What’s New With Complex Regional Pain Syndrome?

crps painComplex regional pain syndrome is often seen as a weird and devastating problem. One of the biggest issues is the lack of identifying it as an issue and beginning the right type of pain management. Fortunately, in my practice, we are known for being able to deal with it and often find good solutions to manage it. Treatments can range from simple to complex. In the educated pain community, a better understanding is occurring. Unfortunately, it seems that some pain doctors are not furthering their education when it comes to CRPS.

Improving Treatment of CRPS

The good news is that we are starting to get a better with diagnosis and treatment of CRPS. The prognosis in general is that the symptoms in most people will resolve within a year; this occurs in 75 percent of people. The understanding of CRPS is better nowadays, and it does not just occur spontaneously. It is not an entity without a cause. It occurs in context with some sort of injury.

Usually it occurs in either the arm or leg, and it is often related to either surgerical trauma or actual physical trauma. Examples include an arm with multiple fractures or a hand injury coupled with carpal tunnel syndrome. In the leg it is often associated with multiple fractures or an ongoing sprain in the foot and ankle. It is also more common in people who already have a sensitized nervous system, such as someone with a neck or low back problem, a diabetic, or someone with fibromyalgia. The research is also showing that there may be a genetic component (there may be 80 or more genes that are involved) and some people may be prone to this occurring, but there is no test yet available.

The answer to why a person has uncontrolled pain is that there are too many sensory “pain” type signals going to the brain for too long of a time period. With most injuries, healing rapidly occurs, especially when treated promptly. Injuries to the foot and hand are more complex since there are multiple tendons, ligaments, bones and nerves present and many of these can be damaged. The medical community often does a great job of fixing the obviously fractured bones, however, if the trauma is with sufficient force to fracture a bone then it can damage surrounding things like tendons, ligaments and nerves.

These “soft tissue” structures are much harder to see and to determine if they are damaged. Repairing them also may be hard and sometimes things like damaged nerves are not really possible to surgically treat. All these structures in the hands and feet must work in a very complex manner; one part not moving correctly often will send messages back to the brain that all is not well. These continuous error messages to the brain start becoming amplified and a short circuit occurs telling the pain signals that there is a problem in the area and something needs to be done to stop the problem. The amplified pain signals is what we perceive in CRPS.

The Goals Of Treatment

The goal of CRPS treatment, if identified early, is to find and fix the issues present. As a medical provider, the goal of understanding CRPS is not that the patient is crazy, it is that something is wrong and what can we do to fix and address the problem. To control the pain, a patient with signs of CRPS must first determine what are all the issues that may be contributing to the problem. A comprehensive evaluation is necessary and all the patient’s medical history can be extremely important. Everything from concurrent medical problems to psychological issues can contribute to the problem.

More frustrating may be that not all of the medical problems contributing to the CRPS may be treatable. Sometimes the fracture damage of an arm or leg cannot be fully corrected. Damaged ligaments, bone misalignment and nerve injury are not able to return to normal function. The signals that tell our brain that something is wrong cannot be turned off since there is no mechanism to shut them down completely. This is especially true in severe trauma or where there are secondary conditions reinforcing the signals like spine problems or diabetes. For the physician, the first mission is to find out what are the problems causing the abnormal signals and correct them. A team approach is often the best since it may take an expert in pain to identify all the problemed areas and the expertise of a variety of specialists to intervene if a fix is available. As noted above, 75 percent of the people will experience symptom relief within in a year, meaning successful management strategies can be implemented.

Identifying CRPS early within the first few weeks to months leads to the best treatment. If pain after an injury does occur, is severe and continues past normal healing time, seek the help of a good pain physician. The mark of good pain physician is one who frequently sees and treats complex problems. Many pain physicians confine their practices to the simple straightforward pain problems; these tougher issues need the physicians that know medical and interventional treatment options and are active in ongoing evaluation and management including high levels of intervention. Physicians who do mostly medical or interventional managements and not both are unlikely to have a full knowledge of the complex issues contributing to CRPS. Understanding and communicating with the patient is essential. Find a good physician that does understand CRPS and the strategies to have the best chance at finding pain relief.

