Complex Regional Pain Syndrome

Syndrome douloureux régional complexe

1. Systematic Reviews and Meta-Analysis

☆☆☆	Evidence for effectiveness and a specific effect of acupuncture.
☆☆	Evidence for effectiveness of acupuncture.
☆	Limited evidence for effectiveness of acupuncture.
Ø	No evidence or insufficient evidence.

1.1. Generic Acupuncture

1.1.1. Xu 2013 ★★

Xu Yan, Li Wan-Yao, Liu Jie, Ma Lin. [Acupuncture versus rehabilitation therapy for shoulder-hand syndrome: a systematic review and meta-analysis]. Lishizhen Medicine and Materia Medica Research. 2013;7:1794-179. [187046].

Objectives	To assess the efficacy of acupuncture versus rehabilitation therapyin the treatment of Shoulder-hand Syndrome.
Methods	Randomized controlled trials (RCTs) involving acupuncture versus rehabilitation therapy in the treatment of Shoulder-hand Syndromewere identified from CBM disc (from 1978 to 2012), VIP (from 1989 to 2012), WANFANG Data base (from 1998 to 2012), CNKI (from 1979 to 2012), Pub Med (1966 to 2012), E M base (1980 to 2009), Cochrane Library (Issue 4, 2008). Also hand searched relevant journals. Data were extracted and evaluated by two reviewers independently with a specially designed extraction form. The Cochrane collaboration’s RevMan5. 1. 6 softwarewas used for data analyses.
Results	A total of 21 trials involving 1515 patients were included. Meta-analyses showed that the FMA score in the acupuncture combined with rehabilitation was different when compared with rehabilitation at week 3 /4 /5 /6 /8 [WMD = 12. 53, 95% CI (4. 56, 20. 49);WMD = 7. 25, 95% CI (3. 38, 11. 12);WMD = 15. 28, 95% CI (13. 81, 16. 75);WMD = 13. 86, 95% CI (11. 17, 16. 55);WMD = 7. 06, 95% CI (5. 66, 8. 47) ], but showing similar result at week. It also shows similar results when acupuncture is compared with rehabilitation. As for the VAS score, no significant difference was noted between acupuncture combined with rehabilitation and rehabilitation at weeks 3 /4, difference between acupuncture and rehabilitation observed at week 2 /5 /8 [WMD =-1. 40, 95% CI (-1. 71, -1. 09);WMD =-1. 88, 95% CI (-3. 08, -0. 68);WMD =-1. 78, 95%CI (-2. 47, -1. 09) ], difference was noted between acupuncture and rehabilitation. As for the ADL score, the acupuncture combined with rehabilitation was different when compared with rehabilitation at week 3 /5 /8 [WMD = 9. 33, 95% CI (1. 14, 17. 52);WMD = 15. 17, 95% CI (12. 00, 18. 34);WMD = 18. 49, 95% CI (15. 15, 21. 83) ], no significant difference was noted between acupuncture and rehabilitation at weeks 3, difference between acupuncture and rehabilitation observed at week.
Conclusions	Acupuncture combine with rehabilitation therapy has probably a great advantage compared with rehabilitation therapy in the treatment of SHS, but acupuncture isn’t better than rehabilitation therapy, Further large-scale trials are required to define the role of acupuncture in the treatment of shoulder-hand syndrome.

1.1.2. Lin 2012 ★

Lin H, Ma TM. [A Meta Analysis on Acupuncture Treatment of Shoulder-Hand Syndrome]. Acupuncture Research. 2012;37(1):77-82. [164743]

Objectives	To assess the effectiveness of acupuncture therapy for shoulder-hand syndrome.
Methods	According to the requirements of evidence-based medicine, papers of randomized controlled clinical trials for shoulder-hand syndrome published in China from 2005 to 2010 collected by databases VIP, Wanfang, CNKI, collections of papers of academic conferences, etc. were retrieved by using key words of shoulder-hand syndrome, reflex sympathetic dystrophy, acupuncture, moxibustion. Then the collected documents were given with Jadad score, and analyed by using software Manager 5. 0 Review Cochrane.
Results	A total of 100 papers were retrieved. Among them, 29 papers that met our inclusion criteria were given with Jadad scores (2 points for 2 papers, 1 point for the rest 27 papers, being low in quality). Twenty-one papers were brought into Meta analysis. These papers contain 1 768 cases of patients who were divided into three sets of groups according to the used intervention measures. Meta-analysis showed that simple acupuncture therapy is significantly superior to acupoint block therapy for relieving shoulder-hand syndrome [odds ratio (OR, 95% CI) 4.80 (2.02 to 11.41), P < 0.05]; electroacupuncture therapy is markedly more effective than simple acupuncture therapy [OR (95% CI) 4.60 (2.08 to 10. 17), P < 0.05]; and acu-moxibustion combined with other therapies is significantly more effective than simple acupuncture therapy [OR (95% CI) 3.31 (2. 30 to 4.77), P < 0.05]. The other 8 papers were not brought into Meta-analysis due to being different to the 21 papers in the intervention measures.
Conclusions	Acupuncture can effectively relieve shoulder-hand syndrome in pain, wrist- and shoulder-joint motor, etc. But, larger size of samples and high quality randomized clinical trials are needed for providing more reliable conclusive evidence.

