In complex regional pain syndrome, an interdisciplinary functional restoration program is typically the starting point. When that program does not achieve its intended pain and functional targets, a distinct next-line treatment path is indicated — one that combines pharmacological and psychological approaches with, where appropriate, targeted procedural intervention.
The first-line treatment was an interdisciplinary functional restoration program delivered over approximately six weeks. It included mirror visual feedback therapy, graded motor imagery, desensitization with progressive sensory stimulation, contrast baths, edema control, active and passive range-of-motion exercises, strengthening, aquatic therapy, exposure therapy, and postural normalization.
Escalation to this protocol is appropriate when that program has not achieved the following: improved active range of motion of the affected extremity, meaningful reduction in pain intensity, decreased edema, or a reduction of five or more points on the CRPS Severity Score.
This protocol introduces pharmacological options — including specific antidepressant agents and neuromodulating compounds — combined with structured psychological pain management strategies. Where clinically indicated, interventional procedures targeting the sympathetic nervous system form part of the overall approach. The full sequence, agent selection, and criteria are in the complete protocol.
Outcomes are agreed with the patient before treatment begins: a pain reduction of at least two points on a 0–10 Numeric Rating Scale, alongside meaningful improvement in specific functional activities.
DOI: 10.1093/pm/pnac046
The tricyclic/heterocyclic drugs are by far the best single agents for managing CRPS.
These drugs must be carefully monitored (frequent visits when starting) and started in low dose with methodical, gradual dose increases.
Gabapentin, first-line treatment for neuropathic pain, came to the attention of pain specialists in an anecdotal report of efficacy for CRPS.
The pain management intervention component of CRPS treatment should include relaxation training (preferably in conjunction with thermal and/or electromyographic biofeedback) and/or mindfulness-based stress reduction, training in cognitive pain coping skills (CBT), related interventions focused on living well with CRPS (i.e., ACT), and behavioral intervention to address disuse and activity avoidance issues, as well as family reinforcement issues.
The empirical utility of the SGB or LSB when used in a short series in conjunction with active reanimation physiotherapy is advocated based on consensus recommendations.
Reasonable treatment outcomes should be agreed upon in partnership with the patient before treatment starts (e.g., a pain reduction of two points on a 0–10 scale, improvement in specific functional activities).
If these targets are not achieved, or if initial beneficial effects later lessen, the drug treatment should then be reconsidered.
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