I.) What is Complex Regional Pain Syndrome Type I?

Complex Regional Pain Syndrome Type I presents as algodystrophy, namely a painful local disturbance of growth, particularly due to focal aseptic necrosis of bone and cartilage with ensuing permanent dysfunction. Tissue changes may point to regional vegetative derailment (Debrunner 1988), hence the predominant phenomenon is a local metabolic disorder.

Patients complain about diffuse and intense burning pain comparable to causalgia (Complex Regional Pain Syndrome Type I I) which presents as persistant severe burning of the skin usually following direct or indirect trauma to a sensory nerve. Often hyperesthesia is encountered with an unusual increased or altered sensitivity to sensory stimuli sometimes even mounting in allodynia, a condition in which ordinarily non-painful stimuli evoke pain.  --------------------------------------------  Complex regional pain syndrome type I in the left hand

Possible Long-Term Consequence

Involved joints may stiffen. Sud eck`s a trophy is especially serious, if the hand is affected, because this may lead to permanent disability.

Leading Causes

Complex Regional Pain Syndrome Type I may develop even after minor arm or leg injury. In the lower limbs Complex regional pain syndrome Type I manifests mostly around the pelvis, knees and feet. Complex Regional Pain Syndrome Type I is not an obligatory consequence following every physical injury, hence this leads to the assumption of an individual disposition for disease development with special lability of the individual’s vegetative nervous system. Pathogenesis, namely the steps in disease development are currently unknown.

How often does Complex regional pain syndrome Type I occur?

The current literature estimates the risk to acquire Complex Regional Pain Syndrome Type I from 0,05% to 5%. Only adults mostly females within the 5^th and 6^th decade of life acquire the disease. 

Course of Disease

1.  stage one (acute stage): The acute stage is characterized by severe pain even at rest and swelling owing to edema, namely an abnormal amount of acquired fluids and ensuing severely restricted function. The skin is bluish to maroon in color with a doughy consistency and shows characteristic increase in temperature.

2.  stage two (dystrophic stage): The dystropic stage marks a disorder which is based on mal- or undernourishment of that particular body part. Tissues become atrophic and eventually swelling retreats. Pain vanishes and temperature in the affected portion of the body will decrease.

3.  stage three (atrop hy): Bones and soft tissues are atrophic, namely they have degenerated, and even muscles as well as involved joint capsules have shrunk. The skin is very thin, pale as well as brittle and involved bones have decalcified. (see x-ray).

How is the Complex regional pain syndrome Type I diagnosed?

1.  Typeical previous medical history (often – not always – following an injury or surgery)

2.  physical exam – inspection, namely thorough examination of the patient, detection of possible alterations as well as palpation, namely pressing lightly on the surface of the body to feel organs or tissues underneath in order to determine consistency, elasticity, mobility and response to painful stimuli (algesia) etc.

3.  x-ray – x-rays present with Typeical spotty osteoporosis. It is necessary to compare findings with the non-affected side, e.g. comparing both limbs.

Treatment of Complex Regional Pain Syndrome Type I:

1) Systemic medical treatment:

• The acute stage responds well to cortisone treatment,  e.g. methylprednisolone 80 mg/day for 4 to 5 days. The dosage is then slowly reduced over the next two weeks. Other causes of infection have to be excluded beforehand.
• The administration of tricyclic antidepressants – a member of the antidepressant group of drugs - have shown useful in the treatment of Complex Regional Pain Syndrome Type I . It is important to explain to the patient that the drug is not prescribed to treat depression, but for its well known pain reduction effect. Pain is eliminated by inhibition of serotonin reuptake – a neurotransmitter and hormone – as well as noradrenaline reuptake – a catecholamine and hormone stored in the adrenal medulla - which ban pain development and foster pain relief. 
  recommended dosage: amitriptyline (e.g. Laroxyl®) and clomipramine (e.g. Anafranil®) up to 150 mg/day.
• Complex Regional Pain Syndrome Type I and accordingly CR PS (Comp lex Reg ional Pain Syndrome) may be treated with antiepileptics - drugs that are used in the treatment of epilepsy – namely medication which has also proven useful in the treatment of Complex Regional Pain Syndrome Type I (Tremount-Lukats et al. 2000). Gabapentin (Neurontin®) and pregabalin (Lyrica®) are today the most important drugs in this group. Depending on individual tolerance dosages may be increased rapidly.
• It is difficult to give general recommendations for pain alleviating drugs based on large differences in individual patient response. Analgestics should be tested prior. However, in most cases centrally acting analgesics, e.g. drugs that act on the brain and the spinal cord, need to be administered. 
• Calcitonin, a hormone, may demonstrate favorable effects in Complex Regional Pain Syndrome Type I, however, results in clinical trials are currently ambiguous and the authors have not been able to demonstrate significant positive results. 
• Intravenous administration of biphosphates (e.g.Ostac®) has also been recommended in the literature (Varenna M, et al 2000).
• Phenoxybenzamine (Dibenzyran®) has been recommended for management (Thoden 1987). Our experience has not shown a positive effect, which justifies the considerable side effects encountered.

