CRPS, Chronic Pain and Your Brain

March 25, 2015 / Thomas Cohn, MD

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.

What is Reflex Sympathetic Dystrophy (RSD)?

December 11, 2013June 24, 2014 / Thomas Cohn, MD

Reflex sympathetic dystrophy is one of the older terminologies for what is currently known as Complex Regional Pain Syndrome (CRPS). Other terms used include:

Causalgia syndrome
Sudeck’s atrophy
Algodystrophy
Algoneurodystrophy
Reflex neurovascular dystrophy

History of RSD and CRPS

At this time the preferred medical term is CRPS. In 1993 the terminology changed from RSD to CRPS to better define underlying problems associated with the syndrome. Two types of CRPS were further defined:

CRPS Type 1 has the characteristic painful limb, but has no definite nerve injury as the cause
CRPS Type 2 has obvious previous nerve damage

Quality of Treatment

Quality of treatment for RSD/CRPS depends on the knowledge and experience of the practitioner coordinating care. CRPS is a complex problem, many physicians work with the syndrome on an occasional basis. A pain physician who treats this condition almost daily is likely the best source to turn to for management and treatment options. Experience in recognizing the problem and offering a comprehensive multi-disciplinary approach is essential.

It truly requires a “hands on” physician who coordinates all aspects of care. The mark of a good physician is one who not only recognizes what is wrong, but one who can determine all the contributing factors to the syndrome and what is maintaining the problem. Few pain specialists truly understand the condition, finding a good physician may seem like finding a needle in the haystack.

Diagnosis and treatment of CRPS and RSD depends on finding the right physician. It is not guess work at management. It often takes time and patience by both the physician and patient. Experienced physicians will be much more successful in management, do not settle for just anyone who just claims to have treated the condition.

Complex Regional Pain Syndrome (CRPS) – Causes & Treatment

September 30, 2013November 17, 2015 / Thomas Cohn, MD

Complex 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:

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.
The second aspect is controlling the sympathetic aspects of pain and the neuropathic pain with injections and medications.
The third part is rehabilitation and physical therapy, restoring mobility and decreasing pain sensitivity.
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.

Woman Struggles with Complex Regional Pain Syndrome (CRPS)

June 5, 2013May 24, 2017 / Thomas Cohn, MD

Amanda Siebe is a young woman living with a rare disease known as complex regional pain syndrome (or CRPS for short).

It began when Amanda sprained her ankle during a shift at the restaurant at which she works. Initially she just dealt with the pain and continued to work on the injured ankle. But in a few days her ankle had grown inflamed and very painful.

After that she attempted to continue working with crutches to take the weight off of her ankle, but another fall forced her to take time off of work. The ankle still did not heal. After roughly a year of suffering, Amanda was finally diagnosed with CRPS.

CRPS is a condition where the body’s nerves record every type of stimulation as pain. For example, simply poking the impacted area with your finger may feel like a stabbing knife. CRPS can eventually move to other parts of the body as well over time.

Click here to read Amanda’s story.

Dr. Cohn Comments

Pain is a complex entity. In medicine it is only considered a symptom. However, pain is the major factor that leads people to visit their doctors. Acute pain is most often related directly to some injury, trauma, or illness. The diagnosis is often easy and the treatment is rapid and then the pain is gone forever. When pain becomes chronic, the pain itself can become self-perpetuating despite the original source being healed. In medicine today, pain has often developed into such a problem with complex roots that a new specialty exists – Pain Medicine.

CRPS is a very complex problem, whose exact cause and treatment is poorly understood. Even among pain practitioners, many do not see the problem, and the challenges associated with it make these patients hard to treat. However, there are a few excellent practitioners who actually understand the condition and have developed a good track record in treatment of this condition especially for ankle and foot disorders, such as Dr. Lance Silverman.

CRPS is from an over active sympathetic nervous system that is being constantly stimulated from an ongoing injury in the ankle or foot region. In the case of multiple ankle sprains, or even a single untreated sprain, the ankle and foot region has damaged structures that have not healed and stimulate pain signals. Two things are needed for successful treatment:

Aggressive surgical repair of all damaged structures by a qualified foot and ankle orthopedic surgeon, and
Pain management by a skilled pain management expert who can handle all aspects of medication, interventional care, and coordinate physical and if necessary psychological care.

Finding the team of the Orthopedic Specialist and Pain Medicine doctor who do this all the time is the trick. I often partner with Dr. Lance Silverman (an ankle & foot orthopedic specialist) in such matters. Working together, we routinely help patients heal effectively and get back to a normal life.