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Pain Relief Foundation Complex regional pain syndrome in adults UK guidelines for diagnosis, referral and management in primary and secondary care 7 2012 Endorsed by Also endorsed by the British Society of Rheumatologists and British Health Professionals in Rheumatology
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Page 1: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

Pain ReliefFoundation

Complex regional pain syndrome in adultsUK guidelines for diagnosis, referral and management in primary and secondary care

��7 2012

Endorsed by

Also endorsed by the British Society of Rheumatologists and British Health Professionals in Rheumatology

Page 2: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

Complex regional painsyndrome in adults���%3'"#*',#1�$-0�"'�%,-1'1A�0#$#00�*��,"+�,�%#+#,2�',�.0'+�07��,"�1#!-,"�07�!�0#Developed by a panel of experts 5'2&�13..-02�$0-+A��,"�0#.0#1#,2�2'-,� 7�2&#��-7�*��-**#%#�-$��#,#0�*�0�!2'2'-,#01A�2&#��-7�*��-**#%#�-$��&71'!'�,1A�2&#��-**#%#�-$��!!3.�2'-,�*��&#0�.'121A�2&#��0'2'1&��11-!'�2'-,-$��#0+�2-*-%'121A�2&#��0'2'1&��#�*2&��0-$#11'-,�*1�',��&#3+�2-*-%7A�2&#��0'2'1&��02&-.�#"'!��11-!'�2'-,A2&# �0'2'1&���',��-!'#27A�2&#��0'2'1&��17!&-*-%'!�*��-!'#27A�2&#��0'2'1&��-!'#27�$-0��#&� '*'2�2'-,��#"'!',#A2&# �0'2'1&��-!'#27�$-0��&#3+�2-*-%7A�2&#��&�02#0#"��-!'#27�-$��&71'-2&#0�.7A�2&#��&71'-2&#0�.7���',�11-!'�2'-,A�2&#��-!'#27�-$��0'2'1&��#30-*-%'!�*��30%#-,1A��,"�2&#���',��#*'#$�-3,"�2'-,@

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Endorsed by :

Also endorsed by the British Society of Rheumatologists and British Health Professionals in Rheumatology

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Pain ReliefFoundation

Page 3: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

© Royal College of Physicians 2012

The Royal College of Physicians

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Citation for this document�-# #*��A���0)#0���A��30,#0Q�2-)#1���et al@�Complex regional pain syndrome in adults: UK guidelines fordiagnosis, referral and management in primary and secondary care@��-,"-,B����A�mklm@

Copyright�**�0'%&21�0#1#04#"@��-�.�02�-$�2&'1�.3 *'!�2'-,�+�7� #�0#.0-"3!#"�',��,7�$-0+�H',!*3"',%�.&-2-!-.7',%�-012-0',%�'2�',��,7�+#"'3+� 7�#*#!20-,'!�+#�,1��,"�5&#2&#0�-0�,-2�20�,1'#,2*7�-0�',!'"#,2�**7�2-�1-+#�-2&#0�31#-$�2&'1�.3 *'!�2'-,J�5'2&-32�2&#�50'22#,�.#0+'11'-,�-$�2&#�!-.70'%&2�-5,#0@��..*'!�2'-,1�$-0�2&#�!-.70'%&2-5,#0`1�.#0+'11'-,�1&-3*"� #��""0#11#"�2-�2&#�.3 *'1&#0@

© 2012 Royal College of Physicians. All rights reserved.

Royal College of Physiciansll��2��,"0#51��*�!#�#%#,2`1���0)�-,"-,A���l�o�

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Page 4: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

© Royal College of Physicians 2012 iii

Contents

Membership of the Guideline Development Panel iv

Abbreviations vi

Summary vii

Methodology of guideline development viii

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Introduction 1

Specialty guidelines 4

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Appendices 31

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Glossary of terms 66

References 70

Page 5: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

© Royal College of Physicians 2012 iv

Membership of the Guideline Development Panel

ChairDr Andreas Goebel PhD FRCA FFPMRCA�#,'-0�*#!230#0�',�.�',�+#"'!',#A��,'4#01'27�-$��'4#0.--*

Professor Roger M Atkins MA MB DM FRCS�-,13*2�,2�-02&-.�#"'!�130%#-,A��0'12-*��-7�*� ,$'0+�07

Dr Chris Barker DRCOG MRCGP�.#!'�*'12�',�.�',�+#"'!',#A�!*','!�*�"'0#!2-0A������#$2-,��-++3,'27���',��#04'!#A��'4#0.--*

Dr Heather Cameron PhD MCSP�&71'-2&#0�.7�.0-$#11'-,�*�*#�"A��#&� '*'2�2'-,��,"��11#11+#,2��'0#!2-0�2#A��!32#��#04'!#1A������0#�2#0��*�1%-5��,"��*7"#A��!-2*�,"

Mrs Linda Cossins MSc MCLIP ,$-0+�2'-,�1!'#,2'12A���',��#*'#$�-3,"�2'-,A��'4#0.--*

Dr David J Eedy MD FRCP�-,13*2�,2�"#0+�2-*-%'12A��-32&#0,��#�*2&��,"��-!'�*���0#��0312A��0�'%�4-,A��-02&#0,� 0#*�,"C��0'2'1&��11-!'�2'-,�-$��#0+�2-*-%'121

Louise Haynes BScOT MRes��',�1.#!'�*'12�-!!3.�2'-,�*�2&#0�.'12A���*2-,��#,20#�$-0��#30-*-%7��,"��#30-130%#07A��'4#0.--*

Dr Martin Johnson DRCOG DCH MRCGP��A��3""#01$'#*"A��-0)1&'0#C������!*','!�*�!&�+.'-,�$-0�!&0-,'!�.�',C�&-,-0�07�1#,'-0�*#!230#0�',�!-++3,'27.�',A��,'4#01'27�-$���0"'$$

Dr Jenny Lewis PhD Dip COT�*','!�*�0#1#�0!&�-!!3.�2'-,�*�2&#0�.'12A���2&��#,20#�$-0���',��#04'!#1A��&#��-7�*���2'-,�*��-1.'2�*�$-0�&#3+�2'!��'1#�1#1A���2&�

Professor Candida S McCabe PhD RGN�0-$#11-0�-$�,301',%��,"�.�',�1!'#,!#1A��,'4#01'27�-$�2&#��#12�-$�,%*�,"A��0'12-*C�!-,13*2�,2�,301#A��-7�*���2'-,�*��-1.'2�*�$-0��&#3+�2'!��'1#�1#1A���2&

Professor Turo J Nurmikko PhD �0-$#11-0�-$�.�',�1!'#,!#A���',��#1#�0!&� ,12'232#A��,'4#01'27�-$��'4#0.--*C���',��#*'#$�-3,"�2'-,

Dr Roger Okell FRCA FRCP FFPMRCA�-,13*2�,2�',��,�#12&#1'���,"�.�',�+#"'!',#A��#'%&2-,��-1.'2�*A��0#5#

Dr Helen Poole PhD CPsychol�#,'-0�*#!230#0�',�&#�*2&�.17!&-*-%7A��'4#0.--*��-&,��--0#1��,'4#01'27

Dr Mick Serpell FRCA, FFPMRCA�-,13*2�,2��,"�1#,'-0�*#!230#0�',��,�#12&#1'���,"�.�',�+#"'!',#A��,'4#01'27��#.2�-$��,�#12&#1'�A���02,�4#*��#,#0�*��-1.'2�*A��*�1%-5

Dr Nicholas Shenker PhD FRCP�-,13*2�,2�0&#3+�2-*-%'12A��""#, 0--)#1��-1.'2�*A���+ 0'"%#

Mr Brian Simpson MD FRCS�-,13*2�,2�,#30-130%#-,A���0"'$$A���*#1

Page 6: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

© Royal College of Physicians 2012 v

Professor Blair H Smith MD MEd FRCGP FRCPEdin�0-$#11-0�-$�.0'+�07�!�0#�+#"'!',#A��,'4#01'27�-$�� #0"##,

Prof Lynne Turner-Stokes DM FRCP�-,13*2�,2�',�0#&� '*'2�2'-,�+#"'!',#C�"'0#!2-0A��#%'-,�*��#&� '*'2�2'-,��,'2A��-02&5'!)���0)��-1.'2�*C�.0-$#11-0�-$�0#&� '*'2�2'-,A��',%`1��-**#%#��-,"-,�

Patient representatives

Ms Suzie Almond��2'#,2�0#.0#1#,2�2'4#A��20-3"

Mr Terrence Carney��2'#,2�0#.0#1#,2�2'4#A��'4#0.--*

Mrs Wendy Hall��2'#,2�0#.0#1#,2�2'4#A��&#12#0

Mrs Penelope Halliday��2'#,2�0#.0#1#,2�2'4#A��'4#0.--*

Mr Alan Pendleton MBE�&�'0+�,A��+'*#���',��3..-02��0-3.A���*2-,��#,20#A��'4#0.--*

