Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy (RSD), is a chronic neuropathic pain condition that can arise from trauma of any kind. It can be the result of something as minor as a blood draw that initiates a reaction. The condition arises more frequently than many emergency physicians may realize: roughly 3 percent of patients suffering a Colles fracture develop CRPS. Often the traumatic event cannot be remembered, and CRPS has been associated with trauma happening anywhere from a day to a year after the event. Its most consistent feature, however, is how often physicians fail to make the diagnosis on initial presentation. Furthermore, our lack of understanding about how to manage the severe pain that occurs during acute flare-ups of this chronic condition worsens the suffering that many patients with CRPS endure over decades.
Early Diagnosis Is Key
As can be seen with diabetic neuropathy, CRPS has both a sensory and an autonomic dysfunction. Unlike patients with diabetic neuropathy, both will be present from the start. Not only do patients suffer from intense pain that does not correspond to a specific nerve distribution, they also suffer visible changes as the result of their autonomic dysfunction.
Feet of a patient with more advanced CRPS, which show clear skin atrophic changes.
Credit: Jim Ducharme
Initially, the involved painful area (usually part of an extremity) becomes red, warm, and edematous; it is often initially misdiagnosed as cellulitis. The presence of severe allodynia (pain induced with a nonpainful stimulus such as light touch) should make the physician consider the true diagnosis. It is very important that CRPS be diagnosed early on because active treatment can reverse and eliminate the condition. Treatment includes neuropathic analgesics (eg, tricyclics, gabapentinoids) combined with active physiotherapy and mindfulness. Many patients who develop this condition will come to the emergency department with their painful condition when it begins, so the emergency physician needs to be able to diagnose and refer appropriately. I personally diagnose two to three new cases per year in my emergency medicine practice.
Failure to treat within the first weeks of symptom onset will allow the physical changes to start. The involved area will develop dystrophic skin changes: a shiny, thin, erythematous appearance. Underlying muscles atrophy so that the involved area becomes wasted in appearance over time. Typical burning neuropathic pain persists. If left untreated (or if poorly treated), CRPS can spread, involving larger parts of the body.
Treating Flare-ups
Patients will also present to the emergency department because of an acute flare-up of their chronic pain. CRPS can become acutely more painful because of N-methyl-D-aspartate (NMDA) activity and hyperresponsiveness to NMDA. NMDA is a neurotransmitter present in the dorsal horns and spinothalamic tracts, and it is the number-one initiator of wind-up in acutely painful conditions. With CRPS flare-ups, it is almost as if wind-up starts over again. The burning pain becomes acutely worse; pain is severe and unresponsive to almost all analgesics. Opioids will not control the pain of a flare-up unless given in a quantity that would make the patient somnolent. Opioids should not be considered a first-line treatment in this situation. It is recognized that many patients with CRPS ask for opioids for their severe pain. As with any patient asking for opioids when suffering from a chronic pain condition, this can create distrust and a stressful environment. Increasingly, national patient groups are educating patients that opioids will not be effective.
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16 Responses to “Tips for Managing Complex Regional Pain Syndrome”
October 1, 2015
MeredithI was given compassion and honest relief in the ER last night from the ER physician who had used this article to treat me. He gave me treatment exactly as the author explained. Within the first fifteen minutes, I had a new optimism that I cannot explain.
I have been trying to negotiate RSD for twenty-five years – with too many reluctant trips to the ER. I have the scars, stories to show it.
To the author – I do not know who you are, but I believe you are on the right track for those of us who have felt defeated. Thank you. Please, continue to share this message. There are too many of us who continue to suffer from undereducation.
January 8, 2016
Crystal NicholeI’ve tried ketamine infusions as part of my long term treatment plan but did not know it could be used in emergency medicine for a flare up.
As an aside, it was strange finding a photo of my feet on here. 🙂 Thanka for such an interesting article.
January 9, 2016
stephenWhat can be done to find some relief or cure?
