What is the treatment approach for a patient with complex regional pain syndrome (CRPS) after an injury or trauma?

Treatment of Complex Regional Pain Syndrome (CRPS)

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

Initial Management Approach

Start physical therapy without delay—waiting for pain to resolve first worsens outcomes through disuse and pain upregulation. 1 The rehabilitation program should include:

• Gentle stretching and mobilization focusing on increasing external rotation and abduction 2
• Active range of motion exercises that gradually increase while restoring alignment and strengthening weak shoulder girdle muscles 2
• Sensorimotor integration training as part of comprehensive physical therapy 1

Pharmacological Support for Therapy Participation

Use analgesics specifically to enable physical therapy participation, not as primary treatment:

• NSAIDs and acetaminophen for pain control if no contraindications exist 1, 2
• Oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) to reduce inflammation and edema in early CRPS 1, 2

Interventional Procedures for Moderate to Severe Cases

Sympathetic nerve blocks (stellate ganglion blocks for upper extremity, lumbar sympathetic blocks for lower extremity) may be used only when there is documented sympathetic dysfunction AND each successive block demonstrates consistent improvement with increasing duration of relief. 1, 2

Critical requirements for continuing sympathetic blocks:

• Must show progressive improvement with each block 2
• Must demonstrate increasing duration of relief with successive blocks 2
• Must be integrated into multimodal rehabilitation, not used as monotherapy 2
• Do NOT continue indefinitely without documented progressive improvement 1, 2

Peripheral somatic nerve blocks should NOT be used for long-term CRPS treatment. 2

Advanced Treatment for Refractory Cases

For CRPS refractory to conservative management, proceed to spinal cord stimulation with mandatory trial before permanent implantation. 1, 2

Additional considerations:

• TENS should be used as part of multimodal pain management 2
• Cognitive behavioral therapy to reduce anxiety and avoidance behaviors that perpetuate disability 1

Diagnostic Imaging When Needed

Three-phase bone scintigraphy is the most useful imaging modality with 78% sensitivity and 88% specificity, particularly helpful for ruling out CRPS given its high specificity. 3, 1 However, diagnosis remains primarily clinical based on Budapest Criteria. 1

Critical Pitfalls to Avoid

• Never delay physical therapy waiting for pain resolution 1
• Never use sympathetic blocks for non-CRPS neuropathic pain—this contradicts evidence-based guidelines 2
• Never continue sympathetic blocks without documenting objective functional outcomes beyond pain scores 1, 2
• Never fail to document duration of relief with each successive block—this is required to demonstrate the necessary pattern of "increasing duration" 2

Monitoring Requirements

Evaluate patients at least twice annually by a specialist due to high recurrence risk. 1 Document objective functional outcomes including:

• Activities of daily living improvements 2
• Cognitive function 2
• Autonomic stability 2
• Temperature dysregulation resolution 2
• Work capacity 2

Treatment Algorithm Summary

1. Immediate initiation: Physical/occupational therapy 1
2. Concurrent support: Analgesics (NSAIDs, acetaminophen) to enable therapy 1, 2
3. Early inflammation control: Consider oral corticosteroids (30-50 mg daily, taper over 1-2 weeks) 2
4. Moderate-severe with sympathetic dysfunction: Sympathetic blocks only if demonstrating progressive improvement 1, 2
5. Refractory cases: Spinal cord stimulation trial, then permanent implantation if successful 1, 2
6. Throughout treatment: Cognitive behavioral therapy for psychological factors 1