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

Treatment 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 sympathetic blocks and spinal cord stimulation for refractory cases. 1

First-Line Treatment Approach

Physical and occupational therapy form the foundation of CRPS management and should be initiated immediately upon diagnosis. 1, 2

Physical Therapy Protocol

• Begin with gentle stretching and mobilization techniques, specifically focusing on increasing external rotation and abduction of the affected limb 1
• Progress to active range of motion exercises that gradually increase intensity while restoring alignment and strengthening weak muscles in the shoulder girdle 1
• Implement progressive tactile stimulation to address allodynia and normalize movement patterns to prevent limited range of motion 3
• Encourage optimal postural alignment and promote even distribution of weight during weight-bearing activities 2

Pharmacological Management

• Use acetaminophen or ibuprofen as first-line analgesics if no contraindications exist 1
• For neuropathic pain components, add anticonvulsants (such as gabapentin) or tricyclic antidepressants 4, 3
• Consider NSAIDs for anti-inflammatory effects 2, 3
• Avoid strong opioids as they are not recommended per the WHO analgesic ladder adaptation for CRPS 4

Early Inflammatory Control

• Administer an early course of oral corticosteroids starting at 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 1
• Consider free-radical scavengers (dimethylsulphoxide or acetylcysteine) for inflammatory symptoms 4

Second-Line Interventional Treatments

When conservative measures fail to provide adequate pain control for rehabilitation participation, escalate to interventional procedures. 1, 3

Sympathetic Nerve Blocks

• Use stellate ganglion blocks for upper extremity CRPS as part of a multimodal treatment approach when there is consistent improvement and increasing duration of pain relief 1, 5
• Employ lumbar sympathetic blocks for lower extremity CRPS using the same criteria 1, 5
• These blocks may be used to support the diagnosis of sympathetically maintained pain 1
• Consider vasodilatory medication first, reserving sympathetic blockades for cases where vasodilatory medication has insufficient effect 4

Targeted Injections

• Administer botulinum toxin injections into affected muscles when pain is related to spasticity 1
• Use subacromial corticosteroid injections when pain is related to injury or inflammation of the subacromial region 1
• Consider medial branch blocks for CRPS with cervical involvement, especially when facet-mediated pain is present 1

Advanced Treatments for Refractory Cases

For patients who have not responded to physical therapy and sympathetic blocks, proceed to neuromodulation with spinal cord stimulation. 1

Spinal Cord Stimulation Protocol

• Perform a spinal cord stimulation trial before considering permanent implantation of a stimulation device 1
• Neurostimulation procedures represent the most effective treatment for refractory CRPS 1
• Novel neuromodulation therapies include new waveforms with dorsal column stimulation and dorsal root ganglion stimulation 5

Adjunctive Neuromodulation

• Implement TENS as part of a multimodal approach to pain management 1

Severe Refractory Disease

• For cases unresponsive to all other modalities, intrathecal baclofen with morphine may be considered 6

Prevention Strategies

Primary Prevention

• Administer vitamin C to prevent CRPS occurrence after wrist fractures 4

Secondary Prevention

• Ensure adequate perioperative analgesia for any surgical procedures 4
• Limit operating time and tourniquet use 4
• Use regional anaesthetic techniques when possible 4

Critical Clinical Pitfalls to Avoid

• Do not delay treatment initiation: Long-term outcomes are significantly improved when treatment begins soon after symptom onset 3
• Do not use sympathetic blocks as monotherapy: They must be integrated into a multimodal rehabilitation approach 1
• Do not arbitrarily cease treatment: Relief duration of 4-5 months with consistent improvement supports continued treatment rather than cessation 1
• Do not rely solely on numeric pain ratings: Document ADL improvements, cognitive function, work capacity, and objective measures including temperature dysregulation 1
• Include shared decision-making regarding interventional procedures with specific discussion of potential complications 1

Monitoring Requirements

• Evaluate patients at least twice annually by a vascular specialist due to the relatively high incidence of recurrence 2
• Monitor for common complications including hair loss, tissue changes, and skin discoloration at the pain site 1
• Recognize that CRPS often does not respond to placebo except at very early time points (15-30 minutes) 1