CRPS/RSD

Complex Regional Pain Syndrome:

“We have some doubt as to whether this form of pain ever originates at the moment of the wounding.…Of the special cause, which provokes it, we know nothing, except that it has sometimes followed the transfer of pathological changes from a wounded nerve to unwounded nerves, and has then been felt in their distribution, so that we do not need a direct wound to bring it about. The seat of the burning pain is very various; but it never attacks the trunk, rarely the arm or thigh, and not often the forearm or leg. It’s favorite site is the foot or hand….Its intensity varies from the most trivial burning to a state of torture, which can hardly be credited, but reacts on the whole economy, until the general health is seriously affected….The part itself is not alone subject to an intense burning sensation, but becomes exquisitely hyperanesthetic, so that a touch or tap of the finger increases the pain.” (1),(2) –Silas Weir Mitchell, 1872.

Things haven’t changed very much since this classic description of ‘causalgia’ by Dr. Silas Weir Mitchell, a U.S. Army surgeon who treated this condition in soldiers injured on the battlefield during the Civil War. Also, known as reflex sympathetic dystrophy, and more recently, complex regional pain syndrome, this condition primarily affects middle-aged adults and typically produces severe pain usually following injury or trauma to the affected part. The types of trauma or injury often associated with complex regional pain syndrome include sprains, fractures, penetrating trauma (including puncture wounds and gunshot injuries), surgery and various crush injuries. Severe, burning pain is the most frequent symptom, which is often difficult for the patient to precisely localize. Hypersensitivity and pain provoked by minor contact, light touch (also known as allodynia), or movement of the affected part is very common. In many patients, abnormal activity of the sympathetic nervous system is thought to be involved because of the coexistence of swelling, abnormal sweating, and/or color and temperature changes of the affected part. With prolonged symptoms, motor weakness, deformities, and muscle spasm may develop.

The current diagnostic criteria for complex regional pain syndrome highlights the typical clinical findings seen in the condition, and differentiates the two main types on the basis of the presence or absence of an injured nerve as shown in the table below.

Recent International Association for the Study of Pain (IASP) Diagnostic Criteria for CRPS-I and CRPS-II (3)

CRPS-I

CRPS-II

1) The presence of an initiating noxious event, or a cause of immobilization.

1) The presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve.

2) Continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event.

2) Evidence at some time of edema (swelling), changes in skin blood flow, or abnormal sudomotor (sweating) activity in the region of the pain.

3) Evidence at some time of edema (swelling), changes in skin blood flow, or abnormal sudomotor (sweating) activity in the region of the pain.

3) This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction

4) This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction

Criteria 2, 3, and 4 must be satisfied

All three criteria must be satisfied

Treatment:

The mainstay of treatment for complex regional pain syndrome is physical therapy and functional rehabilitation of the affected extremity. Often, severe pain limits effective physical therapy and must be controlled with medications, nerve blocks, or special methods before therapy can be used appropriately. Pain specialists at Foothill Regional Pain Center are skilled in the evaluation of complex regional pain syndrome and experienced in the application of proven methods and procedures to control pain and help return function to normal as soon as possible. Feel free to contact our office to arrange a consultation with a member of our staff if you desire further information or evaluation.

1. Mitchell, S.W. Injuries of the Nerves and Their Consequences. Philadelphia, PA; J.B. Lippincott &
  Co., 1872
2. Stanton-Hicks, M.D., Burton, A.W., Bruehl, S.P., et.al., An Updated Interdisciplinary Clinical
  Pathway for CRPS: Report of an Expert Panel. Pain Practice, pp1-16, vol.2 number 1, 2002
3. Merskey, H., Bogduk, N., eds. Classification of Chronic Pain: Descriptions of Chronic Pain
  Syndromes and Definitions of Pain Terms. 2^nd edition, Seattle, WA: IASP Press; 1994

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CRPS-I	CRPS-II
1) The presence of an initiating noxious event, or a cause of immobilization.	1) The presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve.
2) Continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event.	2) Evidence at some time of edema (swelling), changes in skin blood flow, or abnormal sudomotor (sweating) activity in the region of the pain.
3) Evidence at some time of edema (swelling), changes in skin blood flow, or abnormal sudomotor (sweating) activity in the region of the pain.	3) This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction
4) This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction

Criteria 2, 3, and 4 must be satisfied	All three criteria must be satisfied

Complex Regional Pain Syndrome:

Treatment:

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