ResolutionsRTK

Complex Regional Pain Syndrome

Sarah Lovick, B.Physiotheraphy (Hons)
Joanna Wall, B.Physiotheraphy
Consultants, Restore

Complex Regional Pain Syndrome (CRPS) is a chronic pain condition that is often poorly understood and a challenge to manage. Not only is the affected person faced with a range of symptoms, but the people around them including their treaters, family, employer and colleagues are often confused about this condition, how to manage it and how to support them.

CRPS is believed to be the result of dysfunction in the central or peripheral nervous systems. The key symptom of CRPS is continuous, intense pain that is disproportionate to the severity of the injury (if an injury has occurred).

CRPS was formerly known as reflex sympathetic dystrophy (RSD), Sudeck's atrophy, reflex neurovascular dystrophy (RND) or algoneurodystrophy. Type 1 CRPS occurs with no demonstratable nerve damage and Type 2 has evidence of obvious nerve damage.

CRPS most often affects one of the extremities and is also often accompanied by:

A "burning" pain;
Increased skin sensitivity;
Changes in skin temperature: warmer or cooler compared to the opposite extremity;
Changes in skin color: often blotchy, purple, pale, or red;
Changes in skin texture: shiny and thin, and sometimes excessively sweaty
Changes in nail and hair growth patterns;
Swelling and stiffness in affected joints;
Motor disability, with decreased ability to move the affected body part.

CRPS has a low prevalence, and more commonly effects the upper limb more than the lower limb, more often affects women rather than men (Sandroni et al 2003) and fractures tend to be the most common precipitating event.

Causes & Diagnosis

The medical profession has not established definitive causes for CRPS. “Physiological wind-up” and Central Nervous System sensitization are key processes that appear to be involved in the induction and maintenance of CPRS. Put simply, in these people it is likely that after the initial injury there becomes more chemical mediators that activate pain and inflammatory pathways and the receptors to these chemical mediators become more sensitive. Overall the pain and inflammatory responses are activated more easily and to a larger effect.

There is no specific test for CRPS and it is usually diagnosed through the observation of signs and symptoms. In all likelihood, CRPS does not have a single cause, but rather is the result of multiple causes that produce similar symptoms.

Treatment

There is no cure for CRPS so treatment is targeted at relieving painful symptoms so resumption of normal activity can occur. Treatment may combine physical therapy, psychotherapy, medication or surgery. Due to the complexity of CRPS a multi-disciplinary approach is best for achieving a good outcome. It is beneficial for the individual to maintain a good level of activity and strive for the resumption of a normal working life.

What does this all mean for return to work planning?

Resumption of activity is acknowledged as a key treatment strategy to assist in management of symptoms. Returning to work is therefore integral to this return to function, however careful consideration of the following needs to drive return to work planning:

Identification of suitable duties in line with injury and associated medical restrictions;
Clear injury management strategies incorporated into the return to work plan (e.g. rest breaks where icing / stretching / postural changes;
Close integration between return to work upgrades and treatment goals to ensure that functional gaps are targeted;
Education of key stakeholders to increase their awareness of the symptoms and impacts on function and prognosis.