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Canadian Journal of Anesthesia/Journal canadien d'anesthésie
Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie 2/2010

01-02-2010 | Review Article/Brief Review

Treatment of complex regional pain syndrome: a review of the evidence

Authors: De Q. H. Tran, MD, Silvia Duong, BScPhm, Pietro Bertini, MD, Roderick J. Finlayson, MD

Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie | Issue 2/2010

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Abstract

Purpose

This narrative review summarizes the evidence derived from randomized controlled trials pertaining to the treatment of complex regional pain syndrome (CRPS).

Source

Using the MEDLINE (January 1950 to April 2009) and EMBASE (January 1980 to April 2009) databases, the following medical subject headings (MeSH) were searched: “Complex Regional Pain Syndrome”, “Reflex Sympathetic Dystrophy”, and “causalgia” as well as the key words “algodystrophy”, “Sudeck’s atrophy”, “shoulder hand syndrome”, “neurodystrophy”, “neuroalgodystrophy”, “reflex neuromuscular dystrophy”, and “posttraumatic dystrophy”. Results were limited to randomized controlled trials (RCTs) conducted on human subjects, written in English, published in peer-reviewed journals, and pertinent to treatment.

Principal findings

The search criteria yielded 41 RCTs with a mean of 31.7 subjects per study. Blinded assessment and sample size justification were provided in 70.7% and 19.5% of RCTs, respectively. Only biphosphonates appear to offer clear benefits for patients with CRPS. Improvement has been reported with dimethyl sulfoxide, steroids, epidural clonidine, intrathecal baclofen, spinal cord stimulation, and motor imagery programs, but further trials are required. The available evidence does not support the use of calcitonin, vasodilators, or sympatholytic and neuromodulative intravenous regional blockade. Clear benefits have not been reported with stellate/lumbar sympathetic blocks, mannitol, gabapentin, and physical/occupational therapy.

Conclusions

Published RCTs can only provide limited evidence to formulate recommendations for treatment of CRPS. In this review, no study was excluded based on factors such as sample size justification, statistical power, blinding, definition of intervention allocation, or clinical outcomes. Thus, evidence derived from “weaker” trials may be overemphasized. Further well-designed RCTs are warranted.
Appendix
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Footnotes
1
The following article has been retracted: Reuben SS, Rosenthal EA, Steinberg RB, Faruqi S, Kilaru PA. Surgery on the affected upper extremity of patients with a history of complex regional pain syndrome: the use of intravenous regional anesthesia with clonidine. J Clin Anesth 2004; 16: 517-22.
 