Mr John Sanders��2'#,2�0#.0#1#,2�2'4#A��'0+',%&�+

Ms Angeleça Silversides��2'#,2�0#.0#1#,2�2'4#A��-,"-,

Ms Catherine Taylor��2'#,2�0#.0#1#,2�2'4#A��&#$$'#*"

Page 7: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

© Royal College of Physicians 2012 vi

Abbreviations

�-**#%#1��,"�.0-$#11'-,�*�',12'232'-,1B

ABN �11-!'�2'-,�-$��0'2'1&��#30-*-%'121

AOP �11-!'�2'-,�-$��02&-.�#"'!��0�!2'2'-,#01

BAD �0'2'1&��11-!'�2'-,�-$��#0+�2-*-%'121

BAHT �0'2'1&��11-!'�2'-,�-$���,"��&#0�.'121

BAPRAS �0'2'1&��11-!'�2'-,�-$��*�12'!A��#!-,1203!2'4#��,"��#12&#2'!��30%#-,1

BHPR �0'2'1&��#�*2&��0-$#11'-,�*1�',��&#3+�2-*-%7

BOA �0'2'1&��02&-.�#"'!��11-!'�2'-,

BPS �0'2'1&���',��-!'#27

BPS H�17!&-*-%7J�S��0'2'1&��17!&-*-%'!�*��-!'#27�

BSR �0'2'1&��-!'#27�-$��&#3+�2-*-%'121

BSRM �0'2'1&��-!'#27�-$��#&� '*'2�2'-,��#"'!',#

COT �-**#%#�-$��!!3.�2'-,�*��&#0�.'121

CSP �&�02#0#"��-!'#27�-$��&71'-2&#0�.7

PPA �&71'-2&#0�.7���',��11-!'�2'-,

PRF ��',��#*'#$�-3,"�2'-,

RCGP �-7�*��-**#%#�-$��#,#0�*��0�!2'2'-,#01

RCP �-7�*��-**#%#�-$��&71'!'�,1

RCR �-7�*��-**#%#�-$���"'-*-%'121

SBNS �-!'#27�-$��0'2'1&��#30-*-%'!�*��30%#-,1

SCP �-!'#27�-$��&'0-.-"'121��,"��-"'�20'121

Page 8: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

© Royal College of Physicians 2012 vii

Summary

�&'1�%3'"#*',#�!-,!#0,1�2&#�"'�%,-1'1��,"�+�,�%#+#,2�-$�.�2'#,21�5'2&�!-+.*#6�0#%'-,�*�.�',�17,"0-+#H����J@� 2�.0-4'"#1�0#!-++#,"�2'-,1�$-0�"'�%,-1'1A�20#�2+#,2��,"�0#$#00�*�',���4�0'#27�-$�!*','!�*�1#22',%1H�� .0�!2'!#A�-02&-.�#"'!�.0�!2'!#A�0&#3+�2-*-%7A�,#30-*-%7��,"�,#30-130%#07A�"#0+�2-*-%7A�.�',�+#"'!',#A0#&� '*'2�2'-,�+#"'!',#��,"�*-,%Q2#0+�!�0#J@� 21�.30.-1#�'1�2-�.0-4'"#�!-&#0#,2�%3'"�,!#�$-0�.0-$#11'-,�*15-0)',%�',�2&#�"'$$#0#,2�&#�*2&�1.#!'�*'2'#1�5&-�!�0#�$-0�2&#1#�.�2'#,21�H'%�lA�.�%#�mJ@��&#�"-!3+#,2�12�0215'2&��, ',20-"3!2'-,�$-0��**�',2#0#12#"�.�02'#1A�$-**-5#"� 7�1.#!'�*'27Q1.#!'$'!�1#!2'-,1@��3..-02',%�"-!3+#,21�0# �..#,"#"@

�*','!'�,1�5'**�$',"�0#*#4�,2�',$-0+�2'-,�',�0#�"',%� -2&�2&#�',20-"3!2'-,��,"�0#1.#!2'4#�1.#!'�*'27Q1.#!'$'!1#!2'-,1@��#!-++#,"�2'-,1��0#�',�$0�+#"� -6#1��,"��0#�%#,#0�**7� �1#"�-,�.�,#*�!-,1#,131��,"�#6.#02-.','-,C�%0�"',%�'1�,-2�.0-4'"#"@���!-,!'1#�13++�07�-$�2&#�%3'"#*',#�'1��4�'*� *#��1���1#.�0�2#�"-!3+#,2@l

�0�"',%�-$�0#!-++#,"�2'-,1�31',%�2&#�27.-*-%7�"#4#*-.#"�$-0�2&#���2'-,�*��#04'!#�0�+#5-0)�$-0�*-,%Q2#0+!-,"'2'-,1m '1�%'4#,�2&#0#@

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© Royal College of Physicians 2012 viii

Methodology of guideline development

�&#1#�%3'"#*',#1�5#0#�','2'�2#"� 7��0��,"0#�1��-# #*��,"��0��&0'1���0)#0�',��11-!'�2'-,�5'2&�2&#���',��#*'#$-3,"�2'-,��,"�5#0#�"#4#*-.#"� 7������.�,#*�-$�#6.#021�0#.0#1#,2',%���4�0'#27�-$�&#�*2&!�0#�1.#!'�*2'#1��,".0-$#11'-,1@� ,��""'2'-,A�4�0'-31�.0-$#11'-,�*��11-!'�2'-,1��,"�!-**#%#1�5#0#�0#.0#1#,2#"�-,�2&#�.�,#*@6.#,1#1�$-0��22#,"',%�+##2',%1�5#0#�$3,"#"� 7�!-++#0!'�*�1.-,1-01�H1##��..#,"'6�lJ@��&#�%3'"#*',#1��0#',2#,"#"�$-0�31#�2&0-3%&-32�2&#���@

Identification of evidence

1 Diagnosis

��0#4'#5�-$�2&#�*'2#0�230#�$0-+��3*7�mkkk�2-��.0'*�mklk�5�1�!�00'#"�-32@��#"*',#�H�3 �#"J��,"�������"�2� �1#1�5#0#�1#�0!&#"�31',%���!-+ ',�2'-,�-$�2&#�$-**-5',%�1#�0!&�2#0+1B�!-+.*#6�0#%'-,�*�.�',17,"0-+#1C�0#$*#6�17+.�2&#2'!�"7120-.&7��,"�!�31�*%'�C�5'2&�"'�%,-1'1C�"'�%,-12'!C�#�0*7�"'�%,-1'1��,"!*','!�* 20'�*C�+#2��,�*71'1C�.0�!2'!#�%3'"#*',#C�!-+.�0�2'4#�123"7C��,"�!-,1#,131�123"7@�

�23"'#1�5#0#�',!*3"#"�',�2&#��11#11+#,2�'$�2&#7�5#0#�.0-1.#!2'4#��,"G-0�*')#*7�2-�!-,20' 32#�2-�"'�%,-12'!2#!&,'/3#1�$-0�����@��5-�0#4'#5#01��11#11#"�2&#�!&-1#,�123"'#1��!!-0"',%�2-�5&#2&#0�2&#7�#4�*3�2#"��,7,#5 "'�%,-12'!�2#!&,'/3#�-0��*%-0'2&+A�0#Q#4�*3�2#"�2&#��3"�.#12 "'�%,-12'!�!0'2#0'�A�-0�"-!3+#,2#"��,7.-2#,2'�**7�'+.-02�,2�"'$$#0#,2'�*�"'�%,-1#1@

2 Treatment and prevention

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3 Earlier guidelines

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4 Long-term management

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Recommendations

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© Royal College of Physicians 2012 1

Introduction

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Category Symptom (the Sign (you can see patient reports a or feel a problem) problem)

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Table 2 Earlier names for CRPS

?��&#�2#0+�_+�(-0`�5'2&',�-02&-.�#"'!�!-,2#62�'1�,-2�$3**7�"#$',#"@�V ��2&'0"�"'�%,-12'!�13 27.#�!�**#"�����Q����H,-2�-2&#05'1#�1.#!'$'#"J�'1�0#!-++#,"#"�$-0�.�2'#,21�5&-�&�4#�� ,-0+�*'2'#1�',�$#5#0�2&�,2&0##��3"�.#12�17+.2-+�!�2#%-0'#1A�-0�25-�1'%,�!�2#%-0'#1A�',!*3"',%�2&-1#�5&-�&�"�+-0#�"-!3+#,2#"�1'%,1��,"�17+.2-+1�',�2&#�.�12A�'$!300#,2�_1'%,1��,"�17+.2-+1`��0#�12'**�$#*2�2-� #� #12�#6.*�',#"� 7�����@??��1��,�#6!#.2'-,A�',�-02&-.�#"'!�.0�!2'!#A�',������mA���,#04#�*#1'-,�!�,�1-+#2'+#1� #�"'0#!2*7�20#�2#"�H1##�_�30%'!�*�+�,�%#+#,2`�',1#!2'-,�-,�-02&-.�#"'!�.0�!2'!#J@

