What is the recommended treatment approach for reflex sympathetic dystrophy (Complex Regional Pain Syndrome type I)?

Treatment of Complex Regional Pain Syndrome (CRPS) Type I

Physical and occupational therapy are the cornerstone of CRPS treatment, with all other interventions serving primarily to facilitate participation in rehabilitation. 1

Immediate Treatment Priorities

Early diagnosis and prompt initiation of therapy are critical—delaying physical therapy while waiting for pain to resolve worsens outcomes through disuse and pain upregulation. 1, 2

First-Line Treatment: Physical Therapy

• Gentle stretching and mobilization, active range of motion exercises, and sensorimotor integration training are essential components that must begin immediately upon diagnosis. 1
• Physical therapy should be initiated even in the presence of significant pain, as early mobilization prevents permanent disability. 2, 3
• The goal is to restore function and prevent the maladaptive neuroplasticity that perpetuates chronic CRPS. 3

Adjunctive Pharmacological Support to Enable Physical Therapy

Oral corticosteroids are recommended for initial pain management in acute CRPS to reduce peripheral and central neuroinflammation. 4

• NSAIDs and acetaminophen may be used to enable physical therapy participation. 1
• If these medications do not provide sufficient analgesia for physical therapy, add an opioid to the treatment regimen. 2
• Anticonvulsants and/or antidepressants should be considered for mild to moderate cases as adjuvant analgesics. 2

Interventional Treatments for Moderate to Severe Cases

Sympathetic nerve blocks (stellate ganglion blocks for upper extremity, lumbar sympathetic blocks for lower extremity) may be used for moderate to severe cases with sympathetic dysfunction to facilitate physical therapy participation. 1, 2

However, continuing sympathetic blocks indefinitely without documented progressive improvement and increasing duration of relief is not recommended. 1 The efficacy of sympathetic blockade as treatment for CRPS is questionable based on current evidence. 3

Refractory CRPS Management

For patients who fail to respond to the above measures:

• Spinal cord stimulation is recommended for refractory CRPS cases, requiring a trial before permanent implantation. 1, 2
• Intravenous ketamine with midazolam 2 mg before and after ketamine injection can be administered to inhibit the N-methyl D-aspartate receptor if pain persists despite all drug adjustments. 4
• If ketamine fails, intravenous lidocaine can be administered for 2 weeks. 4

Psychological Support

Cognitive behavioral therapy and stepped psychological interventions help reduce anxiety and avoidance behavior that perpetuate disability in CRPS patients. 1

Alternative Pharmacological Options

In early-stage CRPS (within first few months), calcium channel blockers (nifedipine) or alpha-sympathetic blockers (phenoxybenzamine) achieved a 92% cure rate when initiated early, though these were not combined with physical therapy in the studied cohort. 5

• Early-stage success: 11 of 12 patients cured. 5
• Chronic-stage success: only 40% (19 of 47 patients), even when combined with physical therapy. 5
• This underscores the critical importance of early recognition and treatment. 5

Critical Pitfalls to Avoid

• Never delay physical therapy waiting for pain to resolve—this worsens outcomes through disuse and central sensitization. 1
• Do not continue sympathetic blocks indefinitely without objective functional improvement beyond pain scores. 1
• Peripheral somatic nerve blocks are not indicated for long-term treatment. 1
• Do not use sympathetic blocks for non-CRPS neuropathic pain—this contradicts evidence-based guidelines. 1

Monitoring and Follow-Up

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

Document objective functional outcomes (range of motion, strength, ability to perform activities of daily living) rather than relying solely on pain scores to justify continued interventional treatment. 1