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Pathology
The two main characteristics seen in patients with CRPS are Allodynia and Hyperalgesia. Other symptoms seen are
swelling, skin color changes, change in hair growth, muscle atrophy, and limited range of motion. Allodynia is defined as
pain produced by a stimulus that is not usually painful (an example of this would be wind touching your skin and causing
pain). In Hyperalgesia, a normally painful stimulus causes much more irritation and pain than would be typically
produced.
The CRPS effects of allodynia and hyperalgesia are thought to be a development involving both the peripheral nervous
system (PNS) and the central nervous system (CNS). Local tissue injury and inflammation activate the PNS, which sends
signals through the spinal cord and to the brain. There is an increase in the excitability of neurons within the CNS, so that
normal inputs from the PNS begin to produce abnormal responses. Low-threshold sensory fibers activated by light touch
excites neurons in the spinal cord that normally only respond to noxious (painful), or more severe, stimuli. As a result, an
input that would normally produce a harmless sensation now produces significant pain.
CRPS is most frequently seen after trauma to an arm or leg. Major traumas including car accidents, penetrating wounds,
and crush injuries. Other traumas can include surgery, infection, and fractures; all of which can lead to complex regional
pain syndrome.
Two types with similar signs and symptoms, but different causes classify complex regional pain syndrome:
Type I - CRPS I is a condition of persistent pain and swelling that frequently occurs because of trauma to an area and
produces vasomotor disorders (Kandi 2007). This is the most common form.
Type II – CRPS II is produced after a direct and specific nerve injury and is much less common.
Diagnosis
Prospective studies confirmed an incidence of >10% incidence of CRPS developing in patients after distal radial fractures
(Schurmann 2007). Because this disease can be rare, if anyone is suspected of suffering from CRPS it is necessary to be
evaluated immediately by a pain physician. Your physician may perform a physical examination demonstrating
tenderness over certain areas as well as assessing limitations in movement. The doctor will evaluate the extent of your
restricted movements, the amount of pain produced, and the your sensory function. Your physician may also order
radiological imaging such as X-Ray, CT scan, MRI, or bone scan depending on their clinical suspicion and the history
obtained.
Treatment
• Sympathetic Nerve Blocks - The procedure involves inserting a small fine needle through the skin to the origins of
the sympathetic nervous system. When the nerves are blocked, pain relief can be dramatic for some individuals.
Procedures that focus on the face and upper extremities include the Stellate Ganglion Block and Brachial Plexus Nerve
Block. Lumbar Sympathetic Nerve Blocks are commonly performed for CRPS in the lower extremities.
• Infusions Techniques- The procedure involves inserting a small catheter through a needle into the epidural space
or directly next to affected nerves. Local anesthetic and other medicines are often given through the catheter for
extended time periods. When the nerves are blocked continuously with an infusion, pain relief can be dramatic and long
lasting.
• Spinal Cord Stimulation - This method involves tiny electrodes being placed within the epidural space close to the
spinal cord. The electrodes release a small electrical current to the spinal cord that inhibits pain transmission causing
pain relief. In a recent study, ten consecutive active duty United States military personnel with newly diagnosed complex
regional pain syndrome underwent early intervention with spinal cord stimulation with favorable results, including
decreased pain scores and decreased opioid intake (Verdolin 2007).
• Peripheral Nerve Stimulation - This method involves tiny electrodes being placed close to the affected nerves. The
electrodes release a small electrical current that inhibits pain transmission and causes pain relief.
• Medical management - of a patient with CRPS is important and common pharmacologic treatments that are used are
membrane stabilizing drugs, NSAIDs, opiate like medications.
• Physical therapy - In order to decrease or prevent functional limitations, physical therapy and occupational therapy
are recommended as well as medical treatments (Perez 2007). Physical therapy focuses on exercising the affected limbs,
improving range of motion and strength.
• Biofeedback - patients learn to have a better awareness and familiarity with their body. As they learn to relax their
body, pain relief is obtained. The psychological component of treatment can work with medical therapies to improve
function and decrease the severity of the disease (Breuhl 2006).
• Others - Living with a chronic pain condition can be extremely difficult. People with CRPS have an exceptionally
difficult time because others do not understand the amount of pain that they experience. Arizona Pain Specialists are
aware of the emotional hardship that you face and can help you relax and de-stress by offering you coping techniques.
Some of the methods they offer include therapeutic acupuncture, massage, group therapy, and even prayer.
