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## Complete Summary

#### GUIDELINE TITLE

Complex regional pain syndrome: treatment guidelines (third edition).

#### BIBLIOGRAPHIC SOURCE(S)

Reflex Sympathetic Dystrophy Syndrome Association (RSDSA). Complex
regional pain syndrome: treatment guidelines. Milford (CT): Reflex
Sympathetic Dystrophy Syndrome Association (RSDSA); 2006 Jun. 67 p. \[51
references\]

#### GUIDELINE STATUS

This is the current release of the guideline

This guideline updates a previous version: Reflex Sympathetic Dystrophy
Syndrome Association (RSDSA). Clinical practice guidelines (second
edition) for the diagnosis, treatment, and management of reflex
sympathetic dystrophy/complex regional pain syndrome (RSD/CRPS). Milford
(CT): Reflex Sympathetic Dystrophy Syndrome Association (RSDSA); 2002
Feb. 46 p. \[47 references\]

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [December 12, 2007,
    Carbamazepine](http://www.fda.gov/medwatch/safety/2007/safety07.htm#carbamazepine):
    The U.S. Food and Drug Administration (FDA) has provided
    recommendations for screening that should be performed on specific
    patient populations before starting treatment with carbamazepine.

-   [May 2, 2007, Antidepressant
    drugs](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant):
    Update to the existing black box warning on the prescribing
    information on all antidepressant medications to include warnings
    about the increased risks of suicidal thinking and behavior in young
    adults ages 18 to 24 years old during the first one to two months of
    treatment.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Complex regional pain syndrome (CRPS), also known as:

-   Reflex sympathetic dystrophy syndrome

-   Causalgia (minor or major)

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Treatment

#### CLINICAL SPECIALTY

Anesthesiology\
Internal Medicine\
Neurological Surgery\
Neurology\
Physical Medicine and Rehabilitation

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Health Plans\
Managed Care Organizations\
Occupational Therapists\
Patients\
Physical Therapists\
Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### GUIDELINE OBJECTIVE(S)

To provide recommendations for the treatment of complex regional pain
syndrome (CRPS)

#### TARGET POPULATION

Individuals with signs or symptoms suggestive of complex regional pain
syndrome (CRPS)

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

International Association for the Study of Pain (IASP) diagnostic
criteria for complex regional pain syndrome (CRPS), including clinical
and research versions

**Management/Treatment**

1.  Interdisciplinary management including occupational therapy,
    physical therapy, recreational therapy, vocational rehabilitation,
    and other therapeutic interventions (hyperbaric oxygen therapy,
    acupuncture, and chiropractic manipulation)

2.  Pharmacotherapy

    -   Anti-inflammatory drugs/immunomodulators

    -   Anticonvulsants/neuromodulators

    -   Antidepressants/anxiolytics

    -   Opioids

    -   N-methyl-D-aspartate (NMDA) receptor antagonists

    -   Anti-hypertensives and alpha-adrenergic antagonists

    -   Calcitonin

    -   Bisphosphonates

    -   Additional systemic drug treatment options

    -   Topical treatments

3.  Psychological interventions

    -   Patient and family education

    -   Psychological evaluation

    -   Psychological pain management intervention

4.  Interventional therapies

    -   Sympathetic nerve blocks

    -   Intravenous (IV) regional anesthetic bocks (IVRA)

    -   Intravenous infusions

    -   Other (brachial plexus/spinal blocks-infusions) blocks

    -   Neurolytic sympathetic blocks (radiofrequency/alcohol-phenol)

    -   Neurostimulation

#### MAJOR OUTCOMES CONSIDERED

-   Physical functioning

-   Pain

-   Health-related quality of life

-   Sensitivity and specificity of diagnostic tests

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Subjective Review

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Diagnostic Considerations**

**Revised Complex Regional Pain Syndrome (CRPS) Criteria Proposed by the
Budapest Consensus Group**

**General Features of the Syndrome:**

CRPS describes an array of painful conditions that are characterized by
a continuing (spontaneous and/or evoked) regional pain that is seemingly
disproportionate in time or degree to the usual course of any known
trauma or other lesion. The pain is regional (not in a specific nerve
territory or dermatome) and usually has a distal predominance of
abnormal sensory, motor, sudomotor, vasomotor and/or trophic findings.
The syndrome shows variable progression over time.

