Complex regional pain syndrome is one of the most vexing and difficult problems in the world of pain medicine. Traditionally it was thought to be a rare disorder that spontaneously affected some people especially after some sort of injury. Since it has been poorly understood, many pain practitioners have very limited experience and interest in trying to treat this condition. Many physicians actively try to avoid working with patients with the problem, others may try a few things but since they have limited knowledge and experience, they often end up giving up on trying to manage the problem. Luckily there are more than a few pain physicians who see the condition a lot and are becoming more successful with its management.
The thought leaders in pain medicine who treat CRPS seem to be some of the physicians who do a lot of work as interventional pain physicians who also take a very active role in diagnosis of their patients besides just providing treatments. The ability to fully evaluate a person is critical in understanding CRPS. The symptoms of CRPS always have a cause; it is not just a bunch of symptoms that lead to a painful extremity. It usually involves a structure in the body such as joint that is malfunctioning or a nerve in the area that is abnormally functioning. Treatment is needed to correct the structure that is not moving in the right way and to relieve the abnormal functioning of the nerves involved in the area.
The Challenges of CRPS
The first challenge is correcting the structural problems that often are orthopedic in nature that are wrong. The abnormal movement sends signals through the nervous system that something is wrong and often is interpreted by the brain as pain. These problems may start as simple degeneration like from a sprained ankle or a worn out knee. Most of the time, correcting the simple problems work, but if there are nerves malfunctioning in the area, possibly damaged by an injury or treatment, or more centrally also in the spine itself, then complex regional pain syndrome – CRPS may be manifested. The major challenge is finding the nerve problems correlated with the symptoms and finding a way to treat them.
Since CRPS often now is thought to involve peripheral nerve injury in the region of pain, then finding the nerve and extinguishing the signal from that location can sometimes effectively treat the problem. If the source of the pain is strictly peripheral, finding the right nerve and blocking that nerve proximal to the damage may stop the pain. In the last 1-2 years, technology has improved and techniques are now becoming available to electrically block isolated nerves in the extremities.
Spinal cord stimulation has been used to treat CRPS for years, and this is blocking signals more centrally at the spine. Now technology is allowing pain practitioners to more precisely block the nerves either as they exit the spine or superficially in the periphery with special implantable devices. Obtaining better pain control then involves the physician fully evaluating a person for all the places that may be contributing to sending painful sensory signals and then trying to find the simplest place to block the abnormal electrical signals such that they do not travel to the brain and signal pain and disaster to the brain. Further it means the physician who is going to be helpful in treating your pain must be fully evaluating the patient as well as working directly with the interventional techniques. A physician who is just providing injections or not fully involved in all aspects of pain management is unlikely to understand and be helpful in controlling symptoms in CRPS.
The understanding and treatment of CRPS is changing and with the right providers, pain control is often being significantly improved. This is not a mystery disease, but unfortunately not many physicians have seen enough of these types of problems to understand and manage the complex issues. Finding the right person is difficult, but the interventional pain physicians who see CRPS a lot, who actually evaluate their patients themselves and do the treatment may be the best source for a successful strategy toward treatment. The solutions sometimes are complex like the disease, but there are more and better treatments that are becoming available.
Complex 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.
Recent findings suggest that individuals with complex regional pain syndrome deal with a great amount of pain during every day activities. According to some pain scale rankings, CRPS ranks higher on the pain scale than childbirth, cancer and even amputation.
For those of you unaware of what complex regional pain syndrome is, CRPS is categorized as a chronic condition that typically affects one limb, usually arising out of a trauma. CRPS involves a disruption in the way sensory signals are processed and deciphered along the central nervous system, leading to extreme pain even when no traumatic experience is happening. Actions like putting on your socks or brushing against a door frame can trigger inflammation and painful sensory signals.
Treating CRPS
According to the National Institutes of Health, CRPS typically affects women, and the average age of a CRPS sufferer is 40 years old. The issue with CRPS is that since it involves a communication breakdown in the central nervous system, it can be extremely hard to diagnose correctly. One report suggests that the average CRPS sufferer searched for answers for four years before receiving the appropriate diagnosis. Part of the problem is medical oversight, but this is due in large part to it being such a rare condition, and the fact that research dollars are being spent elsewhere.
So how do we work to treat and prevent this problematic condition? For starters, education is key. That’s the main reason we shared a large infographic about CRPS on the blog earlier this week. Both patients and healthcare providers need to be aware of the problem of CRPS. It can be treated and managed, but only with an accurate diagnosis. People should not have to wait four years to get to the bottom of their health problem.
