CRPS Bugle Extra | CRPS Treatment | Systematic review 2013 #CRPS

Specialist Pain Physio Clinics, LondonCossins et al. (2013) have just published a systematic review of the treatments for complex regional pain syndrome (CRPS).

Here is the abstract:

Complex regional pain syndrome (CRPS) is a disabling pain condition with sensory, motor and autonomic manifestations. Uncertainty remains about how CRPS can be effectively managed. We conducted a systematic review of randomized controlled trials (RCTs) for treatment and prophylactic interventions for CRPS published during the period 2000–2012, building on previous work by another group reviewing the period 1966–2000. Bibliographic database searches identified 173 papers which were filtered by three reviewers. This process generated 29 trials suitable for further analysis, each of which was reviewed and scored by two independent reviewers for methodological quality using a 15-item checklist. A number of novel and potentially effective treatments were investigated. Analysing the results from both review periods in combination, there was a steep rise in the number of published RCTs per review decade. There is evidence for the efficacy of 10 treatments (3¥ strong – bisphosphonates, repetitive transcranial magnetic stimulation and graded motor imagery, 1¥ moderate and 6¥ limited evidence), and against the efficacy of 15 treatments (1¥ strong, 1¥ moderate and ¥13 limited). The heterogeneity of trialled inter- ventions and the pilot nature of many trials militate against drawing clear conclusions about the clinical usefulness of most interventions. This and the observed phenomenon of excellent responses in CRPS subgroups would support the case for a network- and multi-centre approach in the conduct of future clinical trials. Most published trials in CRPS are small with a short follow-up period, although several novel interventions inves- tigated from 2000 to 2012 appear promising.

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Within the authors’ analysis they discuss medications, interventions and physiotherapy:

‘There is string evidence that rehabilitation/physiotherapy interventions can reduce pain and improve function for people with CRPS’

The problem with this is that it does not define what physiotherapy actually constitutes. This is with the exception of graded motor imagery (GMI) that is termed ‘a complex physiotherapy intervention’. I use GMI training for rehabilitation in CRPS, teaching individuals the principles of motor learning before guiding their training through the stages – see here. Typically alongside the GMI programme I run a range of strategies that are designed to develop resilience to the stress and anxiety associated with on-going pain. These techniques are skills that the individual learns and becomes accomplished at using to optimise their outcomes by grooving a positive mindset for rehabilitation. The benefits often pervade into other aspects of life as well as they become proficient at controlling attention and regulating emotion. This is a comprehensive and holistic approach to persisting pain using an integrated physical-cognitive-emotional model of care. Pain is multidimensional as is relief and both must be thought of in this way.

It is very useful to have a systematic review. The only omission as far as I can see is that of the effects of cognitive strategies in CRPS. In the general chronic pain literature there is a mass of evidence of the benefit and hence the absolute need to interlace such strategies into a programme.

Full article here: Treatment of CRPS | A systematic review

Visit our clinic page here: Specialist Pain Physio Clinics London

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