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10 Articles in this Series
An AAPM 2019 Preview
APRNs/PAs in Pain Medicine SIG Gets Underway
Cannabis Has Entered Pain Management and Is Here to Stay: What Clinicians Need to Consider
Managing Pain in Marginalized Populations, including Ethnic Minorities, LGBTQ, and the Obese
Neuromodulation: A Roundtable on Current Best Practice & Key Questions
Pro/Con: CGRP Antibodies and Treatment Choice for Chronic Migraine
Pro/Con: Conservative Care is the Best Route for Chronic Pelvic Pain
Pro/Con: CRPS - Use Everything but Stimulation
Pro/Con: Ketamine for Complex Regional Pain Syndrome, Neuropathic Pain, and More
Pro/Con: Radiofrequency Denervation is Effective (The MINT Studies)

Pro/Con: CRPS - Use Everything but Stimulation

A Pro-Con Debate* on the following statement, held at the 2019 annual meeting of the American Academy of Pain Medicine (AAPM):  "CRPS: Use Everything but Stimulation."


PRO, offered by Vivianne Tawfik, MD, PhD:

Given the range of Budapest criteria for Complex Regional Pain Syndrome (CRPS), a multidisciplinary approach is best. There are many components to conservative, multidisciplinary care, but I will focus on physical therapy, bisphosphonates, and ketamine. [Dr. Tawfik noted that the Pain Clinic at Stanford University, under Dr. Sean Mackey, is also trialing low-dose naltrexone for CRPS as results for managing fibromyalgia have been positive.]

Physical, as well as occupational, therapy are first-line CRPS treatments typically aimed at adjusting kinesiophobia of the affected limb so that the patient may regain normal function. Physiotherapy may include graded motor imagery, exposure therapy, and desensitization (normal touch) and the evidence (Smart, Cochrane, 2016 ) is there for this approach, especially regarding graded motor imagery which involves learning laterality, movement, and mirror box therapy.

When looking at pharmacological approaches, bisphosphonates (O’Connell, Cochrane, 2013), offer the best evidence for CRPS. We use alendronate in our practice and see improvements. Ketamine has been shown effective in several studies (see also, O’Connell; Schwartzman, Pain, 2009; and Sigtermans, Pain, 2009) as an outpatient and inpatient protocol respectively, including in a newer review by Zhao (Curr Pain Headache Rep, 2018) ,which showed improvement even at 3 months after ketamine infusion for CRPS. These approaches in combination offer a multidisciplinary approach that is crucial overall.


CON, offered by Jason E. Pope, MD, FIPP, DABPM

There is a lot of robust data around using neuromodulation for the treatment of CRPS. Multiple strategies are mindful and appropriate, certainly … as long as pain control can be achieved, but I propose using SCS earlier in the algorithm of care strategy.

Long-term prospective studies show nothing better than SCS for CRPS (see Deer, et al, Pain, 2017). If a patient is offered an SCS trial, they have a 75% chance of getting at least 50% relief at 3 months and at 12 months. There is real success with SCS for CRPS—67% have reported better than 80% relief at 12 months; and 70% using DRG stimulation for lower extremity CRPS reported at least 80% relief. Even if we took away the experimental group from this study, no other neuromodulation therapy to date has performed this well.

So when people ask me if neuromodulation works to treat CRPS, my answer is, overwhelmingly, “yes.” Assuming patient candidacy is applicable, why would you not trial SCS in an effort to give someone relief?


*Quotes and comments are paraphrased for clarity and style. Commenters’ disclosures may be found on the AAPM35 speakers’ website.

Next summary: Pro/Con: Ketamine for Complex Regional Pain Syndrome, Neuropathic Pain, and More
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