Complex Regional Pain Syndromes

The description of complex regional pain syndromes (CRPS) dates back to the days of the civil war when Mitchell first described this condition in 1864. Mitchell coined the term causalgia, meaning burning pain. The most striking feature of this condition is pain that is disproportional to an injury. The onset of CRPS typically follows minor injuries such as sprains, fractures or surgery. Other names for this condition include;

reflex sympathetic dystrophy syndrome (RSD/RSDS)
Sudeck's atrophy
shoulder-hand syndrome
algodystrophy
peripheral trophoneurosis
sympathetically maintained pain
sympathetically independent pain
post-traumatic pain syndrome
sympathalgia
sympathetic overdrive syndrome

Due to confusion arising from the many names for this set of symptoms, The International Association for the Study of Pain (IASP) developed nomenclature to more accurately describe chronic pain. IASP coined the term chronic regional pain syndrome (CRPS) and broke CRPS into two categories;

CRPS I - Consists of pain, sensory abnormalities, abnormal sweating and blood flow, abnormal motor system function and trophic changes (thickening of the skin and nails, coarse thin hair growth) and atrophy of the superficial and deep tissues (skin, muscle, bone). The most common form is RSD and may not present with an identifiable nerve injury.

CRPS II - Same as CRPS I but presents with an identifiable nerve injury. Symptoms include burning pain made worse by light touch, temperature changes or motion of the limb. These findings are most common in the foot or hand following partial injury to the nerve. The affected area appears cool, reddish, and clammy. The superficial and deep tissue structures may also begin trophic changes.

 

Treatment for complex regional pain syndromes

Treatment of CRPS I and II consists of many different measures, but there is general agreement that the success of treatment depends upon early implementation of treatment. Treatment may include;

Medications
Narcotics- for pain suppression
Anti-inflammatory- non-narcotic control of inflammatory pain
Antidepressants-maintenance of normal sleep cycles, anxiety control
Calcium channel blockers- increased blood flow to extremities
Anticonvulsant- regulation of normal sleep cycle, control of pain

Pain blocks
Peripheral nerve blocks of the affected area
IV regional blocks of the affected extremity
Lumbar sympathetic blocks- given by an anesthesiologist

Physical therapy
Range of motion, strengthening exercises, continuous passive motion
(CPM)
Whirlpool, ultrasound, heat treatment
TENS, nerve stimulation

Steroid injections

Lumbar sympathectomy

Dorsal column stimulation
Morphine pump

Neurectomy - surgical excision of the nerve

Amputation - surgical removal of the affected extremity

The prognosis for patients with CRPS varies greatly and depends upon the degree of symptoms, when treatment is initiated and the type of treatment. Studies have shown that the overall success rate of the treatment of RSD has been 50%. In a study performed by Anderson and Fallat, they found that 3.5 years following the onset of traumatic injury resulting in CRPS, 12 of 13 patients still had pain considered to be moderate to considerable. (1)

Treatment of CRPS requires a team approach to treat not only pain but also the numerous problems associated with chronic pain. These problems include;

Depression.
Disruption of normal sleep cycles.
Inability to walk or bear weight.
Inability to work.
Disruption of relationships with spouse or offspring.

Resources that may be helpful in addition to pain management include psychological counseling, physical therapy and occupational therapy.

Pain - An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Allodynia- Pain due to a stimulus which does not normally provoke pain.

Analgesia - Absence of pain in response to stimulation which would normally be painful.

Anesthesia dolorosa - Pain in an area or region which is anesthetic.

Causalgia - A syndrome of sustained burning pain, allodynia, and hyperpathia after a traumatic nerve lesion, often combined with vasomotor and sudomotor dysfunction and later trophic changes.

Central pain - Pain initiated or caused by a primary lesion or dysfunction in the central nervous system.

 

Dysesthesia - An unpleasant abnormal sensation, whether spontaneous or evoked.

 

Hyperalgesia - An increased response to a stimulus which is normally painful.

Hyperesthesia - Increased sensitivity to stimulation, excluding the special senses.

Hyerpathia - A painful syndrome characterized by an abnormally painful reaction to a stimulus, especially a repetitive stimulus, as well as an increased threshold

Hypoalgesia - Diminished pain in response to a normally painful stimulus.

Hypoesthesia - Decreased sensitivity to stimulation, excluding the special senses.

Neuralgia - Pain in the distribution of a nerve or nerves.

Neuritis - Inflammation of a nerve or nerves.

Neurogenic pain - Pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in the peripheral or central nervous system.

Neuropathic Pain - Pain initiated or caused by a primary lesion or dysfunction in the nervous system.

Neuropathy - A disturbance of function or pathological change in a nerve: in one nerve, mononeuropathy; in several nerves, mononeuropathy multiplex; if diffuse and bilateral, polyneuropathy.

Nociceptor - A receptor preferentially sensitive to a noxious stimulus or to a stimulus which would become noxious if prolonged.

Noxious stimulus - A noxious stimulus is one which is damaging to normal tissues.

Pain Threshold - The least experience of pain which a subject can recognize.

Pain tolerance - The greatest level of pain which a subject is prepared to tolerate.

Paresthesia - An abnormal sensation, whether spontaneous or evoked.

Peripheral neurogenic pain - Pain initiated or caused by a primary lesion or dysfunction or transitory perturbation in the peripheral nervous system.

Peripheral neuropathic pain - Pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system.

 

The terminology listed on this page is an abbreviated version of terminology and definitions complied by The International Association for the Study of Pain.

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No information is available for this topic.

CRPS symptoms vary dramatically in their onset, intensity and duration. One of the difficulties in treating CRPS is making an initial diagnosis due to the complex nature of this group of conditions. Once diagnosed, aggressive and prompt treatment is important to arrest the progression of this disabling disease.

No information is available for this topic.

• Peripheral Neuropathy

• Tarsal Tunnel Syndrome

• Forefoot Pain

• Peroneal Palsy

This article was written by Jeffrey A. Oster, DPM and last updated 2/5/13.

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