January 9, 2016
Stevie RayNice of you to help further the info the cause the awareness. Without living with the pain,the advice given in regards to opiods is easy to say for a Doctor. However immediate pain relief is completely necessary. What is given to the patient is up to the Doctor. If the Doctor was to put their hand or foot on a oven door & then repeat it for 16-18 hours everyday the sympathy empathy would perhaps allow that Doctor to have the proper response in regards to pain relief. We have created the medicines, there are new generation pain relievers that have abuse deterent properties. So instead of sending a patient home to burn and feel that if the Doctor and ER will not properly treat them then what are you the patient to do ?. Having an understanding of what the nervous system can do is critically needed to send said ER pain patient home with the hope of relief, in place of complete helplessness and not knowing what to do next. A question that has no answer but for the patient to have NO or little HOPE. I’m in my 3rd decade of Crps and pain medication has saved MY LIFE !!!
September 24, 2016
Louise HanA year ago I had my first wrist operation for advanced Keinbocks Disease . And 3’months ago a second operation for the same disease, I’ve had a total wrist fusion and a proximal row carpectomy. A visit to my surgeon 3 weeks ago , revealed a diagnosis for Complex Regional Pain Syndrome, my surgeon was visibly shocked to know that my surgery supposedly to fix my pain has in fact made it worse . So any feedback on this Syndrome is very important not only to me but to the others who have falling victim to this condition.
So I am not going nuts , this is a very real condition, and as I have read early detection is vital , to ward of ongoing unnecessary pain. Thank you to all who have taken the time to share their story. Louise.
October 27, 2017
Rick KellyDitto on your opiate position. Easy for you to say. It is very dangerous for you NOT to get the pain down. Spontaneous deaths have been recorded via heart failure.
Jim,… you have NO FREEKN IDEA how bad it hurts. We are NOT lying.
March 29, 2019
Riley KinnI’ve had CRPS now for nearly a year-and-a-half. Stemmed from a back surgery Fusion where the bone got pushed into the L5 nerve root and caused permanent damage. I had a revision surgery 10 days later which took the electric feeling away but the burning is unreal in unbearable to this day. I also have a severe crushing of the bones sensation in a really horrible stinging sensation that is much worse than anything I can describe. I’m in pain all the time although there are flare-ups which occur and I believe it is critical to treat it quickly or the flare-up will not be broken and last a month. I’ve been to the emergency room about nine times and is always very humiliating for me to have to ask for help with pain. I have yet to find a doctor that will think out of the box and do a ketamine infusion or give me any nmda antagonist medications. My pain management doctor refuses to even consider a ketamine infusion. I am getting an electrical stimulation unit put in my back is a trial in the next month. I have a reasonable expectation that may reduce the pain by about 50% and that would be awesome. It’s a difficult disease to explain to people and explaining the severity of pain is equally difficult. I didn’t believe I actually had CRPS for some time but I had three independent doctors come up with the same diagnosis so I began to accept its I’ve been getting cognitive behavioral therapy and I’ve tried virtually every medication on the planet. Gabapentin probably works the best and takes about 15% of my pain away. Opioids probably take about 10% of my pain away which again is wonderful. Nortriptyline probably takes another 10% away surprisingly. I did have a ketamine drip after my last surgery and I was in horrible pain with my back because I was not getting Dilaudid but I have to say I don’t remember any pain to know to write home about regarding my foot. So my conclusion is based on my limited ketamine experience that it completely worked at least during the time I had the infusion. And based on many many anecdotal stories and some hardcore research ketamine may work it atleast in the short-term of several months. I agree that ER doctors don’t seem to understand CRPS and usually have a look of frustration that I would even come in and that they have to treat me. I know I’ve never been told this I get the feeling that most doctors in the ER want to say suck it up and deal with it go home. I’ve had nurses tell me that my blood pressure does not indicate I’m in severe pain. Usually my blood pressure is through the roof but I’m on so many hypertension pills that it is now successfully treated even though I many times in excruciating pain. One way that I know that a flare-up is coming on is not only increased pain but an increase stiffness and inability to wiggle my toes. If not treated immediately eventually my ankle and foot will seize up and the pain will continue along with a dark purple swelling in my right foot. This is a great article and I truly appreciate the doctor that wrote it and I favoured it in my bookmarks so that if I have a flare-up this will be the one article but I will show the ER doctor. Thank you and I wish everyone with CRPS pain relief when they need to go to the ER.
