Complex Regional Pain Syndrome (CRPS)

Ross.Hauser.MD


Complex regional pain syndrome is one of the worst pain syndromes one can experience.  The team at Caring Medical have a lot of experience successfully eliminating CRPS.

Complex regional pain syndrome type I (CRPS I), formerly diagnosed as reflex sympathetic dystrophy (RSD), is what its diagnostic name implies, “Complex,” “Regional,” “Pain.” and “Syndrome.” Syndrome is a term describing that this is a difficult problem, multifactoral in symptoms with controversial suggested treatments.

Complex regional pain syndrome type II (CRPS II) formerly diagnosed as causalgia, is the same as Complex regional pain syndrome type I with the exception that nerve damage has been confirmed in the patient.

CRPS is usually triggered by trauma (most often to the arms or legs). The disorder is unique in that it simultaneously affects the nerves, skin, muscles, blood vessels and bones. Although it often occurs after injuries from high-velocity impacts, it may also occur without any obvious trigger event. In some cases, the cause of CRPS is unknown.

A high number of cases occur after various types of fractures. CRPS is often seen after soft tissue injury, surgery, and after minor traumas and incisive injuries. Fractures, sprains, and surgery also involve soft tissue injury. Additional conditions that can predispose to CRPS include pressure on a nerve, infection, cancer, neck disorders, stroke, arthritis, brain injury, spinal cord injury, herpes, immobilization with a cast or splint, infection, heart attack, ligament sprain, tendonitis or bursitis, and vasculitis.

But why does CRPS occur after these inciting injuries, and what is the pathophysiology of the syndrome?

Many doctors believe that Complex regional pain syndrome is a lack of or confused communication between the immune system, the inflammatory response and the nervous system.  These include the sympathetic nervous system (responsible for getting the muscles ready for intense physical activity), the somatomotor system (coordination and balance), the neuroendocrine systems (metabolism, energy, heart rate), the nociceptive system (our body’s response mechanism to threat or harmful stimulus), as well as an inflammatory response.

However, to date, questions about CRPS continue to be subjects of research and debate, with various theories abounding. Certainly it is a disease with an unpredictable and uncontrollable nature, and is a syndrome covered in controversy and confusion.


Stages of CRPS

Signs & Symptoms of CRPS

CRPS is a deteriorating disease and progresses in three stages.

  • Stage I is the acute phase. In the acute phase, pain is described as burning or aching and is often aggravated by touch, emotional upset or active/passive movement. The pain of simple injuries is much worse and lasts far longer than it should. For example, if CRPS occurs in the foot, a stubbed toe can lead to excruciating pain for up to two months. The involved limb fills with fluid and may be either hot or cold. A bone scan may show an increase of radioactive phosphate in the affected area, which indicates an increased uptake of red blood cells.
  • Stage II is the dystrophic phase. In the dystrophic phase, pain is constant. The pain is exacerbated by simple movement or sensation, such as touching, vibrating, or even blowing on the limb. The affected limb becomes even more edematous (fluid filled) as well as cool and hyperhidrotic (sweaty). There is a decreased uptake of red blood cells and bone scans reveal the initial stages of osteoporosis.
  • Stage III is the atrophic stage. In the atrophic stage, irreversible damage to the extremity has occurred. The limb contracts because of limited movement. Skin becomes cool, thin, and shiny. Scar tissue has formed and because of this it is difficult to move the joint at all. Osteoporosis and arthritis run rampant throughout the joint. This leads to a permanently frozen limb. The burning pain subsides, however at this stage, the limb is essentially useless. This process occurs over and over again in the body’s extremities.

Prolotherapy for treating Complex Regional Pain Syndrome


CRPS is one of the reasons our Medical Director, Ross Hauser, MD, became so fascinated with treating chronic pain patients during medical school. Early on in his career, he set out to find treatments that could actually heal the problem, not just cover it up with stronger and stronger pain medications.

