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Cited by 196Pain Management and TreatmentStroke Rehabilitation and RecoveryMusculoskeletal pain and rehabilitation

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Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II

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Smart, Keith M, Wand, Benedict M, O'Connell, Neil E·2016·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd010853.pub2PMC PMC8646955
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Abstract

BACKGROUND: Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually manifests in response to trauma or surgery. When it occurs, it is associated with significant pain and disability. It is thought to arise and persist as a consequence of a maladaptive pro-inflammatory response and disturbances in sympathetically-mediated vasomotor control, together with maladaptive peripheral and central neuronal plasticity. CRPS can be classified into two types: type I (CRPS I) in which a specific nerve lesion has not been identified, and type II (CRPS II) where there is an identifiable nerve lesion. Guidelines recommend the inclusion of a variety of physiotherapy interventions as part of the multimodal treatment of people with CRPS, although their effectiveness is not known. OBJECTIVES: To determine the effectiveness of physiotherapy interventions for treating the pain and disability associated with CRPS types I and II. SEARCH METHODS: We searched the following databases from inception up to 12 February 2015: CENTRAL (the Cochrane Library), MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, PEDro, Web of Science, DARE and Health Technology Assessments, without language restrictions, for randomised controlled trials (RCTs) of physiotherapy interventions for treating pain and disability in people CRPS. We also searched additional online sources for unpublished trials and trials in progress. SELECTION CRITERIA: We included RCTs of physiotherapy interventions (including manual therapy, therapeutic exercise, electrotherapy, physiotherapist-administered education and cortically directed sensory-motor rehabilitation strategies) employed in either a stand-alone fashion or in combination, compared with placebo, no treatment, another intervention or usual care, or of varying physiotherapy interventions compared with each other in adults with CRPS I and II. Our primary outcomes of interest were patient-centred outcomes of pain intensity and functional disability. DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated those studies identified through the electronic searches for eligibility and subsequently extracted all relevant data from the included RCTs. Two review authors independently performed 'Risk of bias' assessments and rated the quality of the body of evidence for the main outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: We included 18 RCTs (739 participants) that tested the effectiveness of a broad range of physiotherapy-based interventions. Overall, there was a paucity of high quality evidence concerning physiotherapy treatment for pain and disability in people with CRPS I. Most included trials were at 'high' risk of bias (15 trials) and the remainder were at 'unclear' risk of bias (three trials). The quality of the evidence was very low or low for all comparisons, according to the GRADE approach.We found very low quality evidence that graded motor imagery (GMI; two trials, 49 participants) may be useful for improving pain (0 to 100 VAS) (mean difference (MD) -21.00, 95% CI -31.17 to -10.83) and functional disability (11-point numerical rating scale) (MD 2.30, 95% CI 1.12 to 3.48), at long-term (six months) follow-up, in people with CRPS I compared to usual care plus physiotherapy; very low quality evidence that multimodal physiotherapy (one trial, 135 participants) may be useful for improving 'impairment' at long-term (12 month) follow-up compared to a minimal 'social work' intervention; and very low quality evidence that mirror therapy (two trials, 72 participants) provides clinically meaningful improvements in pain (0 to 10 VAS) (MD 3.4, 95% CI -4.71 to -2.09) and function (0 to 5 functional ability subscale of the Wolf Motor Function Test) (MD -2.3, 95% CI -2.88 to -1.72) at long-term (six month) follow-up in people with CRPS I post stroke compared to placebo (covered mirror).There was low to very low quality evidence that tactile discrimination training, stellate ganglion block via ultrasound and pulsed electromagnetic field therapy compared to placebo, and manual lymphatic drainage combined with and compared to either anti-inflammatories and physical therapy or exercise are not effective for treating pain in the short-term in people with CRPS I. Laser therapy may provide small clinically insignificant, short-term, improvements in pain compared to interferential current therapy in people with CRPS I.Adverse events were only rarely reported in the included trials. No trials including participants with CRPS II met the inclusion criteria of this review. AUTHORS' CONCLUSIONS: The best available data show that GMI and mirror therapy may provide clinically meaningful improvements in pain and function in people with CRPS I although the quality of the supporting evidence is very low. Evidence of the effectiveness of multimodal physiotherapy, electrotherapy and manual lymphatic drainage for treating people with CRPS

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  1. Hazneci, 2005, The effects of transcutaneous electroneurostimulation and ultrasound in the treatment of reflex sympathetic dystrophy syndrome, Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi [Turkish Journal of Physical Medicine and Rehabilitation], 51, 83
  2. Mucha, 1992, Effects of CO2-baths in the combined concept of the early functional therapy in cases of algodystrophy, Physikalische Medizin und Kur Medizin, 2, 173
  3. Atkins, 2010, Principles of complex regional pain syndrome, 1, 602
  4. Goebel, 2012, Complex Regional Pain Syndrome in Adults: UK Guidelines for Diagnosis, Referral and Management in Primary and Secondary Care
  5. Moore, 2008, Managing potential publication bias, 15
  6. The Nordic Cochrane Centre; The Cochrane Collaboration Review Manager 2014

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Metadata

Authors
Smart, K. M., Wand, B. M., & O'Connell, N. E.
Affiliations
  • St. Vincent's University Hospital (IE)
  • The University of Notre Dame Australia (AU)
  • Brunel University of London (GB)
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2016-02-24
Volume
2016
Issue
3
Pages
CD010853-CD010853
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd010853.pub2
PMC
PMC8646955
OpenAlex
W1892003845
Cited by
196
References
126
Citations by year
2026: 7 · 2025: 15 · 2024: 23 · 2023: 25 · 2022: 20 · 2021: 31 · 2020: 18 · 2019: 13 · 2018: 23 · 2017: 15 · 2016: 5
FWCI
3.49
Type
journal article
Language
en
Update notices
new_version (2022-05-17)
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • ResearchOnline@ND (The University of Notre Dame) (submittedVersion)
  • Brunel University Research Archive (BURA) (Brunel University London) (submittedVersion)
Topics
  • Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
  • Health Sciences › Medicine › Rehabilitation › Stroke Rehabilitation and Recovery
  • Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
Keywords
complex regional pain syndrome, CRPS type I, CRPS type II, physiotherapy intervention, pain intensity, functional disability, manual therapy, exercise therapy, electrotherapy, multimodal therapy, treatment effectiveness, quality of evidence, risk of bias, GRADE assessment, post-traumatic pain, postoperative pain
MeSH terms
Adult, Humans, Pain Measurement, Randomized Controlled Trials as Topic, Complex Regional Pain Syndromes, Physical Therapy Modalities

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