Complex Regional Pain Syndrome Type 1 (Reflex Sympathetic Dystrophy) Treatment & Management.

Approach Considerations

United Kingdom guidelines on complex regional pain syndrome (CRPS) list four ‘pillars’ of CRPS care: education, pain relief (medication and procedures), physical rehabilitation, and psychological intervention. All four are of equal importance, and addressing them may require involvement of a range of specialties, such as physiotherapy, pain medicine, rheumatology, neurology, and surgery. [12]

International guidelines for the management of CRP, sponsored by the Reflex Sympathetic Dystrophy Syndrome Association (RSDSA) and most recently updated in 2014, acknowledge the paucity of high-level studies, and thus base the recommendations on literature review supplemented with clinical expertise. The guidelines include a treatment algorithm focused on functional restoration provided by an interdisciplinary team (eg, occupational, physical, recreational therapist; vocational rehabilitation counselor). [11]

In addition, the guidelines recommend providing access to medications, psychotherapy, and/or injections from the start of treatment, if needed and appropriate. If the patient cannot begin treatment or fails to progress with treatment at any step or in any regard, consideration should be given to starting or adding more or stronger medication, more intensive psychotherapies, and/or different interventions.

The functional restoration algorithm has four parts.

Initial measures include the following:

· Mirror visual feedback

· Graded motor imagery

· Reactivation

· Contrast baths

· Desensitization

· Exposure therapy

The second phase of therapy includes the following:

· Edema control

· Flexibility (active)

· Isometric strengthening

· Correction of postural abnormalities

· Diagnosis and treatment of secondary myofascial pain

The third phase of therapy includes the following:

· Stress loading

· Isotonic strengthening

· Range of motion (gentle, passive)

· General aerobic conditioning

· Postural normalization and balanced use

The fourth phase of therapy includes the following:

· Ergonomics

· Movement therapies

· Normalization of use

· Vocational/functional rehabilitation

Indications for pharmacotherapy and suggested choices include the following [11]

· Mild-to-moderate pain – Simple analgesics and/or blocks

· Excruciating, intractable pain – Opioids and/or blocks or later, more experimental interventions

· Inflammation/swelling and edema – Steroids, systemic or targeted (for acute treatment) or nonsteroidal anti-inflammatory drugs (for long-term treatment); immune modulators

· Depression, anxiety, insomnia – Sedative, analgesic antidepressant/anxiolytics (and/or psychotherapy)

· Significant allodynia/hyperalgesia – Anticonvulsants and/or other sodium channel blockers and/or N-methyl-D-aspartate (NMDA) receptor antagonists (eg, ketamine)

· Significant osteopenia, immobility and trophic changes – Calcitonin or bisphosphonates

· Profound vasomotor disturbance – Calcium channel blockers, sympatholytics, and/or blocks

· Virtual reality is increasingly under study for treatment of CRPS. This approach expands on principles of mirror therapy, and appears to provide reduction in pain and increase in function. [13, 14]

---

Autor Information and Disclosures

Author

T P Sudha Rao, MD Associate Professor of Medicine, Virginia Commonwealth University School of Medicine; Chief, Rheumatology Fellowship Coordinator, Department of Rheumatology, McGuire VA Medical Center T P Sudha Rao, MD is a member of the following medical societies: American College of Rheumatology Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Lawrence H Brent, MD Associate Professor of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, American College of Rheumatology Disclosure: Stock ownership for: Johnson & Johnson.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa Disclosure: Nothing to disclose.

Additional Contributors

Don R Revis, Jr, MD Consulting Staff, Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine Don R Revis, Jr, MD is a member of the following medical societies: American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, American Medical Association Disclosure: Nothing to disclose.

Robert E Wolf, MD, PhD Professor Emeritus, Department of Medicine, Louisiana State University School of Medicine in Shreveport; Chief, Rheumatology Section, Medical Service, Overton Brooks Veterans Affairs Medical Center Robert E Wolf, MD, PhD is a member of the following medical societies: American College of Rheumatology, Arthritis Foundation, Society for Leukocyte Biology Disclosure: Nothing to disclose.

Elliot Goldberg, MD Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Lewis Katz School of Medicine at Temple University Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology Disclosure: Nothing to disclose.