24×7 Emergency Care

1-8-31/1, Minister Road, Secunderabad, Telangana 500003

EMERGENCY:A CRPS patient with new severe spreading pain, signs of deep tissue infection, or rapidly worsening neurological deficit in the affected limb —call040-46324365immediately — 24 hours, 7 days— 24/7

HEADACHE & PAIN SYNDROMES

Complex Regional Pain Syndrome (CRPS) in Hyderabad: Disproportionate Pain After Injury — Early Diagnosis and Aggressive Rehabilitation Change the Outcome

Expert Budapest Criteria assessment, thermometry, graded motor imagery physiotherapy, pregabalin, amitriptyline, bisphosphonates and ketamine infusions, stellate ganglion and lumbar sympathetic blocks, and spinal cord stimulation for refractory cases at KIMS Neuroscience, Secunderabad, Hyderabad.

View Our Specialists

CRPS is a chronic neuropathic pain condition characterised by severe, disproportionate pain in a limb following a triggering event, accompanied by autonomic dysregulation (skin colour and temperature changes, oedema, sweating), motor dysfunction (weakness, tremor, dystonia), and trophic changes. The hallmark is pain dramatically out of proportion to the initial injury — this disproportion is the reason the diagnosis is often missed or dismissed. Diagnosis uses the Budapest Criteria (2003/2007), requiring pain disproportionate to the inciting event, symptoms in 3 of 4 categories, and signs in 2 of 4 categories. CRPS is not psychological — it is a real neurological condition with established biological basis including peripheral sensitisation, central sensitisation, neuroinflammation, and cortical reorganisation, classified by the IASP with validated diagnostic criteria.

What it is: Severe disproportionate limb pain after injury + vasomotor changes + oedema + motor dysfunction. The disproportion between injury severity and pain is the hallmark.
Budapest Criteria at KIMS: Pain disproportionate to injury · Symptoms in 3 of 4 categories (sensory, vasomotor, sudomotor/oedema, motor/trophic) · Signs in 2 of 4 on examination · No other diagnosis better explains it.
Thermometry at KIMS: Temperature difference >1°C between limbs confirmed by thermometry — objective, measurable documentation of vasomotor asymmetry. Used at KIMS for diagnosis and monitoring.
Graded Motor Imagery: Stage 1: Limb laterality recognition (pictures, no movement) → Stage 2: Imagined movements → Stage 3: Mirror visual feedback. Desensitises the cortical pain map. Multiple RCTs confirm efficacy.
Sympathetic blocks to enable physio: Stellate ganglion block (upper limb) and lumbar sympathetic block (lower limb) at KIMS reduce sympathetically maintained pain sufficiently to allow physiotherapy participation.
SCS for refractory CRPS: Multiple RCTs: >50% pain reduction in 50–60% of patients. Trial period 1–2 weeks before permanent implant. Burst and high-frequency SCS available at KIMS for non-responders to conventional SCS.
Contact KIMS: 040-44885000 · Budapest Criteria assessment · Thermometry · GMI physiotherapy · Sympathetic blocks · SCS evaluation

Fact	Details
Budapest Criteria	Disproportionate pain · Symptoms in 3 of 4 categories · Signs in 2 of 4 · No better explanation · Thermometry at KIMS: >1°C asymmetry confirms vasomotor category
4 categories	Sensory (allodynia) · Vasomotor (colour, temperature) · Sudomotor/oedema · Motor/trophic (weakness, tremor, dystonia, nail/hair changes)
CRPS Type 1 vs 2	Type 1 (most common): no identifiable nerve injury · Type 2: after identifiable peripheral nerve injury · Same management principles
GMI protocol	Stage 1: Laterality recognition (pictures) · Stage 2: Imagined movement · Stage 3: Mirror visual feedback · RCT-proven cortical desensitisation
Medications	Pregabalin/gabapentin · Amitriptyline · NSAIDs (early inflammatory phase) · Bisphosphonates (bone involvement) · Ketamine infusions (NMDA antagonism) · Low-dose naltrexone (off-label)
SCS (refractory)	Multiple RCTs: >50% reduction in 50–60% · Trial 1–2 weeks before permanent · Burst/high-frequency available at KIMS
Prognosis factors	Early diagnosis and early physiotherapy are the two most important prognostic factors · Delay in diagnosis = worse outcome · Within 3 months of injury: best window

About This Condition

Complex Regional Pain Syndrome at a Glance

The essential facts that shape how CRPS is recognised, classified, and managed at KIMS — from its disproportionate pain hallmark and the two clinical types through the Budapest Criteria diagnostic standard to the multidisciplinary treatment philosophy that determines outcome.