There are two versions of the proposed diagnostic criteria: a clinical
version meant to maximize diagnostic sensitivity with adequate
specificity, and a research version meant to more equally balance
optimal sensitivity and specificity.

**Clinical Diagnostic Criteria for CRPS**

1.  Continuing pain, which is disproportionate to any inciting event

2.  Must report at least one symptom in *three of the four* following
    categories:

    -   *Sensory*: Reports of hyperesthesia and/or allodynia

    -   *Vasomotor*: Reports of temperature asymmetry and/or skin color
        changes and/or skin color asymmetry

    -   *Sudomotor/Edema*: Reports of edema and/or sweating changes
        and/or sweating asymmetry

    -   *Motor/Trophic*: Reports of decreased range of motion and/or
        motor dysfunction (weakness, tremor, dystonia) and/or trophic
        changes (hair, nail, skin)

3.  Must display at least one sign\* at time of evaluation in *two or
    more* of the following categories:

    -   *Sensory*: Evidence of hyperalgesia (to pinprick) and/or
        allodynia (to light touch and/or deep somatic pressure and/or
        joint movement)

    -   *Vasomotor*: Evidence of temperature asymmetry and/or skin color
        changes and/or asymmetry

    -   *Sudomotor/Edema*: Evidence of edema and/or sweating changes
        and/or sweating asymmetry

    -   *Motor/Trophic*: Evidence of decreased range of motion and/or
        motor dysfunction (weakness, tremor, dystonia) and/or trophic
        changes (hair, nail, skin)

4.  There is no other diagnosis that better explains the signs and
    symptoms

\*A sign is counted only if it is observed at time of diagnosis.

**Research Diagnostic Criteria for CRPS**

1.  Continuing pain, which is disproportionate to any inciting event

2.  Must report at least one symptom in *each of the four* following
    categories:

    -   *Sensory*: Reports of hyperesthesia and/or allodynia

    -   *Vasomotor*: Reports of temperature asymmetry and/or skin color
        changes and/or skin color asymmetry

    -   *Sudomotor/Edema*: Reports of edema and/or sweating changes
        and/or sweating asymmetry

    -   *Motor/Trophic*: Reports of decreased range of motion and/or
        motor dysfunction (weakness, tremor, dystonia) and/or trophic
        changes (hair, nail, skin).

3.  Must display at least one sign\* at time of evaluation in *two or
    more* of the following categories:

    -   *Sensory*: Evidence of hyperalgesia (to pinprick) and/or
        allodynia (to light touch and/or deep somatic pressure and/or
        joint movement).

    -   *Vasomotor*: Evidence of temperature asymmetry and/or skin color
        changes and/or asymmetry.

    -   *Sudomotor/Edema*: Evidence of edema and/or sweating changes
        and/or sweating asymmetry.

    -   *Motor/Trophic*: Evidence of decreased range of motion and/or
        motor dysfunction (weakness, tremor, dystonia) and/or trophic
        changes (hair, nail, skin).

4.  There is no other diagnosis that better explains the signs and
    symptoms.

\*A sign is counted only if observed at time of diagnosis.

