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Why re-injury is common in CRPS patients

CRPS can be 'fire-fighting'
Complex Regional Pain Syndrome (CRPS) - formerly known as Reflex Sympathetic Dystrophy (RSD) - was initially diagnosed over a century ago. Despite its unquestionable existence, it is often diagnosed late and re-injury of the same or different limb is not uncommon due the characteristics of the disease.

Much of the research has been done only within the last decade - more research is required before this complex disease is better understood. Research indicates that CRPS is a neuropathic pain disorder with autonomic features (see previous publication for an explanation of this). The pathophysiology and impact of the involvement of the sympathetic branch of our autonomic nervous system is what makes this disease relatively unique, poorly understood and multifactorial (Bruehl, 2010). It is believed that the peripheral and central nervous system are involved and deeply sensitized. Inflammatory mediators, genetics and psychophysiological components (psychologic states such as anxiety that bring about a physical response) are also involved in addition to the inexplicable contribution of one's altered sympathetic nervous system pathways.

In regards to genetics, those siblings of patients diagnosed with CRPS were statistically more likely to suffer the diagnosis (Kirkpatrick, 2003). Additionally those who had complications of CRPS after a surgery or injury were far more likely to sustain CRPS should they undergo surgery on an unrelated body part. This is important to note as clinicians, in particular surgeons, rarely warn patients of this increased risk, prior to surgery. A CRPS patient may was the pros and cons quite differently than a person without increased risk.​

CRPS Symptoms

There are six global clinical symptoms that constitute the diagnosis and when delineated it is easy to see why they make a patient prone to re-injury. Click the little arrows for more information:

Pain

Skin changes

Swelling

Movement Disorders

Bone Changes

Variable Duration

Spreading Symptoms

There are three identified patterns:

  • 'continuity type' or upward (proximal) spreads of symptoms, say from a hand to a shoulder
  • a 'mirror image' phenomenon in which symptoms begin in the opposite limb
  • an 'independent type' when CRPS occurs without new injury.

THE NAMING MUDDLE


Because of the complexity of presentation of the various features of this condition, it has over the years been known by different names - Causalgia, Reflex Sympathetic Dystrophy (RSD), Reflex Neurovascular Dystrophy (RND), Amplified Musculoskeletal Pain Syndrome (AMPS), Sudeck's Atrophy - but nowadays the medical fraternity are trying to stick to the term 'Complex Regional Pain Syndrome' (CRPS).

CRPS cycle

The CRPS Cycle

Pain Didactic: Complex Regional Pain Syndrome (CRPS) by Ronald Kaplan, MD

A very interesting historical perspective...


Citations:
Veach RM, Montgomery AA, Dahlberg K. Complex Regional Pain Syndrome: Reasons Physicians do not follow Clinical Guidelines. Journal of the American Medical Association, 2000; 283: 1685-1686​

Bruehl, S. An Update on the Pathophysiology of Complex Regional Pain Syndrome. Anesthesiology 2010 Sep; 113 (3) 713-725​

Kirkpatrick, Anthony MD, PhD RSD/CRPS International Update on CRPS: Clinical Practice Guidelines, third edition. Symposium 2003 www.rsdfoundation.org​

Michelle BoucherPhysician Assistant

On a personal note, as a physician assistant and CRPS patient, I believe I have experienced CRPS in all three ways.

​In the past the inciting incident was a devastating radial (wrist) fracture in my left wrist, and after surgery I developed a postoperative 'compartment syndrome' and median nerve necrosis (nerve death due to lack of oxygen). I was left with severe nerve damage resulting in CRPS of my hand and forearm with all of the characteristics in that first list above. I subsequently experienced a fracture/dislocation of my shoulder and humerus (continuity pattern) on the same left arm.

​Within a few months, I experienced another fracture/dislocation of my right shoulder and humerus, without trauma (mirror image pattern).

When I later ruptured my ACL - several years later - my surgeon never informed me that I had a higher risk of developing CRPS in the operative extremity (knee). Had I known I may not have had the surgery or had it with the assistance of a lumbar/sacral nerve block to decrease the chances of CRPS. I have since learned a great deal from my personal experiences with CRPS that have helped me to identify this likely under-diagnosed entity in my medical practice. Most recently, I sustained a fracture of the fibular head in that leg with almost no trauma (independent type), and patchy osteoporosis was noted.​​