Dramatic improvements and even remission of complex regional pain syndrome are possible. The sooner treatment is
initiated, the more likely dramatic improvements are obtained. Recently, the use of regional anesthetic and nerve
stimulating techniques have also been found to be successful in treating CRPS (Perez 2007).
Articles
Clinical practice guideline 'Complex regional pain syndrome type I Perez RS, Zollinger PE, Dijkstra PU, Thomassen-
Hilgersom IL, Zuurmond WW, Rosenbrand CJ, Geertzen JH. Ned Tijdschr Geneeskd. 2007 Jul 28;151(30):1674-9 PMID:
17725255
Early diagnosis in post-traumatic complex regional pain syndrome Schürmann M, Gradl G, Rommel O. Orthopedics. 2007
Jun;30(6):450-6 PMID: 17598489
Clinical presentation of cutaneous manifestations in complex regional pain syndrome (type 1). Kandi B, Kaya A, Turgut D,
Ozgocmen S, Cicek D. Skinmed. 2007 May-Jun;6(3):118-21 PMID: 17478989
Ten consecutive cases of complex regional pain syndrome of less than 12 months duration in active duty United States
military personnel treated with spinal cord stimulation. Verdolin MH, Stedje-Larsen ET, Hickey AH. Anesth Analg. 2007 Jun;
104(6):1557-60, table of contents PMID: 17513657
Psychological and behavioral aspects of complex regional pain syndrome management. Bruehl S, Chung OY. Clin J Pain.
2006 Jun;22(5):430-7 PMID: 16772797
The two main characteristics seen in patients with CRPS are Allodynia and Hyperalgesia. Other symptoms seen are
swelling, skin color changes, change in hair growth, muscle atrophy, and limited range of motion. Allodynia is defined as
pain produced by a stimulus that is not usually painful (an example of this would be wind touching your skin and causing
pain). In Hyperalgesia, a normally painful stimulus causes much more irritation and pain than would be typically
produced.
The CRPS effects of allodynia and hyperalgesia are thought to be a development involving both the peripheral nervous
system (PNS) and the central nervous system (CNS). Local tissue injury and inflammation activate the PNS, which sends
signals through the spinal cord and to the brain. There is an increase in the excitability of neurons within the CNS, so that
normal inputs from the PNS begin to produce abnormal responses. Low-threshold sensory fibers activated by light touch
excites neurons in the spinal cord that normally only respond to noxious (painful), or more severe, stimuli. As a result, an
input that would normally produce a harmless sensation now produces significant pain.
CRPS is most frequently seen after trauma to an arm or leg. Major traumas including car accidents, penetrating wounds,
and crush injuries. Other traumas can include surgery, infection, and fractures; all of which can lead to complex regional
pain syndrome.
Two types with similar signs and symptoms, but different causes classify complex regional pain syndrome:
Type I - CRPS I is a condition of persistent pain and swelling that frequently occurs because of trauma to an area and
produces vasomotor disorders (Kandi 2007). This is the most common form.
Type II – CRPS II is produced after a direct and specific nerve injury and is much less common.
Diagnosis
Prospective studies confirmed an incidence of >10% incidence of CRPS developing in patients after distal radial fractures
(Schurmann 2007). Because this disease can be rare, if anyone is suspected of suffering from CRPS it is necessary to be
evaluated immediately by a pain physician. Your physician may perform a physical examination demonstrating
tenderness over certain areas as well as assessing limitations in movement. The doctor will evaluate the extent of your
restricted movements, the amount of pain produced, and the your sensory function. Your physician may also order
radiological imaging such as X-Ray, CT scan, MRI, or bone scan depending on their clinical suspicion and the history
obtained.
Treatment
• Sympathetic Nerve Blocks - The procedure involves inserting a small fine needle through the skin to the origins of
the sympathetic nervous system. When the nerves are blocked, pain relief can be dramatic for some individuals.
Procedures that focus on the face and upper extremities include the Stellate Ganglion Block and Brachial Plexus Nerve
Block. Lumbar Sympathetic Nerve Blocks are commonly performed for CRPS in the lower extremities.
• Infusions Techniques- The procedure involves inserting a small catheter through a needle into the epidural space
or directly next to affected nerves. Local anesthetic and other medicines are often given through the catheter for
extended time periods. When the nerves are blocked continuously with an infusion, pain relief can be dramatic and long
lasting.
