Complex Regional Pain Syndrome in Emergency Medicine Treatment & Management
- Author: Steven J Parrillo, DO, FACOEP, FACEP; Chief Editor: Robert E O'Connor, MD, MPH more...
There is nothing for prehospital providers to do except transport. Most state guidelines do not include chronic pain syndromes as an indication for narcotic administration.
Emergency Department Care
Definitive care is really beyond the purview of the ED physician. An emergency physician's primary role with patients who have complex regional pain syndrome (CPRS)/reflex sympathetic dystrophy syndrome (RSDS) is to recognize the possibility of the diagnosis and refer such patients to colleagues who are capable of using available therapies. Breaking through the pain cycle early increases the likelihood of a better outcome.
Once the diagnosis is established, a number of treatment modalities that have been proven helpful are available. The most effective treatment involves differential neural blockade. Children may also benefit from neural blockade.
CRPS experts and researchers have looked at many treatment possibilities. Some have proven beneficial, others less so. The list below includes most of the possibilities that have been considered. Some of the oral medications may be prescribed in the ED after discussion with the primary care physician or pain specialist. Although none of the other modalities will be used in the ED, the clinician should have an overview of the available options.
The anesthesia literature provides good evidence that spinal stimulation is effective. [37, 38]
Tricyclic antidepressants have been used to decrease burning. Gabapentin (Neurontin) and systemic steroids have also been used with varying degrees of success. Other agents include the alpha-1 adrenoreceptor antagonists terazosin and phenoxybenzamine; the alpha-2 adrenoreceptor agonist clonidine; and the NDMA receptor antagonists ketamine, dextromethorphan, and calcitonin. When treatment reaches a plateau, invasive interventions to be considered include tunneled epidural catheters and neuroaugmentation.
Dadure et al recently described a series of pediatric patients with recurrent CRPS who benefited from continuous peripheral nerve blocks given at home. 
Acupuncture has been reported to have some value, especially in children. 
Eckmann et al performed a randomized, controlled trial that looked at several parameters with the use of IV regional block with ketorolac and lidocaine for treating CRPS. This small study of10 patients with lower extremity CPRS type I showed short-term (1 week) pain relief. No improvement was shown in the primary outcome of overall pain numeric rating scale or secondary outcomes of pain in motion, allodynia, joint pain score, edema, range of ankle motion, and skin temperature. 
A Turkish group performed a randomized controlled trial using a Bier block containing methylprednisolone and lidocaine in patients with CRPS type I patients. The group concluded that the therapy did not provide long-term benefit, and the short-term benefit was no better than with placebo. 
A group in the Netherlands reported significant pain decrease in 8 patients treated with an IV infusion of magnesium. 
Work that is looking at the efficacy of bisphosphonates has begun. [8, 54]
Intravenous immunoglobulin has been studied. 
Case reports describe some promise for the injection of botulinum toxin. [55, 56]
For patients who cannot be seen in the ED or cannot be treated in an expeditious fashion with neural blockade, the primary care physician who knows the patient best should arrange for narcotic analgesia, recognizing that neuropathic pain may be very resistant to standard analgesics, even potent ones. Patients who fail neural blockade very well may have disease that has progressed to the sympathetic-independent stage, and they are likely to have a lifelong problem. In this group, treatment by specialists in pain management, who have access to more sophisticated and experimental therapies, is mandatory.
In the ED, narcotics often are required to provide temporary relief while waiting for definitive treatment to begin. Patients with refractory disease may present to the ED with flare-ups that require narcotics. Although distinguishing between those who are truly in pain and those who are malingering is very difficult, the clinician must not assume that all who present without an obvious painful problem are drug seekers. Those with CRPS/RSDS may have a paucity of objective findings. Many are under the care of a knowledgeable pain expert and do not allow themselves to run out of analgesia.
The Reflex Sympathetic Dystrophy Syndrome Association has produced a very user-friendly guideline document that may be helpful to both clinician and patient. 
See the list below:
Consider consultation with an anesthesiologist or other qualified pain management specialist regarding management.
Consider consultation with physical medicine personnel regarding rehabilitation.
Consider consultation with a hand surgeon.
Bruehl S. Complex regional pain syndrome. BMJ. 2015 Jul 29. 351:h2730. [Medline].