Funding For CRPS
We also need to be spending more research dollars on understanding chronic conditions. Chronic pain affects roughly 30 percent of Americans, and the toll it takes on the healthcare system as a whole is billions of dollars, yet funding to better understand the condition and help those who suffer day in and day out continues to be lacking.
St. Paul CRPS Pain Doctor
If you’re dealing with chronic pain, and you’re struggling to get answers about your condition, set up a consultation with a Minnesota Pain Specialist. We won’t stop until we get to the bottom of your condition, because our goal is to help you live a pain-free life. Contact us today for more information.
Complex Regional Pain Syndrome (CRPS) is a complicated condition in which nerves incorrectly send pain signals to the brain, even though there is no painful sensory action taking place. For people with CRPS, actions like a gust of wind on their neck or toweling off after a shower can trigger a painful flareup. CRPS can be difficult to treat because it can be difficult to pinpoint exactly where the problem is along the nerve path to the brain. However, with careful evaluation and coordinated treatment with a pain management specialist, symptoms can be kept under control.
Today, we want to take a closer look at CRPS by partnering up with our friends at Burning Nights CRPS. They’ve created a wonderful infographic that examines the problems caused by CRPS and what actions you can take if you’re suffering from the condition. Check out the infographic below, and be sure to swing over over to BurningNightsCRPS.org to learn more about CRPS and other chronic conditions.
Pain is an extremely complex issue. Complex regional pain syndrome (CRPS) is a prime example of the new understanding pain specialists are finding in the world of pain. Explaining these problems have taken years, but we are finding new information on what is happening when these conditions develop. We know now that there are peripheral issues at the site of injury, problems at the spinal cord and the equivalent of a short circuit in the brain when these conditions occur. Pain is maintained by feed-forward pain reception and feed-back sympathetic efferent loops. The brain stem, hypothalamus, limbic system and cortex all play roles.
Once an injury occurs, pain receptors in the periphery of the body, at the skin, bone and joint start sending signals to the brain. The sensory fibers first go to the periphery of the cord – the dorsal root ganglion where the sensory cell bodies are located. These cells then send signals to the cord in the dorsal horn and then to the brain. At this point, the cells in the DRG also are putting out several inflammatory chemicals IL-1, TNF, and IL-6 that promote inflammation in the periphery and increase the pain sensitivity of the spine and brain. Not only do the nerve cells become active, but glial cells, which we thought were just inert insulation, become active and produce more of these chemicals that promote inflammation. These chemicals then make the nerve cells more sensitive to pain reception and increase the number of signals going to the brain.
Pain and Brain
The brain is the master processing of all nerve and chemical signals in the body. The signals from the periphery for pain travel to the brainstem, then to the hypothalamus, thalamus, limbic system and cortex. The chemicals produced in the periphery also sensitize the brain also to pain signals. There are also an increased number of signals going to multiple areas of the brain, overwhelming certain areas and stimulating brain areas that are active for anxiety and depression in the cortex and limbic areas. Furthermore, the increase in signals also interacts with the motor inhibitory signals that are supposed to block pain signals. Thus in CRPS, there are multiple regions with increased activity, from the periphery to the spinal cord and into the brain.
The treatment of CRPS is now becoming more complex. The first obvious treatment is to try to eliminate the factors in the periphery that are stimulating the sensory signals. This means trying to correct even the small injuries that stimulate pain receptors, allow healing of the injury. During the treatment of the injury, interfering with the delivery of signals to the cord and brain is also important. This may be done with a variety of interventional techniques, physical therapy, medications, and psychological techniques. When the peripheral treatment of the injury is incomplete, then a full array of pain management techniques may need to be fully explored and treatment needs to be coordinated by a knowledgeable pain management specialist with expertise of medications and advanced interventional techniques including implantable options.
Complex regional pain syndrome is one of the most vexing and difficult problems in the world of pain medicine. Traditionally it was thought to be a rare disorder that spontaneously affected some people especially after some sort of injury. Since it has been poorly understood, many pain practitioners have very limited experience and interest in trying to treat this condition. Many physicians actively try to avoid working with patients with the problem, others may try a few things but since they have limited knowledge and experience, they often end up giving up on trying to manage the problem. Luckily there are more than a few pain physicians who see the condition a lot and are becoming more successful with its management.
Recent findings suggest that individuals with complex regional pain syndrome deal with a great amount of pain during every day activities. According to some pain scale rankings, CRPS ranks higher on the pain scale than childbirth, cancer and even amputation.
