Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II

Explicit Motor Imaging Abilities Are Similar in Complex Regional Pain Syndrome, Chronic Limb Pain and Healthy Individuals: A Cross-Sectional Study

Background

Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by peripheral, central sensory and motor dysfunction. Implicit motor imagery is known to be impaired in CRPS patients, but evidence for explicit motor imagery is still lacking. Using a self-rated questionnaire, this study aims to compare explicit motor imagery abilities between individuals with CRPS, with chronic limb pain (CLP), and healthy controls, and to also examine differences between affected and unaffected limbs. We hypothesize that both CRPS and CLP patients will show a decrease in motor imagery abilities compared to healthy controls and in their affected limb compared to their own contralateral, unaffected side.

Patients and Methods

In this single-center observational study, 123 participants were recruited (CRPS = 40, chronic limb pain, CLP = 40, and healthy individuals = 43). Participants completed the Movement Imagery Questionnaire-Revised Second (MIQ-RS) once for each side of the body. The total MIQ-RS score, and the kinesthetic and visual subscores were compared between groups and between the affected and unaffected sides.

Results

A high degree of heterogeneity was observed in the explicit motor imagery scores and subscores, regardless of whether the participants were healthy or individuals with chronic pain. The MIQ-RS did not reveal any significant differences in explicit motor imagery abilities, neither between groups nor between the affected and unaffected side. Bayesian testing of the null hypothesis for kinesthetic motor imagery abilities indicated a sevenfold likelihood of no differences between groups and a more than a fivefold likelihood of no differences between sides.

Conclusion

Individuals with CRPS and chronic limb pain displayed preserved explicit motor imagery abilities, notably on the pain side. The preservation of these abilities supports the recommendation of mental imagery therapy to improve motor function and relieve pain in chronic pain patients.

Ketamine Infusion for Complex Regional Pain Syndrome Treatment: A Narrative Review

PURPOSE OF REVIEW

Complex Regional Pain Syndrome (CRPS) is a neuropathic pain disorder characterized by pain disproportionate to the inciting event that is constant for an extended duration. Numerous treatment options for this condition have been explored with unsatisfactory results in many cases. Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist typically used as an anesthetic and analgesic, presents a promising potential treatment for CRPS in patients who fail to respond to traditional therapies.

RECENT FINDINGS

Numerous studies report significant improvement in the degree of pain, mobility of extremities, and other parameters after ketamine infusion in patients with CRPS. Although adverse effects were not reported often, some subjects experienced nausea, vomiting, headache or psychotropic or psychomimetic symptoms which could be mitigated with cessation of the drug. Although more research is needed to determine optimal dosing and duration, ketamine seems to be a safe and effective treatment for refractory cases of CRPS.

CONCLUSION

The present investigation summarizes existing knowledge and research surrounding ketamine infusions for CRPS to provide a well-rounded depiction of advantages and disadvantages for physicians who may be considering it for patients with this challenging and complex condition.

Rehabilitation Interventions for Adults With Complex Regional Pain Syndrome: A Scoping Review Protocol

OBJECTIVES

This scoping review will explore the literature related to rehabilitation interventions for the treatment of adults living with complex regional pain syndrome (CRPS), describe the domains and outcome measures used to assess their effectiveness, and examine the neurophysiological bases of these interventions.

INTRODUCTION

The unremitting symptoms of CRPS, a chronic pain condition, are associated with long-term disability, poor psychological health, decreased emotional and social well-being, and reduced quality of life. Effective treatment for persistent symptoms is notoriously difficult. Therapeutic approaches such as graded motor imagery or pain exposure therapy are recommended for CRPS but show mixed results, insufficient effectiveness, variability in outcome measures, and unclear neurophysiological bases.

INCLUSION CRITERIA

This review will consider studies that include any form of non-invasive rehabilitation intervention delivered by a healthcare professional in any setting for adults with a CRPS diagnosis. Quantitative, qualitative and observational studies, text and opinion papers will be considered.

METHODS

The Joanna Briggs Institute (JBI) methodology will be used to conduct this scoping review. MEDLINE, Embase, Scopus, APA PsycINFO, CINAHL, Cochrane, OpenGrey Google and ProQuest Dissertations and Theses Global (ProQuest) will be searched for studies in English published between 2007 and 2024. Two independent reviewers will screen the titles, abstracts, and full texts of the selected studies. Data collection will be performed using a tool developed by the researchers based on the standardised JBI tool. Data will be presented in a comprehensive narrative summary.

