Recent evidence of treatment of Complex Regional Pain Syndrome

Recent evidence of treatment of Complex Regional Pain Syndrome

rational approach to the treatment of Complex Regional Pain Syndrome (∗ denotes stronger recent evidence)

  • • Stimulation of inhibitory neurons
    • – Spinal cord stimulation∗
  • • Physical therapy (PT)∗
    • – Massage, counterirritants
    • – Ultrasound
    • – Electroacupuncture
    • – Transcutaneous nerve stimulators
  • • Antiinflammatory agents
    • – Nonsteroidal antiinflammatory drugs (NSAIDs)
    • – Ketorolac in an intravenous (IV) regional block
    • – Corticosteroids∗
  • • Sympathetic blocks
    • – Lidocaine, mepivacaine, bupivacaine, etc., into sympathetic ganglion
    • – Bier block with IV guanethidine, bretylium, reserpine (depletes norepinephrine) (not very effective and rarely used)
    • – Oral β-blockers (not very effective)
    • – Prazosin, phenoxybenzamine, terazosin (α-1 adrenergic blockers)
    • – IV phentolamine (α-1 adrenergic blocker)
    • – Oral, patch, or epidural clonidine
    • – Sympathectomy (surgical)
    • – Injection of opioid into sympathetic ganglion
  • • Depletion of substance P in peripheral nerves
    • – Topical capsaicin
  • • Anticonvulsants
    • – Phenytoin
    • – Carbamazepine
    • – Gabapentin and pregabalin
    • – Valproic acid
  • • Antiosteoporotic therapy
    • – Calcitonin∗
    • – IV bisphosphonates (pamidronate 1 mg/kg)∗
    • – High dose (40 mg/day) or normal dose (70 mg/week) oral alendronate
  • • Treatment of dystonia
    • – Intrathecal baclofen (GABA agonist)
    • – Local botulinum toxin injections
  • • Other treatments
    • – IV lidocaine and 5% lidoderm patches (sodium channel blocking agents)
    • – IV ketamine (block NMDA receptor)∗
    • – Stop ACE inhibitors
    • – Tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitors
    • – Calcium channel blockers
    • – Dimethyl sulfoxide topically
    • – Topical lidocaine
    • – Repetitive transcranial magnetic stimulation (in trials)
  • • Psychological therapy
    • – Establish rapport with the patient, provide emotional support, assess for depression, and treat with psychotherapy and medications if a problem
    • – Thermal biofeedback, relaxation training, alcohol and tobacco cessation
    • – Cognitive behavioral therapy∗.
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