Complex Regional Pain

Syndrome (CRPS)

Objectives
At the conclusion of the presentation, the
audience should be able to:
1. Describe CRPS and its cause.
2. Describe the emotional impact of CRPS.
3. Identify the different types of CRPS.
4. Discuss the nervous system
dysfunctions that
may lead to CRPS.
5. Identify various physical therapy
interventions that can
help improve the
symptoms of CRPS.

What is CRPS
CRPS (a.k.a Reflex Sympathetic Dystrophy

Syndrome) is a chronic pain disorder that is

not fully understood.
CRPS usually starts with an injury to an
extremity, but it can also occur after surgery
or as a result of a heart attack or stroke3.
The initial insult, which has a known and
predictable course of resolution, morphs
into a chronic pain condition often
accompanied by inflammation and some
type of mobility dysfunction2.

The Emotional Impact of

CRPS
CRPS sufferers can experience emotional and

psychological trauma because he/she might not

understand what is happening to them.
Furthermore, friends and family members may not
believe that they could be suffering from as much
pain as they have described.
One solution to this situation would be to educate
everyone involved about condition and symptoms
of CRPS.
Another emotional boost for CRPS sufferers would
be to maintain normal activities and hobbies as
much as possible, getting plenty of rest, and by
staying connected with family and friends.3

What Causes CRPS

Most studies suggest that CRPS may be due to a

dysfunctional interaction between the central

and peripheral nervous systems and an
inappropriate inflammatory response 3.
MRI brain scans of CRPS sufferers revealed that

the emotional, autonomic, and pain perception

area of the brain was different from normal
scans. This suggests that chronic pain may be
driven by the brains interpretation of pain which
may no longer be dependent on the nociceptor
transmission of pain5.

Two Types of CRPS

Complex regional pain syndrome occurs in two
types, with similar signs and symptoms, but
different causes3.
Type 1: Usually occurs after an illness or injury that
did not directly damage the nerves in the affected
limb. Type 1 is the most common form and
effects about 90% of those diagnosed with CRPS 3.
Type 2: This type of CRPS is usually caused by a
distinct
nerve injury3.

Etiology of CRPS
CRPS usually has an early warm phase that

suggests an inflammatory process, with

local swelling, erythema, heat, and the
presence of cytokines2.
It can then progress to a cold phase, which
often goes on for months or even years2.
CRPS can also migrate from the initial
involved site to other limbs as well4.

Incidence of CRPS
The estimated incidence varies from 5.46

to 26.2 per 100,000 persons per year.

CRPS in the adult populations occurs
slightly more often in the upper
extremities, where fracture is the common
initial insult.
Women are affected 3.4 to 4 times more
often than men.4

Risk Factors Associated with

CRPS
Anxiety, frustration and other behavioral

and psychological factors can exacerbate

the pain and dysfunction in CRPS-11.
A sedentary lifestyle after an injury can

make one more prone to developing CRPS 3.

Signs and Symptoms

Symptoms may change over time and vary from

person to person.
Most commonly the first symptoms may be pain,
general swelling, redness, noticeable changes in
temperature and hypersensitivity to cold and
touch.
Over time, the patient may acquire additional
symptoms such as muscle spasms, weakness
and atrophy as well as joint stiffness, swelling
and damage.3
Also, some patients have restricted AROM while
PROM may be normal1.

Diagnosis
There is no single test that can definitively

diagnose CRPS
However, a doctor may use a variety of physical
exams and the patients medical history to help
piece together a diagnosis.
Several exams that a doctor may perform are:
Bone density scan
Test sympathetic nervous system activity
Thermography
Compare affected and non-affected limbs
MRI to detect tissue changes.3

Diagnosis
Bone density scan
Thermography

Diagnosis
Compare affected and non-affected limbs

Prognosis
In some people, signs and symptoms of complex

regional pain syndrome go away on their own.

