Written by: Lauren Sullivan, MS, OTR/L
VHSF Fellow 2023
As an occupational therapist working in hand therapy, I encounter a variety of diagnoses, surgeries, fractures, sprains, nerve compressions, and more. However, when a patient is diagnosed with Complex Regional Pain Syndrome (CRPS), it can present challenges in determining the appropriate treatments and management strategies, which has been my exerpience as a relatively new occupational therapist in this field. Managing CRPS can be daunting due to its unpredictable nature and its impact on functional and health – related quality of life (HRQOL).
Numerous questions arise when faced with a patient with a CRPS diagnosis: Where do you begin? What assessments should be conducted to better understand the diagnosis and the patient’s current quality of life? Which activities of daily living (ADLs), instrumental activities of daily living (IADLs), hobbies/lesiure activities, and work – related tasks are affected? What rehabilitation interventions and treatments are appropriate for CRPS?
Let’s explore the diagnosis of Complex Regional Pain Syndrome (CRPS) in more detail.
What is CRPS?
· “Chronic”
· “Pain out of proportion to the severity of the initial injury”
· “CRPS is uncommon, and cause isn’t clearly understood.”
· “Treatment is most effective when started early. In such cases, improvement and even remission are possible.”
Mayo Clinic (n.d.)
· “Is a clinical diagnosis that includes pain, autonomic dysfunction, trophic changes and functional impairments” (Koman et al., 2021).
Types of CRPS?
· “CRPS type 1: a noxious event without identifiable nerve injury is causative.”
· “CRPS type 2: an identifiable nerve injury exists.”
· “CRPS NOS (not otherwise specified).”
(Koman et al., 2021).
Who does CRPS affect?
· “Age at onset is most frequently between 30 and 55 years (mean, 40 years); however, individuals of any age may be affected.”
· “White women who smoke cigarettes are affected most frequently.”
· “Observed frequently (20% - 40%) of patient after fracture of the distal radius.”
(Koman et al., 2021).
Understanding the Potential Causes of CRPS?
· “An inflammatory or immune reaction in the peripheral or central nervous systems”
· “From nerve trauma injury that damages the sensory or autonomic nerve fibers – which transmits pain, itch, and temperature sensations.”
· “Most common injury associated with CRPS is a bone fracture (wrist fracture)”
· “A displaced or splintered bone or pressure from a tight cast can damage nerves.”
· “Surgery - a surgical incision, stiches or scarring can cause nerve injury.”
· “Sprains or strains when connected tissues are damaged, which can result in excessive movement of the joint, which in turn overstretches nearby nerves.”
· Burns, bruises, or cuts
· Periods of prolonged immobilization
(Cleveland Clinic, 2022)
Signs & Symptoms?
The cardinal feature of CRPS is severe and persistency pain which often exceeds the expected level based on the initial injury, describing it as “burning, throbbing, tearing, cutting, searing, shooting and aching” (Koman et al., 2021). Other symptoms of CRPS that can be present are:
· Trophic changes, which includes edema/swelling, changes in skin color ranging from white and blotchy to red or blue, temperature, or texture, rapid or atrophy of the hair and nail growth, limited range of motion, muscle weakness, altered sensation and stiffness and decreased function (Koman et al., 2021).
Diagnosis and Testing
Due to the unpredictable nature of this diagnosis and no specific tests to diagnose CRPS, it is typically based on clinical findings, patient’s medical history, physical examination, and signs & symptoms. Some tests that a healthcare provider may request are:
· Ultrasound
· Magnetic resonance imaging (MRI)
· Electromyography (EMG)
· Radiographs
(Koman et al., 2021).
Evaluation of CRPS at Therapy Level
Per Packerman and Holly, “early recognition is critical for better outcomes. Therefore, evaluation of a patient with symptoms of or a confirmed diagnosis of CRPS should incorporate a combination of a top – down and bottom – up lenses” (2021).
What should the evaluation consist of?
· Establishing a relationship built on open, honest, and clear communication is crucial between the therapist and patient; we are not finding the “cause” of the pain but identifying potential factors that can contribute to the pain.
· Utilizing the Budapest clinical criteria, which is a 16 – item CRPS severity scale (CSS)
· Documenting observable and objective measurements, if appropriate (i.e. AROM, PROM grip strength, allodynia, autonomic and vasomotor changes, motor function and sudomotor and trophic changes)
· Self – report measures/questionnaires of participation of daily activities and role participation (i.e. DASH, PRW/HEP)
· Self-reported Pain Assessments
Short Form of the McGill Pain Questionnaire, Volume 2
painDETECT Questionnaire
Pain-QuILT
Brief Pain Inventory
(Packerman & Holly, 2021)
“Bottom – up” vs “Top – down” Approach for Treatment? What should you do as the therapist?
