• All patients should be treated with a multidisciplinary approach.
• All patients should receive information explaining their disease.
• All patients should receive PT, occupational therapy, and psychological support throughout their disease course. PT should be instituted slowly and under the supervision of a therapist because a patient is unlikely to do it on his/her own. PT needs to be tailored to the severity of symptoms. During the acute stage when the patient has pain at rest, the PT program should be less aggressive (skin desensitization, gentle passive mobilization). As the pain subsides, PT can be progressed to active isometric strengthening and finally isotonic training.
• Patients with early CRPS (<3–6 months of symptoms), pain and swelling, and a positive TPBS should be treated with prednisone (60–80 mg/day for 2 weeks with taper over next 4 weeks). Corticosteroids can modulate the effect of the inflammatory neuropeptides.
• Analgesics: opioids, NSAIDs, topical lidocaine, tricyclic antidepressants, gabapentin (or pregabalin), selective serotonin/serotonin-norepinephrine reuptake inhibitors (duloxetine and venlafaxine), and/or carbamazepine. Choice depends on severity (opioids versus NSAIDs) and quality (somatic, neuropathic) of pain. Many patients develop a small fiber neuropathy with a decrease in epidermal nerve fiber density in the affected limb. These patients can benefit from neuroleptics.
• If pain is severe (i.e., pain at rest and with movement), then more aggressive therapy should be instituted early. It is clinically impossible to know if the patient’s pain is or is not sympathetically mediated, but CRPS is more likely to be as a result of abnormal sympathetic nerve activity early in the disease course. In these patients, sympathetic blocks can be effective. Up to 50% of patients with symptoms less than 1 year can improve with these blocks. However, recurrent sympathetic blocks do not prolong the analgesic effect. Patients who fail to respond to sympathetic blocks are more likely to have their pain mediated by CNS sensitization.
• The following therapies have been most effective for treatment-resistant and/or cases with prolonged (>12 months) symptoms (15% of patients):
An epidural spinal cord stimulator can be used and will reduce pain approximately 50% in 50% of patients.
IV ketamine: because of the importance of the NMDA receptor, some patients with CRPS type I benefit from these infusions (5-day inpatient versus 10-day outpatient infusion with slow tapering to maintenance therapy; one infusion every 3 months).
Other interventions: epidural clonidine, sympathectomy (if responded to sympathetic nerve blocks).