Treatment of Complex Regional Pain Syndrome (CRPS)
Physical therapy is the cornerstone and first-line treatment for CRPS and must be initiated immediately upon diagnosis, with all other interventions serving to facilitate patient participation in rehabilitation. 1
Treatment Algorithm by Severity
Mild CRPS
- Start with physical therapy alone, focusing on progressive tactile stimulation, normalization of movement patterns, and prevention of limited range of motion 2, 1
- Encourage optimal postural alignment, even weight distribution, and graded activity to increase affected limb use with normal movement techniques 3
- Apply heat therapy to affected regions for 15-20 minutes several times daily 4
- Add NSAIDs (ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily) if pain interferes with therapy participation 4, 2
Moderate CRPS
- Continue aggressive physical therapy as the primary intervention 1, 5
- Add adjuvant analgesics: gabapentin or tricyclic antidepressants for neuropathic pain features 2, 1
- Consider serotonin-norepinephrine reuptake inhibitors as alternative neuropathic pain medication 2
- For early-stage CRPS specifically, add corticosteroids or bisphosphonates (bisphosphonates show clear benefit in controlled trials) 2, 6
- If these medications fail to provide sufficient analgesia for physical therapy participation, add opioids 1
Moderate-to-Severe CRPS with Sympathetic Dysfunction
- Proceed immediately to sympathetic nerve blockade to enable physical therapy participation 1
- For upper extremity CRPS: stellate ganglion blocks using fluoroscopic or ultrasound guidance 7
- For lower extremity CRPS: lumbar sympathetic blocks using fluoroscopic techniques 7
- These blocks are first-line interventional treatments and should not be delayed when pain severity prevents rehabilitation 7, 2
Refractory CRPS
- Refer to pain specialist for spinal cord stimulation when conservative treatments fail 8, 1, 6
- Spinal cord stimulation requires mandatory prerequisites: documented failure of conservative management including physical therapy and pharmacotherapy, successful trial period demonstrating adequate pain relief and functional improvement, and absence of contraindications (active infection, coagulopathy) 8
- Consider dorsal root ganglion stimulation as novel neuromodulation target 7
- Long-term multidisciplinary treatment combining physical therapy, psychological support, and ongoing pain-relieving measures is required 1
Critical Treatment Principles
Timing is everything: Early diagnosis and aggressive management are critical because long-term outcomes improve dramatically when treatment begins soon after symptom onset 2, 1
Avoid these common pitfalls:
- Never use splinting or adaptive aids as they prevent restoration of normal movement, increase symptom focus, promote compensatory patterns, cause muscle deconditioning, and can trigger worsening symptoms or additional CRPS 3
- Do not proceed directly to permanent spinal cord stimulation without trial period—this violates guidelines and ensures denial 8
- Never use spinal cord stimulation as first-line therapy; it is reserved exclusively for refractory cases after documented multimodal conservative treatment failure 8
Psychological treatment must be integrated: Address comorbid depression and anxiety concurrently, as cognitive behavioral therapy demonstrates beneficial effects in controlled trials 6, 5
Occupational therapy strategies: Engage patients in tasks promoting normal movement and good alignment—transfers, sit-to-stand activities, using affected hand to stabilize objects (preventing learned non-use), bilateral tasks using upper limbs while standing 3
Medications Without FDA Approval
No drugs are FDA-approved specifically for CRPS management, but evidence supports off-label use of neuropathic pain medications 2. The treatment hierarchy prioritizes physical function restoration over pain scores alone, with medications serving as adjuncts to enable rehabilitation participation 1, 5.