Complex regional pain syndrome - Treating complex regional pain syndrome

There is no known cure for complex regional pain syndrome (CRPS), but a combination of physical treatments, medication and psychological support can help manage the symptoms.

It's estimated that around 85% of people with CRPS will slowly experience a reduction in some of their symptoms, including pain, over the first two years after the condition starts. However, some people will experience continuous pain despite treatment and, in rare cases, may develop further problems, such as muscle wastage.

There is currently no way to predict which cases will improve and when this may happen.

Your treatment plan

Treatment for CRPS involves four main areas:

education and self-management – advice about any steps you can take to help manage the condition
physical rehabilitation – to help manage symptoms and reduce the risk of long-term physical problems
pain relief – treatments to help reduce your pain
psychological support – interventions to help you cope with the emotional impact of living with CRPS

Some of the main treatments used are described below.

Self-management

As part of your treatment, you will be advised about things you can do yourself to help control your condition.

This may include:

being encouraged to stay as active as possible and not avoid using the affected body part
learning relaxation techniques and methods to help improve your quality of sleep
being advised about pacing yourself (balancing periods of activity with periods of rest)
continuing rehabilitation treatments at home, such as desensitisation techniques (see below)
accessing any support groups in your local area

Read more advice about living with pain.

Physical rehabilitation

Physical rehabilitation involves a number of different treatments that are designed to help you manage your symptoms and prevent physical problems, such as muscle wastage and bone contortions.

Some of the techniques that may be used as part of your physical rehabilitation programme are described below.

Exercises

A physiotherapist can help devise a suitable exercise plan involving a range of exercises designed to gradually improve the strength and flexibility of the affected body part.

Your exercise plan may include a range of exercises, from simple stretches to exercises in water (hydrotherapy) or weight-bearing exercises.

These exercises can be very painful at first, but research has shown that pain can improve significantly in people who persist with the treatment – although this does not always happen. Regular exercises can also reduce the severity of physical problems associated with immobility, such as muscle wastage.

Desensitisation

Desensitisation is a technique used to reduce the sensitivity of body parts affected by CRPS.

It usually involves touching an unaffected body part with materials of different textures, such as wool and silk, and concentrating on how this feels. The same materials are then applied to the painful, affected body part while trying to recall what it felt like when you were touching the unaffected body part.

This process is likely to be uncomfortable or painful at first, but it may eventually reduce the sensitivity in the affected body part so it is more similar to unaffected areas.

Mirror visual feedback and graded motor imagery

Mirror visual feedback and graded motor imagery are two techniques that aim to "trick" the brain into thinking that areas of the body affected by CRPS are no longer affected.

These techniques involve carrying out exercises with a mirror positioned so you see a reflection of the unaffected limb where you would normally see the affected limb.

Pain relief

There are several medicines that may help to treat CRPS, which your pain specialist will be able to discuss with you.

Your treatment team will try lower-strength painkillers first, and will only use stronger painkillers if necessary.

None of the medicines used to treat people with CRPS are licensed for this use in the UK. This means these medicines may not have undergone clinical trials to see if they are effective and safe in treating CRPS specifically.

However, they will have a licence to treat another condition and will have undergone clinical trials for this. Doctors may choose to use an unlicensed medication if they are thought to be effective and the benefits of treatment outweigh any risks.

Some of the main pain relief treatments are discussed below.

Non-steroidal anti-inflammatory drugs (NSAIDs)

The first painkillers often used to treat CRPS are over-the-counter painkillers called non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.

These medications can help reduce the pain caused by the injury that triggered CRPS. They can also treat CRPS-associated pains, such as muscle pain in the shoulder when the CRPS is in the hand. However, NSAIDs are unlikely to directly reduce CRPS pain.

Anticonvulsants

Anticonvulsants are usually used to treat epilepsy, but they have also been found to be useful for treating nerve pain. Gabapentin and pregabalin are the most widely used anticonvulsants for treating CRPS.

Common side effects of these medications include drowsiness and dizziness. There is a small increased risk of suicidal thoughts, which may be seen as early as a week after starting treatment.

You should avoid suddenly stopping treatment with these medications, because you may experience withdrawal symptoms. If you feel you no longer need to take it, your GP will arrange for your dose to be slowly reduced over a period of at least a week.

Tricyclic antidepressants

Tricyclic antidepressants (TCAs) were originally designed to treat depression, but like anticonvulsants were found to be effective in treating nerve pain. Amitriptyline and nortriptyline are the most widely used TCAs for treating CRPS, although nortriptyline generally has fewer side effects.

These medications can often improve sleep, and are generally taken in the early evening, to reduce the risk of "hangover" effects the next morning.

Possible side effects include dry mouth, blurred vision, constipation, heart palpitations and difficulty urinating.

You may experience withdrawal effects if you stop taking these medications suddenly. If you feel you no longer need to take TCAs, your GP will arrange for your dose to be slowly reduced over a period of at least four weeks.

Opiates

If you are experiencing severe pain, opiates such as codeine and morphine can provide pain relief.

Common side effects of opiate painkillers include nausea and vomiting, constipation, dry mouth, tiredness and cognitive problems (thinking processes can be slower). Long-term use of high doses has been linked to more serious problems, such as absent periods in women, absent periods, depression, and erectile dysfunction in men.

There are circumstances where the benefits of using opiates outweigh the associated risks, but unfortunately these medications are often not very effective in CRPS. Long-term use of high doses is generally not recommended, although exceptions may be made in a very small number of cases.

You may worry that you could become addicted to opiates or other pain medications, but genuine addiction (taking a medication despite knowing it is harmful) is rare. However, there is a risk you may become "dependent" on opioids, which means your body and mind do not want to stop taking them, even if they are not very effective, and you may feel worse for a limited period of time when you do reduce or stop taking them.

Spinal cord stimulation

If medication does not lessen your pain, a treatment called spinal cord stimulation may be recommended.

This involves having a device placed under the skin of your tummy or buttocks. This device produces mild electrical pulses that are sent to your spinal cord.

These pulses cause changes to how you feel pain. You should feel a tingling sensation in the part of your body that usually hurts, which masks the pain. The level of stimulation can be adjusted as your pain improves or gets worse, and the device can be removed if necessary.

The National Institute for Health and Care Excellence (NICE) states that spinal cord stimulation should only be considered if:

you are still experiencing pain after six months of trying other treatments
you have had a successful trial of the stimulation

Your care team will discuss spinal cord stimulation with you if they think it could help.

Psychological support

Living with a long-term, painful condition can be distressing, and people with CRPS may experience psychological problems, such as anxiety and depression.

It's important to look after your psychological wellbeing, because feelings of depression and anxiety can interfere with your rehabilitation.

Psychological therapies can also be useful in helping you cope better with the symptoms of pain. For example, some studies have shown that cognitive behavioural therapy (CBT) can help in the management of long-term pain.

The aim of CBT is to help you understand how your problems, thoughts, feelings and behaviour can affect each other. By discussing and altering how you feel about your condition, CBT can help you cope with your symptoms and make it easier for you to continue with your rehabilitation programme.

Abdomen: The abdomen is the part of the body between the chest and the hips.
Inflammation: Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.
Joint: Joints are the connection point between two bones that allow movement.
Spinal cord: The spinal cord is a column of nervous tissue located in the spinal column. It sends messages between the brain and the rest of the body.