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White Paper: Complex Regional Pain Syndrome: Which Treatment
Approaches are Medically Necessary?
For Health Plans, Medical Management Organizations and TPAs
Complex Regional Pain Syndrome: An Overview
Complex regional pain syndrome (CRPS) is a chronic pain condition that often a ects one of the limbs, usually after an
injury or trauma to that limb. It is believed to be caused by damage to, or malfunction of, the peripheral and central
nervous systems, and is characterized by prolonged or excessive
pain and mild or dramatic changes in skin color, temperature, and/ Many health plans consider certain
or swelling in the a ected area. Most cases of CRPS are mild and pa- treatments for CRPS medically necestients recover gradually with time. However, in more severe cases, sary when conservative therapies have
individuals may not recover and may have long-term disability.
failed.
Many cases of CRPS result from a forceful trauma to an arm or leg,
such as a crush injury, fracture, or amputation. Other major and minor traumas, such as surgery, heart attacks, infections,
and sprained ankles, can also lead to CRPS. Another potential precipitating factor is emotional stress.
Diagnosing CRPS
Typical clinical ndings of CRPS include pain, edema, alteration in motor function, alteration in sensory function, and psychological dysfunction. Symptoms can vary in their severity and duration, and pain can become continuous and intense
over a period of time. Common symptoms of CRPS include burning pain, increased skin sensitivity, changes in skin temperature, changes in skin color, changes in skin texture, changes in nail and hair growth patterns, swelling and sti ness in
the a ected joints, and motor disability.
There is no speci c diagnostic test for CRPS that is conclusive. The diagnosis of CRPS is a clinical one, based on history and
physical examination and observation of signs and symptoms. Diagnostic tests that may be helpful, but are not speci c to
CRPS, include: bone scan; sympathetic nervous system tests (sweat test, thermography, electrodiagnostic testing); x-ray;
magnetic resonance imaging; blood tests (to rule out underlying infection); and biopsy.
It is important to di erentiate CRPS from other neuropathic and pain syndromes, in order to avoid the risks of overdiagnosing CRPS. There are numerous CRPS di erential diagnoses, including injury, lumbar degenerative disc disease,
Achilles tendon injuries and tendonitis, adhesive capsulitis, ankle sprain, anterior cruciate ligament injury, brachial neuritis, chronic pain syndrome, compartment syndrome, diabetic lumbosacral plexopathy, diabetic neuropathy, iliotibial
band syndrome, ischemic monomelic neuropathy, medial collateral and lateral collateral ligament injury, meniscal injury,
mononeuritis multiplex, neoplastic brachial plexopathy, neoplastic lumbosacral plexopathy, posterior cruciate ligament
injury, postpolio syndrome, radiation-induced brachial plexopathy, radiation-induced lumbosacral plexopathy, rotator
cu disease, spasticity, spinal stenosis and neurogenic claudication, thoracic outlet syndrome, and traumatic brachial
plexopathy.
Treatment Approaches for Complex Regional Pain Syndrome
Due to the complex nature of CRPS, patients usually require a multidisciplinary approach to treatment. Members of
the treatment team may include a neurologist, a pain relief specialist, a physical therapist, an occupational therapist, a
psychologist, and a social worker.
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Complex Regional Pain Syndrome
Rehabilitation Therapy
Physical therapy to keep a painful limb or body part moving can improve blood ow and lessen circulatory symptoms.
In addition, exercise can help improve the a ected limb’s exibility, strength, and function. Patients undergo a steady
progression from gentle weight bearing to progressive, active weight bearing, allowing gradual desensitization to
increasing sensory stimuli. Together with occupational therapy, physical therapy plays an important role in functional
restoration.
Occupational therapy can help patients learn new ways to work and perform daily tasks. Active compression and
distraction exercises provide stimuli to the a ected extremity without joint motion. The scrubbing technique is one
exercise in which scrubbing is performed by gradually increasing the weight on the patient’s a ected extremity as he/
she scrubs in circles. Weight loading of the joints is completed with increasing weight as the scrubbing process continues. In another exercise called the carrying technique, the patient is instructed to carry a weight (bag) on the a ected
extremity throughout the day, as tolerated. Desensitization techniques include rubbing the skin, massage, tapping, and
vibration.
Psychotherapy
CRPS is often associated with profound psychological symptoms for a ected individuals and their families. Patients with
CRPS may develop depression, anxiety, or post-traumatic stress disorder, all of which heighten the perception of pain
and make rehabilitation e orts more di cult. Recreational therapy can help patients take part in pleasurable activities
that help to decrease pain. Vocational therapy should be recommended and initiated early for all appropriate patients
so that they can return to gainful employment.
Medications
Although a number of di erent classes of medication have been shown to be e ective for treating CRPS, especially if
used early in the course of the disease, there is no treatment for CRPS approved by the U.S. Food and Drug Administration.
