Complex

Regional Pain
Syndrome

General
Background
Information

CRPS- What is it?!

Complex regional pain syndrome (CRPS) is a pain disorder

characterized by constant and intense limb pain associated with
vasomotor and neurosensory abnormalities, skin changes, and
demineralization of bone
CRPS is a chronic pain condition
Most often it affects the arm, hand, leg or foot
Usually occurs after injury or trauma to a limb or a vascular event
Former name: reflex sympathetic dystrophy (RSD)
Involves the sympathetic NS & inflammatory dysfunction
cases have a precipitating event ( peripheral nerve injury, CVA,
localized trauma, fracture or MI)
Strong connection with individuals who have psychological disorders,
such as depression, anxiety or emotional liability

Pathophysiology

Epidemiology & Risk Factors

Females > Males (2-3:1)

Occurs most frequently between the ages of 30-60
Patients who experience a serious limb trauma 5% go
on to develop CRPS
Increased incidence of CRPS in smokers
of individuals have no identifiable precipitating event
Systemic conditions such as DM, MS, osteoarthritis &
hyperthyroidism

Diagnosis

This disease requires a clinical diagnosis & is made

largely based on these historical characteristics:
Symptoms
Physical examination signs typical of the syndrome

There are no specific diagnostic tests that have been

reliably established in patients suspected of having
CRPS
However: a triple-phase bone scan may yield findings

Diagnosis cont.

The International Association for the Study of Pain (IASP) has developed widely accepted
diagnostic criteria based upon clinical presentation. It includes:

Pain

Sensory disturbances

Edema

Skin blood flow abnormalities

Abnormal sudomotor activity

Impaired functionality of affected limb

Ongoing pain and dysfunction

Clinical
Presentatio
n

Acute Stage: CRPS Stage 1

Develops within hours to days of the physical insult.
Type 1 typically develops post surgery or trauma and is
not associated with a nerve lesion.
Signs & Symptoms
Burning or Aching in the effective Extremity
[extreme] sensitivity to touch
Increased hair and nail growth
Muscle Spasm
Stiffness, loss of ROM and function

Dystrophic Stage: CRPS Stage 2

Typically develops 3 to 6 months after the injury and is characterized by

increased pain radiating through the extremity, hypothermia, sweating,
cyanosis, and increased muscle tone
Type 2 develops after trauma and is associated with a nerve lesion
Signs & Symptoms
Pain may radiate both proximally and distally from the site of injury.
Increased sweating/ body temperature (cynaosis, hypothermia, etc)
Swelling may spread, tissue goes from soft to boggy to firm
Muscular atrophy
Nail bed changes
Bone demineralization
Edema
Increase in muscle spasms & Tone

Atrophic Stage: CRPS Stage 3

Occurs about 6 months after the injury and presents with
contractures and skin atrophy
Signs & Symptoms
Pain may stay the same, improve, or get worse; variable
Irreversible tissue damage
Muscle atrophy and contractures
Subcutaneous skin atrophy
Skin becomes thin and shiny
Nails are brittle
Osteoporosis

MID STAGE CRPS

END STAGE CRPS

Prognosis
of CRPS

Prognosis
Once established, CRPS is typically not progressive &
non-life threatening.
Most patients improve with a combination of medications
and therapy
Spontaneous remission has been known to occur
A few cases may require a sympathetic nerve block
Bean, et al performed a systematic review, and found
evidence that many CRPS patients recover within 6 to 13
months, but a significant number experience some lasting
symptoms, and some experience chronic pain and
disability. The quality of the evidence was poor.

The Vicious Cycle of CRPS

Physical
Therapy
Interventions

CRPS
Intervention:
Desensitization
Activities
Intervention:
Desensitization
Activities
The

purpose of desentization activities is to: address the

abnormal response to stimuli, including: touch, hot, cold,
and movement.

The

patient should be encouraged and coached to go the

point of discomfort for any activities that can be done at
home.

CRPS
Intervention:
Desensitization
Activities
Intervention:
Desensitization
Activities
Tap

or vibrate over the affected area 5 times per day

Intermittent use of warm & cold application
Massage area with various textures, progressing from least
noxious and slowly increasing intensity.
Sensory discrimination training
Grated motor imagery
Cognitive

training
Graded motor Imagery
Fear avoidance exposure therapy
Virtual reality techniques

CRPS
Intervention:
Intervention:
Desensitization
Exercise Activities
Each

exercise intervention addresses a different symptom

of Complex regional pain syndrome. Exercise interventions
should be directed towards the specific problems the
patient is experiencing.
Pain/Edema
Passive, gentle ROM activities to decrease swelling.
Increase Independence with functional activities
PNF training

CRPS
Intervention:
Intervention:
Desensitization
Exercise Activities
Restoring

ROM and improve joint mobility for completion

of ADLs and functional tasks
Gentle ROM activities

Stretching and flexibility training

Restore abnormal sympathetic nervous system function in
extremities
Weight-bearing exercises in extremities: quadruped stability
exercises, push-up on table, carrying objects

General aerobic conditioning

CRPS
Intervention:
Intervention:
Desensitization
Exercise Activities
Our

overall goal should be to preserve any coordination,

strength, and endurance that the patient has in order to
decrease risk of secondary impairment.

