Chronic Regional Pain Syndrome (CRPS), Reflex Sympathetic Dystrophy (RSD), Causalgia

CRPS often begins about 4-6 weeks after a significant limb injury or surgery. Invariably there is spontaneous or provoked regional pain in the involved extremity, swelling and vasomotor instability leading to Raynaud syndrome, Thoracic Outlet Syndrome (TOS), skin and hair changes, bone demineralization,

Pain is regional in that it does not follow in a specific nerve territory or dermatome. The sympathetic nervous system is affected in various ways, leading to abnormal sweating, vascular spasm and dilation, muscle and bone atrophy and skin changes. While mainly in a distal extremity, the pain can involve the entire extremity and spinal injuries. Abnormal spinal cord reflex patterns can also lead to involvement of the opposite arm or leg. Pain caused by involvement of the sympathetic nervous system is common to both Type I and Type II CRPS.

CRPS Type I is known as Reflex Sympathetic Dystrophy (RSD) is the most common, and does not have peripheral nerve injury that can be demonstrated on Electromyelography and Nerve Conduction Studies (EMG/NCS).

CRPS Type II is known as Causalgia and refers to the presence of peripheral nerve injury.

While osteopathic methods are good for chronic CRPS, best results are seen when therapy is started early.

After the inciting trauma and at the onset of CRPS, “warm” CRPS has increased skin temperature while “cold” CRPS presents with decreased skin temperature. The cause of CRPS is unknown. Proposed mechanisms include Central nervous system sensitization, spinal cord sensory reflex abnormalities, increased pain signaling, inflammation and pain producing neuropeptides. Genetic and autoimmune factors may also contribute to developing CRPS.

Pain can be debilitating. Normal activities such a grip can be painful in muscles and joints. pain can be variable, usually a continuous baseline of pain which can flair up, especially at night, with movement or position, temperature variations or stress. Sensation can be diminished to light touch and often described as burning, stinging, tearing or buzzing.

Strength is affected in the majority of people with CRPS. Loss of grip strength can lead to dropping things and difficulty with activities such as distance walking or climbing stairs. Swelling (edema) is common. muscle/tendon and ligament contractures can develop. Tremor and abnormal posture can develop. Skin color and skin temperature changes are common when having an exacerbation.

To diagnose CRPS a Bone Scan showing increased radiotracer uptake in joints distant from the trauma site might be useful but is not part of the clinical diagnostic criteria.

The Budapest consensus criteria for the clinical diagnosis of CRPS are:

Continuing pain, which is disproportionate to any inciting event.

For the clinical diagnosis of CRPS, the patient must report at least one symptom in three of the following four categories (the more stringent research criteria require at least one symptom in all four categories):

•Sensory: Reports of hyperesthesia and/or allodynia

•Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry

•Sudomotor/edema: Reports of edema and/or sweating changes and/or sweating asymmetry

•Motor/trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

For the clinical diagnosis of CRPS, the patient must display at least one sign at the time of evaluation in two of the four following categories (the more stringent research criteria require at least one sign in three of the four categories):

•Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or temperature sensation and/or deep somatic pressure and/or joint movement)

•Vasomotor: Evidence of temperature asymmetry (>1°C) and/or skin color changes and/or asymmetry

•Sudomotor/edema: Evidence of edema and/or sweating changes and/or sweating asymmetry

•Motor/trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

There is no other diagnosis that better explains the signs and symptoms.

Osteopathic treatment for CRPS includes myofasical release and joint mobilization, combined with active techniques where the patient provides the activating force by performing small, gentle back and forth movements. These active assisted techniques provide feedback mechanisms to help retrain dysfunctional reflex patterns. Active assisted and other techniques directly release pain triggers and help with healing and remodelling of injured tissue, while at the same time helping the brain make better connection with tissues in order to provide more integrated movement and less tension.