Complex Regional Pain Syndrome (CRPS)

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Complex Regional Pain Syndrome, or CRPS, is an acquired pain condition involving a limb subject to thermal or mechanical trauma. Usually the distal portion of the limb (hand or foot) is affected, with swelling and warmth accompanying the pain. Hypersensitivity to touch or other sensory modality, together with manifestations of autonomic dysfunction such as reddening or sweating, are often present as well. Early on in CRPS, the involved limb is either warm, swollen, and reddened (“warm” CRPS) or cold and dystrophic with skin atrophy (“cold” CRPS); with time warm CRPS can progress to cold CRPS. The point is that all these observations support the idea that the initiation, maintenance, and progression of CRPS is a combination of inflammatory, vasomotor, and neuroplastic processes.

The diagnosis of CRPS is based on the presence of the signs and symptoms above, accompanied by a temporal relationship between the condition and causative trauma. There is no specific diagnostic test for CRPS, and none is required; a careful history and examination is sufficient to rule out competing potential diagnoses. The treatment is non-specific and consists of physical therapy (e.g., exercise) to improve and normalize the blood supply to the affected limb as well as maintain mobility, various medications, and even psychotherapy, as there is often a substantial and even profound psychological component (dysphoria) accompanying the pain and impairment of the condition.

Medications now used to treat CRPS are all aimed at symptomatic and functional improvement; there is no cure. Medications used to manage seizures and depression have proven useful in some cases. Medications that inhibit bone resorption (i.e., bisphosphonates) are being researched as potential treatments, as there is some evidence for increased bone turn-over in limbs affected by CRPS. Some patients require surgery to sever the sympathetic nerve supply to the affected limb to obtain pain relief.

It is of interest that CRPS is most likely to occur in tissues where the muscle and overlying skin receive their blood supply from different vascular branches, suggesting the potential for differential oxygenation dynamics occurring at the microvascular level being ultimately causative in the formation and perpetuation of CRPS. In fact, the focus of “where” CRPS actually happens has shifted towards smaller and smaller scales, down to the tiniest capillaries. Disturbances of ischemia and reperfusion at this level, perhaps mediated by the potently vasoactive molecule NO (nitric oxide) may be responsible for the pathology observed at all levels at which the illness manifests. Research into treatments that target these tissues may hopefully one day offer new and effective therapies to CRPS sufferers.

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