| One-Minute Clinician

Complex Regional Pain Syndrome: Primary Care Sees it First!

There are a lot of theories about CRPS. There are theories about glial cell involvement, or dysfunction of the autonomic nervous system. To my mind, there is a hormonal component because 80 percent of my patients are women. There’s a genetic component because I have seen 18 families where more than one member has the disease and frequently in the same limb, but we really don’t know enough. When you talk about exacerbating factors, way at the top of the list is stress. Lesser factors include infection, hormonal imbalances, including thyroid dysfunction, infection, weather/climate changes. In terms of recognizing CRPS, we’re looking for patients whose pain is disproportionate to the inciting event. We’re looking for pain that doesn’t match up to the diagnostic testing. We’re looking for pain that’s almost always burning, and we’re looking for people who have other symptoms such as gastroenterological or urinary or gynecologic, that just don’t seem to be explained by conventional reasons. A lot of times in medicine when we’re looking to understand patients with unconventional symptoms, it helps to work backwards. As Sherlock Holmes said, “When you eliminate the impossible, whatever remains, however improbable must be the answer.” There’s probably no better explanation than that if you know what it is not, it becomes a lot easier to know what it is.

Thermography to me is the best, if not the only true, diagnostic test for complex regional pain syndrome. We used to think 3D bone scans were diagnostic, but there are so many of them that don’t show the disease, that I don’t even do them anymore. Thermography is a non-invasive, non-contact way to measure the sympathetic function of the body. It measures the sensory portion of the nervous system as opposed to electrodiagnostic testing which measures the motor portion of this system. It’s simple to do. There’s no downside to it. It gives you what I call objective medical evidence in the form of a heat picture or thermogram, which is virtually impossible to “fake.”

Treatment for CRPS always begins with mobilization, get somebody moving. And even if someone presents in my office in a wheelchair, there are still ways to move. So, it’s always movement first. Next, we look at sympathetic blocks. We look at different kinds of medication, not necessarily for pain, but things that will affect the NMDA portion of the brain, like antiepileptic use off label, anti-inflammatories, muscle relaxants for muscle pain. I'm a big one for all natural, so I have everybody on probiotics because everybody that comes in has poor gut health between eating wrong, worrying, antibiotics, and all the things they’ve been through in their lives.  We can also engage physical and occupational therapy, and then ketamine, which is the best therapy for refractory CRPS. Our goal is to get people as better as we can, recognizing that even if they get to 70 percent tomorrow, that doesn’t mean that six months or two years from now, they’re not going to be 80 or 90 percent. I think the most important thing to leave the primary care physician with is to recognize that when you get to a point that you’ve done all you can for a patient, whether it’s CRPS or any other disease, It’s incumbent upon you as the family practitioner to say ‘I’ve done all I can; I need to refer you to someone.’ When simple becomes complex, it’s okay to say I don’t know, and I know somebody who does.

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