Complex Regional Pain Syndromes (CRPS)

By early reactivation treatment these syndromes can largely be avoided. They can be very devastating and can cause the most excruciating pains that I can think of. Unfortunately there are still many misconceptions about these well researched and defined pain syndromes. Type I CRPS or reflex sympathetic disease (=RSD), as it used to be called, occurs about 2 or 3 months after an injury where the patient gets prolonged casting done (prolonged immobilization) or where a patient will not remobilize a limb because of a low pain threshold. It is in that period of immobilization that the sympathetic nervous system redistributes blood into deeper structures including bone. Bone demineralization takes place leading to osteoporosis and bone pain after a few months. The joint capsules shrink and the range of motion is significantly decreased. The muscle strength is disproprotionately weak and shooting pains occur randomly.

Even the light touch of a bed sheet is leading to excruciating pain (called"allodynia" type pain). Unfortunately the negative cycle of pain and inactivity causes more severe pain and inactivity. Only active physiotherapy will help to prevent this CRPS from becoming chronic. There is only a window of opportunity of 2 or 3 months after the start of a CRPS where therapeutic intervention can turn everything around and lead to a successful resolution. Sometimes a pain specialist has to be consulted on a shortterm basis and a sympathetic nerve block or an epidural injection may have to be done in an attempt to reverse the pain process. With CRPS,type II, which was called "causalgia" in the past, there is an underlying direct nerve damage either through a contusion injury to the nerve from outside or due to an internal cut from a fracture splinter.

In this case the pain is often more localized, but injections and physiotherapy might not be too successful. A referral to a pain specialist would be desirable (Ref. 2, p. 2073). In these cases a multidisciplinary team (through a pain clinic) defines the pain and treats it according to the patient's needs with a combination therapy. Part of this often is medication involving gabapentin. Briefly, it was found that gabapentin (brand name: Neurontin) blocks certain pain receptors blocking most of the perception of pain. Bone loss can be lessesned with bone-loss medications, such as risedronate (Actonel) or calcitonin (Miacalcin). Along with antidepressants and the use of cognitive therapy methods it is possible to live with the pain and return to some form of daily functioning including a return to suitable work (Ref. 5).

Here is a link to a Mayo Clinic site with info on CRPS.

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Disclaimer:

This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor. However, the responsibility of treatment stays in the hands of your doctor and you.

References:

1.The Merck Manual, 7th edition, by M. H. Beers et al., Whitehouse Station, N.J., 1999. Chapter 49.

5. Dr. Stephen Clarke, Clinical Assistant Professor in the Div. of Neurology of the University of BC/Vancouver/Canada, reviewed the use of gabapentin at the 50th Annual St. Paul's Hospital Continuing Medical Education Conference for Primary Physicians, Nov. 16 - 19, 2004

Last Modified: Dec. 17, 2006