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

Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually appears after trauma or surgery. The absence of a clear nerve lesion defines CRPS as type I (CRPS I), whereas the presence of a lesion defines it as CRPS type II (CRPS II). For the diagnosis of CRPS, Budapest criteria are used. Those criteria include CRPS main symptoms and signs, which usually involve only a single body region or limb. Typically, the symptoms and signs that characterize this syndrome include continuous pain, which is disproportionate to the inciting event; hyperaesthesia, allodynia vasomotor and sudomotor abnormalities; reduced range of motion; tremor; or trophic changes involving hair or nails. Moreover, any other medical condition that could explain the signs and symptoms should be excluded. The epidemiology of CRPS is not precisely known, but its incidence is estimated to be between 5 and 26 cases per 100,000 person-years.

This condition can be very disabling, diminishing the quality of life of the affected patients, and interfering with their daily activities, social relationships, sleep, work, and leisure time.

In this scenario, rehabilitation aims to reduce pain, minimise disabilities and enhance patients’ functional independence and quality of life.

Modern treatment guidelines recommend an interdisciplinary multimodal approach, comprising pharmacological, pain management strategies, rehabilitation, psychological therapy, and educational strategies. At present the benefits of physiotherapy are not known; nevertheless, it is always recommended in modern guidelines. This review investigated whether physiotherapy interventions are effective in reducing pain and disability in people with CRPS I or II.

This review is important for

People with CRPS and its related disability, their loved ones/caregivers, health professionals caring for this population, general practitioners, researchers, and policymakers.

Outcomes of this review

This is an update of a Cochrane Systematic Review (CSR) published in 2016. The outcomes analyzed were pain intensity and disability, CRPS symptoms scores, quality of life, patient global impression of change, and adverse events. The CSR included 33 clinical studies published and/or registered up to July 2021, with 1,317 participants. Results showed that compared with minimal care, multimodal physiotherapy had no significant difference in adults with CRPS for pain intensity at 12 months. On the other hand, this treatment produced a small positive effect on disability at 12 months follow-up compared to attention control.

These results must be interpreted with caution because (i) the diagnostic criteria of CRPS varied across time and consequently the trials’ inclusion criteria. (ii) The applicability of the results is limited since most of the trials were single-center, whereas in other cases the sites were not even reported. (iii) Most of the trials measured effects at end of treatment, only, or after three months, limiting the applicability of long-term effects. (iv) The interventions were heterogenous, and their (v) reporting was poor. (vi) The trials have not tested programs with multiple treatment modalities. (vii) In addition, few of the included trials reported adverse events. (viii) The studies had only a small sample size.

Author’s conclusion of the review

The authors are uncertain whether in patients with CRPS compared to active control, physiotherapy interventions improve pain, reduce disability, or produce any side effects at any point in time, short-, medium-, or long-term follow-up.

Future recommendations

The authors recommend that multicenter, collaborative research projects are needed to be able to recruit a sufficient number of patients; they suggest that telehealth/telerehabilitation could facilitate this process. Large, high-quality randomized controlled studies are needed, particularly to find out (a) the cost-effectiveness of multimodal physiotherapy treatment for pain and disability. (b) Emotional well-being is part of what constitutes the experience of pain and should be inquired about. The authors advise that (c) all future trials’ protocols be registered according to SPIRIT recommendations (Standard Protocol Items: Recommendations for Interventional Trials). To improve consistency, future trials should (d) conform to CONSORT guidance for reporting and evaluating complex interventions and use a standardized outcome measure core set for CRPS. (e) The outcomes should be reported at all time points and followed up over a clinically meaningful time.

Robin Kuruvila Sentinella