The association between psychological factors and the development of complex regional pain syndrome type 1 (CRPS1) — A prospective multicenter study

The objective of this study was to investigate the association between psychological factors and complex regional pain syndrome type 1 (CRPS1). A prospective multicenter cohort study was performed involving the emergency room of three hospitals, and patients age 18 years or older, with a single fracture, were included in the study. At baseline (T0), participants completed a questionnaire covering demographic, psychological (Symptom Checklist‐90), and medical variables. At plaster removal (T1) and at T2, the participants completed a questionnaire addressing symptoms of CRPS1. Psychological factors that were analysed were agoraphobia, depression, somatization, insufficiency, (interpersonal) sensitivity, insomnia, and life events. In total, 596 consecutive patients were included in the study, and 7.0% were diagnosed with CRPS1. None of the psychological factors predicted the development of CRPS1. The scores on the Symptom Checklist‐90 subscales fell into the range of the general population and were, in most cases, average or below average when compared with those of pain patients or psychiatric patients. No empirical evidence supports a diagnosis of CRPS1 patients as psychologically different, and the current results indicate that there is no association between psychological factors and CRPS1.     

Systematic review of the effectiveness of mirror therapy in upper extremity function

Purpose.?This review gives an overview of the current state of research regarding the effectiveness of mirror therapy in upper extremity function.

Method.?A systematic literature search was performed to identify studies concerning mirror therapy in upper extremity. The included journal articles were reviewed according to a structured diagram and the methodological quality was assessed.

Results.?Fifteen studies were identified and reviewed. Five different patient categories were studied: two studies focussed on mirror therapy after an amputation of the upper limb, five studies focussed on mirror therapy after stroke, five studies focussed on mirror therapy with complex regional pain syndrome type 1 (CRPS1) patients, one study on mirror therapy with complex regional pain syndrome type 2 (CRPS2) and two studies focussed on mirror therapy after hand surgery other than amputation.

Conclusions.?Most of the evidence for mirror therapy is from studies with weak methodological quality. The present review showed a trend that mirror therapy is effective in upper limb treatment of stroke patients and patients with CRPS, whereas the effectiveness in other patient groups has yet to be determined.     

A systematic literature review of psychological factors and the development of late whiplash syndrome

This systematic literature review aims to assess the prognostic value of psychological factors in the development of late whiplash syndrome (LWS). We included prospective cohort studies that provided a baseline measure of at least one psychological variable and used outcome measures relating to LWS (i.e. pain or disability persisting 6 months post injury). A search of electronic databases (Pubmed, Medline, Cinahl, Embase and Psychinfo) up to August 2006 was done using a predetermined search strategy. Methodological quality was assessed independently by two assessors. Data extraction were carried out using a standardised data extraction form. Twenty-five articles representing data from 17 cohorts were included. Fourteen articles were rated as low quality with 11 rated as adequate quality. Meta-analysis was not undertaken due to the heterogeneity of prognostic factors, outcome measures and methods used. Results were tabulated and predefined criterion applied to rate the overall strength of evidence for associations between psychological factors and LWS. Data on 21 possible psychological risk factors were included. The majority of findings were inconclusive. Limited evidence was found to support an association between lower self-efficacy and greater post-traumatic stress with the development of LWS. No association was found between the development of LWS and personality traits, general psychological distress, wellbeing, social support, life control and psychosocial work factors. The lack of conclusive findings and poor methodological quality of the studies reviewed highlights the need for better quality research. Self-efficacy and post-traumatic distress may be associated with the development of LWS but this needs further investigation.     

Life events, coping and breast cancer: state of the art.

In this article the state of the art regarding the possible link between life events and the onset and/or prognosis of breast cancer is reviewed. We can conclude that at this moment there exists no evidence for the contribution of stressful life events to an increased risk of breast cancer in studies of good methodological quality. Only studies of weak methodological quality suggest a relationship between stressful life events and risk of breast cancer. There is a need for studies using a straightforward prospective design. The contribution of life events to the prognosis of breast cancer is small. However, the role of coping is much greater. Coping with the diagnosis of breast cancer in a passive way is associated with a shorter survival time. However, studies of good methodological quality will be needed to replicate the link between coping and the prognosis of breast cancer.     

Static body postural misalignment in individuals with temporomandibular disorders: a systematic review

BACKGROUND:

The association between body postural changes and temporomandibular disorders (TMD) has been widely discussed in the literature, however, there is little evidence to support this association.

OBJECTIVES:

The aim of the present study was to conduct a systematic review to assess the evidence concerning the association between static body postural misalignment and TMD.

METHOD:

A search was conducted in the PubMed/Medline, Embase, Lilacs, Scielo, Cochrane, and Scopus databases including studies published in English between 1950 and March 2012. Cross-sectional, cohort, case control, and survey studies that assessed body posture in TMD patients were selected. Two reviewers performed each step independently. A methodological checklist was used to evaluate the quality of the selected articles.

