CRPS Pain

Introduction

CRPS, also known as Complex Regional Pain Syndrome is a chronic condition characterised by severe pain in one or several limbs. Due to the severity of the CRPS Pain, this medical condition has been nicknamed “The Suicide Disease” on account of the fact that it has no cure and the known treatments have limited effectiveness. The majority of patients have described CRPS pain as a burning, shooting pain often disproportionate to the inciting injury.

The actual cause of CRPS is unclear, but most often, the medical condition results from an injury, minor surgical procedure, or a medical emergency such as a stroke.  Pain is only one of the many signs and symptoms that a patient experiences following the onset of CRPS. It is the best indicator for whether a patient has CRPS or not. However, pain is not exactly quantifiable which makes it difficult for anyone else not experiencing the pain to understand what the patient is feeling and if the pain really is disproportionate to the inciting injury. As a result, the use of pain scales is necessary for a CRPS patient to better communicate their pain.

How Painful Is CRPS?

The best way so far to measure pain is the McGill Pain Index. The McGill Pain Index, also commonly referred to as the McGill Pain Questionnaire is a rigorously tested scientific pain scale, developed in 1971 at McGill University by Melzack and Torgerson. When the index was created, certain sensory qualities such as skin color, temperature changes, pressure, and sensitivity were included; along with affective qualities such as tension, fear, and autonomic properties. It is a valid, reliable, and consistent tool used by doctors and hospitals around the world when looking at chronic pain. The basis of this index is that there is a consistency in the way patients suffering from the same or similar pain syndromes describe the pain they feel.

Out of the 78 words that make up the McGill Pain Index, patients choose the ones that best describe their experience of pain. The words fall under four main categories named Sensory, Affective, Evaluative, and Miscellaneous. Each category has one or more dimensions classified by numbers, with the relevant words under each dimension. The number of words the patient chooses under each category varies. The score of the pain is then tabulated by adding up the values associated with each word and the results range from 0 (no pain) to 78 (severe pain).

So what is CRPS pain ranked as on the McGill Pain Index? CRPS is considered the most painful condition known to man with a ranking of 42 points out of a maximum of 50 on the index. This high ranking indicates that CRPS pain is much more severe than the pain felt during childbirth and from the amputation of a finger or a toe without anaesthesia. According to some research on the CRPS pain scale, it has been said that CRPS Type 2—one of the two forms of CRPS—can reach a score as high as 47 points out of 50 on the McGill Pain Index.

Can CRPS Pain Get Worse?

Considering the fact that CRPS is believed to be the most painful condition in existence, it’s hard to imagine that such immense pain can get worse—and yet it does. A lot of CRPS patients experience what are called flare ups once in a while. These CRPS pain flare ups are periods when the pain feels much worse due to increased sensitivity and the other symptoms may be worse too. The duration and intensity of these flare ups varies for each patient, with some only experiencing flare ups that last for a few days while others have exacerbated pain that lasts weeks. Flare ups can be so bad that a patient with CRPS in the foot will feel extreme pain when their toes touch.

Flare ups are debilitating and can occur at any time due to a variety of factors including stress, fatigue, changes in the weather, hormone fluctuations, staying in the same position for too long, adjustments of medication, or exertion from physical activities. The pain can be so extreme that it doesn’t respond to analgesia or any other pain medication. Besides pain, the other symptoms that can worsen during a flare up are colour changes, temperature changes, and sensitivity.

Contrary to popular belief, flare ups are not a sign or indication that the condition is spreading or getting worse. They are an unfortunate part of a dreadful medical condition, but understanding what causes a particular flare up may help a patient avoid the triggering event in the future. In addition to medications for CRPS pain relief, some self-management techniques such as pacing, deep breathing, distraction techniques, and relaxation techniques can be helpful. Relaxation is especially important as it helps a patient cope with their emotional stress—a key risk factor for flare ups.

CRPS Pain Treatment

CRPS is an incurable medical condition. Most treatment efforts are focused on managing pain, restoring limb functionality, and ensuring a positive mindset. To achieve this, a combination of treatments which include medications, natural treatments, physiotherapy, psychotherapy, and occupational therapy are used. CRPS pain treatment requires a variety of medications and even physical exercises to keep the pain under control. These include the following:

CRPS pain medications

The medications prescribed to each CRPS patient will differ on account of the difference in the progression of the syndrome in each individual. The doses and types of medications may need to be changed over the course of time, so the patient’s response to the treatment should be monitored and evaluated regularly.

  • Neridronate

Also known as Neridronic Acid, Neridronate is so far the best available treatment for CRPS pain. Unfortunately, the use of Neridronate for CRPS pain has only been approved in Italy so this may limit accessibility to the treatment. However, the benefits outweigh the costs of travelling to Italy and the treatment itself, as most patients who have been treated with Neridronate have seen complete relief from their symptoms.

  • Non-steroidal anti-inflammatory drugs

These are used in the treatment of moderate pain and include easily accessible, over-the-counter drugs such as ibuprofen and naproxen.

  • Anti-depressants

Although the primary function of anti-depressants such as gabapentin, pregabalin, amitriptyline, nortriptyline, and duloxetine is in the treatment of seizures or depression; they have shown to be effective in treating neuropathic pain such as CRPS pain.