Literature
1.
Sharma A, Agarwal S, Broatch J, Raja SN. A web-based cross-sectional epidemiological survey of complex regional pain syndrome. Reg Anesth Pain Med 2009; 34: 110-5.CrossRefPubMed
2.
Stanton-Hicks M, Janig W, Hassenbusch S, Haddox JD, Boas R, Wilson P. Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain 1995; 63: 127-33.CrossRefPubMed
3.
Bickerstaff DR, Kanis JA. The use of nasal calcitonin in the treatment of post-traumatic algodystrophy. Br J Rheumatol 1991; 30: 291-4.CrossRefPubMed
4.
Gobelet C, Meier JL, Schaffner W, Bischof-Delaloye A, Gerster JC, Burckhardt P. Calcitonin and reflex sympathetic dystrophy syndrome. Clin Rheumatol 1986; 5: 382-8.CrossRefPubMed
5.
Gobelet C, Waldburger M, Meier JL. The effect of adding calcitonin to physical treatment on reflex sympathetic dystrophy. Pain 1992; 48: 171-5.CrossRefPubMed
6.
Sahin F, Yilmaz F, Kotevoglu N, Kuran B. Efficacy of salmon calcitonin in complex regional pain syndrome (type 1) in addition to physical therapy. Clin Rheumatol 2006; 25: 143-8.CrossRefPubMed
7.
Adami S, Fossaluzza V, Gatti D, Fracassi E, Braga V. Bisphosphonate therapy of reflex sympathetic dystrophy syndrome. Ann Rheum Dis 1997; 56: 201-4.CrossRefPubMed
8.
Manicourt DH, Brasseur JP, Boutsen Y, Depreseux G, Devogelaer JP. Role of alendronate in therapy for posttraumatic complex regional pain syndrome type 1 of the lower extremity. Arthritis Rheum 2004; 50: 3690-7.CrossRefPubMed
9.
Varenna M, Zucchi F, Ghiringhelli D, et al. Intravenous clodronate in the treatment of reflex sympathetic dystrophy syndrome. A randomized, double blind, placebo controlled study. J Rheumatol 2000; 27: 1477-83.
10.
Robinson JN, Sandom J, Chapman PT. Efficacy of pamidronate in complex regional pain syndrome type I. Pain Med 2004; 5: 276-80.CrossRefPubMed
11.
Zuurmond WW, Langendikj PN, Bezemer PD, Brink HE, De Lange JJ, van Loenen AC. Treatment of acute reflex sympathetic dystrophy with DMSO 50% in a fatty cream. Acta Anaesthesiol Scand 1996; 40: 364-7.CrossRefPubMed
12.
Geertzen JH, de Bruijn H, de Bruijn-Kofman AT, Arendzen JH. Reflex sympathetic dystrophy: early treatment and psychological aspects. Arch Phys Med Rehabil 1994; 75: 442-6.CrossRefPubMed
13.
Perez RS, Zuurmond WW, Bezemer PD, et al. The treatment of complex regional pain syndrome type I with free radical scavengers: a randomized controlled study. Pain 2003; 102: 297-307.CrossRefPubMed
14.
van Dieten HE, Perez RS, van Tulder MW, et al. Cost effectiveness and cost utility of acetylcysteine versus dimethyl sulfoxide for reflex sympathetic dystrophy. Pharmacoeconomics 2003; 21: 139-48.CrossRefPubMed
15.
Perez RS, Pragt E, Geurts J, Zuurmond WW, Patijn J, van Kleef M. Treatment of patients with complex regional pain syndrome type I with mannitol: a prospective, randomized, placebo-controlled, double-blinded study. J Pain 2008; 9: 678-86.CrossRefPubMed
16.
Christensen K, Jensen EM, Noer I. The reflex dystrophy syndrome response to treatment with systemic corticosteroids. Acta Chir Scand 1982; 148: 653-5.PubMed
17.
Braus DF, Krauss JK, Strobel J. The shoulder-hand syndrome after stroke: a prospective clinical trial. Ann Neurol 1994; 36: 728-33.CrossRefPubMed
18.
Kalita J, Vajpayee A, Misra UK. Comparison of prednisolone with piroxicam in complex regional pain syndrome following stroke: a randomized controlled trial. QJM 2006; 99: 89-95.CrossRefPubMed
19.
van de Vusse AC, Stomp-van den Berg SG, Kessels AH, Weber WE. Randomised controlled trial of gabapentin in complex regional pain syndrome type 1 [ISRCTN84121379]. BMC Neurol 2004; 4: 13.CrossRefPubMed
20.
Groeneweg G, Huygen FJ, Niehof SP, et al. Effects of tadalafil on blood flow, pain, and function in chronic cold complex regional pain syndrome: a randomized controlled trial. BMC Musculoskelet Disord 2008; 9: 143.CrossRefPubMed
21.
Ogawa S, Suzuki H, Shiotani M, et al. A randomized clinical trial of sarpogrelate hydrochloride for neuropathic pain in patients with post-herpetic neuralgia and reflex sympathetic dystrophy. Pain Clinic 1998; 11: 125-32.
22.
Blanchard J, Ramamurthy S, Walsh N, Hoffman J, Schoenfeld L. Intravenous regional sympatholysis: a double-blind comparison of guanethidine, reserpine, and normal saline. J Pain Symptom Manage 1990; 5: 357-61.CrossRefPubMed
23.
Jadad AR, Carroll D, Glynn CJ, McQuay HJ. Intravenous regional sympathetic blockade for pain relief in reflex sympathetic dystrophy: a systematic review and a randomized, double-blind crossover study. J Pain Symptom Manage 1995; 10: 13-20.CrossRefPubMed
24.
