Oaklander and Fields did a comprehensive review of the literature concerning the role of small-fibre neuropathy in complex regional pain syndrome (CRPS)[1].
We wrote a response to this article in the Annals of Neurology to say that the review builds on a body of elegant work by Oaklander’s group, and others, and presents a compelling argument that many clinical features of CRPS are consistent with persistent dysfunction of C and A-δ fibres. Here is the gist of it:
The review culminates in treatment recommendations and states that rehabilitation and physical therapy are critical. Unfortunately, what constitutes ‘rehabilitation’ or ‘physical therapy’ is not considered. This is like stating that medications are critical but not considering which ones. Oaklander & Fields are by no means the first to make this oversight – guidelines the world over recommend ‘physical therapy’ or ‘rehabilitation’ for CRPS, but make no attempt to sort the wheat from the chaff. This issue is of utmost importance because many and varied treatments for CRPS are undertaken under the banner of ‘rehabilitation’, but most of them are probably not helpful.
It is not that empirical data do not exist (see [2] for review), for example, several randomised controlled trials (RCT’s) show that graded motor imagery reduces pain and disability in chronic CRPS[2]. The number needed to treat for a 50% decrease in pain and a four-point drop on a 10-point scale of disability, is about 4[3], which compares favourably with any other treatment for chronic CRPS, including spinal cord stimulators, for which Oaklander and Fields state there is documented efficacy and are indicated for CRPS.
Oaklander and Fields go on to note the absence of data for pharmacological treatment of CRPS and turn to the results of RCT’s for other neuralgias. RCT’s also show that cognitive-behavioral programs reduce pain and disability in other neuralgias (see [4] for review) and that sensory discrimination training reduces pain in chronic phantom limb pain[5]. Sensory discrimination training has already been extended to patients with chronic CRPS, where preliminary data appear supportive[6]. Oaklander and Fields’ compiled a rigorous and discerning review of the role of smallfibre pathology in CRPS, which provided a strong basis for their proposal that neurologists should return to a central role in CRPS care. We humbly suggest that this role would be greatly enhanced, and, most importantly, patient outcomes would be improved, if the same rigor and discernment were applied to evaluating evidence-based treatment options that fall under the broad category of ’rehabilitation’.
G Lorimer Moseley(ab), Michael Thacker(c) Herta Flor(d)
(a) Prince of Wales Medical Research Institute, Sydney, Australia
(b) Faculty of Medicine, The University of New South Wales, Sydney, Australia
(c) Academic Department of Physiotherapy and Wolfson Centre for Age Related Diseases, King’s College London, UK
(d) Department of Clinical and Cognitive Neuroscience, The University of Heidelberg, Germany.
References
1. Oaklander, AL, and Fields,HL (2009) Is reflex sympathetic dystrophy/complex regional pain syndrome type I a small-fiber neuropathy Ann neurol. 65:629-638
2. Daly A, Bialocerkowski A. Does Evidence Support Physiotherapy Management of Adult Complex Regional Pain Syndrome Type One? A Systematic Review. Euro J Pain
3. Moseley GL. Graded motor imagery for pathologic pain – A randomized controlled trial. Neurology. 2006;67:2129-2134
4. Turk DC. Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clin. J. Pain. 2002;18:355-365
5. Flor H, Denke C, Schaefer M, Grusser S. Effect of sensory discrimination training on cortical reorganisation and phantom limb pain. Lancet. 2001;357:1763-1764.
6. Moseley GL, Zalucki NM, Wiech K. Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain. Pain. 2008;137:600-608
