What does current Complex Regional Pain Syndrome (CRPS) rehabilitation look like?

As a practicing clinician I recognise that CRPS is notoriously difficult to treat. International clinical guidelines recommend rehabilitation therapies as a core treatment for CRPS (1,2,3). They suggest a very broad range of possible treatments with some variation across the guidelines. Despite these recommendations, a recent Cochrane review (4) of physiotherapy interventions for CRPS identified that the evidence base was dominated by small trials of single modality interventions and only one trial of multimodal therapy (5). Indeed, the review concluded that there was no compelling evidence for or against the effectiveness of therapy interventions making it difficult to inform an optimal approach to rehabilitation.

We were interested in establishing what current rehabilitation practice for CRPS consists of, in order to use this information to inform the development of a “best practice” model of rehabilitation. The effectiveness of the “best practice” model would then be evaluated in a clinical trial. We also had a secondary aim: to establish which diagnostic criteria, if indeed any, are currently used for diagnosis.

In our recent study (6), we developed an electronic survey aimed at clinicians involved in the rehabilitation of individuals with CRPS. The survey was hosted on the Body in Mind (BiM) website for a two month period and was publicised by the British Association of Hand Therapists, Association of Chartered Physiotherapists in Orthopaedic Medicine and the Physiotherapy Pain Association. The survey was further promoted through the UK Chartered Society of Physiotherapy online forums and through tweets from the twitter accounts of the authors and the Centre for Rehabilitation Research in Oxford and BiM.

One hundred and thirty two surveys were completed of which 69% of responders were Physiotherapists, 26% were Occupational Therapists and one participant was a specialist nurse. Although the majority of the responders were from the UK (58%), there were also participants from Australia (12%), New Zealand (5%), Canada (5%) and the Republic of Ireland (4%), with single responses from a range of other countries.

One third of participants did not use any established criteria to diagnose CRPS. This is at odds with the international guidelines and of concern. Current practice commonly included patient education, encouragement of self-management and physical exercises. Interestingly pain provocative therapies, splinting, contrast bathing and hot and cold therapy were rarely used in the acute or chronic phase of CRPS.

We also asked participants their views on treatments they felt were ineffective /unsafe in the rehabilitation of CRPS. Some participants felt that the use of splinting could contribute to further disuse, reinforce avoidance of activity and enhance the need for protection. Passive therapies such as transcutaneous electrical nerve stimulation (TENS) and massage were sometimes described as ineffective. There were also concerns that the use of cold therapy and pain provocative or aggressive therapy could result in a flare in an individual’s symptoms. Whilst pain provocative therapies are not specifically recommended in the international guidelines, the results of recent trials evaluating pain exposure in CRPS (6, 7) have been conflicting.

Although 84% of participants expressed an interest in taking part in future research into CRPS, 54% of participants responded that they would not be happy for their patients to be randomised to a minimal care (watchful waiting) arm. Themes identified from open text responses in relation to this were a strong belief in the value of current treatments, ethical concerns related to withholding treatment and pragmatic concerns such as feasibility in private practice.

This study was exploratory in nature and limitations associated with the methods are discussed in the paper. Nonetheless we consider our findings to be useful in informing a best practice model of care for CRPS. It is evident that education and physical exercise are frequently used in the rehabilitation of CRPS in line with international guidelines.

It is clearly difficult to conduct trials that are big enough to give robust answers in a relatively rare condition like CRPS. But there is a further challenge in the form of professional “equipoise”. Our research demonstrated that many therapists would not be happy to randomise patients with CRPS into a minimal care group, raising the question of what type of control may be optimal or feasible in such trials.

About Caroline Miller

Caroline Miller physiotherapyCaroline is an Upper Limb Clinical Specialist Physiotherapist at University Hospital Birmingham. She is also lead Physiotherapist within the Hand and Peripheral Nerve research network at the hospital. Her clinical and academic interests include treating and evaluating rehabilitation for patients with upper limb pain including those following shoulder surgery, trauma, CRPS and Brachial Plexus Injury.

References

[1] Harden RN, Oaklander AL, Burton AW et al, Reflex Sympathetic Dystrophy Syndrome A. Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. Pain Medicine 2013;14:180–229

[2] Goebel A, Barker CH, Turner-Stokes L et al. Complex regional pain syndrome in adults: UK guidelines for diagnosis, referral and management in primary and secondary care. Royal College of Physicians 2011; London

[3] Perez RSGM, Geertzen JHB, Dijkstra PU et al. Updated Guidelines: Complex Regional Pain Syndrome Type I. Netherlands Society of Anaesthesiologists/ Netherlands Society of Rehabilitation Specialists 2014;

[4] Smart, KM, Wand BM, O’Connell NE. Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Database of Systematic Reviews 2016; 2: CD010853

[5] Oerlemans HM, Oostendorp RAB, de Boo T et al. Pain and reduced mobility in complex regional pain syndrome I: outcome of a prospective randomised controlled trial of adjuvant physical therapy versus occupational therapy. Pain 1999;83(1):77–83

[6] Miller C, Williams M, Heine P, Williamson E, O’Connell N (2017). Current Practice in the rehabilitation of complex regional pain syndrome: a survey of practitioners. Disability and Rehabilitation https://doi.org/10.1080/09638288.2017.1407968

[7] Barnhoorn KJ, Van De Meent H, Van Dongen RTM, et al. Pain exposure physical therapy (PEPT) compared to conventional treatment in complex regional pain syndrome type 1: a randomised controlled trial. BMJ open. 2015; n 2015;5:e008283.doi:10.1136/bmjopen

[8] Den Hollander M, Goossens M, De Jong et al. Expose or protect? A randomized controlled trial of exposure in vivo vs pain-contingent treatment as usual in patients with complex regional pain syndrome type 1. Pain. 2016;157(10);2318-29