Complex Regional Pain Syndrome

By Jiang Liu, Diplomate of Oriental Medicine
AR Licensed Acupuncturist and Herbalist
Acupuncture & Chinese Medicine Clinic
2024 Arkansas Valley Dr., Suite 402
Little Rock, AR 72212


Reflex Sympathetic Dystrophy (RSD), recently more commonly known as Complex Regional Pain Syndrome (RSD/CRPS), is a chronic pain condition, which most often affects one of the arms, legs, hands, or feet. The pain often spreads to the entire arm or leg. Usually, its onset is precipitated by a physical injury, such as a fracture, sprain, or surgery. RSD/CRPS can be classified into type I and type II. Type I is the most common, which is frequently triggered by tissue injury without underlying nerve injury, while type II is clearly associated with a nerve injury.

Signs and Symptoms
The key symptom of RSD/CRPS is continuous, intense pain out of proportion to the severity of the injury (if an injury has occurred), which gets worse rather than better over time. RSD/CRPS is also often accompanied by:

  • Increased skin sensitivity
  • Changes in skin temperature: warmer or cooler compared to the opposite extremity
  • Changes in skin color: often blotchy, purple, pale, or red
  • Changes in skin texture: shiny and thin, and sometimes excessively sweaty
  • Changes in nail and hair growth patterns
  • Swelling and stiffness in affected joints
  • Motor disability, with decreased ability to move the affected body part

Pathogenesis and Etiology
The pathogenesis and etiology for RSD/CRPS are not clear. However, recent studies demonstrate that the following may be involved in the pathogenesis of RSD/CRPS.

  • Autonomic nervous system: Increased sweating and vasoconstriction-related coldness of the affected limb have long been considered as results of autonomic hyperactivity.
  • Somatic nervous system: Pain and sensory disturbances in RSD/CRPS have been attributed to pathology of the sensory somatic nervous system.
  • Inflammation: In the early phase, CRPS/RSD is characterized in the acute stage by symptoms of regional inflammation. In RSD/CRPS patients, pro-inflammatory cytokines such as interleukin-6 (IL-6), IL-1b, tumor necrosis factor-a, tryptase, or IL-2 increase in affected extremities or venous blood, while anti-inflammatory cytokines such as IL-4 or tissue growth factor-b decrease.
  • Hypoxia: Hypoxia is observed in the patients with RSD/CRPS. In the skin, decreased capillary oxygenation and increased lactate levels are observed. In muscle, signs of acidosis and impaired high-energy phosphate metabolism are noticed. Hypoxia leads to acidosis and free radical formation, which are well-known triggers for primary afferents to cause severe painful sensations.
  • Psychological factors: Psychological factors and behavioral aspects may contribute to RSD/CRPS. A psychophysiological mechanism that possibly affects chronic pain in RSD/CRPS patients is the mode of anger expression. For example, anger-out influences pain intensity. Another psychophysiological mechanism in RSD/CRPS may be the stress-induced release of catecholamines, which have been observed as systemically elevated in RSD/CRPS patients.

Conventional treatment
Because there is no cure for RSD/CRPS, treatment is aimed at relieving painful symptoms so that people can resume their normal lives. The following therapies are often used:

  • Physical therapy
  • Psychotherapy
  • Medications: Many different classes of medication are used to treat RSD/CRPS, including topical analgesic drugs; antiseizure drugs; antidepressants; corticosteroids; and opioids. However, no single drug or combination of drugs has produced consistent long-lasting improvement in symptoms.
  • Sympathetic nerve block: One technique involves intravenous administration of phentolamine to block sympathetic receptors. Another technique involves placement of an anesthetic next to the spine to directly block the sympathetic nerves.
  • Surgical sympathectomy: One technique destroys the nerves involved in RSD/CRPS, which could have favorable outcome but could make RSD/CRPS worse.
  • Spinal cord stimulation: The placement of stimulating electrodes next to the spinal cord provides a pleasant tingling sensation in the painful area. This technique may help patients with their pain.
  • Intrathecal drug pumps: These devices administer drugs directly to the spinal fluid, so that anesthetic agents can be delivered to pain-signaling targets in the spinal cord at doses far lower than those required for oral administration.

