Hi here is dr. Andrea Furlan, I am a pain specialist in a pain clinic and
today we are going to talk about complex regional pain syndrome or CRPS usually
when people are referred to me they wait many months for the initial appointment
but when I see the referral that says this patient may have CRPS I usually
book that patient right away because we can't delay treatment for people who
have CRPS. so let's talk about it today - so what is CRPS:. It is a type of
pain that is very severe it has some signs and symptoms that are very
characteristic of CRPS presentation of CRPS is usually pain in one of the limbs
upper limbs, arms and hands or lower limbs, knees below the knees ankles and
feet usually affects only one limb, it's only one arm, only one foot, rarely it
affects more than one limb. the initial presentation of CRPS is usually after a
fracture or a surgery some trauma that happens to that limb, but may not be
related to any trauma. people who had a stroke they may have CRPS in their side
affected by the stroke. people who had a brain injury or even people who had a
heart attack they may have signs of CRPS in one of the limbs usually the left arm.
but it also affects people who didn't have any trauma so some people will have
no recollection of anything that happened to them. they will have the
symptoms and signs of CRPS. the symptoms of CRPS are very characteristic so first
of all there is a very severe pain, it's a type of pain that is so excruciating
and it not related to the amount of injury that
happened to that limb this being is also very it's constant being it has some
characteristics of neuropathic pain such as tingling numbness burning electrical
shocks the person is also very sensitive to touch
we call this allodynia or hyperesthesia so this pain that happens
in one limb and also comes with other symptoms such as hypersensitivity
swelling of the extremity can also have it some change in color of that limb
can also have changing temperature change in the sweating how the skin
sweats also changes in the hair of the skin and also how the nails grow the
person will notice this weakness in the side effect edge by CRPS there might be
some tremors on the side affected by CRPS so those are the signs of symptoms
that we observe when we suspected someone had CRPS so what are the causes
of CRPS we actually don't know what causes CRPS but we know from recent
research especially with brain imaging we know that there is a abnormal pain
processing in the brain we call this central sensitization there is also pre
fro sensitization which means that the nerves and the receptors that carry pain
to the brain they're also more sensitive I explained this process of central
sensitization in another video that I made and I explained that the pain
system is like the alarm system of our body and hence the alarm system of a
house can also malfunction our pain system can also malfunction and CIPS
seems to be a malfunctioning of this pain system so we need to find ways of
fixing the pain system to help people who have yet
yes and because the pain system is sensitized in the person that has CRPS
other areas are also sensitized such as the areas that control sleep anxiety
mood and concentration there is a type of CRPS that is called CRPS type 2 and
in this case the person will have a traumatic nerve injury there is a
uropathy or a problem with one of the nerves and that can explain some of the
symptoms so when we make the diagnosis of CRPS we need to make sure that we
exclude and your other diseases or conditions that could be causing this
severe pain in the swelling and should be changing colors and changing
temperature things that we need to think about are for example blood clot or a
infection infection of the senior infection around the bones also some
metabolic diseases like a decompensated diabetes could also be some systemic
problems that are causing this swelling so we need to make that exclusion before
we say this is CRPS so how do we make the diagnosis of CRPS there is not a lot
of like laboratory tests or imaging tests that we can do to say this is your
pas or this is not CRPS none of the tests will be 100% sure but we have to
order some tests to exclude other things that could be causing those symptoms and
they are not CRPS but also in some cases we can order a MRI of the affected area
and also a bone cintilography this is the injection of some radioactive
material which called bone scan and those tests can show some signs some
differences and changes in the results of those tests that are suggestive of
CRPS but of course those tests would be more positive if we order them in the
early stages of si yes if it has been too many months or
years after the CRPS has started we probably not see those changes in those
tests sometimes we also order electromyography nerve conduction
studies and this are because we want to see if this is not a CRPS as type 2 where
there is a nerve damage or nerve injury and how do we treat CRPS well first the
most important thing is the sooner we start treatment the better will be the
results ideally a person with sharp es should be seen by a multidisciplinary
pain team that means that they will see different professions including
physicians I am a physiatrist and I can handle medications I can help them with
manual therapies I can indicate some nerve blocks and procedures they can
also be seen by anesthetists, psychiatrist, neurologists and they also need to see
all the professions that are not physicians they need to see
physiotherapists occupational therapists and psychologists unfortunately it's
frustrating because not a lot of people have access to multidisciplinary pain
team, or if they have a pain clinic close to where they live
sometimes they wait months or even years to see a multidisciplinary pain team in
terms of medications we give preference to anti-inflammatories, we can give
non-steroidal or steroidal anti-inflammatories, we can also give medications
that regulate calcium because calcium is very affected in the bones of people
with sharp yes and those are the same medications that usually people use for
osteoporosis we also tend to give medications that will help to regulate
the pain system and those are the antidepressants, the tricyclic
antidepressants or they SNRI antidepressants, we can also give the gabapentin
or it's like gabapentinods like pregabalin. we can also give medications
that will regulate the sodium channel those are things like lidocaine and also
NMDA blocker is like ketamine there are other medications that I use to treat
the symptoms of CRPS because the pain is so severe sometimes we need to give them
opioids ideally for a short period of time so then they don't develop
tolerance to the opioids we can also use some topical creams this can be topical
creams contain lidocaine or amitriptyline or even in anti
inflammatories if the area that they have to apply is not too large but it's also very
important that they include physiotherapy or physical modalities and
movement therapy to treat patients with CRPS the modalities that people use in
physiotherapy are usually desensitization mirror therapy aquatic
therapy usually it's very good when the person has CRPS of the ankle and foot
because they can't weight bear, are we trying to put weight on that area it
hurts a lot so what doing exercises in a pool is
very helpful also they can do what we call graded motor
imagery and also therapeutic exercises it's also important to remember to do
psychotherapy people with CRPS they will have those areas of the brain that
control the fear emotions and mood affected so these people will benefit a
lot by doing relaxation exercises cognitive behavior therapy biofeedback
breathing deep breathing exercises and in some cases they will also benefit
from nerve blocks and some intravenous injections the nerve blocks that have
been somehow helpful for people is especially on the on those case that
they have swelling and disturbance in the temperature in changing color
because those are what we call autonomic symptoms so blocking the autonomic
nervous system is very helpful and we may recommend
to do some sympathetic nerve blocks in last when the person has tried
everything for pain in this you have very severe debilitating pain we
recommend a neuromodulation and in this class we have spinal cord stimulators
spinal cord simulators are implantable devices that will be give continuous
electrical shots in the spinal cord to block the pain sensations a lot of
people ask me can we prevent CRPS can we avoid this from happening how do I know
if I would develops CRPS and can I do something about it unfortunately there's
not much that we can do we know that there are high risk groups such as older
people who have osteoporosis and then they have a radial fracture which
is this bone here they're more prone to have CRPS after they fix the fracture
however in other cases we don't know exactly how to prevent there has been
some suggestion that vitamin C can prevent a person from developing cips so
in any orthopedic surgery or after after a fracture a person could be taking 500
milligrams of vitamin C for about two months and that may prevent them from
developing CRP as in the future however early treatment is the best prevention
for further complications and please remember that this video is not intended
to provide individual patients advice but it's only to provide education if
you think that you have a condition that is causing you CRPS or complex regional
pain syndrome please consult a physician a diagnosis in a treatment plan for you
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