What it is

A chronic neuropathic pain condition characterised by severe, disproportionate pain in a limb following a triggering event (injury, surgery, immobilisation), accompanied by autonomic dysregulation (skin colour and temperature changes, abnormal sweating, oedema), motor dysfunction (weakness, tremor, dystonia), and trophic changes (skin, hair, nail abnormalities). Pain is dramatically out of proportion to the initial injury — this disproportion is the hallmark and is often the reason the diagnosis is missed or dismissed.

Two types

CRPS Type 1 (formerly Reflex Sympathetic Dystrophy — RSD): occurs without identifiable nerve injury. By far the more common type. CRPS Type 2 (formerly Causalgia): occurs after identifiable peripheral nerve injury. Same management principles; the presence of confirmed nerve injury defines the type.

Who it affects

Prevalence approximately 20–26 per 100,000. Female predominance (female:male approximately 3–4:1). Most common in 40–60-year age group. Most commonly affects the upper limb (wrist and hand after wrist fracture) or lower limb (ankle and foot). The most common precipitating event: a fracture — particularly Colles’ wrist fracture.

Diagnosis

The Budapest Criteria (2003, updated 2007) are the internationally validated diagnostic criteria. Diagnosis requires: continuing pain disproportionate to the inciting event; at least one symptom in 3 of 4 categories (sensory, vasomotor, sudomotor/oedema, motor/trophic); at least one sign in 2 of 4 categories at examination; and no other diagnosis that better explains the findings.

Treatment philosophy

CRPS is best treated early and aggressively with a multidisciplinary approach: physiotherapy is the backbone of treatment (graded motor imagery is the most evidence-based intervention); pharmacological pain management; sympathetic nerve blocks; and spinal cord stimulation for refractory cases. Delay in diagnosis and delay in physiotherapy are the two most important prognostic factors for poor outcome.

Emergency

040-46324365

Appointment

040-44885000

About This Condition

The Wrist Fracture That Would Not Heal

A 47-year-old woman in Hyderabad fell and fractured her right wrist 5 months ago. The fracture was treated in a cast and healed normally on X-ray at 6 weeks. But the pain in her hand and wrist has not improved — it has worsened. The hand is now a different colour from the left: the skin is blotchy red and shiny. The hand feels hotter than the left. It is swollen. She cannot bear anything to touch the back of her hand — even the lightest contact causes severe burning pain (allodynia). She has not been able to use the hand functionally for 3 months because any attempted movement causes severe pain.

Orthopaedic review confirms the fracture is healed. Her surgeon has told her the X-ray is normal. She has been referred to physiotherapy but stopped attending after the first session because the exercises caused unbearable pain. She has been prescribed tramadol, which helps partially. She presents to KIMS for a second opinion.

At KIMS, the Budapest Criteria are systematically applied. She has pain out of proportion to the healed fracture. She reports allodynia, asymmetric skin temperature (confirmed by thermometry: 2.1°C warmer on the right), abnormal skin colour change, and oedema. On examination, allodynia is demonstrated, the hand is warm and red, oedematous, and she has reduced grip strength with a fine resting tremor. She meets Budapest Criteria for CRPS Type 1.

The KIMS management plan starts immediately: physiotherapy with a CRPS-experienced therapist using Graded Motor Imagery protocol; pregabalin 75mg twice daily titrated upward; low-dose amitriptyline at night; topical ketamine gel for allodynia; and a right stellate ganglion block to reduce sympathetically maintained pain and facilitate physiotherapy participation.

Book a Consultation

Speak directly with our CRPS specialist team — neurology, pain medicine, interventional procedures, and CRPS- experienced physiotherapy coordinated under one roof. No referral required. Monday to Saturday.