**Interdisciplinary Management**

Because the symptoms of CRPS patients encompass all the
bio-psycho-social complexities of chronic pain, the best hope of helping
our patients is the adoption of a systematic, stable, empathetic and,
above all, interdisciplinary approach that addresses those symptoms.
Drugs, psychotherapy, and interventions should be efficiently deployed
for patients who either cannot begin or fail to progress using the
interdisciplinary approach (outlined in sections three through five in
the original guideline document). Many patients will require medication
and psychotherapy from the beginning to be successful in the pivotal
functional restoration algorithm (see \"A Sample Stepwise, Functional
Restoration Algorithm\" below). Treatment guidelines that center on
progressive functional restoration delivered by an interdisciplinary
team are traditional, have substantial empiric and anecdotal support,
and have been assessed and ultimately codified by three large, expert,
consensus-building conferences. Although high level evidence supporting
the rationale for interdisciplinary treatment of CRPS is fairly sparse
(as it is for any treatment of CRPS), much stronger evidence exists for
the efficacy of the interdisciplinary approach in other pain conditions,
such as chronic low back pain. That functional restoration can and
should be the central intervention and outcome standard in CRPS is a
theory that must be tested. Until then, the interdisciplinary approach
for treating patients with CRPS remains the most pragmatic, helpful, and
cost-effective therapeutic approach available today.

**A Sample, Stepwise, Functional Restoration Algorithm**

  -------- --------------------------------------------------------------
  **Step   Reactivation\
  1**      \
           Contrast Baths\
           \
           Desensitization\
           \
           Exposure Therapy

  **Step   Flexibility\
  2**      \
           Edema Control\
           \
           Isometric Strengthening\
           \
           Correction of Postural Abnormalities\
           \
           Diagnosis and Treatment of Secondary Myofascial Pain

  **Step   Range of Motion (ROM) (gentle)\
  3**      \
           Stress Loading\
           \
           Isotonic Strengthening\
           \
           General Aerobic Conditioning\
           \
           Postural Normalization & Balanced Use

  **Step   Ergonomics\
  4**      \
           Movement Therapies\
           \
           Normalization of Use\
           \
           Vocational/Functional Rehabilitation
  -------- --------------------------------------------------------------

From the outset, in appropriate cases, the patient should have access to
medications and/or psychotherapy and/or injections. If the patient
cannot begin, or fails to progress, at any step or in any regard, the
clinical team should consider starting (or adding) more or stronger
medications (see Pharmacotherapy below) and/or more intensive
psychotherapies (see Psychological Interventions below) and/or different
interventions (see Interventional Therapies below).

**Pharmacotherapy**

**Pharmacotherapy Guide. The Following Strategies Are Suggested for
Patients Who Have Been Diagnosed with CRPS but Who Cannot Begin or
Progress in the Functional Restoration Algorithm \*:**

  -----------------------------------------------------------------------
  **Reason for inability to **Action**
  begin or progress**       
  ------------------------- ---------------------------------------------
  Mild-to-moderate pain     Simple analgesics and/or blocks (see section
                            5 in the original guideline document)

  Excruciating, intractable Opioids and/or blocks or later, more
  pain \*\*                 experimental interventions (see section 5 in
                            the original guideline document)

  Inflammation/swelling and Steroids, systemic or targeted (acutely) or
  edema                     non-steroidal anti-inflammatory drugs
                            (NSAIDs) (chronically); immunomodulators

  Depression, anxiety,      Sedative, analgesic
  insomnia                  antidepressant/anxiolytics and/or
                            psychotherapy (see section 3 in the original
                            guideline document)

  Significant               Anticonvulsants and/or other sodium channel
  allodynia/hyperalgesia    blockers and/or N-methyl-D-aspartate
                            (NMDA)-receptor antagonists

  Significant osteopenia,   Calcitonin or bisphosphonates
  immobility trophic        
  changes                   

  Profound vasomotor        Calcium channel blockers, sympatholytics
  disturbance               and/or blocks (section 5 in the original
                            guideline document)
  -----------------------------------------------------------------------

\*It is important to remember that these suggestions are overruled by
individual patient presentation.

\*\*It is also important to not that certain drugs, such as
biphosphonates, may be associated with analgesia as well as the more
primary action.