Fig 2 -30�.'**�01�-$�20#�2+#,2�$-0������S��,�',2#%0�2#"�',2#0"'1!'.*',�07��..0-�!&

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Page 14: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

Specialty guidelines

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© Royal College of Physicians 2012 5

Primary care�31.#!2#"�-0�!-,$'0+#"������S�"'�%,-1'1A�+�,�%#+#,2��,"�0#$#00�*�',�.0'+�07�!�0#�',�2&#��B�%3'"�,!#�$-0�%#,#0�*�.0�!2'2'-,#01��,"�-2&#0�.0'+�07�!�0#�!*','!'�,1

�,'*�2#0�*�*'+ �.�',�',�.�2'#,21�.0#1#,2',%�2-�2&#�%#,#0�*�.0�!2'!#�130%#07�&�1�+�,7�.-2#,2'�*�!�31#1@��&'11#!2'-,�-$�2&#�%3'"#*',#��'+1�2-��""�!*�0'27�2-�2&#�"'�%,-1'1��,"�+�,�%#+#,2�H',!*3"',%�'++#"'�2#A�1&-02Q2#0+�,"�*-,%Q2#0+�+�,�%#+#,2J�-$������',�.0'+�07�!�0#@��&#�12�02',%�.-',2�-$�2&#�%3'"#*',#��113+#1���"#%0##�-$131.'!'-,�-$�2&#�.0#1#,!#�-$�����C��,�#6&�312'4#�"'$$#0#,2'�*�"'�%,-12'!�*'12�'1� #7-,"�2&#�1!-.#�-$�2&'1"-!3+#,2�H1##�2&#�*'12�-$�"'$$#0#,2'�*�"'�%,-1#1�',�2&#�_�&#3+�2-*-%7A�,#30-*-%7��,"�,#30-130%#07`�1#!2'-,J@�

�-�'+.0-4#�2&#�!&�,!#�-$���$�4-30� *#�-32!-+#A�2&0##�.0',!'.�*��0#�1�0#/3'0#��22#,2'-,B

F .�',�',2#,1'27

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Diagnosis of CRPS

Recommendations

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Recommendations

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© Royal College of Physicians 2012 6

i �&#,�.�',�20#�2+#,2�H1##�_��,�%#+#,2�-$�131.#!2#"�-0�!-,$'0+#"�����`�*�2#0�',�2&'1�1#!2'-,J�'13,13!!#11$3*@� ,�13!&�!�1#1A�2&#�.�2'#,2�1&-3*"� #�0#$#00#"�2-���.�',�1.#!'�*'12�H',�!-++3,'27�-0�1#!-,"�07!�0#J@��&'1�'1�#11#,2'�*�#4#,�'$�-2&#0�+�,�%#+#,2�'1�-,%-',%�H#%� 7�.&71'-2&#0�.7A�-02&-.�#"'!1�-00&#3+�2-*-%7J@��&#����1&-3*"�,-2�0#*7�-,�,-,Q.�',�!*','!'�,1�2-�+�,�%#�2&#�.#01'12#,2�.�',@

i 4#,�5&#,�2&#�.�2'#,2`1�.�',�'1�+'*"��,"�!-,20-**#"�'$�2&#0#��0#�!-,!-+'2�,2�1'%,1�-$�.�',Q0#*�2#"�"'120#11�-0�"'1� '*'27@� ,�13!&�!�1#1A�2&#�.�2'#,2�1&-3*"� #�0#$#00#"�2-���+3*2'"'1!'.*',�07�.�',�!*','!�H',!-++3,'27�-0�1#!-,"�07�!�0#J@���*'12�-$�.�',�!*','!1�!�,� #�$-3,"��2�2&#���2'-,�*���',��3"'2`1�5# 1'2#H555@,�2'-,�*.�',�3"'2@-0%G1#�0!&@�1.6J@

After trauma or surgery

i �&#,���.�2'#,2�'1��*0#�"7�"'1!&�0%#"�$0-+�2&#�20�3+��-0�130%'!�*�2#�+A�2&#����1&-3*"�!-,1'"#0�0#Q0#$#00�*�S�$-0�#6�+.*#A�2-�2&#��22#,"',%�-02&-.�#"'!�1.#!'�*'12G130%#-,�-0�20�3+��1#04'!#�S�2-��**-5�$-0"#$','2#�#6!*31'-,�-$�-,%-',%�.�2&-*-%7@�

Without trauma (or after minor trauma)

i ��2'#,21�5'2&�131.#!2#"������5'2&-32�.0#!#"',%�20�3+��1&-3*"� #�0#$#00#"�2-�1#!-,"�07�!�0#H#% 0&#3+�2-*-%7J�2-�#6!*3"#�-0��""0#11�1.#!'$'!�.�2&-*-%7@

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Referral of confirmed CRPS

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Management of suspected or confirmed CRPS

Recommendations

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Complex regional pain syndrome in adults Specialty guidelines Primary care

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Phase 2: diagnosing CRPS

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Treatment approaches

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Complex regional pain syndrome in adults Specialty guidelines Orthopaedic practice

© Royal College of Physicians 2012 16

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© Royal College of Physicians 2012 17

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Diagnosis

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Recommendations

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Complex regional pain syndrome in adults Specialty guidelines Rheumatology, neurology and neurosurgery

© Royal College of Physicians 2012 18

Management and referral

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Recommendations

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© Royal College of Physicians 2012 19

Dermatology

Diagnosis

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Page 30: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

Complex regional pain syndrome in adults Specialty guidelines Dermatology

© Royal College of Physicians 2012 20

Referral

Recommendations

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© Royal College of Physicians 2012 21

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Treatment for symptoms and/or signs other than pain

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Box 7 Definitions of rehabilitation

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Complex regional pain syndrome in adults Specialty guidelines Rehabilitation medicine

© Royal College of Physicians 2012 26

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Patient selection and referral

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Specialist rehabilitation team Specialist pain team

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Table 3 Key elements of expertise for the treatment of patients with CRPS and complex disabilitythat may be provided by specialist rehabilitation and pain teams

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Complex regional pain syndrome in adults Specialty guidelines Rehabilitation medicine

© Royal College of Physicians 2012 27

Management

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Vocational rehabilitation*

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Litigation

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Recommendations

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Complex regional pain syndrome in adults Specialty guidelines Rehabilitation medicine

© Royal College of Physicians 2012 28

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© Royal College of Physicians 2012 29

Long-term support in CRPS

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Complex regional pain syndrome in adults Specialty guidelines Long-term support in CRPS

© Royal College of Physicians 2012 30

Recommendations

Person-centred integrated information and care planning (QR1)

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Ongoing access to specialist care (QR2)

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Community rehabilitation and support (QR5 and QR8)

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Support for families and carers (QR10)

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Page 41: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

Appendices

Page 42: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

© Royal College of Physicians 2012 32

Appendix 1 �-++#0!'�*�1.-,1-01

Astellas Pharma Ltd�-4#22��-31#�-4#22��-�"�2�',#1�'""*#1#6���ls�n��

Grünenthal Ltd�12-,��-302�',%+#�"��31',#11���0)0#"#0'!)��*�!#�'%&��7!-+ #�3!)1���ll�l��

Medtronic Ltd�3'2#�lA��3'*"',%�p�0-6*#7��0##,��31',#11���0)��2$-0"�#021���ls�s��

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Page 43: Complex regional pain syndrome in adults: UK guidelines for · PDF file · 2012-06-2511-!' 2'-, -$ * 12'!A #!-,1203!2'4# ," #12&#2'! 30%#-,1 ," 2&# 11-!' 2'-, -$ 0'2'1& #30-*-%'121@

© Royal College of Physicians 2012 33

Appendix 2 �712#+�2'!�0#4'#5�+#2&-"-*-%7�mklk

Methodology

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Complex regional pain syndrome in adults Appendix 2 Systematic review methodology 2010

© Royal College of Physicians 2012 34

Level of effectiveness Evidence required

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Table 4 Levels of evidence of effectiveness of treatments for CRPS

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© Royal College of Physicians 2012 35

Appendix 3 ,$-0+�2'-,�$-0���1

Complex regional pain syndrome (CRPS)

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Epidemiology and impact

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Aetiology

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Diagnosis

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Management in primary care

What to tell patients

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Complex regional pain syndrome in adults Appendix 3 Information for GPs

© Royal College of Physicians 2012 36

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Crisis management

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© Royal College of Physicians 2012 37

