Treatment of Complex Regional Pain Syndrome (CRPS)
Physical therapy with gentle mobilization and progressive exercises is the mandatory cornerstone of CRPS treatment and must be initiated immediately, with all other interventions serving solely to facilitate participation in rehabilitation. 1, 2, 3
First-Line Treatment: Physical Therapy (Initiate Immediately)
Physical therapy is non-negotiable and must begin without delay—waiting for pain to resolve first worsens outcomes through disuse and pain upregulation. 2
Specific Physical Therapy Components:
- Gentle stretching and mobilization 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 in the shoulder girdle (for upper extremity CRPS) 1, 2
- Sensorimotor integration training to normalize movement patterns and prevent limited range of motion 2
- Graded motor imagery (GMI) provides clinically meaningful improvements in pain (21-point reduction on 0-100 VAS) and functional disability at 6-month follow-up 4
- Mirror therapy provides clinically meaningful improvements in pain (3.4-point reduction on 0-10 VAS) and function at 6-month follow-up, particularly in post-stroke CRPS patients 4
Pharmacologic Management to Enable Rehabilitation
Analgesics are used solely to enable participation in physical therapy, not as standalone treatment. 2
Immediate Analgesic Options:
- 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
Neuropathic Pain Adjuvants:
- Tricyclic antidepressants (amitriptyline, nortriptyline) for neuropathic features 2
- Gabapentin for neuropathic component 2
- Topical lidocaine for localized neuropathic pain 2
- Opioids should be added only if other medications fail to provide sufficient analgesia for physical therapy participation 3
Important caveat: NSAIDs alone have not shown significant improvement in controlled trials, but may be useful as part of multimodal therapy 5
Interventional Procedures for Moderate to Severe Cases
These procedures are reserved for patients with moderate to severe pain and/or sympathetic dysfunction who cannot participate in physical therapy despite pharmacologic management. 3
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, 2
- Critical requirement: Must demonstrate consistent improvement AND increasing duration of pain relief with each successive block 1, 2
- Do NOT use sympathetic blocks for long-term treatment of non-CRPS neuropathic pain—this contradicts evidence-based guidelines 1, 2
- Do NOT use peripheral somatic nerve blocks for long-term chronic pain management 1, 2
The ASA and ASRA guidelines strongly support stellate ganglion blocks for CRPS when used appropriately, representing high-level consensus among pain management experts 6, 1
Other Injection Options:
- Botulinum toxin injections into affected muscles when pain is related to spasticity 1, 2
- Subacromial corticosteroid injections when pain is related to injury or inflammation of the subacromial region 1
Advanced Neuromodulation for Refractory Cases
Spinal cord stimulation is recommended for persistent CRPS that has failed multimodal conservative treatment. 1, 2, 3
Spinal Cord Stimulation Protocol:
- Mandatory trial period required to demonstrate adequate pain relief and functional improvement before permanent device implantation 1, 2
- Strong consensus among ASA and ASRA members supports spinal cord stimulation for refractory CRPS 2
- Reserved for the small percentage of patients who develop refractory, chronic pain despite comprehensive treatment 3
TENS Therapy:
- TENS should be used as part of a multimodal approach to pain management in refractory cases 1
Psychological and Behavioral Interventions
Cognitive behavioral therapy, biofeedback, and relaxation training provide pain relief and reduce anxiety/avoidance behaviors that perpetuate disability. 2, 7
- These interventions are particularly important given the association between CRPS and depression/PTSD 5
- Comorbidities such as depression and anxiety should be treated concurrently 7
Treatment Algorithm
Step 1: Immediate Initiation (Day 1)
Step 2: Early Intervention (Days 3-5)
- Add oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) 1, 2
- Consider gabapentin or tricyclic antidepressants for neuropathic component 2
Step 3: Moderate Cases (Weeks 2-4)
- If unable to participate in physical therapy despite pharmacologic management, proceed to sympathetic nerve blocks 1, 2, 3
- Must document consistent improvement and increasing duration of relief with each block 1, 2
Step 4: Refractory Cases (Months 3-6)
- If persistent despite above measures, proceed to spinal cord stimulation trial 1, 2
- Implement TENS as part of multimodal approach 1
- Ensure psychological support is in place 2, 7
Critical Documentation Requirements
For interventional procedures to be justified, you must document: 1, 2
- Objective functional outcomes: measurable improvements in activities of daily living, cognitive function, autonomic stability, and temperature dysregulation
- Duration of relief with each successive sympathetic block to demonstrate the required pattern of "increasing duration"
- Functional status beyond just pain scores—work capacity, ADL improvements, cognitive function
Common Pitfalls to Avoid
- Delaying physical therapy while waiting for pain to resolve worsens outcomes through disuse and pain upregulation 2
- Continuing sympathetic blocks indefinitely without documented progressive improvement and increasing duration of relief contradicts guidelines 1, 2
- Using sympathetic blocks for non-CRPS neuropathic pain contradicts ASA/ASRA guidelines 1, 2
- Failing to document objective functional improvements beyond pain scores weakens medical necessity for continued interventional treatment 1
- Not recording duration of relief with each successive block makes it impossible to demonstrate the required pattern of "increasing duration" 1
Contraindications to Interventional Procedures
Absolute contraindications: 2
- Active infection
- Coagulopathy
- Patient unwillingness
- Patients on anticoagulants, antiplatelet agents, or antiangiogenesis agents without appropriate cessation period