Treatment is often based on the possible mechanisms that cause CRPS, however as previously noted, these causes are elusive.192 The primary goal of treatment is to facilitate functional restoration, however, the natural history of CRPS treatment suggests that reported outcomes of pain relief, functional capacity, and disease remission are far from optimal.193-195 Due to the historic disagreements over diagnosis of the syndrome, there are no scientifically well-established treatment guidelines. Although there are obvious difficulties in treating this disorder, there are few randomized controlled trials of the most widely accepted treatment approaches.196-199 Clinical trials that have been performed had either small numbers of patients or limited clinical follow-up.200 “The consensus of treatment should be to convince the patient and family that CRPS is the diagnosis and that movement of the involved extremity is key for rapid return to function.”201
WHAT ARE THE TRADITIONAL TREATMENT OPTIONS?
Options available for CRPS include interventional, pharmacologic, physical/occupational therapy, and psychologic techniques. Staton-Hicks et al. note in their treatment guidelines that failure to achieve a favorable response with any treatment modality should not persist beyond two weeks.202 Quisel et al. suggest these same treatment guidelines are summarized without a systematic or evidence-based approach, and also raise the question whether any treatment makes a difference, or that possibly CRPS type I resolves on its own.203
Interventional approaches include various sympathetic ganglion blocks (i.e., stellate, thoracic, lumbar), intravenous regional sympathetic blocks (Bier blocks), somatic blocks (i.e., peripheral nerve blocks, brachial plexus), and epidural blocks.204
If CRPS is a pathologic reflex of the sympathetic nerves causing blood flow irregularities, constant pain, muscle atrophy, and fibrosis, then those who support this hypothesis cite pain relief from a sympathetic block as supportive evidence. Sympathetic blocks, however, did not prove to be a reliable predictor of treatment response.205
The following is a note taken from a proponent of the success of the stellate ganglion block: “If the pain returns, and it does in many instances, the patient should receive a series of blocks. In the cases where the pain returns in a few hours, the first four to five blocks should be given once a day and the next three to five blocks, once every three to four days. Persistent, intensive therapy is important. If the disease is well established, the results of stellate ganglion therapy are not as promising.”206 Invasive therapies such as the sympathetic ganglion block are minimally, if at all, effective.207
The use of the regional sympathetic block is based on the theory that chronic pain results from either a central hyperactivity of the sympathetic nervous system or a peripheral hypersensitivity to circulating catecholamines.208 Efficacy of these blocks in treating CRPS is unclear because separate studies dealing with similar patient populations report contradictory levels of response to treatment. Some studies show no difference between the use of the drugs and the saline control, while others report an improvement in 75% of the patients.209, 210 In a study of the effectiveness of sympathetic blocks, one series showed only 12% of patients were pain free at a three-year follow-up.211, 212 Only the subset of CRPS patients with sympathetically maintained pain (SMP) exhibit pain responsiveness to the blockade.213 Many practitioners believe that some patients obtain real benefit from the sympathetic block, and other practitioners do not. Unfortunately, one cannot tell beforehand whether the patient will be one that would respond.214
Pharmacological approaches, including narcotic pain medications, are of little restorative value and frequently result in drug dependence without improving limb function.215, 216 Given these limitations, treatment approaches are based heavily on clinical experience. The best treatments appear to be non-invasive and completely within the realm of family medicine.217 (See Figure 13.) Guidelines help, but creativity, compassion and flexibility are essential.218
| Figure 13. Traditional treatments given to 134 patients, diagnosed with CRPS, in the Allen Study.42 |
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Early intervention is paramount. A multifaceted treatment approach is thought to be most effective. Pain management techniques to restore function are based on a steady progression from very gentle movements on an active basis to gentle weight bearing. This progresses to more active load bearing techniques. These strategies also include progressive stimulation using different textures and different temperatures of bath water. It is thought that this gradual normalization of sensation occurs due to a resetting of the altered central processing in the nervous system. Moving and using the limb is paramount to healing.219-221
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