Complex Regional Pain Syndrome

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Complex regional pain syndrome (CRPS) is a chronic pain condition that is most affecting one of the limbs (arms, legs, hands, or feet) of an individual, normally after an injury or trauma to the affected limb. CRPS is believed to be caused by damage to, or malfunction of, the peripheral and central nervous systems. The central nervous system is composed of the brain and spinal cord. And the peripheral nervous system involves nerve signaling from the brain and spinal cord to the rest of the human body. CRPS is characterized by prolonged or excessive pain and mild or dramatic changes in skin color, temperature, and/or swelling in the affected area. There are two similar forms called CRPS-I and CRPS-II, with the same type of symptoms and treatments. CRPS-II is the term used for patients with confirmed nerve injuries. Individuals without confirmed nerve injury are classified as having CRPS-I. Some researchers have identified evidence of nerve injury in CRPS-I, so the validity of the two separate forms is being currently investigated.

Complex regional pain syndrome symptoms vary in severity and also duration. Studies of the incidence and prevalence of the disease show that most cases are mild and individuals recover gradually within a period of time. In more severe cases, individuals may not recover and may have a long-term disability.

Symptoms & Causes

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Complex regional pain syndrome is uncommon, and its cause isn’t clearly understood. Signs and symptoms regarding CRPS include:

 

  • Continuous burning or throbbing pain, normally in the arm, leg, hand, or foot
  • Sensitivity to touch or cold
  • Swelling of the painful area
  • Changes in skin temperature, alternating between sweaty and cold
  • Changes in skin color, ranging from white and blotchy to red or blue
  • Changes in skin texture, which may become tender, thin, or shiny in the affected area
  • Changes in hair and nail growth
  • Joint stiffness, swelling, and damage
  • Muscle spasms, tremors, weakness, and loss
  • Decreased ability to move the affected body part’

 

Symptoms could change over and vary from person to person. Pain, swelling, redness, noticeable changes in temperature, and hypersensitivity usually occur first. Over some time, the affected limb can become cold and pale. It may undergo skin and nail changes as well as muscle spasms. Once these changes occur, the condition is often irreversible. CRPS occasionally may spread from its source to elsewhere in the body, such as the opposite limb.

CRPS occurs in two types, with similar signs and symptoms, although in different causes:

 

Type 1 – Also known as reflex sympathetic dystrophy (RSD), this type occurs after an illness or injury that did not directly damage the nerves in the affected limb.

 

Type 2 – Once referred to as causalgia, this type has symptoms similar to those of type 1. But yep 2 CRPS occurs after a distinct nerve injury.

 

Many causes of CRPS occur after a forceful trauma to an arm or a leg. This can include a crushing injury or a fracture.

Other major and minor traumas such as surgery, heart attacks, infections, and even sprained ankles – can also lead to CRPS. It’s not well understood as to why these injuries can trigger CRPS. Not everyone who has such an injury will go on to develop CRPS. It might be due to a dysfunctional interaction between the central and peripheral nervous systems and inappropriate inflammatory responses. In some people, signs, and symptoms of CRPS go away on their own. In others, signs and symptoms may persist for months to years. Treatment is likely to be most effective when started early in the course of the illness.

If CRPS isn’t diagnosed and treated early, the disease may progress to more disabling signs and symptoms. These may include:

 

  • Tissue wasting (atrophy). The skin, bones, and muscles may begin to deteriorate and weaken if the individual avoids or has trouble moving an arm or a leg because of pain or stiffness.

 

  • Muscle tightening (contracture). A patient may experience tightening of the muscles. This could lead to a condition in which the hand and fingers of the foot and toes contract into a fixed position.

Who Gets Complex Regional Pain Syndrome?

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Anyone can get CRPS. It can strike at any age and affects both men and women, although it is much more common in women. The average age of affected individuals is about age 40. CRPS is rare in the elderly. Children do not get this illness before age 5 and only very rarely before age 10. However, it is uncommon in teenagers. Children and adolescents with CRPS generally have a better recovery than adults and offer a unique model for the study of chronic pain reversal. Scientists studying children with CRPS are investigating neuroplasticity and the biological processes that cause CRPS to occur, in the hopes of developing more effective therapies and accelerated for adults and children.

How Does It Affect You? How Serious Is It?

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Mechanisms in the development of CRPS vary in different ways. Some these types of development for this illness include:

 

Nerves – Peripheral nerve abnormalities found in individuals with CRPS, usually involve the small unmyelinated and thinly myelinated nerve fibers (axons) that carry pain messages and signals to blood vessels. (Myelin is a mixture of proteins and fat-like substances that surround and insulate some nerve fibers.) Because small fibers in the nerves communicate with blood vessels, small nerve fiber injuries may trigger the many different symptoms of CRPS. Molecules secreted from the ends of hyperactive injured small nerve fibers are thought to contribute to inflammation and blood vessel abnormalities. These peripheral nerve abnormalities in turn trigger abnormal neurological function in the spinal cord and brain, leading in some cases to complex disorders to higher cortical function.

