Treatment of complex regional pain syndrome

Pain and motor impairments of the hand or foot are typical symptoms of complex regional pain syndrome (CRPS). It is a chronic pain syndrome that may be caused by nerve damage following surgery, injury, or disease, but it may also occur without confirmed nerve damage. Treatments are often aimed at reducing pain and improve physical function of the limb.

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Question

What systematic reviews are there on treatment of complex regional pain syndrome?

Identified literature

Table 1. Systematic reviews with low/moderate risk of bias
CI = Confidence Interval; CRPS = Complex Regional Pain Syndrome; GRADE = Grading of Recommendations, Assessment, Development and Evaluations; n = Number of studies; NRS = Numerical Rating Scale (0–10); MD = Mean Difference; RCT = Randomised controlled trial; SHS = Shoulder Hand Syndrome; VAS = Visual Analogue Scale (10 cm line with verbal endpoints at 0 and 10)
Included studies Population/Intervention Outcome and Results
Smart et al, 2016, [1]
Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II
18 RCTs, 739 subjects Population:
Adults diagnosed with CRPS type 1.

Intervention:
Physiotherapy treatments, such as electrotherapy, cortically directed sensory-motor rehabilitation strategies, exercise, manual lymphatic drainage, and pain management advice.

Control:
Placebo (n=5) or other intervention (n=18)		 Pain intensity/severity
(18 studies)
No reduction in pain:
– Virtual body swapping (1 study)
– Tactile discrimination training (1 study)
Very low quality of evidence

No more effective at reducing pain compared to control:
– Stellate ganglion block (2 studies)
– Pulsed electromagnetic field (1 study)
– Manual lymphatic drainage therapy (2 studies)
Low quality of evidence

May be more effective at reducing pain compared to control:
– Multimodal physiotherapy (1 study)
– Graded motor imagery (4 studies)
– Mirror therapy (2 studies)
– Laser therapy (1 study)
– Carbon dioxide baths (1 study)
– Electro-acupuncture (1 study)
Very low quality of evidence

May be inferior compared to control:
– Stellate ganglion block (1 study)
Low quality of evidence

Disability/impairment
(9 studies)
Not more effective for improving hand-specific function than control:
– Electro-acupuncture (1 study)
Very low quality of evidence

Not more effective at improving range of motion than control:
Pulsed electromagnetic field (1 study).
Low quality of evidence

May be more effective at reducing impairment than control:
– Multimodal physiotherapy (1 study)
– Graded motor imagery (4 studies)
– Mirror therapy (2 studies)
Very low quality of evidence
Authors' conclusion:
“Given the paucity of high quality of evidence derived from our analyses of the 18 included randomised controlled trials (RCTs) (739 participants), we cannot draw any firm conclusions regarding the effectiveness or harmfulness of a broad range of physiotherapy-based interventions for treating the pain and disability associated with complex regional pain syndrome (CRPS) I in adults.”
Liu et al, 2019, [2]
Acupuncture for Post-stroke Shoulder-Hand Syndrome: A systematic review and meta-analysis
38 RCTs, 3184 subjects Population:
Patients diagnosed with post-stroke shoulder-hand syndrome/CRPS type 1

Intervention:
Acupuncture (manual or electroacupuncture) + Routine rehabilitation
Control:
Routine rehabilitation		 Pain intensity
(25 studies, 1896 subjects)
After treatment (VAS, 0–10 cm):
MD: −1.59
(95% CI, −1.86 to −1.32)
Low certainty of evidence

Motor function
(29 studies, 2331 subjects)
After treatment (Fugl-Meyer Assessment, 0–66 points):
MD: 8.01
(95% CI, 6.69 to 9.33)
Low certainty of evidence

Range om motion (ROM)
(3 studies, number of subjects not reported)
After treatment (shoulder abduction in degrees):
MD: 11.94 degrees
(95% CI, 9.44 to 14.45)
Low certainty of evidence
Authors' conclusion:
“This systematic review shows that adding acupuncture to routine rehabilitation can improve clinical outcomes (pain and motor function) for people with mild post-stroke SHS. However, the evidence was assessed as “low” by GRADE due to the methodological limitations and heterogeneity of included studies, which made our certainty in recommending acupuncture for this condition in clinical practice as “low.””
O'Connell et al, 2016, [3]
Local anaesthetic sympathetic blockade for complex regional pain syndrome
12 RCTs, 461 subjects Population:
Adults with CRPS

Intervention:
Local anaesthetic sympathetic blockade (LASB)

Control:
Placebo (n=2), other intervention (n=9), or LASB + other intervention (n=2)		 Pain intensity
(VAS, NRS or4-point Hand pain scale)
No difference in pain:
– Treatment vs other interventions (3 studies).
Low to very low quality of evidence