November 24, 2017
TeriWhen I have had a bad flare up 1 500 mg vicodin does work.
November 24, 2018
Niya GilmoreFacts they have me 200mg of fentanyl and it didn’t even knock me out 11years battling this
May 27, 2018
Judy PendletonI have crps ten yrs and am in severe pain in feet it started with bunion surgery I take 1800gapementin daily one opoid a day at night it flares back up this burning pain is real
November 24, 2018
GilmoreI’ve been battling for going on 11 years. This pain is not in your head. The burning knife stabs and etc is more than enough to cause stress on the heart and other organs. With the prolonged use of nerve blocks, opioids and steroids my gallbladder stop working and I developed so many fibroids I had to get a hysterectomy. My teeth began to crack. It causes other health issues. So I try to do without. But days like today I have to take something.
March 1, 2019
GemimaDoes having a flare up mean that the condition is spreading or is worsening or is an indication that its worsening? I’ve been told by my team that the flare ups are an indication that the CRPS is going to spread. Is this right?
March 28, 2019
Carol FeuersteinGemima in my case the flare-ups have not caused the CRSP to spread, and I was diagnosed 18 years ago. The only thing that caused spreading, from one foot to both feet was electro-stimulated acupuncture used on both feet simultaneously. Acupuncture did not help and made the condition worse.
March 8, 2019
LaVesta MattGlad to read that others have the same feelings that I do as well. The picture of the feet was exactly like mine looked almost 3 1/2 years ago after a car wreck at work. Only different it was my right foot. Took about 2 days after my wreck for the horrible pain and swelling. I have everything that you spoke about. I have severe muscle mass loss in my right foot and leg… my feet change colors as well. They swollen so bad then they started shedding the skin. I have burning, sticking needle pains… Now both my feet daily feel like they are in a bucket of ice…. FOlks I live on the Gulfcoast. I live in Texas 2 hours from Houston…. People do not understand this disease and I am fortunate Dr.Robert Bowling figured out what it was. But I saw several neurologist as well. Anyhow, I appreciate this post. Drs in Louisiana know more about this disease than Texas…. This has destroyed my career.. I am on Ss and Medicare. My 30 yr old daughter thinks it’s nothing. This is a hard disease. I’m a very, very outgoing person. I was Branch Manager for 27 years for staffing companies…. Now I cant work… I’m high risk… I pray everyday for a cure….
Everyone… pray and keep your headup….
March 28, 2019
Carol FeuersteinI’ve been dealing with CRPS for 18 years. It is 2 a.m. and I am awake because of the pain, both feet are red and shiny and swollen. I find that cooling my feet ( barefoot on a cold floor ), 6 mg sublingual GABA, and a 50 mg Tramadol help significantly, enough that within an hour my feet have cooled and the pain is subdued enough to get back to sleep.
This is an almost nightly occurrence. I think the warmth of sleep causes the flare up which wakes me with burning pain too severe to stay asleep or remain in bed. I don’t agree that opiates are not helpful, in my case they have been a huge help, and I am very careful not to overuse them and take them only at night when the pain is at it’s worst. During the day the pain is less and I can tolerate it without medication.
March 28, 2019
CindyI am trying very hard today not to give in to the pain and horror that is now my life. I thought it was medically bad enough before, but this puppy is right out of a Stephen King novel.
I just don’t know if I will be able to handle all my previous health issues and now this. God bless all you folks that have year after year.