A methodical, patient approach to pharmacotherapy in CRPS is essential.
To attempt to identify prominent mechanisms involved in the pain
generation, and to try to match drug mechanisms of action to these is
the *sine qua non* of the drug therapy of CRPS. It is often necessary to
use more than one drug, or \"rational polypharmacy,\" and the goal is
often as much to relieve the pain as to allow progress in
interdisciplinary rehabilitation. This is theoretically the best hope
for comprehensive management of the syndrome, as drug therapy alone is
never enough.

In most cases, no single drug will provide sufficient analgesia long
term, nor will it completely prevent the need for abortive/rescue
agents. This clinical reality usually requires two or even multiple
medications to adequately manage the pain. Thus, the problem of
drug-drug interaction is critical to consider, but unfortunately the
literature is very weak in this regard. The traditional sources of
information, such as the *Physician\'s Desk Reference®*, are somewhat
helpful, but it is important to consider competitive metabolic or
catabolic pathways, such as the liver cytochrome P450 catabolic systems.
For instance, the 2D6 enzyme pathway catabolizes codeine, heterocyclic
drugs, tramadol, mexiletine, and methadone (among others), and the
prudent clinician would keep this in mind when combining these drugs. It
is also important that if a drug-drug interaction is observed, this
information should be reported and published.

Refer to the original guideline document for more information on
individual drugs.

**Psychological Interventions**

There is no solid evidence that psychological factors are necessarily
involved in the onset of chronic CRPS. However, there are theoretically
plausible pathways through which psychological factors in some cases
*could* affect the development of CRPS. Evidence is mixed that CRPS
patients are in any way psychologically unique compared to other chronic
pain patients, although the hypothesis that they are as a group more
emotionally distressed has received some support. Once CRPS has
developed, emotional factors may have a greater impact on CRPS pain
intensity than in non-CRPS pain conditions, possibly through the impact
of dysphoric psychological states on catecholamines. Meta-analytic
reviews document the efficacy of various psychological interventions for
many types of non-CRPS chronic pain, and suggest that such interventions
are likely to be beneficial for CRPS patients as well. Adequate
randomized controlled studies of psychological interventions in CRPS
patients are not available to guide this aspect of CRPS management,
although numerous uncontrolled studies suggest the likely utility of
several approaches. These approaches include various forms of relaxation
training, biofeedback, and cognitive and behaviorally focused
interventions. Successful implementation of these interventions requires
recognition of the unique issues in CRPS patients, particularly the
pervasive learned (or centrally mediated) disuse often seen in such
patients. Clinical experience using techniques like those described
above in an integrated multidisciplinary context indicates that many
CRPS patients can achieve significant improvements in functioning and
ability to control pain.

**Psychological Intervention Treatment Algorithm**

  -------- -----------------------------------------------------------------
  **Step   **Patient and Family Education about CRPS**\
  1**      \
           Pathophysiology (lay language)\
           \
           Disuse Issues\
           \
           Reactivation\
           \
           Self-Management Focus\
           \
           Possible Psychophysiological Interactions\
           \
           \
           If patient has chronic CRPS or acute CRPS unresponsive to initial
           treatments

  **Step   **Psychological Evaluation**\
  2**      \
           Comorbid Axis psychiatric disorders\
           \
           Cognitive, behavioral, emotional response to CRPS\
           \
           Ongoing life stressors\
           \
           Responses of significant others to CRPS

  **Step   **Psychological Pain Management Intervention**\
  3**      \
           Relaxation training with feedback\
           \
           Cognitive intervention\
           \
           Reframing for active patient role\
           \
           Challenge dysfunctional cognitions\
           \
           Catastrophic cognitions\
           \
           Inaccurate beliefs about CRPS or treatment\
           \
           Cognitions underlying fear of movement\
           \
           Practice constructive self-talk\
           \
           Behavioral intervention\
           \
           Realistic pain-limited incremental reactivation\
           \
           Family intervention\
           \
           Address barriers to reactivation\
           \
           Increase constructive social support