TRAIL REGISTRATION

https://doi.org/10.17605/OSF.IO/P967T.

Complex regional pain syndrome after distal radius fracture: A survey of current practices

INTRODUCTION

Complex regional pain syndrome (CRPS) is a common complication following distal radius fractures that is difficult to diagnose and can lead to permanent disability. While various proposed prophylaxis and treatment modalities exist, high-quality evidence guiding practice is limited. This survey of Orthopaedic Trauma Association (OTA) and Canadian Orthopaedic Association (COA) members was conducted with the primary aim of assessing practice patterns in distal radius fractures complicated with CRPS.

METHODS

An electronic survey was distributed to practicing orthopaedic surgeons in the COA and OTA. Questions assessed practice setting, preference in management of distal radius fractures and CRPS, comfort level in managing CRPS, and identification of gaps in management. Responses were anonymized and collected over 8 months. Response data was analyzed using descriptive statistics; thematic analysis was used on free text response.

RESULTS

134 survey responses were completed. 84% of respondents felt the incidence of CRPS in distal radius fractures was 1-10%, while 15% felt it was closer to 11-20%. 24% of respondents utilized the "Budapest Criteria" to diagnose CRPS. 40% offered prophylaxis in patients felt to be at high risk of developing CRPS. 66% of surgeons felt neutral, uncomfortable, or very uncomfortable managing CRPS in distal radius fractures. When asked to consider adopting a prophylactic therapy, 38% of surgeons indicated that a therapy that reduced the absolute risk of CRPS by 6-10% would change their practice. Gaps in current practice included lack of evidence-based treatment and prevention strategies and diagnostic uncertainty.

CONCLUSION

This study identified that amongst orthopaedic surgeons in the COA and OTA, diagnosis, treatment, and prophylaxis strategies for CRPS in distal radius fractures are heterogeneous. Surgeons are not confident in their treatment of CRPS. Future studies using rigorous research methods are warranted to improve management.

Deciphering pain: molecular mechanisms and neurochemical pathways-challenges and future opportunities

This review delves into the intricate biological underpinnings of pain perception. It encompasses nociceptive signaling pathways, the molecular mechanisms involved, and the subjective experience of discomfort in humans. The initial focus is on nociceptor transduction, where specialized neurons transform noxious stimuli into electrical impulses. Subsequently, the review explores the central nervous system, elucidating how these signals are processed and modulated by critical elements such as ion channels, receptors, and neurotransmitters (e.g., substance P, glutamate, GABA). Shifting gears toward chronic pain, the review examines the concept of neuroplasticity, highlighting its potential to induce maladaptive responses through alterations in neural networks. The burgeoning field of pain genomics, alongside established genetic research, offers valuable insights that could pave the way for a framework of personalized pain management strategies. Finally, the review emphasizes the significance of these molecular insights in facilitating accurate therapeutic interventions. The overarching objective is to establish an integrative framework for precision medicine in pain management by incorporating this information alongside biopsychosocial models. This framework serves to translate the heterogeneous landscape of pain mechanisms into a coherent roadmap for the development of effective therapies.

Dynamic risk factors for complex regional pain syndrome after distal radius fracture surgery: multivariate analysis and prediction

BACKGROUND

Distal radius fractures are a common orthopedic injury, particularly prevalent among elderly and osteoporotic patients. Although surgical treatment effectively restores fracture alignment and stabilizes the bone, Complex Regional Pain Syndrome (CRPS) can occur as a postoperative complication, severely impacting patients' rehabilitation and quality of life. Therefore, assessing the risk factors for postoperative CRPS is crucial for early clinical intervention, aiming to improve recovery outcomes and overall patient well-being.

OBJECTIVE

This study aims to dynamically evaluate the risk factors for CRPS following distal radius fracture surgery through a retrospective analysis. The goal is to provide scientific evidence for early clinical identification and intervention.

