• Dr. Jason Rountree

Major Pain! CRPS (Complex Regional Pain Syndrome)

Welcome! Let's go ahead and jump into CRPS (complex regional pain syndrome). It was formerly named RSD (reflex sympathetic dystrophy) and remains relatively unknown. In many expert opinions it is referred to as being very rare while others say it can occur in 9%-10% of the population, which is a large number of people.


So, today, I am going be using two sources for the information that I present below. The first one is from Mayoclinic.org. It's not complete, as it is not designed to be, but it gives you the outline of some of the things we are going to talk about. The second resource that I am using is an article from 2014 and published in the Turkish Journal of Physical Medicine and Rehabilitation. The article is titled: Effects of Low-level Laser Therapy and Interferential Current Therapy in the Treatment of Complex Regional Pain Syndrome.



What is CRPS?

First, let's get into what CRPS is, because many people have never even heard of this. If you have heard of it, then your doctor may not have heard of it and it is really hard to get an accurate diagnosis for many reasons. However, let's talk about the symptoms first.


Symptoms of CRPS

The number one, most common symptom here is severe pain or nerve pain in the extremity. It will feel like a continuous burning or throbbing or pulsing pain and there can be significant sensitivities to touch or pressure. For example, even air movement can be extremely agitating as well as general cold temperatures. In many cases, the skin can start looking thinner or shiny and it can change color. You can feel a swelling sensation in the area or you can even have actual swelling. There may be changes in the joint itself if this goes on for long enough. You may even be able to see changes in hair, fingernail and toenail growth.


One of the hallmarks of CRPS is that there is pain that is disproportionate to what originally started it. Now, this takes us to the causes. While we don't know exactly what is going on in the body of somebody with CRPS, we do know that - with most cases - everyone is going to have a minor, or sometimes major, injury or surgery that occurs. It is then followed by the severe amounts of pain that is disproportionate in not only how long it lasts but in the intensity as to what one would expected. For example, if you sprain your ankle, you would expect that to be feeling pretty good within 8-12 weeks, right? If you sprain your ankle and also have an onset of CRPS afterward, you'd have severe pain even four months later, which is not normal or something we would expect.

In many cases, the symptoms themselves can even change and vary in terms of the intensity. It can even be changing in terms of the location, to some degree, and spread to affect the joints nearby. It does not stick to the known nerve distributions, either. Meaning, that when you tell your doctor about this very severe pain where you had an injury and you describe how it seems to change so much, that it is extreme, and sometimes spreads in an area that is not usually connected to one particular nerve, unfortunately, in many cases, the doctor looks at you and goes, "yeah, right." They will not believe it because it looks like you are making it up. Now, if you have a history of drug seeking or something like that, maybe they have good reason to think that, but there are very legitimate cases of CRPS that do not fit the typical clinical picture.


CRPS Nerve Pain

What we believe is going on is something called neurogenic inflammation or irritation and inflammation around the nerves that is sometimes actually sourcing from the nerve’s themselves. When you have inflammation on the nerves, there are a few things that happen. One, it makes the nerves misfire. Therefore, they start to send signals when they are not supposed to. If that inflammation is in a nerve that sends you pain signals then that would obviously generate a lot of pain. If it is in a nerve that controls blood flow to the skin, then you're going to get blood flow changes, color changes, hypersensitivities, and swelling. If it happens to be in the nerves that go to the muscles, then you'll get muscle stiffness, joint stiffness, aching, and spasming as well. It all comes back to this idea that the nerves themselves are inflamed. Sadly, anti-inflammatories do not bring that type of pain down very well.


Further, without getting too much into the chemistry of how your nerves work, they have a threshold and are not supposed to send pain signals until they reach a certain level of stimulus. You do not want every little bump or pressure to feel severely painful, right? That's not the way pain nerves are designed to work. They are supposed to let you know when something is really dangerous but, if the nerve becomes inflamed, then that threshold becomes much lower. This means that even small, tiny stimulus will send a pain signal when otherwise it really should not be doing that.


Now, the pain is so significant and the treatments are so poor that there has actually been two entire conferences of the International Association for the Study of Pain dedicated to CRPS, and they still have not been able to produce a good therapeutic protocol for this disorder. Just getting the diagnosis can be difficult in itself. Now, when you get a diagnosis of CRPS, it is called a diagnosis of exclusion which means that there is not a particular test for the disorder. You can not draw blood and test for CRPS and you can not take an x-ray and know that someone has CRPS. You have to do your testing, end up with nothing, and then put all of this information together to maybe come out with the diagnosis of CRPS. The doctors are going to have to look at your symptoms and the absence of other findings to know if CRPS is really the best fit.


