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Title: | Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews |
Authors: | Ferraro, MC Cashin, AJ Wand, BM Smart, KM Berryman, C Marston, L Moseley, GL McAuley, JH O'Connell, NE |
Advisors: | The Cochrane Collaboration |
Keywords: | Bupivacaine;chronic pain;complex regional pain syndromes;quality of life;systematic reviews as topic;adult;humans |
Issue Date: | 12-Jun-2023 |
Publisher: | Wiley on behalf of The Cochrane Collaboration |
Citation: | Ferraro, C. et al. (2023) 'Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews', Cochrane Database of Systematic Reviews, 2023 (6), Art. No.: CD009416, pp. i, 1 - 90. doi: 10.1002/14651858.CD009416.pub3. |
Abstract: | Background: Complex regional pain syndrome (CRPS) is a chronic pain condition that usually occurs in a limb following trauma or surgery. It is characterised by persisting pain that is disproportionate in magnitude or duration to the typical course of pain after similar injury. There is currently no consensus regarding the optimal management of CRPS, although a broad range of interventions have been described and are commonly used. This is the first update of the original Cochrane review published in Issue 4, 2013. Objectives: To summarise the evidence from Cochrane and non‐Cochrane systematic reviews of the efficacy, effectiveness, and safety of any intervention used to reduce pain, disability, or both, in adults with CRPS. Methods: We identified Cochrane reviews and non‐Cochrane reviews through a systematic search of Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, CINAHL, PEDro, LILACS and Epistemonikos from inception to October 2022, with no language restrictions. We included systematic reviews of randomised controlled trials that included adults (≥18 years) diagnosed with CRPS, using any diagnostic criteria. Two overview authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools respectively. We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes quality of life, emotional well‐being, and participants' ratings of satisfaction or improvement with treatment. Main results: We included six Cochrane and 13 non‐Cochrane systematic reviews in the previous version of this overview and five Cochrane and 12 non‐Cochrane reviews in the current version. Using the AMSTAR 2 tool, we judged Cochrane reviews to have higher methodological quality than non‐Cochrane reviews. The studies in the included reviews were typically small and mostly at high risk of bias or of low methodological quality. We found no high‐certainty evidence for any comparison. There was low‐certainty evidence that bisphosphonates may reduce pain intensity post‐intervention (standardised mean difference (SMD) ‐2.6, 95% confidence interval (CI) −1.8 to −3.4, P = 0.001; I2 = 81%; 4 trials, n = 181) and moderate‐certainty evidence that they are probably associated with increased adverse events of any nature (risk ratio (RR) 2.10, 95% CI 1.27 to 3.47; number needed to treat for an additional harmful outcome (NNTH) 4.6, 95% CI 2.4 to 168.0; 4 trials, n = 181). There was moderate‐certainty evidence that lidocaine local anaesthetic sympathetic blockade probably does not reduce pain intensity compared with placebo, and low‐certainty evidence that it may not reduce pain intensity compared with ultrasound of the stellate ganglion. No effect size was reported for either comparison. There was low‐certainty evidence that topical dimethyl sulfoxide may not reduce pain intensity compared with oral N‐acetylcysteine, but no effect size was reported. There was low‐certainty evidence that continuous bupivacaine brachial plexus block may reduce pain intensity compared with continuous bupivacaine stellate ganglion block, but no effect size was reported. For a wide range of other commonly used interventions, the certainty in the evidence was very low and provides insufficient evidence to either support or refute their use. Comparisons with low‐ and very low‐certainty evidence should be treated with substantial caution. We did not identify any RCT evidence for routinely used pharmacological interventions for CRPS such as tricyclic antidepressants or opioids. Authors' conclusions: Despite a considerable increase in included evidence compared with the previous version of this overview, we identified no high‐certainty evidence for the effectiveness of any therapy for CRPS. Until larger, high‐quality trials are undertaken, formulating an evidence‐based approach to managing CRPS will remain difficult. Current non‐Cochrane systematic reviews of interventions for CRPS are of low methodological quality and should not be relied upon to provide an accurate and comprehensive summary of the evidence. |
Description: | Version 3. Overview stabilised in line with the PaPaS Review Group's policy to assess overviews for updating every five years. Differences between protocol and review: In this updated overview, we made a number of changes compared with the protocol (O'Connell 2011) and the original version of the overview (O'Connell 2013): • Background: this section has been updated in the current version of the overview to include recent information on CRPS diagnosis, pathophysiology and incidence. • Searches: in the current version of this overview, we searched Epistemonikos but did not search the Database of Abstracts of Reviews of Effects (DARE), as it is no longer updated. • Outcomes: in the current version of this overview, we grouped outcomes into post‐intervention, short‐term, medium‐term and long‐term follow‐up periods, reporting only a single effect for each period. • Assessment of methodological quality of included reviews: in the current version of this overview, we used the revised AMSTAR 2 instead of the original AMSTAR tool to assess the methodological quality of both Cochrane and non‐Cochrane reviews. • Assessment of the certainty of the evidence in included reviews: where reviews did not use GRADE to assess the certainty in evidence, we conducted these assessments ourselves using updated criteria compared with the previous version of this overview and the protocol (for a full description see Assessment of methodological quality of included reviews). We applied these judgements to all outcomes rather than only the primary outcomes, as done in the previous version of this overview. • Interpretation of effects: in the current version of this overview, we interpreted minimally important between‐group differences for pain intensity using OMERACT 12 recommendations. |
URI: | https://bura.brunel.ac.uk/handle/2438/26085 |
DOI: | https://doi.org/10.1002/14651858.CD009416.pub3 |
Other Identifiers: | ORCiD: Neil O'Connell https://orcid.org/0000-0003-1989-4537 Article number: CD009416 |
Appears in Collections: | Dept of Health Sciences Research Papers |
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FullText.pdf | Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Green open access: free access to the full article 12 months after publication and the standard publication licence (see: https://www.cochranelibrary.com/about/open-access#Green%20OA). | 1.24 MB | Adobe PDF | View/Open |
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