Regional Pain Syndrome - A resource
A little about me
I am a Physicians Assistant and currently work in occupational medicine. I have worked in occupational medicine and orthopedics for the last 11 years. In my practice, I have treated patients with complex neurological and orthopedic conditions. Complex regional pain syndrome is a serious condition that can cause significant emotional and physical disability. I treat many patients with this condition. In my experience, the patients that I treat know very little about why they have pain and what to expect in the course of their treatment. I am writing this article to help patients who are suffering from this unfortunate condition. I hope to provide some valuable information about the condition. I regularly perform peer reviews on this topic and often reference current evidence based literature on this diagnosis. Most of the information that I reference comes from the Official Disability Guidelines, which is a comprehensive resource that contains evidence based studies on treatments, medications, conditions, surgeries, etc.
For Research Purposes, please answer the following...
Do you feel that you were misdiagnosed by your doctor?
How this is diagnosed...
There is no standard diagnostic test that is used to definitively diagnose this condition. Unlike diabetes or high blood pressure or anemia, there is not a simple lab test that can be performed to establish the presence of this diagnosis. Often times, this diagnosis is based on multiple different factors, including physical examination, subjective complaints, response to injections, bone scan, and the presence of an initial event/injury that caused the condition. Different organizations have compiled different diagnostic criteria that are required to be present in order to make the diagnosis.
As outlined in the Official Disability Guidelines, the IASP (International Association for the Study of Pain) concluded that the following criteria should be met:
(1) Continuing pain disproportionate to the inciting(initial) event. This literally means that a person has pain that lasts longer than is expected for the particular injury or diagnosis.
(2) A report of one symptom from each of the following four categories and one physical finding from two of the following four categories:
(a) Sensory: hyperesthesia. This is the presence of increased pain when you touch the area.
(b) Vasomotor: temperature asymmetry or skin color changes or asymmetry. This means that the affected leg or arm has either a higher or lower temperature compared to the non-affected arm and there are also color changes, such as redness, etc.
(c) Sudomotor/edema: edema or sweating changes or sweating asymmetry. This means that the affected arm or leg is swollen or sweats when the non-affected arm or leg does not.
(d) Motor/trophic: reports of decreased range of motion or motor dysfunction, such as weakness/tremor or dystonia or trophic changes: hair, nail, skin. This means that there is weakness, muscle spasm, absence of hair on the affected extremity, or changes in the skin pattern and color.
Although other organizations have come up with other criteria to make the diagnosis, the above criteria from the IASP is most commonly used in the diagnosis and other criteria from other organizations closely resembles the criteria from IASP with only minor changes.
There should also be evidence of allodynia/hyperalgesia on exam, which is significantly increased pain with even light touch to the area. Some patients report that they cannot even wear socks on that leg because of significant pain. It is almost always necessary to see different patterns of sweating, temperature changes of the skin, and changes in the color of the skin to make this diagnosis.
When there is clinical suspicion for this diagnosis, there is a need for confirmation of the diagnosis with a more objective test in most cases. One of the most specific tests for this diagnosis is what's called a sympathetic block/injection. When this type of injection is administered, a patient who is suffering from CRPS will have improvement of the condition after the injection. Unfortunately, most of the time, this is not a reliable treatment, as the effects of the injection are very short term and usually wear off very quickly in the first week or two, and sometimes even less than that. Only about 1/3 of patients with this condition will have a good response to this type of injection. Sympathetic injections can also be useful to decrease pain so that a patient can attend a physical therapy program. The objective is that the injection decreases pain long enough for the patient to be able to participate in a therapy program.
A bone scan can also be used in the diagnosis of this condition. A bone scan is similar to an x-ray, but they use contrast to look for uptake in certain areas of your body. In CRPS, there is a pattern of uptake that is characteristic of the condition.
For Research Purposes - please answer the following:
What treatments have you tried for CRPS?
There are many available treatments for this condition. It typically takes multiple different treatments used at the same time to get a good control on this condition. Many patients with this diagnosis will need to be treated chronically. Just like a diagnosis of diabetes, this condition can be managed effectively.
The most commonly used medications for this condition include NSAIDs (Motrin, Naproxen, Ibuprofen, Advil); neuropathic pain medications (Lyrica, Neurontin); tricyclic/SNRI anti-depressants (amitriptyline, nortriptyline, duloxetine); NMDA receptor antagonists (ketamine, amantadine), and alpha 1 adrenoceptor blocking agents (terazosin, prazocin).
Often times, a combination of the above medications is necessary to treat the condition.
A program of physical therapy is necessary with a therapist that is specifically trained in this condition. Treatment with a therapist that is not trained in CRPS can be devastating and can actually exacerbate the condition. After a course of therapy, the therapist educates the patient in an exercise program that can be performed at home on a regular basis. Regular participation in an active exercise program can be a quite effective treatment for this condition.
Psychological treatment is focused on improving the patient's quality of life. Psychological sessions for a patient with CRPS focus on developing coping skills to deal with the chronic pain condition. Cognitive behavioral therapy is a specific type of psychotherapy that is commonly used in the treatment of this condition. Additionally, many patients who have CRPS also have comorbid psychological diagnoses, including anxiety or depression. These can also be treated with outpatient psychotherapy.
Generally, patients with CRPS are treated on a long-term basis with a pain management physician. This doctor can provide medications and recommend other treatment options. It is very important that a person with CRPS maintain a good therapeutic alliance with his treating physician to optimize the potential therapeutic benefit.
Spinal Cord Stimulation:
A spinal cord stimulator (SCS) is a type of electrical stimulation unit that is surgically implanted into your spine and provides stimulation to the nerves. An SCS is a rather effective treatment for this condition in most cases. However, they are only considered after all reasonable non-operative treatments have failed and are considered to be a last line treatment.