Complex regional pain syndrome: Which treatments show promise?

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Applied Evidence

Complex regional pain syndrome: Which treatments show promise?

J Fam Pract. 2005 July;54(7):599-603

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References

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TABLE 1
Effectiveness of treatments for CRPS type 1

TREATMENT	STUDY TYPE	STUDY QUALITY	EFFECT*
DMSO	SR⁶	2 – small RCT (n=32)²¹	(+): Analgesia during therapy
Bisphosphonates	RCTs^14,15	1 – multiple RCTs (n=32)¹⁵ and (n=20)¹⁴	(+): Long-term (4 weeks¹⁴ to 180 days¹⁵) overall clinical improvement with significant analgesia
Corticosteroids	2 SRs^6,11	2 – 2 small RCTs, 1 in post-traumatic CRPS type 1 (n=23)²² and 1 (poor-quality) in shoulder-hand syndrome (n=36)³	(+): 75% clinical improvement to 12 wk in CRPS type 1;²² and resolution of symptoms in shoulder-hand syndrome³
Clonidine	SR⁶	2 – small RCT (n=26)²³	(+): Temporary analgesia
Spinal cord stimulation	SR^9-11	2 – multiple SRs based on 1 RCT (n=36)¹⁶	(+): Modest long-term (2-y)¹⁶ analgesic effect, improved health-related quality of life, no improvement in patient functioning and 34% rate of adverse occurrences⁹
Physical therapy and occupational therapy	RCT^17-19	1 – RCT (n=135)	(+/–): Contradictory analyses using different methods of measuring impairment, 1 showing no advantage of PT or OT over control,¹⁷ the other showing improvement with both.¹⁸ Significant improvement in pain at 1 y with PT over OT and control, no significant improvement in active ROM.¹⁹
Calcitonin	SR^6,7	1 – multiple RCTs^24-26	(+/–): Contradictory results – 1 SR indicating a significant analgesic effect⁷ the other suggesting no analgesic effect⁶
IRSBs (bretylium, ketanserin, guanethidine, reserpine, droperidol, or atropine)	SR^6-8	1 and 2 – Good-quality RCTs	(+/–): When collectively analyzed, no overall positive of guanethidine, otherwise effect.^7,8 When evaluated by particular medication, small or poor quality RCTs limited evidence for analgesia with bretylium and ketanserin (not available in the US),^6,8 and no analgesia with guanethidine, reserpine, droperidol and atropine⁶
Sympathetic ganglion blocks (lidocaine/bupivacaine)	RCT¹³	2 – small RCT (n=7)	(+/–): Short-term analgesia with longer duration of pain control in treatment group (3.5 days) vs placebo (1 day)
Sympathectomy (chemical or surgical)	SR¹²	2 – SR based on poor-quality evidence, no placebo controlled RCTs	(+/–): No evidence of effectiveness, high rates (>10%) of adverse effects including worse pain, new neuropathic pain and pathological body sweating
Acupuncture (30 min 5x/wk for 3 wk	RCT²⁰	2 – small RCT (n=14)	(–): Immediate and long-term (6-mo) clinical improvement and analgesia in sham/acupuncture treatment groups
Sympathetic inhibition	SR⁶	1 & 2 – variable-quality RCTs^27-29	(+/–): Contradictory results, with the best-designed study showing only a 9% short-term relief of pain²⁸
DOSAGES: DMSO: 50% cream applied 5x/d for at least 2 mo.²¹
Bisphosphonates: IV alendronate 7.5 mg once daily for 3 days¹⁴ or intravenous clodronate 300 mg once daily for 10 days.¹⁵
Calcitonin: intranasal 400 IU once daily²⁶ or 100 IU 3 times daily²⁷ or intramuscular 100 IU once daily for 3 weeks.²⁸
Corticosteroids: prednisone 10 mg 3 times daily until remission, max. up to 12 weeks,²² or prednisolone 32 mg daily for 2 wk with a 2-wk taper.⁴
Clonidine: 300 μg epidural injection.²³
Sympathetic inhibition: IV phentolamine.^27-29
*Effect: (+) = positive, (+/–) = contradictory results or poor quality evidence, (–) = no effect.
SR, systematic review; MA, meta-analysis; RCT, randomized controlled trial; DMSO, dimethylsulfoxide; PT, physical therapy; OT, occupational therapy; ROM, range of motion.

Acknowledgments

The authors would like to express their appreciation to Cheryl Mongillo, Peggy Lardear, and Brian Pellini for their assistance in preparing the manuscript, Dolores Moran and Diane Wolfe for their assistance in finding articles, and to Roger Rodrigue, MD for reviewing the manuscript. Funding for this project was provided by a grant from the Delaware Department of Health and Social Services, Division of Public Health.

CORRESPONDING AUTHOR
Anna Quisel, MD, c/o Cheryl Mongillo, Family Medicine Center, 1401 Foulk Road, Wilmington, DE 19803. E-mail: DrQuisel@comcast.net