Physical Medicine and Rehabilitation for Complex Regional Pain Syndromes Treatment & Management

Physical Therapy

It is extremely important for patients with RSD to undergo a steady progression from gentle weight bearing to progressive, active weight bearing. ^[15] Gradual desensitization to increasing sensory stimuli also plays an important role. The altered processing in the CNS is typically reset by a gradual increase in normalized sensation. Other intervention should be offered to enable greater confidence and comfort when patients do not progress in a reasonable amount of time.

Physical therapy (PT), ^[16] in association with occupational therapy (OT), plays an important role in functional restoration. The goal is to increase strength and flexibility gradually, beginning with gentle gliding exercises. Patients usually are reluctant to participate in PT because of intense pain. A self-directed or therapist-directed PT program is important and should be individualized to each patient's needs and goals.

Patients with CRPS also may have myofascial pain syndrome. A study by Rashiq and Galer found that myofascial pain syndrome can be treated first, and if it is treated effectively, the entire syndrome may resolve. ^[17] Myofascial pain may be treated with modalities and techniques, such as massage and myofascial release.

Occupational Therapy

An analysis by Steverens and colleagues noted that occupational therapists are very important for initiating gentle, active measurements and preliminary desensitization techniques with patients who have RSD. ^[18]

Occupational therapists usually are responsible for introducing and maintaining a stress-loading program for patients with CRPS. This program involves active compression and distraction exercises that provide stimuli to the affected extremity without joint motion. The scrubbing technique requires use of a scrub brush. Scrubbing is performed by gradually increasing the weight on the patient's affected extremity as he/she scrubs in circles. Weight loading of the joints is completed with increasing weight as the scrubbing process continues.

The next part in this program involves a carrying technique. The patient is instructed to carry a weight (bag) in the affected extremity throughout the day, as tolerated. The patient should monitor his/her symptoms and keep a daily record to share with the therapist.

The stress-loading program usually is started as a home exercise program. The patient also can use desensitization techniques (eg, rubbing the skin, massage, tapping, vibration) to reduce sensitivity and pain.

Recreational Therapy

Recreational therapy can help the patient with chronic pain to take part in pleasurable activities that help to decrease pain. The patient finds enjoyment and socialization in previously lost or new recreational activities. Usually, patients with chronic pain are depressed. Recreational therapists may play an important role in the treatment process and enable the patient to become active.

Vocational therapy should be recommended and initiated early for all appropriate patients. Vocational therapy can provide work capacities and targeted work hardening, and the patient may return to gainful employment.

Therapeutic strategies include pharmacologic pain relief, sympatholytic interventions, and rehabilitation. ^[16]

• All treatments should focus primarily on functional restoration. Use of drugs, sympathetic blocks, and psychotherapy helps to achieve good pain control during PT.

• Early intervention is important. The key to successful treatment of RSD is recognition of symptoms in stage I or early in stage II. Physicians should be alert to signs and symptoms of RSD. When RSD is suspected, the treating physician should ensure that that the patient receives evaluation by a pain specialist or other clinician experienced in treating this condition.

• The time between the start of RSD and clinic attendance may vary from several days to years.

• Identifying any underlying disease (eg, fracture, sprain, radiculopathy) and tailoring specific management are important.

• Johnston and Howell reported significant pain improvement after release and anterior transposition of the nerve. ^[19] Five patients had RSD, 3 cases of which resolved after nerve release. Careful evaluation with diagnostic local nerve blocks and other conservative measures should be tried before surgery is considered.

• Sympathetic or somatic block, if performed, should be integrated into a good rehabilitation program.

Sympathetic blocks

For the upper extremity, a stellate (cervicothoracic) ganglion block is recommended. Bupivacaine is preferred over lidocaine because of its longer half-life. Not all patients experience pain relief after blocks.

Percutaneous lumbar sympathetic plexus catheter placement usually provides short-term pain relief in most patients and may have some long-term effect.

Bier block (intravenous regional block)

In 1974, the concept of intravenous regional guanethidine was introduced. Block with bretylium or reserpine has less profound effect than it does with guanethidine, which may last for 2-3 days.

A double-blind, randomized study was designed to compare the effectiveness of intravenous regional sympatholysis using guanethidine, reserpine, and normal saline; the study reported significant pain relief in all 3 groups. No significant differences were noted among the 3 groups in the degree of pain relief. The saline group's high rate of pain relief could be due partially to a mechanism of tourniquet-induced analgesia.

