Treating and rehabilitating a patient with the pain Jane describes are among the most difficult challenges facing pain management specialists and physical and occupational therapists. Typically, the CRPS patient has already been to many health care providers but still has severe pain that’s difficult to manage. As the pain continues, functionality in the affected limb decreases, and the limb may atrophy or permanently contract. The goal of treatment and rehabilitation is to return the patient to the best possible functional level and the lowest possible pain level.

What is CRPS?

CRPS, a neuropathic pain syndrome, most commonly occurs in an arm or a leg, but it can spread to other areas, including from arm to arm and leg to leg. CRPS occurs predominantly in women, and the average age of a CRPS patient is 36 to 46.¹

Two types of CRPS exist: CRPS I occurs without a nerve lesion; and CRPS II, has a detectable nerve lesion.

The pain appears to result from surgical nerve injury or trauma, particularly crush injuries in which pain persists for a long time. CRPS pain may be produced either by alpha-adrenergic-receptor hypersensitivity to catecholamines or a functional interaction between sympathetic and sensory neurons.² Current research is trying to determine if the immune system plays a role by allowing autoantibodies to attack nervous system structures.³ This sets up a cyclical process of more damage, more inflammation, and more pain. Researcher Clifford Woolf has described this immune process for neuropathic pain as “pain without any brakes.” The movement of CRPS pain from limb to limb is thought to result from increased commissural conductance in the brain.⁴

Some of the criteria for a diagnosis of CRPS include:

• regional pain
• sensory changes (sudomotor  
• abnormalities, variations in
• temperature perception, and extreme
• sensitivity to cold)
• skin changes
• nail thickening
• hair loss in the affected area.

 Treatment options

The best treatment for CRPS is prevention. Ensuring early mobilization after surgery or trauma and making sure a cast or brace isn’t too tight after a limb fracture can help prevent CRPS.

 The next best treatment is early intervention. After CRPS becomes established, successful treatment is difficult. In a retrospective study, only 29% of patients reported being pain free, and 64% reported severe pain with an average pain rating of 7 on a 0-to-10 pain intensity rating scale.¹

 Drugs prescribed for CRPS include:

• alendronate (Fosamax)
• clonidine (Catapres)
• corticosteroids
• gabapentin (Neurontin)
• nonsteroidal anti-inflammatory drugs
• opioids
• tricyclic antidepressants.

Any intervention that blocks or interrupts the sympathetic nervous system should effectively relieve pain. Unfortunately, a Cochrane database systematic review yielded little research support for using intermittent sympathetic blocks and no recommendations for their use or efficacy.⁵ Epidural and intrathecal techniques using tunneled epidural catheters with local anesthetic alone and with local anesthetic and ketamine produced limited success.¹ However, these techniques allow manipulation of the affected limb with the least pain possible.

The main goals of physical and occupational therapies for CRPS patients are to decrease edema, decrease pain, increase range of motion (ROM), promote normal sensitization, and maximize limb function.

Therapies such as transcutaneous electrical nerve stimulation (TENS) may control pain. To start, apply TENS to the spinal region that supplies the painful area. If that’s effective, move TENS spinally and proximally toward the painful area and stimulate the regions superior and inferior to it. Then, apply TENS directly to the affected area. TENS should be applied at frequencies up to 200 Hz in the spinal region and decreased to 4 Hz in distal regions. Initially, the patient should wear the TENS unit 8 hours a day for 3 days to determine if it’s effective. If so, change the electrode placement as described above, based on patient tolerance.⁶

You can reduce edema using electrical stimulation, ultrasound, and arm or leg elevation. For some patients, applying a special compression garment, such as an Isotoner glove or Jobst garment, can reduce swelling while providing gentle warmth.⁷

Another key treatment technique for CRPS is a desensitization program, which consists of stimulating the painful area with a variety of materials, starting with soft ones, such as cotton, and progressing to coarser ones as the patient’s tolerance increases. The program should also progress from light to deep touch and from intermittent to constant stimulation with each material.⁸

Stress loading, which consists of  “scrubbing and carrying,” reverses the abnormal sensory process characteristic of CRPS by stimulating large fiber receptors. “Scrubbing” involves using a repetitive back-and-forth movement with weight bearing, as if scrubbing a table. The goal is to gradually increase the weight bearing and duration of the activity. For the arms, the patient can assume the quadruped position to make the most of weight bearing. For the legs, the patient can sit or stand, depending on his activity tolerance. “Carrying” involves holding objects that gradually increase in weight. A patient may start with a half-pound object and gradually increase the weight to 10 pounds, as tolerated. At first, some patients experience a mild increase in pain or swelling, but over time it should decrease. If the increase in pain or swelling is more than mild, the weight progression was too fast.⁹

When edema-reduction and stress-loading programs are in place, the patient can begin ROM exercises to prevent atrophy and abnormal positioning of the affected limb. All ROM exercises should be gentle and progress from active-assisted to active. Exercises should be pain free. Short sessions of about 3 minutes every half hour throughout the day are preferable to one long session.⁷

While a patient receives therapy to restore normal function in a limb, you may use static or dynamic splinting to prevent contractures and promote lengthening of tight structures. Large-handled eating utensils can help a patient eat independently.

Two keys 

A treatment that works for one patient may not work for another. Thus, one key to successful intervention is tailoring therapy to the patient. Another key is time. Remember, the earlier a diagnosis is made and the sooner intervention starts, the better the odds are for a successful outcome.

Yvonne D’Arcy, CRNP, CNS, MS, is a pain and palliative care nurse practitioner, and Jennifer Werdell, PT, MS, GCS, is a physical therapy clinical coordinator at Suburban Hospital in Bethesda, Md.

References:
1. Ghai B, Dureja GP. Complex regional pain syndrome: A review. Journal of Postgraduate Medicine. 50(4):300-307, October–December 2004.
2. D’Arcy Y. Severe pain: What’s the diagnosis? American Nurse Today. 2(1):29-30, January 2007.
3. Blaes F, et al. Autoimmune etiology of complex regional syndrome. Neurology. 63(9):1734-1736, November 2004.
4. Forss N, et al. Mirror-like spread of chronic pain. Neurology. 65(5):748-750, September 13, 2005.
5. Cepeda MS, et al. Local anesthetic sympathetic blockade for complex regional pain syndrome. The Cochrane Database of Systematic Reviews. 4:October 19, 2005.
6. Berger P. The role of the physiotherapist in the treatment of complex peripheral pain syndromes. Pain Reviews. 6(3):211-232, October 1, 1999.
7. Lankford LL. Reflex sympathetic dystrophy. In: CM Everts, ed. Surgery of the Musculoskeletal System. New York: Churchill Livingstone, 1983.
8. Swan M. Treating complex regional pain syndrome: A guide for therapy. Pamphlet for the Reflex Sympathetic Dystrophy Syndrome Association, June 2004.
9. Carlson LK, Watson HK. Treatment of reflex sympathetic dystrophy using the stress-loading program. Journal of Hand Therapy. 1:149-154, 1988.
Reprinted with permission from Therapy Insider, June 2008, published by Lippincott Williams & Wilkins. For more information, visit www.lww.com