The Reality of CRPS Treatments and Outcomes

Once you have a diagnosis, the treatments are really not much better. The treatments rely on some medications that can, in some cases, help reduce the pain; although, always with side effects. There can be additional alternative medicine strategies to approach this, including acupuncture or physical therapy, which is extremely common. As a matter of fact, in the study that we are referring back to today, they say that physical therapy is the most significant procedure and treatment of CRPS. Physical therapy includes things such as hot packs, interferential current, and mobilization of the soft tissues or joints when it is bearable. The idea behind the treatment is to try and reduce the amount of nerve irritation to get this pain levels under control.

The next piece of this Complex Regional Pain Syndrome is that, a majority of the time, there will be a recurrence of pain. It is often located in a different area or sometimes back in the same area, which can be incredibly frustrating if you are not told about it early on. Getting this under control just for it to flare up again can be understandably depressing and upsetting. You think, "I had this nailed down and now it is right back to being severe again." Now, I do not want to sound too hopeless here because, again, there are solutions out there. You just need to understand that every case of CRPS is different and most respond differently from one another. Therefore, you may need to be willing to try several different methods of treatment discussed above:

  • medications

  • physical therapy

  • chiropractic

  • acupuncture

Laser Therapy for CRPS

Presently, I would encourage you to consider laser therapy and to look for someone who knows how to treat CRPS using laser therapy. In this study we are referring to today, they say0" the application of laser therapy had a particularly beneficial effect in reducing pain, intensity, and edema" and that "no negative effects of the applied therapy were recorded." So, if you can have a successful therapy with no side effects and no negative effects then that is even better. The researchers go on to say that "laser therapy has specific therapeutic effects such as analgesia (the reduction of pain), anti-edematous (anti-swelling), anti-inflammatory effects, and improvement of regenerative abilities."


This takes us back to the idea that the threshold that these nerves are operating at is improper. As I stated before, the nerves are not supposed to send you pain signals until that threshold of stimulus is reached. That is why it does not hurt to touch a desk (or it should not). Yet, someone with CRPS brushing up against something or having a bit of air pass over the area that is affected can be extremely painful due to those nerves not operating normally. Laser is specifically said to have an "influence on the tone of the nervous system with the aim of its normalization." The research also says that it has modulation of pain perception, how your body feels pain, and what that signaling is like as well as increased production of endogenous opioids. These endogenous opioids are your body's own pain reducing chemicals. The researchers go on to say, "laser therapy blocks the entrance of sodium ions into the cell, which is a stabilizing factor in the cell membrane resting potential." Again, it all goes back to that threshold idea. If you do not have the proper balance of sodium ions, then you end up with that improper signaling when it should not be. The researchers also say that laser "has anti-edematous, anti-inflammatory effects and, by increasing local microcirculation, laser reduces the edema, increases tissue oxygenation, and facilitates elimination of allogenic substances" (things that create pain signals).


Montana Laser and CRPS

At Montana Laser and Medical Center, we have gotten to be pretty good at helping people with CRPS and reducing their pain. To the point that, most of the time, someone comes to us with CRPS, we get them fixed up, and they are back out the door within a few weeks of treatment. Then, when they do have a recurrence, they can come back and see us for a few visits of laser therapy to get that pain back under control. I am thinking of one particular patient that was referred to us for her diagnosed CRPS, she'd had it for a couple of years, and it started after she had iced her leg a lot following a surgery. She felt like the ice had really contributed to this hypersensitivity that was going on and it was so severe that you could not even breathe on the leg. The leg could not have clothes on it could she stand to have any air movement. Therefore, she was miserable a majority of the time due to the constant and severe pain. Fortunately, we were able to work with her and, within just a few weeks, we had her in great shape! She felt amazing and, after nearly every treatment on the area, the intensity of pain on her leg reduced as it got less and less sensitive. Once she had improved, we completed her treatment and turned her loose. We ended up seeing her a couple of months later after she had fallen on the ice and she experienced a recurrence as that impact had started a new episode of this CRPS pain in a different spot on the same leg. However, because we got to it so quickly, we were able to have it resolved within three or four visits. That is another key factor of CRPS. The longer you have CRPS going on, the harder it is to fix.


If you are struggling with this right now or you are not convinced you have an accurate diagnosis for your pain, I would strongly encourage you to come see us. If you are undergoing treatment and it is not satisfactory, if you are not really getting better like you feel you should be, definitely look into laser therapy here in Kalispell.


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