Complex regional pain syndromes

Red flags

  • Unexplained weight loss
  • History of malignancy

The following may lead to more urgent categorisation

  • Recent onset CPRS may be considered a Category 1 condition
  • Severe symptoms despite optimum management
  • Escalating opioid dependency

Complex regional pain syndrome (CRPS) is a chronic pain condition most often affecting one of the limbs (arms, legs, hands, or feet), usually after an injury or trauma to that limb. CRPS is characterized by prolonged or excessive pain, motor impairment and mild or dramatic changes in skin colour, temperature, and/or swelling in the affected area. Budapest criteria should be noted.

CRPS symptoms vary in severity and duration and may spontaneously recover or be a longstanding condition. Acute CRPS may be seen as an urgent condition as treatment may be more successful during this phase.

Other important information for referring practitioners

Lifestyle changes

  • Encourage healthy activity within pain limits. Graded exercise to reduce limb neglect and encourage regular movement of the limb. Be aware of associated muscular tension. Rehabilitation therapy is an important part of treatment.
    • Consider physio/OT referral (for mobilisation, desensitisation, graded motor imagery)
  • Ensure adequate sleep
  • Check for mood disturbances and relationship difficulties
    • Consider psychology referral for any mood disturbances and to assist in pain control

Medical management

  • Optimise medical management of predisposing secondary condition (if present)
  • Set realistic goals
  • Treat associated mood disorders
  • Avoid over-reliance of medication, encourage self-management and set realistic goals for treatment
    • Consider nerve blocking procedure if single nerve involvement
    • Sympathetic nerve blocking procedure (no evidence of long term benefit but can provide some temporary relief)
    • If trialling medication start at low dose and titrate upwards (do not continue if ineffective)
    • Agree on trial period for medication. Current medications used in CRPS are:
      • NSAIDs (short term for acute exacerbations if helpful)
      • Corticosteroids (used mainly in early stages when inflammation/oedema is present)
      • Amitriptyline:
        • Start at 10mg and slowly escalate dose (this may take weeks)
        • Max dose 75-100mg
        • Consider Nortriptyline in older patients
        • Anti-cholinergic effects on bladder can be troublesome in elderly males
      • Duloxetine:
        • PBS approved for neuropathic pain and major depressive disorder
      • Pregabalin:
        • PBS restricted for neuropathic pain refractory to treatment with other drugs
      • Local anaesthetic creams and patches
    • Try to avoid opioid drugs. Only use opioids for exacerbations and set time limits on prescribing
    • Spinal stimulation

Referral requirements

A referral may be rejected without the following information.

  • Persistent Pain Management Service eReferral form
  • Reason for referral
    • Comprehensive multidisciplinary management plan
    • Specific concerns re medication polypharmacy/overuse/dependence
    • Need for focussed multidisciplinary approach
  • History of condition
    • Date of onset and timeline
    • Any cause identified for pain, notably the precipitating injury
    • Management of condition.
    • Treatments trialled and reasons for failure
    • Include relevant specialist letters (esp. if seen by other pain management service)
    • List any red flags
  • Current and previous relevant medical conditions
  • Current medications and previous medications trialled for pain
  • List drug dependencies, inappropriate drug use and prescribed drug misuse e.g. nicotine, alcohol, cannabis, opioids
  • Allergies
  • Relevant examination findings
    • Plot sensory symptom distribution
    • Look for patterns of involvement (single nerve (entrapment), glove/stocking etc)
    • List any associated skin changes (pallor, flushing, sweating, hair loss, pigmentary changes)
  • Investigations
    • Relevant imaging

Additional referral information (useful for processing the referral)

  • Preferably patient to complete entry patient questionnaire prior to first consultation
  • Investigations related to co-morbidities e.g. diabetic control
  • Nerve conduction studies

Out of catchment

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and/or Torres Strait Islander
  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for GP/second opinion
  • For a specified test/investigation the GP can’t order, or the patient can’t afford or access
  • Reassurance for the patient/family
  • For other reason (e.g. rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary
  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use
  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Telephone contact number/s – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and/or Torres Strait Islander
  • Full name
  • Full address
  • Contact details – telephone, fax, email
  • Provider number
  • Date of referral
  • Signature
  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)
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