The CRPS Puzzle

How is CRPS treated?

The following therapies are often used:

Rehabilitation and physical therapy.  An exercise program to keep the painful limb or body part moving can improve blood flow and lessen the circulatory symptoms.  Additionally, exercise can help improve the affected limb’s flexibility, strength, and function.  Rehabilitating the affected limb also can help to prevent or reverse the secondary brain changes that are associated with chronic pain.  Occupational therapy can help the individual learn new ways to work and perform daily tasks.

Psychotherapy. CRPS and other painful and disabling conditions often are associated with profound psychological symptoms for affected individuals and their families.  People with CRPS may develop depression, anxiety, or post-traumatic stress disorder, all of which heighten the perception of pain and make rehabilitation efforts more difficult.  Treating these secondary conditions is important for helping people cope and recover from CRPS.

Medications. Several different classes of medication have been reported to be effective for CRPS, particularly when used early in the course of the disease.  However, no drug is approved by the U.S. Food and Drug Administration specifically for CRPS, and no single drug or combination of drugs is guaranteed to be effective in every person.  Drugs to treat CRPS include:

• bisphosphonates, such as high dose alendronate or intravenous pamidronate

• non-steroidal anti-inflammatory drugs to treat moderate pain, including over-the-counter aspirin, ibuprofen, and naproxen

• corticosteroids that treat inflammation/swelling and edema, such as prednisolone and methylprednisolone (used mostly in the early stages of CRPS)

• drugs initially developed to treat seizures or depression but now shown to be effective for neuropathic pain, such as gabapentin, pregabalin, amitriptyline, nortriptyline, and duloxetine

• botulinum toxin injections

• opioids such as oxycodone, morphine, hydrocodone, and fentanyl. These drugs must be prescribed and monitored under close supervision of a physician, as these drugs may be addictive.

• N-methyl-D-aspartate (NMDA) receptor antagonists such as dextromethorphan and ketamine, and

• topical local anesthetic creams and patches such as lidocaine.

• Medical Marijuana & CBD tinctures, juicing, topicals, edibles and flower herb

All drugs or combination of drugs can have various side effects such as drowsiness, dizziness, increased heartbeat, and impaired memory. Inform a healthcare professional of any changes once drug therapy begins.

Sympathetic nerve block. Some individuals report temporary pain relief from sympathetic nerve blocks, but there is no published evidence of long-term benefit.  Sympathetic blocks involve injecting an anesthetic next to the spine to directly block the activity of sympathetic nerves and improve blood flow.

Surgical sympathectomy.  The use of this operation that destroys some of the nerves is controversial.  Some experts think it is unwarranted and makes CRPS worse, whereas others report a favorable outcome.  Sympathectomy should be used only in individuals whose pain is dramatically relieved (although temporarily) by sympathetic nerve blocks.

Spinal cord stimulation.  Placing stimulating electrodes through a needle into the spine near the spinal cord provides a tingling sensation in the painful area.  Electrodes may be placed temporarily for a few days in order to assess whether stimulation is likely to be helpful.  Minor surgery is required to implant all the parts of the stimulator, battery, and electrodes under the skin on the torso.  Once implanted, the stimulator can be turned on and off, and adjusted using an external controller.  Approximately 25 percent of individuals develop equipment problems that may require additional surgeries.

Other types of neural stimulation. Neurostimulation can be delivered at other locations along the pain pathway, not only at the spinal cord.  These include near injured nerves (peripheral nerve stimulators), outside the membranes of the brain (motor cortex stimulation with dural electrodes), and within the parts of the brain that control pain (deep brain stimulation).  A recent option involves the use of magnetic currents applied externally to the brain (known as repetitive Transcranial Magnetic Stimulation, or rTMS).  A similar method that uses transcranial direct electrical stimulation is also being investigated.  These stimulation methods have the advantage of being non-invasive, with the disadvantage that repeated treatment sessions are needed.

Intrathecal drug pumps.  These devices pump pain-relieving medications directly into the fluid that bathes the spinal cord, typically opioids, local anesthetic agents, clonidine, and baclofen.  The advantage is that pain-signaling targets in the spinal cord can be reached using doses far lower than those required for oral administration, which decreases side effects and increases drug effectiveness.  There are no studies that show benefit specifically for CRPS.

Emerging treatments for CRPS include:

• Intravenous immunoglobulin (IVIG). Researchers in Great Britain report low-dose IVIG reduced pain intensity in a small trial of 13 patients with CRPS for 6 to 30 months who did not respond well to other treatments. Those who received IVIG had a greater decrease in pain scores than those receiving saline during the following 14 days after infusion.

• Ketamine. Investigators are using low doses of ketamine—a strong anesthetic—given intravenously for several days to either reduce substantially or eliminate the chronic pain of CRPS. In certain clinical settings, ketamine has been shown to be useful in treating pain that does not respond well to other treatments.

• Graded Motor imagery. Several studies have demonstrated the benefits of graded motor imagery therapy for CRPS pain. Individuals do mental exercises including identifying left and right painful body parts while looking into a mirror and visualizing moving those painful body parts without actually moving them.

• Myofascial Release Therapy. This therapy is mostly provided by massage therapists who’ve had additional training in myofascial nerve release techniques. A MR Therapist performs nerve releasing techniques on the nerves that become trapped directly under the skin and that communicate to other nerve message centers with pain signals. Interrupting the constant firing also allows the release of the toxins that cause inflammation of the entrapped nerves.

• EMDR is the most effective and rapid method for healing PTSD(Post Traumatic Stress Disorder) as shown by extensive scientific research studies. The EMDR therapy uses bilateral stimulation, right/left eye movement, or tactile stimulation, which repeatedly activates the opposite sides of the brain, releasing emotional experiences that are “trapped” in the nervous system. This assists the neurophysiological system, the basis of the mind/body connection, to free itself of blockages and reconnect itself. As troubling images and feelings are processed by the brain via the eye-movement patterns of EMDR, resolution of the issues and a more peaceful state are achieved.

• Reflexology, also known as zone therapy, is an alternative medicine involving application of pressure to the feet and hands with specific thumb, finger, and hand techniques without the use of oil or lotion. It is based on a pseudoscientific system of zones and reflex areas that purportedly reflect an image of the body on the feet and hands, with the premise that such work effects a physical …

Several alternative therapies have been used to treat other painful conditions.  Options include behavior modification, acupuncture, relaxation techniques (such as biofeedback, progressive muscle relaxation, and guided motion therapy), and chiropractic treatment.