The goal of treatment is increasing functional ability to participate in activities of daily living and decrease pain. Per “Packerman & Holly””, a combination of a “bottom – up” and “top – down” approaches is the optimal rehabilitation strategy to assist in comprehensive pain and symptom management (2021).
· Bottom – up Approaches to address the signs and symptoms. Inflammation
Manual lymph drainage techniques (HEP of self-massage and therapist hands – on treatment)/light compression garments
Kinesio taping for lymphatic drainage.
Low – level laser
Neuromuscular Electrical stimulation
Whirlpool baths
Contrast baths.
Fludiotherapy
o Prevention of vasoconstriction and hypoxia
Vitamin C
Early motion at adjacent joints, monitoring of casting, and healthy eating.
o Pain and painful somatosensory disturbances
Acupuncture
TENS
Tactile discrimination training program and with mirror visual feedback
Desensitization applied to areas adjacent to the pain that may lack normal sensory function.
o Stiffness
PROM to be utilized only if the signs and symptoms are stabilized and to improve functional use of the hand.
Joint mobilizations
Use of Static progressive orthoses with prolonged and uniform gentle pressure for joint contractures and soft tissue limitations with functional implications
o Custom vs over the counter orthoses
Superficial heat (paraffin baths)
(Packerman & Holly, 2021)
· Top – down Approaches to address the person and systems.
“The goal of a top – down approach is to reduce pain, preserve or restore function, and enable patients to manage their condition and improve their quality of life” (Packerman & Holly, 2021)
o Graded Motor Imagery (GMI) is the gold standards of CRPS rehabilitation. This includes three stages:
1. Laterality Discrimination is to be able to distinguish between left and right hand or shoulder by viewing images of the part of the body affected by CRPS. (i.e. apps – Recognize, Orientate – Pain Management, creating your own images through Google Images and PowerPoint)
2. Motor Imagery is to imagine using the affected limb without actually moving it.
3. Mirror therapy is the approach of tricking the brain to move the affected UE limb without producing any CRPS signs and symptoms utilizing a mirror.
(Packerman & Holly, 2021)
Conclusion
When managing a patient diagnosed with Complex Regional Pain Syndrome (CRPS), it is crucial to determine a personalized and effective treatment plan based on the individual’s specific needs, as these can vary significantly from person to person. Drawing from my experience, I encountered four CRPS cases, each displaying similar yet distinct signs and symptoms, often stemming from various causes such as surgery, trauma, fractures, or ill – fitting cast/brace.
Presently, one of my patients has successfully attained her functional goals, experiencing CRPS remission and improved daily functioning, leading to her discharge from therapy services. However, I continue to work with three other patients on my caseload, each grappling with diverse symptoms and challenged in performing daily tasks. The dynamic nature of CRPS means that the condition can fluctuate on a daily or weekly basis.
Identifying the most suitable course of treatment tailored to each individual’s needs requires time and collaboration with orthopedic doctors, pain management specialists, and other healthcare providers. It is important for both therapists and patients to recognize that addressing CRPS is not a quick or straightforward process; it may take weeks to months of concerted efforts to find the optimal treatment approach.
When working with individuals facing one of the most challenging periods in their lives, our role in hand therapy is to deliver personalized care aimed at restoring function and enhancing overall quality of life. The journey involves ongoing collaborating with the patient and a multidisplinary healthcare team to navigate the complexities of CRPS and achieve positive outcomes.
Sources:
Cleveland Clinic (2022). Complex regional pain syndrome (CRPS). Retrieved from https://my.clevelandclinic.org/health/diseases/12085-complex-regional-pain-syndrome-crps#overview
Koman, A., McBride, E., Patterson Smith, B., Smith, T. Complex Regional Pain Syndrome: Type 1 & Type 2. In: Skirvin, Osterman, Fedorczyk, Amadio, Feldscher, and Shin (eds). Rehabiliation of the Hand and Upper Extremity. 7th ed. Philadelphia: Elsevier, 2021, pp 1368 – 1377. Ch. 97
Mayo Clinic (n.d.). Complex regional pain syndrome. Retrived from
Noigroup. (2016). Recognise. (Version 1.6) [Mobile App]. App Store. https://apps.apple.com/us/app/recognise/id1081707515
Packerman, T., Holly, J. Therapist’s Management of Complex Regional Pain Syndrome. In: Skirvin, Osterman, Fedorczyk, Amadio, Feldscher, and Shin (eds). Rehabiliation of the Hand and Upper Extremity. 7th ed. Philadelphia: Elsevier, 2021, pp 1378 – 1392. Ch. 98
Reflex Pain Management Ltd. (2011). Orientate – Pain Management. (Version 1.8.0) [Mobile App]. App Store. https://apps.apple.com/us/app/orientate-pain-management/id479540062