The most important factor in the management of CRPS is early diagnosis and early treatment. CRPS can affect a person at any age but has a peak onset at approximately 37–50 years [4]. Treatment of CRPS should be directed at restoring function and decreasing pain as soon as possible. Therapeutic guidelines include the multidisciplinary approach to treatment of pain, including physical therapy, medical intervention, and behavioral and psychological interventions. These have been proven most effective in the overall treatment of patients and their return to function with effective decrease in pain. Stanton-Hicks et al. reported specific guidelines in therapeutic intervention and algorithm for functional improvement, with the use of physical therapy at a measured pace and time contingent, to alleviate symptoms in a timely manner [5]. The following are essential to the treatment: the process of desensitization of the involved area, mobilization of the area, electrical stimulation if tolerated to reduce the pain secondary to myofascial changes, and isometric strengthening. Furthermore, a range of motion, stress loading, aerobic conditioning, and movement therapies, including vocational and functional rehabilitation, have been proposed in treatment algorithms for patients with CRPS. Adjunctive psychological intervention has been used in parallel with physical therapy to manage expectations, to improve motivation, and to use with behavioral, biofeedback, relaxation, imagery, and hypnosis techniques to help improve overall outcome (Fig. 3.1) [6].

Oral pharmacological treatment of CRPS has shown beneficial treatment with early-onset CRPS. The use of corticosteroids in early stages of CRPS has proven effective in some patients. Kozin et al. demonstrated that the pulsed use of steroids in patients with chronic regional pain syndrome showed improvement in 60–80 % of patients after 2 weeks [7]. Similarly, Christensen et al. confirmed decrease in pain in the first 3–4 months [8]. Farah et al. have also shown effectiveness of NSAIDS in some forms of CRPS in early stages of disease [9].

Opioid use has not been studied in controlled trials for the treatment of CRPS, although it is frequently used early in the treatment of CRPS. Intravenous use of opioids has shown some response in patients with neuropathic pain and may have a role in the treatment of severe CRPS [10, 11]. Other oral medication treatments such as gabapentin, carbamazepine, valproic acid, phenytoin, and tricyclic antidepressants have also shown beneficial effects in a subgroup of patients with CRPS [12–15].

Topical medications have shown efficacy in the treatment of neuropathic pain in those with diabetic and postherpetic neuralgia. This treatment may be an intuitive approach in treating allodynia and hyperalgesia at the affected area. Robbins et al. reported significant efficacy in patients with CRPS using large doses of topical capsaicin [16]. Davis et al. studied the topical use of clonidine to relieve the localized hyperalgesia in patients with sympathetically mediated pain, with favorable results [17]. Similarly, topical ketamine use as described by Finch et al. has been effective in reducing symptoms of allodynia among patients with CRPS [18].

Several forms of intravenous medication have shown promise in the treatment of CRPS. There are a number of controlled studies on bisphosphonate such as pamidronate, alendronate, and clodronate, all of which have shown considerable improvement in pain with patients with CRPS. Also, intravenous use of ketamine in the treatment of CRPS has shown a significant reduction in allodynia [19, 20]. Other intravenous medications such as lidocaine as demonstrated by Wallace et al to have shown to help decrease pain in patients with CRPS types I and II [21].

Interventional therap ies have been used in conjunction with manual and physical therapy as well as behavioral therapy in order to reduce pain and increase the likelihood of positive outcomes. These treatments should not be used in the absence of multimodality treatment and should not be started if there is no improvement with physical therapy.

Interventional therapies are best used as an adjunctive treatment to decrease pain and to allow faster improvement in symptoms. One such therapy, sympathetic nerve blockade, has been historically used among those with CRPS as a diagnostic and therapeutic intervention to alleviate pain. Several studies have shown a reduction in sympathetically mediated pain with this blockade [22]. These nerve blocks should be continued as long as they provide improvement. If the effect of the nerve blockade plateaus, other treatments should be considered. Intrathecal use of morphine and baclofen has also been studied in the treatment of CRPS [23].

Intravenous regional anesthesia refers to the use of clonidine and lidocaine, as described by Reuben and Sklar. They showed complete pain relief after 4–6 sessions of such treatment [24].

Spinal cord stimulation has been shown in a randomized control trial to alleviate pain among patients with refractory CRPS [25]. Furthermore, Harke et al. found improvement in pain among those who had previously responded well to sympathetic block, with reduction in their level of pain. This was a prerequisite to spinal cord stimulation [26].

Peripheral nerve stimulation and peripheral field stimulation are also viable options when conventional treatment protocols have not provided adequate relief [27]. The use of ultrasound-guided intervention to help directly visualize the affected nerve has allowed for the use of direct visualization techniques, such as imaging, to implant peripheral electrodes without need for surgical dissection. Others have used peripheral field stimulation for localized extremity pain or regional pain rather than directly stimulating the nerve [28]. Finally, the stimulation of the dorsal root ganglion has also been considered [29]. This offers more specific targeting of a regional area and may have value in treatment of refractory conditions.