Complex Regional Pain Syndrome - CRPS
Complex Regional Pain Syndrome is the label for a troubling syndrome characterized by post traumatic pain, usually present in the extremities, that persists beyond the expected duration of healing for the original trauma, or beyond the healing itself. It is a chronic pain condition and can be thought of as a complication to an injury or as a reaction pattern to an injury. CRPS was formerly called Reflex Sympathetic Dystrophy or Causalgia, and references can still be found to it under those labels. There is often significant impairment resulting from CRPS and it is a problematic condition as there is no correlation between the extent of the precipitating injury and the resulting degree of CRPS.
CRPS can present differently over time. It was formerly thought that there were three stage of CRPS, however that is no longer considered to be true. What is true is that CRPS changes over time, and while not present in all patients, the following symptoms can be present at various times in CRPS: burning pain, hypersensitivity, increased or decrease hair and nail growth, temperature changes of the skin, abnormal sweating in the affected area, swelling, osteoporosis, muscle atrophy and contractures. To a large degree the changing and variable nature of possible CRPS symptoms is what makes this a difficult condition to diagnose and treat.
Evaluation of CRPS involves physical examination to determine the presence or absence, and degree, of the attributes listed above, and specific diagnostic procedures to get at any underlying pathology and to help confirm the diagnosis. It is important to note that this is a controversial syndrome in that some practitioners rush to a diagnosis without the appropriate diagnostic procedures, and others are reluctant to make a definitive diagnosis even in the presence of diagnostic findings suggestive of this syndrome. In either instance there is possible risk for the patient in that early, accurate identification of CRPS is important for developing an appropriate and effective treatment plan.
There is a wide variability in reliance on specific diagnostic procedures used to identify CRPS, and these vary not only from physician to physician but from locality to locality. Centennial’s CRPS Clinic uses the diagnostic criteria established by the Colorado Division of Workers’ Compensation as determinative of CRPS. The division promotes the use of 5 diagnostic test types or procedures, along with the patient’s physical exam and history, and defines CRPS as being present if 2 out of these 5 are positive for CRPS. These tests include: X ray and triple phase bone scan, where the provider is looking for osteoporotic changes; injections, with there being an expectation of temporary symptom relief and functional improvement in the case of CRPS; autonomic testing, which would reveal sweating changes; and thermography, or functional infrared imaging, in which one would expect temperature changes in the affected extremity.
For more information about this last testing procedure click on the image below.
As noted above, symptoms of CRPS usually change over time, so the physical exam and history are crucial components in applying these test results to the determination of a CRPS diagnosis. In addition there are a number of other non-CRPS specific diagnostic tests which are helpful. Included in these would be psychological evaluation to provide some insight into the patient’s psychosocial status and how it is affecting his or presentation.
So what does a treater do with all this once the diagnosis is made relative to treatment? There are a number of procedures that can be tried for CRPS, including injections, medication, active therapy, psychological intervention, biofeedback, sleep hygiene, patient education, and activity restriction. The delivery of these treatments is often times best accomplished in an interdisciplinary setting given that CRPS is difficult to treat and is a multifaceted condition. This is the treatment available for patients in Centennial’s CRPS Clinic.