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

Management of Complex Regional Pain Syndrome (CRPS)

Physical and occupational therapy must be initiated immediately as the cornerstone of CRPS treatment, with all other interventions serving solely to facilitate participation in rehabilitation. 1

Immediate First-Line Treatment

Start physical therapy without delay—waiting for pain to resolve first worsens outcomes through disuse and pain upregulation. 1

• Begin gentle stretching and mobilization focusing on increasing external rotation and abduction 2
• Progress to active range of motion exercises that gradually increase while restoring alignment and strengthening weak muscles 2
• Implement sensorimotor integration training as an essential component 1
• Use analgesics (NSAIDs or acetaminophen) solely to enable physical therapy participation, not as primary treatment 1, 2

Early Pharmacological Adjuncts

For acute CRPS with significant inflammation and edema, prescribe oral corticosteroids 30-50 mg daily for 3-5 days, then taper over 1-2 weeks. 2

• Consider antiepileptic drugs (gabapentin) for neuropathic pain component 3
• Tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors may be added for neuropathic pain 3
• Bisphosphonates have demonstrated pain relief and functional improvement in multiple controlled trials 4
• No FDA-approved medications exist specifically for CRPS 3

Interventional Procedures for Moderate to Severe Cases

Use sympathetic nerve blocks (stellate ganglion blocks for upper extremity, lumbar sympathetic blocks for lower extremity) only when there is consistent improvement and increasing duration of relief with each successive block. 2

• Blocks must be integrated into multimodal rehabilitation, not used as monotherapy 2
• Document objective functional outcomes beyond pain scores: activities of daily living, cognitive function, autonomic stability, temperature dysregulation 2
• Stop blocks if progressive improvement is not documented or duration of relief does not increase 2
• Do NOT use sympathetic blocks for non-CRPS neuropathic pain—this contradicts evidence-based guidelines 1, 2
• Do NOT use peripheral somatic nerve blocks for long-term treatment 2

Refractory CRPS Management

For patients who fail conservative management and remain unable to participate in rehabilitation due to pain severity, proceed to spinal cord stimulation trial. 1, 2

• Perform a trial before permanent implantation 2
• Spinal cord stimulation is the most effective treatment for refractory CRPS 2
• Consider TENS as part of multimodal approach 2

Psychological and Behavioral Interventions

Implement cognitive behavioral therapy and stepped psychological interventions to reduce anxiety and avoidance behavior that perpetuate disability. 1

• Patient education on pain neurophysiology improves physical performance and pain cognitions 5
• Address co-occurring substance use or psychiatric disorders through interdisciplinary teams 5

Critical Pitfalls to Avoid

• Never delay physical therapy waiting for pain to resolve—this is the single most harmful error 1
• Never continue sympathetic blocks indefinitely without documented progressive improvement 1
• Never use sympathetic blocks for non-CRPS neuropathic pain 1
• Never fail to document objective functional outcomes beyond numeric pain ratings 1
• Never use peripheral somatic nerve blocks for long-term chronic pain treatment 2

Monitoring Requirements

Evaluate CRPS patients at least twice annually by a specialist due to high recurrence risk. 1

• Reassess at regular intervals after adequate time for each treatment change to take effect 5
• Focus assessments on functional goals, pain severity, quality of life, and treatment-related adverse events 5
• Monitor for trophic changes including hair loss, tissue changes, and skin discoloration 1, 2

Treatment Algorithm Summary

1. Immediate: Start physical/occupational therapy + analgesics for therapy participation 1, 2
2. Early (if significant inflammation): Add oral corticosteroids 30-50 mg daily for 3-5 days, taper over 1-2 weeks 2
3. Moderate cases with sympathetic dysfunction: Add sympathetic nerve blocks only if progressive improvement documented 2
4. Refractory cases: Spinal cord stimulation trial 1, 2
5. Throughout: Cognitive behavioral therapy and patient education 5, 1

The goal is restoring function, not eliminating pain. 5 A holistic, multimodal interdisciplinary approach is required for all CRPS patients. 5, 6, 4