The treatment of complex regional pain syndrome (CRPS) usually involves a combination of physical treatment methods and medication to manage the pain.
Your treatment will usually be co-ordinated by a multi-disciplinary team (a number of different healthcare professionals working together). See the box to the right for more details about who may be involved in your treatment.
Physiotherapy
Many experts feel that physiotherapy is the most important factor in treating CRPS. The aim of physiotherapy is to:
- improve, or restore, movement to the affected body part
- prevent muscle wastage
- prevent contortion of the bones (when the bones are bent out of shape)
Your physiotherapist (a healthcare professional who is trained in the use of physical methods, such as massage and manipulation, to promote healing) will teach you a range of exercises. These will gradually improve the strength and flexibility of the affected body part.
Initially, physiotherapy can be very painful, but research has shown that the symptoms of pain tend to improve significantly for people who persist with physiotherapy.
See the Health A-Z topic about Physiotherapy for more information about this type of treatment.
Graded motor imagery
A review of a number of different techniques used in physiotherapy found that graded motor imagery may be most effective for reducing pain in people with CRPS.
Graded motor imagery aims to change the way your brain thinks about pain. There are three steps to this treatment, which are described below.
- Step one: testing your "laterality" (your ability to tell left from right). This is where you teach your brain to recognise right and left images, for example by correctly identifying a picture of a left hand or a right hand.
- Step two: "motor imagery" (imagining movements, or watching other people move). As you watch other people move you imagine that it is you doing the movement.
- Step three: mirror therapy (a mirror is used to reflect the ‘good’ limb). For example, if your left hand is causing you pain, it is placed in a mirror box so that your right hand (the "good" hand) is reflected. Your brain sees two "good" images and is tricked into thinking that your left hand no longer hurts.
Mirror therapy is sometimes used when people have had a limb amputated to help with phantom limb pain (a sensation that their limb is still attached to their body and is causing them pain). Mirror therapy has also been found to be effective in CRPS, and works best after following the first two steps which help prepare the brain for this type of treatment.
While mirror therapy has been used in physiotherapy for some time, graded motor imagery is a relatively new technique and it may not be available from your local primary care trust. If it is available, your physiotherapist will discuss the technique with you if they think that it may be beneficial.
Occupational therapy
An occupational therapist can help to identify problem areas in your everyday life, such as dressing yourself or getting to the shops. They can then help you to work out practical solutions that will enable you remain independent.
For example, if you are experiencing pain in one arm, an occupational therapist will be able to teach you how to complete activities one-handed. Alternatively, they can find ways for you to continue using your arm by practising certain movements.
Pain relief
There are a number of medicines that have proved successful in treating the pain of CRPS. Your GP or pain specialist will discuss these with you, as well as the possible side effects of each, in order to find a programme of medicine that is effective.
In treating CRPS, a step-wise approach to pain management is usually recommended. This means that your treatment team will try lower strength painkillers first, and will only use stronger painkillers if they are necessary.
Alternatively, a short-term course of strong painkillers may be used so that you are able to begin physiotherapy. Once you begin to respond to the positive effects of physiotherapy, you move on to weaker painkillers. Some pain relief treatments are discussed below.
Non-steroidal anti-inflammatory drugs (NSAIDs)
The first type of painkillers that are often used to treat the pain of CRPS are over-the-counter (OTC) painkillers called non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen.
People are often surprised that NSAIDs are recommended to treat severe pain. However, they have been shown to be very effective in relieving the symptoms of CRPS in many people. They can also help to reduce any associated swelling.
See the Health A-Z topic about NSAIDs for more information about this type of medicine.
Nerve blocks
Nerve blocks are often used to provide short-term pain relief for people with CRPS. A nerve block involves injecting local anaesthetic into a group of affected nerves. This prevents the pain signals from reaching the brain. A reduction in pain often continues even after the effect of the local anaesthetic has worn off.
Side effects of a nerve block can include:
- a rash
- itching
- weight gain
- soreness at the site of the injection
- bleeding
Although nerve blocks are considered a standard treatment for CRPS, there is a lack of research into how effective they are.
