Physical Therapy Guide to Complex Regional Pain Syndrome
Complex Regional Pain Syndrome can be a painful and disabling condition. CRPS generally arises from a minor injury to an arm or leg, such as a scrape, sprain, or strain, that has had enough time to heal. It can result in the syndrome defined as being complex, regional (limited to one region of the body), and painful. Around 80,000 people are diagnosed with CRPS in the United States each year. A team approach that includes care from doctors, psychologists, and physical therapists is recommended for treating CRPS.
Physical therapists are movement experts who improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To locate a physical therapist in your area, visit Find a PT.
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What Is Complex Regional Pain Syndrome?
CRPS, formally known as reflex sympathetic dystrophy, is a multisystem disorder. It typically results in severe, long-term pain and can include:
- Changes to the bones, joints, and skin.
- Excessive sweating.
- Tissue swelling.
- Extreme sensitivity to light touch.
There are generally two types of CRPS:
- Type 1: Not resulting from a distinct nerve injury.
- Type 2: Resulting from a distinct nerve injury.
CRPS involves multiple systems in the body, including:
Central nervous system: The CNS consists of the brain, spinal cord, and membranes that envelop the brain and spinal cord. It processes information from your body and your environment and provides context from past experiences for the brain to process. This system helps the brain make decisions about whether you will experience pain or not. The feeling of pain is based on whether your CNS deems that it needs protection based on the factors mentioned above.
With CRPS, your CNS can be too sensitive, making it overprotective. People with CRPS experience pain from things that normally are not painful (like your shirt brushing against your skin).
Peripheral nervous system: The nerves outside your CNS that go from your spinal cord to your limbs and trunk make up the peripheral nervous system. The PNS sends danger signals from your muscles, joints, bones, skin, and all structures in your body to your CNS.
With type 1 CPRS, there is no distinct nerve injury. However, symptoms of an original former injury may develop due to hypersensitivity of your peripheral nerves. This ultimately leads to CNS hypersensitivity.
Autonomic nervous system: The autonomic nervous system, or ANS, is the part of your nervous system that regulates your heart rate, digestion, breathing, and other automatic functions. It is often called your “fight or flight” and “rest and digest” system.
There is some evidence that people who experience a long period of “fight or flight” activity or live in a state of chronic stress may develop a more sensitive CNS.
Immune system: Your immune system detects danger in your body and sends inflammatory chemicals to fight the problem. This increases the sensitivity of the involved nerves and the likelihood that you will experience pain.
For example, when you are sick, all your joints and muscles ache. Even though there is no physical injury, your body still hurts because your immune system has increased its activity to protect your body against danger. There is some evidence that people with CRPS have higher amounts of immune activity. This could explain why some people experience continued severe pain despite their original injury having had enough time to heal.
Although research has not yet determined why CRPS occurs, physical therapy has been shown to help with managing its symptoms, improving function, and increasing the quality of life for people with CRPS.
How Does It Feel?
Most people with CRPS experience:
- Extreme sensitivity to light touch. Common everyday activities, such as wearing clothing, bathing, or applying skin creams or lotions, may become difficult and uncomfortable.
- Significant pain, often described as burning, pins and needles, stabbing, grinding, or throbbing. The pain is often more extreme than what would be expected from the original injury.
Specific signs and symptoms of CRPS may include:
- Pain and sensitivity to touch.
- A higher or lower skin temperature in the affected limb.
- A change in the color of the affected limb.
- Awkward positioning of the affected limb (dystonia) as a result of sustained muscle contractions. This occurs in about 25% of CRPS cases.
- Fearful or guarded use of the painful body part.
- The feeling that your painful body region is much larger than normal or no longer belongs to you.
- Change in the appearance of hair and nails on the affected body part.
- Tissue and joint swelling.
- Heightened release of sweat by the affected limb.
- Pain that may spread in the affected limb. In more rare cases, pain may spread to the opposite limb.
