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.
