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 is the cornerstone of CRPS treatment, with all other interventions serving to facilitate participation in rehabilitation. 1

Initial Management Approach

The treatment algorithm for CRPS after injury or trauma follows a stepwise progression:

First-Line: Rehabilitation (Mandatory Foundation)

• Initiate physical therapy immediately with gentle stretching and mobilization techniques, focusing on increasing external rotation and abduction 2
• Progress to active range of motion exercises that gradually increase while restoring alignment and strengthening weak shoulder girdle muscles 2
• Incorporate sensorimotor integration training as part of the rehabilitation program 1
• Critical pitfall to avoid: Delaying physical therapy while waiting for pain to resolve worsens outcomes through disuse and pain upregulation 1

Pharmacological Support for Therapy Participation

• Use acetaminophen or NSAIDs (ibuprofen) to enable physical therapy participation, not as primary treatment 2, 1
• Consider oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) to reduce inflammation and edema in acute presentations 2, 3
• Employ neuropathic pain medications for refractory cases 4

Second-Line: Interventional Procedures

Sympathetic Nerve Blocks (Selective Use)

Stellate ganglion blocks (upper extremity) or lumbar sympathetic blocks (lower extremity) may be used for moderate to severe cases with documented sympathetic dysfunction, but ONLY when demonstrating consistent improvement with increasing duration of relief with each successive block. 2, 1

Key criteria for continuing sympathetic blocks:

• Progressive improvement with each successive block 2
• Increasing duration of pain relief (not just intensity reduction) 2
• Objective functional improvements documented beyond pain scores 1
• Integration into multimodal rehabilitation approach 2

Critical pitfalls to avoid:

• Do NOT continue sympathetic blocks indefinitely without documented progressive improvement 1
• Do NOT use sympathetic blocks for non-CRPS neuropathic pain 2
• Do NOT use peripheral somatic nerve blocks for long-term treatment 2

Additional Interventional Options

• Botulinum toxin injections into affected muscles when pain relates to spasticity 2
• Subacromial corticosteroid injections when pain relates to subacromial injury or inflammation 2

Third-Line: Neuromodulation for Refractory Cases

Spinal cord stimulation is recommended for CRPS patients who have not responded to conservative management and appropriate interventional treatments. 2, 1

• Mandatory trial period before permanent implantation 2, 1
• Consider TENS as part of multimodal approach 2
• Motor cortex stimulation may be considered in highly refractory cases 4

Psychological Interventions

• Implement cognitive behavioral therapy to reduce anxiety and avoidance behavior that perpetuate disability 1
• Address comorbidities including depression and anxiety concurrently 5
• Use stepped psychological interventions as part of comprehensive care 1

Diagnostic Confirmation During Treatment

While treating, confirm diagnosis using:

• Three-phase bone scintigraphy (78% sensitivity, 88% specificity) as most useful imaging modality 1
• Clinical Budapest Criteria as primary diagnostic tool 1
• MRI has high specificity (91%) but low sensitivity (35%), making it unsuitable for screening 1

Monitoring and Follow-Up

• 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 1
  • Cognitive function 1
  • Autonomic stability 1
  • Temperature dysregulation resolution 1
  • Work capacity 1

Clinical Characteristics to Monitor

Watch for these hallmark features:

• Excruciating, burning pain disproportionate to initial injury that worsens with touch or stimulation 1, 2
• Sensory abnormalities including allodynia and hyperalgesia 1
• Autonomic dysfunction: temperature dysregulation, skin color changes, abnormal sweating 1
• Motor impairment: functional limb weakness, decreased active range of motion 1
• Trophic changes: hair loss, tissue changes, skin discoloration in chronic cases 1, 2

Evidence Quality Note

The strongest evidence supports physical therapy as foundational treatment 1, with moderate evidence for bisphosphonates, spinal cord stimulation, and cognitive behavioral therapy 5. Evidence for sympathetic blockade shows mixed results with most studies containing small patient numbers 5, which is why guidelines emphasize the requirement for documented progressive improvement before continuing this intervention 2.