What treatments are there for complex regional pain syndrome (CRPS)?
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There's no single treatment available that will help everybody with complex regional pain syndrome (CRPS) but movement – as far as possible – is the most important aim. This usually involves a combination of physical rehabilitation therapies and pain-relieving medication. You will also be offered advice on managing the condition and may be offered psychological therapies to help you develop coping strategies.
Rehabilitation therapies play a very important part in the treatment of CRPS and are usually most effective when started early.
The most important goals of rehabilitation are to restore as much function as possible and to improve quality of life.
Rehabilitation therapies probably won't stop the pain completely but will help you use the limb more normally. They should also help to avoid secondary problems like weakening of the muscles through lack of use.
Most therapies will begin very gently to avoid a flare-up of your symptoms, and you’ll probably need pain medication to help lessen the pain so that you can start the therapies. You'll need to build up the length of time and intensity of your therapies gradually, even if progress seems slow at times.
Rehabilitation will involve elements of physiotherapy and occupational therapy, but in some areas you will see the same person for both.
Physiotherapy is probably the single most important treatment for CRPS. The aim is to reduce pain and keep the affected limb mobile. This will help prevent stiffness and loss of muscle tone as well as promoting circulation.
Exercise can be difficult if you have severe pain so you’ll need to work with your physiotherapist to find out which exercises work best for you, when you should stop, and the techniques you can use to cope if your pain does increase for a time.
Your therapist will also advise on pain relief therapies such as transcutaneous electrical nerve stimulation (TENS), and they may be able to loan you a TENS machine to try or advise on where you can hire one. Hydrotherapy (exercises performed in water) and combinations of mind/body exercises such as t'ai chi may also be useful.
Your therapist may also suggest more specialised therapies such as graded image therapy – these are becoming more widely used and aim to 'retrain' the way the brain interacts with the limbs. Graded image therapy consists of three elements:
Left–right discrimination: It's thought that in CRPS, the ability of the brain to quickly recognise left and right may be reduced. You'll be shown images of different parts of the body and asked to identify whether each is the left or right side. You may also be shown moving images and asked whether the movement is to the left or the right. Repeating this exercise regularly improved how quickly and accurately the brain recognises left and right.
Explicit motor imagery: You'll be shown images of movements or actions and asked to imagine how it would feel without actually performing the action.
Mirror visual feedback therapy: A mirror is placed so that the painful limb is hidden behind it and you see only the normal limb and its reflection. The brain processes visual feedback more readily than other senses, so when you move both limbs in the same way, the brain 'sees' both limbs moving easily and painlessly.
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physiotherapy or hydrotherapy. Occupational therapy
Your therapist can suggest a range of techniques, but practising these on your own whenever you can will increase the benefit:
Desensitisation: This is a technique that aims to normalise touch sensations in the affected limb. It involves touching the skin frequently with different-textured fabrics and other substances (for example, wool, silk, cotton wool), gradually working towards the painful areas. It's important to focus fully on the sensation of touching the normal limb and to remember that feeling when you touch the affected limb. Getting as relaxed as possible before starting can help you manage these touches. As you practise, you can start to progress from gentle movements like light stroking to firmer stroking, tapping or circular movements.
Relaxation and/or stress management techniques: These can help in managing pain on a day-to-day basis.
Body perception awareness: This can be especially helpful if you develop negative feelings about the affected limb. It encourages you to look at, touch and think about the affected limb as often as possible so that the limb begins to feel a normal part of your body again.
You may find some of these techniques uncomfortable or painful while you're doing them and for a while afterwards. If you can't manage one of them, try a different one to begin with.
Try to build some of the activities into your everyday life – for example:
Concentrate on the feel of the bed sheets or your clothes against your skin.
Think about the feel of water on your skin as you shower – if you can, try different water temperatures or different textures (e.g. flannel, sponge) as you wash.
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occupational therapy. Psychology, education and coping techniques
CRPS isn't all in the mind, but long-term severe pain is very likely to affect your mood and can sometimes lead to depression.
A psychologist can help you develop coping strategies to manage this. This may include stress management and relaxation exercises, cognitive behavioural therapies (CBT), acceptance and learning to ask for support.
Pain management programmes
These are offered in specialist pain centres or clinics, usually on an outpatient basis, though some centres may offer residential programmes. The programmes are group-based and may last for a few days or a few weeks. There will often be people on the programme with other painful conditions besides CRPS.
These programmes draw on the skills of a wide range of professionals, including physiotherapists, occupational therapists, pain specialists, social workers and employment advisors, and aim to improve your quality of life. Group sessions are often led by psychologists who can offer therapies such as cognitive behavioural therapies (CBT) to help you develop new skills to cope with the pain and the anxiety that it can cause. These skills may help you through difficult times in your rehabilitation programme.
A pain management programme can help to lessen the impact of long-term pain, but isn't designed to take the pain away.
No drugs are specifically licensed in the UK to treat CRPS, and there’s no single drug treatment that works for everyone with CRPS. However, pain medications can be useful to reduce pain to a level that allows you to begin rehabilitation therapies:
Anticonvulsants such as gabapentin and pregabalin can help by reducing pain signals from the nerves to the brain.
Painkillers (analgesics) such as paracetamol, tramadol and codeine may play a part in controlling moderate pain – your doctor will be able to advise on the best options for you. Pamidronate, a drug used mainly to prevent thinning of the bones, may also provide pain relief, although the reasons for this aren't fully understood.
Tricyclic antidepressants such as
amitriptyline, given in low doses, can also reduce pain signals to the brain and may be helpful if you have trouble sleeping because of pain. Other antidepressants, such as duloxetine, also have pain-relieving properties.
Some pain specialists may suggest
steroids (e.g. prednisolone). Patches filled with lidocaine (a local anaesthetic) may also be used.
Blocking of the sympathetic nervous system can be carried out using injections of local anaesthetic – this will be given by an anaesthetist with expertise in pain management.
Spinal cord stimulation
In spinal cord stimulation (SCS), a fine wire is implanted in the epidural space close to the nerves in your back. This is connected to an external hand-held control unit that allows you to control the stimulation. This is usually done fro a trial period. If it helps, then a battery unit can be implanted in your tummy or buttock. The wire and battery can be removed later on if you no longer need SCS.
The treatment is only available in specialist centres for people who haven't benefited from other treatments.
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