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

Management of Complex Regional Pain Syndrome (CRPS)

Physical therapy is the cornerstone and first-line treatment for CRPS, with early diagnosis and immediate referral to specialized care being critical for successful outcomes. 1

First-Line Treatment Approach

Initiate physical therapy immediately as the foundation of CRPS management, focusing on:

• Gentle stretching and mobilization techniques targeting external rotation and abduction of affected limbs 2
• Active range of motion exercises that progressively increase while restoring alignment and strengthening weak muscles in the shoulder girdle 2
• Protect the affected limb from trauma and avoid overhead pulleys, which encourage uncontrolled abduction and worsen outcomes 3

For pain control during physical therapy:

• Acetaminophen or ibuprofen as first-line analgesics if no contraindications exist 2
• Topical NSAIDs for mild to moderate pain 3
• Topical capsaicin for hand involvement 3

Second-Line Treatment for Moderate Cases

When first-line measures are insufficient:

• Oral corticosteroids starting at 30-50 mg daily for 3-5 days, then tapering over 1-2 weeks to reduce swelling and pain 2, 3
• Anticonvulsants and/or tricyclic antidepressants for neuropathic pain components 4
• Opioids should be added only if other medications fail to provide sufficient analgesia for participation in physical therapy 1

Sympathetic nerve blocks (stellate ganglion for upper extremity, lumbar sympathetic for lower extremity) may be used as components of multimodal treatment when there is consistent improvement and increasing duration of pain relief with each successive block 2, 5

• These blocks should NOT be used for long-term treatment of non-CRPS neuropathic pain 2
• Continue blocks only when demonstrating progressive improvement with each successive treatment 2

Advanced Treatment for Refractory Cases

For patients with moderate to severe pain unresponsive to conservative measures:

Spinal cord stimulation is recommended for refractory CRPS 2, 5:

• Perform a trial before permanent implantation 2
• Novel approaches include dorsal root ganglion stimulation and new waveforms with dorsal column stimulation 5

TENS (transcutaneous electrical nerve stimulation) should be integrated as part of a multimodal pain management approach 2

For severe, refractory chronic pain, a small percentage of patients require long-term multidisciplinary treatment including physical therapy, psychological support, and pain-relieving measures such as spinal analgesia 1, 6

Critical Clinical Pitfalls to Avoid

• Do not delay referral to specialized care—early diagnosis and treatment dramatically improve outcomes 1
• Avoid overhead pulley exercises which increase risk of developing and worsening hemiplegic shoulder pain 3
• Do not continue sympathetic blocks indefinitely without documented progressive improvement and increasing duration of relief 2
• Do not use strong opioids as routine treatment; reserve for cases where other analgesics fail to enable physical therapy participation 1, 4
• Do not use peripheral somatic nerve blocks for long-term chronic pain treatment 2

Monitoring and Documentation Requirements

Document the following to justify continued interventional treatment:

• Objective functional improvements in activities of daily living, cognitive function, and autonomic stability 2
• Duration of relief with each successive sympathetic block to demonstrate the required pattern of increasing benefit 2
• Temperature dysregulation changes and other autonomic symptoms 2
• Response pattern confirming the sympathetic component when using stellate ganglion or lumbar sympathetic blocks 2

Prevention Strategies

For at-risk patients (post-fracture, post-stroke, post-surgery):

• Vitamin C supplementation to prevent CRPS after wrist fractures 4
• Adequate perioperative analgesia with regional anesthetic techniques 4
• Active, active-assisted, or passive range of motion exercises to prevent CRPS development 3
• Protect hemiplegic limbs from trauma in stroke patients 3

Treatment Algorithm Summary

1. Immediate: Physical therapy + simple analgesics (acetaminophen/ibuprofen)
2. If insufficient: Add topical NSAIDs/capsaicin + oral corticosteroids (short course)
3. If still insufficient: Add anticonvulsants/tricyclic antidepressants for neuropathic pain
4. If moderate-severe pain: Add sympathetic nerve blocks (with documented progressive improvement)
5. If refractory: Spinal cord stimulation trial → permanent implantation if successful
6. Throughout: Maintain physical therapy, psychological support, and protect from trauma

The key principle is that all interventions must support the primary goal of restoring function through physical therapy 1, 7. CRPS requires individualized strategies within this framework due to poorly delineated pathophysiology and variable course 7, but the treatment hierarchy remains consistent.