Review Question - QID 1155

Complex regional pain syndrome is a chronic progressive disease of unknown etiology characterized by pain, swelling and skin changes. If nonoperative modalities fail, a surgical sympathectomy of the affected limb is indicated.

The first line of treatment is physical therapy including intermittent splinting, elevation and massage, contrast baths, and transcutaneous electrical nerve stimulation. Aggressive passive range-of-motion exercises should be avoided. If nonoperative modalites fail and symptoms remain severe, a surgical sympathectomy of the affected limb is indicated. Keys to successful treatment include early clinical suspicion and treatment. Late CRPS is highly refractory to treatment and often results in permanent disability.

Two forms of Complex regional pain syndrome exist: 1) Reflex sympathetic dystrophy - which does not demonstrate nerve lesions, and 2) Causalgia - which is associated with damage to peripheral nerves. Diagnostic criteria include:
Major criteria: intense and prolonged pain, swelling, stiffness, and discoloration (vasomotor disturbances).
Minor criteria: trophic changes, osseous demineralization, temperature changes, and palmar fibromatosis.

Tran et al present their systemic review of 41 RCTs of the research regarding treatment of CRPS. Their data suggest that only bisphosphonates offer clear medicinal benefits in the treatment of CRPS. Evidence regarding a beneficial effect of lumbar sympathetic blocks, gabapentin, and physical therapy is lacking. As such, these authors advocate for further study thru well-designed RCTs to better evaluate appropriate and effective treatment strategies.