Complex Regional Pain Syndrome
CRPS
Jacksonville, FL
CRPS is one of the most challenging pain conditions in hand surgery — disproportionate burning pain, skin changes, and exquisite sensitivity that can develop after an injury or procedure. R. David Graham, MD at JOI manages CRPS together with his hand therapy team, who are experienced in desensitization and mirror therapy. Early, aggressive therapy is the most effective treatment.
- CRPS = disproportionate pain, swelling, skin changes after injury or surgery
- Dr. Graham manages CRPS with his hand therapists — they do a great job
- Multidisciplinary: desensitization, mirror therapy, active PT
- Stellate ganglion blocks referred out (less helpful in late presentation)
- Dr. Graham typically sees these patients later — stellate ganglion blocks are less effective at that stage
- Surgical trigger (underlying hardware, nerve entrapment) addressed when present
CRPS is treated with motion and desensitization — immobilization is the enemy. The hand therapy team at JOI has extensive experience with CRPS and oversees the full rehabilitation process.
Understanding CRPS
Disproportionate Pain After Injury —
When the Nervous System Overreacts
Complex Regional Pain Syndrome (CRPS) is a chronic pain condition characterized by pain that is disproportionate to the original injury, accompanied by autonomic and inflammatory changes in the affected limb. In the upper extremity, it most commonly follows wrist fractures, hand surgery, or peripheral nerve injuries — though it can occur after seemingly minor trauma or even spontaneously.
The cardinal features are burning pain, allodynia (pain from stimuli that should not be painful, like light touch), swelling, skin color and temperature changes, and hypersensitivity of the affected hand or arm. In the early phase, the skin may be warm, red, and sweaty. In later stages, the skin can become cool, pale, and atrophic, with nail and hair changes. Without treatment, the hand can develop contractures and profound functional loss.
In Dr. Graham's experience, he typically sees CRPS patients somewhat later in their course — after the diagnosis has been established elsewhere and initial conservative measures have been tried. Stellate ganglion blocks, which can be effective in early CRPS, are less helpful at that stage and are referred to pain management when appropriate. What Dr. Graham and his hand therapy team oversee is the core of CRPS treatment: aggressive desensitization, mirror therapy, graded motor imagery, and active range-of-motion rehabilitation.
When there is an identifiable surgical trigger — underlying retained hardware that is irritating, a nerve entrapment that developed after surgery, or a painful neuroma — that structural problem is addressed operatively. But CRPS itself is not a surgical condition in the traditional sense; the treatment is motion, desensitization, and nervous system retraining.
- → Burning, aching pain disproportionate to the injury
- → Allodynia — pain from light touch, clothing, air movement
- → Swelling that persists beyond expected healing
- → Skin color changes — red/purple/pale at different stages
- → Temperature changes — warm early, cool late
- → Stiffness and guarding — the hand is held protectively
- → Nail and hair growth changes over the affected hand
Treatment
Motion and Desensitization —
Managed with Hand Therapy
The most effective treatment for CRPS is aggressive therapy that retrains the nervous system. Dr. Graham and his JOI hand therapy team oversee the full rehabilitation process.
Why Therapy — Not Rest — Is the Treatment
The instinct with CRPS is to protect the painful limb — and that instinct, followed consistently, leads to progressive stiffness, atrophy, and worsening of the condition. The nervous system amplification that drives CRPS is reinforced by disuse. It is reversed by graded sensory exposure, active motion, and progressive loading.
Desensitization — graded exposure of the hypersensitive skin to progressively more intense textures and stimuli — resets the sensory threshold over weeks to months. Mirror therapy uses the visual system to retrain the motor cortex: the patient watches their unaffected hand move in a mirror positioned to create the visual illusion that the affected hand is moving normally. This is one of the most effective tools for CRPS-associated motor dysfunction. Graded motor imagery builds on the same principles through progressive mental rehearsal before physical movement.
The JOI hand therapy team has extensive experience managing CRPS and guides patients through the full rehabilitation protocol. Dr. Graham oversees the overall management and addresses any structural or surgical issues that arise during the course of treatment.
Desensitization
Graded texture exposure — from soft materials to progressively rougher surfaces — retrains the skin's sensory threshold. Performed multiple times daily with guidance from hand therapy. The goal is tolerance of normal touch before advancing to functional use.
Mirror Therapy
The unaffected hand moves in front of a mirror positioned to create the visual appearance of the affected hand moving. The visual feedback reduces cortical pain representation and allows progressive motor rehabilitation even when direct movement is too painful.
Active Motion & Loading
Progressive active range of motion and graded loading under formal therapy supervision. Moving the affected hand — through discomfort, with guidance — is central to recovery. Passive motion without active engagement is less effective.
FAQs
Frequently Asked Questions
Related Conditions
Next Steps
Burning hand pain after injury
that isn't getting better?
CRPS is most responsive to early, aggressive therapy. If you or your patient has disproportionate pain, skin changes, or allodynia after an upper extremity injury, prompt evaluation and initiation of desensitization therapy gives the best outcome.
Jacksonville Beach, FL 32250
No imaging required.