2) Localized medical treatment in Complex Regional Pain Syndrome Type I:

• DMSO (dimethylsulfoxide) (e.g. Rheumabene®) – fatty cream, applied 4 times /day (Zuurmond WW, 1996). 

3) Specialized pain management/ therapeutic local anaesthesia

Continuous administration of therapeutic local anaesthesia using a local anesthetic has shown significant positive results in the management of Complex Regional Pain Syndrome Type I. 
For the upper limbs blockade of the stellate ganglion – a „vegetative switch“ on the side of the neck – using continuous ganglion blockade with an opium related drug employing a catheter has demonstrated positive therapeutic outcomes. Continuous blockade of the brachial plexus with the use of a catheter seems to show favorable results, because the network of nerves in the arm contains many vegetative fibers. Hence, next to the desired inhibition of nociceptors – a peripheral nerve organ or mechanism for the reception and transmission of painful stimuli – there is also an increase in blood circulation which in turn enhances prior disturbed microcirulation in the affected painful portion.

Within the lower limb region including the hips continuous block procedures are also applied.

• hip: continuous blockade of the lumbar plexus via femoral nerve catheter
• upper leg, knee, lower leg: continuous femoral nerve block (peripheral block)
• lower leg (back portion and side) as well as foot: continuous sciatic nerve block**

The femoral and the sciatic nerve also contain vegetative fibers, hence fostering the desired symphaticolysis  - which has a vessel dilating and thus blood circulation enhancing effect.                                                       
Next step in management marks continuous epidural – close to the spinal cord - blockade with a catheter. Complex Regional Pain Syndrome Type I may require longer block treatment often at least 2 to 3 weeks. 

4) Additional therapeutic management in this Complex Regional Pain Syndrome:

• Intravenous guanethidine blockade
• acupuncture
• physical therapy including ultrasound, which seems to be especially suitable for the disorder (Thomalske 1991)
• magnetic field therapy may also prove helpful 
• Important management options are physiotherapy including lymphdrainage and functional ergotherapy treatments. Physiotherapy should not be strenuous or painful as this may lead to constriction of vessels with ensuing local dysfunction in metabolism. Physiotherapy is best done when pain transmission is mostly cut off by blockade treatment.
• hypnotic – mind altering – procedures including autogenic training, or progressive muscle relaxation according to Jakobson and pain-coping strategies mark sensible supportive measures.

Recently, our center has been able to demonstrate very good results employing SynOpsis therapy for the lower limbs. The lower legs are placed in a container filled with water. Sound waves of a predetermined frequency are transmitted pulse synchronously. This is also referred to as syncardial - namely in the same rhythm  - tissue training. Enhancing blood circulation in this area causes improvement in localized metabolism disorders. Please go to: www.1-avk.de ,if you would like to find out more about this therapeutic option.

If chronic pain had been persisting in Complex Regional Pain Syndrome Type I a chronic stage I or II - according to the Mainz classification - of the disease may be present. These cases will often not suffice with physical treatment, however, additional psychological counseling or psychotherapy may serve a very supportive function in management.

**Continuous blockade

A thin flexible tube is inserted close to the nerve network, or the nerve respectively, in a so-called continuous nerve blockade procedure employing a catheter. Implantation is done via a commercially available canula, hence „incisions“ are not necessary. The dosage of the local anesthetic is injected pain free several times daily depending on individual patient needs. A pump may also be connected for administration of local anesthetic, if necessary. The dosage of the anesthetic is adjusted to allow for sufficient muscle strength to do physiotherapy, hence in some cases physiotherapy can only be done with a supporting block, namely the inhibition of pain transmission. Pain alleviation usually lasts longer than the actual treatment, which may be due to  involvement of vegetative nerve fibers in blockage leading to significant increase in blood circulation and thus resulting in improvement of local metabolism which is crucial in Complex Regional Pain Syndrome Type I.  
Newer clinical research has shown that intensive blockage therapy may erase so-called pain memory even in pain disorders based on Complex Regional Pain Syndrome Type I.
Intensive nerve blockade treatment is only available in specialized clinics.

