What Are Complex Regional Pain Syndrome (CRPS)?
As the name indicates, the symptoms and signs of this disease have been a mystery for doctors and patients. It is a disabling condition characterized by chronic pain in one side of the limb or arm or the body following trauma to that area. The affected area is extremely sensitive to touch, swollen or stiff, and has discoloration. Reflex sympathetic dystrophy syndrome, causalgia, Sudeck’s dystrophy, and post-traumatic dystrophy were the other names referring to this condition. The degree of pain is more than the expected amount for a minor injury, and the duration of pain is prolonged. In the past, it was thought to be a psychological problem. There are two types of this disorder:
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Type I (Reflex Sympathetic Dystrophy Syndrome): It is caused due to an injury to a specific area, and the pain produced is disproportionate to the damage caused. There may be allodynia or hyperalgesia and abnormal sudomotor activity (abnormal sweating) in the brain. Allodynia is an abnormal pain response caused by a stimulus that is usually not painful. Hyperalgesia is an abnormal elevated pain response caused by stimulation that is generally not very painful. Sudomotor activity refers to sweat gland activity of the brain.
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Type II (Causalgia): This type is caused due to nerve injury, and excessive amounts of pain are produced but not confined to the affected area and can be found in many places. There will be an abnormal sudomotor activity, swelling, and blood flow near the affected area after the injury or event.
What Are the Causes?
The exact cause of this disease is unknown, but injuries and chronic conditions like stroke have been related to CRPS (complex regional pain syndrome) in many patients. CRPS usually affects the extremities after an injury or damage, although it can affect any body part. It can occur due to the following:
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Musculoskeletal injuries.
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Fracture.
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Crush injuries.
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Nerve injuries.
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Stroke patients (a stroke is a condition in which blood supply is lost to the brain, leading to brain damage).
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Sprains and strains in the muscles.
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Head trauma and contusions (damaged blood vessels due to interruption of blood supply).
What Are the Clinical Manifestations?
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The patient feels extremely sensitive to light touch.
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Chronic persistent pain in the affected limb.
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Pain may be exaggerated in the affected limb.
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Pain aggravated on moving the affected limb.
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Discoloration and warmth over the affected area.
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Weakness of the affected limb.
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There is swelling over the affected area.
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Spasms of the muscles.
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Dystonia (involuntary movement of muscles) of limbs.
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Changes in the hair and nails of the affected limb.
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Excessive sweating on one side of the body is affected.
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Disproportionate pain even in a mild stimulus that does not elicit pain in normal conditions.
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Extremities of the limbs are cold.
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Depression in some patients.
How Can It Be Diagnosed?
A thorough examination is mandatory to rule out other symptoms characteristic of another condition. Medical history is taken to rule out any underlying conditions. Any falls or accidents recently have to be considered for diagnosis. A bone scan is done to observe for any bone density changes or any other structural abnormalities. X-rays and MRIs (magnetic resonance imaging) are done to check for any loss of minerals or bone or tissue changes in the affected area. Sweat testing is done through an instrument called Q-sweat that will help measure the amount of sweat produced. Pain testing is done by inflicting various stimuli and recording the response.
What Is the Treatment Strategy?
1. Pharmacological Management:
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Pain can be relieved by taking analgesics.
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Corticosteroids can be used to reduce swelling.
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Clonidine and Ketamine have been given epidurally (space near the spinal cord) for patients who do not respond to rehabilitation.
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Calcitonin and Alendronate are provided to compensate for bone loss.
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Sympathetic nerve blocks that relieve pain by blocking the affected nerves are given to the nerves.
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Baclofen can be given intrathecally into the spinal cord, which can help cure dystonia.
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Amitriptyline can be given to calm the patients and assist in sleep.
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Hyperbaric oxygen therapy can decrease pain and swelling and change the discoloration of the skin. It involves allowing the patient in a pressurized chamber and infusing pure oxygen in a controlled environment.
2. Physiotherapy for CRPS (Complex Regional Pain Syndrome):
There are various types of interventions for CRPS (complex regional pain syndrome) in physiotherapy:
1. TENS (Transcutaneous Electrical Nerve Stimulation): An electrical current is sent through electrodes to the affected area to stimulate the sensory nerves supplying that region, which will reduce the pain.
2. Aquatic Therapy: It is a technique in which the patients are asked to exercise in water since the body feels lighter in water and the movements done inside the water are less painful. This therapy relaxes the affected muscles and improves mobility and range of motion.
3. Movement Therapy: Movement therapy is a technique in which muscle movements are encouraged immediately after CRPS (complex regional pain syndrome) is diagnosed. This will prevent the functional degradation of the muscles, like stiffness and swelling.
4. Mirror Therapy: In this technique, a mirror is placed near the unaffected hand, and the affected hand is placed behind the mirror. If the unaffected hand is moved and seen through the mirror, it appears like the affected hand is moving. A perception is created, which has been proven to reduce pain in patients in the early stages of CRPS (complex regional pain syndrome).
5. Virtual Reality: This is a technological therapy in which virtual reality is created through sensors. The patient wears a glove containing sensors and is asked to do basic movements like grasping and reaching. It is replicated on the screen with the affected hand doing all those activities. It also has been proven to give an analgesic effect (reducing pain).
6. Desensitization: Desensitization is a technique in which the patients are exposed to the same kind of environment that they undergo during pain. It is done by touching the unaffected areas using different clothes made of wool and silk, and then the same is done to the affected area, which will cause pain. Next, the patient is asked to compare the effects on both regions.
As this progresses, the patient's pain perception will reduce over time. Exposure therapy and tactile discrimination are similar techniques in which the patient is exposed to different stimuli with both affected and unaffected areas and allowing them to discriminate the pain.
7. Manual Therapy: The therapist does this passively by giving gentle massages and stretching the affected area. This will improve mobility and relieve stress from the joints.
8. Graded Motor Imagery: A patient affected with CRPS (complex regional pain syndrome) usually avoids activities that may create pain and are super-vigilant and extra protective of the affected area. This, in turn, will cause inactivity of the affected limb, ultimately leading to declining function. In order to remove the patients from this fear, controlled exposures to the activities that stimulate pain are done as therapy. It has multiple stages, and the individual progresses through each step.
Conclusion:
CRPS (complex regional pain syndrome), being a complex disease, is still not fully understood. However, these physiotherapeutic interventions have greatly helped improve the symptoms of affected patients. Modern techniques like virtual reality and graded motor imagery have been a boon to medical science. These techniques have been helpful in the upbringing of current treatment methods in physical therapy. Choosing to use them is at the hands of the patient. With adequate knowledge of the disease and different treatment protocols, it would be easy to overcome the hurdles caused by CRPS (complex regional pain syndrome).
