Physical Therapist's Guide to Complex Regional Pain Syndrome (CRPS)
Complex Regional Pain Syndrome (CRPS) can be a painful and disabling condition. CRPS generally arises from a minor injury, such as a scrape, sprain, or strain and can result in the syndrome that is defined as being complex, regional (symptoms are generally in 1 region of the body), and painful. It is estimated that 80,000 people living in the United States are diagnosed with CRPS each year. A multi-disciplinary approach to treatment is currently recommended, consisting of care from physicians, psychologists, and physical therapists.
The American Physical Therapy Association launched a national campaign to raise awareness about the risks of opioids and the safe alternative of physical therapy for long-term pain management.
CRPS, formally known as RSD (regional sympathetic dystrophy), is considered to be a multi-system disorder characterized by severe pain; pathological changes of the bones, joints, and skin; excessive sweating; tissue swelling; and hypersensitivity to light touch. It is generally categorized as one of 2 types:
- Type 1: not resulting from a distinct nerve injury
- Type 2: resulting from a distinct nerve injury
CRPS involves the central nervous system, autonomic nervous system, and immune system. Although research has not yet determined exactly why CRPS occurs, physical therapy has proved to be quite beneficial in managing its symptoms, improving function, and increasing the quality of life for people with CRPS.
Most people with CRPS experience:
- Extreme sensitivity to light touch—a symptom known as tactile hyperesthesia. Common everyday activities, such as wearing clothing, bathing, or applying skin creams or lotions may become very difficult and uncomfortable.
- Significant pain, often described as burning, stabbing, grinding, or throbbing that is often more extreme than what would be expected from the original injury.
Specific signs and symptoms may include:
- Pain and sensitivity to touch.
- A higher or lower skin temperature in the affected limb.
- Discoloration of the affected limb.
- Awkward positioning of the affected limb as a result of sustained muscle contractions. (This condition, known as dystonia, occurs in about 25% of CRPS cases.)
- A change in the appearance of hair and nails on the affected body part.
- Tissue and joint swelling.
- Heightened release of sweat by the affected limb.
Other symptoms reported by people with CRPS include increased difficulty in sleeping, decreased sexual desire, increased irritability or agitation, depression, and memory loss.
A diagnosis of CRPS is generally made by a physician who is familiar with the syndrome, such as a neurologist. Your physician may first attempt to rule out other conditions, such as Lyme disease or peripheral neuropathy, before making a definitive diagnosis.
A physical therapist may be the first practitioner to recognize the onset of CRPS. If your physical therapist suspects the condition may be present, the therapist will discuss those concerns with you and your physician to determine the best plan of action for your care. If suspected, your physical therapist may ask if you have experienced any of the signs or symptoms noted above.
Physical therapists play a vital role in the treatment of CRPS. Your physical therapist will work with you to develop a treatment plan to help address your individual condition. Because the symptoms of CRPS vary, the approach to care will also vary. CRPS treatment is generally based on the chronicity and severity of the episode.
Treatment for CRPS may include:
Movement therapy. Mobilization of the affected body part, begun immediately following diagnosis of CRPS, is crucial to help prevent contractures (the tightening of muscles or joints), and to maintain function. Therapy may include a combination of passive and active movements; the best treatment for your specific condition will be determined by your physical therapist.
Graded Motor Imagery (GMI). All movements, even the smallest ones, are a result of complex computations of various networks within the brain. GMI is a rehabilitation process often used to treat disorders, such as CRPS, that result in pain and movement problems. GMI exercises the brain in measured and monitored steps, and includes left and right discrimination training, motor imagery exercises, and mirror box therapy.
Mirror Box Therapy. Usually introduced as the third step in a typical GMI protocol, mirror box therapy requires an individual to exercise their unaffected limb in front of a mirror, while watching the reflection, as if their affected limb were performing the exercise.
Note: High-level physical activities and thermo-electric modalities (such as, ice, heat, electrical stimulation, or ultrasound) are not recommended in the treatment of CRPS, and actually can be harmful. Finding providers who commonly treat CRPS is key to receiving the best treatment.