METHODS

A retrospective analysis was conducted on 191 adult patients who underwent distal radius fracture surgery between January 2021 and December 2022, comprising 89 males and 102 females, with an average age of 59.7 ± 11.6(18-75) years. Baseline and follow-up data, including demographic information, clinical characteristics, and psychological assessments, were collected. Descriptive statistics, univariate, and multivariate logistic regression analyses were used to identify independent risk factors and assess their dynamic changes over time.

RESULTS

Age, gender, occupation, fracture type, surgical method, osteoporosis, pain score (VAS), functional disability score (DASH), anxiety score (GAD-7), depression score (PHQ-9), physical therapy, and occupational therapy significantly affected the incidence of CRPS. Age and VAS scores were consistent risk factors. Female gender, internal fixation surgery, and high DASH scores posed higher risks in the early postoperative period but decreased over time. Occupation and fracture type were more significant in the mid to late postoperative period. Psychological factors were most significant in the midterm, while physical and occupational therapy were protective factors early on.

CONCLUSION

The occurrence of CRPS is the result of many factors. Elderly patients, females, and manual laborers had higher risks, with complex fractures and internal fixation surgery patients showing increased risk later on. Osteoporotic patients had higher risks in the mid to late postoperative period. VAS, DASH, GAD-7, and PHQ-9 scores were significantly associated with CRPS. Early physical and occupational therapy can effectively prevent CRPS, but further research is needed to evaluate their long-term effects.

Is CRPS-1 a Chronic Disabling Disease? A Long-term, Real-Life Study on Patients Treated With Neridronate

Background

Complex Regional Pain Syndrome type 1 (CRPS-1) is severely debilitating and painful disease that is difficult to treat.

Objective

The objective was to evaluate the long-term residual disability of patients with CRPS-1 following parenteral neridronate treatment.

Design

This is real-life retrospective observational study.

Methods

Patients affected by CRPS-1 of the upper limb were treated with neridronate infusions (400 mg over 10 days) between February 2017 and December 2021 for whom clinical and demographic information was collected. From November 2022, patients treated ⩾1 year previously were recalled for clinical evaluation. A dedicated instrument (DASH questionnaire, Disabilities of the Arm, Shoulder and Hand) was employed to assess residual disability. Multivariate logistic regression analysis was used to investigate predictors of disability.

Results

Forty-nine patients aged 61.1 ± 11.5 years and 73.5% female with CRPS-1 of the upper limb were included. Disease duration before treatment was 9.9 ± 8.0 weeks, and the mean length of follow-up was 4 years (47.7 ± 22.0 months). The disease had fully resolved in 46 patients (93.9%) for whom the diagnostic criteria were no longer recognized. According to the DASH score, 38 patients (77.6%) resulted free of functional limitations, whereas 11 patients (22.4%) were still suffering from disability. The DASH score was positively correlated with residual visual analogue scale (VAS; Spearman's Rho = 0.61; P < .001). Predictors of residual disability were younger age (odds ratio [OR]: 0.77, 95% CI: 0.63-0.93; P = .012) and delay between disease onset and treatment (OR: 1.45, 95% CI: 1.13-1.96; P = .004).

Conclusions

In this real-life study, neridronate parenteral treatment provided a full recovery of CRPS-1 in over 3 quarters of patients, provided they are treated early.

[Prospective, multicenter study of the outcome of complex regional pain syndrome after 12 months]

BACKGROUND AND OBJECTIVES

Complex regional pain syndrome (CRPS) can lead to severe pain and limited functionality in the long term. Guidelines should help to optimize treatment procedures. It should be investigated which outcome is achieved after 1 year with guideline-based therapy.

MATERIALS AND METHODS

In a prospective multicenter study, 40 patients with newly diagnosed CRPS were examined to determine how their pain and functional limitations changed within 1 year. In addition, it was investigated whether the time of diagnosis and invasive measures influence these outcome parameters.

RESULTS

All patients received physiotherapy and/or ergotherapy, treatment with glucocorticoids and/or bisphosphonates 29 (72.5%); various invasive measures were carried out in 13 (32.5%). After 1 year, both pain and functionality were significantly improved; two-thirds reported a tolerable average pain intensity. Severe functional impairment according to von Korff disability points was found after 1 year in 9 (22.5%), and a moderate or severe impairment according to medical evaluation in 6 (15%) and 3 (7.5%) patients, respectively. Earlier diagnosis and corresponding earlier start of treatment correlated with better outcome in terms of pain and functionality according to von Korff, but not according to medical evaluation. The influence of invasive procedures on the outcome parameters tended to be low.