Our physicians are very experienced in treating Complex Regional Pain Syndrome Type I. We have administered ongoing treatments for this disorder for several years.

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II.) Injury to a nerve can lead to neural pain, also known as Complex Regional Pain Syndrome Type II or Cau salgia.

This condition is characterized by excruciating burning-hot pain of the involved limb, triggered or enhanced by even the slightest touch (Allodynia); sometimes the painful response may be in body parts distant to the site of injury (Synaesthalgia). Other triggers are optical or acoustic stimuli, dryness (Xerosalgia), heat, emotional stimuli or the mere imagination of pain (Sympsychalgia). In addition, poor perfusion and trophic skin changes (i.e. changes in skin growth and nutritional status) occur.

This painful response by slight touch shares a similarity to trigger mechanisms in Neuralgia. However, in complex regional pain syndrome type II, pain distribution is independent of the area which the injured nerve supplies; it may even affect the contralateral limb (Alloparalgia).

Sometimes this complex regional pain syndrome is erroneously described as neuralgia. 

Characteristics of a this complex regional pain syndrome: 

1.     Damage to a nerve trunk following direct injury

2.     Persistent burning pain

3.     Exaggerated pain response after mechanical stimulation (Hyperalgesia) or – in extreme cases – after simple tactile stimulation (Allodynia).

4.     The pain does not necessarily coincide with the supply area (innervation area) of the damaged nerve.

5.     The regional pain is accompanied by disturbances of blood perfusion (hypoperfusion) and increased sweat secretion. Edema (= swelling) may occur.

The term “ca usalgia” for nerve pain emphasizes the characteristic burning nature of the pain, whereas a Sud eck`s a trophy incorporates additional symptoms. Complex regional pain syndrome type I is called Sudeck’s Atrophy.

Pharmacological pain management in complex regional pain syndrome type II:

In the acute or subacute phase Non-Steroidal Anti-Inflammatory Drugs (NSAID`s), e.g. Mobec® (long-acting, with gastric protection). The so-called COX-2 Inhibitors have demonstrated the best gastric protection, e.g. Parecoxib (Dynastat®) or Etoricoxib (Arcoxia®). However, this class of drugs appears to have an increased cardio-vascular risk, at least with prolonged use. It remains to be seen if Parecoxib and Etoricoxib will be taken off the market as has happened with other drugs of this class.

Sometimes the painful conditions can be controlled only with centrally acting (i.e. in the brain and/or spinal cord) analgesics (e.g. Tramadol®, Valoron N®). Carbamazepine (Tegretol®), an anti-convulsant drug, Gabapentin (Neurontin®) or Pregabalin (Lyrica®) are very helpful in the treatment of complex regional pain syndrome type II. Pyridine Nucleotides (Keltican N®) are helpful with the sequelae of nerve damage in complex regional pain syndrome type II.

In general, the long-term administration of analgesics should be avoided in complex regional pain syndrome type II due to the risk of dependence and even addiction. Combinations with antidepressants that help patients distance themselves from the pain they are suffering (e.g. Doxepin, Maprotilin) but also neuroleptic drugs help reduce analgesic requirements in many cases.
 

Therapeutic Local Anesthesia (= treatment with a local numbing medication):

Repeated nerve blocks (= numbing of nerves) with a long-acting local anesthetic, ideally continuously with a catheter, are helpful. With this technique a thin plastic tube is inserted in close proximity to a nerve bundle or the nerve involved. A standard catheter is inserted through a hollow needle, therefore no surgery or “cutting” is required. Subsequently, the local anesthetic is injected – entirely pain-free – several times a day, each time after the previous dose has worn off. In certain cases the administration of the local anesthetic through the catheter can be achieved with a small pump. In this case the local anesthetic is dosed such that muscle strength remains intact while the propagation of pain is being blocked thus enabling concomitant physical therapy. The fact that pain relief usually persists beyond the actual treatment can be explained with the concomitant effect on vegetative (sympathetic) nerve components which increases perfusion and subsequently improves local metabolism (this is a particularly important aspect of prolonged pain relief in complex regional pain syndrome type II).

It has recently been recognized that this type of intensive nerve block therapy can extinguish the so-called pain memory in complex regional pain syndrome type II.
 

