Reanimation : The concept of emphasizing physical activity in the patient, given that commonly patients with CRPS are reluctant to move or permit manipulation of their affected limb, is vital to rehabilitation. As a corollary to this, immobilization is a poor prognostic sign, and pain programs must emphasize movement in CRPS patients as even healthy individuals will develop pain symptoms after prolonged immobilization [7]. Several therapy techniques aid in achieving reanimation.

Physical therapy: PT has long been a critical component of functional restoration, but it is used in conjunction with other therapies. It is often a first-line treatment of CRPS, and concomitant sympathetic nerve blocks may be used to improve the ability of the patient to participate in physical therapy and regain function [8]. PT may be intensive and can include desensitization, aerobic physical therapy, or hydrotherapy. Often it is supplemented by cognitive behavioral therapy. This has been shown to be particularly effective in treating childhood CRPS, reducing the rate of long-term dysfunction [9].

Graded motor imagery : This is one of the therapies with very strong evidence from multiple clinical trials that support its efficacy in CRPS patients. Graded motor imagery exercises are mental in nature and consist of three different components [10]:

These three components used for an intensive 2-week period can reduce pain in a statistically significant manner even in patients with long-standing intractable CRPS [11].

Occupational therapy : Occupational therapists (OTs) will evaluate the patient’s initial active range of motion, edema, coordination, dexterity, and ability to use the extremity during activities of daily living. This therapy may also utilize mirror visual feedback in an attempt to desensitize the patient to performing normal activities. Additionally, OTs often use a stress-loading program to improve the patient’s ability to use the affected limb for activities requiring strength or contact with substances causing pain [12]. In severe cases of CRPS, e.g., subtype 3, patients may need desensitization therapy with OT in order to tolerate the touch of clothing on the affected skin surfaces. If the patient is limited in even relatively benign activities due to pain, a sympathetic nerve block may assist in enabling the patient to participate in therapy [13].

Recreational therapy : In particularly recalcitrant cases of CRPS, recreational therapy is an attractive option to engage the patient in activity to break their phobia of movement or contact. If planned appropriately, recreational therapy may incorporate the goals of the physical therapist and occupational therapist [14].

Vocational rehabilitation : This is an advanced level rehabilitation therapy in which the patient is prepared for return to work. Alternatively it is termed “work hardening.” The vocational rehabilitation specialist must work closely with the patient to fully understand the physical demands of the patient’s prior occupation. Although it is utilized late in the rehabilitation process, vocational rehabilitation should also be addressed early on to ensure that the final goal of return to work is constantly the focus of the patient’s therapeutic process. The therapist may also work with the patient’s employer in an attempt to optimize the workplace for any new limitations the patient may possess [15].

A handful of medications have been evaluated in randomized controlled trials (RCTs) specifically for use in CRPS, but the majority of medications prescribed for the disease state have only been evaluated in other neuropathic syndromes.

Fusion of the inferior cervical and first thoracic ganglia forms the stellate ganglion, which is only present in 80% of the population and provides sympathetic innervation to the upper extremities, head, and neck. With a pure stellate ganglion block, a majority of the sympathetic nerves of the upper extremity will be blocked, but anomalous pathways exist that bypass the ganglion. These pathways, known as Kuntz’s nerves , are responsible for the incomplete nature of sympathetic blockade if a pure stellate ganglion block is performed without blockade of the second and third thoracic ganglia [26]. The stellate ganglion itself is usually 1–2.5 cm long, 1 cm wide, and 0.5 cm thick near the level of the C7 vertebrae. Although its location may vary, it is most often at the lateral border of the longus colli muscle (LCM) in the region anterior to the first rib and posterior to the vertebral vessels [27]. Therefore, the stellate ganglion is located in close proximity to various fragile soft tissue structures, which is responsible for the increasing popularity of ultrasound guidance as compared to the blind or even fluoroscopic techniques. Vulnerable soft tissues in the vicinity of the stellate ganglion include the esophagus, recurrent laryngeal nerve, pleural space, subarachnoid and epidural spaces, thyroid artery, and vertebral artery.

The vertebral artery consists of four segments . The first section stems from the subclavian artery and travels superiorly to the transverse foramen of the C6 vertebral body. At this point, the second segment begins and passes through the transverse foramina of C6–C2 vertebral bodies. The C2 level delineates the beginning of the third segment of the vertebral artery, which exits the C2 foramen and courses posteriorly to enter the dura at the foramen magnum. The fourth portion of the vertebral artery is entirely intracranial and spans from the foramen magnum to the basilar artery, where it joins the contralateral vertebral artery [28]. SGB requires needle manipulation in a position that is very near in the second segment of the vertebral artery. As this artery has wide anatomic variability, the distribution of stroke symptoms may differ for any patient that suffers an injury. However, the insult may fall into two broad categories: (1) CNS toxicity from direct injection of local anesthetic to the blood supply or (2) vertebral injury/spasm causing decreased blood flow to critical central nervous system structures.