What are therapeutic guidelines for complex regional pain syndrome (CRPS)?

Updated: Jun 20, 2018
  • Author: Gaurav Gupta, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

Treatment for CRPS is most effective when applied in a cohesive multidisciplinary venue. The treating physician should be aggressive with medical therapies, systematically experimenting with opportunistic pharmaceutical approaches to eliminate the patient’s pain. If the pain and other CRPS symptoms evade satisfactory treatment, then alternative or additional medications should be considered. All treatments work best when applied early, and early-stage CRPS is easier to treat as well. First-line analgesics and coanalgesics for CRPS are opioids, tricyclic antidepressants, gabapentin (or pregabalin), and carbamazepine. In addition, a course of corticosteroids can be considered if inflammatory signs and symptoms predominate.

Sympatholytic procedures, such as sympathetic ganglion blocks, help identify the central pain component maintained by the SNS. Calcium-regulating agents and gabapentoids have been shown to help with acute refractory neuropathic pain. For intractable cases, SCS, IV ketamine, hyperbaric oxygen therapy (HBOT), and epidural clonidine should be strongly considered, especially SCS. [166, 59, 167]

Psychological therapies that include stress management, supportive psychotherapy, and the treatment of psychological comorbidities should also be initiated early as an integral component of the multidisciplinary approach. Psychological treatments, including cognitive behavioral therapies, are frequently used strategies. Identifying an individual’s coping style and then reinforcing healthy coping behaviors; discovering contributing environmental or operant factors; and determining, then treating, associated emotional states are often necessary for steering a chronic pain process to a successful outcome. [166, 59, 167]

Perhaps the most important component of multidisciplinary treatment is active physiotherapy, which is best instituted in a slowly progressive and active, rather than passive, manner. The severity of the disease determines the therapeutic regimen. Pain reduction is the precondition for all interventions, and applied therapies for CRPS should not be painful.

In the acute stages of CRPS when the patient still suffers from severe pain at rest, it is usually impossible to carry out intensive active physical therapy. Painful or aggressive physiotherapy interventions at this stage may lead to deterioration. Therefore, progressive, but cautious, mobilization is indicated. If the affected extremity is too painful to be actively moved, then contralateral physical therapy can be applied. When the resting pain subsides, physical therapy can progress to active isometric strengthening, followed by active isotonic training. Functional restoration should be performed in combination with sensory desensitization programs until the complete recuperation of motor function occurs. [97, 59, 14]


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