Multifaceted Approach To Treatment

Not all CRPS cases can be easily resolved. Obviously, not all injuries can be corrected and when there are multiple problems contributing to CRPS, it may be an ongoing issue. The treatment plan often needs to include physical therapy to improve functional problems associated with the body parts involved. With any significant injury, it often takes a lot of exercise for a long period of time to restore function, and it may involve complex strategies to retrain the body. The efforts with physical therapy need to be continued on your own, and stopping the exercises does not work for recovery.

Psychology is another important aspect to manage and improve when it comes to CRPS treatment. The pain is not imagined, and psychologists can help the patient understand how the brain decides to perceive the pain signals and how patients interpret them. The brain can only do a couple of things at one time and psychologists often can help train the brain not to pay attention to these pain signals. Recognizing the associated cognitive issues like the perception of pain and that depression is not a sign of being weak leads to more successful outcomes.

CRPS is a complex phenomenon and involves understanding of all parts of the syndrome. There are now a variety of medications used for treatment. Common medications include those that affect nerve signaling like Gabapentin and Lyrica. Some depression medications also decrease nerve signaling. Cymbalta does this well, and older medications like amytriptyline and nortriptyline can also be very helpful, and they may also help with related sleep problems. Newer medications that have found to be helpful range from those used to treat osteoporesis like Boniva (or many of the other drugs in this category know as biphosphonates), to Botox, Viagra, and odd blood pressure medications like clonidine. Ketamine, an anesthetic, is used occasionally but is difficult to safely administer, works for a limited amount of time, may have significant side affects, is costly and often insurance does not cover its use.

Spinal Cord Stimulators For CRPS

For the most refractory cases of CRPS, implantable devices are one of the best and most cost effective treatments. These devices are primarily spinal cord stimulators (SCS) but sometimes may include intrathecal pumps to deliver medication directly to the spine. A good pain physician will be able to coordinate and make sure all the conservative medical issues are addressed prior to working with implantable devices.

If this is the first suggestion without working with a team to address all the other issues, be careful with proceeding forward. SCS systems are wonderful treatments, but there is a lot of marketing being done toward physicians with these devices so an experienced implanter is needed since treatment with these systems may need to be aimed at multiple targets. There are systems that can be used just for a specific target known as DRG spinal cord stimulators and they are good when there is absolutely no other problem contributing to a foot or ankle CRPS that is not fixable (they are not used for hand and arm CRPS).

Multiple companies make SCS units. It is debatable who has the best unit, but other factors like manufacturer support and MRI scan safety also need to be considered. Properly placed, a SCS’s effectiveness can usually be determined after a trial period of about 5-7 days. Improved function, improved ability to stand, walk, do activities, and sleep are the goals associated with a SCS. If nothing is working, implantable pain pumps are reasonable. These do have risks but they can greatly improve the patient’s quality of life. A variety of medications can be delivered to the spine and the best medication may not be an opioid, but Ziconitide, which is a snail toxin.

CRPS is a complex issue, in reality it may affect the whole body due to the impact of the pain. It takes a team to treat and help the patient through this medical problem. A good pain physician will help one navigate the treatment path of CRPS. It is a very tough medical problem, and its not only in your brain. Treatment needs to be an interaction with your provider who fully understands and helps with coordinating and providing care for all the issues. CRPS does feel like a scary medical problem, but good pain physicians can lead one to a successful outcome.

Complex Regional Pain Syndrome in Minnesota

CRPS in MinnesotaComplex regional pain syndrome (CRPS) is a difficult medical issue to treat. If you think you may have it, you want it gone. Unfortunately, there are few physicians and even less specialists who understand it and are able to manage the problem. Pain specialists, neurologists, and many other experts struggle with the diagnosis and treatment of the condition. In any field of work, 90% of people do a good job, however with CRPS, you need to find the 10% who are superior in their skill level. They are the artists, they put in a phenomenal effort to find a cause and a set of solutions to cover all the complex interrelated issues.