Chinese medicine
Chinese medicine has more than 3000 years of history. In recent years, it has become popular in western world, especially for treatment of RSD/CRPS. Since Chinese medicine can address every aspect of RSD/CRPS, the utilization of acupuncture or/and herbal medicine can be extremely effective. Multiple studies have shown that acupuncture can:

  • Attenuate inflammation
  • Regulate immune function
  • Relieve pain or reduce pain level
  • Improve or relieve stress, anxiety and depression
  • Improve sleeping quality
  • Increase the energy
  • Reduce reliance on inappropriate medication
  • Enhance the quality of life

Scientific researches
Over the years, scientists throughout the world have done numerous studies to explore the mechanism of acupuncture. The results show that acupuncture possesses scientific basis. The following are some of the evidence:

  • Increase blood circulation to the injured areas, therefore alleviating tissue swelling and expediting recovery of injury
  • Reduce the muscular contraction, therefore, lessening muscle spasm
  • Inhibit the production of pro-inflammatory cytokines and increase anti-inflammatory cytokines, therefore reducing inflammation and edema
  • Increases the release of natural pain-relieving endorphins
  • Block the conduction of sensory fibers in the algetic nerves
  • Perform local and systemic immunomodulation
  • Modulate neuroendocrinological factors
  • Increases the levels of serotonin (5-HT), acetylcholinesterase, dopamine and homovanillic acid, all of which help to increase the pain threshold and result in pain relief
  • Stimulate the brain to produce polypeptides that reduce pain sensitivity

Principles of pathogenesis and classification
The principle of Chinese medicine is that the body maintains a balance between yin and yang, and among qi, blood and body fluid. qi and blood travel through the body along the pathways called meridians or channels. When there is not enough qi or blood, or when qi or blood is stuck in some area, there is an imbalance between yin and yang, or an imbalance among qi, blood and body fluid, which result in dysfunction of the tissue or organs, and illness develops.

Chinese medicine considers RSD/CRPS as obstructive “bi” Syndrome. In early stage, meridians and channels are damaged and blood is extravasated. Therefore, qi is stagnated and blood is stuck, so thatqi and blood could not be flowed freely and pain occurs. Protective qi is deficient in the patients with RSD/CRPS so that blood and fluid can not be flowed smoothly, which results in edema. Protective yangcan not express that leads to protective qi can not go out to protect skin so patients is afraid of cold and sweating. Due to stagnation of qi or blood, meridians and channels are blocked and skin and nails are lack of nourishing: skin becomes thin and atrophy; nails become crispy and easy to break; the tendons, ligaments and joints are easily invaded by coldness and dampness. If these situations last for long time, the devils disturb heart and spirits, the patients may present psychiatric symptoms.

There are two theories for the pathogenesis of RSD/CRPS
1. Stagnation or obstruction

  • qi stagnation
  • Blood obstruction
  • A combination of qi stagnation and blood obstruction
  • Cold retention to stagnate the flow of qi and blood
  • Dampness retention to block yang qi, therefore blood can not be passed along smoothly

2. Disharmony of yin and yang

  • yin deficiency: yin consists of blood and body fluid. If blood or body fluid is deficient, the tissue or organ can not get nurtured and pain develops.
  • yang deficiency: yang initiates, activates, and maintains the function of body and promotes blood circulation. Yang deficiency may happen to heart, spleen, or kidney.

RSD/CRPS is a complex disorder. Clinical symptoms and manifestations are various from person to person. In my clinical practice, the following types of RSD/CRPS are commonly observed.

  • Liver qi stagnation
  • yin deficiency and fire domination
  • Deficiency of kidney essence
  • Dominant damp restraining spleen
  • Phlegm fire disturbing interiors
  • Deficiency of both heart and spleen
  • Disharmony of heart and kidney
  • qi deficiency of both heart and gallbladder

Herbal medicine (oral administration)
1. buyanghuanwutang as a major formula but additional herb(s) can be added, according to individual situation.

  • Numb in the limb: add juanxie, puochuanshanjia, sigualuo, mugua, and dianshen
  • Severe pain: add chaoruxiang, chaomeyao, xuchangqing, mugua, and yanhusuo,
  • Edema: add fuling, cheqiangzi, and zexie
  • qi deficiency: add taizishen, fuling, and baishu
  • yang deficiency: duchong, tusizi, and weilingxian
  • yin deficiency: shashen, tianhuafeng, yuzhu, and lugen

2. guizitang as a major formula but additional herb(s) can be added, according to individual situation.

  • qi deficiency and blood stagnation: add dangshen, huangqi, jixieteng, sanling, and eshu
  • Aversion to coldness and wind in affected area: fangfen, yianghou, danggui, and chuanqiong
  • Severe edema and pain in affected area: xiuanhum xixing, and dilong
  • Finger spasm: chuangmugu, gegen, xiuanxhen, and zhishouwu
  • Severe pain affecting sleeping: jiangbanxia, zhanzhumu, suanzhaoren, and yiejiantang

Herbal medicine (topical administration)

  • Tangliaoyao: stuff these herbs into a cotton bag, boil it, and place it onto the accupoints according to patient’s symptoms
  • Shujinhuoluosan: stuff these herbs into a bag, cook it, and made into pasta. Place the bag on the accupoints according to patient’s symptoms
  • Shujinxiyaokeli: boil these herbs, and soak sick limb in the solution

According to recent studies, these herbs possess dilate blood vessels, eradiate spasm, increase urine, attenuate edema, suppress pain, inhibit central nerve system and calm the mind, and improve sleeping.

