Guideline for the treatment of CRPS (2018)
10th September 2018 – The S1 guideline „Diagnosis and treatment of complex regional pain syndromes (CRPS)“ (AWMF register number 030/116) is available in a comprehensively revised new version. Prof Dr Frank Birklein, Mainz, coordinated the guideline work.
The approximately 50-page guideline provides specific recommendations for the diagnosis and treatment of complex regional pain symptoms (CPRS), also with the aim of avoiding factors that promote chronification, such as painful invasive treatment procedures, and recognising psychological comorbidities in good time.
CRPS develops in around 2% of cases following trauma to the distal extremities. The symptoms do not adhere to nerve innervation territories. It is extremely rare for the symptoms to spread to other extremities during the course of the disease. A high intensity of pain even 1 week after a conservatively treated radius fracture, for example, can be an initial indicator that CRPS may be developing.
Diagnosis
The diagnosis is made according to defined clinical criteria, provided that diseases that can mimic CRPS have been ruled out. The presence of pressure pain hyperalgesia in the joints distal to a fracture/surgery site helps to confirm the clinical diagnosis of CRPS. Instrumental examinations can be used to confirm the clinical diagnosis, especially in doubtful cases. However, due to their medium sensitivity (approx. 75 per cent), they are not suitable for ruling out CRPS.
All CRPS patients should be examined for the presence of post-traumatic stress symptoms and generalised anxiety symptoms. The latter have a negative predictive value for the course of therapy.
Therapy: spinal ganglion stimulation of the lumbar spine could be an alternative to SCS
In acute stages, anti-inflammatory therapy with steroids (e.g. start with 100 mg prednisolone, taper off over 2 weeks) is indicated. Bisphosphonates (different dosages depending on the substance) can reduce pain and hyperalgesia and improve the quality of life in CRPS lasting less than six months. Ketamine infusions over several days reduce pain and improve function in CRPS over a period of several weeks, but only to a limited extent. In principle, there is an increased risk of undesirable psychotropic effects, dependence and, with repeated use, organ damage with ketamine.
Combined physiotherapy and psychotherapy that identifies and specifically treats the connection between pain, anxiety and avoidance („graded exposure“) is more effective for CRPS than standard physiotherapy. Pain exposure physiotherapy (PEPT) improves function but not pain in CRPS and is no longer recommended. There is still no evidence of efficacy for regional anaesthetic procedures on the sympathetic nervous system. Spinal ganglion stimulation at the lumbar spine could be an alternative to effective spinal cord electrical stimulation (SCS).
If there are no complicating factors and adequate treatment is initiated in good time, the prognosis for CRPS is not necessarily poor. In most cases, relevant pain lasting a year, especially during exertion, must be expected, often even longer. It is important to differentiate between the consequences of trauma that are not caused by the CRPS itself but are associated with it by patients, such as bone marrow oedema, arthrosis, myofascial complaints and changes in proximal joints due to the CRPS-associated relieving posture.
Assessment sheet for the diagnosis/treatment of CRPS
“Clinical Pathways“
Download evaluation sheet english version
PDF document [218.0KB]
Guidelines for diagnostics and therapy in neurology
The 5th edition of these guidelines was last published in book form in September 2012 and has been continuously updated on this website since then. Due to the long update cycles for printed works, the DGN guidelines have since been published exclusively online: on this website and shortly afterwards by the Association of Scientific Medical Societies in Germany (AWMF). Guidelines are valid for up to 5 years in some cases and the complex deliberation process involving dozens of experts and various specialist societies can sometimes take months or years. The approximately 900 volunteer authors and the editorial team endeavour to publish updates on this website as quickly as possible. In this way, new scientific findings benefit doctors and ultimately patients more quickly. Contact the editorial team: leitlinien@dgn.org
Download guideline – english version
PDF document [482.0 KB]
Link to the website of the German Society of Neurology
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