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Meta-Analysis
. 2013 Apr 30;2013(4):CD009416.
doi: 10.1002/14651858.CD009416.pub2.

Interventions for treating pain and disability in adults with complex regional pain syndrome

Neil E O'Connell  1 , Benedict M Wand, James McAuley, Louise Marston, G Lorimer Moseley
Affiliations
Meta-Analysis

Interventions for treating pain and disability in adults with complex regional pain syndrome

Neil E O'Connell et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: There is currently no strong consensus regarding the optimal management of complex regional pain syndrome although a multitude of interventions have been described and are commonly used.

Objectives: To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the effectiveness of any therapeutic intervention used to reduce pain, disability or both in adults with complex regional pain syndrome (CRPS).

Methods: We identified Cochrane reviews and non-Cochrane reviews through a systematic search of the following databases: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Ovid MEDLINE, Ovid EMBASE, CINAHL, LILACS and PEDro. We included non-Cochrane systematic reviews where they contained evidence not covered by identified Cochrane reviews. The methodological quality of reviews was assessed using the AMSTAR tool.We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes of quality of life, emotional well being and participants' ratings of satisfaction or improvement. Only evidence arising from randomised controlled trials was considered. We used the GRADE system to assess the quality of evidence.

Main results: We included six Cochrane reviews and 13 non-Cochrane systematic reviews. Cochrane reviews demonstrated better methodological quality than non-Cochrane reviews. Trials were typically small and the quality variable.There is moderate quality evidence that intravenous regional blockade with guanethidine is not effective in CRPS and that the procedure appears to be associated with the risk of significant adverse events.There is low quality evidence that bisphosphonates, calcitonin or a daily course of intravenous ketamine may be effective for pain when compared with placebo; graded motor imagery may be effective for pain and function when compared with usual care; and that mirror therapy may be effective for pain in post-stroke CRPS compared with a 'covered mirror' control. This evidence should be interpreted with caution. There is low quality evidence that local anaesthetic sympathetic blockade is not effective. Low quality evidence suggests that physiotherapy or occupational therapy are associated with small positive effects that are unlikely to be clinically important at one year follow up when compared with a social work passive attention control.For a wide range of other interventions, there is either no evidence or very low quality evidence available from which no conclusions should be drawn.

Authors' conclusions: There is a critical lack of high quality evidence for the effectiveness of most therapies for CRPS. Until further larger trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult.

PubMed Disclaimer

Conflict of interest statement

GLM receives a salary from the National Health and Medical Research Council of Australia and University of South Australia.

One of our group (GLM) was the sole author on the two included trials of GMI (Moseley 2004; Moseley 2006) and has co‐authored a recent textbook on its use in chronic pain, including CRPS. This author was not involved in the data extraction process related to GMI nor the writing of the results relating to this approach.

NOC, BMW and LM were all authors of one of the included reviews (O'Connell 2010). As such, to reduce bias a different author (JM) performed the primary AMSTAR assessment and data extraction on this review.

Figures

1
1
Study flow diagram.
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2
Effect sizes for RCTs of bisphosphonates versus placebo (immediate post‐treatment period).
3
3
Meta‐analysis using SMD of pain VAS scores for studies of ketamine identified in the review by Collins 2011.
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4
Meta‐analysis using mean difference of pain VAS scores for studies of ketamine identified in the review by Collins 2011.
5
5
Mean difference calculated for the trial of tadalafil versus placebo (Groeneweg 2008).
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6
Physiotherapy (PT) versus social work (SW). Outcome: pain (0‐100 VAS). Data extracted by hand from graphical format (Oerlemans 1999a).
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Occupational therapy (OT) versus social work (SW). Outcome: pain (0‐100 VAS). Data extracted by hand from graphical format (Oerlemans 1999a).
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8
Physiotherapy (PT) versus social work (SW). Outcome: impairment (0‐50 scale). Data extracted by hand from graphical format (Oerlemans 1999).
9
9
Occupational therapy (OT) versus social work (SW). Outcome: impairment (0‐50 scale). Data extracted by hand from graphical format (Oerlemans 1999).
10
10
Meta‐analysis of GMI programmes versus usual care for pain. Outcome 0‐100 VAS. Immediate post‐treatment results.
11
11
Meta‐analysis of GMI programmes versus usual care for pain. Outcome 0‐100 VAS. Results at follow up (3 or 6 months).
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Meta‐analysis of GMI programmes versus usual care for function. Outcome 0‐11 patient specific functional scale. Immediate post‐treatment results.
13
13
Meta‐analysis of GMI programmes versus usual care for function. Outcome 0‐11 patient‐specific functional scale. Results at follow up (3 or 6 months).
See this image and copyright information in PMC

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