Schwartzman RJ. Reflex sympathetic dystrophy. Curr Opin Neurol Neurosurg. 1993 Aug. 6(4):531-6. [Medline].
Campbell JN, Meyer RA, Raja SN. Is nociceptor activation by alpha-1 adrenoreceptors the culprit in sympathetically mediated pain?. Am Pain Soc J. 1992. 1:3-11.
Sharma A, Agarwal S, Broatch J, Raja SN. A web-based cross-sectional epidemiological survey of complex regional pain syndrome. Reg Anesth Pain Med. 2009 Mar-Apr. 34(2):110-5. [Medline].
Goebel A, Baranowski A, Maurer K, Ghiai A, McCabe C, Ambler G. Intravenous immunoglobulin treatment of the complex regional pain syndrome: a randomized trial. Ann Intern Med. 2010 Feb 2. 152(3):152-8. [Medline].
[Guideline] Harden RN, Oaklander AL, Burton AW, Perez RS, Richardson K, Swan M, et al. Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. Pain Med. 2013 Feb. 14 (2):180-229. [Medline].
Bruehl S. An update on the pathophysiology of complex regional pain syndrome. Anesthesiology. 2010 Sep. 113(3):713-25. [Medline].
Maihöfner C, Seifert F, Markovic K. Complex regional pain syndromes: new pathophysiological concepts and therapies. Eur J Neurol. 2010 May. 17(5):649-60. [Medline].
Maihofner C, Handwerker HO, Neundorfer B, Birklein F. Mechanical hyperalgesia in complex regional pain syndrome: a role for TNF-alpha?. Neurology. 2005 Jul 26. 65(2):311-3. [Medline].
Blaes F, Schmitz K, Tschernatsch M, et al. Autoimmune etiology of complex regional pain syndrome (M. Sudeck). Neurology. 2004 Nov 9. 63(9):1734-6. [Medline].
Oaklander AL, Fields HL. Is reflex sympathetic dystrophy/complex regional pain syndrome type I a small-fiber neuropathy?. Ann Neurol. 2009 Jun. 65(6):629-38. [Medline].
de Mos M, Huygen FJ, Stricker BH, Dieleman JP, Sturkenboom MC. The association between ACE inhibitors and the complex regional pain syndrome: Suggestions for a neuro-inflammatory pathogenesis of CRPS. Pain. 2009 Apr. 142(3):218-24. [Medline].
Swart CM, Stins JF, Beek PJ. Cortical changes in complex regional pain syndrome (CRPS). Eur J Pain. 2009 Oct. 13(9):902-7. [Medline].
Schwartzman RJ, Erwin KL, Alexander GM. The natural history of complex regional pain syndrome. Clin J Pain. May 2009. 25(4):273-80.
Stanton-Hicks M. Complex regional pain syndrome. Anesthesiol Clin North America. 2003 Dec. 21(4):733-44. [Medline].
Tong HC, Nelson VS. Recurrent and migratory reflex sympathetic dystrophy in children. Pediatr Rehabil. 2000 Apr-Jun. 4(2):87-9. [Medline].
Stanton-Hicks M. Plasticity of complex regional pain syndrome (CRPS) in children. Pain Med. 2010 Aug. 11(8):1216-23. [Medline].
Kachko L, Efrat R, Ben Ami S, Mukamel M, Katz J. Complex regional pain syndromes in children and adolescents. Pediatr Int. 2008 Aug. 50(4):523-7. [Medline].
de Rooij AM, de Mos M, van Hilten JJ, Sturkenboom MC, Gosso MF, van den Maagdenberg AM, et al. Increased risk of complex regional pain syndrome in siblings of patients?. J Pain. 2009 Dec. 10(12):1250-5. [Medline].
de Rooij AM, de Mos M, Sturkenboom MC, Marinus J, van den Maagdenberg AM, van Hilten JJ. Familial occurrence of complex regional pain syndrome. Eur J Pain. 2009 Feb. 13(2):171-7. [Medline].
Merskey H, Bogduk N, eds. International Association for the Study of Pain. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. IASP Press; 1996.
Sumitani M, Shibata M, Sakaue G, Mashimo T. Development of comprehensive diagnostic criteria for complex regional pain syndrome in the Japanese population. Pain. 2010 Aug. 150(2):243-9. [Medline].