040-44885000Emergency line: 040-46324365

Diagnosis at KIMS

Budapest Criteria for Diagnosis — The Four Clinical Categories

The Budapest Criteria (2003, updated 2007) are the internationally validated diagnostic criteria for CRPS. The cards below summarise the four clinical categories — sensory, vasomotor, sudomotor/oedema, and motor/trophic — across which symptoms and signs are systematically evaluated at the KIMS first assessment.

Sensory Category

Allodynia and hyperalgesia

•

Pain from light touch or pinprick hypersensitivity in or around the painful region.

•

Allodynia (pain from light touch) is almost universally present in CRPS.

•

On examination, allodynia is demonstrated and forms a central part of the bedside assessment at KIMS.

Vasomotor Category

Asymmetric skin temperature and colour change

•

Temperature difference >1°C between limbs; skin colour changes (red, blue, mottled).

•

Typically warmer than the contralateral limb in early CRPS, sometimes cooler in chronic CRPS; red or violaceous in warm phase; pale or cyanotic in cold phase.

•

Often the first visible signs noticed by the patient and family — confirmed at KIMS using thermometry.

Sudomotor / Oedema Category

Asymmetric sweating / oedema

•

Swelling or sweating differences between the affected and unaffected limb.

•

Oedema (pitting swelling of the affected limb) and abnormal sweating (increased or decreased relative to the contralateral limb) are common.

•

Oedema contributes to stiffness and reduced joint mobility — unlike the pain, these features may be objectively measured and documented at KIMS for monitoring.

Motor / Trophic Category

Reduced motion, weakness, tremor, dystonia, trophic changes

•

Reduced range of motion, weakness, tremor, dystonia.

•

Hair, nail, and skin changes — thickened or brittle nails, increased or decreased hair growth, shiny or thickened skin.

•

Motor dysfunction significantly impairs function and is driven by both pain avoidance and central motor reorganisation.

Clinical Pearl

Budapest Criteria diagnostic rules

For clinical diagnosis: at least one symptom in 3 of the 4 categories AND at least one sign (on examination) in 2 of the 4 categories, with pain disproportionate to the inciting event, and no other diagnosis better explaining the features. For research diagnosis (more strict): symptoms in all 4 categories AND signs in 3 of 4. At KIMS, the clinical Budapest Criteria are applied systematically at the first assessment, with thermometry for temperature asymmetry and careful sensory examination for allodynia.

Recognising CRPS

Clinical Features — From Disproportionate Pain to Cortical Reorganisation

CRPS presents with a characteristic combination of severe disproportionate pain, vasomotor changes, sudomotor and oedema abnormalities, and motor and trophic dysfunction. Recognising this combination — and applying graded motor imagery as the most evidence-based rehabilitation approach — is central to the KIMS management strategy.

Pain — severe, burning, out of proportion

•

The defining feature: severe burning, aching, or throbbing pain in the affected limb, dramatically greater than would be expected from the degree of tissue injury or its stage of healing.

•

The pain is constant, often rated 7–10/10 even at rest, and is worsened by movement, temperature change, emotional stress, and physical contact.

•

Allodynia (pain from light touch) is almost universally present.

Vasomotor changes — the visible clue

•

Asymmetric skin temperature (typically warmer than the contralateral limb in early CRPS, sometimes cooler in chronic CRPS).

•

Abnormal skin colour (red or violaceous in warm phase; pale or cyanotic in cold phase; mottled throughout).

•

These changes are often the first visible signs noticed by the patient and family.

Sudomotor and oedema — the swelling and sweating

•

Oedema (pitting swelling of the affected limb) and abnormal sweating (increased or decreased relative to the contralateral limb) are common.

•

Oedema contributes to stiffness and reduced joint mobility.

•

These features, unlike the pain, may be objectively measured and documented at KIMS for monitoring.

Motor and trophic changes — the disability

•

Reduced active range of motion, weakness, tremor (fine resting or postural), and dystonia (sustained abnormal posturing of the hand or foot).

•

Trophic changes develop over weeks to months: thickened or brittle nails, increased or decreased hair growth, shiny or thickened skin.

