Does physiotherapy improve pain and disability in adults with complex regional pain syndrome? – Cochrane

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Key messages
We are very uncertain if physiotherapy treatments improve the pain and disability associated with complex regional pain syndrome (CRPS).
We are very uncertain because the clinical trials we found:
– were not conducted or reported as well as they could have been (or both);
– included small numbers of patients with CRPS;
– tested a large range of different types of physiotherapy treatments; and
– because there were a limited number of trials that investigated any particular physiotherapy treatment.
We are very uncertain if physiotherapy treatments cause unwanted side effects; more evidence is required to clarify this.
Good-quality clinical trials are required to further investigate whether or not physiotherapy treatments improve the pain and disability associated with CRPS.
Treating pain and disability in adults with complex regional pain syndrome
Complex regional pain syndrome is a painful and disabling condition that can occur after 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 injury has not been identified and type II (CRPS II) where there is an identifiable nerve injury. Guidelines recommend that physiotherapy rehabilitation should be included as part of the treatment for CRPS. Physiotherapy for CRPS could include a range of treatments and rehabilitation approaches, such as exercise, pain management, manual therapy, electrotherapy or advice and education, either used alone or in combination. Physiotherapy is recommended because it is thought that it may improve the pain and disability associated with CRPS.
What did we want to find out?
We wanted to find out if physiotherapy treatments improve pain and disability in adults (aged over 18) with CRPS.
What did we do?
We searched for clinical trials that involved adults with CRPS, which compared physiotherapy treatments to placebo treatments or routine care or which compared different physiotherapy treatments to each other.
We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as trial methods, size and length of follow-up.
What did we find?
We found 33 clinical trials that involved 1317 people in total with CRPS type I of the upper or lower limb, or both. The trials investigated the effect of a range of physiotherapy treatments. We found only one trial involving 22 people with CRPS type II.
Here we present the findings from comparisons between different physiotherapy treatments and placebo treatments or routine care and for comparisons of different physiotherapy treatments to each other.
Reducing pain
We are uncertain if any of the physiotherapy treatments investigated in the clinical trials we identified help reduce the pain associated with CRPS.
Reducing disability
We are uncertain if any of the physiotherapy treatments investigated in the clinical trials we identified help reduce the disability associated with CRPS.
Side effects
We are uncertain if any of the physiotherapy treatments investigated in the clinical trials we identified cause any unwanted side effects.
What are the limitations of the evidence?
Clinical trials were small and most have been conducted in ways that could introduce errors into their results. This limited our confidence in the evidence.
How up to date is the evidence?
The evidence is up to date to July 2021.
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.
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.
To determine the effectiveness of physiotherapy interventions for treating pain and disability associated with CRPS types I and II in adults.
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.
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.
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.
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.

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