Other symptoms reported by people with CRPS include increased problems sleeping, decreased sexual desire, increased irritability or agitation, depression, and memory loss.
How Is It Diagnosed?
A diagnosis of CRPS is generally made by a doctor who is familiar with the syndrome, such as a neurologist or pain management doctor. Your doctor may first attempt to rule out other conditions, such as Lyme disease or peripheral neuropathy (a nerve injury most commonly caused by type 2 diabetes), before making a final diagnosis.
A physical therapist may be the first health care provider to recognize the onset of CRPS. Around 90% of CRPS cases occur after a trauma that may be the original reason to seek physical therapy. If your physical therapist suspects CRPS, they will discuss those concerns with you and your doctor to determine the best plan of care. Your physical therapist may ask if you have experienced any of the signs or symptoms noted above.
How Can a Physical Therapist Help?
Physical therapists play a vital role in the treatment of CRPS. Your physical therapist will work with you to develop a treatment plan to help address your condition. Because the symptoms of CRPS vary, the approach to care will also vary. CRPS treatment is based on how regular and severe your symptoms are. More importantly, physical therapy focuses on helping you achieve your personal goals.
If it is the physical therapist who first recognizes the symptoms of CRPS, your physical therapist will perform an initial evaluation of your condition as the first step to helping you get better. The goals of the initial exam are to assess the degree of your symptoms by listening to you describe the history of your condition. CRPS is complicated; people who have it may have tried often to get help from various other health care providers. Past treatments may not have been effective in relieving symptoms and improving quality of life.
Your physical therapist will begin by interviewing you to gather information about your condition. This will include your medical history, which may be assisted by forms you fill out before your first session with the physical therapist. The interview will become more specific to your condition and the area of symptoms. The term “regional” in CRPS means that the entire extremity — either arm or leg — may have experienced changes that contribute to your ongoing symptoms. Your physical therapist may ask you questions such as:
- How did your injury occur?
- Were there previous injuries to the same body region earlier in your life?
- How have you taken care of your condition? Have you seen other health care providers for treatment? Have you had imaging, such as an MRI, or other tests? What were the results?
- What are your current symptoms, and how do they change your typical activities or day?
- Do you have pain? If so, what is the location and intensity of your pain? Does your pain vary during the day?
- Are there activities that you find difficult to do? What activities are you unable to do since your injury or the onset of pain?
- Your physical therapist will take note of any activities that aggravate your symptoms and how you reduce your symptoms.
- Some people with CRPS have trouble with work or other activities, such as shopping, cooking, and walking.
- More active patients may have symptoms during higher levels of activity, such as running or other sports, that cause them to stop their desired activity.
CRPS is a multisystem disorder that causes severe pain to last longer than expected. Your physical therapist also will discuss other factors with you that affect your pain and disability, such as:
- Cognitive and emotional stresses. These can affect your nervous system sensitivity.
- Any feared movements or activities. Continued fear can mean that you are in a constant stressed state.
- Sleep quality. The quality of sleep can affect your immune system activity and general mood.
- Nutritional issues. Certain foods can heighten the sensitivity of your immune and nervous systems.
This information allows the physical therapist to better understand the condition you are experiencing and helps them determine the course of the physical examination. A physical exam will entail various tests and measures.
For people experiencing CRPS, the “region” of concern may be so sensitive that your physical therapist may be unable to touch the area. Also, the person with CRPS may fear moving the painful body part or allowing it to be moved.
Physical exams will vary from patient to patient, but most often will begin with your physical therapist observing any movements discussed in the interview. The physical exam will target the area of your symptoms, but also may include other areas of your body that may have changed or been forced to overwork due to your symptoms. Your physical therapist also may assess your low back, hip and thigh, and ankle and foot regions.
As part of the physical exam, your physical therapist may:
- Watch you walk, and go up and down stairs.
- Ask you to squat and balance on one leg.
