Management

CRPS represents a very complicated pathophysiological disturbance, further complicated by its biopsychosocial complications.38 The pain is disproportionate to the initiating stimulus, and the consequences are likewise disproportionate. The specific initiating factor is often unknown, and the specific pathophysiological changes are also unknown. Prevention is therefore difficult or impossible.39 Specific therapy is therefore not possible, so generalized functional restoration must occur. This is itself a difficult concept, as there are few studies that have been able to define the active modality or combination in overall successful comprehensive pain rehabilitation programs. General principles are necessarily espoused on reasonable empiric bases which sound logical.40[III] If there is acceptance by both practitioner and patient, then positive results might occur. If one or both do not subscribe to the treatment premise, then no improvement will occur, or the situation might become even worse. It is an article of faith in the chronic pain and rehabilitation communities that interdisciplinary collaboration is essential for production of optimal outcomes. This is evident at the community level where the total expenditure on complementary and alternative medicine may exceed that on allopathic medicine.

An implicit assumption in CRPS treatment algorithms is that the precipitating or maintaining factors will be removed, or at least minimized. Unfortunately, there are no epidemiological data regarding this aspect of the condition. It could be argued that the Olmsted County study showed a high rate of "spontaneous" recovery because the underlying pathology was treated, without addressing the CRPS component. Clearly, more attention needs to be paid to this aspect of the problem. This author has seen patients who have not responded to conventional treatment of CRPS but who have recovered when an underlying problem was successfully treated. One case was referred after her insurance company declined further treatment after 49 stellate ganglion blocks. It was clear that she had carpal tunnel involvement, and she recovered after a surgeon could be prevailed upon to operate in the face of severe CRPS.

Integrated therapy has to address four interrelated aspects of functional restoration in CRPS. These aspects have been suggested as the result of thought experiments and not on the basis of evidence-based recommendations. The goal of therapy is to return the patient to pre-CRPS function at home, work, and community, with minimal ongoing involvement of the medical system. All aspects are ideally addressed simultaneously, continuing faith-based hope, rather than evidence-based outcomes.

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