Appendix 4 �����"'�%,-12'!�!&#!)*'12

�*#�1#�,-2#B�

F �'12',!2'-,� #25##,������27.#�l�H,-�,#04#�',(307J��,"������27.#�m�H+�(-0�,#04#�',(307J�'1�.-11' *#A� 32�&�1,-�0#*#4�,!#�$-0�20#�2+#,2@��1��,�#6!#.2'-,A�',�-02&-.�#"'!�.0�!2'!#A�',������mA���,#04#�*#1'-,�!�,1-+#2'+#1� #�"'0#!2*7�20#�2#"�H1##�_�30%'!�*�+�,�%#+#,2`�',�_�02&-.�#"'!�.0�!2'!#`�1#!2'-,J@

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Explanation of terms

_�7.#0�*%#1'�`�'1�5&#,���,-0+�**7�.�',$3*�1#,1�2'-,�H#%�$0-+���.',.0'!)J�'1�+-0#�.�',$3*�2&�,�,-0+�*C_�**-"7,'�`�'1�5&#,���,-0+�**7�,-2�.�',$3*�1#,1�2'-,�H#%�$0-+�2-3!&',%�2&#�1)',J�'1�,-5�.�',$3*C_&7.#0#12&#1'�`�'1�5&#,�2&#�1)',�'1�+-0#�1#,1'2'4#�2-���1#,1�2'-,�2&�,�,-0+�*@�

A special feature in CRPS

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Category Symptom (the Sign (you can see patient reports a or feel a problem) problem)

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+312� #��l��

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Complex regional pain syndrome in adults Appendix 4 CRPS diagnostic checklist

© Royal College of Physicians 2012 38

!-++3,'!�2'-,� #25##,�2&#� 0�',��,"�2&#�*'+ @���&#*.$3*�/3#12'-,�2-��11#11�2&'1�$#�230#�'1B�_ $� �&�"���+�%'!5�,"�2-�2�)#�7-30�.�',��5�7A�!-3*"�7-3�2&#,�+-4#�7-30�@@@�H#%�$',%#01J=`@���,7�.�2'#,21�5'**��,15#0�5'2&�_,-`2-�2&�2�/3#12'-,@

Unusual CRPS

�0-3,"�lk|�-$�.�2'#,21�!�,,-2�0#!�**���1.#!'$'!�20�3+��-0�+�7�0#.-02�2&�2�2&#'0������"#4#*-.#"�5'2&��,#4#07"�7��!2'4'27�13!&��1�5�*)',%�-0�27.#50'2',%@� ,�1-+#�.#-.*#������!�,�&�4#��� '*�2#0�*�-,1#2@� ,�� -32r|������!�,�1.0#�"�2-�',4-*4#�-2&#0�*'+ 1@��0-3,"�lp|�-$������!�1#1�"-�,-2�'+.0-4#��$2#0�m�7#�01@� 2�'1�..0-.0'�2#�2-�+�)#�2&#�"'�%,-1'1�-$������',�2&#1#�3,313�*�!�1#1@�

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© Royal College of Physicians 2012 39

Appendix 5 �#1#,1'2'1�2'-,

General patient information on therapy to help sensations to the skin feel more normal*

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General instructions

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Regular practice: little and often

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�1�7-3�.0-%0#11�7-3�+�7�$',"�-2&#0��!2'4'2'#1�5'2&',�7-30�"�'*7�0-32',#�',�5&'!&�2-�',!-0.-0�2#�2&#1#.0',!'.*#1@�

Discomfort

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Concentration is important

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?��"�.2#"�$0-+���*#�$*#2�.0-4'"#"� 7�#6.#021��2�2&#��-7�*���2'-,�*��-1.'2�*�$-0��&#3+�2'!��'1#�1#1A�5'2&�.#0+'11'-,@

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Complex regional pain syndrome in adults Appendix 5 Desensitisation

© Royal College of Physicians 2012 40

Suggested activities

1) Activities of daily living

�#1#,1'2'1�2'-,�2&#0�.7�!�,� #�',!-0.-0�2#"�',2-��!2'4'2'#1�-$�"�'*7�*'4',%��1�.�02�-$�7-30�,-0+�*�0-32',#@

Whilst in bed

##*�2&#� #"�1&##2��%�',12�7-30�3,�$$#!2#"�*'+ @��*-1#�7-30�#7#1��,"�!-,!#,20�2#�-,�2&#�/3�*'27�-$�2&�21#,1�2'-,@��-5�$##*�2&#� #"�1&##2��%�',12�7-30��$$#!2#"��0#���,"�0#!�**�&-5�2&�2�,-0+�*�1#,1�2'-,�$#*2�5&'*122&',)',%�� -32�2&#��0#��7-3��0#�2-3!&',%@�

Whilst dressing

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Whilst having a bath or shower

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�#,2*7�03 �#'2&#0���1-$2�$*�,,#*A�1.-,%#�-0�_1!03,!&7`�-,�2&#�3,�$$#!2#"��0#�1�-$�7-30� -"7@��1#�4�0'-31+-4#+#,21�13!&��1�!'0!3*�0��!2'-,1A�03 ',%A�.�22',%��,"�120-)',%@��-,!#,20�2#�-,�&-5�2&#1#�,-0+�*1#,1�2'-,1�$#*2�5&'*12��..*7',%�2&#�+-4#+#,21�2-�2&#��$$#!2#"��0#�1�-$�7-30� -"7@

Activities for the upper limb only:

Whilst washing up

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Whilst cooking

�&#,�7-3��0#�+�)',%�.�1207�-0� 0#�"A�+'6�'2�5'2&� -2&�&�,"1@��-,!#,20�2#�-,�2&#�2#6230#�-$�2&#�+'6230#��,"�!2'-,��1�7-3��0#�"-',%�1-@

2) Use of different textures

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F �+--2&�S�#*2A�1�2',A�1'*)A�4#*4#2A�+�)#Q3.�-0�1-$2�.�',2� 031&#1

F �-3%&�S�2-5#**',%A�,#22',%A�1!-30#01A�$*�,,#*A�5--*A�&--)�4#*!0-@

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Complex regional pain syndrome in adults Appendix 5 Desensitisation

© Royal College of Physicians 2012 41

�*�!#�2&#+�-,�7-30�3,�$$#!2#"�*'+ ��,"��..*7�+-4#+#,21�13!&��1�*'%&2�120-)',%A�$'0+�120-)',%A�2�..',%��,"!'0!3*�0��!2'-,1@��-2#�2&#�4�0'-31�,-0+�*�1#,1�2'-,1�2&�2�7-3�$##*@��-5�-,�2&#��$$#!2#"�*'+ A��..*7�2&#�2#6230#',�1'+'*�0�+-4#+#,21�5-0)',%�$0-+��,��0#��2&�2�7-3�!�,�2-*#0�2#�2-5�0"1�2&#�+-0#�3,!-+$-02� *#�1)',��0#�1A$-0�#6�+.*#�$0-+�2&#�2-.�-$�2&#��0+�2-5�0"1�2&#�&�,"@��-,!#,20�2#�-,�2&#��0#�� 7�*--)',%��2�'2��,"�2&',)',%� -32�'2@��#!�**�2&#�,-0+�*�1#,1�2'-,1�2&�2�7-3�$#*2�-,�2&#�3,�$$#!2#"�*'+ @�

3) Massage

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© Royal College of Physicians 2012 42

Appendix 6 �2)',1��,"��#*"+�,�"'�%,-12'!�!0'2#0'��$-0�����',��,�-02&-.�#"'!�1#22',%

Veldman criteriall�

l �&#�.�2'#,2�.0#1#,21�5'2&�$-30�-0�$'4#�-$�2&#�$-**-5',%�17+.2-+1B

S 3,#6.*�',#"�"'$$31#�.�',

S "'$$#0#,!#�',�1)',�!-*-30�0#*�2'4#�2-�-2&#0�*'+

S "'$$31#�-#"#+�

S "'$$#0#,!#�',�1)',�2#+.#0�230#�0#*�2'4#�2-�-2&#0�*'+

S *'+'2#"��!2'4#�0�,%#�-$�+-2'-,@

m �&#0#�'1�-!!30#,!#�-0�',!0#�1#�-$�� -4#�1'%,1��,"�17+.2-+1��$2#0�31#@

n � -4#�1'%,1��,"�17+.2-+1�.0#1#,2�',��,��0#��*�0%#0�2&�,�2&#��0#��-$�.0'+�07�',(307�-0�-.#0�2'-,��,"',!*3"',%�2&#��0#��"'12�*�2-�2&#�.0'+�07�',(307@