- Assess the mobility and strength of your arm, leg, or other regions of your trunk and lower extremity. This will help them determine if other areas require treatment to improve your condition.
- Ask if they can gently but skillfully touch (palpate) the areas where you have symptoms.
Your physical therapist will determine if your condition and pain are due to an ongoing injury to your tissue structures, or due to the ongoing sensitivity of your nervous system. Your physical therapist will discuss their findings with you. They will work with you to develop a program that begins your recovery.
Treatment for CRPS may include:
Patient education. Your physical therapist will work with you to identify and change any external factors causing your pain, such as the type and amount of exercises you perform, your athletic activities, or your footwear. Your therapist will recommend improvements in your daily activities and develop a personalized exercise program to help you safely return to your desired activities.
- Learning about pain has shown to help decrease disability in people who experience pain over a long time.
- Your physical therapist also will discuss how your musculoskeletal, nervous, autonomic, and immune systems play a role in your pain experience. They will help you understand how to address those issues.
- Your physical therapist may educate you on ways to improve your sleep quality and nutrition. They will show you specific exercises that you can do to decrease your fear of certain movements or activities.
Movement therapy. Mobilizing (moving) the affected body part immediately after a diagnosis of CRPS is crucial to help prevent contractures (the tightening of muscles or joints) and maintain function. Physical therapy may include a combination of passive and active movements. Your physical therapist will determine the best treatment for your specific condition.
Graded motor imagery. Sometimes pushing through pain can make the pain worse. Other times, a person is too fearful of moving due to the thought of making pain worse. Both cases lead to less movement and withdrawal from taking part in your desired activities. Graded motor imagery, or GMI, is a process designed specifically for CRPS. It has distinct stages that allow you to gradually be exposed to movement to allow your body to adapt to that painful or feared movement without a significant worsening of your pain. As CRPS involves a hypersensitive central nervous system, the goal of GMI is to decrease sensitivity by first exercising your brain through pain education, including:
- Left/right discrimination training.
- Motor imagery exercises.
- Mirror box therapy. This is usually added as the third step in GMI. It requires a person to exercise their unaffected limb in front of a mirror while watching their reflection, as if their affected limb is performing the exercise.
Your physical therapist will teach you all about GMI, and carefully guide you through these exercises to help you perform those painful or feared movements with more confidence.
Other physical therapy treatments for CRPS can include:
Range-of-motion exercises. In CPRS, movement of an entire limb can be limited. This can cause increased stress in the region. Abnormal tightness of muscles or other soft tissue (skin and connective tissue) will alter the movement of an affected arm or leg and your joints may become stiff. Your physical therapist will teach you self-stretching techniques to decrease tension in your muscles and joints within your tolerance for the exercises. The goal is to restore normal motion of your affected joints.
Manual therapy. Your physical therapist may treat your condition by applying hands-on treatments to gently move your muscles and joints. These techniques help improve motion and improve your confidence to move your affected body part to ranges and positions you have avoided. Hands-on therapy also may be used to guide your joints into a less stressful movement pattern.
Muscle strengthening. Muscle weaknesses or imbalances can contribute to your condition. They also can cause symptoms to persist as a result of lack of movement due to pain or fear of pain. Based on your specific condition, your physical therapist will work with you to begin a safe, personalized, progressive muscle-strengthening program. This program may include exercises for the region involved in your symptoms as well as your core (midsection). Every person with CRPS requires a program to be personalized to their unique tolerance and symptoms.
Functional training. During your recovery, it is important to minimize any stress to the affected region and to learn safe, controlled movements. Based on your unique movement assessment and goals, your physical therapist will create a series of activities to help you learn how to use and move your body correctly and safely.
Physical therapy treatment will not necessarily avoid all pain, as some CRPS pain can be due to nervous system hypersensitivity. However, your physical therapist will help ensure that you are doing exercises safely without causing further musculoskeletal pain.
Can This Injury or Condition Be Prevented?