Unfortunately, the actual mechanisms behind CRPS are yet to be completely understood. Therefore, there is currently no clear way to predict or prevent its onset. However, early detection of signs and symptoms related to CRPS will help you and your medical providers begin early management, which may improve your long-term outcomes.
Upon diagnosis, your physical therapist will work with you to develop strategies to better understand and manage your symptoms. Patients with CRPS are encouraged to:
- Learn all you can about the syndrome. As with many conditions, education is key to maintaining function and good health when experiencing CRPS. Understanding some of the underlying mechanisms affecting your CRPS may help you better manage it daily.
- Keep moving. It is important that you continue to move the affected limb following your diagnosis of CRPS, to help prevent contractures and secondary effects such as dystonia.
- Learn relaxation exercises. Individuals with CRPS often report a variety of pain triggers in their daily lives, such as stress at work, loud city noises, an uncomfortable living situation, and so on. Your physical therapist will teach you helpful ways to relax your body and calm your nervous system.
Tommy is a 28-year-old electrician who recently had to have arthroscopic surgery on his left knee. A few months after the surgery, he began to feel a painful sensation like a "brush burn" in his leg above the knee. He had bumped his knee on a piece of equipment earlier in the day, but had thought nothing of it. As the day progressed, he noticed his knee became swollen, red, and painful to touch. Over the next few days, his condition worsened. Tommy's wife convinced him to visit the emergency room at the local hospital.
The attending physician ruled out other conditions, such as a blood clot, and referred Tommy to physical therapy.
Tommy's physical therapist noticed he was hypersensitive to even a light touch above his knee, and he appeared hesitant when asked to move his knee. His range of motion was limited, and Tommy reported any movement as "very painful." When his physical therapist asked him to stand up and walk, she noticed that he was trying to avoid putting too much pressure on his left leg.
Tommy's physical therapist suspected CRPS, and contacted a local physician who regularly treated CRPS cases. The physician diagnosed the condition as Type 1 CRPS.
Tommy immediately began a multidisciplinary treatment program, including pain education, medication, and a personalized course of physical therapy. His physical therapy consisted of a GMI protocol, which began with left/right discriminatory training. His physical therapist gave him flash cards, which allowed him to perform this routine daily as a home-exercise program. As his accuracy of distinguishing between left- vs right-handed images improved, he started motor imagery activities (he was asked to imagine moving his left knee into positions seen in pictures). Tommy's physical therapist also performed very gentle mobilizations to his knee to prevent contractures, and only moved him into positions that were comfortable for him.
Today, although Tommy still experiences some CRPS symptoms, he is able to maintain knee mobility and live a functional, active life. A major key to Tommy's successful outcome was the early detection and treatment of his CRPS.
This story highlights an individual experience of CRPS. Your case may be different. Your physical therapist will tailor a treatment program to your specific needs.
All physical therapists are prepared through education and experience to treat conditions, such as CRPS. However, when seeking a provider, you may want to consider:
- A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in Physical Therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.
- A physical therapist who is well-versed in the treatment of CRPS or other complex, painful conditions.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with painful conditions.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible; keeping a journal highlighting when you experience pain will help the physical therapist identify the best approach to your individual treatment.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence for the treatment of CRPS. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Di Pietro F, McAuley JH, Parkitny L, et al. Primary motor cortex function in complex regional pain syndrome: a systematic review and meta-analysis. J Pain. 2013;14(11):1270–1288. Article Summary on PubMed.
Moseley GL, Gallace A, Di Pietro F, Spence C, Iannetti GD. Limb-specific autonomic dysfunction in complex regional pain syndrome modulated by wearing prism glasses. Pain. 2013;154 (11):2463–2468. Article Summary on PubMed.
O’Connell NE, Wand BM, McAuley J, Marston L, Moseley GL. Interventions for treating pain and disability in adults with complex regional pain syndrome.Cochrane Database Syst Rev. 2013;(4):CD009416. Free Article.
Moseley GL. Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain. 2004;108(1-2):192–198. Article Summary in PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.
Joseph Brence, PT, DPT, COMT, DAC. Reviewed by the MoveForwardPT.com editorial board.
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