Harden, R. N. & Bruehl, S.P.

The ability to identify and target psychological and sociologic diagnoses is crucial for clinical success.  CRPS pathophysiology could be influenced by the patient’s psychological factors such as life stress and dysphoric emotional states (e.g., anxiety, anger, depression) through increased catecholaminergic activity indicating the possible impact stress and emotional distress. CRPS patients report being more emotionally distressed (depression and anxiety) than non-CRPS pain patients.  Psychological stress could be a result of CRPS rather than a cause evidenced by depression levels on a given day are a significant predictor of CRPS pain intensity on the following day.  Moreover, increased stress could be in reaction to the difficulty understanding, coping, and experiencing complex symptomology.

Pain intensity and both anxiety and anger expressiveness are correlated significantly stronger in CRPS patients than in non-CRPS chronic pain patients and results suggest psychological interventions that reduce distress may directly contribute to reductions in CRPS symptoms.

Pain avoidance is one of the most common reasons for CRPS-related activity impairments and can lead to dramatic disuse to avoid stimuli that may trigger pain flare ups.  Learned disuse, reinforced by either avoidance of actual pain or kinesiophobia, may  prevent desensitization and eliminate the normal tactile and proprioceptive input necessary to restore normal central signal processing.  Learned disuse inhibits the natural movement-related pumping action helping prevent accumulation of catecholamines, tachykinins, and other nociceptive and inflammatory mediators in the affected extremity.  Pain-related learned disuse might help maintain and exacerbate both the pain-related and autonomic features of CRPS.

The only treatment methodology that can succeed between the varied presentation and mechanisms of disease is a systematic and orderly interdisciplinary approach.  Interdisciplinary treatment is a dedicated, coherent, coordinated, specially trained group of relevant professionals that meet regularly to plan and adapt to treatment eventualities.

Imaging studies suggest CRPS-related brain changes may reverse after successful treatment; thus cortical reorganization may be possible with a reduction or resolution of CRPS pain.

The treatment of CRPS should rely upon a measurable and stepwise functional restoration algorithm emphasizing physical activity, desensitization, and normalization in the affected limb involving gradual progression from least invasive interventions to complete rehabilitation.

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