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Complex Regional Pain Syndrome: Treatment & Medication
Updated: Oct 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
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. The 3 basic measures in therapy include pain management, rehabilitation (including physical therapy), and psychological therapy.21
- 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.20
- The anesthesia literature provides good evidence that spinal stimulation is effective.22,23
- Most patients, especially children, can benefit from physical therapy.10,24,25
- 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.20
- Acupuncture has been reported to have some value, especially in children.26
- In a randomized controlled trial of 84 currently pain-free patients with CRPS, Reuben et al used intravenous regional anesthesia with either lidocaine and saline or lidocaine and clonidine.27 All required surgery on the previously affected extremity. The recurrence rate of CRPS was significantly less in those who received the lidocaine and clonidine combination.
- Topical and intravenous lidocaine have been reported to be effective in some cases. Most of the literature appeared several years ago, but the group at Drexel University College of Medicine in Philadelphia recently reported favorable results for a 5-day lidocaine infusion.28
- Case reports and small number studies have reported good efficacy for topical and IV infusion of ketamine. As a dissociative anesthetic, the logic is to try to "erase the memory" of the pain stimulation.29,30,31
- A group in the Netherlands reported significant pain decrease in 8 patients treated with an IV infusion of magnesium.32
- 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.3
Consultations
- 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.
Medication
Specialists in pain management (usually an anesthesiologist or physiatrist) commonly perform neural blockade. Use of pain modifying agents, such as cyclic antidepressants and gabapentin, usually is left to the primary care physician or pain management team.
The ED physician's primary responsibilities are to recognize the disease and refer patients to an appropriate specialist. However, these patients experience severe pain and should be given sufficient analgesia to provide relief. Narcotics usually are required.
Discussion of available agents has been limited to morphine and hydromorphone. ED physicians choose the agent with which they are most familiar and comfortable. Clinicians who choose to use meperidine should remember that it provides some euphoria and also has an active metabolite that may accumulate.
Agents with a short duration of action (such as fentanyl) are not usually appropriate.
Some pain specialists prefer methadone for its long duration of action and mechanism of action benefit. This agent is an NMDA antagonist and may therefore be more effective in neuropathic pain syndromes. Conversion from other opioids to methadone should be done by a qualified pain management professional.33 Other long-acting agents include sustained-release forms of oxycodone and morphine.
Analgesics
Pain relief should be a high priority. Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties. Note that controversy exists among authors about the appropriateness of chronic narcotic analgesia. Some are opposed. Others note that, when more specific measures fail, patients must have pain relief in order to live their lives. The latter believe that patients with CRPS have a true chronic pain syndrome.
Morphine sulphate (Duramorph, MS Contin)
DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Initial dose dependent on whether patient already is taking narcotic analgesics. For patients not using long-term agents, as little as 2 mg IV/SC may be sufficient, though higher doses are often needed. Larger doses may be required in patients taking long-term narcotic analgesics.
Also available in oral form in immediate-release and timed-release preparations. Long-acting form usually is administered q12h, but many believe that it loses much of its effect after 8 h; immediate-release form may be needed for periods of pain "break-through," dose dependent on previous use. ED physician should begin at lowest available dose in newly diagnosed patients.
No intrinsic limit to the amount that can be given exists, as long as patient is observed for signs of adverse effects, especially respiratory depression. Various IV doses are used, commonly titrated until desired effect obtained.
Adult
0.05-0.1 mg/kg IV/IM/SC initial, repeated as needed
Pediatric
Not established but commonly given as 0.05-0.1mg/kg
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult; severe reactive airway disease; respiratory depression; paralytic ileus
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Hydromorphone (Dilaudid)
Used to manage moderate to severe pain. Available IV and PO.
Adult
2 mg PO initial; 1 mg IV slow push initial
Pediatric
Not established
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway with uncertain rapid airway control; hypotension; respiratory depression; nausea; emesis; constipation; urinary retention
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in atrial flutter and other supraventricular tachycardias; has vagolytic actions and may increase ventricular response rate
More on Complex Regional Pain Syndrome |
| Overview: Complex Regional Pain Syndrome |
| Differential Diagnoses & Workup: Complex Regional Pain Syndrome |
 Treatment & Medication: Complex Regional Pain Syndrome |
| Follow-up: Complex Regional Pain Syndrome |
| References |
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References
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Further Reading
Keywords
complex regional pain syndrome symptoms, complex regional pain syndrome treatment, RSDS, RSD, reflex sympathetic dystrophy syndrome, causalgia, sympathetic maintained pain syndrome, complex regional pain syndrome, CRPS, CRPS I, CRPS II, peripheral nerve injury
