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A Study on Chronic Pain and Review of an Editorial on Crps by Frank Birklein and Violeta Dimova

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In the article, Complex regional pain syndrome-up-to-date, Frank Birklein and Violeta Dimova examines the topic of the chronic pain condition complex regional pain syndrome. Birklein and Dimova thoroughly explains the history, classification/diagnosis, symptoms, pathophysiology and treatment plans for complex regional pain syndrome.

Let’s start with the history, it took about 100 years to form the acronym CRPS. It started with Silas Weir Mitchell reporting on causalgia in 1864, then it moved to Paul Sudeck in 1901 in Hamburg Germany reporting “acute reflex bone atrophy after inflammation and injuries of the extremities and their clinical appearances,” this is commonly known as CRPS type 1. Next was in 1936 when James A. Evans created the phrase “reflex sympathetic dystrophy” which has since been used. It wasn’t until a conference in Orlando, 1995 that it was agreed to use the phrase “complex regional pain syndrome.”

CRPS usually comes after an injury or trauma to an extremity. It is more common in women between 40-60 and the risk of developing CRPS seems to be higher for patients with a rheumatological disease, complicated fractures or intense pain 1 week after a trauma.

The diagnosis of complex regional pain syndrome is made by the Budapest diagnostic criteria for CRPS. It can be differentiated between the two types, Type 1, without obvious nerve lesion and type 2, with verifiable nerve lesion. The trauma typically comes before the clinical symptoms. Instrument based investigations are beneficial if there are doubts about the diagnosis. Limb magnetic resonance imaging helps eliminate diagnoses like rheumatic disease or infection, X-rays can prove osteoporosis or differential a diagnosis such as psuedoarthrosis after a fracture. The CRPS severity scale is an instrument that may be used to grade the severity of CRPS and to supervise the course.

The most important symptoms is pain that is permanent or sporadic often in the deep tissue. Pain becomes more severe through movements and changes in temperature. In chronic and severe cases allodynia is present and unique. Sensory deficits are reported such as hypoesthesia and weakening of thermal perception after glove like pattern. Patients often report feeling that the affected extremity no longer belongs to their body. Patients also have diminished muscle strength and pain induced movement avoidance. Contractures improve slowly and sometimes remain permanent. Other changes can be found on the skin, nails and the hair. All patients display a change in skin color often red(warm) to blue(cold). Rare symptoms are tremors, myoclonus, or fixed dystonia.

The pathophysiology of complex regional pain syndrome. The first step in the pathophysiology is signs of inflammation like redness, swelling, hyperthermia, pain, and reduced function. A trauma causes a complex immune response, cytokines activate osteoblasts and osteoclasts which explains the osteoporosis. The cytokines provoke pain and hyperalgesia through the sensitization of peripheral nociceptors which enables the release of neuropeptides which causes the visible inflammatory signs. Next is neuro plasticity. Plasticity is important for CRPS, which is when treatment is resistant for 6 to 12 months. When symptoms cannot be explained via pathophysiology it is attributed to learning processes. If inflammatory processes fade within the first year however if visible autonomic symptoms remain they must have another pathophysiology. Depression and anxiety are not related to the development of CRPS, however it would be foolish to not think that psychosocial would not be involved in continuance of pain, suffering and reduced participation.

Lastly treatment options, there is no such thing as a one fit solution treatment for CRPS. Most treatments are made up by treating the symptoms of CRPS. Gabapentin is commonly prescribed for allodynia, sedative tricyclic antidepressants are used if sleeping problems continue, and glucocorticoids reduce posttraumatic inflammation. Analgesic can be tested in the acute phase and if opioids are chosen it is suggested that efficient amount of pain (>50% with reasonable dose) is reduced within 2 weeks. Opioid effectiveness must be strictly controlled otherwise opioid insensitive paid will lead to false increase of dosage, dependency, and an increase in pain. Other forms of management for pain is intravenous ketamine infusions and sympathetic nerve blocks. When noninvasive remedies fail a spinal cord stimulator is another course of treatment. A spinal cord stimulator for an upper extremity might cause problems because of problems such as a dislocation of an electrode. Physical therapy assists in training a physiological use of an extremity. Many patients are encouraged to willingly use the affected limb even if it causes a momentary increase in pain and other symptoms. It is a widespread misconception that a patient with CRPS should avoid pain to prevent aggravation, but if the extremity is not moved during the inflammatory point contractures follow quickly. Even though a limb should be moved, forced movement by others should be avoided because of a loss of patients’ self-control. Mirror therapy is a valuable treatment for acute CRPS that involves learning to adapt the mirror image of the healthy limb as the affected. Patients should also undergo psychotherapeutic and sociotherapeutic methods especially if any psychosocial circumstances or comorbidities exist (ex. Depressive mood, pain related avoidance, PTSD, financial worries). For a treatment if dystonia, Botulinum toxin might be less helpful for fixed dystonic positioning than for action related dystonia in neurology. Though because of the minimal invasive characteristics it makes sense in some cases. If the dystonia makes progress, pain will also get better.

The reason I chose to summarize an article on Complex Regional Pain Syndrome is because of my own personal experience with the condition. I was diagnosed with CRPS a little over a year ago after a trip on some bleachers at a football game. I struggled and still do on becoming educated on my condition.

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A Study on Chronic Pain and Review of an editorial on CRPS by Frank Birklein and Violeta Dimova. (2019, April 26). GradesFixer. Retrieved June 24, 2022, from
“A Study on Chronic Pain and Review of an editorial on CRPS by Frank Birklein and Violeta Dimova.” GradesFixer, 26 Apr. 2019,
A Study on Chronic Pain and Review of an editorial on CRPS by Frank Birklein and Violeta Dimova. [online]. Available at: <> [Accessed 24 Jun. 2022].
A Study on Chronic Pain and Review of an editorial on CRPS by Frank Birklein and Violeta Dimova [Internet]. GradesFixer. 2019 Apr 26 [cited 2022 Jun 24]. Available from:
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