CONCLUSION

Guideline-based treatment led to a good outcome in terms of pain and functionality in the majority of patients. Early diagnosis correlated with better outcome, so suspected cases should be referred quickly to a medical facility with appropriate expertise.

Effects of mirror therapy in post-traumatic complex regional pain syndrome type-1: a randomized controlled study

OBJECTIVE

To investigate the effects of mirror therapy applied in addition to routine rehabilitation on clinical outcomes in post-traumatic complex regional pain syndrome type 1.

DESIGN

Single-blind randomized controlled trial.

SUBJECTS

Patients with trauma-induced complex regional pain syndrome type 1 of the hand receiving outpatient rehabilitation.

METHODS

Patients were randomized into mirror therapy and control groups. All patients received routine physical therapy and rehabilitation for 20 sessions (5 sessions/week, for 4 weeks). The mirror group received additional mirror therapy at each session. The primary outcome was pain intensity by numeric rating scale. Secondary outcomes were grip/pinch strength, hand/wrist circumference, dexterity, hand activities, and health-related quality of life. All assessments were performed before and immediately after the treatment, and 4 weeks later at follow-up.

RESULTS

Forty patients were enrolled, 20 in each group. Both groups revealed statistically significant improvements from therapy regarding pain, grip/pinch strength, wrist circumference, dexterity, and hand activities (p <  0.05). When groups were compared regarding the improvements in assessment parameters, no statistically significant difference was found between the 2 groups in any of the outcomes (p > 0.05).

CONCLUSION

Mirror therapy applied in addition to routine therapy in post-traumatic complex regional pain syndrome type 1 did not provide extra benefit to the improvement of pain, function, and other clinical outcomes.

Postoperative Medial Plantar and Sural Neuropathy With Complex Regional Pain Syndrome

This case illustrates a distinct presentation of coexistent medial plantar and sural neuropathy leading to the development of complex regional pain syndrome (CRPS) in a 49-year-old male patient. CRPS is a broad medical diagnosis describing prolonged and excessive pain that is out of proportion to exam and has historically been diagnosed according to the Budapest criteria. To our knowledge, this is a rare report of a case of medial plantar and sural neuropathy further complicated with CRPS, status-post calcaneal fracture, surgery, and post-surgical boot placement. The case highlights the complexity of diagnosing and managing multiple concurrent neuropathies and underscores the need for interdisciplinary approaches in treating CRPS to improve patient outcomes.

Repetitive Transcranial Magnetic Stimulation with Sensorimotor Training for the Treatment of Complex Regional Pain Syndrome Type 2 of the Upper Limb Case Report

This case report describes the use of repetitive transcranial magnetic stimulation (rTMS) combined with sensorimotor training (SMT) to treat an individual with complex regional pain syndrome (CRPS) type 2 with allodynia of the right hand/wrist. After the 9-week intervention, there was a clinically meaningful reduction in pain intensity which continued to 3 months after intervention. Further, clinically meaningful improvements in wrist and hand function and allodynia were observed. Although the use of rTMS for CRPS has been reported, this unique report provides valuable insight into the clinical utility of rTMS plus SMT for the treatment of CRPS and related symptoms.

Therapeutic management of the painful nerve: a narrative review of common rehabilitation interventions

There are many ways that rehabilitation therapists, including occupational and physical therapists, treat nerve-related pain. Commonly used interventions include neurodynamic treatment, pain neuroscience education, desensitization, exercise, physical agent modalities, mirror box therapy, and Kinesio taping. Despite common practice and anecdotal support, it can be challenging to determine the appropriate intervention for each patient. In this article, each of these treatment approaches is discussed, including indicated pain phenotypes and diagnoses, timing, efficacy, mechanism, contraindications, and limitations.

