Complex Regional Pain Syndrome: Prevention, Assessment, Treatment

Why is complex regional pain syndrome so challenging? I think part of the debate is what really constitutes CRPS, because it’s really a difficult diagnosis.  You can see flagrant cases of it where you’ll get some atrophy and you’ll get color changes, temperature changes.  Typically diagnostic tests are not particularly helpful.  You might have negative EMG or EMG and never conduction testing, imaging studies, triphasic bone scan may be normal.  So I think making the diagnosis is very difficult.

I think that there’s very specific algorithm in treating complex regional pain syndrome as an acute presentation.  If it seems like, and smells like, and looks like, and feels like CRPS, then doing a series of nerve blocks along with activating physical therapy can be very effective.  Oftentimes people do not get that combination together or it gets diagnosed a year out or a year and a half out, which means that it tends to be more of a chronic condition at that point. But I think if you really get a really good pain physician who understands the dynamics of CRPS and works with the primary care physician, taking both a pharmacologic perspective, which is usually the use of antiepileptic drugs, in combination with restorative physical therapy and you catch it early enough, in many cases you can reverse the whole process.

Another thing that’s kind of new on the horizon in treating these types of refractory pain disorders such as CRPS and phantom limb pain is what’s called graded motor imagery. It comes out of work from Lorimer Moseley and David Butler, and involves a process of retraining the brain to decrease pain sensations. In my clinic, we had a patient who was a Vietnam vet with phantom limb pain for 40 or 50 years, and using this greater motor imagery he actually had about a 40 percent decrease in his pain.  It has a lot to do with laterality and left/right orientation.  You’ve probably seen these things with the mirror therapy that’s been effective, but those are the kind of cutting edge type of therapies that most people aren’t aware of, but I think have a very low iatrogenic risk.

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