What is the recommended management for chronic regional pain syndrome?

Management of Chronic Regional Pain Syndrome (CRPS)

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

Immediate First-Line Rehabilitation (Start Day 1)

Physical therapy is non-negotiable and must begin immediately, even in the presence of severe pain. Delaying therapy while waiting for pain resolution worsens outcomes through disuse and pain upregulation. 2

Essential physical therapy components include:

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

Pharmacologic Management to Enable Rehabilitation

Medications are adjuncts to facilitate therapy participation, not standalone treatments.

First-line analgesics:

• NSAIDs (ibuprofen) or acetaminophen (up to 3g/day) as initial analgesics if no contraindications exist 2, 4
• Early oral corticosteroids: 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and inflammation 2, 5

For neuropathic pain component:

• Gabapentin with appropriate dose adjustments based on renal function 4, 6
• Tricyclic antidepressants (amitriptyline, nortriptyline) for neuropathic features 7, 5
• Topical lidocaine for localized neuropathic pain 7

Note: No FDA-approved drugs exist specifically for CRPS; these recommendations are extrapolated from neuropathic pain evidence. 3

Interventional Procedures for Moderate to Severe Cases

Proceed to interventional options only when pain severity prevents rehabilitation participation despite pharmacologic optimization.

Sympathetic nerve blocks:

• Stellate ganglion blocks for upper extremity CRPS 2
• Lumbar sympathetic blocks for lower extremity CRPS 2
• Critical requirement: Each successive block must demonstrate consistent improvement AND increasing duration of relief 2
• Pitfall to avoid: Continuing blocks indefinitely without documented progressive improvement contradicts evidence-based practice 1

Advanced neuromodulation:

• Spinal cord stimulation for persistent CRPS that has failed multimodal conservative treatment 2, 3
• Mandatory trial period required before permanent device implantation to demonstrate adequate pain relief and functional improvement 2

Psychological Interventions (Concurrent with Physical Therapy)

Cognitive behavioral therapy is strongly recommended to reduce anxiety and avoidance behaviors that perpetuate disability. 4, 2

Additional beneficial modalities include:

• Biofeedback 2
• Relaxation training 2
• Stepped psychological interventions addressing self-esteem, coping skills, and mood disorders 4

Treatment Algorithm

Week 1-2:

1. Initiate physical therapy immediately with gentle mobilization 2
2. Start NSAIDs/acetaminophen 2
3. Add oral corticosteroids (30-50 mg daily for 3-5 days, then taper) 2
4. Begin CBT concurrently 4

Week 2-4:

• Add gabapentin or tricyclic antidepressant for neuropathic component if pain persists 4, 6
• Continue aggressive physical therapy progression 2

Week 4-8 (if inadequate response):

• Consider sympathetic nerve blocks only if pain prevents therapy participation 2
• Refer to pain specialist for procedural interventions 3

Beyond 8 weeks (refractory cases):

• Evaluate for spinal cord stimulation trial 2
• Ensure continued physical therapy throughout 1

Critical Pitfalls to Avoid

• Never delay physical therapy waiting for pain to resolve—this worsens outcomes 1, 2
• Do not continue sympathetic blocks indefinitely without documented progressive improvement and increasing duration of relief 1
• Avoid peripheral somatic nerve blocks for long-term treatment 1
• Do not use sympathetic blocks for non-CRPS neuropathic pain 1
• Never focus solely on pain scores—document objective functional outcomes including activities of daily living, range of motion, and autonomic stability 2

Monitoring Requirements

• Evaluate patients at least twice annually by a specialist due to high recurrence risk 1, 2
• Document measurable improvements in functional status, not just pain intensity 2
• For sympathetic blocks: record duration of relief with each successive block to demonstrate required pattern of increasing duration 2
• Assess for treatment-related adverse events regularly 4

Contraindications to Interventional Procedures

• Active infection 2
• Coagulopathy or patients on anticoagulants/antiplatelet agents without appropriate cessation period 2
• Patient unwillingness 2