What is the treatment approach for Complex Regional Pain Syndrome (CRPS)?

Treatment Approach for Complex Regional Pain Syndrome (CRPS)

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

Immediate First-Line Treatment (Start Day 1)

Physical and Occupational Therapy (mandatory foundation):

• Gentle stretching and mobilization techniques focusing on increasing external rotation and abduction of the affected limb 1, 2
• Active range of motion exercises that gradually increase while restoring alignment and strengthening weak muscles 1, 2
• 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, 3

Pharmacologic Support to Enable Rehabilitation:

• 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, 2
• Consider gabapentin or tricyclic antidepressants for neuropathic pain component 2

Second-Line Treatment for Moderate to Severe Cases

Sympathetic Nerve Blocks (when physical therapy participation is limited by pain):

• Stellate ganglion blocks for upper extremity CRPS 1, 2
• Lumbar sympathetic blocks for lower extremity CRPS 1, 2
• Critical requirement: Must demonstrate consistent improvement AND increasing duration of pain relief with each successive block 1, 2
• Documentation mandate: Record duration of relief with each block and objective functional improvements (ADLs, cognitive function, autonomic stability, temperature dysregulation) 1, 2
• Contraindication: Do NOT use sympathetic blocks for long-term treatment of non-CRPS neuropathic pain 1, 2

Alternative Injections:

• Botulinum toxin into affected muscles when pain is related to spasticity 1, 2
• Subacromial corticosteroid injections when pain is related to subacromial inflammation 1

Third-Line Treatment for Refractory Cases

Spinal Cord Stimulation (highest quality evidence for refractory CRPS):

• Indicated for persistent CRPS that has failed multimodal conservative treatment 1, 2, 4
• Mandatory trial period required before permanent device implantation to demonstrate adequate pain relief and functional improvement 1, 2
• Strong consensus from American Society of Anesthesiologists and American Society of Regional Anesthesia and Pain Medicine 1, 2
• Dorsal root ganglion stimulation is an alternative neuromodulation target with emerging evidence 5

TENS Therapy:

• Should be used as part of a multimodal approach to pain management 1

Psychological Interventions (Integrated Throughout)

Stepped Psychological Support:

• Cognitive behavioral therapy to reduce anxiety and avoidance behaviors that perpetuate disability 2, 4
• Biofeedback and relaxation training provide pain relief 2
• Address neurocognitive disorders of body perception and symptom processing 4

Treatment Algorithm Summary

1. Day 1: Initiate physical therapy + NSAIDs/acetaminophen 2
2. Days 1-5: Add oral corticosteroids (30-50 mg daily) if significant inflammation/edema 1, 2
3. Week 1-2: Add gabapentin or tricyclic antidepressants for neuropathic component 2
4. Weeks 2-4: If physical therapy participation remains limited, consider sympathetic blocks (stellate ganglion for upper extremity, lumbar sympathetic for lower extremity) 1, 2
5. Months 3-6: If no adequate response to conservative treatment, proceed to spinal cord stimulation trial 1, 2
6. Throughout: Integrate cognitive behavioral therapy and psychological support 2, 4

Critical Pitfalls to Avoid

• Never delay physical therapy waiting for pain to resolve—this worsens outcomes 2, 3
• Never continue sympathetic blocks indefinitely without documented progressive improvement and increasing duration of relief 1, 2
• Never use peripheral somatic nerve blocks for long-term chronic pain management in CRPS 1, 2
• Never use sympathetic blocks for non-CRPS neuropathic pain—this contradicts evidence-based guidelines 1, 2
• Never rely solely on pain scores—document objective functional outcomes (ADLs, work capacity, autonomic stability) 1, 2
• Never perform interventional procedures in patients with active infection, coagulopathy, or on anticoagulants without appropriate cessation period 2

Monitoring Requirements

• Evaluate CRPS patients at least twice annually by a specialist due to high recurrence risk 2, 3
• Ongoing reassessment of functional status, not just pain scores 2, 3
• For sympathetic blocks: document duration of relief with each successive block to demonstrate required pattern of "increasing duration" 1, 2

Evidence Quality Note

The treatment approach is based on 2025 American Society of Anesthesiologists and American Society of Regional Anesthesia and Pain Medicine guidelines 1, 2, with strong consensus among pain management experts. The modern conceptualization of CRPS as a primary pain condition of multifactorial origin (ICD-11) emphasizes early active treatments acting both centrally and peripherally, rather than predominantly passive peripheral measures 4.