What is the treatment for complex regional pain syndrome (CRPS)?

Treatment of Complex Regional Pain Syndrome (CRPS)

Neurostimulation procedures are the most effective treatment for complex regional pain syndrome, with physical therapy as the cornerstone first-line approach. 1, 2

First-Line Treatment Approach

• Physical therapy is the cornerstone and first-line treatment for CRPS, focusing on progressive tactile stimulation and normalization of movement to prevent limited range of motion 3, 2
• Mild cases may respond to physical therapy and physical modalities alone 3
• For mild to moderate cases, adjuvant analgesics should be added, including:
  • Anticonvulsants (e.g., gabapentin) 3, 2
  • Antidepressants (tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors) 2
  • NSAIDs for inflammatory component 2

Pharmacological Interventions

• No FDA-approved medications exist specifically for CRPS management 2, 4
• The most effective pharmacological options based on recent evidence:
  • Bisphosphonates provide long-term pain relief (beyond one month) with moderate certainty evidence (MD -2.21,95% CI -4.36--0.06, p = 0.04) 4
  • Ketamine provides long-term pain relief with low certainty evidence (MD -0.78,95% CI -1.51--0.05, p = 0.04) 4
• Both bisphosphonates and ketamine cause more mild adverse events than placebo but rarely require intervention 4
• Early pharmacological intervention is crucial, particularly in "warm" forms of CRPS to prevent functional limitations 5
• Opioids should be added only if other medications don't provide sufficient analgesia to allow participation in physical therapy 3

Interventional Procedures

• For moderate to severe pain and/or sympathetic dysfunction, regional anesthetic blockade is necessary to enable participation in physical therapy 3
• Sympathetic nerve blocks are the first-line interventional treatment:
  • Stellate ganglion blocks for upper extremity CRPS 6
  • Lumbar sympathetic blocks for lower extremity CRPS 6
• Neurostimulation procedures are particularly useful for CRPS and include:
  • Traditional spinal cord stimulation with newer waveforms 1, 6
  • Dorsal root ganglion stimulation as a novel target 6
• Medial branch blocks may be considered for CRPS with cervical involvement, especially when facet-mediated pain is present 7

Treatment Algorithm Based on Severity

1. Mild CRPS:

   • Physical therapy and physical modalities 3
   • NSAIDs and adjuvant analgesics (anticonvulsants, antidepressants) 2

2. Moderate CRPS:

   • Continue physical therapy with adjuvant analgesics 3
   • Consider bisphosphonates or ketamine for long-term pain relief 4
   • Add opioids if necessary for participation in therapy 3

3. Severe or Refractory CRPS:

   • Sympathetic nerve blocks (stellate ganglion or lumbar sympathetic) 6
   • Neurostimulation (spinal cord stimulation or dorsal root ganglion stimulation) 1, 6
   • Multidisciplinary approach including psychological support 3
   • Consider spinal analgesia for intractable cases 3

Important Clinical Considerations

• Early diagnosis and treatment significantly increase the likelihood of successful outcomes 3, 2
• CRPS often does not respond to placebo except at very early time points (15-30 minutes) 1
• Patients with refractory, chronic pain require long-term multidisciplinary treatment 3
• Monitor for common complications including hair loss, tissue changes, and skin discoloration at the pain site 1
• The pain in CRPS is described as excruciating and worsened by touch or stimulation 1