What is the management approach for Complex Regional Pain Syndrome (CRPS)?

Management of Complex Regional Pain Syndrome (CRPS)

Start immediately with physical therapy as the cornerstone of treatment, combined with analgesics for pain control, and escalate to interventional procedures only if conservative measures fail after 4 weeks of aggressive rehabilitation. 1, 2

First-Line Treatment: Aggressive Rehabilitation (Weeks 0-4)

Physical and occupational therapy must begin immediately and intensively to prevent permanent disability and restore function. 1, 2, 3

• Initiate gentle stretching and mobilization focusing on increasing external rotation and abduction of the affected limb 1
• Progress to active range of motion exercises that gradually increase while restoring alignment and strengthening weak muscles 1
• Include 20 sessions each of physical therapy and occupational therapy over 4 weeks, supplemented with water therapy 2
• Maintain optimal postural alignment and promote even weight distribution during all activities 4

Concurrent analgesic therapy:

• Start with acetaminophen or ibuprofen for pain relief if no contraindications exist 1
• Consider early oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) to reduce swelling and pain 1

Critical pitfall: Do not delay physical therapy waiting for pain to resolve—the pain prevents activity, and lack of activity increases pain, creating a vicious cycle. 5

Second-Line Pharmacological Management

If pain remains inadequately controlled after 1-2 weeks of first-line therapy, add neuropathic pain medications:

• Antiepileptic drugs (gabapentin, pregabalin) based on efficacy in neuropathic pain conditions 6, 7
• Tricyclic antidepressants for neuropathic pain component 6, 7
• Topical agents for localized pain relief 6, 7
• Bisphosphonates have shown benefit in multiple controlled trials for pain relief and functional improvement 7

Opioids may be considered as part of multimodal therapy but should not be first-line monotherapy. 6, 7

Interventional Procedures (Weeks 4-8 if refractory)

Sympathetic blocks may be considered to support diagnosis of sympathetically maintained pain, though efficacy is questionable. 1, 3

• Stellate ganglion blocks can be incorporated into comprehensive treatment programs 2
• Botulinum toxin injections into affected muscles when pain relates to spasticity 1
• Subacromial corticosteroid injections when pain relates to subacromial inflammation 1

Important caveat: The efficacy of sympathetic blockade as treatment for CRPS is questionable despite widespread use. 3

Advanced Neuromodulation (After 8+ weeks if still refractory)

Spinal cord stimulation is the most effective interventional treatment for refractory CRPS. 1

• Perform a trial of spinal cord stimulation before permanent implantation 1
• TENS should be used as part of multimodal approach to pain management 1
• Consider implantable spinal medication pumps for severe, treatment-resistant cases 7

Shared decision-making must include specific discussion of potential complications before any interventional procedure. 1

Interdisciplinary Team Approach

Establish an interdisciplinary team immediately for all CRPS patients, especially those with co-occurring psychiatric or substance use disorders. 5

The team should include:

• Physical and occupational therapists as core members 1, 2
• Pain management specialists for medication optimization 5
• Psychologists for group psychotherapy (20 sessions recommended) to improve pain tolerance and coping 2
• Vascular specialists for biannual evaluation due to high recurrence risk 4

Monitoring and Reassessment

Reassess at regular intervals after adequate time for each treatment change to take effect. 5

• Monitor for autonomic changes: hair loss, tissue changes, skin discoloration at pain site 5, 4
• Track functional outcomes: weight tolerance, fine and gross motor skills, return to work 2
• Document pain characteristics: CRPS typically presents with excruciating pain worsened by touch (allodynia), gradually increasing in intensity and potentially spreading to contralateral limb 5, 1, 4

Key diagnostic consideration: CRPS often does not respond to placebo except at very early time points (15-30 minutes), distinguishing it from other pain syndromes. 1

Expected Outcomes with Comprehensive Treatment

With intensive 4-week interdisciplinary programs:

• 75% employment rate at 2-year follow-up 2
• Dramatic improvements in upper extremity function: 29-pound increase in weight tolerance, 35-50 inch-pound gains in strength 2
• Normalization of fine and gross motor skills from 72 to 48 seconds on multifunctional testing 2

Treatment goals prioritize: maximal pain relief, functional improvement, and prevention of permanent disability through early aggressive intervention. 6, 3