•

Motor dysfunction significantly impairs function and is driven by both pain avoidance and central motor reorganisation.

Graded Motor Imagery — the most evidence-based rehabilitation approach

•

GMI is a three-stage rehabilitation protocol specifically developed for CRPS and phantom limb pain.

•

Stage 1: Limb laterality recognition (from pictures — training the brain to identify left vs right limb without pain). Stage 2: Imagined movements of the affected limb (using mental imagery without actual movement). Stage 3: Mirror visual feedback (using a mirror box to create the illusion of moving the affected limb by reflecting the unaffected limb).

•

GMI desensitises the cortical pain map and reorganises motor representation. Multiple RCTs demonstrate significant pain reduction and functional improvement. Available through KIMS-coordinated physiotherapy.

Treatment

Treatment at KIMS — Physiotherapy, Pharmacological Pain Management, Sympathetic Blocks, and Spinal Cord Stimulation

Physiotherapy — The Backbone

Physiotherapy — The Backbone of CRPS Treatment

Physiotherapy is the most important treatment in CRPS and must begin as early as possible. The key challenge: pain prevents the patient from participating in physiotherapy.

The pharmacological and interventional treatments at KIMS are designed to make physiotherapy participation possible — they are not the treatment themselves.

Graded Motor Imagery (GMI) is the first-line physiotherapy approach for CRPS at KIMS. Desensitisation therapy for allodynia. Graded exposure to touch and movement. Hydrotherapy for facilitated movement.

Pharmacological Management

Medications for CRPS Pain

• Pregabalin or gabapentin: First-line for neuropathic pain in CRPS. Pregabalin 75–600mg/day. Titrated to maximum tolerated dose.

• Amitriptyline 10–50mg at night: For burning pain, allodynia, and sleep.

• NSAIDs: For the inflammatory component in early CRPS (warm, red phase). Limited long-term use.

• Bisphosphonates: Alendronate or pamidronate IV for CRPS with bone involvement (osteoporotic changes on X-ray). Evidence for pain reduction in CRPS with bone change.

• Low-dose naltrexone: Emerging evidence for CRPS, modulating glial activation. Used off-label at KIMS in refractory cases.

• Ketamine: Low-dose ketamine infusions (NMDA receptor antagonism, resetting central sensitisation) for severe refractory CRPS. Topical ketamine gel for local allodynia. Administered at KIMS under anaesthesia supervision.

Sympathetic Interventional Procedures

Nerve Blocks to Facilitate Physiotherapy

• Stellate ganglion block: For upper limb CRPS. Local anaesthetic injected around the stellate ganglion (cervicothoracic sympathetic ganglion), blocking sympathetically maintained pain. Temporary but can facilitate physiotherapy participation during the block. Repeated at KIMS when clinically beneficial.

• Lumbar sympathetic block: For lower limb CRPS. Similar mechanism, different anatomical target. Performed under fluoroscopic guidance at KIMS.

• Intravenous regional sympatholysis (Bier block): IV guanethidine or phentolamine under tourniquet for limb CRPS. Used at KIMS when ganglion blocks are technically difficult.

Spinal Cord Stimulation — For Refractory CRPS

Spinal cord stimulation (SCS) is the most evidence-based interventional treatment for refractory CRPS that has failed conservative management. Multiple RCTs demonstrate significant pain reduction (>50% in approximately 50–60% of patients) and improved function.

At KIMS, SCS involves: a trial period (1–2 weeks of external stimulation via a temporary lead) to confirm response before permanent implantation; followed by implantation of epidural electrodes and a subcutaneous pulse generator.

Newer SCS modalities (burst stimulation, high-frequency stimulation, dorsal root ganglion stimulation) are available at KIMS for patients who do not respond to conventional tonic SCS.

