|Does CRPS spread?
By Steve Stanos, DO
Medical Director, Chronic Pain Care Center, Rehabilitation Institute of Chicago
That's a difficult question to answer. Cases of CRPS
"spreading" are limited to a small number of classic
case reports and a small number of more recent case studies
from academic tertiary-based pain treatment facilities. The
"spreading" more likely represents dysfunction or
chronic changes of the central nervous system (plasticity)
at the level of the spinal cord and brain. Similar nervous
system changes have been recognized in other chronic pain
conditions. Maleki et al1 reviewed a number of CRPS/RSD "spreading"
cases where they described three clinical scenarios: contiguous
spread (higher up in the same limb), mirror image (same limb,
opposite side), and independent spread. Most of the patients
in this study with "spreading" also suffered some
type of trauma or underwent some type of invasive procedure.
A number of the mirror image cases were postulated to have
developed from compensatory overuse of the other initially
Recent clinical studies of CRPS patients have demonstrated
manifestations of these changed in the nervous system. A patient,
for example, who suffered a severe crush injury to the hand,
was found to have pain and sensitivity to normal innocuous
light touch (allodynia) and other changes of sensation and
strength in the same contiguous. Similar changes in sensation
and the presence of swelling was noted in leg on the same
side of the body of the original trauma. More importantly,
"spreading" of symptoms in the same limb or region
of the body is more likely related to myofascial pain syndrome.
With respect to patients, this can be considered an important
and viable target for treatment. Myofascial pain can be treated
effectively with medications, active physical therapy, and
other behavioral treatment techniques. Many times, appropriate
treatment of the myofascial component of their pain problem
can have significant and profound effects on reducing pain,
increasing range of motion, improving posture, and returning
patients to greater levels of function.
Is myofascial pain the same as fibromyalgia?
No. Although both are controversial muscle pain conditions,
they are distinct clinical entities. Myofascial pain is a
soft tissue disorder localized primarily to one region of
the body, characterized by myofascial trigger points. Myofascial
trigger points, are hyperirritable locations within an area
of skeletal muscle fibers, that when compressed , can give
rise to characteristic referred pain patterns and tenderness.
For example, trigger points from the neck or cervical region
can "refer" pain to the head. Other trigger point
referral patterns from muscles along the lower back region
can refer pain down the leg. Fibromyalgia, also a disorder
of muscle sensitivity, is a syndrome characterized by widespread
musculoskeletal pain. Although the clinical spectrum varies
among patients, it generally involves more generalized muscle
tenderness, above and below the waist (all four quadrants
of the body), neuroendocrine effects, sleep and gastrointestinal
disturbance, and psychological distress (depression and anxiety).
How do CRPS patients develop myofascial pain?
As with many other chronic pain conditions, normal pain mechanisms
go awry. Inflammatory, autonomic, and neuropathic changes
at the level or area of injury cause significant changes at
the spinal cord and brain amplifying pain and dysfunction.
Compensating for the injured limb over time causes long-term
maladaptive changes in the body and supporting muscles. For
example, protecting an injured hand with CRPS, may cause
weakness or tightening in the supporting muscles of the shoulder
and neck. These overused and deconditioned muscle groups are
more likely to develop myofascial pain. Myofascial trigger
points in the neck and shoulder can cause pain to radiate
to the head (headache) or to the same or opposite limb. These
painful and sometimes disabling symptoms may be misinterpreted
by the patient and health care providers that the CRPS
How do you treat myofascial pain? Do injections work?
Yes, in some circumstances injections may be beneficial. Drs.
Travell and Simons2 have meticulously described muscle patterns
of pain with trigger points and a broad range of treatment
approaches for aggressively treating myofascial trigger points.
Active treatments include injection therapies, stretching
exercises and other physical modalities (heat and ice). Common
injection therapies include the use of local anesthetics,
steroids and/or saline. Dry needle techniques and injection
of botulinum toxin (Botulinum toxin A/ BOTOX) have more recently
gained popularity in the field of pain management. Biofeedback
assisted relaxation training may also be an effective tool
patients can learn in reducing muscle tension and subsequent
pain. Correcting postural abnormalities, strengthening and
stretching muscle groups in the effected myofascial areas
is a key component of any individual's treatment program.
Many times, aerobic conditioning is also coordinated into
the patient's treatment and home exercise program.
What is the incidence of myofascial pain with CRPS?
Published reports vary greatly between 60% and 80% of CRPS
How about botulinum (Botox) injections for myofascial pain?
Botulinum toxin is a potent neurotoxin indicated for dystonia
and spasticity. Its use for cosmetic purposes cannot be ignored
either. The neurotoxin is injected directly into a trigger
point. The toxin is thought to be effective in reducing muscle
spasm at the site of injection and by causing changes in pain
processing at the spinal cord. Recent animal and human research
has also supported the toxin's possible additional analgesic
effects. A number of studies of its potential use for myofascial
pain, chronic tension type headache, and migraine have revealed
conflicting results regarding its therapeutic benefit. Obviously,
careful patient selection is an important factor. Neurotoxin
injections or any other modality should not be used in isolation,
but incorporated into a more comprehensive treatment program.
1. Maleki J, LeBel A, Bennett GJ, Schwartzman RJ. Patterns
of spread in Complex Regional Pain Syndrome, type I. Pain. 2000;88:259-266.
2. Travell JG, Simons DG. Myofascial pain
and dysfunction: the trigger point manual, the upper extremity.
Vol 1. Baltimore: Williams & Wilkins; 1983.
Updated July 19, 2005