At this time, its cause is unknown, but the treatment
is no mystery — early mobilization of the affected
limb. “In reality, we don’t see it that often in modern
rehabilitation care because we tend to mobilize
patients fairly early even in acute hospitals and in doing
so, it seems to prevent it,” Harvey said.
Patients who do get CRPS are those who tend to be
immobilized for an extended period, perhaps because
they’re comatose or they’re on a ventilator for a long time.
Getting survivors to put weight on the affected limb
can be difficult. Harvey says he sometimes helps the
process by giving high-dose steroids to help reduce the
inflammation and allow the survivor to be mobilized and
then as they get mobilized, the CRPS begins to resolve
“The key thing is when you discover it, to hit it hard
and early. We want to prevent patients from losing range
of motion because as the tissue swells up with all the
inflammation, affected patients will begin to lose range
of motion in their joints. If you don’t treat that early on,
eventually the CRPS sort of burns out and you have this
atrophic limb with loss of range of motion. At that point,
it’s almost impossible to ever get that range of motion
back. But you don’t let that happen. You prevent it from
the get-go. Prevention is the treatment,” Harvey said.
Spasticity, an abnormal activation pattern of muscles,
occurs to some degree within a week in about a quarter
of survivors. While it may look painful, spasticity itself
is not typically painful, though it often foretells pain
syndromes — nearly three-quarters of survivors with
spasticity developed pain.
Spasticity may cause nociceptive pain because
of injury to tissue. “Depending on how severe their
spasticity is and where it’s located, in some people, it
may cause stress on the joints and tendons,” said Harvey.
Although the mechanism is not clearly understood,
spasticity may cause inflammation of those joints and
tendons, which is painful. “The treatment is to treat the
spasticity with medications and Botox® injections. We
also use medications like Tylenol® or anti-inflammatory
drugs as appropriate and that generally will take care
of the spasticity-associated pain. That one is pretty
Non-pharmacological treatment for spasticity is
stretching, maintaining good range of motion, staying
active and moving a lot. “Some would recommend
splinting but it’s not yet clear whether splinting really
helps prevent spasticity,” Harvey said.
The shoulder is the most complex joint in our bodies,
perhaps because it has the greatest range of motion. It
is a ball-and-socket joint like the hip, but the socket is
shallow and the ball at the end of the arm is held in place
by rotator cuff muscles. “When a survivor has paralysis
of the muscles including the rotator cuff, they will tend to
have instability of the shoulder,” Harvey said. The shoulder
pain usually develops as the survivor starts getting muscle
tone back, perhaps because of poor mechanics around the
shoulder or because of spasticity, which also leads to poor
mechanics around the shoulder that can lead to shoulder
pain. “But that shoulder pain is due to inflammation of the
joints, or the biceps and tendons — nociceptive pain, not
neuropathic,” Harvey said.
But this is not a subluxation, where the ball and
socket dislocate. “The only way that subluxation can
cause shoulder pain is if you don’t properly support the
arm early on and the rotator cuff gets torn because you
just let the arm hang and the tissue gets torn,” Harvey
said. That, of course, is a tissue injury (nociceptive pain)
and inflammation, but the subluxation itself is not the
cause of pain.
COMPREHENSIVE PAIN MANAGEMENT CENTERS
Today there are comprehensive pain
management centers that teach emotional
coping skills for both survivors and
caregivers as well as meditation and
mindfulness techniques. “They show them
non-pharmacological ways of managing pain
like relaxation techniques, massage and
good sleep hygiene and reduction of certain
stimulants like caffeine, all these things.
“They also teach them how to exercise without
fear that they’re going to injure themselves,” he
said. People in pain often do less, and because
of that, they get deconditioned and lose
strength and endurance.
“One of the methods in comprehensive pain
management programs is to show patients how
to exercise without making the pain worse.
As they become more physically fit, the pain
actually reduces a little bit over time, or at least
if it’s not reduced, it’s not as bothersome.”