BMC Neurology has just published the findings of a group of Dutch researchers in their quest to develop multidisciplinary guidelines for treatment of CRPS[1]. They looked at literature from 1980 – 2005. It is a major piece of work and I reckon it deserves publication. It is also a shocker when one produces such a monumental piece of work to have it cut down as soon as it is ‘out’. However, I reckon there are a couple of aspects of this paper that we should consider when interpreting it. Before we get into that though, here is a snapshot of what they found:
there is insufficient evidence that paracetamol, NSAIDS, oral opioids, morphine injection, local anaesthetics, some anti-convulsants, anti-depressants, capsaicin, muscle relaxants, botox, sympathetic block, amputation, TENS, multidisciplinary treatment (whatever that actually is here) or psychological treatment works.
They then report that IV ketamine might work, that gabapentin might work in the first 2 months, that two months of daily DMSO or NAC cream might help, that corticosteroids might work, that calcium-channel blockers have some effect in acute CRPS, that surgical sympathectomy can help some patients as can spinal cord stimulators, and that physiotherapy and occupational therapy (whatever they are) probably help. Got it?
The keen beans among you might observe that most things that were seen as vaguely positive were categorised as Level 3 evidence, which meant that they had at least one high quality RCT or low quality RCT or just a non-randomised non-controlled trial. Clearly this makes it difficult to tell what is what – I contend that we need more precise information to be able to sort the pickles from the gerkins here. Of course SINCE 2005, a systematic review[2] conclude that some types of physiotherapy are helpful, which is Level 1 evidence.
So, how does one develop guidelines for treatment when there is such a large number of things that don’t seem to work, or that we don’t know enough about? Well, as the authors state, they consider more than just the state of the evidence to come up with guidelines that endorse the WHO ladder, physio and OT. Actually – if you really want to know, download it here.
[1] Perez, R., Zollinger, P., Dijkstra, P., Thomassen-Hilgersom, I., Zuurmond, W., Rosenbrand, K., Geertzen, J., & Task force, T. (2010). Evidence based guidelines for complex regional pain syndrome type 1. BMC Neurology, 10 (1) DOI: 10.1186/1471-2377-10-20
[2] Daly AE, & Bialocerkowski AE (2009). Does evidence support physiotherapy management of adult Complex Regional Pain Syndrome Type One? A systematic review. European journal of pain, 13 (4), 339-53 PMID: 18619873