Complex Regional Pain Syndrome

Clearwaer, Tampa, St Petersburg, Florida

Complex regional pain syndrome (CRPS) is an uncommon, chronic condition that usually affects an arm or leg. Complex regional pain syndrome is marked by intense burning or aching pain. A patient with CPRS may also experience swelling, skin discoloration, altered temperature, abnormal sweating and hypersensitivity in the affected area. The cause of complex regional pain syndrome isn’t clearly understood, though it often follows an illness or injury. Treatment for complex regional pain syndrome is most effective when started early. In such cases, dramatic improvement and even remission are possible. From a historical perspective, the term “complex regional pain syndrome” was introduced in 1994 by the International Association for the Study of Pain (IASP) to replace a myriad of terms that were often conflicting and confusing in the medical literature, such as causalgia, reflex sympathetic dystrophy (RSD), sympathetic maintained pain, and numerous other descriptive terms for syndrome of yet no unknown etiology.To date, a known pathophysiologic mechanism of the syndrome has not been obtained. This is critical because patients and physicians often fail to understand that CRPS is not a known medical disorder with a known pathophysiologic mechanism of how it proceeds. It is, as with fibromyalgia, considered a syndrome with discrete physical examination findings necessary to provide the diagnosis. What also adds to the confusing nature of complex regional pain syndrome is the fact that there lacks a veterinary correlate to CRPS, meaning animals do not contract CRPS. Also, there is no credible sports medicine correlate for athletics or professional athletes that will draw a parallel with other population studies.

Symptoms of Complex Regional Pain Syndrome

The main symptom of CRPS is intense pain, which gets worse over time. Additional signs and symptoms include:

• “Burning” pain in the arm, leg, hand or foot
• Skin sensitivity
• Changes in skin temperature, color and texture. At times the skin may be sweaty; at other times it may be cold. Skin color can range from white and mottled to red or blue. Skin may become tender, thin or shiny in the affected area.
• Changes in hair and nail growth in the limb
• Joint stiffness, swelling and damage
• Muscle spasms, weakness and loss (atrophy)
• Decreased ability to move the affected body part

Physical examination findings should result in pain proportionate to what would normally be expected, and often include edema, sweating, hair or growth changes, vasomotor changes, as well as temperature changes. Most importantly, exclusion of some other explanation for what is causing the pain should be addressed prior to assigning the descriptive term of complex regional pain syndrome. Diagnosis of complex regional pain syndrome is based on a physical exam and the patient’s medical history. While there is no single test that can definitively diagnose CRPS, the following procedures may provide important clues:

• Bone scan, which may show increased circulation to the joints in the affected area.
• Sympathetic nervous system tests, which look for disturbances in the sympathetic nervous system. For example, thermography measures the skin temperature and blood flow in the affected and unaffected limbs. Other tests can measure the amount of sweat on both limbs.
• X-rays. Loss of minerals from the bones may show up on an X-ray in later stages of the disease.
• Magnetic resonance imaging (MRI), which may show tissue changes.

In the past, various testing has been done that were inconsistent and lacking in reproducible and pathodiagnostic for this particular disorder. Often testing, which were considered diagnostic in the past, such as thermography, bone scanning or sympathetic nerve tests could not be reproduced reliably in clinical testing. Thus the call in 1994 from the International Association for the Study of Pain to change nomenclature to one of a descriptive nature rather than one of a known pathophysiologic mechanism. It has long been noted that there were possible psychogenic factors that may be influencing this disorder. Dramatic improvement and even remission of complex regional pain syndrome is possible if treatment begins within a few months of the first symptoms. Conservative management has been used for centuries in what appears to be a variety of disorders given various labels that seem to apply to complex regional pain syndrome and the results for conservative measures have been favorable in motivated patients. Treatment for Complex Regional Pain Syndrome Various medications can be used to treat the symptoms of CRPS, including:

• Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve), may ease pain and inflammation.
• Antidepressants, such as amitriptyline, and anticonvulsants, such as gabapentin (Neurontin), are used to treat pain that originates from a damaged nerve (neuropathic pain).
• Corticosteroids, such as prednisone, may reduce inflammation.
• Bone-loss medications, such as alendronate (Fosamax) and calcitonin (Miacalcin) may be appropriate.
• Opioid medications may be another option. Taken in appropriate doses, they may provide acceptable control of pain. However, they may not be appropriate if there is a history of substance abuse.

Therapies that could help relieve symptoms include:

• Applying cold may relieve swelling and sweating. If the affected area is cool, applying heat may offer relief.
• Various creams are available that may reduce hypersensitivity, such as lidocaine or a combination of ketamine, clonidine and amitriptyline.
• Gentle, guided exercising of the affected limbs may improve range of motion and strength.
• Injection of an anesthetic to block pain fibers in the affected nerves may relieve pain in some people.
• Chronic pain is sometimes eased by applying electrical impulses to nerve endings, using a TENS unit.
• In some cases, learning biofeedback techniques may help. In biofeedback, you learn to become more aware of your body so that you can relax your body and relieve pain.

Often the syndrome’s progression or lack of progression is due to the patient’s perception of pain control. Negative attitudes are often perpetuated by poor education and promotion of hysteria. In these cases, psychological assessment is paramount. A variety of treatment techniques are available that can help and there is no medical evidence that suggests that CRPS is an incurable or progressive disorder. If you continue to suffer with chronic pain and your current treatment plan leaves you feeling hopeless, perhaps a fresh set of experienced eyes can change your outlook. Since 1990, Dennis M. Lox, M.D has applied his personal interests in sports medicine, cutting-edge regenerative medicine and chronic pain management to helping patients increase their quality of life.

Contact us for an appointment at 727-462-5582 . Dennis M. Lox, MD, and the Florida Spine Center serve patients within the greater Tampa Bay area, including Clearwater, Tampa and St. Petersburg, as well as all of Florida and the US.  All statements, information or opinions provided by this website are provided for educational purposes only. We do not diagnose nor treat through this website or by telephone. As you consider any treatment, discuss them with your physician.