Complex regional pain syndromes

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.