Livingstone JA, Atkins RM. Intravenous regional guanethidine blockade in the treatment of post-traumatic complex regional pain syndrome type 1 (algodystrophy) of the hand. J Bone Joint Surg Br 2002; 84: 380-6.CrossRefPubMed
25.
Kettler RE, Abram SE. Intravenous regional droperidol in the management of reflex sympathetic dystrophy: a double-blind, placebo-controlled, crossover study. Anesthesiology 1988; 69: 933-6.CrossRefPubMed
26.
Hanna MH, Peat SJ. Ketanserin in reflex sympathetic dystrophy. A double-blind placebo controlled cross-over trial. Pain 1989; 38: 145-50.
27.
Glynn CJ, Stannard C, Collins PA, Casale R. The role of peripheral sudomotor blockade in the treatment of patients with sympathetically maintained pain. Pain 1993; 53: 39-42.CrossRefPubMed
28.
Taskaynatan MA, Ozgul A, Tan AK, Dincer K, Kaylon TA. Bier block with methylprednisolone and lidocaine in CRPS type I: a randomized, double-blinded, placebo-controlled study. Reg Anesth Pain Med 2004; 29: 408-12.PubMed
29.
Rocco AG, Kaul AF, Reisman RM, Gallo JP, Lief PA. A comparison of regional intravenous guanethidine and reserpine in reflex sympathetic dystrophy. A controlled, randomized, double-blind crossover study. Clin J Pain 1989; 5: 205-9.
30.
Ramamurthy S, Hoffman J. Intravenous regional guanethidine in the treatment of reflex sympathetic dystrophy/causalgia: a randomized, double-blind study. Guanethidine Study Group. Anesth Analg 1995; 81: 718-23.CrossRef
31.
Bonelli S, Conoscente F, Movilia PG, Restelli L, Francucci B, Grossi E. Regional intravenous guanethidine vs. stellate ganglion block in reflex sympathetic dystrophies: a randomized trial. Pain 1983; 16: 297-307.CrossRefPubMed
32.
Hord AH, Rooks MD, Stephens BO, Rogers HG, Fleming LL. intravenous regional bretylium and lidocaine for treatment of reflex sympathetic dystrophy: a randomized, double-blind study. Anesth Analg 1992; 74: 818-21.CrossRefPubMed
33.
Price DD, Long S, Wilsey B, Rafii A. Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients. Clin J Pain 1998; 14: 216-26.CrossRefPubMed
34.
Manjunath PS, Jayalakshmi TS, Dureja GP, Prevost AT. Management of lower limb complex regional pain syndrome type 1: an evaluation of percutaneous radiofrequency thermal lumbar sympathectomy versus phenol lumbar sympathetic neurolysis- a pilot study. Anesth Analg 2008; 106: 647-9.CrossRefPubMed
35.
Haynsworth RF Jr, Noe CE. Percutaneous lumbar sympathectomy: a comparison of radiofrequency denervation versus phenol neurolysis. Anesthesiology 1991; 74: 459-63.CrossRefPubMed
36.
Carroll I, Clark JD, Mackey S. Sympathetic block with botulinum toxin to treat complex regional pain syndrome. Ann Neurol 2009; 65: 348-51.CrossRefPubMed
37.
Tran KM, Frank SM, Raja SN, El-Rahmany HK, Kim LJ, Vu B. Lumbar sympathetic block for sympathetically maintained pain: changes in cutaneous temperatures and pain perception. Anesth Analg 2000; 90: 1396-401.CrossRefPubMed
38.
Rauck RL, Eisenach JC, Jackson K, Young LD, Southern J. Epidural clonidine treatment for refractory reflex sympathetic dystrophy. Anesthesiology 1993; 79: 1163-9.CrossRefPubMed
39.
van Hilten BJ, van de Beek WJ, Hoff JI, Voormolen JH, Delhaas EM. Intrathecal baclofen for the treatment of dystonia in patients with reflex sympathetic dystrophy. N Engl J Med 2000; 343: 625-30.CrossRefPubMed
40.
Kemler MA, Barendse GA, van Kleef M, et al. Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med 2000; 343: 618-24.CrossRefPubMed
41.
Kemler MA, De Vet HC, Barendse GA, Van Den Wildenberg FA, Van Kleef M. The effect of spinal cord stimulation in patients with chronic reflex sympathetic dystrophy; two years’ follow-up of the randomized controlled trial. Ann Neurol 2004; 55: 13-8.CrossRefPubMed
42.
Kemler MA, De Vet HC, Barendse GA, Van Den Wildenberg FA, Van Kleef M. Effect of spinal cord stimulation for chronic complex regional pain syndrome type I: five-year final follow-up of patients in a randomized controlled trial. J Neurosurg 2008; 108: 292-8.CrossRefPubMed
43.
Oerlemans HM, Oostendorp RA, de Boo T, Goris RJ. Pain and reduced mobility in complex regional pain syndrome I: outcome of a prospective randomised controlled clinical trial of adjuvant physical therapy versus occupational therapy. Pain 1999; 83: 77-83.CrossRefPubMed
44.
Oerlemans HM, Goris JA, de Boo T, Oostendorp RA. Do physical therapy and occupational therapy reduce the impairment percentage in reflex sympathetic dystrophy? Am J Phys Med Rehabil 1999; 78: 533-9.CrossRefPubMed
45.
Oerlemans HM, Oostendorp RA, de Boo T, van der Laan L, Severens JL, Goris JA. Adjuvant physical therapy versus occupational therapy in patients with reflex sympathetic dystrophy/complex regional pain syndrome type I. Arch Phys Med Rehabil 2000; 81: 49-56.CrossRefPubMed
