Summary: In 2018, Johnathan H. Goree, MD, proposed a treatment protocol for complex regional pain syndrome (CRPS). In the new study, researchers validated it. They found it worked quite well in Complex Regional Pain Syndrome treatment and in reducing allodynia. Complex regional pain syndrome (CRPS) is one of the hardest chronic pain conditions to treat. It also makes the body more sensitive to many kinds of triggers. Even slight contact with some irritants may cause severe pain. So the condition is disabling.
Some pains are very hard to treat. They cause allodynia, a condition where common things that do not normally cause pain may cause severe pain. CRPS is one example of a chronic, painful condition that lowers the pain threshold. It is still poorly understood, because its pathogenesis (how the disease starts and develops) is unclear. Still, there has been real progress in new treatments for CRPS over the years. Many doctors and pain specialists now see it as its own disease that needs a specific treatment plan. In 2018, Johnathan H. Goree, MD, developed a treatment protocol for CRPS. This protocol calls for gabapentin, bisphosphonates, ketamine, stellate ganglion blocks, and neuromodulation through occupational therapy. It also calls for quitting smoking. The protocol came from years of research. But in medicine, a protocol only wins wide acceptance once it holds up in several studies. It must also work in different groups of people. A treatment plan is worth little if its results cannot be repeated in other clinics. And there is always a risk that the person who built the protocol missed something. Now a new study shows that this protocol works. It was validated in an independent study by Mi Mi Kim, M.D., M.P.H., Loren Guzman, M.D., and Johnathan Goree, M.D. from the Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR. They shared their findings at the 19th Annual Pain Medicine Meeting. It has four main parts: pain management, sympathetic nerve block, occupational therapy, and quitting smoking. In the study, patients got 300 mg gabapentin three times a day and 35 mg alendronate daily. They also got 10% topical ketamine and some other painkillers like tramadol. For nerve blocks, they mostly used bupivacaine plus epinephrine. After one month of treatment, most patients reported significant relief from CRPS symptoms. Those who reported significant benefits kept going with home therapy and occupational therapy. Some patients responded early but stopped responding later. For them, the therapy was repeated. The study had 25 patients, and all reported significant benefits. The benefit also rose with how well patients stuck to the therapy. 40% of the patients reported a significantly better range of motion. But that number was close to 85% in patients who stuck to the therapy better. In the same way, 60% of patients reported less allodynia. Again, this improvement was barely 11% in those who did not stick to treatment, but above 80% in those who mostly did. The researchers found that bisphosphonate use and stellate ganglion blocks were closely tied to the reported benefits. They also noted that issues like depression, anxiety, and opioid use at the first visit did not change the final results. So this protocol is good for different kinds of patients. In short, the study validated the proposed treatment protocol for CRPS. It found that the benefit was significant only when patients followed the prescribed treatment. Even patients with moderate adherence benefited significantly. Only those with very poor adherence reported no benefit at all. CRPS is one of the hardest chronic pain conditions to treat, and it lowers the pain threshold. The pain is disabling in most cases. And patients do not respond to the most common pain treatments. That is why this new protocol offers hope.
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Frequently asked questions
What is the most successful treatment for CRPS?
The validation study had 25 patients with CRPS. The protocol had four parts. The first was pain medicines, including gabapentin, a bisphosphonate and topical ketamine. The others were stellate ganglion nerve blocks, occupational therapy, and quitting smoking. Bisphosphonates and stellate ganglion blocks were the parts most closely tied to benefit. The biggest factor was sticking with the plan. Only patients with very poor adherence reported no benefit.
What is allodynia in CRPS?
Allodynia is severe pain from everyday things that normally do not hurt. It is a hallmark of complex regional pain syndrome. CRPS lowers the pain threshold, so even slight contact with an irritant can cause severe pain. In the validation study, 60% of patients reported less allodynia. The improvement rose above 80% among those who followed the treatment well.
How long does CRPS treatment take to work?
In the study, most patients reported significant improvement in their CRPS symptoms after one month of treatment. Those who improved kept going with home therapy and occupational therapy. When a patient who responded early stopped responding later, the therapy was repeated. Results tracked adherence. Patients who stuck with the plan did far better, and even moderate adherence brought significant benefit.
Do depression or anxiety affect CRPS treatment results?
Not in this study. Researchers found that depression, anxiety and opioid use at the first visit did not change the final outcomes. That suggests the approach works for many different kinds of patients with CRPS. What did matter was sticking to the treatment plan.
Dr. Gurpreet Singh Padda, MD, MBA, MHP