  **Step   If Axis I disorders or major life stressors are identified,
  4**      conduct focused cognitive behavioral therapy targeting these
           issues
  -------- -----------------------------------------------------------------

**Interventional Therapies**

With a new understanding of CRPS as encompassing *both* sympathetically
independent pain (SIP) and sympathetically maintained pain (SMP) in
varying degrees among different patients, sympatholysis remains an
important diagnostic (SMP vs. SIP) and therapeutic modality (in the SMP
subgroup). Because of the considerable difficulty in \"clinically
assessing\" the successful sympathetic block, and because \"clinically
successful\" blocks provide varying degrees of sympatholysis, the role
of local anesthetic injection sympathetic blockade versus intravenous
regional anesthesia (IVRA), intravenous (IV), or epidural sympatholysis
is unknown and largely based on local practice patterns. Additionally,
with the notable paucity of good quality supportive outcomes studies,
the clinician is left to utilize these blocks or sympathectomy-inducing
infusions within the context of a broad algorithm of interdisciplinary
treatment, while awaiting further pathophysiological data and outcomes
research to guide our practice to the most beneficial treatments.

The decision to proceed with radiofrequency (RF) ablative techniques
versus other nondestructive alternatives is a complex one, with less
evidence for the ablative versus augmentative treatments. Due to the
adverse long-term post sympathectomy syndromes, this author currently
recommends against surgical ablative sympathectomy. Future studies may
expand on the role of pulsed RF (cold RF) techniques or such unstudied
techniques as cryosurgery as alternative therapies to treat SMP.

Our recommended strategy (and tactic) is to use interventional
treatments for CRPS patients who are having difficulty either starting
or progressing in the functional restoration/interdisciplinary
algorithm. If patients are not progressing because of high pain levels
(especially associated with autonomic dysfunction), then a stepwise
progression --- from the less invasive blocks, to infusions or catheter
infusion therapies, and ultimately perhaps to neurostimulation --- is
recommended in order to facilitate the patient\'s functional improvement
and pain control. One suggested algorithm developed by an expert panel
for the integrated use of these procedures is shown below and has been
previously published.

**Interventional Pain Treatment Algorithm for CRPS**\*

  ---------- ------------------------------------------------------------
  **Step 1** **Minimally Invasive Therapies**\
             \
             Sympathetic Nerve Blocks\
             \
             Intravenous Regional Nerve Blocks\
             \
             Somatic Nerve Blocks

  **Step 2** **More Invasive Therapies**\
             \
             Epidural and Plexus Catheter Block(s)\
             \
             Neurostimulation\
             \
             Intrathecal Drug Infusion (e.g., Baclofen)

  **Step 3** **Surgical and Experimental Therapies**\
             \
             Sympathectomy\
             \
             Motor Cortex Stimulation
  ---------- ------------------------------------------------------------

Inadequate or partial response to any given therapy should lead to a
stepwise progression down through these modalities (moving from less to
more invasive) in conjunction with other noninterventional treatments.

\*Adapted from Stanton-Hicks M, Burton A, Bruehl S, et al. An updated
interdisciplinary clinical pathway for CRPS: report of an expert panel.
Pain Practice. 2002;2:1-16.