  • Analgesics

Analgesics are effective in the treatment of mild to moderate pain although their degree of efficacy may vary for each patient.

  • Anaesthetics

These drugs induce a state of anaesthesia where the patient feels a temporary loss of awareness or sensation, which in turn desensitises them from pain.

  • Opioids

In the event of excruciating pain that is experienced on a regular basis, opiates such as codeine and morphine are the best treatment for notable CRPS pain relief.

  • Calcium channel blockers

Calcium channel blockers are prescribed for treating symptoms resulting from vasomotor disturbances as they relax the blood vessels to improve blood flow. However, they also provide mild to significant pain relief, so they can be included in the patient’s treatment regimen.

CRPS pain natural treatments

  • Exercise

Gentle exercises help increase the patient’s pain threshold and change their perception of pain so they can handle it better. Consulting an experienced, qualified physiotherapist is recommended so they can advise on the best exercises that will benefit the patient and not worsen their condition. As a bonus, exercise helps retain function, strength, muscle mass, and flexibility in the affected limb and also improves blood flow which is a major CRPS problem resulting from vasomotor disturbances affecting natural body processes such as vasodilation and vasoconstriction. During exercise, the body produces endorphins which can be thought of as the body’s natural pain killers. These endorphins help to reduce CRPS pain so a graded exercise program that begins with low intensity activities and frequency, and gradually increases is necessary.

  • Restorative or gentle rehabilitative yoga

Similar to exercise, some yoga poses can be very effective for treating chronic pain by activating the parasympathetic system which is the resting, digesting, and healing system. It is recommended that a patient undergoing this type of treatment should start with gentle yoga poses under the instruction of a knowledgeable practitioner.

  • Vitamins

Vitamin supplements have shown to be effective in treating CRPS pain, especially fish oil which is popular for its anti-inflammatory properties. In a study where CRPS patients used fish oil as a treatment for their pain, more than half reported significant CRPS pain relief and even stopped using prescription painkillers.

  • Heat therapy

The use of heat to soothe pain and relax the mind is well documented. For CRPS patients, heat therapy in the form of Epsom salt baths, electric heated blankets, and infrared saunas have proven to improve symptoms especially CRPS pain.

  • Meditation and breathing exercises

These techniques help a patient relax and reduce stress, which in turn helps to minimise the risks of pain flare ups. Meditation in particular encourages relaxation, reduces pain, and lowers the levels of anxiety and depression.

  • Diet changes

There’s no specific diet for CRPS patients but some foods such as fresh fruit, fresh vegetables, fish, and fowl are believed to have anti-inflammatory properties and contribute to giving the patient relief from symptoms such as pain.

  • Naturopathy

Naturopathic medicine uses natural substances and treatments to improve the health of a patient and treat an illness. The main goal of naturopathy is to find the cause of the illness instead of just treating or suppressing the patient’s symptoms. Naturopathy involves the use of several therapies which include clinical nutrition, botanical medicine, homeopathic medicine, acupuncture, physical therapies, and counselling.

CRPS pain alternative treatments

  • Sympathetic nerve block

With this type of treatment, an anaesthetic is injected next to the spine to directly block the activity of sympathetic nerves which are believed to be a key part of CRPS pain. The nerve blocks also improve blood flow.

  • Surgical Sympathectomy

During this operation, some of the nerves are destroyed in order to prevent the transmission of pain signals that manifests as the severe chronic pain. The surgery is only recommended for patients who feel significant CRPS pain relief from sympathetic nerve blocks. Some believe that surgical Sympathectomy worsens CRPS instead, so it is considered a last resort when all other treatments have failed.

  • Spinal cord stimulation

The use of this treatment is based on the belief that increasing a patient’s pain threshold through stimulation can increase their tolerance of pain. For spinal cord stimulation, stimulating electrodes are injected into the spine, near the spinal cord. Those electrodes cause a tingling sensation in the painful area. They can be used temporarily to evaluate whether they are helpful with regards to CRPS pain relief or not.

New CRPS pain treatments

  • Ketamine

Ketamine is strong anaesthetic which has proven to substantially reduce or eliminate the chronic CRPS pain in low doses. The treatment is administered intravenously over the course of several days and is often used when other pain medications such as the ones mentioned above fail to elicit a favourable response.

  • Graded Motor Imagery

This therapy involves the use of mental exercises whereby the patient is asked to identify left and right painful body parts while they look into a mirror. The patient then has to visualise moving the painful body parts without actually moving them.

  • Intravenous immunoglobulin (IVIG)

Trials using low doses of IVIG have proven to reduce pain intensity in patients who did not respond well to other CRPS pain treatments.

Conclusion

Knowing that there is no cure for CRPS pain can feel daunting and contribute to emotional stress, which will often lead to flare ups and worse pain. The best thing anyone diagnosed with CRPS can do is to find ways to manage their pain, emotional and mental state and use the above treatments. Sometimes, CRPS pain can subside on its own and other times, a variety of treatments will have to be administered. The sooner the treatment begins, the better the chances of managing pain and recovering from CRPS. With the various types of available treatments, the pain may disappear completely or at least subside significantly.

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