Atkins criteriaqsArmAlko

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l ,#30-.�2&'!�.�',C�,-,"#0+�2-+�*A�5'2&-32�!�31#A� 30,',%A�5'2&��11-!'�2#"��**-"7,'���,"�&7.#0.�2&'�

m 4�1-+-2-0�',12� '*'27��,"�� ,-0+�*'2'#1�-$�15#�2',%C�5�0+�0#"��,"�"07A�!--*� *3#��,"�!*�++7�-0�, ',!0#�1#�',�2#+.#0�230#�1#,1'2'4'27C��11-!'�2#"�5'2&��,�� ,-0+�*�2#+.#0�230#�"'$$#0#,!#� #25##,2&# *'+ 1

n 15#**',%

o *-11�-$�(-',2�+- '*'27�5'2&��11-!'�2#"�(-',2��,"�1-$2Q2'113#�!-,20�!230#A�',!*3"',%�1)',�2&',,',%��,"�&�'0��,",�'*�"7120-.&7@

�&#�"'�%,-1'1�'1�#6!*3"#"� 7�2&#�#6'12#,!#�-$�!-,"'2'-,1�2&�2�5-3*"�-2&#05'1#��!!-3,2�$-0�2&#�"#%0##�-$"71$3,!2'-,@

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© Royal College of Physicians 2012 43

Appendix 7 �-12Q$0�!230#G-.#0�2'-,�.�2'#,2�',$-0+�2'-,*#�$*#2�&'1�1�+.*#�*#�$*#2�&�1� ##,�)',"*7�.0-4'"#"� 7�.0-$#11'-,�*1��2�2&#��-7�*��'4#0.--*��-1.'2�*A��'4#0.--*A��,"&�1� ##,��"�.2#"�$-0�2&'1�%3'"�,!#@

[�mkll��&#��-7�*��'4#0.--*��,"��0-�"%0##,��,'4#01'27��-1.'2�*1������0312@��**�0'%&21�0#1#04#"@��&'1�+�2#0'�*+�7� #�!-.'#"�$-0�31#�5'2&',�����-0%�,'1�2'-,1�-,*7�-,�2&#�3,"#012�,"',%�2&�2��&#��-7�*��'4#0.--*��,"�0-�"%0##,��,'4#01'27��-1.'2�*1������0312�'1��!),-5*#"%#"��1�2&#�"#4#*-.#0�-$�2&#�+�2#0'�*�-,��**�!-.'#1��,"2&�2�2&'1�!-.70'%&2�12�2#+#,2�'1�0#2�',#"@

Looking after your fractured wrist

��$0�!230#�'1��� 0#�)�-$�2&#� -,#@��-12�50'12�$0�!230#1��0#�!�31#"� 7���$�**�-,�2-��,�-32120#2!&#"�&�,"A� 32� "'0#!2� *-5�2-�2&#�$-0#�0+�!�,��*1-�!�31#���$0�!230#@�-**-5',%���$0�!230#A�2&#�50'12�'1�-$2#,�'++- '*'1#"�',.*�12#0�!�12�313�**7�$-0�3.�2-�1'6�5##)1@��&'1��11'121�',�12� '*'1',%�2&#� -,#1�2-�&#*.�#,130#�2&#7�&#�*�',��%--" .-1'2'-,@� ,�+-12�1'+.*#�$0�!230#�!�1#1�2&'1�'1�13$$'!'#,2�13..-02@��&#�.*�12#0�!�12�!�,��*1-�&#*.�2-�!-,20-*7-30�.�',@

,�1-+#�!�1#1A��,�-.#0�2'-,�+�7� #�13%%#12#"�2-�'+.0-4#�2&#�.-1'2'-,�-$�2&#� -,#1�1-�2&�2�2&#7�&#�*�',�� +-0#,�230�*�.-1'2'-,��,"�2&#�1-$2�2'113#1�H+31!*#1A�2#,"-,1A�*'%�+#,21��,"�1)',J��0#�13..-02#"@��-+#2'+#1�2&#13..-02�$0-+���.*�12#0�'1�,-2�#,-3%&�2-�)##.�2&#� -,#1�',�2&#� #12�.-1'2'-,@� $�2&'1�'1�2&#�!�1#�7-3�+�7�&�4#�2&#-.2'-,�-$�20#�2',%�2&'1�5'2&��,�-.#0�2'-,�31',%�.',1��,"G-0�.*�2#1�2-�&-*"�2&#� -,# $'0+*7�5&'*#�'2�&#�*1@��&'1-.2'-,�5'**� #�"'1!311#"�5'2&�7-3�',�!*','!�'$�'2�'1�0#*#4�,2�2-�7-3@� 2�'1�,-2��*5�71���!*#�0�!�1#��1�2-�5&'!&�-.2'-,�S�,�-.#0�2'-,�-0�2&#�.*�12#0�S�'1�2&#� #12�20#�2+#,2A��,"�2&#�.0-1��,"�!-,1�5'**� #�"'1!311#"�5'2&�7-3�-,��,',"'4'"3�*� �1'1�2-�&#*.�7-3�"#!'"#�5&'!&�5�7�7-3�5-3*"�.0#$#0�2-� #�20#�2#"@

Fig A1 �Q0�7�-$���0�"'31�$0�!230#

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Complex regional pain syndrome in adults Appendix 7 Post-fracture/operation patient information leaflet

© Royal College of Physicians 2012 44

What can I do now?

Control your pain

2�'1�'+.-02�,2�2&�2�7-30�.�',�'1�+','+�*�2-��**-5�2&#�3,',(30#"�.�021�2-� #�)#.2�+-4',%��,"��**-5�7-3�2-1*##.�5#**@��1)�',�!*','!�-0�7-30�$�+'*7�"-!2-0�H��J�$-0���.0#1!0'.2'-,�'$�,#!#11�07@��-30�.&�0+�!'12�+�7��*1-� #� *#�2-��"4'1#�7-3@

Reduce swelling

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Fig A2 �0+�',�.*�12#0�!�12��$2#0�0�"'31�$0�!230#

Fig A3 (a) ��"'31� -,#�5'2&���$0�!230#�20#�2#"�5'2&�5'0#1�2-�&-*"�2&#� -,#1�',�.-1'2'-,�5&'*#�2&#7�&#�*C�(b) ��"'31� -,#5'2&���$0�!230#�20#�2#"�5'2&�1!0#51��,"���.*�2#�2-�&-*"�2&#� -,#1�',�.-1'2'-,�5&'*#�2&#7�&#�*

(a) (b)

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Complex regional pain syndrome in adults Appendix 7 Post-fracture/operation patient information leaflet

© Royal College of Physicians 2012 45

12'$$,#11�-$�2&#�3,�$$#!2#"�(-',21�+�7�"#*�7�7-30�0#230,�2-�5-0)�-0��$$#!2�7-30�� '*'27�2-�.#0$-0+��!2'4'2'#1�-$"�'*7�*'4',%@�

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Fig A4 �#!-++#,"#"�#6#0!'1#1��1�"#1!0' #"�',�2&#�2#62

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Complex regional pain syndrome in adults Appendix 7 Post-fracture/operation patient information leaflet

© Royal College of Physicians 2012 46

Keep fingers, thumb, elbow and shoulder moving

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Make sure your plaster fits comfortably

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Try to use your hand normally for all light activities (except in water)

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Eat healthily and avoid smoking

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What should I do if I have a problem with my plaster?

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Complex regional pain syndrome in adults Appendix 7 Post-fracture/operation patient information leaflet

© Royal College of Physicians 2012 47

Further information

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© Royal College of Physicians 2012 48

Appendix 8 �#,20#1�5'2&���1.#!'�*�',2#0#12�',�����

University College London Hospitals �-,2�!2B��0���3*���,"'�-0��',��*','! �-,2�!2B��0��'�0+3'"��#,,#07��3##,��/3�0#�-,"-,���l��n���#*B�ksop�lppp�kkk

Manchester Royal Infirmary �-,2�!2B��0���!&#*��-0-")',H�#,20�*���,!&#12#0��,'4#01'27��-1.'2�*1������0312J�&#3+�2-*-%7��#.�02+#,2�6$-0"��-�"��,!&#12#0��ln�t���#*B�klql�mrq�lmno

Hope Hospital �-,2�!2B��01��*'1-,��57#0�,�#12&#2'!��#.�02+#,2�2-22���,#��*$-0"��,!&#12#0��q�s���#*B�klql�rst�rnrn

The Walton Centre for Neurology �-,2�!2B��0��,"0#�1��-# #*and Neurosurgery NHS Trust�-5#0���,#�8�)#0*#7�'4#0.--*��t�r���#*B�klpl�pmp�nqll

St Thomas’ Hospital �-,2�!2B��0��-3%*�1��312',1��',��*','!��+ #2&���*�!#��-�"�-,"-,��l�r��#*B�kmk�rlss�rlss

