Complex Regional Pain Syndrome (CRPS or RSD) is a hugely impacting condition that is often regarded as a neuropathic pain disorder that typically evolves following a trauma that in some cases can be minor. In addition to the pain, CRPS usually consists of vasomotor and sudomotor changes, trophic and motor disturbances, oedema and somatosensory changes.
Diagnostic Guidelines – click here
In simple terms, the limb is often guarded, oedematous, discoloured (reddened or mottled), features changes in hair, skin and nails, is difficult and painful to move and is extremely sensitive to light touch. Of course, the presentation is different from person to person but the common issues are with movement, control of movement, heightened sensation, an altered perception of the affected area, blood flow and tissue changes (skin, muscles etc.). There can also be some unusual experiences that are difficult to describe – see here.
When a limb is immobilised either as part of a post-operative plan or to allow tissues to heal, on removing the immobilisation device there are usually obvious changes. These include an increase in sensitivity to light touch, stiffness in the tissues, colour changes, swelling…..familiar?
There are similarities in the presentations that we can potentially learn from as the study below points out. Both are as a result of an injury although the context is very different–and this can make a huge difference. Each person who is diagnosed with CRPS has their own story that incudes prior experiences that ‘prime’ the nervous system to respond in the way it does at the moment of injury, for example previous painful problems and if they were managed successfully.
Thorough thinking about an individual’s situation includes understanding the pain mechanisms (e.g. neuropathic pain, neurogenic inflammation), how the condition is impacting and their coping ability. All of these must be addressed with a comprehensive physical-cognitive-emotional programme of care, recognising the multidimensional and multisystem (i.e. immune, endocrine, autonomic) nature of pain and relief.
Changes Resembling Complex Regional Pain Syndrome Following Surgery and Immobilization.
Pepper A, Li W, Kingery WS, Angst MS, Curtin CM, Clark JD.
Department of Anesthesia, Stanford University, Palo Alto, California.
The study of complex regional pain syndrome (CRPS) in humans is complicated by inhomogeneities in available study cohorts. We hoped to characterize early CRPS-like features in patients undergoing hand surgery. Forty-three patients were recruited from a hand surgery clinic that had elective surgeries followed by cast immobilization. On the day of cast removal, patients were assessed for vasomotor, sudomotor, and trophic changes, and edema and pain sensitization using quantitative sensory testing. Pain intensity was assessed at the time of cast removal and after 1 additional month, as was the nature of the pain using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS). Skin biopsies were harvested for the analysis of expression of inflammatory mediators. We identified vascular and trophic changes in the surgical hands of most patients. Increased sensitivity to punctate, pressure, and cold stimuli were observed commonly as well. Moreover, levels of IL-6, TNF-alpha, and the mast cell marker tryptase were elevated in the skin of hands ipsilateral to surgery. Moderate-to-severe pain persisted in the surgical hands for up to 1 month after cast removal. Exploratory analyses suggested interrelationships between the physical, quantitative sensory testing, and gene expression changes and pain-related outcomes. PERSPECTIVE: This study has identified CPRS-like features in the limbs of patients undergoing surgery followed by immobilization. Further studies using this population may be useful in refining our understanding of CRPS mechanisms and treatments for this condition.