Patient talking about her chronic pain to a doctor

Complex Regional Pain Syndrome (CRPS) Therapies and Treatment Options

Complex Regional Pain Syndrome (CRPS) is a chronic and often debilitating condition that typically affects one or more limbs after injury, surgery, or trauma.

While conventional treatments often aim to manage symptoms, many patients seek alternative or holistic therapies to alleviate their suffering.

What is Complex Regional Pain Syndrome (CRPS)?

Characterised by severe pain, swelling, and changes in skin colour and temperature, CRPS can be challenging to treat, as its causes are not entirely understood.

CRPS is classified into two types:

  • Type 1 CRPS (formerly known as Reflex Sympathetic Dystrophy or RSD): Occurs without nerve damage following an injury.
  • Type 2 CRPS (formerly known as Causalgia): Occurs with confirmed nerve injury.

While the exact cause of CRPS remains unclear, it is thought to be related to abnormal responses in the central and peripheral nervous systems, leading to prolonged or excessive pain after injury.

Type 1 CRPS (Reflex Sympathetic Dystrophy or RSD)

  • Cause: Type 1 CRPS occurs without confirmed nerve damage. It often follows an injury or trauma, such as a sprain, fracture, or surgery, but the exact cause is unclear. It is thought to result from an abnormal response of the autonomic nervous system or immune system to the injury.

  • Symptoms:

    • Persistent, intense pain that may seem disproportionate to the initial injury.
    • Sensitivity to touch or cold, even from something as light as clothing brushing against the skin.
    • Swelling, changes in skin colour (bluish or reddish), and changes in temperature (hot or cold).
    • Abnormal sweating in the affected area.
    • Decreased mobility, stiffness, or weakness in the affected limb.
    • Hair and nail changes, such as excessive hair growth or brittle nails.

  • Onset: CRPS Type 1 typically develops after an injury or immobilisation (e.g., a cast after a fracture) and can spread beyond the initial site of trauma.

  • Common Triggers: Fractures, sprains, soft tissue injuries, or surgeries. The exact mechanism isn't fully understood, but the body's pain regulation and immune response become exaggerated, leading to chronic pain and swelling.

Type 2 CRPS (Causalgia)

  • Cause: Type 2 CRPS occurs with confirmed nerve damage. This means that the injury or trauma has directly affected one or more nerves, leading to ongoing, abnormal pain sensations. The nerve damage might be identified through imaging or nerve conduction studies.

  • Symptoms:

    • Similar to Type 1 CRPS, with persistent, burning, or shooting pain, but directly associated with nerve injury.
    • Pain is typically more localised to the area served by the damaged nerve, although it can spread.
    • Swelling, skin temperature changes, and sensitivity to touch or cold.
    • Loss of function, such as weakness, muscle atrophy, or decreased mobility, may be more pronounced due to the direct involvement of nerves.

  • Onset: This type is often triggered by events that cause nerve damage, such as crush injuries, surgical errors, or lacerations that directly injure the nerve tissue.

  • Common Triggers: Type 2 CRPS usually follows events like a penetrating injury (e.g., knife wound, surgical injury), fractures that damage nerves, or conditions that cause prolonged nerve compression (e.g., herniated discs pressing on nerve roots).

Key Differences Between CRPS Type 1 and Type 2:

Feature Type 1 CRPS (RSD) Type 2 CRPS (Causalgia)
Nerve Damage No confirmed nerve injury Confirmed nerve damage
Causes Often follows minor injury or trauma Follows injury causing nerve damage
Symptoms Intense pain, swelling, skin changes Similar symptoms but localised to nerve injury
Diagnosis Based on clinical symptoms Confirmed with nerve conduction studies
Response to Treatment Varies, typically complex Varies but may respond to treatments for neuropathic pain

Conventional Treatments for CRPS

Conventional treatments for CRPS primarily aim to manage symptoms, improve function, and enhance quality of life. Treatment is often multidisciplinary, involving pain specialists, physiotherapists, and other healthcare professionals.

1. Medications

  • Pain relievers: Over-the-counter analgesics like paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) may help alleviate mild pain. For more severe pain, opioids or prescription medications such as gabapentin or pregabalin (used for neuropathic pain) are sometimes prescribed.
  • Corticosteroids: These are used to reduce inflammation and can help mitigate pain in the early stages of CRPS.
  • Antidepressants: Tricyclic antidepressants (e.g., amitriptyline) or serotonin-norepinephrine reuptake inhibitors (SNRIs) are often prescribed to manage chronic pain, as they influence pain perception pathways.
  • Bisphosphonates: These drugs are used to treat bone loss and have shown promise in some studies in reducing CRPS-related pain.
  • Intravenous immunoglobulin (IVIG): In certain cases, IVIG has been used to manage CRPS, although it remains experimental.
  • Nerve blocks: Injections of local anaesthetics around the affected nerves can temporarily block pain signals.

2. Physical Therapy

  • Physiotherapy is one of the most effective conventional treatments for CRPS. Early mobilisation is crucial to prevent further loss of function. Exercises focus on improving range of motion, reducing stiffness, and strengthening muscles.

