Finding the balance in complex regional pain syndrome

Complex regional pain syndrome (CRPS), perhaps more than any other chronic pain disorder, is perplexing. It is highly disabling, particularly once it has “set in,” and it has a tendency to polarize the community—some view it as a quasidiagnosis to obscure malingering or conceal substandard clinical skills,¹ and others as a multiple system overprotective response.² What is agreed is that its pathophysiology is not completely understood and that it is difficult to treat. In light of this rather murky backdrop, we welcome the new perspectives article in this issue of Neurology® by Birklein et al.³ They describe their own clinical approach to the problem and their impressions of what works, what does not, and where the field might be heading. The lead author is the most prolific and arguably the most important researcher in this field, and the article clearly draws on a wealth of expertise and clinical experience probably unmatched globally. The article reminds us of the remaining substantial challenges that we face: for example, the need for prospective studies, higher quality clinical trials and audits, and a putative model that accounts for the transition from acute CRPS to chronic CRPS, which is arguably characterized by distinct pathophysiology. Anyone who treats a good number of CRPS patients will recognize the clinical patterns to which the authors allude and be comforted by the realization that even this group, at the top of the field, share the same substantial treatment challenges.