MULTIDISCIPLINARY APPROACH BEST FOR TREATING COMPLEX REGIONAL PAIN SYNDROME
From Washington University Physicians, posted August 1, 2009, written by Mary Jo Blackwood, RN, MHA
As far back as the Civil War, physicians have documented debilitating pain in soldiers that persisted long after their wounds were healed. Since then, similar syndromes have been identified with the same symptoms, one group with nerve injury and the other without.
Reflex sympathetic dystrophy (RSD) is the older term for the condition that was thought to be associated with sympathetic nerve injury. Now called complex regional pain syndrome (CRPS) type II, the cluster of symptoms describes the type of pain clearly associated with nerve injury, such as might occur with a high-velocity impact.
CRPS-I is the diagnosis when no overt injury or nerve involvement can be found. Whether a person has Type I or Type II, the symptoms are similar and require a multi-disciplinary approach to treat. No single treatment has a good success rate.
Washington University pain specialist, Rahul Rastogi, M.D., cautions that if one doesn't look at all aspects of the syndrome, effective treatment can be delayed and the chances of remission lowered. “The pain and effect on quality of life tend to worsen with time, not get better. We see three to four patients a month who have already seen specialist after specialist who have treated the condition from one angle, until now the condition is chronic and much harder to treat. The multidisciplinary approach gives the best results.”
RSD/CRPS Symptoms and Diagnosis
This condition is difficult to diagnose and depends on identifying the combination of symptoms that make up the syndrome. If there is a wound - a simple fracture or deep bruising - and the pain lasts longer than the wound did, a patient should seek care from a physician - the sooner the better. The overriding symptom is intense, continuous burning pain, out of proportion to the severity of the injury—if an injury even occurred. It becomes worse over time and most often affects the arms, legs, hands, or feet. The pain often is accompanied by:
- Increased skin sensitivity
- Changes in skin temperature, color, and texture
- Excessive sweating
- Joint involvement such as swelling and stiffness, and a decreased range of motion
- Reduced bone mineralization
“There is no specific diagnostic test available for RSD, so diagnosis is made on the basis of history, clinical presentation and supportive tests, including a three-phase bone scan, which can show decreased bone mineralization and increased contrast uptake around the joint. Diagnostic sympathetic blocks can also be telling.”
Treatment for RSD/CRPS
CRPS is a multi dimensional disease requiring a multi-disciplinary approach that includes:
Medication: “Certain anticonvulsants and antidepressants are useful in treating the pain. In refractory, or resistant, cases, we have had success with oral steroids or bisphosphonates, such as used to treat osteoporosis. Opioid medications have also shown some benefit in controlling pain symptoms.”
Regional nerve blocks: “When the sympathetic nervous system is involved, a regional nerve block with a local anesthetic can be very helpful. If the nerve block gives short-term relief, we can make it permanent with a surgical sympathectomy, in which the pain nerves are cut, or a chemical sympathectomy, in which the nerve fibers are ablated by phenol or alcohol injections.”
Neuromodulation: "There are advanced therapies like spinal neuromodulation (NM), which creates spinal cord stimulation by placing thin electrodes near the spine under the skin, and connecting them to a pacemaker-like battery. NM has shown good results in improving symptoms and quality of life in this patient group."
Overall therapy: “Incorporated with any of the above treatments are physical modalities such as biofeedback, relaxation techniques, and physical therapy."
The Washington University Pain Center provides access to a variety of approaches, including psychology, physical therapy, medication, and interventional therapies to give the patient the best chances for remission. A group therapy program called STEPP, Supportive Training and Education for People with Pain is an important tool for multidisciplinary pain management, along with medications and injections.”
Rastogi emphasizes that this condition has a tremendous impact on a patient’s activity levels, socialization, and quality of life. It requires a wide arsenal of tools to help the patient achieve the greatest relief. Even in remission, the condition can recur over a three to five year period.
“One of the most common questions I get is from patients who are in remission but are contemplating surgery on the affected limb for another problem and want to know if the surgery can make the condition return. It’s difficult to answer.”