Managing complex regional pain syndrome

Early diagnosis and management of complex regional pain syndrome (CRPS) is the key to successful recovery. CRPS becomes resistant to treatment if it is started too late. First-line treatment is early rehabilitation aimed at restoring function to the affected limb. If self-management is not sufficiently effective, consider referral to allied health providers to guide physical rehabilitation and provide psychological support. Early referral to an age-appropriate multidisciplinary pain service is recommended; see The role of healthcare providers in chronic pain management.

Pain intensity may slow or limit progress with physical rehabilitation, especially in acute CRPS (ie less than 3 months since onset). Analgesia may be considered second-line, to enable the patient to participate in rehabilitation. Choice of analgesic will depend on the patient’s age, whether the pain is acute or chronic, and risk associated with the analgesic.

In adults, oral opioids, tricyclic antidepressants, serotonin and noradrenaline reuptake inhibitors, gabapentinoids, and ketamine (specialist only) are often used for acute CRPS; see Using analgesics to manage acute pain for dose advice. Corticosteroids and bisphosphonates have been used with some success in acute-phase CRPS when inflammation predominates and impacts physical rehabilitation. Sympathetic blocks are not effective. In severe or poorly responsive cases, consider specialist referral for spinal cord stimulation.

Ascorbic acid (vitamin C) may be considered for prevention of CRPS, especially for those at increased risk (eg radius fracture, history of previous CRPS). Use:

In children, if analgesics are indicated, trial oral paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs); see here for doses. Discontinue paracetamol or NSAIDs if they do not facilitate physical rehabilitation. Oral opioids are second-line analgesics that should only be used for severe pain in acute CRPS. Discontinue opioids if they do not facilitate physical rehabilitation. Seek specialist advice if oral opioids are required for more than 2 weeks.

There is insufficient evidence to recommend any other medication or procedure for the management of CRPS in children. If physical rehabilitation, psychological techniques or analgesia are ineffective, seek advice from a paediatric multidisciplinary pain service.

There is no evidence that ascorbic acid (vitamin C) prevents or improves CRPS in children.