Different Types of Pain in Complex Regional Pain Syndrome Require a Personalized Treatment Strategy

Complex regional pain syndrome (CRPS) is a debilitating painful state of an extremity that can develop after trauma. CRPS is diagnosed by the new International Association for the Study of Pain (IASP) diagnostic criteria for CRPS. The syndrome is characterized by continuing regional pain with abnormal sensory, motor, sudomotor, vasomotor, edema, and/or trophic signs. The clinical presentation of CRPS can be very heterogeneous because CRPS is a multi-mechanism syndrome. Therefore, mechanism-based subgroups have been suggested to personalize treatment for CRPS. Additionally, the presentation of symptom pain may also be able to identify different subgroups of CRPS. In this review, the types of pain recognized by the IASP-nociceptive, neuropathic, and nociplastic pain-will be discussed as possible subgroups for CRPS. Each pain type should be identified in CRPS patients, with a thorough history taking, physical examination, and diagnostic tests or (novel) biomarkers to optimize treatment effectiveness. Over the course of the syndrome, patients with CRPS probably experience more than one distinct pain type. Therefore, pain specialists should be alert to not only adjust their treatment if underlying pathophysiologic mechanisms tend to change but also to personalize the treatment of the associated type of pain in the CRPS patient.

[Complementary methods in the treatment of complex regional pain syndrome]

BACKGROUND

Complex regional pain syndrome (CRPS) affects 10-15% of patients following injuries (fractures, surgery) to the outer extremities and people after a stroke. The affected area hurts, is inflamed and lacks strength, while mobility and sensitivity are restricted. Complementary medicine as part of integrative medicine offers additional effective treatment options.

RESEARCH QUESTION

Complementary therapies that extend the guideline recommendations, demonstrate clinical evidence and/or are plausible are presented.

RESULTS

Mind-body medicine procedures (mindfulness, relaxation, yoga, Qi Gong, etc.) support the patient's self-efficacy and stimulate the vagus nerve as well as promoting the reduction of pain, depression and anxiety and improving quality of life. Phytotherapeutics such as turmeric or stinging nettle have an anti-inflammatory effect. Water treatments reduce pain, and acupuncture and neural therapy can be tried.

CONCLUSIONS

Integrative, complementary medical therapy options support the CRPS patient in coping with their disease and the related pain. These options can play an important role in the multimodal, interdisciplinary treatment of this disease.

Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments

PURPOSE OF REVIEW

This review presents the most current information about the epidemiology of complex regional pain syndrome (CRPS), classification and diagnostic criteria, childhood CRPS, subtypes, pathophysiology, conventional and less conventional treatments, and preventive strategies.

RECENT FINDINGS

CRPS is a painful disorder with multifactorial pathophysiology. The data describe sensitization of the central and peripheral nervous systems, inflammation, possible genetic factors, sympatho-afferent coupling, autoimmunity, and mental health factors as contributors to the syndrome. In addition to conventional subtypes (type I and type II), cluster analyses have uncovered other proposed subtypes. Prevalence of CRPS is approximately 1.2%, female gender is consistently associated with a higher risk of development, and substantial physical, emotional, and financial costs can result from the syndrome. Children with CRPS seem to benefit from multifaceted physical therapy leading to a high percentage of symptom-free patients. The best available evidence along with standard clinical practice supports pharmacological agents, physical and occupational therapy, sympathetic blocks for engaging physical restoration, steroids for acute CRPS, neuromodulation, ketamine, and intrathecal baclofen as therapeutic approaches. There are many emerging treatments that can be considered as a part of individualized, patient-centered care. Vitamin C may be preventive. CRPS can lead to progressively painful sensory and vascular changes, edema, limb weakness, and trophic disturbances, all of which substantially erode healthy living. Despite some progress in research, more comprehensive basic science investigation is needed to clarify the molecular mechanisms of the disease so that targeted treatments can be developed for better outcomes. Incorporating a variety of standard therapies with different modes of action may offer the most effective analgesia. Introducing less conventional approaches may also be helpful when traditional treatments fail to provide sufficient improvement.

Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews

BACKGROUND

Complex regional pain syndrome (CRPS) is a chronic pain condition that usually occurs in a limb following trauma or surgery. It is characterised by persisting pain that is disproportionate in magnitude or duration to the typical course of pain after similar injury. There is currently no consensus regarding the optimal management of CRPS, although a broad range of interventions have been described and are commonly used. This is the first update of the original Cochrane review published in Issue 4, 2013.

OBJECTIVES

To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the efficacy, effectiveness, and safety of any intervention used to reduce pain, disability, or both, in adults with CRPS.

