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. 2022 May 17;5(5):CD010853.
doi: 10.1002/14651858.CD010853.pub3.

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

Keith M Smart  1   2 , Michael C Ferraro  3   4 , Benedict M Wand  5 , Neil E O'Connell  6
Affiliations

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

Keith M Smart et al. Cochrane Database Syst Rev. .

Abstract

Background: Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually manifests in response to trauma or surgery and is associated with significant pain and disability. 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. This is the first update of the review originally published in Issue 2, 2016.

Objectives: To determine the effectiveness of physiotherapy interventions for treating pain and disability associated with CRPS types I and II in adults.

Search methods: For this update we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL, PsycINFO, LILACS, PEDro, Web of Science, DARE and Health Technology Assessments from February 2015 to July 2021 without language restrictions, we searched the reference lists of included studies and we contacted an expert in the field. We also searched additional online sources for unpublished trials and trials in progress.

Selection criteria: We included randomised controlled trials (RCTs) of physiotherapy interventions compared with placebo, no treatment, another intervention or usual care, or other physiotherapy interventions in adults with CRPS I and II. Primary outcomes were pain intensity and disability. Secondary outcomes were composite scores for CRPS symptoms, health-related quality of life (HRQoL), patient global impression of change (PGIC) scales and adverse effects.

Data collection and analysis: Two review authors independently screened database searches for eligibility, extracted data, evaluated risk of bias and assessed the certainty of evidence using the GRADE system.

Main results: We included 16 new trials (600 participants) along with the 18 trials from the original review totalling 34 RCTs (1339 participants). Thirty-three trials included participants with CRPS I and one trial included participants with CRPS II. Included trials compared a diverse range of interventions including physical rehabilitation, electrotherapy modalities, cortically directed rehabilitation, electroacupuncture and exposure-based approaches. Most interventions were tested in small, single trials. Most were at high risk of bias overall (27 trials) and the remainder were at 'unclear' risk of bias (seven trials). For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as very low, downgraded due to serious study limitations, imprecision and inconsistency. Included trials rarely reported adverse effects. Physiotherapy compared with minimal care for adults with CRPS I One trial (135 participants) of multimodal physiotherapy, for which pain data were unavailable, found no between-group differences in pain intensity at 12-month follow-up. Multimodal physiotherapy demonstrated a small between-group improvement in disability at 12 months follow-up compared to an attention control (Impairment Level Sum score, 5 to 50 scale; mean difference (MD) -3.7, 95% confidence interval (CI) -7.13 to -0.27) (very low-certainty evidence). Equivalent data for pain were not available. Details regarding adverse events were not reported. Physiotherapy compared with minimal care for adults with CRPS II We did not find any trials of physiotherapy compared with minimal care for adults with CRPS II.

Authors' conclusions: The evidence is very uncertain about the effects of physiotherapy interventions on pain and disability in CRPS. This conclusion is similar to our 2016 review. Large-scale, high-quality RCTs with longer-term follow-up are required to test the effectiveness of physiotherapy-based interventions for treating pain and disability in adults with CRPS I and II.

Trial registration: ClinicalTrials.gov NCT01944150 NCT02753335.

PubMed Disclaimer

Conflict of interest statement

KMS: none known. KMS maintains a small clinical caseload as a clinical specialist physiotherapist and manages patients with CRPS.

MCF: none known.

BMW: none known.

NOC: none known. NOC is an author as well as PaPaS Co‐ordinating Editor but had no input into the editorial decisions or processes for this review.

KMS, BMW and NOC are qualified physiotherapists, and MCF is a health scientist, although none currently practice in private health care or for a 'for profit' organisation.

Since NOC is an author and PaPaS Co‐ordinating Editor, we acknowledge the input of Christopher Eccleston, who acted as Sign‐off Editor for this review. NOC had no input into the editorial decisions or processes for this review.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included trial.
1.1
1.1. Analysis
Comparison 1: Graded motor imagery versus standard care, Outcome 1: Pain intensity (0 to 100 VAS; higher scores indicate worse pain) (post‐treatment)
1.2
1.2. Analysis
Comparison 1: Graded motor imagery versus standard care, Outcome 2: Disability (0 to 10 patient‐specific functional scale; higher scores indicate better function) (post‐treatment)
See this image and copyright information in PMC

Update of

References

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References to studies awaiting assessment

Dimitrijevic 2019 {unpublished data only}
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Dimitrijevic 2020 {published data only}
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ISRCTN39729827 {published data only}39729827
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Patru 2017 {unpublished data only}
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UKCRN ID 12602 {published data only}
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References to ongoing studies

ChiCTR1900020835 {unpublished data only}
    1. ChiCTR1900020835. Manual lymphatic drainage combined with transcranial magnetic stimulation for post-stroke type I complex regional pain syndrome: an exploratory clinical study. http://www.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR1900020835.
CTRI/2019/01/017272 {unpublished data only}
    1. CTRI/2019/01/017272. Efficacy of an integrated approach encompassing pregabalin and mirror therapy in management of complex regional pain syndrome type 1-a pilot study. http://www.who.int/trialsearch/Trial2.aspx?TrialID=CTRI/2019/01/017272.
JPRN‐UMIN000029801 {unpublished data only}
    1. JPRN-UMIN000029801. The effectiveness of graded mirror therapy based on the assessment of mirrored limb perception to the patients with complex regional pain syndrome. http://www.who.int/trialsearch/Trial2.aspx?TrialID=JPRN-UMIN000029801.
NCT02395211 {unpublished data only}
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NCT02753335 {unpublished data only}
    1. NCT02753335. A randomized trial of patients with complex regional pain syndrome comparing graded motor imagery and desensitization versus simple desensitization and changes in resting-state connectivity of cerebral networks before and after treatment. https://clinicaltrials.gov/ct2/show/NCT02753335 (first received 27 April 2016).
NCT03377504 {unpublished data only}
    1. NCT03377504. Clinical evaluation of the effects of mirror therapy in patients with complex regional pain syndrome (CRPS) type 1: prospective randomized single blind controlled study. https://clinicaltrials.gov/ct2/show/NCT03377504 (first received 19 December 2017).
NCT03887962 {unpublished data only}
    1. NCT03887962. Trial of virtual reality biofeedback in patients with motor neglect from chronic pain or cerebrovascular disease. https://clinicaltrials.gov/ct2/show/NCT03887962 (first received 25 March 2019).

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