A. HAVE A TREATMENT PLAN
Treatment for CRPS should be initiated early and aggressively. An interdisciplinary approach is often useful. A treatment plan should encourage patients to take an active role in their rehabilitation plan. This can include having the patient keep a journal, to record symptoms, activity tolerance, and pain and function levels. Emphasis should be on improving functional activity in the symptomatic limb andshould include elements of the following:
- Physical therapy (PT) or occupational therapy (OT)
- Medication for pain control
- Psychological or psychiatric consultation and therapy
- Sympathetic blocks
- Multidisciplinary Program for Pain Management
1. Physiotherapy and Occupational Therapy
A physical or occupational therapy treatment plan specific to CRPS should be developed by a therapist who is experienced in the treatment of CRPS. Therapy should be active, focused on desensitization, normalizing movement patterns, improving strength and range of motion and improving functional activities. A CRPS- focused physical or occupational therapy plan should include the following elements:
A.An Evaluation to include:
1. Date of onset of original injury (helpful in determining if early or late stage) and a date of onset of the CRPS symptoms and signs
2. Baseline objective measurements including ROM of all involved joints, strength, sensory loss, hypersensitivity, appearance, temperature, function (e.g. weight bearing and gait for lower extremity; fine motor tasks, pinch and grip for upper extremity), and use of assistive devices, braces and orthotics. If possible, include objective measurements of swelling
B. Specific, measurable functional goals:
which will allow assessment of progress and the effectiveness of treatment for the affected area
C. All treatment programs should include a core of:
2. Neuromuscular re-education, which might include graded motor imagery16,17, mirror box therapy18or other techniques to promote normalization of neuromuscular function
3. A progressive, active exercise program designed to promote improvement in ROM, strength and endurance 4. Activities targeted to attain the functional goals,e.g.weight bearing and gait training for the lower extremity and fine motor tasks for the upper extremity 5. A monitored home exercise program to promote the patient’s participation in rehabilitation activities on a daily basis
D. Documentation should be done at least every two weeks to include:
1. Reassessment of relevant baseline measurements described in A2 above. This provides objective evidence of response or non-response to treatment
2. Assessment of progress toward functional goals (e.g. how the condition interferes with daily activities or activities related to employment)
3. Level of patient motivation
4. Participation in a home exercise program
2. Medication for Pain Control
Pain inhibits movement, and inadequate pain control may be an obstacle to activity, so judicious use of medications for pain control can be a useful adjunct to therapy. There is no drug with high-quality evidence to support use in either pain reduction or facilitation of function in CRPS. However, the committee recognizes that various medications are commonly used in clinical practice to manage pain or associated symptoms in CRPS.19 The categories of medications often used include non-steroidal anti-inflammatory drugs (NSAIDS), anticonvulsants20, antidepressants, opioids, N-methyl-D-aspartate receptor antagonists
3. Psychological or Psychiatric Consultation and Therapy
It is not uncommon for a fear-avoidance behavior pattern to emerge with a CRPS diagnosis. Patients are frequently fearful that pain indicates danger. They are sometimes concerned that ongoing pain means their condition has been misdiagnosed. Consequently, education and frequent reassurance are essential.This may be addressed using cognitive-behavioural therapy.
4. Sympathetic Blocks
Sympathetic blocks have long been a standard treatment for CRPS and can be useful for a subset of cases. Stellate ganglion blocks (cervical sympathetic blocks) and lumbar sympathetic blocks are widely used in the management of upper and lower extremity CRPS. There is limited evidence to confirm effectiveness.23 An initial trial of up to three sympathetic blocks should be considered when the condition fails to improve with conservative treatment, including analgesia and physical therapy.
5. Multidisciplinary Treatment
A multidisciplinary program for pain management will provide coordinated and closely monitored care using physical and/or occupational therapy, medication management, psychological screening and counselling, patient education, and other pain management techniques. The goal is to coordinate therapeutic interventions that ensure adequate pain control so reactivation of the affected body part can occur.
B. TREATMENT IN PHASES
Treatment can be thought of in phases. Although each phase has a general time frame, the time needed for an individual case is difficult to predict. Each phase can be shortened or lengthened as needed, allowing patients to move from one phase to another depending on their individual progress.
1. Phase One – Prevention and Mitigation of CRPS Risk Factors
The duration of Phase One will depend on the expected healing time for the specific injury, commonly spanning the first few weeks following the injury. The emphasis during Phase One is on pain control, appropriate mobilization, and monitoring of pain and function. After an initial injury, the patient should Effective October 1, 2011 Page 8be encouraged to move as much as is safe for whatever injury he or she has. PT/OT will be directed at what is appropriate for the specific injury and may be limited during this phase.
While there are no fixed rules as to the time of immobilization for a given injury, 6-8 weeks for the upper extremity and 8-12 weeks for the lower extremity are typical durations. It may be worth noting that mobility can continue in spite of casting. For example a patient in a long arm cast can still move his fingers, and a patient in an ankle cast can still move his toes.
With appropriate immobilization, pain should generally decrease progressively with time. If pain is not decreasing over time, the provider must reassess the plan of treatment. If at any point the patient demonstrates unusual distress, pain complaints that appear to be out of proportion to the injury, or unexpectedly slow progress, the frequency of clinic visits should be increased. In this situation, it is important to consider the possibility of a missed diagnosis or an unrecognized comorbidity such as a behavioural or substance abuse disorder.
2. Phase Two –Recovery is Not Normal
The sooner treatment for suspected CRPS is initiated, the more likely it is that the long term outcome will be good. When recovery is delayed, and if no specific cause for the delay is identified, CRPS may be the diagnosis. Referral to a pain management or rehabilitation medicine specialist is strongly recommended.
3. Phase Three – CRPS Initial Treatment
Following a CRPS diagnosis, treatment should be initiated early and aggressively in the patient’s community whenever possible. Care should be coordinated and include physical or occupational therapy, psychological or psychiatric therapy, and medication management. An initial sympathetic block trial may be considered in cases that do not demonstrate functional gains during initial treatment.
4. Phase Four – CRPS Intensive Treatment
When the patient is unlikely to benefit from Phase Three treatment, an immediate referral to a multidisciplinary treatment program may be made. If the patient’s condition has not substantially improved within 6 weeks of Phase Three treatment, referral to an approved multidisciplinary treatment program is recommended.
5. Treatment Not Authorized for CRPS
The Department will not authorize the following interventions for CRPS:
- Sympathectomy (no effect/no improvement in function26)
- Spinal cord stimulation (non-covered benefit; see Health Technology Assessment decision 2010:
- Ketamine infusions (no effect/no improvement in function, serious adverse events27,28)