What are the treatment options for a patient with Complex Regional Pain Syndrome (CRPS)?

Treatment of Complex Regional Pain Syndrome (CRPS)

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

Immediate First-Line Treatment (Start Day 1)

Physical Therapy (Non-Negotiable Foundation)

• Begin gentle stretching and mobilization techniques focusing specifically on increasing external rotation and abduction of the affected limb 1, 2
• Progress to active range of motion exercises that gradually increase while restoring alignment and strengthening weak muscles in the shoulder girdle (upper extremity) or corresponding muscle groups (lower extremity) 1, 2
• Implement sensorimotor integration training to normalize movement patterns and prevent limited range of motion 1
• Critical pitfall: Delaying physical therapy while waiting for pain to resolve worsens outcomes through disuse and pain upregulation 1

Analgesics to Enable Rehabilitation

• Start NSAIDs (ibuprofen) or acetaminophen as first-line analgesics if no contraindications exist 1, 2
• Add early oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) to reduce swelling and inflammation 1, 2

Second-Line Pharmacologic Management (If First-Line Insufficient)

Neuropathic Pain Medications

• Initiate tricyclic antidepressants (amitriptyline, nortriptyline) for neuropathic features 1
• Consider gabapentinoids (gabapentin or pregabalin) for neuropathic component 1
• Apply topical lidocaine for localized neuropathic pain 1
• Add opioids only if above medications fail to provide sufficient analgesia to allow participation in physical therapy 3

Interventional Procedures (For Moderate to Severe Cases)

Sympathetic Nerve Blocks

• Perform stellate ganglion blocks for upper extremity CRPS or lumbar sympathetic blocks for lower extremity CRPS as components of multimodal treatment 4, 1, 2, 5
• Critical requirement: Each successive block must demonstrate consistent improvement AND increasing duration of pain relief 1, 2
• Document the duration of relief with each block to demonstrate the required pattern of "increasing duration" 1
• Important limitation: Sympathetic blocks should NOT be used for long-term treatment of non-CRPS neuropathic pain 4, 1, 2
• Contraindication: Peripheral somatic nerve blocks should NOT be used for long-term chronic pain management 4, 2

Botulinum Toxin

• Inject botulinum toxin into affected muscles when pain is related to spasticity 1, 2

Contraindications to All Interventional Procedures

• Active infection, coagulopathy, or patient unwillingness 1, 6
• Patients on anticoagulants (warfarin, heparin), antiplatelet agents (clopidogrel, dipyridamole), or antiangiogenesis agents (bevacizumab) must discontinue for appropriate duration before and after procedures 4, 1

Advanced Neuromodulation (For Refractory Cases)

Spinal Cord Stimulation

• Use spinal cord stimulation for persistent CRPS that has failed multimodal conservative treatment (physical therapy, medications, sympathetic blocks) 4, 1, 2, 6
• Mandatory requirement: Perform a trial period (3-7 days with temporary leads) to demonstrate adequate pain relief (typically >50% reduction) and measurable functional improvement before permanent device implantation 4, 1, 2, 6
• Strong consensus: The American Society of Anesthesiologists and American Society of Regional Anesthesia and Pain Medicine members strongly support spinal cord stimulation for refractory CRPS 4, 1
• Critical prerequisite: Psychological evaluation is explicitly required to identify untreated psychiatric comorbidity or substance abuse that would predict poor outcomes 6

Transcutaneous Electrical Nerve Stimulation (TENS)

• Use TENS as part of a multimodal approach to pain management 4, 2

Psychological and Behavioral Interventions

• Implement cognitive behavioral therapy, biofeedback, and relaxation training to provide pain relief and reduce anxiety/avoidance behaviors that perpetuate disability 1

Treatment Algorithm

Phase 1 (Immediate - Days 1-14):

• Start physical therapy with gentle mobilization immediately 1
• Begin NSAIDs/acetaminophen 1, 2
• Add oral corticosteroids (30-50 mg daily for 3-5 days, taper over 1-2 weeks) 1, 2

Phase 2 (Weeks 2-8 if Phase 1 Insufficient):

• Add gabapentin or tricyclic antidepressants for neuropathic component 1
• Consider sympathetic blocks (stellate ganglion for upper extremity, lumbar sympathetic for lower extremity) if pain prevents physical therapy participation 1, 2, 5
• Add opioids only if necessary to enable physical therapy 3

Phase 3 (After 3-6 Months if Refractory):

• Obtain psychological clearance (mandatory) 6
• Verify no contraindications (coagulation studies, rule out infection) 6
• Perform spinal cord stimulation trial 4, 1, 2, 6
• If trial successful (>50% pain reduction + functional improvement), proceed to permanent implantation 6

Documentation Requirements

For Sympathetic Blocks:

• Record duration of relief with each successive block to demonstrate "increasing duration" pattern 1
• Document objective functional outcomes: measurable improvements in activities of daily living, cognitive function, autonomic stability, and temperature dysregulation 1, 2

For Spinal Cord Stimulation:

• Document specific deficits in activities of daily living, not just pain scores 6
• Measure work capacity, mobility limitations, sleep disturbance, and quality of life impacts 6
• Create timeline showing progression through conservative therapies with dates, medications/interventions tried, dosages, duration, and documented reasons for failure 6

Monitoring and Follow-Up

• Evaluate patients at least twice annually by a specialist due to high recurrence risk 1
• Perform ongoing reassessment of functional status, not just pain scores 1

Common Pitfalls to Avoid

• Never delay physical therapy while waiting for pain to resolve—this worsens outcomes 1
• Never use sympathetic blocks for long-term treatment of non-CRPS neuropathic pain 4, 1, 2
• Never proceed directly to permanent spinal cord stimulator implantation without a successful trial period 4, 1, 2, 6
• Never continue sympathetic blocks indefinitely without documented progressive improvement and increasing duration of relief 1, 2
• Never focus solely on pain scores—document functional improvements in ADLs, work capacity, and quality of life 1, 6