RESULTS:

Twenty studies were analyzed for their methodological quality. Only one study was classified as a moderate quality study and two were classified as strong quality studies. Among all studies considered, only 12 included craniocervical postural assessment, 2 included assessment of craniocervical and shoulder postures,, and 6 included global assessment of body posture.

CONCLUSION:

There is strong evidence of craniocervical postural changes in myogenous TMD, moderate evidence of cervical postural misalignment in arthrogenous TMD, and no evidence of absence of craniocervical postural misalignment in mixed TMD patients or of global body postural misalignment in patients with TMD. It is important to note the poor methodological quality of the studies, particularly those regarding global body postural misalignment in TMD patients.     

Spinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: a systematic review of effectiveness and complications

We conducted a systematic review of the literature on the effectiveness of spinal cord stimulation (SCS) in relieving pain and improving functioning for patients with failed back surgery syndrome and complex regional pain syndrome (CRPS). We also reviewed SCS complications. Literature searches yielded 583 articles, of which seven met the inclusion criteria for the review of SCS effectiveness, and 15 others met the criteria only for the review of SCS complications. Two authors independently extracted data from each article, and then resolved discrepancies by discussion. We identified only one randomized trial, which found that physical therapy (PT) plus SCS, compared with PT alone, had a statistically significant but clinically modest effect at 6 and 12 months in relieving pain among patients with CRPS. Similarly, six other studies of much lower methodological quality suggest mild to moderate improvement in pain with SCS. Pain relief with SCS appears to decrease over time. The one randomized trial suggested no benefits of SCS in improving patient functioning. Although life-threatening complications with SCS are rare, other adverse events are frequent. On average, 34% of patients who received a stimulator had an adverse occurrence. We conclude with suggestions for methodologically stronger studies to provide more definitive data regarding the effectiveness of SCS in relieving pain and improving functioning, short- and long-term, among patients with chronic pain syndromes.     

Does evidence support physiotherapy management of adult Complex Regional Pain Syndrome Type One? A systematic review

Objective: To source and critically evaluate the evidence on the effectiveness of Physiotherapy to manage adult CRPS‐1. Design: Systematic literature review. Methods: Electronic databases, conference proceedings, clinical guidelines and text books were searched for quantitative studies on CRPS‐1 in adults where Physiotherapy was a sole or significant component of the intervention. Data were extracted according to predefined criteria by two independent reviewers. Methodological quality was assessed using the Critical Review Form. Results: The search strategy identified 1320 potential articles. Of these, 14 articles, representing 11 studies, met inclusion criteria. There were five randomised controlled trials, one comparative study and five case series. Methodological quality was dependent on study type, with randomised controlled trials being higher in quality. Physiotherapy treatments varied between studies and were often provided in combination with medical management. This did not allow for the ‘stand‐alone’ value of Physiotherapy to be determined. Heterogeneity across the studies, with respect to participants, interventions evaluated and outcome measures used, prevented meta‐analysis. Narrative synthesis of the results, based on effect size, found there was good to very good quality level II evidence that graded motor imagery is effective in reducing pain in adults with CRPS‐1, irrespective of the outcome measure used. No evidence was found to support treatments frequently recommended in clinical guidelines, such as stress loading. Conclusions: Graded motor imagery should be used to reduce pain in adult CRPS‐1 patients. Further, the results of this review should be used to update CRPS‐1 clinical guidelines.     

Psychological and behavioral aspects of complex regional pain syndrome management

Psychological and behavioral factors can exacerbate the pain and dysfunction associated with complex regional pain syndrome (CRPS) and could help maintain the condition in some patients. Effective management of CRPS requires that these psychosocial and behavioral aspects be addressed as part of an integrated multidisciplinary treatment approach. Well-controlled studies to guide the development of a psychological approach to CRPS management are not currently available. A sequenced protocol for psychological care in CRPS is therefore proposed based on available data and clinical experience. Regardless of the duration of the condition, all CRPS patients and their families should receive education about the negative effects of disuse, the pathophysiology of the syndrome, and possible interactions with psychological/behavioral factors. Patients with acute CRPS (<6-8 weeks) may not need additional psychological care. All patients with chronic CRPS should receive a thorough psychological evaluation, followed by cognitive-behavioral pain management treatment, including relaxation training with biofeedback. Patients making insufficient overall treatment progress or in whom comorbid psychiatric disorders/major ongoing life stressors are identified should additionally receive general cognitive-behavioral therapy to address these issues. The psychological component of treatment can work synergistically with medical and physical/occupational therapies to improve function and increase patients' ability to manage the condition successfully.     