According to individual patient’s diagnosis, different accupoints can be applied. Electric acupuncture is often used for the patients with RSD/CRPS. First, according to individual patient’s diagnosis, appropriate accupoints are chosen for:

  • qi stagnation
  • Blood obstruction
  • qi stagnation and blood obstruction
  • Cold retention to stagnate the flow of qi and blood
  • Damp retention to block yang qi
  • yin deficiency
  • yang deficiency

Second, according to patient’s location of affected tissue or organ, as well as characteristics of patient’s signs and symptoms, additional accupoints should be chosen for:

  • Numb
  • Severe pain
  • Severe edema
  • Swelling and stiff joints
  • Insomnia due to severe pain
  • Motor disability with decreased ability to move the affected body part

Other modalities of Chinese medicine

  • Accupiont injection: Accupiont injection is another modality of Chinese medicine and is a technique in which some liquid medicines (western medicine or herbal medicine) are injected into the accupoint(s). This is technique is banned in Arkansas.
  • Moxibustion: Moxibustion is one of modalities of Chinese medicine. It stimulates the acupoints to adjust or realign stagnated qi, restoring normal flow of qi to the areas where the pain or illness was originating from.
  • Tui Na: Tui Na is another modality, also called Chinese therapeutic message and is now very popular in US as a powerful therapeutic extension of traditional western massage. Tui Na utilizes the theory of Chinese medicine (such as meridians and qi) as its basic therapeutic principle. Tui Na has a variety of different systems that emphasize particular aspects of these therapeutic principles, such as rolling, gliding, kneading, percussion, friction, pulling, rotation, rocking, vibration, and shaking by using fingers, thumb, knuckles, palm, and elbow. Tui Na relaxes tightened tendons and ligaments, opens up the meridians and channels, warms meridians and eradicates coldness, improves blood circulation and eradicates stagnation, eradicates edema and attenuates the pain, and strengthens spleen and harmonizes stomach. According to individual patient’s diagnosis, appropriate accupoints are chosen for Tui Na.
  • Cupping: Cupping often follows the pattern of point selection that is used for standard acupuncture therapy. During cupping therapy, the practitioner creates a vacuum in a cup by a fire and applies the cup onto selected point of the body, which then draws the skin and some subcutaneous tissues up into the cup. Cupping warms up qi and promotes the free flow of qi and blood in the meridians, therefore, dispelling coldness and dampness and diminishing swellings and pains. Cupping improves local blood circulation, increases the tissue threshold to pain, relaxes muscle tightness, eradicates spasm, and attenuates the pain and edema. Cupping is also useful to strengthen immune system.
  • GuaSha: GuaSha is one of Chinese medicine modalities, which involves repeated pressured strokes over lubricated skin with a smooth edged wood or ceramic cap. The smooth edge is placed against the pre-oiled skin surface, pressed down firmly, and then moved down the muscles along the pathway of the acupuncture meridians, along the surface of the skin. GuaSha:
    • Improve local blood circulation
    • Reduce fever
    • Attenuate fatigue
    • Relax muscle, tendon, and ligaments
    • Ameliorate headache
    • Improve stiffness, pain, and immobility
    • Treat digestive disorders
    • Treat urinary and gynecological problems

In Chinese medicine practice, making correct diagnosis and choosing correct accupoints or herbal formula are the first two most important steps. Second important thing is that during the period of treatment, adjust accupoints and regulate herbal formula such as adding additional herb(s) to the original herbal formula, taking off existing herb(s) from original formula, or increasing/decreasing the quantity of individual herb(s) in original formula, according to patient’s response to the treatment. Third is to combine different modalities of Chinese medicine according to individual patient’s situation and diagnosis. Appropriate combination of different modalities has synergistic effect, which reaches maximal effects of Chinese medicine. In my practice, I have successfully treated the patients with RSD/CRPS. For each RSD/CRPS patient, I make individual treatment plan according to one’s situation and diagnosis. I often take acupuncture and/or herbal formula as a major regimen and combine it with moxibustion, cupping, Tui Na, GwaSha, or reflexology, according to individual patient’s diagnosis. During the period of the treatment, I adjust the accupoints or herbal formula, according to patient’s response.