Related Conditions

Complex Regional Pain Syndrome belongs to the family of headache and pain syndromes evaluated and managed at KIMS Neuroscience:

Central Pain Syndrome Trigeminal Neuralgia Tension-Type Headache Headache & Pain Syndromes (Master)

FAQs

Frequently Asked Questions

Yes — and this is one of the most characteristic presentations of CRPS. The key phrase is "disproportionate pain" — pain that is far more severe than would be expected given that the fracture has healed. Additional features that suggest CRPS: the hand or foot looks different from the other side (different colour, different temperature, more swollen), light touch is excruciatingly painful, and you are unable to use the limb functionally despite the fracture having healed on imaging. At KIMS, we assess this systematically using the Budapest Criteria, which require specific signs and symptoms in four clinical categories. Early diagnosis and immediate physiotherapy initiation are critical — outcomes are significantly better when treatment starts within the first 3 months. Please call 040-44885000 urgently.

This is the most common and most important challenge in CRPS management, and the solution is the specific approach to physiotherapy used for CRPS — not standard post-fracture rehabilitation. Graded Motor Imagery (GMI) begins without any physical movement: first stage involves looking at pictures of hands and identifying left vs right. Second stage involves imagining movement without actually moving. Third stage uses mirror visual feedback — watching the reflection of the unaffected hand moving, which the brain processes as the affected hand moving. This cortical approach progressively desensitises the pain system before physical movement is re-introduced. Simultaneously, nerve blocks at KIMS reduce the sympathetically maintained pain sufficiently to allow physiotherapy participation. The physiotherapy and the nerve blocks work together. Please call 040-44885000 for a coordinated CRPS management plan.

Yes — and SCS is particularly supported by evidence for exactly this situation: refractory CRPS that has not responded to conservative management. Multiple randomised controlled trials have shown that SCS produces >50% pain reduction in approximately 50–60% of patients with CRPS. Before permanent implantation, a trial is performed: a temporary electrode is placed epidurally under local anaesthesia, and the patient uses the stimulator for 1–2 weeks to assess their response. If significant pain reduction occurs during the trial, a permanent system is implanted. At KIMS, SCS is offered to patients with refractory CRPS following a comprehensive pain team assessment. Newer forms of stimulation (burst and high-frequency) are available for patients who do not respond to conventional stimulation. Please call 040-44885000.

What you describe is CRPS-associated dystonia — fixed abnormal posturing of the limb that develops in approximately 25% of CRPS patients, usually when treatment has been delayed or inadequate. CRPS dystonia is caused by central motor system reorganisation, not by contracture of the muscles themselves (though secondary contractures develop if the posture is maintained for long enough). Treatment is difficult but not impossible. At KIMS: physiotherapy with splinting to maintain range of motion and prevent secondary contractures; botulinum toxin injections to the dystonic muscles to allow passive correction; intrathecal baclofen for severe generalised CRPS dystonia; and in selected cases, deep brain stimulation (DBS) for refractory CRPS dystonia has been reported in specialist centres. the KIMS Neuroscience team has extensive DBS experience. Please call 040-44885000 for an assessment.

No — this is one of the most damaging things that can be said to a CRPS patient, and it is wrong. CRPS is a real neurological condition with an established biological basis involving peripheral and central sensitisation, abnormal sympathetic nervous system activity, neuroinflammation, and cortical reorganisation. It is classified by the International Association for the Study of Pain (IASP) as a distinct pain syndrome with validated diagnostic criteria (the Budapest Criteria). The absence of a visible structural abnormality on imaging does not mean the condition is psychological — neuropathic pain syndromes inherently do not show on X-ray or CT. Research using fMRI and PET scanning has demonstrated specific patterns of cortical changes in CRPS patients. At KIMS, the CRPS diagnosis is made using internationally validated criteria, and the condition is treated as the serious neurological pain syndrome it is. Please call 040-44885000.

Disproportionate pain after an injury that should have healed. A limb that looks and feels different from the other side. Light touch that is unbearable. CRPS is a real, diagnosable, and treatable neurological pain syndrome — but the outcome depends on early diagnosis and aggressive multidisciplinary rehabilitation.

At KIMS Neuroscience, Secunderabad, Hyderabad, the CRPS programme provides: Budapest Criteria systematic assessment; thermometry; graded motor imagery physiotherapy; pregabalin, amitriptyline, bisphosphonates, and ketamine infusions; stellate ganglion and lumbar sympathetic blocks; and spinal cord stimulation for refractory cases. Early referral is the single most important factor in outcome. Call 040-44885000.

040-44885000

International enquiries: info@kimsneurosciences.com