The association between malnutrition and oral health status in elderly in long-term care facilities: A systematic review

ObjectivesMalnutrition is a common problem in the elderly. It is not clear if oral health is associated to malnutrition in this population. The aim of this systematic review is to determine whether an association exists between oral health and malnutrition in the elderly in a long-term care facility.DesignSystematic review.Data sourceMedline, Cochrane and Cinahl were systematically searched for to identify articles published between January 1985 and May 2011. Reference lists were checked for additional publications.Review methodsPublications were included if they explored the association between oral health status and malnutrition. As no consensus about terminology was found, a sensitive filter was developed. The methodological quality of the studies was assessed. Two independent reviewers performed all methodological steps.ResultsSixteen studies met the criteria for inclusion. Eleven studies used a multivariate approach; nine of these found an association between oral health status and malnutrition. Four studies found a relationship between masticatory problems and malnutrition. Five studies found an association between malnutrition and dental condition, number of oral problems, tongue alteration, problems with saliva flow, and candidiasis. Overall, the methodological quality of the studies was medium.ConclusionsTentative evidence indicates an independent association between oral health status and malnutrition in the elderly residing in a long-term care facility. Caution is needed for the interpretation of these results because of the absence of a gold standard to define and assess malnutrition and oral health status and the presence of methodological limitations throughout the studies.     

Predisposing psychological factors in the development of reflex sympathetic dystrophy. A review of the empirical evidence.

OBJECTIVE: To examine the literature for evidence that psychological factors predispose certain individuals to development of reflex sympathetic dystrophy (RSD). DATA SOURCES: English-language journal articles that described psychological data on patients diagnosed with RSD, identified through Medline search and bibliography reviews. STUDY SELECTION: All studies reporting data on psychological factors in adult, adolescent, or child patients with RSD were included. DATA EXTRACTION: We extracted data regarding psychological factors in patients with RSD and assessed validity of these studies through evaluation against seven basic research criteria. DATA SYNTHESIS: Of the 20 articles reviewed, 15 reported the presence of depression, anxiety, and/or life stress in patients with RSD. However, the methodological quality of these studies was generally poor, with most meeting three or less of the seven validity criteria. In particular, the absence of prospective designs restricts conclusions concerning whether psychological factors are etiologically related to RSD. CONCLUSIONS: The data reviewed are consistent with a theoretical model in which depression, anxiety, or life stressors may influence development of RSD through their effects on alpha-adrenergic activity. However, conclusions regarding etiological significance of these factors are not possible due to the dearth of high-quality studies. Suggestions for prospective research are described.     

The Outcome of Complex Regional Pain Syndrome Type 1: A Systematic Review

The purpose of this systematic review was to examine the outcome of complex regional pain syndrome (CRPS) type 1. We searched MEDLINE, Embase, and PsycINFO for relevant studies and included 18 studies, with 3,991 participants, in this review. The following data were extracted: study details, measurement tools used, and rates or severity scores for the symptoms/signs of CRPS at baseline and follow-up, or in groups of patients with different disease durations. A quality assessment revealed significant limitations in the literature, with many studies using different diagnostic criteria. The 3 prospective studies demonstrated that for many patients, symptoms improve markedly within 6 to 13 months of onset. The 12 retrospective studies had highly heterogeneous findings, documenting lasting impairments in many patients. The 3 cross-sectional studies showed that rates of pain and sensory symptoms were highest among those with the longest duration of CRPS. Additionally, most studies showed that motor symptoms (stiffness and weakness) were the most likely to persist whereas sudomotor and vasomotor symptoms were the most likely to improve. Overall, this suggests that some CRPS patients make a good early recovery whereas others develop lasting pain and disability. As yet little is known about the prognostic factors that might differentiate between these groups.PerspectiveWe found evidence that many CRPS patients recover within 6 to 13 months, but a significant number experience some lasting symptoms, and some experience chronic pain and disability. The quality of the evidence was poor. Future research should examine the factors associated with recovery and identify those at risk of poor outcomes.     

Psychische Veränderungen bei Patienten mit komplexem regionalem Schmerzsyndrom (CRPS)

Question

Do comorbid psychological disorders, dysfunctional pain processing, and psychosocial pain coping occur with complex regional pain syndrome (CRPS) and is a connection between clinical and psychological manifestations apparent?

Methods

In addition to securing information on case histories and performing clinical neurological examinations of chronic CRPS patients, the structured clinical interview (SCID), pain perception scale, and the Kiel Pain Inventory were employed.

Results

The structured clinical interview revealed evidence of a depressive episode in 65% of CRPS patients. Pain perception is similar to neuropathic pain syndromes and patient history revealed a slightly increased frequency of anxiety and affective disorders. Depressive syndrome occurred significantly more often in right-sided CRPS; otherwise, there were no significant correlations between medical history, clinical examination, and frequency of psychological disorders. However, CRPS patients with allodynia manifest clinical signs of special psychological distress.