Medications used to treat CRPS include:
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Nonsteroidal anti-in ammatory drugs: ibuprofen, naproxen sodium
Corticosteroids: prednisolone, methylprednisolone
Antidepressants: nortriptyline, amitriptyline, duloxetine
Anticonvulsants: gabapentin, pregabalin
Opioid analgesics: oxycodone, morphine sulfate, fentanyl transdermal patch
N-methyl-D-aspartate receptor antagonists: dextromethorphan, ketamine
Nasal calcitonin
Botulinum toxin injections
Toopical local anesthetic creams and patches: lidocaine
Surgical Intervention
Sympathetic nerve blocks involve injecting an anesthetic next to the spine to directly block the activity of sympathetic
nerves and improve blood ow. Some individuals report temporary pain relief with this procedure, but there are limited
data to support the long-term bene t of sympathetic nerve blocks.
The use of surgical sympathectomy, which destroys some of the nerves, is controversial. Some experts think it is unnecessary and actually worsens CRPS, while others report favorable outcomes. Sympathectomy should be used only in
individuals whose pain is dramatically relieved by sympathetic nerve blocks.
Spinal cord stimulation involves placing stimulating electrodes through a needle into the spine near the spinal cord,
producing a tingling sensation in the painful area. The electrode is typically kept in place for a few days to assess whether
stimulation will be helpful. Minor surgery is required to implant parts under the skin on the torso. Once implanted, the
stimulator can be turned on and o and adjusted using an external controller. Some patients may develop equipment
problems that require additional surgeries.
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Complex Regional Pain Syndrome
Other types of neural stimulation can be delivered along the pain pathway, at locations other than the spinal cord, such
as: near injured nerves (peripheral nerve stimulators); outside the membranes of the brain (motor cortex stimulation
with dural electrodes); and within the parts of the brain that control pain (deep brain stimulation). In addition, repetitive
transcranial magnetic stimulation (rTMS) involves the use of magnetic currents applied externally to the brain. Although
surgery is not necessary, rTMS requires repeated treatment sessions.
Intrathecal drug pumps pump pain-relieving medications (e.g., opioids, local anesthetic agents) directly into the uid
that bathes the spinal cord. Pain-signaling targets in the spinal cord can be reached using doses far lower than those
required for oral administration, which may decrease side e ects and increase drug e ectiveness.
In general, most patients with CRPS will respond well to conservative measures. However, some patients may undergo a
number of failed therapies. Amputation may be a last-resort option in these extreme cases.
Determining Medical Necessity for Complex Regional Pain Syndrome Treatment
Many health plans consider certain treatments for CRPS medically necessary when conservative therapies have failed
or have been determined to be unsuitable or contraindicated. Conservative measures may include pharmacological,
surgical, psychological, or physical interventions. Spinal cord stimulators, peripheral nerve stimulators, intrathecal drug
delivery with subcutaneous pump, and sympathectomy may be covered when these measures fail.
Early diagnosis and treatment of CRPS is recommended for optimal management of the condition. Treatment is often
multidisciplinary, including rehabilitation, psychological, and pain therapies. Exert panel consensus guidelines developed in 1998 state that treatment should be developed around functional restoration and that most patients will
improve as long as su cient analgesia and symptomatic control can be provided to support exercise therapy. Updated
consensus treatment guidelines continue to focus on rehabilitation, psychological, and pain therapies, but add that the
three areas should be addressed simultaneously. Although the guidelines do not include recommendations for the timing of treatments, there is widespread agreement among experts that patients who do not respond to an acceptable
level of treatment by 12 to 16 weeks should be given a trial of more interventional therapies.
The Role of External Independent Medical Review in Determining Medical Necessity for Complex
Regional Pain Syndrome Treatment
An independent medical review, which is normally used by healthcare payers, looks at whether or not a speci c therapy
or procedure was medically necessary. It facilitates e ective evaluation and treatment of patients with CRPS, who can
achieve optimal management of their condition if diagnosed and treated early on.
Independent review organizations (IROs) allow ready access to a range of board-certi ed physician specialists, which
healthcare plans may lack internally. The specialists who review cases for IROs keep up-to-date with the latest medical research literature and with the latest standard of care, staying on top of continually evolving therapies as they are studied
more extensively and potentially accepted into clinical guidelines.
External independent medical review also helps to avoid con icts of interest, which can relate to economics, lack of specialists to review cases, and having the same doctor who denied a case review an appeal.
Conclusion
CRPS was once considered a controversial diagnosis. However, recent evidence suggests that CRPS is a multifactorial
disorder that requires a multidisciplinary treatment approach, including pharmacotherapy, physiotherapy, and psychotherapy. The clinical heterogeneity of the disorder presents challenges in diagnosis and treatment, but further advances
in understanding the multiple mechanisms implicated in the pathophysiology of CRPS will likely provide a basis for
more targeted therapeutic interventions in the not-so-distant future.
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Complex Regional Pain Syndrome
Bibliography
Stanton-Hicks M. Complex regional pain syndrome. Anesthesiol Clin North America. 2003;21:733-744.
Stanton-Hicks M, Baron R, Boas R, et al. Complex regional pain syndromes: guidelines for therapy. Clin J Pain.
1998;14:155-166.
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