METHODS

We identified Cochrane reviews and non-Cochrane reviews through a systematic search of Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, CINAHL, PEDro, LILACS and Epistemonikos from inception to October 2022, with no language restrictions. We included systematic reviews of randomised controlled trials that included adults (≥18 years) diagnosed with CRPS, using any diagnostic criteria.  Two overview authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools respectively. We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes quality of life, emotional well-being, and participants' ratings of satisfaction or improvement with treatment.  MAIN RESULTS: We included six Cochrane and 13 non-Cochrane systematic reviews in the previous version of this overview and five Cochrane and 12 non-Cochrane reviews in the current version. Using the AMSTAR 2 tool, we judged Cochrane reviews to have higher methodological quality than non-Cochrane reviews. The studies in the included reviews were typically small and mostly at high risk of bias or of low methodological quality. We found no high-certainty evidence for any comparison.  There was low-certainty evidence that bisphosphonates may reduce pain intensity post-intervention (standardised mean difference (SMD) -2.6, 95% confidence interval (CI) -1.8 to -3.4, P = 0.001; I2 = 81%; 4 trials, n = 181) and moderate-certainty evidence that they are probably associated with increased adverse events of any nature (risk ratio (RR) 2.10, 95% CI 1.27 to 3.47; number needed to treat for an additional harmful outcome (NNTH) 4.6, 95% CI 2.4 to 168.0; 4 trials, n = 181).  There was moderate-certainty evidence that lidocaine local anaesthetic sympathetic blockade probably does not reduce pain intensity compared with placebo, and low-certainty evidence that it may not reduce pain intensity compared with ultrasound of the stellate ganglion. No effect size was reported for either comparison. There was low-certainty evidence that topical dimethyl sulfoxide may not reduce pain intensity compared with oral N-acetylcysteine, but no effect size was reported. There was low-certainty evidence that continuous bupivacaine brachial plexus block may reduce pain intensity compared with continuous bupivacaine stellate ganglion block, but no effect size was reported. For a wide range of other commonly used interventions, the certainty in the evidence was very low and provides insufficient evidence to either support or refute their use. Comparisons with low- and very low-certainty evidence should be treated with substantial caution. We did not identify any RCT evidence for routinely used pharmacological interventions for CRPS such as tricyclic antidepressants or opioids.

AUTHORS' CONCLUSIONS

Despite a considerable increase in included evidence compared with the previous version of this overview, we identified no high-certainty evidence for the effectiveness of any therapy for CRPS. Until larger, high-quality trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult. Current non-Cochrane systematic reviews of interventions for CRPS are of low methodological quality and should not be relied upon to provide an accurate and comprehensive summary of the evidence.

Modern Principles of Diagnosis and Treatment in Complex Regional Pain Syndrome

BACKGROUND

Background: Complex regional pain syndrome (CRPS) is a relatively common complication, occurring in 5% of cases after injury or surgery, particularly in the limbs. The incidence of CPRS is around 5-26/100 000. The latest revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) now categorizes CRPS as a primary pain condition of multifactorial origin, rather than a disease of the skeletal system or the autonomic nervous system.

METHODS

Method: Based on a selective search of the literature, we summarize current principles for the diagnosis and treatment of CRPS.

RESULTS

Results: Regional findings in CRPS are accompanied by systemic symptoms, especially by neurocognitive disorders of body perception and of symptom processing. The therapeutic focus is shifting from predominantly passive peripheral measures to early active treatments acting both centrally and peripherally. The treatment is centered on physiotherapy and occupational therapy to improve sensory perception, strength, (fine) motor skills, and sensorimotor integration/ body perception. This is supported by stepped psychological interventions to reduce anxiety and avoidance behavior, medication to decrease inflammation and pain, passive physical measures for reduction of edema and of pain, and medical aids to improve functioning in daily life. Interventional procedures should be limited to exceptional cases and only be performed in specialized centers. Spinal cord and dorsal root ganglion stimulation, respectively, are the interventions with the best evidence.

CONCLUSION

Conclusion: The modern principles for the diagnosis and treatment of CRPS consider both, physiological and psychological mechanisms, with the primary goal of restoring function and participation. More research is needed to strengthen the evidence base in this field.