Complex Regional Pain Syndrome

What is complex regional pain syndrome?

A complex of systems that include extreme pain, joint stiffness, diffuse edema, trophic skin changes, and vascular instability

What is CRPS caused by?

painful lesion, predisposition to condition, abnormal sympathetic reflex

What can be events that precede CRPS?

Fracture, sprain, surgery, immobilization of the limb, spinal cord injury, stroke, infection skin or joint, injections, venipuncture, burn, frostbite

CRPS Type 1

• no known peripheral nerve injury

• Classic reflex sympathetic dystrophy

• pain out of proportion to injury

• autonomic dysfunction

• trophic changes

• functional impairment

CRPS Type II

• Involves peripheral nerve injury → typically median or sciatic nerve

• classic causalgia

• similar signs and symptoms as Type 1

Precipitating event with CRPS Type 1 and CRPS Type 2

CRPS 1: Sometimes

CRPS 2: Yes

Single peripheral nerve involvement with CRPS Type 1 and Type 2

CRPS Type 1: Sometimes

CRPS Type 2: Yes

Physiologic changes in affected limb CRPS Type 1 and Type 2

CRPS Type 1: Yes

CRPS Type 2: No

Cardinal signs of CRPS Type 1

spontaneous pain, swelling, different skin temperatures

Cardinal signs of CRPS Type 2

Burning pain, allodynia, hyperalgesia

Progression of CRPS Type 1 and Type 2

CRPS Type 1 progresses

CRPS Type 2 sometimes progresses

Bone atrophy CRPS Type 1 and Type 2

CRPS Type 1: Yes

CRPS Type 2: No

Types of pain associated with CRPS

Allodynia, hyperalgia, hyperpathia

Allodynia

Painful response to a normally innocuous stimulus

Hyperalgia

increased sensitivity to pain

Hyperpathia

stimuli evoke exaggerated levels of pain

How does pain present in CRPS?

Abnormal sympathetic reflex arc, meaning the processing of pain is not normal. Most common and universal complain associated with CRPS. It is disproportionate to injury. There can be burning, throbbing, deep aching, cramping, flashing hot/cold, or increased pressure

CRPS Joint stiffness characteristics

There will be joint thickening and palmar nodules. It will exceed the expected response and occur rapidly and increases. The client will typically be in protective posturing that will lead to contractures.

CRPS Edema Characteristics

Can be extreme in nature, and is initially soft and relieved by retrograde massage. Brawny edema will localize to dorsal hand.

Stage 1

Stage 2

stage 3

Autonomic changes with CRPS

Vasoconstriction which can lead to blue, sweaty, and cold limbs

Vasodilation which can lead to red, dry, and hot hands

Trophic changes for CRPS

Skin becomes tight and shiny, possibly goose bumps, Pencil pointing of fingertips. Abnormal hair growth and texture, fingernail changes, atrophy of soft tissues

What motor dysfunctions can occur with CRPS?

Tremor, dystonia, increased tone, spasms, and loss of strength/endurence

True or False: CRPS can affect bone density

True, bone demineralization can occur

True or false: CRPS cannot affect skin color

False, CRPS can affect skin color

What vasomotor change can occur with CRPS?

temperature alteration

What sudomotor change can occur with CRPS?

hyperhidrosis

Acronym to remember characteristics of CRPS

STAMP

sensory, trophic, autonomic, motor, pain

Stage 1 CRPS

Acute

Within weeks of injury

Swollen, red, and burning; increased diaphoresis; pain near site of injury; limb hot and sweating; protective posturing

Bone demineralization within 3-5 weeks

Soft, pitting swelling edema

Stage 2 of CRPS

Dystrophic

Cool and diaphoretic, pain throughout limb, bone atrophy on x-ray; skin becomes glossy and shiny; disuse develops; limb cool and sweaty

Within months of injury

Edema becomes hard and brawny

Stage 3 CRPS

Atrophic

Pale and shiny, atrophy of muscle and bone, pain may be constant

years after injury, also may resolve

Extreme stiffness

Periarticular thickening/joint enlargement

Contractures, nonfunctioning limb

CRPS Medical Interventions

• pharmacologic agents

• stellate ganglion blocks

• sympatholytic drugs

  • sympathectomy

Assessing CRPS

Absolutely necessary and non-provocative testing

Monitor circulatory and sympathetic changes

Observation at rest and during activity

Pain assessment

What are we assessing with active ROM in CRPS? What should we be careful of?

Joint tightness versus musculotendinous limitation

Intrinsic versus extrinsic tightness

We should be careful of pain during testing

What should be used assessing sensibility during CRPS?

Monofilaments and two-point discrimination

What should we assess when looking at skin temperature with CRPS?

To see if the skin is hot or cold to determine what stage the CRPS is in

How can we measure the quality of edema?

Figure of eight, circumferential measurement (be mindful with pain, and volumeter with warm water

What should be the goal of OT for CRPS?

management of pain and other symptoms, maximize motion, restore function. We should be a cheerleader for our clients to encourage functional use of the limb

How can pain be managed for CRPS?

For cold limbs → superficial heat modalities (hot packs or fluidotherapy at 98 degrees

For warm limbs —> cryotherapy

Ultrasound

TENs

How can edema be managed with CRPS?

simple elevation, gentle pain-free AROM, pulsed electrotherapy, pneumatic compression, manual edema mobilization, compression garments, retrograde massage

How can retrograde massage be used for CRPS?

Massage distal to proximal to increase blood and lymph flow. It is performed during stage 1. Prior to and after therapeutic exercise.

Can sensory issues be managed with CRPS?

For hypersensitive clients, desensitization for 5 to 6 times a day is important. The stimuli must be mildly irritating. Start outside sensitive areas and work toward hypersensitive area. Protect hypersensitive areas between sessions

What interventions can be used to treat vasomotor changes?

Generalized aerobic exercise routine, avoid caffeine and alcohol, self management for cold, cyanotic limbs, electro therapy for circulation, temperature biofeedback

Mirror therapy for CRPS

Done 5 minutes 2 times a day, working up to 15 minutes/day

Remove jewelry and watches

quiet area, same time of day, same location

progress to making one change at a time,

progress to practice with distractions

Move from exercises to activities

Stress loading for CRPS

3 to 5 minutes 3 times a day working up to 10 minutes

Compressive active exercises

follow with distraction techniques

aquatic therapy can also be utilized

When should a continuous passive motion orthotic be utlized?

as a last ditch effort, to increase tissue nutrition, used periodically, only within comfort range, supplemental

What position should a static orthosis be in for CRPS?

Intrinsic plus

Why should orthotic be used for CRPS?

To manage contractures. No more than 2 orthotics should be used per client.

What is the purpose of improving functional activities for CRPS?

To improve self-care, IADLs, work skills, craft activities, start simple and move to more difficult tasks, and to reinforce confidence

What stage of CRPS should strengthening begin?

Stage 3, however if they can tolerate it in earlier stages, start it sooner

Why is strengthening important for CRPS?

to prevent weakness, to build endurance, and to provide stimulation for work

What patient education tools can be used for CRPS?

joint protection, energy conservation, assistive devices, encourage participation in a support group, psychosocial issues, home programs