3. Psychological Support

CRPS is often accompanied by anxiety, depression, and other psychological challenges. Cognitive-behavioural therapy (CBT) and counselling can help patients manage the emotional toll of chronic pain.

4. Nerve Stimulation

  • Transcutaneous Electrical Nerve Stimulation (TENS): This involves placing electrodes on the skin to deliver low-level electrical currents to block pain signals.
  • Spinal cord stimulation (SCS): SCS involves implanting a device that sends electrical impulses to the spinal cord, which can help reduce pain in certain patients.

Alternative and Holistic Treatments for CRPS

Many patients turn to alternative or holistic treatments, especially when conventional therapies offer limited relief. These treatments focus on the whole person and aim to reduce pain while improving overall well-being.

1. Alternative Medicine for Pain Management

In Australia, alternative medicine is becoming an increasingly popular option for managing CRPS. Alternative medicine contains cannabinoids which interact with the body’s endocannabinoid system, influencing pain perception and inflammation.

2. Acupuncture

Acupuncture, a traditional Chinese medicine practice, involves inserting fine needles into specific points on the body to stimulate nerve endings and promote natural pain relief. Some studies suggest that acupuncture can help reduce pain and inflammation in CRPS patients, though more research is needed to confirm its effectiveness.

3. Mindfulness and Meditation

Mindfulness-based stress reduction (MBSR) and meditation can help patients with CRPS by promoting relaxation and reducing the psychological impact of chronic pain. These practices encourage patients to focus on the present moment, helping them manage their pain through mindfulness techniques.

4. Nutritional Therapy

Anti-inflammatory diets, rich in omega-3 fatty acids, antioxidants, and whole foods, can help reduce systemic inflammation that may exacerbate CRPS symptoms. In contrast, processed foods, sugars, and trans fats may contribute to chronic inflammation, making the condition worse.

Supplements like Vitamin C have been explored in CRPS treatment to prevent the onset of symptoms after surgery or trauma. A 2014 study published in the journal The Lancet in 2007 suggested that daily doses of Vitamin C might reduce the likelihood of developing CRPS after wrist fractures.

5. Physical Rehabilitation & Complementary Therapies

Complementary therapies, such as massage, hydrotherapy, and chiropractic care, can help improve circulation, reduce muscle stiffness, and alleviate pain. These therapies should be overseen by healthcare professionals experienced in treating chronic pain conditions like CRPS.

Expert Insights

Dr. Anne Burke, a leading pain specialist in Sydney, explains,

"Complex Regional Pain Syndrome is a highly individualised condition. What works for one patient may not work for another, so a personalised, multidisciplinary approach is key. While conventional treatments remain the first line of defence, many patients find relief through alternative therapies and mindfulness practices."

Pain Australia CEO, Carol Bennett,

"We are seeing a shift in how chronic pain is managed, especially with the advent of medical cannabis and a greater focus on holistic care. Australia is at the forefront of exploring these options, although we still have a long way to go in ensuring equitable access."

Conclusion

CRPS is a complex and challenging condition to treat, but a combination of conventional and alternative therapies may offer hope to those affected. In Australia, advancements in alternative medicine, psychological support, and physical rehabilitation are helping to reshape the treatment landscape. By embracing both medical and holistic approaches, CRPS patients can find ways to manage their symptoms and improve their quality of life.

For anyone dealing with CRPS, it's crucial to consult with a pain specialist to create a comprehensive, tailored treatment plan that addresses their unique needs.

References

  • Zollinger, P.E., Tuinebreijer, W.E., Breederveld, R.S., Kreis, R.W. (2007). Vitamin C for prevention of complex regional pain syndrome in patients with distal radius fractures: a double-blind, randomised, controlled trial. The Lancet, 369(9567), 1065-1071.
  • Goebel, A., Barker, C. (2018). Complex regional pain syndrome in adults: pathogenesis, clinical features, and diagnosis. BMJ, 362.
  • Stanton-Hicks, M., et al. (2019). Complex regional pain syndrome: guidelines for therapy. Clinical Journal of Pain, 35(4), 311-316.
  • Marinus, J., Moseley, G.L., Birklein, F., Baron, R., Maihöfner, C., Kingery, W.S., & van Hilten, J.J. (2011). Clinical features and pathophysiology of complex regional pain syndrome. The Lancet Neurology, 10(7), 637-648.
  • Pain Australia. (2021). Managing Chronic Pain in Australia. Retrieved from www.painaustralia.org.au.
  • Therapeutic Goods Administration (TGA). (2021). Access to medicinal cannabis products: Special Access Scheme (SAS). www.tga.gov.au.
  • Mellick, L.H. (2006). Pathophysiology of complex regional pain syndrome: A review. The Journal of Pain Research, 9, 7-19.
  • Australian Pain Management Association (APMA). (2022). CRPS: Resources and treatment options in Australia. www.painmanagement.org.au.
  • Grieve, S., Jones, K., Walsh, J., & Pitzul, K. (2020). Chronic pain and complex regional pain syndrome: The role of physical therapy. Physical Therapy Journal, 102(3), 413-422.
  • Frost, M., von Hehn, C.A.A., & Costigan, M. (2018). Can cannabinoids help neuropathic pain?. The Journal of Pain, 19(3), 1-9.
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