Physical Therapy:

Electrical stimulation can also provide relief in complex regional pain syndrome type II. Transcutaneous (= via the skin) stimulation by low frequency generator through stick-on electrodes (TENS = Transcutaneous Electrical Nerve Stimulation) has the advantage that patients can treat themselves. The electrodes are applied as close as possible to the area of pain. Treatment effect can be optimized by changing the stimulation frequency and the size of the electrodes. Physical therapy is mandatory in the treatment of complex regional pain syndrome type II.
 

Other Treatment Modalities:

Acupuncture must not remain unmentioned. Hypnotic modalities such as biofeedback or Jakobson’s Method of Progressive Muscle Relaxation are sensible additions to the comprehensive treatment strategy for chronic complex regional pain syndrome type II, as well as learning techniques designed to help patients deal with chronic pain (Cognitive behavioral therapy).

What are the key advantages for pain management at pain therapy center Bad Mergentheim 

• extensive experience: treatment has focused on exclusively treating chronic pain patients since 1983
• professional specialization: residency training program for pain medicine
• high quality medical care: an average of 50 patients are being treated by five physicians, four are medical specialists in the area of pain medicine
• comprehensive therapeutic offer: conventional medicine including specialized procedures like implantation of morphium pumps and permanent spinal cord stimulation systems reaching to some individual naturopathy applications

An all inclusive offer of 144,42 Euros/day including drug treatments, physicians bills, accommodations and all meals.

Patients with Complex Regional Pain Syndrome Type I within the European Union may hand in their E - 112 of their individual health insurance company from their country of origin.

Airport transfer is available upon request from Frankfurt (or Munich) airport.

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Unsere internationalen (englischsprachigen) Themen: Face Pain (www.face-pain.com), low back pain (www.low-back-pain.net), Prosopalgia (www.prosopalgia.de), Complex Regional Pain Syndrome (www.complex-regional-pain-syndrome.de),

