What are the treatment options for chronic regional pain syndrome (CRPS)?

Treatment for Complex Regional Pain Syndrome (CRPS)

Physical therapy with gentle mobilization and progressive exercises is the cornerstone of CRPS treatment and must be initiated immediately, with all other interventions serving solely to facilitate participation in rehabilitation. 1, 2

First-Line Treatment Approach

Begin physical therapy immediately with the following specific components:

• Gentle stretching and mobilization techniques focusing on increasing external rotation and abduction of the affected limb 1
• Active range of motion exercises that gradually increase while restoring alignment and strengthening weak muscles in the shoulder girdle (for upper extremity) 1
• Progressive tactile stimulation to address allodynia and hyperalgesia 3
• Sensorimotor integration training to normalize movement patterns and prevent limited range of motion 2

Critical pitfall to avoid: Delaying physical therapy while waiting for pain to resolve worsens outcomes through disuse and pain upregulation 2

Pharmacologic Management to Enable Rehabilitation

For pain control to facilitate physical therapy:

• NSAIDs (ibuprofen) or acetaminophen as first-line analgesics if no contraindications exist 1, 2
• Early oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) to reduce swelling and inflammation 1, 4
• Gabapentin or tricyclic antidepressants for neuropathic pain component (no FDA-approved drugs exist specifically for CRPS, but these are supported by evidence from other neuropathic conditions) 3, 4

Note: The evidence for corticosteroids and bisphosphonates is strongest when used early in the disease course 4, 5

Interventional Procedures for Moderate to Severe Cases

When conservative management fails or pain prevents rehabilitation participation:

Sympathetic Nerve Blocks

• Stellate ganglion blocks (for upper extremity CRPS) or lumbar sympathetic blocks (for lower extremity) may be used as components of multimodal treatment 6, 1
• Critical requirement: Blocks should only be continued if there is consistent improvement AND increasing duration of pain relief with each successive block 1
• Strong consensus exists among ASA and ASRA members that these blocks should be used for CRPS 1

Important caveat: Sympathetic blocks should NOT be used for long-term treatment of non-CRPS neuropathic pain, and peripheral somatic nerve blocks should not be used for long-term chronic pain management 6, 1

Botulinum Toxin

• Botulinum toxin injections into affected muscles when pain is related to spasticity 1
• Subacromial corticosteroid injections when pain is related to injury or inflammation of the subacromial region 1

Advanced Neuromodulation for Refractory Cases

For patients who have not responded to conservative therapies:

Spinal Cord Stimulation

• Spinal cord stimulation is recommended for persistent CRPS that has failed multimodal conservative treatment 6, 1, 7
• Mandatory trial period required: A temporary spinal cord stimulation trial must be performed and demonstrate adequate pain relief and functional improvement before permanent device implantation 6, 1, 7
• Strong consensus among ASA and ASRA members supports this intervention for refractory CRPS 6, 7

Critical pitfall: Proceeding directly to permanent implantation without a trial period violates guidelines and will likely result in denial 7

Transcutaneous Electrical Nerve Stimulation (TENS)

• TENS should be used as part of a multimodal approach to pain management for CRPS patients 6, 1

Psychological and Behavioral Interventions

Integrate psychological treatment to address disability perpetuation:

• Cognitive behavioral therapy, biofeedback, and relaxation training provide pain relief and reduce anxiety/avoidance behaviors that perpetuate disability 6, 2
• Supportive psychotherapy or group therapy may be useful as adjunctive treatment 6

Treatment Algorithm

1. Immediate initiation: Physical therapy with gentle mobilization + NSAIDs/acetaminophen 1, 2
2. Early intervention (first weeks): Add oral corticosteroids (30-50 mg daily, taper over 1-2 weeks) 1
3. If inadequate response: Add gabapentin or tricyclic antidepressants for neuropathic component 3, 4
4. If pain prevents rehabilitation: Consider sympathetic nerve blocks (stellate ganglion or lumbar sympathetic) with requirement for progressive improvement 6, 1
5. For refractory cases: Trial of spinal cord stimulation, followed by permanent implantation if successful 6, 1, 7
6. Throughout all stages: Integrate cognitive behavioral therapy and psychological support 6, 2

Documentation Requirements for Interventional Procedures

When pursuing sympathetic blocks or spinal cord stimulation:

• Document objective functional outcomes including measurable improvements in activities of daily living, cognitive function, autonomic stability, and temperature dysregulation 1
• Record duration of relief with each successive block to demonstrate the required pattern of "increasing duration" 1
• Chronological treatment history demonstrating progression through conservative therapies with documented inadequate response 7
• Shared decision-making discussion regarding potential complications of interventional procedures 6

Contraindications to Interventional Procedures

Do not proceed with interventional therapies if:

• Active infection, coagulopathy, or patient unwillingness 6, 7
• Patient is on anticoagulants (warfarin, heparin), antiplatelet agents (clopidogrel), or antiangiogenesis agents (bevacizumab) without appropriate cessation period 6
• Very short life expectancy (relevant in cancer-related CRPS) 6

Monitoring and Follow-Up

• Evaluate CRPS patients at least twice annually by a specialist due to high recurrence risk 2
• Ongoing reassessment of functional status, not just pain scores, is essential 6, 7