CRPS is a diagnosis of exclusion

Below is the script that I used to record this video about Complex Regional Pain Syndrome (CRPS):

I am a physician in a pain clinic, and there is usually a wait list of many months to be seen by me. But when I see a referral for CRPS I book the patient right away because CRPS is very serious and the sooner the treatment starts the better the results.

Complex regional pain syndrome is a type of chronic pain that is very severe. It is a pain problem with symptoms and signs that are characteristics of the syndrome. It only affects the limbs: upper limbs or lower limbs. It usually affects only one limb, rarely more than a limb.

It usually occurs after a physical trauma to the limb such as fracture or surgery, but it can also occur after stroke, or brain injury. Or sometimes without any apparent cause. There is a type of CRPS, called type II, that happens when there is a nerve injury present.

The symptoms are very characteristic:

1) pain that cannot be explained by something else. There is no neurological problem, no infection, no blood clot, metabolic imbalance, and the limb is very painful, to the point that even light touch evokes excruciating pain.

2) There are other symptoms such as swelling, redness, altered sweating, strange sensations such as touch causes pain, or complete numbness.

On physical examination we find very specific signs such as temperature and colour change, swelling, extreme sensitivity to touch or pain, change is sweating, hair grow and nails.

The causes of CRPS are unknown, however there is more evidence of abnormal pain processing. We call this sensitization of the pain system. I explained in another video that our pain system is like the alarm system of our body, and like the alarm system of a house can malfunction, the same can happen to our pain system.

Because the pain system is sensitized, many other areas of the brain are also affected, and it is expected that people with CRPS will show more signs of anxiety, depression, sleep and concentration problems.

How do we make the diagnosis?

First, by excluding any other potential cause for the pain and alterations in the limb.

There is no definite test to say this is CRPS or not. In some cases, bone scan with radioactive material (called cintilography) and MRI can show some alterations that suggest CRPS, but those are more pronounced in the early stages of CRPS.

Electromyography and nerve conduction studies are useful if we suspect of CRPS type 2.

How do we treat CRPS?

The sooner the treatment starts the better the results are.

Ideally, patients with CRPS would be better managed by a multidisciplinary approach that involves physiatrist, anaesthetists, psychiatrist, physiotherapists, occupational therapists and pyschologists. However, finding these multidisciplinary pain teams can be very frustrating because there are not that many available, and the wait lists are usually very long.

• Medications that are used to treat the underlying cause of CRPS: anti-inflammatories: both Non-steroidal or steroidal,
• Medications that regulate calcium, like the ones that are used for osteoporosis
• Medications that regulate the pain system such as sodium channel blockers (lidocaine), gabapentinoids, tricyclic antidepressants and SNRIs.
• Medications that are used to treat the symptoms of CRPS are the analgesics like the opioids, or the hyper sensitivity to touch with topical creams.

Physiotherapy:

-         Desensitization

-         Mirror therapy

-         Aquatic therapy for lower extremities

-         Gradual weight bearing

-         Graded motor imagery/learning

-         Therapeutic exercises

Psychotherapy

-         Cognitive behavoiural therapy

-         Relaxation

-         Deep breathing exercises

-         Biofeedback

Nerve blocks and Intravenous infusions (especially for cases that present with swelling, changes in colour or temperature)

-         Chemical sympathectomy

-         Nerve blocks

-         Ketamine IV infusion

Neuromodulation (for refractory cases that the pain has not responded to other treatments).

-         Spinal cord stimulation

Can we prevent CRPS?

High risk group includes older patients with distal radius fractures

Prevention with Vitamin C if a person knows they are having ortopaedic surgery, they can take 500 mg for a few days before surgery, and up to 2 months after surgery.

Early treatment is the best prevention for further complications

Remember that this article is not intended to offer individual patients’ advice, but rather, just a way to learn more about pain. If you think you have a condition that is causing chronic pain, consult your physician to get a proper diagnosis and treatment plan for you.