Early Intervention Is Key for CRPS Treatment, Experts Say Rose Fox PAIN MEDICINE NEWS: ISSUE: AUGUST, 2007 | VOLUME: 5 NEW YORK-Complex regional pain syndrome (CRPS) is frequently misunderstood, misdiagnosed and mistreated. A panel of experts at the annual American Conference on Pain Medicine explained what is known about the origins and treatment of this condition. "If there's one take-home message that you get out of this lecture," said Joshua P. Prager, MD, MS, "it's that [CRPS] is not a disease of the extremity. This is a disease of the nervous system that manifests itself in the extremity. I can't overemphasize that. The number of patients who come to me because someone has tried to amputate a part of the body to make this go away is incredible to me. You can't cut it away and you can't kill nerves to make it go away because it is a central nervous system disorder," said Dr. Prager, director of the Center for the Rehabilitation of Pain Syndromes at the University of California, Los Angeles. Citing the seminal work of John Bonica, MD, Dr. Prager described the original "three stages" concept of CRPS: 1) the hyperemic phase, in which the affected extremity is tender and swollen; 2) the dystrophic phase, in which there is some atrophy and the extremity is cold to the touch; and 3) the atrophic phase, which has contracture, marked atrophy and abnormal growth of hair and nails. Daniel S. Bennett, MD, pointed out that CRPS is now considered to be a continuum rather than a staged disease. "The motor component actually can occur prior to the patient complaining of pain, and can then progress to a full dystonic state," said Dr. Bennett, medical director, Interventional Spine/Pain Management, Integrative Treatment Centers, Denver. "I've had a few patients like that, who came in with neuropathic pain and dystonia. Or they will come in with an arm or a leg that is so atrophied, with contraction deformities. This can be very, very rapid; you can see it as early as five weeks, or five years." Dr. Prager noted that although CRPS often stems from trauma, the two entities should be carefully differentiated. "There are several other local pathologies that can cause this disease: peripheral neuropathies, inflammatory and infectious disorders and vascular disorders," he said. "If you see motor changes, trophic changes and sweating, you don't get that with trauma but you do with CRPS. Women [develop CRPS] more than men; mean age at evaluation is 42 years; it usually starts unilateral in distal extremity. Causes include sprains and strains, post-surgical, fracture, contusion, but almost a quarter of cases have no known etiology." The goal of treatment is not complete resolution of pain but to give "the patients their lives back and to give them function once again," Dr. Prager said. "If we do a sympathetic block or give analgesics, it is to allow the patient to do physical therapy. The basic concept of this treatment protocol is physical therapy with pain management and psychological support as adjuvants. The important thing is to intervene early." Referencing the CRPS treatment paradigm proposed by Bennett and Cameron, Dr. Bennett said, "Unfortunately, with medications, about 34% to 36% of patients respond and of those, 50% are partial responders. We don't have much in the way of medication that is going to be very effective, because we don't have a great medication to restore blood flow. If you don't have good results in the first six months, then we recommend moving on to electrical stimulation, which is everything from the base of the brain down to the tailbone: nerve root, spinal cord and peripheral nerve." The Role of Spinal Cord Stimulation "All of us who practice in pain medicine and see patients with CRPS have found spinal cord stimulation [SCS] to be an effective therapy for some of our patients," said Peter S. Staats, MD, adjunct associate professor of anesthesiology and critical care at Johns Hopkins University, Baltimore. SCS, he said, "can stimulate the production of the inhibitory neurotransmitters GABA [g-aminobutyric acid], glycene and serotonin. It is also thought to turn off beta- hyperexcitability. It probably works in a variety of different ways." He added, "One of the advantages of SCS is that it's a reversible, nondestructive therapy. You can test the therapy before you put it in, as opposed to ablative therapies that are nonreversible." Dr. Staats noted that most of the literature on SCS is already outdated. "Today, it is very common for physicians to put in 16 contacts, which give 64 million different combinations of electrical stimulation that we can use," he said. It is now known that frequency of electric stimulation, amplitude, number of contact and spacing of contacts can determine treatment outcome, he said. "As we improve our technology and our ability to use electricity, it is likely that we will be able to stimulate and capture some nociceptive pains, but for right now, this is largely used for neuropathic pain. I consider CRPS one type of neuropathic pain and I think most people would agree with me on that."

Thanks for posting this Joan.

I have no doubt that early intervention is the key. I think early "mobility" with having the right pain control so one can be mobile....whatever is neccessary given the specific situation, is the best thing.

I think one of the problems with rsd is that depending on what set off the rsd, some actually can't be all that mobile. Speaking from my own experience, I recall having a broken leg/ dislocated ankle, and not being able to have your "normal" cast on while it healed. (after an op to set it and add hardware lol) etc.) Ergo, bed rest for me for six weeks etc. No chance of being mobile then. That darn rsd really got entrenched then I bet. About two months after that break and op, I went off to "physical therapy". (oh yes during that two months the med people in charge then were aware of rsd) Perhaps then those people didn't know about some stuff re rsd. In any case I was given hot baths vs cold/ice baths. ( uh huh) and it made me so much worse that other patients there were coming up to me and asking what the .... is going on here? Fast fwd: i left that place... saw an ortho in another city. Was told to keep up with the air pressure cast I now had ( a cast with air pumped in all around. Was not to put weight on it. ( darn hard crutching around for months with one foot and leg in the air). Then began great physio in the second city. Foot in warm water with electrodes of some sort applied to bottom of foot and then pulsing along it ( level could be adjusted etc). (is this like having an SCS only I had the electrical stimulation directly on my extremity?......) had all sorts of machines for movement with that foot/ leg too while trying to get it moving. Gentle manipulation. Caring medical people. Over time, a stationary bicycle; a treadmill; a bouncing trampoline; mirrors so I wouldn't lean to one side etc.; the list goes on. My time on any of them might have been anywhere from 3 min to 5 min. But basically I was not only learning to walk again but I was trying to figure out how to pace activity and cope with all pain that came from anything I did do. It was not easy. But my goal was to get out of having to use a wheelchair at home. And I did. So I can say that mobility does matter.

I'd like to be able to say that I went on to be back to pre-rsd. Unfortunately I was not. But I have managed to stay mobile for paced times each day . And I am very grateful that I had docs who got me to that point.

Thanks again Joan for posting an abstract dated this year.....

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