What is the recommended management for complex regional pain syndrome?

Management of Complex Regional Pain Syndrome

Physical and occupational therapy are the cornerstone of CRPS treatment and must be initiated immediately—all other interventions exist solely to facilitate participation in rehabilitation. 1, 2, 3

Immediate First-Line Treatment

Physical Therapy (Mandatory Foundation)

• Start gentle stretching and mobilization exercises immediately, progressing to active range of motion and sensorimotor integration training 1
• Use graded motor imagery protocols, progressive tactile stimulation (desensitization), and normalization of movement patterns to prevent contractures 2, 4
• Manual lymph drainage improves hand function and quality of life, though benefits require continuous supervised therapy 1
• Critical pitfall: Delaying physical therapy while waiting for pain to resolve worsens outcomes through disuse and pain upregulation 1

Analgesics to Enable Therapy Participation

• Acetaminophen is first-line for enabling physical therapy participation 1
• NSAIDs can be added for additional analgesia, particularly in early-stage CRPS 2, 4
• Oral corticosteroids should be used in acute CRPS (within first few months) to reduce inflammation and edema 1, 4

Second-Line Pharmacotherapy for Neuropathic Pain

When pain prevents therapy participation despite analgesics:

• Gabapentin or pregabalin (87% of pain centers use these as preferred agents) 5, 2
• Tricyclic antidepressants (e.g., amitriptyline) for neuropathic pain control 5, 2
• SNRIs as alternative neuropathic pain agents 2
• Important: Improvement may take weeks to manifest with neuropathic pain medications 5

Interventional Procedures for Moderate-to-Severe Cases

Sympathetic Nerve Blocks

• Indicated for moderate-to-severe CRPS with sympathetic dysfunction when pain prevents physical therapy participation 1, 3
• Stellate ganglion blocks for upper extremity CRPS 1
• Lumbar sympathetic blocks for lower extremity CRPS 1
• Critical pitfall: Do not continue blocks indefinitely without documented progressive improvement and increasing duration of relief 1
• Peripheral somatic nerve blocks are NOT indicated for long-term treatment 1

Spinal Cord Stimulation

• Recommended for refractory CRPS after failure of conservative treatments 1, 6, 3, 4
• Mandatory trial period required before permanent implantation—proceeding directly to permanent device will result in denial 6
• Trial must demonstrate >50% pain reduction and measurable functional improvement 6
• Psychological evaluation is explicitly required to identify untreated psychiatric comorbidity or substance abuse 6
• Contraindications include coagulopathy, active infection, and inability to operate device 6

Psychological Support (Essential Component)

• Cognitive behavioral therapy reduces anxiety and avoidance behaviors that perpetuate disability 1
• Stepped psychological interventions should be integrated early, not reserved for treatment failures 1
• Address fear-avoidance patterns that prevent engagement in beneficial but anxiety-provoking activities like exercise 5

Treatment Algorithm

Step 1: Immediate initiation of physical/occupational therapy + acetaminophen ± NSAIDs 1, 2

Step 2: Add oral corticosteroids if acute CRPS (within first few months) 1, 4

Step 3: If pain prevents therapy participation, add gabapentin/pregabalin or tricyclic antidepressants 5, 2

Step 4: For moderate-to-severe cases with sympathetic dysfunction, add sympathetic nerve blocks to enable therapy 1, 3

Step 5: For refractory cases after 3-6 months of failed conservative management, consider spinal cord stimulation trial 6, 4

Throughout all steps: Integrate cognitive behavioral therapy and psychological support 1

Monitoring Requirements

• Evaluate patients at least twice annually due to high recurrence risk 1, 7
• Document objective functional outcomes beyond pain scores (ADLs, work capacity, mobility, sleep quality) 6
• Measure outcomes with validated instruments at each treatment stage 6

Critical Pitfalls to Avoid

• Never delay physical therapy waiting for complete pain resolution—this worsens outcomes 1
• Do not use sympathetic blocks for non-CRPS neuropathic pain 1
• Avoid continuing interventional treatments without documented objective functional improvement 1
• Do not proceed to permanent spinal cord stimulator without successful trial 6
• Consider age-related risks when prescribing sedating medications (tricyclics, gabapentinoids, opioids) in older adults 5