1.1.3. Albazaz 2008 ★

Albazaz R, Wong YT, Homer-Vanniasinkam S. Complex regional pain syndrome: a review. Ann Vasc Surg. 2008;22(2):297-306.148328

Purpose	This review gives a synopsis of complex regional pain syndrome (CRPS) and discusses the principles of management based on the limited available literature in the area.
Methods	A literature search was conducted using electronic bibliographic databases (Medline, Embase, Pubmed, CENTRAL) from 1970 to 2006. Keywords complex regional pain syndrome, reflex sympathetic dystrophy, neuropathic pain, and causalgia were used for the search. Relevant articles from the reference lists in retrieved articles were also studied.
Results	There were 3,771 articles published in the area. Seventy-six randomized controlled trials were identified. Most studies were on the role of sympathetic blockade in the treatment of CRPS (n = 13). The role of sympathectomy is unclear, with some studies showing transient benefit and others showing no beneficial effects, with most studies containing only a small number of patients. Nine studies were on bisphosphonates or calcitonin. Studies involving bisphosphonates showed benefit, but studies involving calcitonin showed no definite benefit. Four studies were on cognitive behavioral therapy, physiotherapy, or occupational therapy, all of which demonstrated a potential beneficial effect. Three studies on spinal cord stimulation and two studies each on acupuncture, vitamin C, and steroid all showed a potential beneficial effect in pain reduction.
Conclusion	There is very little good evidence in the literature to guide treatment of CRPS. Early recognition and a multidisciplinary approach to management seems important in obtaining a good outcome. Treatments aimed at pain reduction and rehabilitation of limb function form the mainstay of therapy.

1.2. Special Clinical Forms

1.2.1. Post-stroke Shoulder-Hand Syndrome

See corresponding item

2. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

2.1. Japan Stroke Society (JSS, Japan) 2021 ⊕

The Japan Stroke Society. [Japanese Guidelines for the Management of Stroke, 2021] . Kyowa Kikaku Co. Ltd.; 2021 [in Japanese] . Cited by Okawa Y, Yamashita H, Masuyama S, Fukazawa Y, Wakayama I. Quality assessment of Japanese clinical practice guidelines including recommendations for acupuncture. Integr Med Res. 2022 Sep;11(3):100838. https://doi.org/10.1016/j.imr.2022.100838

Recommended for complex regional pain syndromes, in conjunction with training.

2.2. Colorado Division of Workers' Compensation (USA) 2017 ⊕

Complex regional pain syndrome/reflex sympathetic dystrophy medical treatment guideline. Denver (CO): Colorado Division of Workers' Compensation. 2017:96p. [198276].

Acupuncture for the treatment of CRPS is thought to work by promoting relaxation and allowing chemicals and blood within the body to flow properly. Acupuncture may not be well tolerated by CRPS patients, but some have reported relief of pain that is immediate, but temporary, lasting only 1 or 2 hours. Acupuncture is recommended for subacute or chronic pain patients who are trying to increase function and/or decrease medication usage and have an expressed interest in this modality. It is also recommended for subacute or acute pain for patients who cannot tolerate NSAIDs or other medications, and it should generally be used in conjunction with manipulative and physical therapy/rehabilitation. Refer to the Division’s Chronic Pain Disorder Medical Treatment Guideline for indications, evidence, and time frames.

2.3. Colorado Division of Workers' Compensation (USA) 2011 ⊕

Colorado Division of Workers' Compensation. Complex regional pain syndrome/reflex sympathetic dystrophy: medical treatment guidelines. Denver (CO): Colorado Division of Workers' Compensation. 2011; :107P. [165664].

THERAPY MANAGEMENT- Some treatment may be helpful on a continued basis during maintenance care if the therapy maintains objective function and decreases medication use. With good management, exacerbations should be uncommon; not exceeding two times per year and using minimal or no treatment modality beyond self-management. On occasion, exacerbated conditions may warrant durations of treatment beyond those listed below. Having specific goals with objectively measured functional improvement during treatment can support extended durations of care. It is recommended that if after 6 to 8 visits no treatment effect is observed, alternative treatment interventions should be pursued. Active Therapy, Acupuncture, or Manipulation Maintenance Duration: 10 visits [for each treatment] during the first year and then decreased to 5 visits per year thereafter.

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