#### CLINICAL ALGORITHM(S)

An additional clinical algorithm titled \"Overall Treatment Algorithm
(see other algorithms presented in the \"Major Recommendations\" field)
is provided in the original guideline document.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Appropriate, timely diagnosis and treatment of complex regional pain
    syndrome (CRPS)

-   Restoration of function

-   Minimization of pain

-   Improved quality of life

#### POTENTIAL HARMS

Complications of pharmacotherapy and interventional therapies

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

There are numerous, obvious contraindications to chronic steroid use.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Patient Resources\
Pocket Guide/Reference Cards\
Resources\
Slide Presentation

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Reflex Sympathetic Dystrophy Syndrome Association (RSDSA). Complex
regional pain syndrome: treatment guidelines. Milford (CT): Reflex
Sympathetic Dystrophy Syndrome Association (RSDSA); 2006 Jun. 67 p. \[51
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2002 Feb (revised 2006 Jun)

#### GUIDELINE DEVELOPER(S)

Reflex Sympathetic Dystrophy Syndrome Association - Private Nonprofit
Organization

#### SOURCE(S) OF FUNDING

Funding has been provided by grants from the National Organization of
Rare Disorders, Purdue Pharma L.P., and Celegene Corporation; donations
from Reflex Sympathetic Dystrophy Syndrome Association (RSDSA) members;
and from memorial gifts.

#### GUIDELINE COMMITTEE

Scientific Advisory Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Editor*: R. Norman Harden, MD

*Contributing Authors*: R. Norman Harden, MD; Stephen Bruehl, PhD; Allen
Burton, MD; Melanie Swan, OTR/L; Brienne R. Costa, CTRS; Jennifer
Barthel, MS; CRC; Amie L. King, PT

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline

This guideline updates a previous version: Reflex Sympathetic Dystrophy
Syndrome Association (RSDSA). Clinical practice guidelines (second
edition) for the diagnosis, treatment, and management of reflex
sympathetic dystrophy/complex regional pain syndrome (RSD/CRPS). Milford
(CT): Reflex Sympathetic Dystrophy Syndrome Association (RSDSA); 2002
Feb. 46 p. \[47 references\]

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Reflex Sympathetic Dystrophy
Syndrome Association (RSDSA) Web
site](http://www.rsds.org/3/clinical_guidelines/index.html#diagnosis).

Print copies: Available from the Reflex Sympathetic Dystrophy Syndrome
Association; PO Box 502, Milford, CT 06460; Phone: 203-877-3790; Web
site: [www.rsds.org](http://www.rsds.org/)

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Reflex sympathetic dystrophy (RSD)/complex regional pain syndrome
    (CRPS) slide kit. Reflex Sympathetic Dystrophy Syndrome Association
    (RSDSA); 2006 Oct. 36 p. Available from the [RSDSA Web
    site.](http://rsds.org/3/education/index.html)

-   TellTale signs of RSD/CRPS. Reflex Sympathetic Dystrophy Syndrome
    Association (RSDSA); 2006 2 p. Available from the [RSDSA Web
    site](http://rsds.org/3/education/index.html).

#### PATIENT RESOURCES

Brochures and resource guides on concerns related to complex regional
pain syndrome (CRPS) (e.g., sports injuries, helping children with CRPS
succeed in school, hospital protocols, treatment and therapy options,
government assistance programs, finding a specialist) are available from
the [RSDSA Web site](http://rsds.org/4/resources/index.html).

#### NGC STATUS

This NGC summary was completed by ECRI on December 11, 2002. The
information was verified by the guideline developer on January 27, 2003.
This summary was updated by ECRI on January 12, 2005 following the
release of a public health advisory from the U.S. Food and Drug
Administration regarding the use of some non-steroidal anti-inflammatory
drug products. This summary was updated on April 15, 2005 following the
release of heightened warnings for nonselective nonsteroidal
anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on
June 16, 2005, following the U.S. Food and Drug Administration advisory
on COX-2 selective and non-selective non-steroidal anti-inflammatory
drugs (NSAIDs). This summary was updated by ECRI on November 28, 2006.
The updated information was verified by the guideline developer on
November 30, 2006. This summary was updated by ECRI Institute on
November 9, 2007, following the U.S. Food and Drug Administration
advisory on Antidepressant drugs. This summary was updated by ECRI
Institute on January 10, 2008, following the U.S. Food and Drug
Administration advisory on Carbamazepine.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008