Unfortunately, the processes behind CRPS are not yet understood entirely. Therefore, there is currently no clear way to predict or prevent its onset. However, early detection of signs and symptoms related to CRPS will help you and your health care providers begin early management, which may improve your long-term quality of life.
Upon diagnosis, your physical therapist will work with you to develop strategies to better understand and manage your symptoms and help avoid any new problems developing. Patients with CRPS are encouraged to:
- Learn all you can about the syndrome. As with many conditions, education is key to maintaining function and good health. Understanding some of the underlying mechanisms affecting CRPS may help you better manage it daily.
- The fear associated with believing that persisting pain leads to continued harm to your body may cause further disability by avoiding activities and movements. A trained physical therapist can answer your questions and assess whether you are at risk for further injury. They also can determine when it is safe for you to gradually return to normal activities.
- Keep moving. It is important that you continue to move the affected limb following your diagnosis of CRPS. This will help prevent the tightening of muscles and joints and secondary effects such as dystonia.
- Learn relaxation exercises. People with CRPS often report various pain triggers in their daily lives, such as stress at work, worries about further injury and disability, loud noises, an uncomfortable living situation, and so on. Your physical therapist will teach you helpful ways to relax your body and calm your nervous system.
- Decrease systemic inflammation. Getting quality sleep, decreasing sugars in your diet, exercising regularly, managing stress, and taking part in activities that you enjoy will balance your central nervous system, autonomic nervous system, and immune system activity. When these systems are in balance, it lowers the body’s inflammatory response. Working with a physical therapist will help you identify what areas to work on and begin a plan to address your needs.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat conditions such as CRPS. However, when seeking a provider, you may want to consider:
- A physical therapist who is a board-certified clinical specialist in orthopedics or neurology or who completed a residency or fellowship in one of these areas. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
- A physical therapist who is well-versed in the treatment of CRPS or other complex, painful conditions.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you are looking for a physical therapist (or any other health care provider):
- Get recommendations from family, friends, or other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with CRPS or other painful conditions.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible. Keeping a journal highlighting when you experience pain will help the physical therapist identify the best approach to your individual treatment.
To learn more about physical therapy as a safe alternative for long-term pain management, visit our Safe Pain Management page.
Additional resources that may be helpful include:
The American Physical Therapy Association believes that consumers should have access to information to help them make health care decisions and prepare them for a visit with a health care provider.
The following articles provide some of the best scientific evidence for the treatment of CRPS. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The articles link to a PubMed* abstract of the article, which may offer the free full text so that you can read it or print out a copy to bring with you to your health care provider.
Graded Motor Imagery. Graded Motor Imagery website: http://www.gradedmotorimagery.com/. Accessed October 27, 2020.
Birklein F, Dimova V. Complex regional pain syndrome–up-to-date. Pain Rep. 2017;2(6):e624. Article Summary in PubMed.
den Hollander M, Goossens M, de Jong, et al. Expose or protect? A randomized controlled trial of exposure in vivo vs pain-contingent treatment as usual in patients with complex regional pain syndrome type 1. Pain. 2016;157(10):2318–2329. Article Summary in PubMed.
Moseley GL, Gallace A, Di Pietro F, Spence C, Iannetti GD. Limb-specific autonomic dysfunction in complex regional pain syndrome modulated by wearing prism glasses. Pain. 2013;154(11):2463–2468. Article Summary in PubMed.
Moseley GL. Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomized controlled trial. Pain. 2004;108(1-2):192–198. Article Summary in PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information. PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.
Reviewed and revised in 2020 by Kevin Ozaki, PT, DPT, board-certified clinical specialist in orthopaedic physical therapy, and Stephen F. Reischl, PT, DPT, board-certified clinical specialist in orthopaedic physical therapy, on behalf of the Academy of Orthopaedic Physical Therapy. Authored in 2014 by Joseph Brence, PT, DPT.