Reflex sympathetic dystrophy: alternative modalities for pain management.

For the patient presenting with early symptoms (< 6 months) I usually start treatment with a dose pack of methylprednisolone, analgesics, and daily occupational/physical therapy for 2 weeks (Fig. 2). If they do not respond within the first week, I add stellate ganglion blocks and acupuncture to the treatment regimen. For patients presenting with established chronic pain, I immediately start them on a dose pack of methylprednisolone for 1 to 2 weeks, a nonsteroidal anti-inflammatory such as indomethacin, 50 mg 3 times a day for 10 days and then switch to 75 mg twice daily until there is a response. Amitriptyline is helpful for sleep and depression and also has a beneficial effect on blood flow. Calcium channel blockers (nifedipine) may help improve peripheral circulation by its effect on vascular smooth muscle. In this patient group, I almost always start stellate ganglion blocks on the first visit. I have the patient try at least 2 blocks before deciding whether or not blocks are helpful. Many patients will not respond to the first block, but will start to respond after the second block. If the blocks are helping, I recommend 3 blocks a week, every other day for 3 weeks. Patients get the most benefit from their blocks if they have occupational or physical therapy immediately following the block. Surgical sympathectomy may be helpful but only in patients who have responded to sympathetic blockade.