Complex Regional Pain Syndrome (CRPS) - Luca Pella

Complex Regional Pain Syndrome (CRPS)


Complex Regional Pain Syndrome, also known as Algodystrphy, is a rare disease that begins, in its main manifestation, with pain often regionalised in the limbs (hands, shoulders or feet) and resistant to common painkillers. In some cases, but not always, the onset is consequent to a traumatic event, but the severity of the pain and the course of the disease are not related to the severity of the original trauma.
Pain is generally associated with edema and localized osteoporosis may appear from radiological examination, which generally decreases with the regression of the disease. The disease has been known for over 100 years and in the Anglo-Saxon world it is mainly identified with the term complex regional pain syndrome (CRPS) divided into type 1 and type 2. Algodystrophy is not included in the list of exempt rare diseases.

Another name with which it is often identified is: Sudeck's syndrome.

The onset often occurs as a consequence of a major trauma or a surgical operation. The appearance of the algodystrophic syndrome following a surgical operation has nothing to do with the success of the surgery: It often happens that the operation was perfectly successful, but the patient is faced with abnormal pain and all the above symptoms listed with difficulty in returning to a normal life of work and relationships.

The symptoms that arise in this case are similar, but greatly increased, to those that are identified as signs of an inflammatory response:

Rubor -> redness of the area caused by an increase in superficial circulation with a consequent increase in local sweating
Tumor -> Swelling partly as a consequence of the increase in superficial circulation, partly due, like the increase in circulation, to an Autonomous Nervous System that no longer responds as it should to stimuli.
Calor -> increase in local temperature and hypersensitivity to thermal stimuli due to the production of catabolites that are not drained sufficiently and alter perception because they make some nerve receptors more sensitive than others
Algor -> PAIN. The pain in these cases can be very intense to the point of being disproportionate to the stimulus: for example, the slightest touch of the skin or some movements can be extremely painful (in these cases it is called Allodìnia). The involvement of the autonomic nervous system is also evident due to the presence of symptoms such as nausea sometimes associated with pain. Most of the fibers that make up a peripheral nerve are of the autonomic type and therefore have to do with the neuro-vegetative system.
Functio Lesa -> or the loss of function. That is, you are no longer able to use your hand or foot due to the symptoms described above. This is also highlighted by the appearance of osteoporosis localized only to the affected area in the most advanced stages of the disease. In the initial stages it can be linked to the very rapid loss of muscle mass that is witnessed: this could be due to the imbalance of the Autonomous Nervous System which no longer supports muscle trophism.

We usually know these symptoms well: they are the ones we can find after any minor trauma or inflammation. They are part of a PHYSIOLOGICAL response, that is normal, that our body puts in place to allow the area to heal better.

When an algodystrophy is established, the same symptoms recur in a very increased way for no apparent reason.

It is as if our Nervous System deems it appropriate to protect us much more than is necessary.

Our brain and the Vegetative System have evolved with a very specific purpose: to coordinate multiple bodily functions in order to facilitate our survival. The animal species that in the past proved to be more efficient at managing bodily functions is the one that had an advantage over others and therefore managed to survive better. To give a concrete example:

Cold-blooded animals need long hours in the sun to reach an adequate temperature for their biological reactions.

Warm-blooded animals, on the other hand, exploit some endogenous thermoregulation mechanisms to always have the same temperature and avoid standing still in the sun, making them easy prey for other animals and being able to adapt to colder environments.

Thermoregulation takes place automatically and independently of will. Its goal is to survive changes in temperature in order to keep our body efficient.

In algodystrophy this automatic mechanism enters a vicious circle: an event such as a trauma (physical or psycho-emotional) evokes a protective response on the part of the Autonomous Nervous System; the response is automatic and is represented by inflammation.

In this case, however, we will have an exaggerated inflammatory response that leads to a greater excitability of free nerve fibers due to the creation of neuropeptides such as Substance P which lower the activation threshold of mechanoreceptors by increasing the signal that goes to the brain.

At the central level, the response that arrives will not be a mechanical stimulus information, but a real scream of alarm to which it will have to respond by increasing the "guard" and therefore bringing greater attention to the affected area; Increased attention will lead to a misinterpretation of the signals coming from the periphery, magnifying them and perpetuating the vicious circle.

Making the person aware of these mechanisms through an adequate knowledge of how pain works, can already make a great contribution to understanding how to best deal with this pathology.

Educate the person

When dealing with an algodystrophy, the role of education becomes fundamental and it is necessary for the person to understand the mechanisms of pain based on the most current studies and evidence in order to have a powerful ally at our side.

The password must be RESPECT for oneself and above all for the color which can be a subject with a very difficult character to manage and for this reason it must be treated with gloves, but at the same time one cannot think of not considering it.

what techniques might be indicated in this case?

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