Management

Early Intervention
It is a progressive disorder unless vigorous intervention is used during the acute stage. The best intervention is prevention when it is recognized that development of CRPS type I (RSD) is a possibility, such as when there has been trauma to the extremity or when the extremity is immobilized. It requires that the therapist motivate the patient to move the entire extremity safely, minimize edema and vascular stasis with elevation and activity of the distal segments (squeeze and open hand with upper extremity lesions, or ankle pumping and toe curls with lower extremity lesions), and be alert to the development of adverse symptomatology.

Summary of Guidelines for Management of Complex Regional Pain Syndrome Type I (RSD)

Stage I (early intervention)
Relieve pain and control edema
• Modalities
• Retrograde massage
• Elevate, elastic compression

Increase mobility (specific to involved tissues)
• Tendon gliding in the hand
• Nerve mobilization

Improve muscle performance
• Stress loading in quadruped position
• Distraction
Improve total body circulation
• Low impact aerobic exercise

Desensitize the area
• Desensitization techniques for brief periods 5x/day

Educate the patient

• Teach interventions that deal with variable vasomotor responses; when to use heat, cold, gentle exercises
Medical intervention is a necessity to manage this syndrome. The physician may choose to utilize analgesics, sympatholytic drugs, local anesthetic blocks, stellate ganglion blocks, spinal cord stimulation, or upper thoracic sympathectomy or may use oral steroids or intramuscular medication. Because there is often an emotional or psychological component, medical intervention includes therapies to manage this area (antidepressants). This is done in conjunction with active exercise (including exercise in warm water) to manage physical impairments and functional limitations.

• Pain and edema control. Use modalities such as ultrasound, vibration, transcutaneous electrical nerve stimulation (TENS), or ice. Utilize retrograde massage. Elevate and use elastic compression when not undergoing pneumatic compression treatment.

• Mobility. In the early stages, use gentle, active exercises to manage the increasing stiffness. Have the patient actively contract the musculature while the part is held near the end of the pain-free range. It is important to avoid increasing painful reactions that would decrease mobility. Support and have the patient actively move each joint for a short period of time. They should follow this program of brief motion frequently throughout the day.
  • In the hand, include tendon glide exercises

  • Butler suggested that there may be adverse tension in the sympathetic trunk influencing sympathetic activity and therefore suggested mobilization of the nervous system.

• Muscle performance. Facilitate active muscle contractions. Include joints proximal to the symptoms (shoulder/hip); they often develop restrictions due to pain or lack of use. Use both dynamic and isometric exercise and alternating controlled stress loading (compressive loading) with distraction activities for neuromuscular control as well as afferent fiber stimulation. The objective is to provide tissue stress with minimal joint motion. Suggested exercises include:

  • Stress load the upper extremity by scrubbing with a brush in the quadruped position, beginning at 3 minutes and incrementally increasing to 10 minutes three times a day. For the lower extremity, utilize progressive weight-bearing activities.

  • Distraction by carrying 1 to 5 pounds up to 10 minutes at a time frequently throughout the day

• Total body circulation and cardiac output. Initiate a program of low-impact aerobic exercises.

• Desensitization. Utilize desensitization techniques for brief periods five times per day, such as having the patient work with various textures and tap or vibrate over the sensitive area. The patient is instructed to wear a protective glove during activities of daily living.

• Patient education. Emphasize the importance of following the program of increased activity. Teach the patient interventions that deal with the variable vasomotor responses with the use of gentle heat when at home, gentle exercises for short periods throughout the day, and use of associated parts of the extremity.

Intervention-Stages II and III

• Pain management. Modalities are often used as palliative interventions prior to or in conjunction with exercise to minimize pain.

• Desensitization. Progress the desensitization techniques to increase the patient’s tolerance to various textures.

• Mobility. Use joint mobilization, neuromobilization, and stretching techniques to address tissues limiting mobility. Because of the pain and significant limitations, little progress is sometimes seen with the stretching maneuvers, so surgical intervention may be required to gain motion.

• Muscle performance. Develop an exercise program to improve strength, endurance, and overall functional performance that meets the specific needs of the patient.

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