Which patients with chronic reflex sympathetic dystrophy are most likely to benefit from physical therapy?

BACKGROUND: Chronic reflex sympathetic dystrophy (RSD) is a painful and disabling disorder for which no treatment with proven effects exists. Physical therapy (PT) has been demonstrated to be effective for recently diagnosed RSD, but its value in chronic RSD has not yet been studied. OBJECTIVE: To find predictors for successful use of PT in RSD with regard to (1) function, strength, and mobility and (2) patient satisfaction. SUBJECTS: Fifty-four patients with chronic RSD, age range 21 to 65 years. METHODS: All patients were treated in accordance with a standardized PT protocol for at least 6 months. The effects of treatment (functional status, strength, range of motion) and patient satisfaction measures (grade for result, would repeat, global effect) were evaluated at 12 months. Subgroup analyses were performed to find predictors for success of PT. RESULTS: The subgroup analyses revealed that patients with better baseline function (especially of the hands) obtained better results and greater satisfaction. Greater satisfaction was also associated with less baseline pain and higher baseline range of motion and strength (of leg) values. In general, PT did not show large improvements on effect measures, and the patients' mean grade for the result was 3.8 (on a 10-point scale). CONCLUSIONS: In overall terms, PT did not influence functional parameters or give satisfaction to patients with chronic RSD in this study. A randomized trial is required to prove or exclude the actual value of PT for these patients.

Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy.

BACKGROUND: Chronic reflex sympathetic dystrophy (also called the complex regional pain syndrome) is a painful, disabling disorder for which there is no proven treatment. In observational studies, spinal cord stimulation has reduced the pain associated with the disorder. METHODS: We performed a randomized trial involving patients who had had reflex sympathetic dystrophy for at least six months. Thirty-six patients were assigned to receive treatment with spinal cord stimulation plus physical therapy, and 18 were assigned to receive physical therapy alone. The spinal cord stimulator was implanted only if a test stimulation was successful. We assessed the intensity of pain (on a visual-analogue scale from 0 cm [no pain] to 10 cm [very severe pain]), the global perceived effect (on a scale from 1 [worst ever] to 7 [best ever]), functional status, and the health-related quality of life. RESULTS: The test stimulation of the spinal cord was successful in 24 patients; the other 12 patients did not receive implanted stimulators. In an intention-to-treat analysis, the group assigned to receive spinal cord stimulation plus physical therapy had a mean reduction of 2.4 cm in the intensity of pain at six months, as compared with an increase of 0.2 cm in the group assigned to receive physical therapy alone (P<0.001 for the comparison between the two groups). In addition, the proportion of patients with a score of 6 ("much improved") for the global perceived effect was much higher in the spinal cord stimulation group than in the control group (39 percent vs. 6 percent, P=0.01). There was no clinically important improvement in functional status. The health-related quality of life improved only in the 24 patients who actually underwent implantation of a spinal cord stimulator. Six of the 24 patients had complications that required additional procedures, including removal of the device in 1 patient. CONCLUSIONS: In carefully selected patients with chronic reflex sympathetic dystrophy, electrical stimulation of the spinal cord can reduce pain and improve the health-related quality of life.