Complex regional pain syndrome (CRPS) type I: historical perspective and critical issues.

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Abstract

9. Pain Physician. 2025 Jul;28(4):E287-E327. Diagnostic Guidance for Chronic Complex Regional Pain Syndrome Type I and Type II from The American Society of Interventional Physicians (ASIPP). Gharibo C(1), Day M(2), Aydin SM(3), Kaye AD(4), Abdi S(5), Diwan S(6), Doan LV(6), Feng D(7), Ferguson K(8), Georges K(9), Kaufman A(10), Knezevic NN(11), Li S(12), Liongson FA(13), Nampiaparampil D(14), Navani A(15), Sanapati M(16), Schatman ME(17), Soin A(18), Staats PS(19), Varrassi G(20), Wang J(21), Manchikanti L(22). Author information: (1)Department of Anesthesiology, Perioperative Care, and Pain Medicine Department of Orthopedic Surgery, NYU Grossman School of Medicine New York, NY. (2)Department of Anesthesiology, Texas Tech University Health Sciences Center, Lubbock, TX. (3)Physical Medicine & Rehabilitation and Interventional Pain Management, Kayal Medical Group, NJ and Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY. (4)Department of Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center at Shreveport; Department of Anesthesiology, Tulane School of Medicine; Department of Anesthesiology and Pharmacology, LSU School of Medicine, New Orleans, LA. (5)Department of Pain Medicine, University of Texas, MD Anderson Cancer Center Houston, TX. (6)Albert Einstein College of Medicine, New York, NY. (7)Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY. (8)Medical College of Wisconsin, Wausau, WI. (9)Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Medical Center, New York, NY. (10)Rutgers New Jersey Medical School, Director, Division of Pain Management, Department of Anesthesiology, Newark, NJ. (11)Department of Anesthesiology, Advocate Illinois Masonic Medical Center; Department of Anesthesiology and Department of Surgery, College of Medicine, University of Illinois, Chicago, IL. (12)National Spine and Pain Centers, Shrewsbury, NJ; Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ. (13)Department of Anesthesiology, Perioperative Care, and Pain Medicine, Department of Psychiatry, NYU Grossman School of Medicine, NYU Langone Health, New York, NY. (14)Metropolis Pain Medicine, New York, NY; Department of Rehabilitation Medicine, NYU Grossman School of Medicine, New York, NY, USA. (15)Department of Research and Development, Le Reve Regenerative Center, San Jose, CA, USA; Boomerang Health Care, Walnut Creek, CA, USA. (16)Pain Management Centers of America, Evansville, IN; Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, Louisville, KY; Indiana University School of Medicine, Evansville, IN. (17)Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY; Department of Population Health-Division of Medical Ethics, NYU Grossman School of Medicine, New York, NY. (18)Ohio Pain Clinic, Dayton, OH; Wright State University, Dayton, OH. (19)Vagus Nerve Society, Atlantic Beach, FL; Best Practices Pain Management Inter-agency Task Force, US Department of Health and Human Services, Washington, DC. (20)Research and Development Department, Fondazione Paolo Procacci NGO, Roma, Italy. (21)Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health; Department of Neuroscience and Physiology, New York University Grossman School of Medicine, New York, NY. (22)Pain Management Centers of America, Paducah, KY; Departments of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY; Department of Anesthesiology, School of Medicine, LSU Health Science Center, New Orleans, LA. BACKGROUND: Complex Regional Pain Syndrome (CRPS) is a challenging and often disabling condition marked by persistent pain, most commonly in a limb following injury or surgery. It presents with a wide array of symptoms, including intense pain, swelling, alterations in skin color and temperature, motor dysfunction, and trophic changes such as skin and tissue atrophy. While the precise cause of CRPS is not fully understood, it is thought to stem from abnormal nervous system activity, leading to heightened pain sensitivity and inflammatory responses. A thorough understanding of CRPS is essential for accurate diagnosis, effective treatment, and enhancing patients' quality of life.Although attempts have been made to distinguish between acute and chronic CRPS, there are currently no established diagnostic criteria specific to chronic CRPS in medical literature. OBJECTIVE: This ASIPP guidance document offers updated, evidence-based recommendations for the diagnosis and management of Chronic Complex Regional Pain Syndrome (CRPS), with a primary focus on introducing novel, time-based diagnostic criteria specific to the chronic phase. These proposed criteria address significant gaps in the current literature, where existing standards, such as the Budapest Criteria, do not sufficiently differentiate between the acute and chronic stages of the condition. METHODS: An expert panel convened by the American Society of Interventional Pain Physicians (ASIPP) conducted a comprehensive literature review and employed a structured consensus process to develop recommendations. Acknowledging that the clinical and pathological characteristics of CRPS change significantly beyond 12 months, the panel proposed chronic-specific diagnostic criteria based on disease duration, clinical history, physical examination findings, and optional diagnostic tests. These draft criteria were refined through multidisciplinary input and expert consensus. RESULTS: The diagnostic framework for chronic CRPS consists of four key components:General Criteria - Require fulfillment of the Budapest Criteria for at least 12 months, continued recognition of CRPS as a diagnosis of exclusion, and differentiation from generalized nociplastic pain syndromes.History-Based Criteria - Mandate the presence of at least three out of five specific historical features.Physical Examination Criteria - Include asymmetric limb findings, sensory disturbances, and musculoskeletal changes.Optional Diagnostic Testing - May involve assessments such as intraepidermal nerve fiber density (IENFD) and imaging evidence of regional bone demineralization.This framework builds upon the Budapest Criteria by incorporating time-dependent features of chronic CRPS, including musculoskeletal dystrophy, neurogenic inflammation, and sympathetic dysfunction. Emerging objective tools-such as quantitative sensory testing (QST), skin biopsy for IENFD, functional MRI, and serum biomarkers of neuroinflammation-may further support diagnosis in complex or uncertain cases.Treatment recommendations highlight a multimodal strategy that integrates physical rehabilitation, pharmacologic management of neuropathic pain, sympathetic nerve blocks, and advanced neuromodulation. Emphasis is placed on individualized care pathways tailored to disease stage and patient-specific characteristics. CONCLUSIONS: This article presents the first structured, time-sensitive diagnostic criteria for chronic CRPS, aimed at improving diagnostic accuracy and informing treatment strategies. Adoption of these criteria may enhance clinical outcomes and promote further research into the natural history and pathophysiology of CRPS progression.