A small controlled, randomized, double-blinded, prospective study of intravenous regional block with lidocaine and ketorolac resulted in only short-term pain reduction in patients with CRPS of the lower extremity. Of the several parameters measured, only one outcome resulted in significant improvement; in the ketorolac group, one day of significant pain reduction was noted. ^[20]

Somatic block

Somatic block, consisting of continuous epidural infusion with different variants of brachial plexus blocks, includes an axillary, supraclavicular, or infraclavicular approach that may be useful.

Dorsal column stimulator

Localized extremity pain may be relieved by a dorsal column stimulator. A spinal cord stimulator (SCS) can be an effective treatment for the pain of RSD, including recurrent pain after ablative sympathectomy.

Kumar and colleagues note that the low morbidity associated with this procedure and its efficacy in patients with refractory pain related to RSD suggest that SCS is superior to ablative sympathectomy in the management of RSD. ^[21] Careful evaluation is recommended before patient selection.

A study by Geurts et al of spinal cord stimulation in RSD found the treatment to be an effective long-term strategy in 63% of patients. It also suggested that achievement of at least 50% mean pain relief 1 week after test stimulation predicts long-term treatment success. The study included 84 patients with an implanted SCS, with 41% of patients feeling at least 30% pain relief at 11-year follow-up and 63% of patients still using their device at 12-year follow-up. ^[22]

Intrathecal infusion

Careful selection of patients is needed, as follows:

• Baclofen pump: According to van Hilten and coauthors, an intrathecal (IT) Baclofen pump may be useful for treatment of dystonia in patients with RSD ^[23]

• Morphine pump: Intrathecal opioids should be considered carefully for chronic pain of nonmalignant origin

• Intrathecal bupivacaine infusion: As noted in a study by Lundborg and colleagues, this approach may alleviate the refractory pain, but it does not affect other associated symptoms or the natural course of CRPS I ^[24]

Sympathectomy

This includes the following strategies:

• Radiofrequency or cryoprobe lesioning: If a sympathetic block produces significant pain relief twice, denervation with radio frequency or a cryoprobe could provide long-term relief ^[25]

• Surgical sympathectomy: Endoscopic cervicothoracic sympathectomy could be an effective minimally invasive therapy for upper extremity RSD

• Chemical sympathectomy

Amputations

Dielissen and colleagues reviewed cases of 28 patients with RSD who had amputations for intractable pain or recurrent infection or to improve residual function. ^[26] Only 2 patients were relieved of pain by amputation, and this number could not be predicted. RSD recurred in the stump, especially after amputation at a level that was not free of symptoms.

In CRPS, as in other chronic pain conditions, the high incidence of personality pathology, as noted by Monti and co-authors, may represent an exaggeration of maladaptive personality traits and coping styles resulting from chronic, intense pain. ^[27] Such pathology can be addressed with the help of the following:

• Evaluation - An evaluation by a psychologist is appropriate to identify the stressor and to gather information about the distress of the patient. The evaluation should consist of a structural clinical interview and a personality measure (eg, Minnesota Multiphasic Personality Scale, Hopelessness Index).

• Psychotherapist

• Biofeedback and counseling

Management strategies in CRPS also include the following:

• Transcutaneous electrical nerve stimulation (TENS): According to Hassenbusch and co-authors, peripheral nerve stimulation can provide good relief for RSD when the condition is limited to the distribution of 1 major nerve ^{[28, 29]}

• Ultrasonography

• Superficial hot packs

• A double-blind, prospective, multicenter trial of 416 patients by Zollinger and colleagues has shown that Vitamin C seems to reduce the prevalence of CRPS after wrist fracture. The authors recommended a daily dose of 500 mg for 50 days. ^[30]

• Improvements in pain and bone density following intravenous administration of pamidronate, alendronate, or clodronate have been described in a few patients

A literature review and meta-analysis by Mbizvo et al indicated that placebo treatment is for the most part ineffective in patients with long-standing CRPS (ie, CRPS of 6 months or more). The study, which encompassed 18 trials (340 patients), found that although patients did demonstrate a significant placebo response during the first 15-30 minutes of treatment, at the other time periods in the analysis (1 week, 3-4 weeks, and 6 weeks or more), no significant response occurred. ^[31]