As

the patient progresses, increasing and restoring

normal strength, motion, and mobility should be the goal,
while taking into consideration patient preferences, and
altering activities if they exacerbate the patient's
symptoms.

CRPS
Intervention:
Intervention:
Desensitization
Mirror Therapy
Activities
What is it?
A treatment that creates an illusion of normality in
the affected limb
How does it work?
Concealing the affected limb behind the mirror allows
for the uninvolved limb to be superimposed in the
reflection, where the affected limb should be.
The brain prioritizes the visual input over the
proprioceptive input, allowing the individual to feel
like the affected limb is functioning normally.
The mechanisms of action are not fully understood.
Some theories include:
Increased attention to the limb
Activation of the mirror neurone system
Improved ownership of the limb
Reduction of sensorimotor incongruence

CRPS
Intervention:
Intervention:
Desensitization
Mirror Therapy
Activities
Why use it?
Inexpensive and accessible form of treatment for acute and intermediate stages
of CRPS
Can it be used for every stage of CRPS?
Acute CRPS (<8 weeks) Mirror therapy significantly lowered pain intensity
Intermediate stages of CRPS Those who did mirror therapy showed a
reduction in stiffness
Chronic CRPS No beneficial outcome

CRPS
Intervention:
Intervention:
Desensitization
Mirror Therapy
Activities
CAUTION! The affected
limb must be moved in
synchrony with the
observed reflection!
Otherwise, conflicting
sensory feedback and motor
output will be exaggerated
and CRPS pain will
actually be increased

CRPS
Intervention:Desensitization
Pain Neurophysiology
Education
Intervention:
Activities
What is it?
A type of education that can change
pain perception, disability and
catastrophization in patients with
CRPS
How does it work?
Helps patients realize that pain may be
caused by neural sensitivity rather
than tissue injury
Why use it?
May allow patients to gain active
movement, and allow clinicians to gain
passive movement

CRPS
Intervention:Desensitization
Pain Neurophysiology
Education
Intervention:
Activities
Focus on education about:
Description of biology and physiology of:
The nervous system
The brains processing of pain and nociceptive input
De-emphasis on tissue injury
Impart a clear understanding between nociception and
pain
One-on-one education found to be superior to group
sessions
Provide education proficiently in as little as 30-45 minutes

Summary
Intervention:
of Interventions
Desensitization Activities

Consider the stage of CRPS the patient is in

Incorporate pain neurophysiology education for each
patient with CRPS
Choose activities that incorporate desensitization
Consider mirror therapy for acute and intermittent
stages
Choose exercises that preserve coordination, strength
and endurance

References
Intervention: Desensitization Activities
1.
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9.

Bean, D. J., Johnson, M. H., & Kydd, R. R. (2014). The outcome of complex regional pain syndrome
type 1: A systematic review. The Journal of Pain, 15(7), 677-690. doi:10.1016/j.jpain.2014.01.500
De Mos, M., Huygen, F. J., Dieleman, J. P., Koopman, J. S., Stricker, B. H., & Sturkenboom, M. C. (2008).
Medical history and the onset of complex regional pain syndrome (CRPS). Pain, 139(2), 458-466.
doi:10.1016/j.pain.2008.07.002
Goodman, C. C. (2013). Differential Diagnosis for Physical Therapists (5 ed.): Elsevier Saunders.
Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed new diagnostic criteria for complex
regional pain syndrome. Pain Medicine. 2007. 6(4):326 31.
Louw A, Diener I, Butler DS, Puentedura EJ. The Effect of Neuroscience Education on Pain, Disability,
Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine & Rehabilitation.
2011;92(12):2041-2056.
Mujahed M. Alikhan, MD, Rheumatology Fellow, University of Kentucky, Lexington, Kentucky; Kristine
M. Lohr, MD, MS, Interim Chief, Division of Rheumatology, Professor of Medicine, and Director,
Rheumatology Training Program, University of Kentucky, Lexington, Kentucky. Published January 4,
2014.
Palmer, E., & Callanen, A. (2016). Complex Regional Pain Syndrome. CINAHL Rehabilitation Guide
Pollard C. Physiotherapy management of complex regional pain syndrome. New Zealand Journal of
Physiotherapy. 2013;41(2):65-72 68p.
Topcuoglu, A. Kutay, N. Gokkaya, O. Ucan, H. Karakus, D. The effect of upper-extremity aerobic
exercise on complex regional pain syndrome type 1: a randomized controlled study on acute stroke.
Topics in Stroke Rehabilitation. 2015;22(4).