For example, one older study found that nearly half of people with CRPS might not get any pain relief from this form of treatment. Moreover, a more recent review could not find enough research into nerve blocks for CRPS to make any definite conclusions about their effectiveness.
Anticonvulsants
Anticonvulsants were originally designed to treat epilepsy (a condition that causes seizures or fits). However, they have also been found to be useful for treating nerve pain. Gabapentin is the most widely used anticonvulsant for treating CRPS.
Possible side-effects of gabapentin include:
- drowsiness
- dizziness
- tiredness
- loss of co-ordination
Do not drive, or operate heavy machinery, if you find that gabapentin is making you drowsy.
You should not suddenly stop taking gabapentin because you will experience withdrawal symptoms. These could include:
- anxiety
- insomnia
- nausea
- pain
- sweating
If you want to stop taking gabapentin, or no longer need to take it, your GP will arrange for your dose to be slowly reduced over a week. Gradually reducing your dosage in this way will ensure that you do not experience withdrawal symptoms.
Tricyclic antidepressants (TCAs)
Tricyclic antidepressants (TCAs) were originally designed to treat depression, but like anticonvulsants, they were found to be effective in treating nerve pain. Amitriptyline is the most widely used TCA for treating CRPS.
You may have side effects when taking amitriptyline, including:
- drowsiness
- dry mouth
- blurred vision
- constipation
- difficulty urinating
Do not drive, or operate heavy machinery, if you find that amitriptyline is making you drowsy. Amitriptyline should not be taken by people with a history of heart disease.
See the Health A-Z topic about Antidepressants for more information about this type of medicine.
Opiates
If you are experiencing a severe episode of pain, opiates such as codeine and diamorphine can be used to provide short-term relief.
The long-term use of opiates is usually discouraged because of the potential side effects. However, there may be circumstances where the benefits of using opiates outweigh any associated risk.
The long-term use of an opiate does carry the risk that you will develop an addiction to the medication. Your dosage will therefore be carefully monitored to reduce this risk as much as possible, but it can never be entirely eliminated.
Other side effects of opiates include constipation and drowsiness – although this should improve as your body develops a tolerance to the opiate.
Do not drive or operate heavy machinery while taking opiates.
Spinal cord stimulation
Spinal cord stimulation is a possible treatment for neuropathic pain, which is pain that is caused by problems with the body’s nerves. It involves having an operation to place a small device inside your body, usually under the skin of your tummy or buttocks.
The device produces mild electrical pulses that are sent to your spinal cord (a column of nervous tissue in the spinal column that sends messages between your brain and the rest of your body).
These pulses cause a stimulating effect that changes 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 taken out if necessary.
A trial in people with type one CRPS found that, compared to physical therapy alone, spinal cord stimulation was more effective at reducing pain.
The National Institute for Health and Clinical Excellence (NICE) has issued guidance stating that spinal cord stimulation will 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 multidisciplinary team will discuss spinal cord stimulation with you if they think that this treatment may benefit you.
Psychological treatments
Living with a chronic (long-term), painful condition can be very stressful and distressing, and people with CRPS may experience feelings of anxiety and depression.
It is important to look after your psychological wellbeing, because otherwise, as well as the adverse effect on your quality of life, feelings of depression and anxiety can interfere with your physiotherapy.
If you have been feeling very down during the past month, and you no longer take pleasure in the things that you used to enjoy, you may be experiencing depression. If this is the case, visit your GP.
Psychological therapies can also be useful in helping you to cope better with the symptoms of pain. For example, some studies have shown that a type of therapy called cognitive behavioural therapy (CBT) can help in the management of chronic pain.
CBT is based on the principle that the way a person feels is partly dependent on the way that they think about things. People who have trained themselves to react differently to their pain, by using relaxation techniques and maintaining a positive attitude, have reported that their pain levels decreased. They were also more likely to persist with their physiotherapy, which also helped to reduce their symptoms of pain.
See the Health A-Z topics about Depression and CBT for more information about these subjects.
