Complex Regional Pain Syndrome

Complex Reginal Pain Syndrome (CRPS) is a central pain condition that usually affects the arm or leg, and may present with pain in the region, temperature changes, and sensitivity of the skin. It often occurs after a physical injury, but symptoms tend to be elevated compared to the actual injury.

Pain is a protective response. Sometimes the brain continues to send signals that something is wrong, even after the area has healed. Psychological issues are not the cause, but they can escalate or prolong the symptoms.

The pain is very real. If your child believes that an activity will cause pain, the protective response will kick in and the child will have pain. However, if your child does not believe that a certain activity will cause pain, the brain will not send pain messages, and he/she will be able to perform the activity. For example, walking on sand requires increased work for the foot/ankle, but the child may be able to go to the beach if he/she thinks it will be fun -- after all, the sand is soft. If, as a parent, you point out that the sand actually causes more work for the ankle and you change the brain’s perception, pain will result with the activity.

When the foot is affected, the child may be unable to put weight onto their foot, which limits their ability to walk, run, or participate in sports activities. Often, they are unable to put on a sock or shoe due to the increased sensitivity of the skin. In addition, they may not be able to put a bedsheet over their foot at night. The foot may also be cold to the touch. In some cases, the child is unable to move the foot actively.

When the hand is affected, they may not be able to write, type, perform hygiene activities, play a musical instrument, or perform sports activities.

Physical therapy exercises, temperature training, desensitization training, visualization training and mirror therapy are tools that can be used in conjunction with psychological support to promote your child’s return to normal functioning. Based on your child’s specific needs, other team members that provide art therapy, music therapy, yoga, hypnotherapy, biofeedback, or acupuncture may be recommended and beneficial in your child’s recovery.

Physical Therapy

Exercises presented as games are often successful as they distract the child from the pain. If the child believes that the interventions will not harm the foot or cause pain, the activity will promote function. For example, using stability trainers (foam discs) as an obstacle course can seem like fun. The discs are soft, not hard like the floor. It is always amazing to see a child who is unable to walk move along the obstacle course without difficulty, even though the foot has to work harder due to the softness of the foam. It is important not to point this out to your child because then the exercise will no longer be workable in their treatment plan.

Exercises may first be directed at the unaffected foot/hand as there will be positive cross-over in the brain. Exercises for the foot gradually progress to include weight bearing exercises, balance exercises, and even into sports-related activities. Exercises for the hand/arm are designed to improve functions such as dressing, eating, writing, and computer activity.

Do not comment on your child’s progress or specific activities as this may cause a flare-up. Encourage your child to perform activities that they enjoy. Avoid pushing your child back into previous sports activities. Let them take the lead.

Desensitization Training

If your child has skin sensitivity, performing desensitization training is helpful. Have your child use a Kleenex to gently stroke the affected region. Once this becomes easy, progress to something a bit firmer, such as a smooth kitchen towel. To further progress, use a washcloth or bumpy kitchen towel. The stroking is done lightly to tolerance and the child should be in charge of how much is done. Perform 1-3 times a day for a few minutes per your child’s tolerance.

Temperature Training

Temperature training can be performed on the fingers or toes. Purchase a Digital Stress Thermometer. It is the most economical one currently available. If the CRPS is in the hand, place the probe on the middle finger (do not use the index finger, as one can actually train just the index finger to increase temperature, and the goal is to have the entire hand warm). The goal is to achieve a temperature of 93 degrees or more. This is the superficial temperature and not to be compared to core temperature. Have your child focus on easy breathing through the belly and have them observe the temperature rise as their hand becomes warmer.

If your child has difficulty, have them visualize their hand in warm water or warm sunshine or any visualization that they can relate to. If this doesn’t work, I sometimes have used a heating pad on low heat so that they can feel the blood move into their hand. Once they feel it, have them practice without it.

You can also do temperature training with the foot. Place the probe on the big toe. It is more challenging to change foot temperature. Start with temperature training in the hand, even if the CRPS is in the foot. Once your child is successful in the hand, progress to the foot.

Visualization Training

Visualization is another way of addressing central pain. Have your child imagine an activity that they enjoy doing without pain. It can be any activity: baking cookies in the kitchen, playing a sport, hiking on a trail, running along the beach, etc. Let them come up with the activity. Have them start out with belly breathing and then go into visualization.

Home Activities

Encourage your child to do activities that they enjoy. Be creative. Do silly things that encourage general movement. Bring fun and play into your family activities. Laughter feels good.

At home, you can use sand or rice in a container larger than the hand or foot, allowing the hand or foot to squeeze or move the sand or rice. You can put objects in the sand/rice to pick up, such as buttons or marbles. Art activities, baking or cooking activities, or other activities that your child is interested in, can encourage standing time or hand activity.

Mirror Therapy

Make a mirror box by attaching a mirror to a box. The box must be big enough to place the foot or hand into the box. If you have a closet mirror or standing mirror, and the hand/foot can be hidden comfortably behind the door, this will work, too.

Or you can purchase one. Here is an example on Amazon.

Once the box is made, the hand/foot that is painful is placed in the box so it cannot be seen. The other hand/foot is placed so that its reflection can be seen in the mirror. The hand/foot actively moves while the child looks at the reflection in the mirror. The reflection looks like the involved hand/foot is moving without pain. This tricks the brain into thinking that the foot/hand can move without pain, even though the child knows differently. Optimally, this should be performed for 5 minutes, 6 times a day (for a total of 30 minutes).

Suggestions for movements for the hand:

• Open and close the hand
• Move the fingers together and spread them apart
• Alternate fingertips to thumb
• Bring hand palm up, then palm down
• Bring the fingertips to palm and then straighten the fingers
• Pretend that you are drawing or writing or painting or conducting an orchestra

Suggestions for movements for the foot:

• Flex and point the ankle
• Make ankle circles
• Spread the toes
• Flex and extend the toes
• Turn ankle in and out
• Wiggle the toes
• Draw the alphabet with your foot

Talking About Pain and Function With Your Child—DON’T!

Be sure to avoid talking about your child’s pain and function. For example, a family had all gone camping and their daughter was out all morning playing with her cousins. At lunch time, Mom told her daughter that she was surprised that her foot didn’t hurt while playing tag outside. Her daughter spent the afternoon lying in the tent with foot pain. Bringing up the pain will cause it to increase.

Let your child know that you will no longer ask them about their pain because it can facilitate it, but if they want to bring it up, you are there to listen.

It is also best not to comment when you see your child doing an activity that they previously couldn’t do. This might be simple, such as walking into the kitchen or standing to brush their teeth. Keep your conversations away from their pain and function. Your child’s psychologist can help you with your communication.