From the Guidelines
Complex Regional Pain Syndrome (CRPS) should be treated with a multidisciplinary approach, prioritizing early diagnosis and aggressive treatment to improve outcomes, as the condition becomes more difficult to treat when established.
Diagnosis
CRPS is a chronic pain condition that typically affects a limb after an injury or trauma, characterized by abnormal inflammatory responses, central and peripheral sensitization, and autonomic nervous system dysfunction, which explains the burning pain, swelling, skin color and temperature changes, and movement disorders characteristic of this condition 1.
Treatment
Treatment should begin as early as possible and include:
- Physical therapy as the cornerstone of treatment, focusing on gradual desensitization, range of motion exercises, and functional restoration
- Medications such as:
- Neuropathic pain agents like gabapentin (300-1200mg three times daily) or pregabalin (75-300mg twice daily)
- Antidepressants such as duloxetine (30-60mg daily) or amitriptyline (10-75mg at bedtime)
- Short-term use of NSAIDs like ibuprofen (400-800mg three times daily) for inflammatory pain
- For severe cases, short courses of oral corticosteroids like prednisone (starting at 30mg daily with taper over 2 weeks) may help in early stages 1
- Interventional procedures such as sympathetic nerve blocks, spinal cord stimulation, or intrathecal drug delivery can be considered for refractory cases
- Psychological support through cognitive behavioral therapy helps patients develop pain coping strategies It is essential to note that the management of pain in CRPS patients should be individually tailored and based on the drugs that have proved to be effective in controlling pain due to other vasculitides and neuropathies 1.
Key Considerations
- Early diagnosis and aggressive treatment improve outcomes
- A multidisciplinary approach is crucial for effective management
- Treatment should be tailored to the individual patient's needs and response to therapy
- Psychological support is essential for developing pain coping strategies and improving quality of life 1.
From the Research
Diagnosis of Complex Regional Pain Syndrome (CRPS)
- The diagnostic criteria for CRPS are purely clinical, and the use of diagnostic tests has not been demonstrated 2
- CRPS can be classified into different subtypes, namely inflammatory, nociplastic/neuropathic, vasomotor, and motor, depending on the underlying pathophysiological mechanisms 3
Treatment of CRPS
- The most appropriate management of CRPS uses a multidisciplinary approach, with the inclusion of medical and psychologic intervention, and physical and occupational therapy 2
- Physical therapy is the cornerstone and first-line treatment for CRPS, with mild cases responding to physical therapy and physical modalities 4
- Medications such as anticonvulsants, antidepressants, and opioids may be used to manage pain, with the goal of facilitating participation in physical therapy 4
- Regional anesthetic blockade, sympathetic blocks, and spinal cord stimulation may be used to manage moderate to severe pain and/or sympathetic dysfunction 4, 5
- Personalized treatment can be applied depending on the subtype of CRPS, with bisphosphonates effective in treating the inflammatory subtype, and ketamine providing pain relief for the nociplastic/neuropathic subtype 3
- Neurostimulation is a viable option for patients with refractory symptoms, due to its multimechanistic properties for all subtypes 3
- Interventional treatments such as sympathetic nerve blocks, dorsal column stimulation, and dorsal root ganglion stimulation may be used to treat CRPS 5
Treatment Goals
- The key to managing CRPS is gradual, persistent, functional improvement 2
- Pain relief, however temporary, is intended to facilitate participation in functional therapies to normalize use and to improve motion, strength, and dexterity 2
- The treatment choices should be aimed at remodulating, normalizing, disrupting, or preventing the progression of abnormalities in pain processing 2