• Spinal Cord Stimulation - This method involves tiny electrodes being placed within the epidural space close to the
spinal cord. The electrodes release a small electrical current to the spinal cord that inhibits pain transmission causing
pain relief. In a recent study, ten consecutive active duty United States military personnel with newly diagnosed complex
regional pain syndrome underwent early intervention with spinal cord stimulation with favorable results, including
decreased pain scores and decreased opioid intake (Verdolin 2007).
• Peripheral Nerve Stimulation - This method involves tiny electrodes being placed close to the affected nerves. The
electrodes release a small electrical current that inhibits pain transmission and causes pain relief.
• Medical management - of a patient with CRPS is important and common pharmacologic treatments that are used are
membrane stabilizing drugs, NSAIDs, opiate like medications.
• Physical therapy - In order to decrease or prevent functional limitations, physical therapy and occupational therapy
are recommended as well as medical treatments (Perez 2007). Physical therapy focuses on exercising the affected limbs,
improving range of motion and strength.
• Biofeedback - patients learn to have a better awareness and familiarity with their body. As they learn to relax their
body, pain relief is obtained. The psychological component of treatment can work with medical therapies to improve
function and decrease the severity of the disease (Breuhl 2006).
• Others - Living with a chronic pain condition can be extremely difficult. People with CRPS have an exceptionally
difficult time because others do not understand the amount of pain that they experience. Arizona Pain Specialists are
aware of the emotional hardship that you face and can help you relax and de-stress by offering you coping techniques.
Some of the methods they offer include therapeutic acupuncture, massage, group therapy, and even prayer.
Dramatic improvements and even remission of complex regional pain syndrome are possible. The sooner treatment is
initiated, the more likely dramatic improvements are obtained. Recently, the use of regional anesthetic and nerve
stimulating techniques have also been found to be successful in treating CRPS (Perez 2007).
Articles
Clinical practice guideline 'Complex regional pain syndrome type I Perez RS, Zollinger PE, Dijkstra PU, Thomassen-
Hilgersom IL, Zuurmond WW, Rosenbrand CJ, Geertzen JH. Ned Tijdschr Geneeskd. 2007 Jul 28;151(30):1674-9 PMID:
17725255
Early diagnosis in post-traumatic complex regional pain syndrome Schürmann M, Gradl G, Rommel O. Orthopedics. 2007
Jun;30(6):450-6 PMID: 17598489
Clinical presentation of cutaneous manifestations in complex regional pain syndrome (type 1). Kandi B, Kaya A, Turgut D,
Ozgocmen S, Cicek D. Skinmed. 2007 May-Jun;6(3):118-21 PMID: 17478989
Ten consecutive cases of complex regional pain syndrome of less than 12 months duration in active duty United States
military personnel treated with spinal cord stimulation. Verdolin MH, Stedje-Larsen ET, Hickey AH. Anesth Analg. 2007 Jun;
104(6):1557-60, table of contents PMID: 17513657
Psychological and behavioral aspects of complex regional pain syndrome management. Bruehl S, Chung OY. Clin J Pain.
2006 Jun;22(5):430-7 PMID: 16772797
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Complex Regional Pain Syndrome (CRPS)
by Nicole Berardoni M.D, Paul Lynch M.D, and Tory McJunkin M.D
Complex regional pain syndrome (CRPS) formerly known as Reflex
Sympathetic Dystrophy (RSD), is a chronic pain and sensory
condition that typically affects the upper and lower extremities
(arms and legs). Women are more likely to be affected than men
and the disease is most common between the ages of 40-60.
by Nicole Berardoni M.D, Paul Lynch M.D, and Tory McJunkin M.D
Complex regional pain syndrome (CRPS) formerly known as Reflex
Sympathetic Dystrophy (RSD), is a chronic pain and sensory
condition that typically affects the upper and lower extremities
(arms and legs). Women are more likely to be affected than men
and the disease is most common between the ages of 40-60.
At Arizona Pain Specialists we are a center of
excellence for CRPS, offering treatments not
found anywhere else in the valley.
excellence for CRPS, offering treatments not
found anywhere else in the valley.
