What is the treatment approach for Complex Regional Pain Syndrome (CRPS), also known as Reflex Sympathetic Dystrophy (RSD)?

Treatment of Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)

Physical and occupational therapy must be initiated immediately as the cornerstone of CRPS treatment, with all other interventions serving solely to facilitate participation in rehabilitation. 1, 2

First-Line Treatment Approach

Start physical therapy immediately—do not delay waiting for pain to resolve, as this worsens outcomes through disuse and pain upregulation. 1

Essential Physical Therapy Components

• Gentle stretching and mobilization techniques focusing on increasing external rotation and abduction 2
• Active range of motion exercises that gradually increase while restoring alignment and strengthening weak muscles 2
• Sensorimotor integration training to address the neuroplastic changes 1
• Encourage optimal postural alignment and promote even distribution of weight 3

Pain Control to Enable Therapy

• NSAIDs or acetaminophen for pain relief if no contraindications exist 1, 2
• Short course of oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) to reduce inflammation and edema 2

Second-Line Interventions for Moderate to Severe Cases

Sympathetic Nerve Blocks

Stellate ganglion blocks (upper extremity) or lumbar sympathetic blocks (lower extremity) may be used ONLY when there is consistent improvement and increasing duration of relief with each successive block. 2

Critical criteria for continuing blocks:

• Document progressive improvement with each block 2
• Demonstrate increasing duration of pain relief 2
• Measure objective functional outcomes beyond pain scores (ADL improvements, cognitive function, work capacity) 2
• Integrate into multimodal rehabilitation approach, not as monotherapy 2

Do NOT continue sympathetic blocks indefinitely without documented progressive improvement—this contradicts evidence-based guidelines. 1, 2

Do NOT use sympathetic blocks for non-CRPS neuropathic pain. 2

Do NOT use peripheral somatic nerve blocks for long-term treatment. 2

Third-Line Treatment for Refractory Cases

Spinal Cord Stimulation

For CRPS refractory to physical therapy and sympathetic blocks, proceed to spinal cord stimulation trial before considering permanent implantation. 1, 2

• Perform trial stimulation before permanent device implantation 2
• Use as part of multimodal approach 2
• Include TENS as adjunctive therapy in the multimodal regimen 2

Psychological Interventions

• Cognitive behavioral therapy to reduce anxiety and avoidance behavior that perpetuate disability 1
• Stepped psychological interventions integrated with physical rehabilitation 1
• Treat comorbid depression and anxiety concurrently 4

Adjunctive Pharmacological Options

Based on limited evidence from research studies:

• Bisphosphonates have shown benefit in pain reduction 4
• Vitamin C may have preventive effects 4
• Calcitonin has NOT shown definite benefit 4

Monitoring Requirements

Evaluate CRPS patients at least twice annually by a specialist due to high recurrence risk. 1, 3

Document at each visit:

• Objective functional outcomes (not just pain scores) 2
• Duration of relief from interventions 2
• ADL improvements 2
• Autonomic stability and temperature regulation 2

Critical Pitfalls to Avoid

• Delaying physical therapy while waiting for pain to resolve 1
• Continuing sympathetic blocks without documented progressive improvement 1, 2
• Using peripheral nerve blocks for long-term management 2
• Failing to document objective functional outcomes beyond numeric pain ratings 2
• Using sympathetic blocks for non-CRPS neuropathic pain 2

Clinical Presentation to Recognize

CRPS typically presents with:

• Excruciating pain disproportionate to initial injury that worsens with touch (allodynia) 1, 3
• Pain that gradually increases in intensity and spreads within the affected limb, sometimes to the contralateral limb 1, 3
• Autonomic dysfunction: temperature dysregulation, skin color changes, abnormal sweating 1
• Motor impairment: functional weakness, decreased active range of motion 1, 3
• Trophic changes in chronic cases: hair loss, tissue changes, skin discoloration 1, 3

The diagnosis is primarily clinical based on Budapest Criteria—three-phase bone scintigraphy has 78% sensitivity and 88% specificity but is not required for diagnosis. 1