46.
Severens JL, Oerlemans HM, Weegels AJ, van t’ Hof MA, Oostendorp RA, Goris RJ. Cost-effectiveness analysis of adjuvant physical or occupational therapy for patients with reflex sympathetic dystrophy. Arch Phys Med Rehabil 1999; 80: 1038-43.CrossRefPubMed
47.
Lee BH, Scharff L, Sethna NF, et al. Physical therapy and cognitive-behavioral treatment for complex regional pain syndromes. J Pediatr 2002; 141: 135-40.CrossRefPubMed
48.
Moseley GL. Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain 2004; 108: 192-8.CrossRefPubMed
49.
Moseley GL. Is successful rehabilitation of complex regional pain syndrome due to sustained attention to the affected limb? A randomised clinical trial. Pain 2005; 114: 54-61.CrossRefPubMed
50.
Perrigot M, Bergego C, Hocini A, Pierrot-Deseilligny E. Algodystrophic syndrome in hemiplegia. Clinical and therapeutic study (French). Ann Med Interne (Paris) 1982; 133: 544-8.
51.
Friez L, Pere G, Breuillard P, Meignan S. Comparison of treatment with griseofulvin, beta blockers and calcitonin in 55 cases of post-traumatic algoneurodystrophies (French). Rev Rhum Mal Osteoartic 1982; 49: 857-60.PubMed
52.
Cherot A, Amor B. Treatment of algodystrophy. A randomized study of 95 cases with 3 treatments: calsyn 100, visken, grisefuline and penthonium (French). Rev Rhum Mal Osteroartic 1983; 50: 95-7.
53.
Gobelet C. The role of calcitonin in the treatment of algoneurodystrophy (French). Schweiz Rundsch Med Prax 1986; 75: 7-9.PubMed
54.
Kotzki N, Pelissier J, Dusotoit C, et al. Preventive processes of shoulder-hand syndrome in bedridden hemiplegic patients: evaluation of three processes (French). Ann Réadaptation Méd Phys 1991; 34: 351-5.
55.
Riou C, Daoudi Y, Langlais F, Pawlotsky Y, Cheverry C. Can algodystrophy be prevented by thyrocalcitonin? (French). Rev Chir Orthop Reparatrice Appar Mot 1991; 77: 208-10.PubMed
56.
Uher EM, Vacariu G, Schneider B, Fialka V. Comparison of manual lymph drainage with physical therapy in complex regional pain syndrome, type I. A comparative randomized controlled therapy study (German). Wien Klin Wochenschr 2000; 112: 133-7.PubMed
57.
Tabak Y, Entok E, Tascioglu F, et al. The efficacy of intranasal salmon calcitonin in the treatment of reflex sympathetic dystrophia (Turkish). J Rheum Med Rehab 2004; 15: 234-40.
58.
Bruehl S, Harden RN, Galer BS, et al. External validation of IASP criteria for complex regional pain syndrome and proposed research diagnostic criteria. International Association for the Study of Pain. Pain 1999; 81: 147-54.CrossRefPubMed
59.
de Jong JR, Vlaeyen JW, Onghena P, Cuypers C, den Hollander M, Ruijgrok J. Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo. Pain 2005; 116: 264-75.CrossRefPubMed
60.
Kho KH. The impact of acupuncture on pain in patients with reflex sympathetic dystrophy. Pain Clinic 1995; 8: 59-61.
61.
Korpan MI, Dezu Y, Schneider B, Leitha T, Fialka-Moser V. Acupuncture in the treatment of posttraumatic pain syndrome. Acta Orthop Belg 1999; 65: 197-201.PubMed
62.
Wu WH, Bandilla E, Ciccone DS, et al. Effects of qigong on late-stage complex regional pain syndrome. Altern Ther Health Med 1999; 5: 45-54.PubMed
63.
Durmus A, Cakmak A, Disci R, Muslumanoglu L. The efficiency of electromagnetic field treatment in complex regional pain syndrome type I. Disabil Rehabil 2004; 26: 537-45.CrossRefPubMed
64.
Kiralp MZ, Yildiz S, Vural D, Keskin I, Ay H, Dursun H. Effectiveness of hyperbaric oxygen therapy in the treatment of complex regional pain syndrome. J Int Med Res 2004; 32: 258-62.PubMed
65.
Pleger B, Janssen F, Scwenkreis P, Volker B, Maier C, Tegenthoff M. Repetitive transcranial magnetic stimulation of the motor cortex attenuates pain perception in complex regional pain syndrome type I. Neurosci Lett 2004; 356: 87-90.CrossRefPubMed
66.
Fischer MJ, Reiners A, Kohnen R, et al. Do occlusal splints have an effect on complex regional pain syndrome? A randomized, controlled proof-of-concept trial. Clin J Pain 2008; 24: 776-83.PubMedCrossRef
Metadata
Title
Treatment of complex regional pain syndrome: a review of the evidence
Authors
De Q. H. Tran, MD
Silvia Duong, BScPhm
Pietro Bertini, MD
Roderick J. Finlayson, MD
Publication date
01-02-2010
Publisher
Springer-Verlag
Published in
Canadian Journal of Anesthesia/Journal canadien d'anesthésie / Issue 2/2010
Print ISSN: 0832-610X
Electronic ISSN: 1496-8975
DOI
https://doi.org/10.1007/s12630-009-9237-0

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