Thursday, November 28, 2019

Complex Regional Pain Syndrome (CRPS) - Symptoms, Causes and Treatment


Complex regional pain syndrome (CRPS) is a neurological disorder that causes chronic pain. This pain is often in the arms, hands, legs or feet. Symptoms on the affected area are as follows: Significant changes in temperature and color, severe burning pain, increased skin sensitivity. Symptoms can worsen over time and can spread to other parts of the body. The cause of complex regional pain syndrome is still unknown. In some cases, it can go away on its own, either temporarily or permanently. There is no cure for this syndrome. Treatment focuses on pain relief and may include anticonvulsant medications, physiotherapy, and psychotherapy.


Complex Regional Pain Syndrome
Complex regional pain syndrome - Types, symptoms, causes, diagnosis, and Treatment

Complex Regional Pain Syndrome (CRPS) - Symptoms, Causes and Treatment

What is Complex Regional Pain Syndrome (CRPS)?

Complex regional pain syndrome (CRPS) is a chronic pain condition and an uncommon neurological disorder. It causes severe pain in the arms, hands, legs or feet. Usually, this syndrome occurs after injury to the nerve or tissue in the affected area.
Complex regional pain syndrome is a condition that is still not fully understood, in which the patient experiences severe and persistent pain.
CRPS is also considered as a post-traumatic disorder characterized by a chronic, non-dermatomal distributed, sustained pain in the affected limb and associated with motor, sudomotor, vasomotor, sensory processing and trophic disturbances. Although most cases of this syndrome are caused by an injury, the pain is more severe and lasts longer than usual.
The pain is usually limited to one side, but sometimes it can spread to other parts of the body. The skin in the affected part of the body can become so sensitive that touch, mild impact or even a change in temperature can provoke severe pain.
The affected areas can also become swollen or stiff, or fluctuate in color or temperature.
Many cases improve gradually over time and may fully recover. However, some cases do not improve, and the patient suffers from pain for many years.



Types of Complex Regional Pain Syndrome

There are two types of Complex Regional Pain Syndrome; Complex Regional Pain Syndrome Type I (Reflex Sympathetic Dystrophy - RSD) and Complex Regional Pain Syndrome Type II (Causalgia)

Type I CRPS or Reflex Sympathetic Dystrophy (RSD) is a neurodegenerative disorder of variable clinical course characterized by lasting pain, swelling, and motor, sudomotor and vasomotor impairment of the extremities, usually in an arm or leg, and appears after an injury, stroke or even a heart attack.

Type II CRPS, also known as Causalgia, is a neurological disorder that can result in severe and long-term pain. CRPS II may appear after a bone fracture, surgery, or after a serious infection or trauma to a peripheral nerve. Peripheral nerves extend from the spine and brain to the extremities.

Stages of CRPS
Complex regional pain syndrome is rare and appears mainly in the extremities, characterized by pain, contraindicated pain (Allodynia), edema, discoloration and heat of the affected limb skin.
There are three clinical stages of complex regional pain syndrome:
1. Acute stage: The acute stage is characterized by severe pain, often of a burning nature, allodynia, edema, and the tendency of the affected palm to be cold or bluer than the healthy limb.
2. Subacute stage: If the process is not controlled in the acute stage, the condition can progress to the subacute stage. In this stage, the patient experiences persistent pain in extreme and stable edema that could be reversible with elevation during the acute stage. CRPS in the subacute stage can last up to 9 months.
3. Chronic stage: permanent with limb deformity and spinal muscular atrophy.


Symptoms of Complex Regional Pain Syndrome 

The symptoms of complex regional pain syndrome (CRPS) vary from person. to person Symptoms can also change from time to time. Their intensity may also change. The main symptom of complex regional pain syndrome is persistent severe pain in the affected area. This syndrome often affects the arms, legs, hands or feet.
Pain tends to increase over time rather than subside. Psychological distress can also increase pain. The pain often passes to the whole arm, or to the whole leg. It can also move to the other arm or leg. Other common symptoms of CRPS include:
  • Decreased ability to move the affected part of the body.
  • Swelling and stiffness in the joints in the affected area.
  • Changes in the way nails and hair grow.
  • Increased skin sensitivity.
  • Burning pain.

Some CRPS symptoms can also appear on the skin of the affected area. This includes changes in:

Skin Nature: The skin usually becomes matte and thin. The skin in the affected area can also be very sweating.
Heat: The affected area is hotter or colder compared to the same area on the opposite side.
Color: The skin often becomes spotted, purple, pale or red.
You should consult your doctor if you experience severe pain in one of your limbs so that moving or touching the limb is difficult. The more effective the treatment of composite regional pain syndrome is, the earlier it begins.

Causes of Complex Regional Pain Syndrome

As we mentioned above, there are two types of complex regional pain syndrome. Each type has a different reason. About 90% of patients have type I CRPS. This syndrome typically occurs after the patient passes into a disease or injury.