The Royal National Hospital �-,2�!2B��0-$#11-0���,"7��!�� #�for Rheumatic Diseases NHS Foundation Trust��2&��#,20#�$-0���',��#04'!#1�..#0��-0-3%&���**1��2&���l�l���#*#.&-,#B�klmmp�oqptol

Addenbrooke’s Hospital �-,2�!2B��0��'!)��&#,)#0��+ 0'"%#��,'4#01'27��-1.'2�*1�����-3,"�2'-,��0312��'**1��-�"���+ 0'"%#���m�k���#*B�klmmn�mop�lpl

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Complex regional pain syndrome in adults Appendix 8 Centres with a special interest in CRPS

© Royal College of Physicians 2012 49

New Stobhill Hospital �-,2�!2B��0��'!)��#0.#**�2- &'**������&0-,'!���',��#04'!#lnn���*-0,-!)��-�"�-5,��#,20#�*�1%-5��ml�n���#*B�klol�npp�lotk

West Suffolk NHS Foundation Trust �-,2�!2B��0���(#1&��3,%*�,'�#.�02+#,2�-$���',���,�%#+#,2��0"5'!)���,#�307��2�"+3,"1�3$$-*)� �nn�m���#*B�klmso�rlnnnk

Royal Devon and Exeter Hospital NHS Foundation Trust �-,2�!2B��0��'!&�0"���'%&�&#3+�2-*-%7��#.�02+#,2��00�!)��-�"6#2#0��m�p���#*B�klntm�ollqll

Derriford Hospital �-,2�!2B��0���0)��-!)#22�#00'$-0"��-�"�0-5,&'**�*7+-32&�#4-,���q�s����#*B�ksop�lpp�slpp�G�klrpm�mkmksm

University Hospital of Wales �-,2�!2B��0��0'�,��'+.1-,�#�2&���0)��0"'$$��lo�o���#*B�kmt�mkro�rror

Royal National Othopaedic Hospital (Stanmore) �-,2�!2B��0��#*#,��-&#,�&#3+�2-*-%7�0-!)*#7��'**�2�,+-0#���r�o���#*B�kmk�stpo�mnkk

�*#�1#�,-2#�2&�2�2&'1�*'12�'1�,-2�#6&�312'4#@��&#0#��0#�*')#*7�2-� #��""'2'-,�*�!#,20#1��,"�!*','!'�,1�5'2&��,',2#0#12��,"��..0-.0'�2#�#6.#02'1#�',�2&#�20#�2+#,2�-$�����@�

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© Royal College of Physicians 2012 50

Appendix 9 �#!-++#,"�2'-,1�$-0�2&#�20#�2+#,2�-$�1)',3*!#01A�1)',�',$#!2'-,��,"�.0- *#+�2'!�-#"#+�

�&�,%#1�',�1)',�',,#04�2'-,A� *--"�$*-5A�',2#012'2'�*�$*3'"�H-#"#+�JA�2&#�20-.&'!�!-,12'232'-,�-$�2&#�1)',��,"1)',�2#+.#0�230#A�',�2&#�.#0'.&#0'#1�',!0#�1#�2&#�0'1)�-$�1)',�3*!#0�2'-,@slAlkq �-+#�-$�2&#1#�!&�,%#1��0#-$2#, .0#1#,2�',�!-+.*#6�0#%'-,�*�.�',�17,"0-+#�H����J@��&#,�3*!#0�2'-,�-!!301A�2&'1��**-51�2&#�#,207�," +3*2'.*'!�2'-,�-$�+'!0--0%�,'1+1A�1-�2&�2�.�2'#,21��0#��2�0'1)�-$�"#4#*-.',%�!#**3*'2'1��,"�"##.#02'113# ',$#!2'-,1@

Assessment

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,"'!�2'-,�-$�',$#!2'-,�',!*3"#1�1712#+'!�17+.2-+1�H#%�$#4#0��,"�*#3!-!72-1'1J�-0�*-!�*�1'%,1�13!&��11.0#�"',%�0#",#11A�5�0+2&A�',"30�2'-,A�.�',�-0�2#,"#0,#11@�072&#+��+�7� #�5#**�"#+�0!�2#"�-0�+-0#"'$$31#@� ,�1#4#0#�!�1#1A� *'12#0',%G 3**�#A�13.#0$'!'�*�&�#+-00&�%#�',2-� *'12#01A�"#0+�*�,#!0-1'1A�*7+.&�,%'2'1�,"�*7+.&�"#,-.�2&7�+�7�-!!30@lkrAlks �##.�',$#!2'-,�H#%�,#!0-2'1',%�$�1!''2'1�-0�-12#-+7#*'2'1J�&�1�2&#�0'1)-$�2&0#�2#,',%���*'+ A��,"�'$�131.#!2#"�1&-3*"� #�20#�2#"��%%0#11'4#*7�H1##�3,"#0�_��,�%#+#,2`J@�

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Management

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Complex regional pain syndrome in adults Appendix 9 Recommendations for treatments

© Royal College of Physicians 2012 51

H�3%+#,2',J�31#$3*�',�+-0#�1#4#0#�',$#!2'-,@sp �-$2Q2'113#�',$#!2'-,1�0#/3'0#�lk�"�71`�2&#0�.7A�5&'*#-12#-+7#*'2'1�+�7�0#/3'0#�+-0#�2&�,�1'6�5##)1�-$�2&#0�.7@lkq �,2'+'!0- '�*�2&#0�.7�',�.�2'#,21�5&-�"-�,-2'+.0-4#�!�,� #�%3'"#"� 7� -2&�1)',� '-.17Alln 5&'!&�'1�+-0#�0#*'� *#�2&�,�13.#0$'!'�*�15� 1A��,"�#�0*7��"4'!#$0-+��� �!2#0'-*-%'12G+'!0- '-*-%'12@�

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© Royal College of Physicians 2012 52

Appendix 10 ��2'#,2�',$-0+�2'-,

Information leaflet for patients: complex regional pain syndrome

What is complex regional pain syndrome (CRPS)?

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What is it like to have CRPS?

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�$2#,�2&#0#�'1�"'$$'!3*27�',�+-4',%�2&#�*'+ A�2-%#2&#0�5'2&�5#�),#11��,"�1-+#2'+#1�1&�)',%�-0�(#0)',%@�-+#2'+#1�2&#�+31!*#1�',�2&#��0#��!�,�5�12#��,"�2&#�&�,"�-0�$--2�!�,� #!-+#�25'12#"@

��,7�.�2'#,21�1�7�2&�2�2&#'0�*'+ �_$##*1�120�,%#`@� 2�!�,�$##*��1�'$�'2�"-#1�,-2� #*-,%�2-�2&#�0#12�-$�2&#� -"7�,"��1�'$�'2�'1�,-2�7-30�-5,�*'+ @��-+#2'+#1�2&#�*'+ �$##*1� '%%#0�-0�1+�**#0�2&�,�2&#�-..-1'2#A�,-0+�*�*'+ @

�-+#�.�2'#,21�&�4#�$0#/3#,2�2&-3%&21�� -32�5'1&',%�2-�!32�-$$�2&#�*'+ @��,$-023,�2#*7�#4#,�130%'!�*�+.32�2'-,�"-#1�,-2�&#*.�2&#�.�',�H�!23�**7A�'2�+�7�+�)#�'2�5-01#J@� ,�#620#+#�.�',A�1-+#�.#-.*#�+�7!-,1'"#0�13'!'"#@� $�7-3�"-�$##*�*')#�2&'1A�.*#�1#�1##�7-30�"-!2-0@

What causes CRPS?

�����'1���120-,%#0Q2&�,Q,-0+�*�0#�!2'-,�-$�2&#� -"7�2-�',(307@��#�"-,`2�),-5�5&�2�!�31#1�����@��&�2�5#�"-),-5�'1�2&�2�2&#�� ,-0+�*�0#�!2'-,�2-�',(307�&�..#,1� -2&�',�2&#��$$#!2#"�*'+ ��,"�',�2&#� 0�',@��&#�,#04#1�',2&#��$$#!2#"�*'+ ��0#�+3!&�+-0#�1#,1'2'4#�2&�,�-2&#0�,#04#1��,"�2&'1�!�31#1�1-+#�-$�2&#�2#,"#0,#11�2-�2-3!&�,"�.0#1130#@��&#� 0�',�'1��*1-�',4-*4#"@��&#�5�7�2&#� 0�',�!-++3,'!�2#1�5'2&�2&#��$$#!2#"�*'+ �-$2#,!&�,%#1��,"�2&'1�!�,�!�31#�1-+#�-$�2&#�.0- *#+1�5'2&�+-4#+#,2@�

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Complex regional pain syndrome in adults Appendix 10 Patient information

© Royal College of Physicians 2012 53

�����'1�,-2�',�7-30�+',"@��#��*1-�),-5�2&�2�7-30�+',"1#2�!�,,-2�!�31#�����A� 32�2&�2�1-+#�.17!&-*-%'!�*$�!2-01�13!&��1�$#�0�-0�5-007�!�,�+�)#�2&#�.�',�5-01#�2&�,�'2��*0#�"7�'1@�

Does CRPS run in families?