CRPS treatment is based on the various mechanisms thought to cause CRPS, however since the cause is controversial, the outcomes of traditional treatment are less than optimal. Due to the disagreement over diagnosis, there are no established treatment guidelines.

  • The goal of treatment should be to first correctly diagnose the patient with CRPS and then follow a treatment course that includes movement of the affected extremity in order for the patient to have a return of function.

Options available for CRPS include interventional, pharmacologic, physical/occupational therapy, and psychological techniques.

  • Interventional means such treatments as sympathetic or somatic nerve blocks.

The sympathetic ganglion blocks cause an increase in temperature to the limb due to the increased blood flow. Although the patient will experience immediate pain relief, its effect is only temporary.

The problem with this approach is that it does not repair the weakened ligaments and tendons involved and, thus, does not alleviate the chronic pain that people with this condition experience. CRPS patients may even receive multiple sympathetic blocks to the point of having anesthetic pumps placed in their backs, or their sympathetic nerves may be severed in an attempt to relieve the pain.

  • Pharmacologic includes narcotic pain medications, but these medications do little to restore health and limb function and frequently result in dependence on the medication.
  • Physical/occupational therapy are other therapies offered.
  • Antidepressants and anticonvulsants are also commonly prescribed.

Prolotherapy can help because it treats the initial problem—the soft tissue injury. Prolotherapy stimulates healing in the soft tissue injury and permanently fixes the problem, as opposed to temporarily alleviating the symptoms.

In our experience with CRPS/RSD, if comprehensive Prolotherapy is utilized at any point in the cycle before stage III, the condition is reversible.


Assessing the role of ligaments and tendons in Prolotherapy treatment of CRPS


First, the initial soft tissue injury occurs. This may include ligament and tendon injuries sustained due to fracture or any other type of soft tissue injury, such as a sprain, a strain, or tendonitis.

  • Ligaments stabilize and support the joints through their full range of motion; therefore an injury to the ligament negatively affects the joint mechanics.
  • Blood supply to ligaments is poor, and if blood vessels to the ligaments are sheered due to injury, fracture or surgery, the healing ability of the ligament is impeded further.

Most traditional approaches for treating CRPS involve the doctor prescribing the traditional treatment of RICE (Rest, Ice, Compression, Elevation). If the patient begins RICE treatment, he or she further decreases circulation to their injured ligaments and tendons by elevating, icing and compressing them.

Rest involves immobilization of the joint. Just four days of joint immobilization can induce changes indicative of osteoarthritis, and most patients immobilize through splints and casts for much longer than four days. This approach perpetuates the issue of unhealed ligaments and soft tissue leading to the development of CRPS.  If the joint is casted, there will also be the issue of muscle atrophy and constriction once the cast is removed. The cycle of CRPS has now begun, and because CRPS is a deteriorating disease, when the cycle repeats things get systematically worse until stage III of CRPS, when the limb becomes essentially useless.


A discussion of nerve blocks


 

Prolotherapy will be used to heal the soft tissue damage such as ligament injury. Prolotherapy involves injections at the site of the damaged ligament. This will initiate a local inflammatory response which will encourage blood to flow to the injured site.

It is important to restore mobility to the affected area, and therefore a steady progression of gentle movements and gentle weight bearing will be prescribed. Progressive stimulation is also a part of the treatment, utilizing different textures and temperatures to gradually normalize the senses, which have been altered by the nervous system. Exercise will gradually increase since movement of the limb is of utmost importance.

We will often see patients who need to revamp their diet, along with checking hormone levels and other metabolic factors in order to get a more fully functioning immune system and permanent resolution of the condition. Nutrition plays a vital part in the healing and recovery phases of injuries.

If you have CRPS, please call us for an appointment. We treat patients who travel to our clinic from all across the country, and internationally. When it comes to the horrible pain inflicted from CRPS, we hope you will find that the potential pain relief with Prolotherapy is well worth the visit to see us!

 

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