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Q Querschnittslähmung, Querschnittlähmung, Querschnittsverletzung, Querschnittverletzung, Querschnittsyndrom,
R Rachenschmerz, Radikuläres Syndrom, Radikulopathien, Raucherbeine (www.raucherbeine.com), Reaktive Gelenkentzündung, Rectumresektion, Reizdarmsyndrom (www.reizdarmsyndrom.org), Reizcolon (www.reizcolon.com), Retropatellare Arthrose, Rheumaschmerzen (www.rheumaschmerzen.com), Rheumatoide Gelenkentzündung, Rippenschmerzen, Rückenschmerz (www.rueckenschmerz-info.de)(1), Rückenschmerz (www.xn--rckenschmerz-dlb.at)(2), Rückenschmerzen (www.rueckenschmerzen.li)(1), Rückenschmerzen (www.dauerschmerzen.de/rueckenschmerzen)(2),
S Sacroiliitis, Sakroiliakalgelenk, Schambeinschmerzen, Schaufensterbeine, Scheuermannsche Erkrankung, Schienbeinschmerz, Schläfenkopfschmerzen, Schläfenschmerz, Schmerzbehandlungen, Schmerzen im Abdomen, Schmerzen im Arm, chronische Schmerzen in der Bauchhöhle, Schmerzen im Bauch, Schmerzen im Becken, Schmerzen im Bein, Schmerzen in den Beinen, Schmerzen bei Berührung, Schmerzen bei Entzündung, Schmerzen bei Berührungen, Schmerzen bei Bewegung, Schmerzen bei Bewegungen, chronische Schmerzen in der Blase, Schmerzen im Brustbein, Schmerzen im Brustkorb, Schmerzen in der Brust, Schmerzen der BWS (BWS-Bereich, BWS-Region), Schmerzen im Darm, chronische Schmerzen in den Extremitäten, Schmerzen in den Fersen, Schmerzen der Füße, Schmerzen in der Flanke (Flanken), Schmerzen im Fuß, Schmerzen in der Fußsohle, Schmerzen im Gaumen, Schmerzen im Gelenk, Schmerzen im Genick, Schmerzen im Gesicht, Schmerzen in den Gliedern, Schmerzen in den Gliedmaßen, Schmerzen in der Harnblase, Schmerzen im Hoden, Schmerzen in der Hüfte, Schmerzen im Hüftgelenk, Schmerzen der HWS (HWS-Bereich, HWS-Region), Schmerzen im Kiefer, Schmerzen im Kiefergelenk, Schmerzen im Kniegelenk, Schmerzen im Knochen, Schmerzen im Kopf (1), Schmerzen im Kopf (2), Schmerzen im Knie, Schmerzen im Kreuz, Schmerzen im Kreuzbein, Schmerzen im Leib (Bereich des Leibes), Schmerzen in der Leiste (Leisten), Schmerzen der LWS (LWS-Bereich, LWS-Region), Schmerzen in den Lippen (der Lippe), Schmerzen im Nacken (www.nacken-schmerzen.de), Schmerzen an der Nase, Schmerzen im Oberbauch, Schmerzen im Oberkiefer, Schmerzen bei Osteoporose, Schmerzen im Rachen, Schmerzen im Rücken (1), Schmerzen im Rücken (www.ruecken-info.com), Schmerzen im Schambein, Schmerzen in der Schulter, Schmerzen in der Scheide, Schmerzen im Schultergelenk, Schmerzen am Steiß, Schmerzen im Thorax, Schmerzen im Steißbein, chronische Schmerzen im Unterbauch, Schmerzen im Unterarm, Schmerzen im Unterleib, Schmerzen im Unterschenkel, Schmerzen in den Waden, Schmerzen der Wirbelsäule, Schmerzforum (www.schmerzforum.net), Schmerzkliniken (http://www.schmerzkliniken.eu), Schmerzmittelkopfschmerzen, Schmerzpraxis (http://www.schmerzpraxis.eu), Schulterarthrose (www.schulterarthrose.org), Schulterentzündung, Schultererkrankung, Schultergelenkarthrose, Schultergelenkschmerz (1), Schultergelenkschmerz (2), Schultergürtelkompressionssyndrom, Schulterschmerzen (www.schulterschmerzen.net) (1), Schulterschmerzen (www.schulter-schmerzen.de) (2), Schulternschmerzen (3), Schulter-Arm-Schmerzen, Schuppenflechtenarthritis, Sehnenentzündungen, sekundäre Kopfschmerzen, Sehnenerkrankung, Sehnenschmerz, sekundärer Gesichtsschmerz, Sinusitiden, Skalenus-Syndrom, Somatoforme Schmerzstörung, Spezielle Schmerztherapie, Spondarthritiden, Spondylitis ankylosans, Spondylodese (www.spondylodese.com), Spondylopathie, Sprunggelenkarthrose, Sprunggelenksschmerzen, Steiß, Steißbeinschmerzen, Steißschmerzen, Sternalgie, Stirnkopfschmerzen, Stirnschmerz, Stumpfschmerz (www.stumpfschmerz.de), Styloiditis, Subacromiales Syndrom, Syndrom des M. gracilis, Symphysenschmerzen, Syndrom der BWS, Syndrom der HWS, Syndrom der LWS, Synovialitis,
T Tarsalgie, Tendinopathien, Tendopathie (www.tendopathie.de), Tendinitis calcarea, Tenosynovialitis, Tennisellbogen (www.tennisellbogen.com), Thorakodynie, Tiefenschmerz, Tinnitus aurium, Trigeminusschmerzen, Tunnel-Syndrom,
U Übertragungsschmerz, Unkarthrose (http://www.unkarthrose.de), Unterarmschmerzen, Unterbauchschmerz (www.unterbauchschmerz.com), Unterbauchschmerzen, Unterleibsschmerzen, Unterschenkelschmerz, unruhiges Bein
V Vasomotorische Kopfschmerzen, Venenschmerzen, Venöse Durchblutungsstörung (www.venoese-durchblutungsstoerung.de), Vertebragene Schmerzen, Vertebralsyndrome, Verwachsungsbauch, Virale Gelenkentzündung, Viszerale Schmerzen, viscerale Schmerzen,
W Wadenkrampf, Wadenschmerzen (www.wadenschmerzen.de), Weichteilschmerzen, Wirbelkanalstenose, Wirbelsäulenschmerzen, Wirbelsäulenversteifung, Wirbelsäulenerkrankungen (www.wirbelsaeulenerkrankungen.com), Wirbelsäulenkrümmung, Wirbelsäulenleiden (www.wirbelsaeulenleiden.com), Wirbelsäulenverbiegung, Wirbelversteifung (www.wirbelversteifung.de), WS-Schmerzen, WS-Syndrom (www.ws-syndrom.de), Wurzelentzündung, Wurzelkompression (www.wurzelkompression.de), Wurzelreizsyndrome,  
Z  Zahnschmerzen, Zeckenbiß (www.zecken-biss.de), Zehenschmerzen, zentrale Schmerzen, Zephalodynie, Zervikobrachiales Syndrom, Zoster-Erkrankungen, Zervikobrachialsyndrom (http://www.zervikobrachialsyndrom.eu), Zosterschmerzen, Zungenentzündung, Zungenschmerzen,