Physical Therapy in the Treatment of Lower Extremity Complex Regional Pain Syndrome Type I: A Case Report

Introduction: Complex Regional Pain Syndrome (CRPS) is a relatively unknown condition with no known gold-standard for its treatment. The evidence supports various treatments for CRPS, including the use of pain exposure physical therapy (PEPT), to decrease pain and improve function in patients with CRPS.1 The founding principles of PEPT are to encourage the use of the affected limb despite complaints of pain.2 Because CRPS is thought to be closely intertwined with the central nervous system, encouraging patients to push through what they perceive as a “danger” signal from their body will stop the reinforcing belief that use of the affected limb is “bad.” Education on pain science and the function of pain as a “false alarm” in the case of CRPS is also thought to help combat pain symptoms.3 Due to the lack of concrete evidence supporting any one treatment for CRPS, a multimodal therapy in combination with the principles of PEPT was employed to treat a 32-year old female with ankle pain and complex regional pain syndrome. Methods: This case report focused on the use of PEPT in combination with manual therapy, electrotherapeutic modalities, temporal agents, and traditional therapeutic exercise techniques in the treatment of CRPS of a 32-year old woman following an ankle sprain due to a fall at work. Data was analyzed retrospectively. Results: Following four weeks of treatment, improvements were seen in the areas of pain, ROM, strength, function, Lower Extremity Functional Scale (LEFS), Orebro Musculoskeletal Pain Questionnaire (OMSPQ), and global function rating. Worst pain on the Numeric Pain Rating Scale decreased 3 points from 9/10 to 6/10, indicating a medium clinical change4, and overall global function increased from 30% to 45% indicating an increase in ADL and IADL function. Strength and ROM gains were also seen, with dorsiflexion range increasing past neutral versus lacking two degrees before treatment. Ankle strength increased by three points on the Kendall manual muscle testing scale in three out of four muscles tested.5 The patient’s LEFS score increased and OMSPQ score decreased, both indicating a positive change. The OMSPQ score moved below the low-cost cut-off for worker’s compensation cases, thereby reducing long-term disability costs to the employer.6 Ambulation distance and assistive device used improved from 100ft with bilateral axillary crutches at initial evaluation to 300ft with one crutch at re-evaluation. Limb circumference of the calf increased ¼ centimeter most likely due to the beginning of muscle hypertrophy from strengthening activities and increased use, although four weeks may not have been enough time to achieve optimum hypertrophy of the musculature.7 Conclusion: Multimodal physical therapy in combination with PEPT tailored to an individual patient may be an effective way to treat CRPS. Pain science education and exposure principles of PEPT may also be important aspects of pain management