CRPS 1 or RSD & CRPS 2
Complex regional pain syndrome (CPRS)
As the . Name suggests, it is a complex condition with several distressing features. There is considerable confusion about the Pathophysiology , investigations and treatment.
There are 2 types of CRPS called CRPS 1 and CRPS 2 depending on the original injury . When the initial trauma is to the bone and soft tissues it is called CRPS1. When the injury is to the nerves themselves like the brachial plexus or spinal cord etc, it is called CRPS 2.
This has been called many names in the past like RSD ( reflex sympathetic dystrophy) Erythromelalgia) Sudecks atrophy etc. The presentation is disproportionately severe compared to the initiating injury and the severity lasts well beyond the expected period of resolution . Eg the fracture heals, the wound heals but the pain swelling and muscle weakness continue and in fact increase as time goes by.
There is usually a triggering event like injury to the s bones or soft tissues. However the trigger may be so trivial as to be ignored and forgotten by the patient.
The cause of this condition remains unknown. The natural course , the investigations and the treatment remain uncertain. Only the clinical symptoms are well defined by expert committees though there is considerable dissention among experts in this too.
To read about it in world literature on CRPS Regarding the causes (aetiology) why andhow it develops( pathophysiology) confirmatory investigations, AND MOST IMPORTANTLY! The TREATMENT is to read a morass of contradictions confusions and new possible therapies that do not seem to stand the test of time. Only physical therapy has been a constant, stable feature of all the multimodal therapies suggested and discarded for CRPS. However even that has been recently criticized as being too varied and diverse in the studies to be comparable or to be recommended as a specific set of exercises , manipulations or modalities.
However we at ashirvad take a look at this from a different perspective and have evolves a treatment which has been consistently and uniformly effective. The treatment has evolved over the years In a manner similar to ancient physicians who understood diseases by listening to patients describe their problems, observing their problems their response to treatments and then revising treatment or improvising new ones to suit the needs of the individual patient. We did justhis right fromour firstpatient of CRPS 10 years ago. We looked at it with a fresh perspective; reading about it in literature did not tell us howto treatthe patient. So we spent time with our patients, used modifications of the Treatments known to provide pain relief in any condition. Once the patient was madepain free, they could guide us with theirdaily inputs about our treatments. As we treated more patients, we began to understand CRPS From avery differentperspective. Because of these countless hours Spent with the patients, thinking about the mechanisms that cause this devastating problem, and puzzling out he possible treatments has led us toinnovate a treatment. For CRPS. Thathas produced. Consitently. Positive outcome. At Ashirvad, patients of CRPS are treated as VIPs, with compassion and heard patiently because it is the patients who have been our teachers not the textbooks or journalarticles. Once the patients realize that we arereally interested in their feedback they feel empowered as they are participants inhaling themselves rather. Than passive rexipientsof treatment. This category of patients particularly needs this attention as they suffer tremendously but most people includingdoctors Dismiss them as the present understanding of this condition is vague.
The diagnosis is made on the basis of diagnostic criteria defined by IASP( International association for the study of pain) Confusions persist regarding different subtypes and symptom progression through stages of hypertrophy, dystrophy, atrophy. But for us wioth a different perspective there is no confusion. Varying degrees of pain relief from some treatments have been reported but there is no scientifically established treatment that reports long-term functional recovery . In the past 8 years we have evolved a multi-modality treatment regimen (MMTR) that achieved a consistent predictable complete reversal of pathology of CRPS1 with restoration of function.
After informed consent, photographs comparing both hands in neutral position, making a fist, movements at elbow and are documented. Videos of hyperaesthesia to a gentle stroking by hand and allodynia and mechanical hyperalgesia to gentle pressure by the finger pulp are recorded. The range of movement (ROM) at the metacarpophalangeal (MPJ), interphalangeal, joints (IPJ), wrist, and elbow and shoulder joints are measured. Pain report on verbal rating scale (VRS) at rest and on movement at all the joints of upper extremity, forearm circumference 5cm below olecranon and temperature in both limbs are measured.
All these measurements are repeated at weekly intervals to assess the improvement . The desirable goals od CRPS treatment are
1. Relief of pain – both the pain at rest as well as that on movement : with MMTR this is achieved from day1
2. Reduction of the swelling, the temperature and other changes: this is achieved in about 48 hours though these symptoms transiently recur now and then for about 10-15 days. After this they do not recur
3. Reduction of stiffness, return of free movements.: this is the most important as well as difficult problem of CRPS. To quote one of our patients "CRPS is a disease of stiffness from beginning to end " . The activities of daily living where actions which were natural for them prior to CRPS. Become great feats of endurance. Simple things like holding a ball, or a glass are impossible because the fingers and thumb can neither flex nor oppose. They cant even dream of fine activities like holding a pen for writing , or a spoon for eating Or buttoning a shirt . Activities like. Fastening a. Trouser or A skirt requires both finesse as well as strength neither of which is available to CRPS patients . The disability of CRPS occurs so suddenly and proceeds rapidly that the patients have no time to prepare or cope. People who had complete. Activity suddenly find themselves totally dependent on others for all their activities. The Psychological trauma which is considerable is compounded by the disbelieving attitude of those around them and the doctors who are not familiar with this. Devastating condition. The disbelief, shock and and anger can only be understood by someone who has suffered CRPS or has been close to them. Often, pain swelling and redness are so florid that the stiffness is intuitively attributed to them but It is the stiffness that unequivocally leads to disability. Unless this. Is addressed. ThEre can be very little recovery of function in these patients. This problem is systematically addressed by MMTR With dry needling. This. Reduces the stiffness in an incremental manner . With every session, the stiffness. Reduces to increase the range of movement at the joints of the. Fingers and wrist.