Physicians do not know precisely the cause of the appearance of complex regional pain syndrome. This syndrome may be caused by inflammation in the body after an injury, surgery, infective or ankle sprains, stroke or heart attack. It can be caused by the inability of the nerves in the body to work together properly. This syndrome can even be caused by a number of factors that lead to similar symptoms.

Complex regional pain syndrome is often caused by injury or trauma to the arm or leg. The disease or injury does not lead to direct nerve damage in the affected area. Type II CRPS occurs after the nerve itself is injured. The nerve damage may lead to symptoms of the syndrome.
It is likely that there is no single cause responsible for complex regional pain syndrome. Further studies are still needed to understand the syndrome



Diagnosis of Complex Regional Pain Syndrome

The exclusion of all other possible causes of the patient's symptoms leads to a diagnosis of complex regional pain syndrome. Neuropathies, nerve compression syndrome and central pain syndrome (CPS) can mimic the symptoms of complex regional pain syndrome.
Diagnosis is mainly done clinically, supported by typical changes in the three-stage bone scan and in advanced stages through an x-ray - bone mineral density (BMD) test to identify osteoporosis around the joints.
Complex regional pain syndrome symptoms may or may not be simultaneously present in a patient. So, the diagnosis of CRPS is often based on the patient's history. In addition, depending on the treatment and the patient's ability to cope with pain, atrophy patients are only slightly affected by the continued use of the affected limb. Some or all of these symptoms may extend to the opposite side.
Due to the potential impact on a person's life and the cost of disability and care, the diagnosis of complex regional pain syndrome must be made carefully, and further action should be taken after fully assessing the patient's condition.

Treatment of Complex Regional Pain Syndrome

There is no proven cure for complex regional pain syndrome, but early treatment can be able to relieve symptoms. In some cases, the symptoms can disappear for a period of time. Often a combination of processors is used. The doctor will develop a treatment plan based on the symptoms and how severe they are. 
If CRPS treatment is not provided in the acute phase, the hand becomes warmer and it is possible to have excessive sweating and changes in hair growth, changes on the surface of the skin and nails, and eventually a specific deformity.
The only way to improve the patient's condition is to move the limb. Patients who refrain from moving the sick limb because of pain will develop a vicious circle that aggravates the condition quickly. The treatment offered to patients combines natural physiotherapy, anticonvulsant medications for pain, and neurological, psychological, behavioral and cognitive therapy.

Pharmacotherapy - Drug therapy
There are several medications that can be used to treat complex regional pain syndrome. These include:

Anticonvulsants: Some anticonvulsant drugs can be effective in CRPS treatment, including: Acetazolamide, Carbamazepine, Clobazam, Clonazepam Diazepam, Ethosuximide, etc.It is also possible to control the pain caused by the affected nerve using these drugs. These drugs are also able to prevent complex regional pain syndrome.
Tricyclic antidepressants (TCAs): Tricyclic antidepressants are a class of medications that were originally prepared to treat depression, but like anticonvulsants, TCAs have been shown to be effective in the treatment of neuropathic pain. There is strong scientific evidence to support the use of tricyclic antidepressants (TCAs) in nerve pain. Although there is a lack of literature for the use of TCAs in CRPS, medications are generally used to manage complex regional pain syndrome. Amitriptyline and nortriptyline are the most commonly used Tricyclic antidepressants for the treatment of CRPS, although nortriptyline generally has fewer side effects.
Corticosteroids: Examples of Corticosteroids include Betamethasone, Prednisone, Prednisolone, Triamcinolone, Methylprednisolone, etc. This type of medicine relieves inflammation. Reducing inflammation in the affected area can make it easier to move the affected limb.
Other drug therapy options: Alternative options may include painkillers and anti-inflammatory agents, vasodilator agents, muscle relaxant agents, over-the-counter (OTC) drugs, hypnotic drugs and sometimes local anesthetic agents, including Stellate ganglion block to relieve pain in the hand, and Lumbar sympathetic block to relieve chronic leg and foot pain. Your doctor may also prescribe other pain medications if they are not enough. 

Note: All the drugs discussed here for CRPS treatment are for informational purposes only; we do not recommend these drugs for self-treatment. Therefore, do not try any type of medicines before consulting your doctor. Read the disclaimer page.

Physiotherapy 
Physiotherapy includes desensitization, deep heat therapy, deep massage, as well as potential exercises - passive and active exercises. 

Psychotherapy
Psychotherapy focuses on patient perception, cognitive coping, biofeedback education, muscle relaxation, and individual and group support therapy. 

Conclusion
Complex regional pain syndrome of type II shows similar clinical symptoms, but in addition to the obvious injury in one or more nerve in the limb. This syndrome responds less to previously described treatments. In those cases where conservative treatment or semiconservative treatment fails, there is the possibility of experimenting with electrical stimulation of the spinal cord (Spinal Cord Stimulation).


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