Perez RS, Collins S, Marinus J, Zuurmond WW, de Lange JJ. Diagnostic criteria for CRPS I: differences between patient profiles using three different diagnostic sets. Eur J Pain. 2007 Nov. 11(8):895-902. [Medline].
Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms of reflex sympathetic dysrophy: prospective study of 829 patients. Lancet. 1993. 342:1012-1016.
Bruehl S, Harden RN, Galer BS, Saltz S, Bertram M, Backonja M, et al. External validation of IASP diagnostic criteria for Complex Regional Pain Syndrome and proposed research diagnostic criteria. International Association for the Study of Pain. Pain. 1999 May. 81(1-2):147-54. [Medline].
Brunner F, Lienhardt SB, Kissling RO, Bachmann LM, Weber U. Diagnostic criteria and follow-up parameters in complex regional pain syndrome type I--a Delphi survey. Eur J Pain. 2008 Jan. 12(1):48-52. [Medline].
Harden RN, Bruehl SP. Diagnosis of complex regional pain syndrome: signs, symptoms, and new empirically derived diagnostic criteria. Clin J Pain. 2006 Jun. 22(5):415-9. [Medline].
van Hilten JJ, van de Beek WJ, Vein AA, van Dijk JG, Middelkoop HA. Clinical aspects of multifocal or generalized tonic dystonia in reflex sympathetic dystrophy. Neurology. 2001 Jun 26. 56(12):1762-5. [Medline].
Hulsman NM, Geertzen JH, Dijkstra PU, van den Dungen JJ, den Dunnen WF. Myopathy in CRPS-I: disuse or neurogenic?. Eur J Pain. 2009 Aug. 13(7):731-6. [Medline].
Schwartzman RJ. New treatments for reflex sympathetic dystrophy. N Engl J Med. 2000 Aug 31. 343(9):654-6. [Medline].
Beerthuizen A, van 't Spijker A, Huygen FJ, Klein J, de Wit R. Is there an association between psychological factors and the Complex Regional Pain Syndrome type 1 (CRPS1) in adults? A systematic review. Pain. 2009 Sep. 145(1-2):52-9. [Medline].
Peterlin BL, Rosso AL, Nair S, Young WB, Schwartzman RJ. Migraine may be a risk factor for the development of complex regional pain syndrome. Cephalalgia. 2009 Jul 9. [Medline].
Borsook D, Sava S. Pain: Do ACE inhibitors exacerbate complex regional pain syndrome?. Nat Rev Neurol. 2009 Jun. 5(6):306-8. [Medline].
Maihofner C, Handwerker HO, Birklein F. Functional imaging of allodynia in complex regional pain syndrome. Neurology. 2006 Mar 14. 66(5):711-7. [Medline].
Dadure C, Motais F, Ricard C, Raux O, Troncin R, Capdevila X. Continuous peripheral nerve blocks at home for treatment of recurrent complex regional pain syndrome I in children. Anesthesiology. 2005 Feb. 102(2):387-91. [Medline].
Markman JD, Philip A. Interventional approaches to pain management. Anesthesiol Clin. 2007 Dec. 25(4):883-98, viii. [Medline].
Kemler MA, Reulen JP, Barendse GA, van Kleef M, de Vet HC, van den Wildenberg FA. Impact of spinal cord stimulation on sensory characteristics in complex regional pain syndrome type I: a randomized trial. Anesthesiology. 2001 Jul. 95(1):72-80. [Medline].
Oakley JC, Weiner RL. Spinal cord stimulation in complex regional pain syndrome: a prospective study of 19 patients at 2 centers. Neuromodulation. 1999. 2:47-50.
Kemler MA, Rijks CP, de Vet HC. Which patients with chronic reflex sympathetic dystrophy are most likely to benefit from physical therapy?. J Manipulative Physiol Ther. 2001 May. 24(4):272-8. [Medline].
Cleary AG, Sills JA, Davidson JE, Cohen AM. Reflex sympathetic dystrophy. Rheumatology (Oxford). 2001 May. 40(5):590-1. [Medline].
Daly AE, Bialocerkowski AE. Does evidence support physiotherapy management of adult Complex Regional Pain Syndrome Type One? A systematic review. Eur J Pain. 2009 Apr. 13(4):339-53. [Medline].
