What are the treatment options for Complex Regional Pain Syndrome (CRPS)?

Treatment of Complex Regional Pain Syndrome (CRPS)

Spinal cord stimulation is the most effective treatment for Complex Regional Pain Syndrome (CRPS), with physical therapy as the cornerstone first-line approach. 1

First-Line Treatments

Physical and Occupational Therapy

• Physical therapy is the cornerstone and first-line treatment for CRPS 2
• Treatment should include:
  • Gentle stretching and mobilization techniques, focusing on increasing external rotation and abduction 3
  • Active range of motion exercises that gradually increase in conjunction with restoring alignment and strengthening weak muscles in the shoulder girdle 3
  • Active, active-assisted, or passive range of motion exercises to prevent CRPS progression 3

Pharmacological Management

• For pain management:
  • If no contraindications exist, analgesics such as acetaminophen or ibuprofen can be used for pain relief 3
  • For inflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are recommended 4
  • For neuropathic pain components, consider anticonvulsants and tricyclic antidepressants 4
  • Follow the WHO analgesic ladder with the exception of strong opioids 4

Second-Line Treatments

Interventional Procedures

• Sympathetic nerve blocks are the first-line interventional treatment options:
  • Stellate ganglion blocks for upper extremity CRPS 5
  • Lumbar sympathetic blocks for lower extremity CRPS 5
• The use of sympathetic blocks may be considered to support the diagnosis of sympathetically maintained pain 3
• Injections of botulinum toxin into affected muscles can be used when pain is thought to be related to spasticity 3
• Subacromial corticosteroid injections can be used when pain is related to injury or inflammation of the subacromial region 3

Management of CRPS with Edema

• An early course of oral corticosteroids, starting at 30–50 mg daily for 3–5 days, and then tapering doses over 1–2 weeks can be used to reduce swelling and pain 3

Advanced Treatments for Refractory Cases

Neuromodulation

• Spinal cord stimulation may be considered for CRPS patients who have not responded to other therapies 3
• A spinal cord stimulation trial should be performed before considering permanent implantation of a stimulation device 3
• Newer neuromodulation therapies include dorsal root ganglion stimulation, which targets different nerve pathways than traditional spinal cord stimulation 5

Transcutaneous Electrical Nerve Stimulation (TENS)

• TENS should be used as part of a multimodal approach to pain management 3

Clinical Characteristics and Monitoring

• CRPS typically presents with:
  • Excruciating pain that is made worse by touch or stimulation 3, 6
  • Pain that gradually increases in intensity and size in the affected limb, sometimes spreading to the contralateral limb 3
  • Hair loss, tissue changes, and skin discoloration at the site of pain 3, 6
  • Decreased motor function that may appear flaccid 6
  • Difficulty with transfers, weight-bearing activities, and using the affected limb 6

Treatment Algorithm

1. Initial Management:

   • Begin physical therapy immediately with focus on gentle mobilization 3, 2
   • Start appropriate analgesics (acetaminophen/NSAIDs) 3
   • Consider free-radical scavengers for inflammatory symptoms 4

2. If inadequate response after 2-4 weeks:

   • Add anticonvulsants or tricyclic antidepressants for neuropathic pain 4
   • Consider sympathetic nerve blocks (stellate ganglion for upper extremity, lumbar sympathetic for lower extremity) 5
   • For edema, consider short course of oral corticosteroids 3

3. For refractory cases:

   • Proceed to neuromodulation with spinal cord stimulation trial 3
   • Consider dorsal root ganglion stimulation if traditional SCS is ineffective 5
   • Implement TENS as part of multimodal approach 3

Important Considerations

• Early diagnosis and treatment increase the likelihood of a successful outcome 2
• CRPS often does not respond to placebo except at very early time points (15-30 minutes) 3, 1
• A multidisciplinary approach involving pain specialists, physical therapists, and psychological support provides the best outcomes for moderate to severe cases 2
• Shared decision-making regarding interventional procedures should include specific discussion of potential complications 3