Physical Medicine and Rehabilitation for Complex Regional Pain Syndromes Guidelines

Updated: Feb 06, 2019
  • Author: Manish K Singh, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Guidelines Summary

Royal College of Physicians

Updated guidelines regarding the management of CRPS in adults were published in 2018 by the Royal College of Physicians. [32]

Treatment by surgeons

These guidelines include the following:

  • Management should be initiated with simple analgesia (nonsteroidal anti-inflammatory drugs and paracetamol) and possibly tricyclic antidepressants (eg, amitriptyline) or anticonvulsants (eg, gabapentin), although follow-up and titration of doses may be best arranged by the patient’s general practitioner
  • If anticonvulsants or strong opiates are required, surgeons should consider urgent patient referral to a pain consultant
  • Urgent physical therapy, the mainstay of CRPS treatment, should be organized
  • Although plastic surgeons should not administer guanethidine blocks, pain clinicians may consider employing them; however, randomized, controlled trials have not demonstrated a benefit to their use


Surgical guidelines include the following:

  • Limbs that have previously been affected by CRPS can be treated with elective surgery, with less than 15% disease recurrence in patients who undergo surgery after acute symptoms have settled; following settlement of symptoms, surgery should, if possible, be delayed another 12 months or longer
  • In patients with CRPS type II who have sustained a recognized nerve insult or in whom the nerve appears to have been caught in a suture or scar contracture, surgery may be indicated
  • Surgery in CRPS should be performed by a surgeon with experience in managing the condition; the anesthetist should also be a pain specialist


Guidelines regarding amputation include the following:

  • Cases in which amputation is being considered should involve a multidisciplinary team that at minimum includes, along with a surgeon, a pain consultant, an appropriate psychologist or psychiatrist, and a physical therapist and/or occupational therapist
  • Amputation should be performed only after all other treatments have been assessed
  • Generally, amputation should not be performed within the first 2 years after CRPS has been diagnosed; intractable infection is the one strong indication for amputation