The nature of complex regional pain syndrome is puzzling
STATEN ISLAND, N.Y. — Complex Regional Pain Syndrome (CRPS) affects between 200,000 and 1.2 million Americans each year. There appears to be two to three times more women than men affected and any age group can be afflicted. This issue usually follows a trauma, surgery, or a period of immobilization where pain develops and never subsides in an affected limb. Over time it may actually grow worse.
There are essentially two subsets: Type I, which was previously called Reflex Sympathetic Dystrophy (RSD) and was preceded by an injury without direct nerve trauma and Type II, previously termed “causalgia,” which implied a direct nerve injury.
We have used numerous other terms to describe this entity such as “shoulder-hand syndrome,” “Sudek’s syndrome,” and ” Steinbroker’s syndrome.” Causalgia was first documented in the 19th century by physicians treating Civil War veterans who experienced pain after their wounds healed.
The cardinal feature of CRPS is pain that is often described as burning, which is made worse by any kind of touch, including clothing, a bed sheet or even a mild breeze. It can progress to other areas on the body.
Other symptoms include:
abnormal changes in skin color: white, mottled, or red
abnormal sweating or chilling
extreme pain sensitivity
Most patients have experienced a minor trauma that doesn’t resolve as expected. It appears that there is a disruption in the healing process. Normally, when one has an injury, a signal is sent to the brain to register pain. This triggers part of the nervous system — the sympathetic system — to react, resulting in an inflammatory response.
The reaction is due to the “fright or flight response.” The blood vessels in the skin contract so more blood can be directed to the muscles so that a victim can move away quickly. In CRPS, the system does not turn off and the body continues to overreact. Therefore, the skin color changes and there is an excessive sympathetic response as manifested by sweating, tremors and pain.
There is no specific blood or diagnostic test for this disorder. It is based on the patient’s history and the constellation of symptoms.
Treatment can be equally as frustrating as there is no specific treatment that helps all patients.
Medications are often prescribed to alleviate the pain, reduce stiffness and assist in sleep. Traditional non-steroidal, prednisone, antidepressants such as cymbalta, and anticonvulsants such as gabapentin or carbamazepine may be helpful. Narcotics may be an alternative for some patients and antihypertensive medications such as clonidine can often assist.
Physical therapy can help on many levels. It is important to control and maintain the movement of the affected limb and prevent weakening and contractures (loss of movement in a joint). The use of heat and cold, transcutaneous electrical stimulation, biofeedback and range of motion are crucial to an overall program approach.
Specialized injections to block the activity of the sympathetic nerves may be helpful both diagnostically and in treatment. These can be repeated if effective.
While this is not a psychological issue it can be quite traumatizing and often patients need assistance to address the impact in their lives. The loss of being able to do many of the work and recreational activities that are crucial to our lives can be devastating and if not addressed lead to a secondary disability.
On the average, patients seek care from five physicians before they are committed to a diagnosis and a treatment plan. Patient education becomes a crucial keystone to living successfully with this problem.
The Internet has provided a valuable resource for clinicians and patients in assuring patients that they are not alone, that treatment can be complicated but symptoms can be diminished, and that life can go forward. In certain instances the process has been noted to diminish and resolve over time. The National Institutes of Health Web site (www.nih.gov) can be helpful with the latest updates in clinical trials and treatment advances.
This column is provided by the Richmond County Medical Society. Dr. D’Angelo is a past-president of the Society, and has been an active member since 1994. He specializes in pain management, physical medicine and rehabilitation and maintains a practice in New Dorp.