Clinical Review State of the Art Review

Complex regional pain syndrome

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h2730 (Published 29 July 2015) Cite this as: BMJ 2015;351:h2730
  1. Stephen Bruehl, professor
  1. 1Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN 37212, USA
  1. Correspondence to: S Bruehl Stephen.Bruehl{at}vanderbilt.edu

Abstract

Complex regional pain syndrome is a chronic pain condition characterized by autonomic and inflammatory features. It occurs acutely in about 7% of patients who have limb fractures, limb surgery, or other injuries. Many cases resolve within the first year, with a smaller subset progressing to the chronic form. This transition is often paralleled by a change from “warm complex regional pain syndrome,” with inflammatory characteristics dominant, to “cold complex regional pain syndrome” in which autonomic features dominate. Multiple peripheral and central mechanisms seem to be involved, the relative contributions of which may differ between individuals and over time. Possible contributors include peripheral and central sensitization, autonomic changes and sympatho-afferent coupling, inflammatory and immune alterations, brain changes, and genetic and psychological factors. The syndrome is diagnosed purely on the basis of clinical signs and symptoms. Effective management of the chronic form of the syndrome is often challenging. Few high quality randomized controlled trials are available to support the efficacy of the most commonly used interventions. Reviews of available randomized trials suggest that physical and occupational therapy (including graded motor imagery and mirror therapy), bisphosphonates, calcitonin, subanesthetic intravenous ketamine, free radical scavengers, oral corticosteroids, and spinal cord stimulation may be effective treatments. Multidisciplinary clinical care, which centers around functionally focused therapies is recommended. Other interventions are used to facilitate engagement in functional therapies and to improve quality of life.

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I have received consulting fees from Eli Lilly, Grunenthal GmbH, and Thar Pharmaceuticals for assistance in the design of clinical trials of complex regional pain syndrome.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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