No difference in pain:
– Treatment vs placebo (Note: in total 23 subjects from 2 studies, of which one study lacked direct group comparison)
Moderate quality of evidence

Studies show benefit of treatment for some follow-up time points but not for others: 4 studies.
Low to very low quality of evidence

Adding LASB to another intervention:
– Beneficial in one study
– No benefit in the other
Very low quality of evidence

Duration of pain relief
Botulinum toxin (1 study, 9 subjects):
Longer analgesic effect than bupivacaine
Low quality of evidence
Authors' conclusion:
“Given the limited evidence available and the various sources of potential bias and uncertainty, we conclude that there is little credible evidence to support the use of LASB for CRPS and that the majority of the limited evidence available suggests that LASB may be ineffective.”

References

  1. Smart KM, Wand BM, O'Connell NE. Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Database Syst Rev. 2016;2:CD010853. Available from: https://doi.org/10.1002/14651858.CD010853.pub2.
  2. Liu S, Zhang CS, Cai Y, Guo X, Zhang AL, Xue CC, et al. Acupuncture for Post-stroke Shoulder-Hand Syndrome: A Systematic Review and Meta-Analysis. Front Neurol. 2019;10:433. Available from: https://doi.org/10.3389/fneur.2019.00433.
  3. O'Connell NE, Wand BM, Gibson W, Carr DB, Birklein F, Stanton TR. Local anaesthetic sympathetic blockade for complex regional pain syndrome. Cochrane Database Syst Rev. 2016;7:CD004598. Available from: https://doi.org/10.1002/14651858.CD004598.pub4.
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Published: Report no: ut202211 Registration no: SBU 2021/643
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Literature search

Embase via Elsevier 17 January 2022

Title: Treatment of complex regional pain syndrome
The final search result, usually found at the end of the documentation, forms the list of abstracts.

/de = Term from the EMTREE controlled vocabulary; /exp = Includes terms found below this term in the EMTREE hierarchy; /mj = Major Topic; :ab = Abstract; :au = Author; :ti = Article Title; :ti,ab = Title or abstract; * = Truncation; ' ' = Citation Marks; searches for an exact phrase; NEAR/n = Requests terms that are within 'n' words of each other in either direction; NEXT/n = Requests terms that are within 'n' words of each other in the order specified
Search terms Items found
Population: Complex regional pain syndrome
1. 'complex regional pain syndrome'/exp 11 211
2. 'complex regional pain syndrome*':ti,ab,kw 4 990
3. algodystrophy:ti,ab,kw 659
4. algoneurodystrophy:ti,ab,kw 84
5. (sudeck* NEAR/3 atrophy):ti,ab,kw 223
6. #1 OR #2 OR #3 OR #4 OR #5 12 029
Study types: Systematic reviews and meta-analyses 
7. 'systematic review'/de OR 'meta analysis'/exp OR 'cochrane database syst rev':ta OR ((systematic NEAR/3 review):ti,ab) OR 'meta analys*':ti,ab OR metaanalys*:ti,ab 556 565
Combined sets
8. #6 AND #7 451
Final result
  #8 451

Medline via OvidSP 25 March 2022

Title: Treatment of complex regional pain syndrome
The final search result, usually found at the end of the documentation, forms the list of abstracts.
.ab. = Abstract; .ab,ti. = Abstract or title; .af. = All fields; Exp = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; .sh. = Term from the Medline controlled vocabulary; .ti. = Title; / = Term from the Medline controlled vocabulary, but does not include terms found below this term in the MeSH hierarchy; * = Focus (if found in front of a MeSH-term); * or $ = Truncation (if found at the end of a free text term); .mp = Text, heading word, subject area node, title; “ “ = Citation Marks; searches for an exact phrase; ADJn = Positional operator that lets you retrieve records that contain your terms (in any order) within a specified number (n) of words of each other.
Search terms Items found
Population: Complex regional pain syndrome
1. complex regional pain syndromes/ or causalgia/ or reflex sympathetic dystrophy/ 5 805
2. "complex regional pain syndrome*".ab,kf,ti. 3 437
3. algodystrophy.ab,kf,ti. 440
4. algoneurodystrophy.ab,kf,ti. 59
5. ((sudeck's or sudecks) adj atrophy).ab,kf,ti. 164
6. #1 OR #2 OR #3 OR #4 OR #5 7 249
Study types: Systematic reviews and meta-analyses
7. (Systematic Review or Meta-Analysis).pt. or Cochrane Database Syst Rev.ja. or ((systematic adj3 review) or "meta analys*" or metaanalys*).ti,ab. 380 789
Combined sets
8. #6 AND #7 173
Final result
  #8 173
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