From the Guidelines
Complex regional pain syndrome (CRPS) should be managed with a multidisciplinary approach, prioritizing physical therapy and medication options such as nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, and antidepressants to reduce pain and maintain function. CRPS is a chronic pain condition that typically affects a limb after an injury or trauma, characterized by severe pain, changes in skin color, temperature, swelling, and abnormal sweating in the affected area 1. The condition likely involves abnormal inflammatory responses, nervous system sensitization, and changes in brain processing of pain signals, which explains the complex and varied symptoms patients experience.
Key Considerations
- Physical therapy is the cornerstone of treatment, focusing on gentle, progressive movement to maintain function and reduce pain.
- Medication options include NSAIDs like ibuprofen (400-800mg three times daily), anticonvulsants such as gabapentin (starting at 300mg daily and gradually increasing to 1800-3600mg daily in divided doses), and antidepressants like amitriptyline (10-25mg at bedtime) 1.
- For severe cases, bisphosphonates like alendronate (70mg weekly) may help with bone changes, and nerve blocks with lidocaine or bupivacaine can provide temporary relief.
- Psychological support is crucial as CRPS can cause significant emotional distress.
- Newer treatments include spinal cord stimulation and intrathecal drug delivery for refractory cases.
Diagnostic Considerations
- Bone scintigraphy may be helpful in assessing for CRPS in patients experiencing chronic post-traumatic pain without clear etiology, although it has low sensitivity for detection of CRPS when compared with clinical diagnostic criteria 1.
- Bone scintigraphy does have high specificity and can be used to rule out CRPS 1.
Treatment Approach
- Treatment should begin as early as possible with a multidisciplinary approach, including physical therapy, medication, and psychological support.
- A comprehensive treatment plan should be individualized to each patient's needs, taking into account the severity of symptoms, medical history, and response to previous treatments.
From the Research
Definition and Characteristics of Complex Regional Pain Syndrome
- Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by intense pain, usually in a body region that has experienced trauma, and autonomic and inflammatory features 2.
- It most commonly develops after an arm or leg injury, with patients typically presenting with extreme hyperalgesia and/or allodynia 2.
- CRPS is divided into two types: CRPS-I, which occurs when there is no confirmed nerve injury, and CRPS-II, which occurs when there is known associated nerve injury 3.
Diagnosis and Diagnostic Criteria
- The Budapest Criteria are used to make a clinical diagnosis of CRPS 2.
- Female gender is a risk factor for developing CRPS, and other risk factors include fibromyalgia and rheumatoid arthritis 3.
Treatment Options
- The primary management options for CRPS are rehabilitation and physical therapy, including approaches such as progressive tactile stimulation and normalization of movement to prevent limited range of motion 2.
- No drugs are approved by the Food and Drug Administration (FDA) for CRPS management, but some evidence supports the use of drugs used to manage other types of neuropathic pain, such as gabapentin, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors 2.
- Other treatment options include nonsteroidal anti-inflammatory drugs, corticosteroids, bisphosphonates, ketamine, and procedural interventions such as sympathetic nerve blockade and spinal cord stimulation 2, 4, 3, 5, 6.
- A combination of IV 20% mannitol and steroid with oral gabapentin has been shown to be an effective treatment for CRPS type 1 4.
- Continuous peripheral nerve blocks and parenteral ketamine infusions have also been used to treat CRPS, particularly in cases that are refractory to standard therapy 5.