Complex Regional Pain Syndrome (CRPS), commonly referred to as reflex sympathetic dystrophy or RSD, is a syndrome in which pain, usually burning type, is out of proportion to the injury (either nerve or no nerve involvement). The pain may spread through the entire limb and/or to other parts of the body. Examples of precipitating events that may cause CRPS include the following: fractures, surgery, frostbite, soft tissue trauma, burns, MS, tight cast, strokes, heart attack and amputations. The symptoms are characterized by autonomic dysregulation such as swelling, vasomotor instability (skin becoming pale/cool/cyanotic or red/warm/dry), abnormal sweating, trophic changes (course hair, thick rigid or brittle nails, skin may become coarse or thin, smooth, and tight), hypersensitivity, abnormal motor activity, and decreased bone density.
Medically, CRPS is managed by a variety of medications aimed lowering the rate of nerve firing, reducing inflammation, reducing anxiety, and reducing pain. More invasive measures include sympathetic nerve blocks in the spinal column or ganglion blocks, implanted dorsal column stimulation or decompression, all of which carry the same risks of any invasive procedure.
The main reason for this entry is to share a positive treatment outcome for CRPS using IMT. In general, the physical therapy treatment for CRPS includes reduction of pain to allow the pt. to maintain function. Traditional forms of exercise such as aerobic, pool therapy, ROM, joint mobilization/soft tissue mobilization, exercise emphasizing compression and distraction, functional ex. and exercise that increases blood flow to the extremity or increase proprioception to the spinal cord may be beneficial All exercise must be extremely gentle and nonaggressive especially if not initiated during times of sympathetic blocks.
My past experience with CRPS includes most patients unable to tolerate any manual techniques and very minimal exercise resulting in extremely slow progress. It has been shown in research that early intervention with physical therapy is extremely important to minimize loss of function. The earlier the intervention the more likely to reverse the dysfunction.
Recently I evaluated a pt. with CRPS onset following a bunionectomy. The pt. presented 3 months post op with extremely antalgic gait, inability to bear more than 30% weight on the affected foot, and requiring a walking cast boot to tolerate being on her feet. The patient’s foot was swollen, reddened, and there was no active mov’t in the big toe. Within 5 treatments of IMT including light touch on areas of the body specific to affecting the autonomic nervous system and indirect myofascial release (vs. more aggressive direct techniques) the patient is able to bear 50-50% body weight, ambulate w/o the walking boot with more normality. Gait quality still consisted of slight antalgia, decreased push off and mild trunk shift but the patient is able to walk further and have more energy throughout the day to function. The skin has returned to a more normal color and edema has decreased resulting in less smooth/shiny appearance. The slough and calluses which persisted on her incision long after surgery fell off naturally within 1 week and active ROM has returned in the big toe. Range of motion home exercises are being performed in a warm bath and also passively to isolate different joints of the toe. Ankle ROM exercises are also completed in the bath. In no way is this patient healed or pain free but the quality of the toe/foot appearance, gait quality and tolerance have progressed more rapidly than I have ever seen in the past.
I know I’m more than a little biased towards IMT but I want people out there to know that there is gentle, effective treatment out there that can make life a lot easier and functional if you have CRPS. Please spread the word!!
Sally Skurdahl, MPT