The Theoretical Basis for and Treatment of Complex Regional Pain Syndrome with ProlotherapyAuthors: Ross A. Hauser, MD & Debra K. Brinker, RN |
Introduction
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Complex regional pain syndrome (CRPS) typically refers to post-traumatic pain that spreads from the site of injury, exceeds in magnitude and duration the expected clinical course of the inciting event, and progresses variably over time. Burning pain is the primary symptom, but patients frequently report allodynia, changes in the color or temperature of the skin, and if the condition progresses, trophic changes of the skin, nails, and bone occur. The condition produces a high degree of suffering, lost productivity and cost of treatment. While there are many theories as to why CRPS occurs, success in treatment of CRPS with traditional medical therapies is dismal.
CRPS generally appears following a physical trauma, involving the bone and soft tissues which are treated with long periods of immobility. While this immobility itself may be needed to heal a bone injury such as a fracture, it encourages ligament injuries to not heal. Stress deprivation or immobility causes a protracted state of progressive atrophy and lack of mechanical strength in the injured ligaments. The high density of both myelinated and unmyelinated nociceptors in the non-healed ligaments then become sensitized to the point that even normal or less than normal activities activate them to fire causing severe burning pain. These activated nociceptors through local and feedback loops in the central nervous system, cause autonomic phenomenon in the extremity including referral pain, edema and temperature disturbances. Research by George S. Hackett, M.D., who coined the term Prolotherapy, found that ligament relaxation (his term for non-healed ligament injuries) caused bone dystrophy (osteopenia/osteoporosis), which is a common feature of CRPS. He also noted that ligament relaxation often activated the sympathetic nervous system and that when Prolotherapy was performed to the injured ligament(s), not only did the local pain remit, but so did the autonomic phenomenon. Since traditional treatments do not address non-healed ligament injuries, this entity could be the reason that so many cases of CRPS are never resolved. Since Prolotherapy causes ligament regeneration, it should be in the arsenal of any clinician treating patients with unresolved CRPS symptoms. |
Complex regional pain syndrome (CRPS) is a chronic pain and potentially disabling syndrome which typically affects the extremities. It is characterized by a variety of autonomic and vasomotor disturbances, of which diffuse pain, spreading edema, temperature disturbances, and functional impairment are most prominent.1 CRPS generally appears following a physical injury, is disproportionate to the precipitating event or level of tissue damage, progresses inconsistently over time, and is associated with nonspecific signs and symptoms.2 It is a disease with an unpredictable and uncontrollable nature, and is a syndrome covered in controversy and confusion.3, 4 CRPS may appear at any age, indiscriminately affecting young and old, male and female. It spreads like wild fire, perhaps starting in the foot, moving its way up to the knee and back, then down the other leg, and up into the arms.
SIGNS AND SYMPTOMS OF CRPS
Complex regional pain syndrome typically refers to post-traumatic pain that spreads from the site of injury, exceeds in magnitude and duration the expected clinical course of the inciting event, and progresses variably over time. It is characterized by a variety of nonspecific symptoms and signs. (See Figure 1.) In a large sample of patients, 81% noted burning or stinging pain as the number one symptom.5 Patients frequently report allodynia, where the skin becomes so exquisitively sensitive to touch or temperature that normal light contact, such as clothing touching the skin or a draft blowing on the affected area, produces severe pain.6 Other common symptoms of CRPS include changes in the color or temperature of the skin, asymmetric sweating, trophic changes of the skin, nails and hair.7 Galer et al. noted that the most common symptoms included severe pain (100%), abnormal swelling (96.7%), and weakness (96.7%). Other initial symptoms were abnormal coldness or heat, color changes, inability to move an extremity, muscle spasms, abnormal sweating, tremors, skin dryness, and feelings as though the limb were disconnected.8, 9 The swelling may spread with accompanied muscle and joint stiffness. CRPS patients may then experience limited movement in the affected area, with atrophied muscles, limited range of motion, and possible contractures.10
| Figure 1. The signs and symptoms of complex regional pain syndrome (CRPS). | |||||||||||||||||||||||
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Signs and Symptoms of CRPS
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