4. Activities of daily living like eating, dressing one’s self, moving about freely etc independently. By about 25-30 days the stiffness reduces to a level where the patient is able to comfortably carry out most of the activities of daily living, like Mixing food. With their hand, eating, dressing themselves, combing their hair etc. Fastening bra is probably one of the most difficult act, sit entails finesse as well as strength not to mention anextreme level of internal rotation at the shoulder. However our patients achieve it by 3 weeks. Once the ROM is achieved they have to work with physiotherapy to achieve strength so that they can make a tight fist so essential for lifting, grasping turning twisting objects. However all our patients achievethse consistently so thattheycan return to personal and professional activities.
5. Rehabilitation towards the level of activities that the patient was routinely capable of prior to the onset of CRPS . This includes the ongoing medications, physicaltherapy to sustain and augment the functionality and restoration of fine-tuning of activities
6. Professsional activities like writing, lifting weights, using the computer, cooking, sewing, skilled activities etc
Correction of deformities which were already present at the time first visit to Ashirvad . Some of these like the clawing of the hand can be reduced by MMTR but can't completelybe reversed. Importantly in spite of the deformity restoration of function and rehabilitation to normalcy in Personal and professional life is possible in most of our patients.
Our multimodality treatment developed at Ashirvad achieves all of the above goals except the last one. The deformities that the patient presents with are minimized but in some patients it is not possible to reverse them completely.
Patients usually resume daily activities of living within 18-25days. Minimal deformity persists in patients with hand and forearm surgery and those who had developed claw hand before our treatment. But none had any restriction of hand function.
Ashirvad Treatment of CRPS and other neuropathic pains.
At Ashirvad, patients of neuropathic pain are treated with compassion and heard patiently- and then treated promptly. Simpler forms of CRPS may require only assurance, medications, local application of local anaesthetic creams or patches and IMS.
For CRPS the whole gamut of treatments may be necessary as MMTR (multimodality treatment ) Steroid injections into sympathetic and somatic nerve plexuses with Continuous catheter techniques, IMS, mirror box therapy, Rehabilitation and medications, Interventions are performed in the operation theatre with oximetry, non-invasive blood pressure monitoring and with antibiotic cover. Blocks are performed under Fluoscopic guidance after confirmation of dye spread with Omnipaque a radio opaque contrast.
However those who developed an infection of the catheter or where the catheter came out accidentally had to have the catheter reinserted unless they had already resumed daily activities of living.
This combination of treatments of MMTR is unique to Ashirvad and has proved to be a winner in the terrible condition of complex regional pain syndrome. We have a CONSISTENT RECORD OF SUCCESS in restoring patients to their prior lifestyle. The reversal of the condition is achieved in a predictable step by step manner. With the Initial nerve block the patient is immediately relieved of pain and hypersensitivity. Later, with successive IMS increases range of movement at several joints that were stiff initially. The patients start gradually performing their daily activities of living till they return to a full active use of the hand or leg or whatever part is affected by CRPS A feat not claimed by any report so far by any other treatment. Physical and occupational therapy plays a major role in the restoration of quality of life to help our patients suffering from chronic neuropathic pains. The treatment is tailor made for every patient as underlying causes in each patient is different with different manifestations.
We attribute our success to IMS in this very difficult condition where no other published treatment claims a recovery of function of the limb. The reason for the utilization of IMS started with
1. A different understanding of CRPS as compared to the prevalent opiinnion in scientific publications and books
2. A gradual development of MMTR over 2-3 years as our understanding of the cause effect relationship of the CRPS symptoms. We have spent hours, observing the patients, the dynamics of the movements and their restriction in CRPS , to understand the cause of sensory motor and autonomic symptoms etc. MMTR was refined by this ongoing experience till we arrived at the final one about 5 years ago
3. Subsequently we have successfully treated more than 100 patients with CRPS of hand, leg and after Knee replacement surgery. The old ones get cured and move on to make way for new ones who continue to be treated successfully
4. When we assess the patient we know what treatment is needed and how it is likely to yield results. This approach does not prevail anywhere else other than at Ashirvad.
CRPS-2 or causalgia : Here again we look at the problem from a different perspective and as such the treatment is also different. In causalgia also the above treatment has helped many of our patients to normalcy though the paralysis from the nerve damage may persist. The nerve damage adds another dimension to the problem that makes a complete cure a little more difficult. Occupational therapy is then very important to these patients for an approximation towards normalcy.