2�+�7� #�2&�2�%#,#1�&�4#�1-+#2&',%�2-�"-�5'2&�5&-�"#4#*-.1������.�',��$2#0�',(307A� 32�2&#7��0#�!#02�',*7,-2�2&#�-,*7�$�!2-0�',�"#!'"',%�5&-�%#21�'2@� 2�'1��*1-�4#07�3,*')#*7�2&�2��,7-,#�#*1#�',�7-30�$�+'*7�5'**�#4#0"#4#*-.������.�',@

Could it have been prevented?

2�'1�4#07�3,*')#*7�2&�2������.�',��$2#0�7-30�',(307�!-3*"�&�4#� ##,�.0#4#,2#"@��&#�0'%&2�"'�%,-1'1��,"20#�2+#,2�!�,�0#"3!#�13$$#0',%�$0-+������.�',@

Will it get better?

�����313�**7�%#21� #22#0� 7�'21#*$�-0�5'2&�20#�2+#,2@� ,�1-+#�.#-.*#A������"-#1�,-2�%#2� #22#0@��#�&�4#�,-5�7�-$�.0#"'!2',%�5&#2&#0�7-30������5'**�%#2� #22#0��,"�5&#,@��,*')#�!�,!#0�-0�0&#3+�2-'"��02&0'2'1A�����"-#1�,-2�"#120-7� -"7�2'113#1@�4#,�'$�7-3�&�4#������$-0�1#4#0�*�7#�01A�2&#�0#12�-$�7-30� -"7�5'**�!-,2',3#�2-5-0)��1�,-0+�*@�

Does treatment help?

�0#�2+#,2��'+1�2-�'+.0-4#�7-30�/3�*'27�-$�*'$#A�$3,!2'-,',%��,"�0#"3!#�.�',@� 2�'1�*')#*7�2&�2�7-3�!�,�%#2�1-+#.�',�0#*'#$�5'2&�20#�2+#,2@��&#�13!!#11�-$�1-+#�20#�2+#,21�"#.#,"1�-,�2&#��+-3,2�-$�#$$-02�7-3�.32�',2-2&#+@��&#0#�'1���0�,%#�-$�20#�2+#,21��,"�7-30�!-,13*2�,2�-0�2&#0�.'12�5'**�"'1!311�2&#1#�5'2&�7-3@�

Exercise treatment

�-12�.�2'#,21�1##�.&71'-2&#0�.'121�H��1J�-0�-!!3.�2'-,�*�2&#0�.'121�H��1J@��&#1#�2&#0�.'121�5'**�5-0)�5'2&�7-3',���5�7�5&'!&�'1�1.#!'�**7�%#�0#"�2-5�0"1�7-30�����@�-0�#6�+.*#A�2&#7�+�7�,-2�#4#,�2-3!&�7-30�*'+ @� 2�'14#07�'+.-02�,2�2-�#6#0!'1#�2&#�*'+ �%#,2*7�$-**-5',%��"4'!#� 7������-0���@�

Medication treatment

�03%1�!�,�1-+#2'+#1�0#"3!#������.�',��,"�+�7��*1-�&#*.�7-3�2-�1*##.@��-30�!-,13*2�,2�5'**�"'1!311�2&#!-00#!2�"03%�20#�2+#,2�5'2&�7-3@� $��..0-.0'�2#A�7-30�!-,13*2�,2�+�7��*1-�"#!'"#�2-�-$$#0�7-3��,�',(#!2'-,20#�2+#,2@� ,�2&'1�!�1#A�7-3�5-3*"�0#!#'4#�+-0#�1.#!'�*�',$-0+�2'-,�� -32�2&�2@

Psychological intervention

�-+#2'+#1�.17!&-*-%'!�*�',2#04#,2'-,�!�,� #�&#*.$3*�2-�0#"3!#�"'120#11�H2&'1�"-#1�,-2�+#�,�2&�2�2&#�.�',�'1�',7-30�+',"C�'2�'1�,-2J@��-30�!-,13*2�,2�5-3*"� #�&�..7�2-�"'1!311�2&'1�5'2&�7-3@�

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Complex regional pain syndrome in adults Appendix 10 Patient information

© Royal College of Physicians 2012 54

Information leaflet for patients: specialised treatments for CRPS

What are specialised treatments for CRPS?

�.#!'�*'1#"�20#�2+#,21�#'2&#0�0#/3'0#���1.#!'�*�2#�+�-$�&#�*2&!�0#�.0-$#11'-,�*1�2-�"#*'4#0�2&#+A�-0�2&#1#��0#,#5�20#�2+#,21A�5&'!&�,##"�2-� #�$-**-5#"�!*-1#*7�2-�+�)#�130#�2&#7�5-0)@

Should I be treated with a specialised treatment for CRPS?

�&#�0'%&2�20#�2+#,2�$-0������4�0'#1�$0-+�.�2'#,2�2-�.�2'#,2@��&#0#��0#�25-�1.#!'�*'1#"������20#�2+#,21�5&'!&,##"�2-� #�%'4#,� 7�2#�+1�-$�!*','!'�,1@��&#1#��0#B�.�',�+�,�%#+#,2�.0-%0�++#�H���J��,"�1.',�*�!-0"12'+3*�2'-,�H���J@��#1#�0!&�1&-51�2&�2�',�1-+#�.�2'#,21�2&#1#�20#�2+#,21�!�,�5-0)�4#07�5#**@��-30�!-,13*2�,25'**�"'1!311�2&#1#�20#�2+#,21�5'2&�7-3A�'$�&#�-0�1&#�2&',)1�7-3�+�7�,##"�#'2&#0�-$�2&#+@��-3�+�7��*1-�0#!#'4#�������,"G-0�����',$-0+�2'-,�*#�$*#2@�

�&#�����'1���.0-%0�++#�"#1'%,#"�2-�&#*.�7-3�2-�'+.0-4#�7-30�/3�*'27�-$�*'$#��,"�+�,�%#�7-30�.�',� #22#0@ 2 '1�%0-3.Q �1#"A��,"�*�121� #25##,���$#5�"�71��,"���$#5�5##)1@��&'1�'1�_+3*2'"'1!'.*',�07�20#�2+#,2`A�5&'!&+#�,1�2&#0�.'121�$0-+�"'$$#0#,2�.0-$#11'-,1�5-0)�2-%#2&#0�H#%�.&71'-2&#0�.'121A�"-!2-01A�-!!3.�2'-,�*2&#0�.'121��,"�.17!&-*-%'121�#2!J@��&#�����'1�13'2� *#�$-0�.�2'#,21�5'2&�����A��,"��*1-�$-0�.#-.*#�5'2&�-2&#0!&0-,'!�.�',1@� 2�'1�"#1'%,#"�2-�'+.0-4#�7-30�/3�*'27�-$�*'$#@� 2�'1�'+.-02�,2�2-�3,"#012�,"�'2�'1�,-2�"#1'%,#"�2-2�)#�7-30�.�',��5�7@�

�&#�1#!-,"�20#�2+#,2A����A�'1���$',#�5'0#�5&'!&�'1�.*�!#"�!*-1#�2-�2&#�,#04#1�',�7-30� �!)��,"�!-,,#!2#"�2-� _12'+3*�2-0`@��&#�"-!2-0�.321�2&#�5'0#�',�2&#�0'%&2�.*�!#� 7�31',%���1'+'*�0�2#!&,'/3#�2-�.322',%�',��,#.'"30�*�$-0�.�',�0#*'#$�"30',%�.0#%,�,!7@��&#�5'0#�'1�313�**7�)#.2�',�.*�!#�*')#�2&'1�$-0���1&-02�2'+#A��,"�'$�'25-0)1�5#**A��,�-.#0�2'-,�'1�"-,#�2-�+�)#�'2�.#0+�,#,2@��&#�����!�,� #�2�)#,�-32�',�2&#�$3230#�5&#,�'2�'1�,-2,##"#"��,7+-0#@

Are there any other treatments?

