Complex Regional Pain Syndrome

Question 1

What is CRPS?

Answer 1

Complex Regional Pain Syndrome

Definition:

• Vasomotor dysfunction characterized by very severe pain, swelling, stiffness, and discoloration
• Localized to one area of an extremity, to an entire extremity or more than one extremity
• Pain is most outstanding complaint
• Edema is most outstanding physical feature
• Also known as Reflex Sympathetic Dystrophy, Shoulder-Hand Syndrome, Sudek’s atrophy, Causalgia (post nerve injury/surgery

Question 2

What is the diagnosis and cause of CRPS?

Answer 2

Diagnosis

• History
• Physical Exam
• X-rays (Mineral loss)
• Bone Scan (Osteoporosis)
• Thermography

Cause

• Unknown
• Post injury, surgery, trauma, disease
  
  • May be minor or severe
  • Symptoms don’t necessarily match severity of primary cause

Question 3

What are the symptoms of CRPS?

Answer 3

Primary “Cardinal” Symptoms**in order to be diagnosised.

• Pain
  
  • Allodynia :
    
    • pain with stim not typically painful
  • Hypersensitive response
• Swelling
• Stiffness
• Discoloration

Secondary Symptoms

• Osseous demineralization
• Sudomotor changes
  
  • Increased sweating
• Temperature changes
• Trophic changes
  
  • Skin texture, nail changes, hair growth
• Vasomotor changes
• Palmar fibromatosis

Question 4

What are the stages of CRPS?

Answer 4

Acute Stage

• Onset to approx. 3 months (slow and chronic)
• Symptoms:
  
  • Pain (burning/aching)
  • Skin changes: Redness, shiny/thin
  • Increased nail/hair growth
  • Hyperhidrosis (excessive sweating)
  • Limited ROM (secondary to pain)
• X-rays may reveal demineralization/osteoporsis

Subacute Stage

• Extends from 3-9 months
• Symptoms:
  
  • Intense pain –spreads
  • Continued decreased ROM
  • Swelling is brawny (thick) and fixed
  • Skin:
    
    • Redness, sweating decrease
    • Mottled, white, blue
  • Nails
    
    • Split, brittle, grooved
  • Stiffness continues
    
    • Peri-articular thickening around joints of digits
    • Palmar thickening
  • Osteoporosis is pronounced

Chronic Stage

• May last for several months/years
• May affect the entire limb
• Symptoms
  
  • Pain/edema subside
  • Fibrotic changes
  • Continued joint stiffness – maybe permanent
  • Skin: pale and glossy – maybe irreversible
  • Difficult to gain full ROM-permanent contractures

Question 5

What is the medical treatment for CRPS?

Answer 5

• Blocks
  
  • Stellate: local anesthetic, numbs them and gives a chance for therapy to Range FROM
  • Bier : regional anesthetic, into vein
• Medication
  
  • Pain meds: Oral Steroids/Opioids
  • Sympatholytic medication: inhibits SNS
• Surgery
  
  • Sympathectomy: sympathetic ganglia removed

Question 6

What is the OT treatment for CRPS?

Answer 6

OT Treatment

Acute:

• Establish trust/patient education
• Decrease pain and edema
  
  • TENs
  • Retrograde massage
  • Elevation
  • Compression
• Desensitization
  
  • Fluidotherapy, retrograde massage, graded textures, protection (gloves, elastomer inserts etc.)
• AROM exercises (aerobic exercise-walking)
• Stress Loading
• Splinting: (careful with splinting, they will become dependent on splint) depending on pt./level/symptoms
  
  • Static: 20 deg wrist extension, MP’s 70 deg of flex, IP’s 0
• Consider patient’s emotional, psychological state

Question 7

What are more OT treatments for CRPS?

Answer 7

Stress Loading Protocol- compression and distraction/ districfile?

• Scrub and Carry
  
  • The scrub exercise is performed in 3-minute sessions, 3 times a day. (Progress to 10/day)
    
    • Scrub: all fours, scrub board/floor, apply as much pressure as possible
    • Carry: weighted purse/briefcase, whenever standing or walking (1-5 lbs as tolerated, progressing to 10 min)

OT Treatment

Subacute/Chronic

• Increase ROM (A/PROM)
• Stretches
• CPM constant passive motion
• Splinting: dynamic to increase ROM
• Functional Activities