Kundu A, Berman B. Acupuncture for pediatric pain and symptom management. Pediatr Clin North Am. 2007 Dec. 54(6):885-9; x. [Medline].
Rickard JP, Kish T. Systemic Intravenous Lidocaine for the Treatment of Complex Regional Pain Syndrome: A Case Report and Literature Review. Am J Ther. 2015 Sep 22. [Medline].
Schwartzman RJ, Patel M, Grothusen JR, Alexander GM. Efficacy of 5-day continuous lidocaine infusion for the treatment of refractory complex regional pain syndrome. Pain Med. 2009 Mar. 10(2):401-12. [Medline].
Eckmann MS, Ramamurthy S, Griffin JG. Intravenous regional ketorolac and lidocaine in the treatment of complex regional pain syndrome of the lower extremity: a randomized, double-blinded, crossover study. Clin J Pain. 2011 Mar-Apr. 27(3):203-6. [Medline].
Taskaynatan MA, Ozgul A, Tan AK, Dincer K, Kalyon TA. Bier block with methylprednisolone and lidocaine in CRPS type I: a randomized, double-blinded, placebo-controlled study. Reg Anesth Pain Med. 2004 Sep-Oct. 29(5):408-12. [Medline].
Everett A, Mclean B, Plunkett A, Buckenmaier C. A unique presentation of complex regional pain syndrome type I treated with a continuous sciatic peripheral nerve block and parenteral ketamine infusion: a case report. Pain Med. 2009 Sep. 10(6):1136-9. [Medline].
Finch PM, Knudsen L, Drummond PD. Reduction of allodynia in patients with complex regional pain syndrome: A double-blind placebo-controlled trial of topical ketamine. Pain. 2009 Nov. 146(1-2):18-25. [Medline].
Sigtermans MJ, van Hilten JJ, Bauer MC, Arbous MS, Marinus J, Sarton EY, et al. Ketamine produces effective and long-term pain relief in patients with Complex Regional Pain Syndrome Type 1. Pain. 2009 Oct. 145(3):304-11. [Medline].
Schwartzman RJ, Alexander GM, Grothusen JR. The use of ketamine in complex regional pain syndrome: possible mechanisms. Expert Rev Neurother. 2011 May. 11(5):719-34. [Medline].
Azari P, Lindsay DR, Briones D, Clarke C, Buchheit T, Pyati S. Efficacy and safety of ketamine in patients with complex regional pain syndrome: a systematic review. CNS Drugs. 2012 Mar 1. 26(3):215-28. [Medline].
Tran de QH, Duong S, Bertini P, Finlayson RJ. Treatment of complex regional pain syndrome: a review of the evidence. Can J Anaesth. 2010 Feb. 57(2):149-66. [Medline].
Collins S, Zuurmond WW, de Lange JJ, van Hilten BJ, Perez RS. Intravenous magnesium for complex regional pain syndrome type 1 (CRPS 1) patients: a pilot study. Pain Med. 2009 Jul-Aug. 10(5):930-40. [Medline].
Brunner F, Schmid A, Kissling R, Held U, Bachmann LM. Biphosphonates for the therapy of complex regional pain syndrome I--systematic review. Eur J Pain. 2009 Jan. 13(1):17-21. [Medline].
Safarpour D, Jabbari B. Botulinum toxin A (Botox) for treatment of proximal myofascial pain in complex regional pain syndrome: two cases. Pain Med. 2010 Sep. 11(9):1415-8. [Medline].
Oh HM, Chung ME. Botulinum Toxin for Neuropathic Pain: A Review of the Literature. Toxins (Basel). 2015 Aug 14. 7 (8):3127-54. [Medline].
Hsu ES. Practical management of complex regional pain syndrome. Am J Ther. 2009 Mar-Apr. 16(2):147-54. [Medline].
Bruehl S, Harden RN, Galer BS, Saltz S, Backonja M, Stanton-Hicks M. Complex regional pain syndrome: are there distinct subtypes and sequential stages of the syndrome?. Pain. 2002 Jan. 95(1-2):119-24. [Medline].
Karmarkar A, Lieberman I. Management of complex regional pain syndrome type II using lidoderm 5% patches. Br J Anaesth. 2007 Feb. 98(2):261-2. [Medline].
Moseley GL. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology. 2006 Dec 26. 67(12):2129-34. [Medline].