Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) is a chronic progressive disease characterized by severe pain, swelling and changes in the skin. Symptoms include: burning pains; sensitivity to light touch; intolerance to cold; decreased circulation; discolouration; sweating; swelling; clumsiness; tremor; dystonia or inability to move a joint though its full range of motion. However, it is not necessary to have all of these.

Q: Are there any tests for CRPS?

A: At the present time CRPS is a clinical diagnosis based on your symptoms and the doctor's examination. Bone scans are advocated by some but are not diagnostic. Plain X-rays, and MRIs are rarely of any use. Thermography has been advocated but is not available in Edmonton.

Q: How can CRPS be treated?

A: Some cases can be reversed if CRPS is treated within the first six months it can be reversed. The major treatment of CRPS is mobilization of the affected limb. The natural response to pain is to not use the limb but this can actually make things worse. Treatments with medications and other adjuncts may help with the mobilization.

For the upper limb, scrubbing is a useful type of mobilization, for the lower limb walking is useful.

Desensitization therapy is also useful. In this therapy your limb is exposed to a variety of touches.

It is important to realize that while pain normally means there is ongoing damage, in CRPS if you have increased pain due to activity, you have not damaged anything (and may be helping yourself).

Relaxation, hypnosis and biofeedback may be useful.

Q: Is amputation a solution?

A: Unfortunately the results of amputation are poor with the usual result that you would be left with a painful stump which might in fact be worse than the pain you already suffer.

Q: Is CRPS known by other names?

A: Complex Regional Pain Syndrome (CRPS) is sometimes referred to as Sudek's Atrophy or Causalgia. It was formerly known as Reflex Sympathetic Dystrophy (RSD).

Q: What about smoking?

A: CRPS appears to be more common in smokers than in non-smokers and given the known effect of smoking on your circulation, it seems intuitively obvious that if you smoke, you should stop as soon as possible. There are a variety of stop smoking programs available.

Q: What about sympathetic blocks?

A: Sympathetic blocks are frequently used in the treatment of CRPS alone or in combination with other treatments. The purpose of the sympathetic block is to reduce your pain to enhance mobilization.

Not everybody with CRPS will respond to sympathetic blocks and whether or not you respond to a block does not affect your diagnosis.

Not all experts in CRPS believe in the value of sympathetic blocks. Surgical or permanent sympathectomy is usually not effective.

Q: What causes CRPS?

A: CRPS can occur after an injury or surgery to a limb. It frequently occurs after injury to a nerve although that is not necessary. The severity of the injury has nothing to do with whether CRPS will or will not develop. CRPS can develop without an apparent injury.

Q: What happens if CRPS does not get better?

A: Unfortunately CRPS is often diagnosed too late or does not respond to appropriate measures. Under those circumstances you can expect to have pain indefinitely. There are treatments available to reduce your pain and improve your quality of life. These include the medications mentioned above. Often in our clinic it is necessary to prescribe narcotic pain killers.

Q: What is the mechanism of CRPS?

A: The mechanism remains unclear and several different mechanisms are probably simultaneously at play. It appears that in response to an injury the central nervous system becomes more sensitive so that mild pain and non painful stimuli like touch become interpreted as pain. It also appears that the peripheral pain receptors become more sensitive and also respond to circulating adrenaline.

Q: What medications are used?

A: Gabapentin, an anti-epilepsy medication, is the first line treatment in our pain clinic. If you don't tolerate gabapentin other anticonvulsants can be used.

Antidepressants such as amitryptiline, nortryptiline and desipramine are also effective and can be used along with or instead and an anticonvulsant. Antidepressants are used for their effect on pain not to treat depression. If pain is severe, narcotic pain killers are often prescribed.

Some doctors advocate the use of steroids like Prednisone and this drug can be useful if there is a lot of swelling.

Palmidronate, a drug used for the treatment of osteoporosis has been suggested to be useful. It has to be given by injection. Some of the oral medications which are similar to palmidronate may be effective.