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

Management of Complex Regional Pain Syndrome (CRPS)

Physical therapy with gentle stretching and mobilization is the cornerstone first-line treatment for CRPS, with sympathetic nerve blocks (stellate ganglion for upper extremity, lumbar sympathetic for lower extremity) reserved for moderate-to-severe cases that fail to respond adequately to allow participation in rehabilitation. 1, 2, 3

First-Line Treatment Approach

Physical Therapy (Mandatory Foundation)

• Initiate gentle stretching and mobilization techniques immediately upon diagnosis, focusing on increasing external rotation and abduction of affected joints 1, 4
• Progress to active range of motion exercises gradually, restoring alignment while strengthening weak muscles in the shoulder girdle for upper extremity involvement 1, 4
• Apply local heat before exercise sessions for symptomatic relief 4
• Avoid overhead pulleys entirely—they encourage uncontrolled abduction and dramatically worsen outcomes 4

Pharmacological Management (Stepwise)

• Start with acetaminophen or ibuprofen if no contraindications exist 1, 4
• Consider topical NSAIDs as first pharmacological option for mild-to-moderate pain 4
• Add topical capsaicin for hand involvement specifically 4
• For neuropathic pain components, add anticonvulsants or tricyclic antidepressants 5
• Escalate to opioids only if pain prevents participation in physical therapy 2

Early Corticosteroid Course

• Administer oral corticosteroids at 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 1, 4
• This approach targets the inflammatory component present in early CRPS 4

Second-Line Interventional Treatments

Sympathetic Nerve Blocks (Critical Decision Point)

• Use stellate ganglion blocks for upper extremity CRPS when moderate-to-severe pain or sympathetic dysfunction prevents physical therapy participation 1, 2, 3
• Use lumbar sympathetic blocks for lower extremity CRPS under the same criteria 1, 3
• These blocks should demonstrate consistent improvement with increasing duration of pain relief to justify continuation 1
• Implement as part of multimodal treatment, not as monotherapy 1

Targeted Injections for Specific Presentations

• Inject botulinum toxin into affected muscles (subscapularis, pectoralis for shoulder) when pain relates to spasticity 1, 4
• Use subacromial corticosteroid injections when pain stems from injury or inflammation of the subacromial region 1, 4

Advanced Treatments for Refractory Cases

Neuromodulation (Third-Line)

• Perform spinal cord stimulation trial before considering permanent implantation 1
• This applies to patients who have failed physical therapy, medications, and sympathetic blockade 1, 2
• Integrate TENS as part of multimodal approach for refractory cases 1
• Consider dorsal root ganglion stimulation as a novel nerve target option 3

Refractory Disease Management

• For truly refractory chronic CRPS, consider intrathecal baclofen with morphine 6
• Maintain long-term multidisciplinary treatment including physical therapy, psychological support, and pain-relieving measures 2

Critical Clinical Pitfalls to Avoid

Diagnostic Recognition

• CRPS presents with excruciating pain worsened by touch or stimulation, gradually increasing in intensity and spreading within the affected limb 7, 1
• Look for hair loss, tissue changes, and skin discoloration at the pain site 7, 1
• CRPS typically does not respond to placebo except at very early time points (15-30 minutes) 7, 1

Treatment Errors

• Never use overhead pulleys—this single intervention dramatically increases risk and worsens existing CRPS 4
• Do not arbitrarily cease sympathetic blocks if patient demonstrates 4-5 month relief duration with consistent improvement 1
• Avoid delaying referral to specialists—early diagnosis and treatment dramatically improve outcomes 2

Documentation Requirements

• Document functional outcomes objectively: activities of daily living, cognitive function, autonomic stability, temperature regulation 1
• Measure beyond numeric pain ratings to strengthen medical necessity for interventional procedures 1
• Include specific discussion of potential complications in shared decision-making for interventional procedures 1

Prevention Strategies

Primary Prevention

• Administer vitamin C to prevent CRPS after wrist fractures 5
• Protect hemiplegic limbs from trauma in stroke patients 4
• Use adequate perioperative analgesia, limit operating time, minimize tourniquet use, and employ regional anesthetic techniques for surgical cases 5

Secondary Prevention in High-Risk Populations

• Stroke patients with combined motor, sensory, and visuoperceptual deficits face 67% incidence of CRPS 4
• Implement active, active-assisted, or passive range of motion exercises immediately 4
• Educate staff on proper handling of hemiplegic shoulders to prevent trauma 4

Treatment Algorithm Summary

1. Immediate initiation: Physical therapy + acetaminophen/ibuprofen + protect from trauma
2. Week 1-2: Add oral corticosteroids (30-50 mg, then taper) if inadequate response
3. Week 2-4: Add anticonvulsants or tricyclic antidepressants for neuropathic component
4. Week 4-8: If pain prevents PT participation, proceed to sympathetic nerve blocks
5. Month 3+: If refractory, trial spinal cord stimulation before permanent implantation
6. Chronic refractory: Intrathecal baclofen with morphine, maintain multidisciplinary approach

The central principle is restoration of function through systematic, coordinated, progressive therapeutic strategies, with interventional procedures serving to enable—not replace—active rehabilitation. 2, 8