In others, signs and symptoms may persist for
months to years.
Aggressive Physical Therapy treatment in the early
stages has produced improvement of symptoms and
even remission of the condition in some cases.
The pain associated with CRPS may make many
sufferers reluctant to actively move the affected
limb. Over time, the affected limb can become cold
and pale and undergo skin and nail changes as well
as muscle atrophy and contracture. Once these
changes occur, the condition is often irreversible. 3

Prognosis
Muscle atrophy and contractures are often
irreversible3.

Medical Interventions
Doctors may prescribe various medications
and treatments for CRPS such as:
NSAIDS
Antidepressants & Anticonvulsants
Corticosteroid and Bone-loss medications
Intravenous ketamine (strong anesthetic 3)
Phentolamine (an intravenous regional
block4)
Spinal cord stimulation2.

Medical Interventions
Spinal cord stimulation2
The controller and
electrodes are implanted
under the skin and leads
are placed into the
epidural space of the
spine. When activated, it
stimulates the spine at a
higher frequency than the
incoming pain which
blocks the pain and
paresthesia.

Physical Therapy
Interventions
Biofeedback
Warm or cool water bath
Transcutaneous electrical nerve stimulation

(TENS)
Mirror image therapy
Pain Exposure Physical Therapy and Self
massage

Physical Therapy
Interventions
Biofeedback: Exercises that emphasize

body awareness which help to relieve pain

by learning relaxation techniques3.
Warm or cool water bath: helps to make the

limb easier to move by reducing muscle

guarding2.

Physical Therapy
Interventions
Transcutaneous Electrical Nerve Stimulation
Electrical stimulation that sends signals to the
brain that block pain signals.

Physical Therapy
Interventions
Mirror Image Therapy
An image of the affected limb is presented to the
patient normalized by substitution with the mirror
image of the normal limb. This is presumed to work
through central neuronal plastic reorganization 2.

Physical Therapy
Interventions
Pain Exposure Physical Therapy (PEPT)
PEPT is a progressive-loading exercise program used to
desensitize patients to pain, mobilize joints, and
increase muscle stretching.
Patients are reassured that an increase in pain is not a
sign of injury or tissue damage, and they are
encouraged to push through the exercise.
Self-massage and forced use of the affected limb in
daily activities is encouraged to decrease sensitivity.
Studies have shown that up to 92% of the children with
CRPS had a complete recovery of symptoms and 106
patients with chronic CRPS-1 had 94% improved
function and 49% experienced full functional recovery. 1

Cited References
1Barnhoorn, K. J., Bogdan D., Peter S., Melanie L., Volkmar N., Christoph M., and Martin
T., "The effectiveness and cost evaluation of pain exposure physical therapy and
conventional therapy in patients with complex regional pain syndrome type 1.
Rationale and design of a randomized controlled trial." BMC Musculoskeletal Disorders
13 (2012): 58. ProQuest. Web. 17 Feb. 2015.
2Lee, J., BSc, MSc, MBBS, M.R.C.P., F.F.P.M.R.C.A., and Nandi, P., MBBS, FRCP, F.R.C.A.,
F.F.P.M.R.C.A. "Early aggressive treatment improves prognosis in complex regional pain
syndrome." Practitioner 255.1736 (2011): 23, 6, 3. ProQuest. Web. 26 Feb. 2015.
3Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/complex-regional-painsyndrome/basics/definition/con-20022844. 12 April 2014. Article. 26 February 2015.
4Niaki, A. S., et al. "Intravenous regional block with phentolamine in the treatment of
complex regional pain syndrome." Acta Medica Iranica 49.8 (2011): 523-6. ProQuest.
Web. 26 Feb. 2015.
5Pleger, B., et al. "Complex regional pain syndrome type I affects brain structure in
prefrontal and motor cortex." PLoS One 9.1 (2014): e85372. ProQuest. Web. 17 Feb.
2015.