�&#0#�+�7� #�-2&#0�20#�2+#,21A� 32�2&#1#��0#�,-2��1�5#**�0#1#�0!&#"��1�2&#�20#�2+#,21�+#,2'-,#"�',�7-30.�2'#,2�',$-0+�2'-,�*#�$*#21@��-30�!-,13*2�,2�5'**�"'1!311�5'2&�7-3�5&#2&#0�-0�,-2�-2&#0�20#�2+#,21�5-3*"� #13'2� *#�',�7-30�!�1#@�

Sources of information for patients on the web

Arthritis Research UK555@�02&0'2'10#1#�0!&3)@-0%G�02&0'2'1U',$-0+�2'-,G�02&0'2'1U27.#1U�,"U17+.2-+1G!-+.*#6U0#%'-,�*U.�',U17,"0-+#@�1.6

Reflex Sympathetic Dystrophy Association (RSDSA)&22.BGG01"1@-0%G',"#6m@&2+*

CRPSUK 555@!0.13)@-0%

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Complex regional pain syndrome in adults Appendix 10 Patient information

© Royal College of Physicians 2012 55

�&#�$-**-5',%�',$-0+�2'-,�&�1� ##,�!-+.'*#"��,"�.0-"3!#"� 7�2&#��������2'#,21�-03+��2�2&#��-7�*���2'-,�*�-1.'2�*�$-0��&#3+�2'!��'1#�1#1�H�����J��$2#0��"�.2�2'-,�$0-+���4#01'-,�.0-"3!#"� 7�2&#��#$*#6�7+.�2&#2'!��7120-.&7��7,"0-+#��11-!'�2'-,�',��+#0'!�@

�&'1�$-**-5',%�',$-0+�2'-,�+�7� #�31#$3*�'$�7-3�,##"�2-�#6.*�',�7-30�!-,"'2'-,�2-�7-30�"-!2-0B

I have CRPS (complex regional pain syndrome)

�����'1���,#04#�"'1-0"#0�2&�2�313�**7�-!!301��$2#0��,�',(307�-0�.#0'-"�-$�'++- '*'1�2'-,@��&#�.0',!'.*#�17+.2-+'1�.�',�5&'!&�!�,�*#�"�2-�"'1� '*'27@

�+�7�*--)�&#�*2&7� 32� �-$2#,�13$$#0�$0-+�1#4#0#A�3,0#*#,2',%A�,#04#�.�',@��7�1)',�+�7�15#**A�!&�,%#�!-*-30�-02#+.#0�230#A�15#�2�-0�&302�2-�2&#�*'%&2#12�2-3!&@

�$2#,�'2�'1�"'$$'!3*2�$-0�+#�2-�1*##.A�5&'!&��$$#!21�+7��22#,2'-,��,"�!-,!#,20�2'-,A�-0� �+�7� #�-,�"03%1�5&'!&"-�2&#�1�+#@

�&0-,'!�.�',�-$2#,�*#�"1�2-�"#.0#11'-,@��20#11�',!0#�1#1�.�',@� �&�4#�%--"�-0� �"�"�71A�-0�#4#,�&-301@

�&#0#�'1�,-�!30#��2�.0#1#,2@

Please help me by...

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F 0#+#+ #0',%�2&�2�'2�!�,�#4#,�&302�2-� #�2-3!&#"

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© Royal College of Physicians 2012 56

Appendix 11 �11#11+#,2�-$������ 7�-!!3.�2'-,�*2&#0�.'121��,"�.&71'-2&#0�.'121

Assessment tools

�&#0#�'1�,-�12�,"�0"'1#"� �22#07�-$��11#11+#,21�$-0�����@� 2�'1�,-2�5'2&',�2&#�1!-.#�-$�2&#1#�%3'"#*',#1�2-� #.0#1!0'.2'4#�� -32�2&#1#�+#�130#1A�7#2�4�*'"�2#"�+#�130#1�1&-3*"� #�31#"��1�$�0��1�.-11' *#@

What to assess

�11#11+#,21�1&-3*"� #�13!&�2&�2�2&#7��"#/3�2#*7�+#�130#�!&�,%#�',�1'%,1��,"�17+.2-+1A��*-,%�5'2&�2&#$3,!2'-,�*�!-,1#/3#,!#1�-$�2&#1#@��11#11+#,21�1&-3*"�2&#0#$-0#�!-4#0�2&#�$-**-5',%��0#�1B

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When to assess

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© Royal College of Physicians 2012 57

Appendix 12 �#7�!-,2#,21�-$��,�',2#0"'1!'.*',�071.#!'�*'12�0#&� '*'2�2'-,�.0-%0�++#

F �!2'4#�#,%�%#+#,2�-$�2&#�.�2'#,2G$�+'*7�',�%-�*�1#22',%A�%-�*�0#4'#5

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Complex regional pain syndrome in adults Appendix 12 Key contents of an interdisciplinary specialist rehabilitation programme

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Complex regional pain syndrome in adults Appendix 15 Experimental treatments for CRPS – published research

© Royal College of Physicians 2012 62

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Complex regional pain syndrome in adults Appendix 15 Experimental treatments for CRPS – published research

© Royal College of Physicians 2012 63

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© Royal College of Physicians 2012 64

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Picarelli 2010lmo

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�#04'!#�0�+#5-0)�$-0�*-,%Q2#0+�!-,"'2'-,1B���,#5�0#1#�0!&�27.-*-%7@�Clin Med mkkqCqHlJBtlSr@n -0-38�,$�0��A��-)#���A�4�,��*##$���A��# #0��@��0#�2+#,2�-$�!-+.*#6�0#%'-,�*�.�',�17,"0-+#�27.#� @�Eur J

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0�,"-+'1#"�!-,20-**#"�20'�*1�$0-+�mkkk�3,2'*�mklm@�Eur J Pain H',�.0#.�0�2'-,J@p 4�,��3*"#0���A��-#1���A��-32#0���@��-,1#04�2'4#�20#�2+#,2�-$��!32#��,"�!&0-,'!�,-,1.#!'$'!�*-5� �!)�.�',@

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q �2�,2-,Q�'!)1���A��302-,���A��03#&*����et al@��,�3."�2#"�',2#0"'1!'.*',�07�!*','!�*�.�2&5�7�$-0�����B�0#.-02-$��,�#6.#02�.�,#*@�Pain Pract mkkmCmHlJBlSlq@

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s �-# #*��A��-.#��A��--*#���et al@��&#�,�230#��,"�'+.�!2�-$�!-+.*#6�0#%'-,�*�.�',�17,"0-+#B���2'#,21`�4'#51@Eur J Pain lnH�lJBmkkt@�

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lm 4�,��'(,���A���0',31��A��322#0���et al@��.0#�"',%�-$�!-+.*#6�0#%'-,�*�.�',�17,"0-+#B�,-2���0�,"-+�.0-!#11@J Neural Transm mkllCllsHtJBlnklSt@

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lq �##02&3'8#,��A�4�,�_2��.'()#0��A��37%#,��A��*#',��A�"#��'22���@� 1�2&#0#��,��11-!'�2'-,� #25##,�.17!&-*-%'!�*$�!2-01��,"�2&#��-+.*#6��#%'-,�*���',��7,"0-+#�27.#�l�H����lJ�',��"3*21=���1712#+�2'!�0#4'#5@�Pain mkktClopHlSmJBpmSt@

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ls �##02&3'8#,��A��20-,)1���A��37%#,���et al@��&#��11-!'�2'-,� #25##,�.17!&-*-%'!�*�$�!2-01��,"�2&#"#4#*-.+#,2�-$�!-+.*#6�0#%'-,�*�.�',�17,"0-+#�27.#�l�H����lJ�S���.0-1.#!2'4#�+3*2'!#,2#0�123"7@�Eur J PainmkllClpHtJBtrlSp@

lt ��'*'1Q��%,-,��A��'!&-*1-,��A��*3+ #0%#0��A��30-51)'��@��&�0�!2#0'12'!1��,"�.#0'-"�.0#4�*#,!#�-$�1#*$Q',"3!#"�"'1-0"#0�',�.�2'#,21�0#$#00#"�2-���.�',�!*','!�5'2&�2&#�"'�%,-1'1�-$�!-+.*#6�0#%'-,�*�.�',�17,"0-+#@Clin J Pain mkksCmoHmJBlrqSsp@

mk �'0)*#',�@��-+.*#6�0#%'-,�*�.�',�17,"0-+#@�J Neurol mkkpCmpmHmJBlnlSns@ml ��0"#,���A��03#&*��A��2�,2-,Q�'!)1��A��'*1-,���@��0-.-1#"�,#5�"'�%,-12'!�!0'2#0'��$-0�!-+.*#6�0#%'-,�*�.�',

17,"0-+#@�Pain Med mkkrCsHoJBnmqSnl@mm �!�0'"#��A��2)',1��@��-+.*#6�0#%'-,�*�.�',�17,"0-+#@�Current Orthopaedics mkkpCltBlppSqp@mn '#*"��A���05'!)��A���,,'12#0���@�#�230#1�-$��*%-"7120-.&7�2#,�7#�01��$2#0��-**#1`�$0�!230#@�J Hand Surg Br

lttmClrHnJBnlsSmk@mo �!&�1$--02��A��311+�,���A��2�+���@� +.�'0+#,21��,"��!2'4'27�*'+'2�2'-,1�',�13 (#!21�5'2&�!&0-,'!�3..#0�*'+

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