Complex regional pain syndrome
Introduction
Complex regional pain syndrome (CRPS) - one type of which was formerly known as reflex sympathetic dystrophy syndrome - is an uncommon, chronic condition that usually affects your arm or leg. Rarely, the disease can affect other parts of your body. You may experience intense burning or aching pain along with swelling, skin discoloration, altered temperature, abnormal sweating and hypersensitivity in the affected area.
The nature of CRPS is puzzling, and the cause isn't clearly understood.
Women are more likely to be affected by CRPS than men are. The condition is most common in people between the ages of 40 and 60, but it can occur at any age. Treatment is most effective when started early in the course of the syndrome.
Signs and symptoms
CRPS occurs in two types, with similar signs and symptoms but different causes:
Type I. Previously known as reflex sympathetic dystrophy syndrome, this type occurs after an illness or injury that didn't directly damage the nerves in your affected limb.
Type II. Once referred to as causalgia, this type follows a distinct nerve injury. Signs and symptoms of both types of CRPS vary in severity and duration.
The main symptom of CRPS is intense pain, often described as "burning." Additional signs and symptoms include:
Skin sensitivity.
Changes in skin temperature, color and texture. At times your skin may be sweaty; at other times it may be cold. Skin color can range from white and mottled to red or blue. Skin may become tender, thin or shiny in the affected area.
Changes in hair and nail growth.
Joint stiffness, swelling and damage.
Muscle spasms, weakness and loss (atrophy).
Decreased ability to move the affected body part.
Causes
Complex regional pain syndrome may result from disturbances in the sympathetic nervous system, the part of the nervous system that controls blood flow and your sweat glands. This syndrome commonly follows an acute problem.
Many cases of CRPS occur after a forceful trauma to an arm or a leg, such as a gunshot wound or shrapnel blast. Other major and minor traumas - surgery, heart attacks, infections, fractures and even sprained ankles - also can lead to CRPS. It's not well understood why these injuries sometimes trigger CRPS.
The syndrome was first described after the Civil War when soldiers continued to report severe pain after their wounds had healed. It was often referred to as "hot pain" during that period.
When to seek medical advice
If you experience constant, severe pain that affects a single limb and makes touching or movement of the limb seem intolerable, see your doctor to determine the cause. It's important to treat CRPS early.
Screening and diagnosis
Your doctor may base a diagnosis of CRPS on:
Review of your medical history. The onset of CRPS symptoms can often be traced back to an accident, illness or injury.
Physical examination. An examination of your skin, muscles and joints may reveal information about the source of your tenderness and pain. There may be changes in the normal texture and color of your skin, and you may have problems with range of motion of one or more of your joints.
Bone scan. A radioactive substance injected into your veins permits viewing of your bones with a special camera. This procedure may show increased circulation to the joints in the affected area.
Sympathetic nervous system tests. These tests look for disturbances in your sympathetic nervous system. For example, thermography measures the skin temperature and blood flow of your affected and unaffected limbs. Other tests can measure the amount of sweat on both limbs. Dissimilar results can indicate CRPS.
X-rays. Loss of minerals from your bones may show up on an X-ray in later stages of the disease.
Complications
If CRPS isn't diagnosed and treated at an early stage, the disease may progress to more disabling signs and symptoms. If you avoid moving an arm or a leg because of pain, or if you have trouble moving a limb because of stiffness, your skin and muscles may begin wasting (atrophy). You may also experience tightening of your muscles as they lose their tone. This may lead to a condition in which your hand and fingers or your foot and toes contract into a fixed position.
The illness may also spread from its source to elsewhere in your body in these patterns:
Continuity type. The symptoms may migrate from the initial site of the pain - for example, from your hand - to your shoulder, trunk and face, affecting a quadrant of your body.
Mirror-image type. The symptoms may spread from one limb to the opposite limb.
Independent type. Sometimes, the symptoms may leap to a distant part of your body.
Treatment
Dramatic improvement and even remission of CRPS is possible if treatment begins within a few months of your first symptoms. Treatment options include:
Medications. Doctors use many types of medications to treat the symptoms of CRPS. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve) may ease pain and inflammation. In some cases, doctors may recommend prescription medications. For example, antidepressants, such as duloxetine (Cymbalta), and anticonvulsants, such as gabapentin (Neurontin), are used to treat pain that originates from a damaged nerve (neuropathic pain). Corticosteroids, such as prednisone, may reduce inflammation.
Your doctor may also have you take bone-loss medications, such as risedronate (Actonel) and calcitonin (Miacalcin). Opioid medications may be another option. Taken in appropriate doses, they may provide acceptable control of pain. However, they may not be appropriate for people who have a history of substance abuse or lung disease.
Some pain medications, such as COX-2 inhibitors (Celebrex), may increase your risk of heart attack and stroke. It's wise to discuss your individual risk profile with your doctor.
Applying heat and cold. Applying cold may relieve swelling and sweating. If the affected area is cool, applying heat may offer relief.
Physical therapy. Gentle, guided exercising of the affected limbs may improve range of motion and strength. The earlier the disease is diagnosed, the more effective exercises may be.
Sympathetic nerve-blocking medication. Injection of an anesthetic to block pain fibers in your affected nerves may relieve pain in some people.
Transcutaneous electrical nerve stimulation (TENS). Chronic pain is sometimes eased by applying electrical impulses to nerve endings.
Biofeedback. In some cases, learning biofeedback techniques may help. In biofeedback, you learn to become more aware of your body so that you can relax your body and relieve symptoms of pain.
Spinal cord stimulation. Your doctor inserts tiny electrodes along your spinal cord. A small electrical current delivered to the spinal cord sometimes results in pain relief.
Coping skills
Living with a chronic, painful condition can be challenging, especially when - as is often the case with CRPS - your friends and family don't believe you could be feeling as much pain as you describe. Share information from reliable sources about CRPS with those close to you to help them understand what you're experiencing.
Take care of your physical and mental health by following these suggestions:
Maintain normal daily activities as best you can.
Pace yourself and be sure to get the rest that you need.
Stay connected with friends and family.
Continue to pursue hobbies that you enjoy and are able to do.
If CRPS makes it difficult for you to do things you enjoy, ask your doctor about ways to get around the obstacles.
Keep in mind that your physical health can directly affect your mental health. Denial, anger and frustration are common with chronic illnesses.
At times, you may need more tools to deal with your emotions. Professionals such as therapists or behavioral psychologists may be able to help you put things in perspective. They can also teach you coping skills that may help you, including relaxation techniques.
Sometimes, joining a support group, where you can share experiences and feelings with other people, is a good approach. Ask your doctor what support groups are available in your community.
