CRPS Type I or II?

There are two types of CRPS – type 1 is caused by an initiating event such as a soft tissue injury or immobilisation in a tight cast. CRPS type II is characterised by the presence of a defined nerve injury. Both types of CRPS involve continuing pain, allodynia, or hyperalgesia that is usually disproportionate to the inciting event.

As the condition progresses both Type I and II will likely show evidence of oedema, changes in skin blood flow which can be seen in colour changes and skin temperature changes. Key to diagnosis is that both types of CRPS will exclude any other condition which could account for the degree of pain or dysfunction involved for the sufferer.

Treatment

One of the most important factors in successfully treating CRPS is early treatment preferably within an interdisciplinary setting for ease of access to the range of treatments required to manage this complex and debilitating condition.

Treatment usually takes the form of a multidisciplinary approach using a combination of treatments including multi-modal pain medication and extensive physical rehabilitation. Very often psychological support including learning coping strategies will be needed to assist the sufferer in managing the pain.

Treatment plans should always be tailored to each individual, as no two sufferers will respond to the same treatment pathway.

Despite receiving treatment, many sufferers are left with varying degrees of chronic pain, tropic changes, and disability. Pain will be the most important factor leading to any disability they are left with.

Case Study

Claire, a hairdresser, found herself in this position following a car accident when her car collided with another car on a dual carriageway.

As a result of the accident she suffered a fracture of her wrist and shoulder. Despite receiving appropriate treatment for her injuries including surgery and physiotherapy she did not recover as planned and was left with severe pain in her shoulder and limited movement and pain in her hand.

An MRI revealed nothing unusual and confirmed the fractures had healed well. After not responding to her treatment pathway, she was eventually diagnosed with CRPS type I and referred to the pain management team at her local hospital.

Claire began further treatment with medication and a tens machine to try to control her pain, she also had more physiotherapy and mirror therapy. Despite this she failed to improve and was unable to work, drive or undertake a number of normal activities of daily living such as cooking and laundry.

Following more than a year of treatment she still struggled to make a fist and had no pinch grip making it impossible to return to work. She continued to suffer with debilitating pain which had extended up into her shoulder. Hydrotherapy and injections failed to offer enough relief to enable her to function. She was eventually referred for further surgery as clinicians were at a loss as to how best to resolve her pain, however, on examination it was decided that surgery would not provide her with a solution to her pain and disability.

As a result she became very low and depressed secondary to the CRPS. She was diagnosed with post-traumatic stress disorder and underwent an extensive course of psychiatric support and anti-depressant medication. Her shoulder and deltoid shows signs of wastage and she is now wearing a support which provides limited relief.

Dr Jenner recommended a different regime of treatment which included:

• A multi-modal analgesic regime unlike her current medication.
• X-ray guided cervical facet joint injections +/- radiofrequency denervation.
• Ultrasound guided left suprascapular nerve pulsed radiofrequency.
• Trigger point injections with Botulinum Toxin A.
• Ultrasound guided stellate ganglion pulsed radiofrequency.
• To engage with a pain psychologist to master “self-help” techniques to empower her to manage her pain more effectively.
• Physiotherapy based rehabilitation using a number of treatment modalities.

If this multi-dimensional treatment failed to provide improvement Dr Jenner recommended Claire consider a spinal cord stimulator. He was also keen for her to undergo work with a highly experienced occupational therapist to work towards a graded return to the workplace, albeit in a more suitable role, to help her back into work as she was very keen to resume her working life.

Claire is making positive progress under the new treatment regime assisted by the release of funds despite the fact her case is still underway.

More information about treatment options can be found on our ‘Treatments for Chronic Pain’ blog post or the Burning Nights website which is a charity set up to provide advice and information to sufferers and their families.

Dr Chris Jenner and Dr Ivan Ramos-Galvez are experienced Consultants in Pain Medicines and Expert Witnesses who are qualified to diagnose, treat and opine on CRPS or any other pain disorder.

To instruct them please contact us on 020 7118 0650, info@medicolegal-partners.com or visit www.medicolegal-associates.com/contact/