 

Blood vessels – Another abnormality in CRPS involves the blood vessels in the affected limb, which may dilate (open wider) or leak fluid into the surrounding tissue, causing red, swollen skin. The underlying muscles and deeper tissues can become starved of oxygen and nutrients, causing muscle and joint pain damage. At times, the blood vessels may over-constrict (clamp down), causing cold, white, or bluish skin. The dilation and constriction of small blood vessels are controlled by small nerve fiber axons as well as chemical messengers in the blood.

 

Immune system – CRPS also affects the immune system. High levels of inflammatory chemicals (cytokines) have been discovered in the tissues of people living with CRPS. These contribute to the redness, swelling, and warmth reported by many patients. CRPS is more common in individuals with other inflammatory and autoimmune conditions such as asthma.

 

Family history – Limited data suggest that CRPS also may be influenced by genetics. Rare family clusters of CRPS have been reported. Familial CRPS may be more severe with earlier onset, greater dystopia, and more than one limb being affected.

 

Occasionally, CRPS develops without any known injury. There may have been an internal injury caused by an infection, a blood vessel problem, or entrapment of the nerves, so careful examination is required to determine the cause and treat it.

Recommended Treatment

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Diagnosis of CRPS is based on a physical exam and your medical history. There’s no single test that can diagnose CRPS, but the following procedures may provide important clues:

 

  • Bone scan – This procedure might help find bone changes. A radioactive substance injected into one of your veins allows your bones to be seen with a special camera.
  • Sweat production tests – Some tests can measure the amount of sweat on both limbs. Uneven results may indicate CRPS.
  • X-rays – Loss of minerals from your bones may show up on an X-ray in later stages of the disease.
  • Magnetic resonance imaging (MRI) – Images captured with an MRI test may show tissue changes that rule out other conditions.

 

Since symptoms vary from person to person and may change over time, CRPS can be very difficult to diagnose and treat. In general, the sooner someone gets a diagnosis and starts treatments after the initial injury, the more likely he or she is to respond to the treatment. While many cases get better on their own over some time, some people living with chronic pain may require a combination of medication, therapy, and procedures. There are a variety of medications used to treat CRPS, depending on the severity and the specific symptoms. These may include nerve pain medication, muscle relaxants, narcotics, aesthetics, and more. Non-steroidal and anti-inflammatory drugs, or NSAIDs, including over-the-counter (OTC) pain relievers such as ibuprofen (Motrin IB, Advil) and aspirin, may provide pain relief. For more severe cases, a doctor may prescribe opioid medications to help control the pain, although, high doses should be avoided. Anticonvulsants, such as gabapentin (Neurontin), are often used to treat neuropathic pain. These medications have nerve-calming properties that can alleviate symptoms of CRPS. Some antidepressants, such as amitriptyline, have been shown to decrease pain and reduce autonomic and motor symptoms. Antidepressants can also help with depression, stress, and anxiety, which can trigger CRPS flare-ups.

A class of drug that prevents stalls the loss of bone density, including alendronate (Fosamax), have been shown to decrease pain Steroid medications, such as prednisone, can help reduce inflammation and improve mobility in the affected limb. Some clinical trials show that low doses of intravenous ketamine, a strong anesthetic, may substantially alleviate pain. Injection of an anesthetic to block pain fibers in the affected nerves may relieve pain in some people.

Alternative & Homeopathic Treatments

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CRPS responds well to a mix of medication, holistic treatments, and lifestyle modifications. Since CRPS is often aggravated by stress, anything a patient can do to calm their nervous system will help. The goal is to get out of the “fight or flight” mode triggered by the sympathetic nervous system and into the “rest and digest” mode that comes from the parasympathetic nervous system. Patients should pay attention to what triggers their flare-ups and maybe even consider keeping a journal. Creating a safe environment for themselves and maintaining a self-care routine is important. This can include :

 

  • Relaxation techniques – Diaphragmatic breathing and meditation can ease the mind and provide a distraction from the pain.
  • Daily exercise – Exercise improves circulation and helps rehabilitate damaged nerves, as well as stimulate endorphins. Beneficial activities include walking, swimming, biking, yoga, and martial arts as tolerated.
  • Anti-inflammatory diet – Leafy greens, berries, nuts, and fatty fish can reduce inflammation and supply important nutrients.
  • Salt baths – Relaxing baths can soothe the body and mind while reducing pain.
  • Vitamins and supplements – Fish oil is a natural anti-inflammatory.
  • Heat therapy – Heated blankets or infrared saunas can be used if tolerated.
  • A regular sleep routine – Sleep helps the body and brain reset and restore. Helpful tips to improve sleep quality include turning off screens before bedtime, taking a soothing bath, taking melatonin if needed, and aiming for at least eight hours of restful sleep.

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