The starting point with complex regional pain syndrome is finding a Pain Specialist certified by the American Board of Physical Medicine and Rehabilitation. These are medical doctors with the extensive qualifications in all aspects of understanding pain. Board subspecialty qualifications insures a higher level of knowledge. The next quality is that the physician sees and treats the problem frequently. If they only see a couple of cases a year, it is unlikely they will have the interest and skill needed to successfully manage the problem. If the doctor walks into the room, immediately knows what is wrong and can talk to you sensibly about the problem, you have found the expert. He will also take a team approach to treating you, guiding you through any additional diagnosis and the variety of treatment options.

Treatment of CRPS

A CRPS expert will also understand this is a not a final diagnosis. CRPS is being caused by some sort of damage to the a particular region of the body. Finding the cause behind CRPS is essential in finding the route to managing and possibly resolving some or most of the pain. Treating symptoms rarely treats the CRPS. An expert will dig deep to find the all the issues that stimulate the sympathetic nervous system maintaining the pain. At times, treating the underlying problems resolves the CRPS. Unfortunately, at times, the damage to structures cannot all be solved and residual issues remain despite the best management.

Complex regional pain syndrome affects both the upper and lower extremities. Finding the diagnosis that is causing the problems is essential in treating CRPS. Treating the symptoms is helpful initially, but treating the underlying problem is essential in improving the outcome. In the lower extremity, orthopedic injuries especially to the foot and ankle cause CRPS in about five percent of individuals. Common causes include injuries to the ligaments and tendons of the ankle and foot that caused instability. Surgical management of the foot and ankle problems, along with aggressive simultaneous lumbar sympathetic injections may resolve the issues. Complex regional pain syndrome is less common in the upper extremities, but is also related to ongoing, unresolved injuries that are continuing to stimulate pain signals.

Find a Minnesota Pain Doctor

Finding a pain specialist who understands the complex issues related to the pain is difficult. Experience and training is essential to achieve a good outcome. Look for the physician who sees many patients with this problem on a regular basis. If the physician has not seen these patients frequently, it is unlikely that you will be satisfied with your treatment results. CRPS is a difficult problem to treat and finding the pain specialist with experience is necessary for a satisfactory outcome.

Complex Regional Pain Syndrome (CRPS) – Causes & Treatment

crps treatment st. cloudComplex regional pain syndrome (CRPS) is a pain problem manifested by severe pain.  It is a poorly understood disorder that causes intense pain.

With CRPS, the nervous system becomes hyper sensitized – normal sensations become amplified.  The thermostat for pain sensitivity becomes set at the wrong level.  The sympathetic autonomic nervous system also becomes hyperactive.  This combination of problems leads to severe pain in the affected area, often a hand or foot.

2 Types of CRPS

There are two basic types of CRPS:

  • Type I occurs with no known nerve injury
  • Type II occurs in association with a known nerve injury

CRPS describes an array of painful conditions characterized by regional symptoms seemingly disproportionate to the usual course of trauma or injury.  The pain is regional, not in a specific nerve or muscle distribution.  The patient will report sensory changes such as:

  • Hyperesthesia
  • Changes in skin color
  • Edema and temperature changes
  • Motor changes – inability to move the affected region

It usually begins in one limb, often diagnosed months after onset, and is 3 times more common in females.  The initial injury is usually minor, such as an ankle sprain.  Because of this, there is often a delay in finding an expert who recognizes the diagnosis and can initiate treatment.

How to Treat CRPS

Treatment of CRPS is difficult, but should be done in four steps:

  1. The first step is evaluating and treating any treatable injuries that contribute to the pain.  This may include surgical interventions for injuries such as ankle sprains.
  2. The second aspect is controlling the sympathetic aspects of pain and the neuropathic pain with injections and medications.
  3. The third part is rehabilitation and physical therapy, restoring mobility and decreasing pain sensitivity.
  4. The last part is psychology to use cognitive strategies to control central pain perceptions.

Complex regional pain can be devastating.  The earlier it is diagnosed, the better the prognosis.  Experienced pain management physicians are essential in improving the outcome.  It can be successfully treated and there are many good interventions available. Find an experienced Pain physician, and find a solution.