Book I - Pain Syndromes
Chapter 1 Low Back Pain
Chapter 2 Neck Pain
Chapter 3 Cancer Pain
Chapter 4 Headaches
Chapter 5 Spinal Stenosis
Chapter 6 Sciatica
Chapter 7 Arthritis
Chapter 8 Fibromyalgia
Chapter 9 Motor Vehicle Injuries
Chapter 10 Complex Regional Pain
Syndrome
Chapter 11 Vertebral Body
Fractures
Chapter 12 Hip and Leg Pain
Chapter 13 Diabetic Peripheral
Neuropathy
Book II - Interventional Procedures
Chapter 14 Epidural Steroid
Injection
Chapter 15 Facet Injections/Medial
Branch Blocks
Chapter 16 Radiofrequency Ablation
Chapter 17 Spinal Cord Stimulator
Implants
Chapter 18 IntraDiscal
Electrothermal Therapy (IDET)
Chapter 19
Vertebroplasty/Kyphoplasty
Chapter 20 Discography
Chapter 21 Percutaneous
Discectomy
Chapter 22 Occipital Nerve Block
Chapter 23 Sympathetic Block
Chapter 24 Stellate Ganglion Block
Chapter 25 Intrathecal Pump
Implants
Chapter 26 Caudal Steroid Injection
Chapter 27 Adhesiolysis
Chapter 28 Cervical Steroid
Injection
Chapter 29 Sacroiliac Joint
Injections
Chapter 30 Celiac Plexus Block
Chapter 31 Head and Neck
Procedures
Chapter 32 Joint Injections
Chapter 33 Continuous Catheter
Nerve Blocks
Chapter 34 Peripheral Nerve
Stimulation/Field Stimulation
Chapter 35 Disc Denervation
Book III Other Treatments
Chapter 36 Medication Management
Chapter 37 Acupuncture
Chapter 38 Prolotherapy
Chapter 39 Botox
Chapter 40 Massage
Chapter 41 Alternative and
Complementary Medicines
Chapter 42 Exercise and Nutrition
Counseling
Chapter 43 Prayer
Chapter 44 Cognitive Behavioral
Therapy
Chapter 45 Group Therapy
Chapter 46 Biofeedback
Chapter 47 Chiropractic
Manipulations
Chapter 48 Vitamin Supplements
Chapter 49 Customized
Pharmaceutical Formulations
Chapter 50 Hormone Therapy
Frequently Asked Questions
Chapter 1 Low Back Pain
Chapter 2 Neck Pain
Chapter 3 Cancer Pain
Chapter 4 Headaches
Chapter 5 Spinal Stenosis
Chapter 6 Sciatica
Chapter 7 Arthritis
Chapter 8 Fibromyalgia
Chapter 9 Motor Vehicle Injuries
Chapter 10 Complex Regional Pain
Syndrome
Chapter 11 Vertebral Body
Fractures
Chapter 12 Hip and Leg Pain
Chapter 13 Diabetic Peripheral
Neuropathy
Book II - Interventional Procedures
Chapter 14 Epidural Steroid
Injection
Chapter 15 Facet Injections/Medial
Branch Blocks
Chapter 16 Radiofrequency Ablation
Chapter 17 Spinal Cord Stimulator
Implants
Chapter 18 IntraDiscal
Electrothermal Therapy (IDET)
Chapter 19
Vertebroplasty/Kyphoplasty
Chapter 20 Discography
Chapter 21 Percutaneous
Discectomy
Chapter 22 Occipital Nerve Block
Chapter 23 Sympathetic Block
Chapter 24 Stellate Ganglion Block
Chapter 25 Intrathecal Pump
Implants
Chapter 26 Caudal Steroid Injection
Chapter 27 Adhesiolysis
Chapter 28 Cervical Steroid
Injection
Chapter 29 Sacroiliac Joint
Injections
Chapter 30 Celiac Plexus Block
Chapter 31 Head and Neck
Procedures
Chapter 32 Joint Injections
Chapter 33 Continuous Catheter
Nerve Blocks
Chapter 34 Peripheral Nerve
Stimulation/Field Stimulation
Chapter 35 Disc Denervation
Book III Other Treatments
Chapter 36 Medication Management
Chapter 37 Acupuncture
Chapter 38 Prolotherapy
Chapter 39 Botox
Chapter 40 Massage
Chapter 41 Alternative and
Complementary Medicines
Chapter 42 Exercise and Nutrition
Counseling
Chapter 43 Prayer
Chapter 44 Cognitive Behavioral
Therapy
Chapter 45 Group Therapy
Chapter 46 Biofeedback
Chapter 47 Chiropractic
Manipulations
Chapter 48 Vitamin Supplements
Chapter 49 Customized
Pharmaceutical Formulations
Chapter 50 Hormone Therapy
Frequently Asked Questions