Treatment for CRPS

Complex regional pain syndrome (CRPS), also previously known as Reflex Sympathetic Dystrophy (RSD), is a is a rare condition affecting less that 3 in 10,000 people in the UK. It is a debilitating, painful condition usually affecting one limb and associated with sensory, motor, autonomic, skin and even bony changes. It often, but not always, follows a relatively minor injury or period of limb immobilisation for example in a cast or boot. It is not clear why this happens and there is no obvious relationship with the severity of any initial injury. It usually affects one limb only but in a small number of cases it spreads to the opposite side, clearly without any injury involvement at all in this instance.

When patients are able to recollect an injury preceding the onset of CRPS there is usually a significant delay, even up to 1 month in some cases. This makes it hard to explain to patients as most people are only familiar with an onset of pain as a result of trauma which we think of as being immediate. The symptoms are totally disproportionate to any prior injuring event and, as such, very confusing for patients to process, often adding to the somewhat scary nature of what is happening.

Early diagnosis is important for a more successful outcome and in children there is usually a better prognosis than in adults for some reason. However, it is not uncommon for patients to get an accurate diagnosis some time after the onset of symptoms which the delays the start of effective treatments and in older patients around 15% have continued significant pain and physical impairment even after 2 years.

Severe pain, associated disability and fear and avoidance of movement are the main symptoms of CRPS. This is linked to significant psychological distress, disrupted sleep quality, anxiety and depression as patients withdraw from their normal social interactions including exercise, school and work. It is generally agreed that there are no obvious psychological characteristics in patients prior to the onset of the condition. However, the complex nature of this cause and effect relationship is likely to be hard to establish and certainly, once the condition is obvious, psychological help is one of the main treatments for this group of patients.

The use of a team of pain specialists is vital and good communication between themselves as well as with the patient and relevant carers and family members is needed to ensure patients continue to make good progress. The main initial part of treatment involves large amounts of ongoing reassurance and accurate education for both patient and family members. Communication with work occupational health departments and or school is also important to try to ensure that patients’ lives can continue with as little disruption as possible during what is often a long period of recovery. Pain relief, physical rehabilitation and psychological interventions are the mainstay of subsequent treatment and there are several exciting, relatively new, modalities we use to facilitate this including various methods of pain desensitisation, graded motor imagery and graded exposure to physical activity.