Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews

  • Review
  • Overview

Authors


Abstract

Background

There is currently no strong consensus regarding the optimal management of complex regional pain syndrome although a multitude of interventions have been described and are commonly used.

Objectives

To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the effectiveness of any therapeutic intervention used to reduce pain, disability or both in adults with complex regional pain syndrome (CRPS).

Methods

We identified Cochrane reviews and non-Cochrane reviews through a systematic search of the following databases: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Ovid MEDLINE, Ovid EMBASE, CINAHL, LILACS and PEDro. We included non-Cochrane systematic reviews where they contained evidence not covered by identified Cochrane reviews. The methodological quality of reviews was assessed using the AMSTAR tool.

We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes of quality of life, emotional well being and participants' ratings of satisfaction or improvement. Only evidence arising from randomised controlled trials was considered. We used the GRADE system to assess the quality of evidence.

Main results

We included six Cochrane reviews and 13 non-Cochrane systematic reviews. Cochrane reviews demonstrated better methodological quality than non-Cochrane reviews. Trials were typically small and the quality variable.

There is moderate quality evidence that intravenous regional blockade with guanethidine is not effective in CRPS and that the procedure appears to be associated with the risk of significant adverse events.

There is low quality evidence that bisphosphonates, calcitonin or a daily course of intravenous ketamine may be effective for pain when compared with placebo; graded motor imagery may be effective for pain and function when compared with usual care; and that mirror therapy may be effective for pain in post-stroke CRPS compared with a 'covered mirror' control. This evidence should be interpreted with caution. There is low quality evidence that local anaesthetic sympathetic blockade is not effective. Low quality evidence suggests that physiotherapy or occupational therapy are associated with small positive effects that are unlikely to be clinically important at one year follow up when compared with a social work passive attention control.

For a wide range of other interventions, there is either no evidence or very low quality evidence available from which no conclusions should be drawn.

Authors' conclusions

There is a critical lack of high quality evidence for the effectiveness of most therapies for CRPS. Until further larger trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult.

Plain language summary

Which treatments are effective for the treatment of complex regional pain syndrome in adults?

Complex regional pain syndrome (CRPS) is characterised by persistent pain, usually in the hands or feet, that is not proportionate in severity to any underlying injury. It often involves a variety of other symptoms such as swelling, discolouration, stiffness, weakness and changes to the skin. This overview sought to summarise and report all of the available evidence arising from systematic reviews for all treatments for this condition regarding how well they work and any potential harm that they might cause.

We identified six Cochrane reviews and 13 non-Cochrane systematic reviews that included evidence relating to a broad range of treatments, from drugs to surgical procedures, rehabilitation and alternative therapies. For most treatments there were only a small number of published trials and the quality of these trials was mixed. As such, most of the evidence for most treatments is of low or very low quality and can not be regarded as reliable.

We found low quality evidence that a daily course of the drug ketamine delivered intravenously may effectively reduce pain, although it is also associated with a variety of side effects. We found low quality evidence that the bisphosphonate class of drugs, calcitonin and programmes of graded motor imagery may be effective for CRPS, and that mirror therapy may be effective in people who develop CRPS after suffering a stroke. Low quality evidence suggested that physiotherapy and occupational therapy did not lead to clinically important benefits at one year follow up, and that blocking sympathetic nerves with local anaesthetic is not effective. There is moderate quality evidence that an intravenous regional blockade using the drug guanethidine is not effective and may be associated with complications.

For a range of other interventions we found only very low quality evidence or no evidence at all. No conclusions should be drawn regarding the value of these interventions based on this level of evidence.

Based on the existing evidence it is difficult to draw firm conclusions as to which therapies should be offered to patients with CRPS. Better quality research is vital to reduce uncertainty in this area and is necessary before confident recommendations can be made.

Laički sažetak

Terapije za liječenje boli i onesposobljenosti u odraslih s kompleksnim regionalnim bolnim sindromom - prikaz svih Cochrane sustavnih pregleda

Kompleksni regionalni bolni sindrom (KRBS) obilježava trajna bol, obično u šakama i stopalima, koja nije proporcionalna težini bilo kakve postojeće ozljede. Često uključuje niz drugih simptoma kao što su otekline, promjene boje tkiva, ukočenost, slabost i promjene na koži. U ovom prikazu svih Cochrane sustavnih pregleda na tu temu, analizirani su i prikazani svi dostupni dokazi iz sustavnih pregleda objavljenih u Cochrane knjižnicu, u kojem je ispitano koje sve terapije mogu djelovati na to stanje, i kakve potencijalne štetne učinke mogu imati.

Pronađeno je 6 Cochrane sustavnih pregleda i 13 sustavnih pregleda izvan Cochrane knjižnice, a koji su uključili dokaze koji se odnose na različite terapije, uključujući lijekove, kirurške postupke, rehabilitaciju i alternativne terapije. Za većinu terapija pronađen je samo malen broj objavljenih kliničkih pokusa, a kvaliteta tih studija bila je raznolika. Stoga je većina dokaza, za većinu terapija, niske ili vrlo niske kvalitete, i ne mogu se smatrati pouzdanima.

Pronađeni su dokazi niske kvalitete da svakodnevno davanje lijeka ketamina (intravenski) može djelotvorno ublažiti bol, iako je povezan s nizom nuspojava. Pronađeni su dokazi loše kvalitete da bisfosfonati, kalcitonin i programi postupnih motoričkih prikaza i terapija pomoću zrcala mogu biti djelotvorni u osoba koje razviju KRBS nakon moždanog udara. Dokazi niske kvalitete ukazuju da fizioterapija i radna terapija ne dovode do klinički važnih poboljšanja nakon godinu dana praćenja, i da blokiranje simpatičkih živaca lokalnim anestetikom nije djelotvorno. Pronađeni su dokazi umjerene kvalitete da intravenska regionalna blokada korištenjem lijeka gvanetidina nije djelotvorna i da može biti povezana s komplikacijama.

Za niz drugih postupaka pronađeni su samo dokazi vrlo niske kvalitete ili nikakvi dokazi. O vrijednosti tih intervencija, temeljem takve razine dokaza, nema smisla donositi zaključke.

Temeljem postojećih dokaza teško je donositi čvrste zaključke o terapijama koje bi trebalo ponuditi pacijentima koji pate od KRBS. Nužno je provesti istraživanja bolje kvalitete kako bi se umanjile dvojbe u tom području medicine, i kako bi se mogle dati odgovarajuće pouzdane preporuke.

Bilješke prijevoda

Hrvatski Cochrane
Prevela: Livia Puljak
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

Ancillary