Conclusion

In chronic CRPS depressive syndrome frequently develops and psychological treatment can be recommended.     

The relationship between structural empowerment and psychological empowerment for nurses: a systematic review

wagner j.i.j., cummings g., smith d.l., olson j., anderson l. & warren s. (2010) Journal of Nursing Management 18 , 448–462
The relationship between structural empowerment and psychological empowerment for nurses: a systematic review Aim To describe the findings of a systematic review examining the relationship between structural empowerment and psychological empowerment for registered nurses (RNs). Background Workplace empowerment research reveals a link between empowerment and positive work behaviours and attitudes. Research demonstrating the essential relationship between structural empowerment and psychological empowerment will provide direction for future interventions aimed at the development of a strong and effective health care sector. Methods Published research articles examining structural empowerment and psychological empowerment for nurses were selected from computerized databases and selected websites. Data extraction and methodological quality assessment were completed for the included research articles. Results Ten papers representing six studies reveal significant associations between structural empowerment and psychological empowerment for RNs. Implications for nursing management Creation of an environment that provides structural empowerment is an important organizational strategy that contributes to RNs’ psychological empowerment and ultimately leads to positive work behaviours and attitudes. Critical structural components of an empowered workplace can contribute to a healthy, productive and innovative RN workforce with increased job satisfaction and retention.     

Systematic review of prognostic factors predicting outcome in non‐surgically treated patients with sciatica

Identification of prognostic factors for surgery in patients with sciatica is important to be able to predict surgery in an early stage. Identification of prognostic factors predicting persistent pain, disability and recovery are important for better understanding of the clinical course, to inform patient and physician and support decision making. Consequently, we aimed to systematically review prognostic factors predicting outcome in non‐surgically treated patients with sciatica. A search of Medline, Embase, Web of Science and Cinahl, up to March 2012 was performed for prospective cohort studies on prognostic factors for non‐surgically treated sciatica. Two reviewers independently selected studies for inclusion and assessed the risk of bias. Outcomes were pain, disability, recovery and surgery. A best evidence synthesis was carried out in order to assess and summarize the data. The initial search yielded 4392 articles of which 23 articles reporting on 14 original cohorts met the inclusion criteria. High clinical, methodological and statistical heterogeneity among studies was found. Reported evidence regarding prognostic factors predicting the outcome in sciatica is limited. The majority of factors that have been evaluated, e.g., age, body mass index, smoking and sensory disturbance, showed no association with outcome. The only positive association with strong evidence was found for leg pain intensity at baseline as prognostic factor for subsequent surgery.     

The psychological impact of testing for thrombophilia: a systematic review

Summary.  Background : Nowadays, large numbers of patients are tested for thrombophilia, even though the benefits of this strategy remain unclear. A potential disadvantage of this predominantly genetic testing is the psychological impact, including fear, depression and worry. Objectives : To systematically review studies that determined the nature and extent of the psychological impact of testing for thrombophilia. Patients/methods : We searched the MEDLINE data base (1966–2008), the EMBASE data base (1985–2008) and the PsychInfo data base (1806–2008) for relevant trials, without language restrictions. Bibliographies of relevant articles were scanned for additional articles. We reviewed all relevant studies that focused on the psychological impact of testing for thrombophilia. Only full papers of studies that included 15 patients or more were considered eligible for this review. Two reviewers independently extracted data and assessed quality. Results : Six studies fulfilled the eligibility criteria. As these studies varied appreciably in methodology, the pooling of data was not possible. Studies of psychological impact of genetic testing for thrombophilia report few negative results, although most assessments were limited to short-term follow-up, or lacked methodological accuracy. Conclusions : No valid conclusions can be drawn about the psychological impact of genetic testing in patients based on the current available literature. Given the large number of patients that are being exposed to testing for thrombophilia, and the uncertain benefits, there is an urgent need for more uniformity in the measurement of the psychological impact of thrombophilia testing.     

Demographic and medical parameters in the development of complex regional pain syndrome type 1 (CRPS1): prospective study on 596 patients with a fracture

Limited data are available on the incidence of complex regional pain syndrome type 1 (CRPS1) and on demographic and medical risk factors for the development of CRPS1. The objective of this study was to investigate the incidence of CRPS1 in patients with a fracture using 3 sets of diagnostic criteria and to evaluate the association between demographic/medical factors and the development of CRPS1 diagnosed with the Harden and Bruehl criteria. A prospective multicenter cohort study of 596 patients (ages 18 years and older) with a single fracture of the wrist, scaphoid, ankle, or metatarsal V, recruited patients from the emergency rooms of 3 Dutch hospitals. Of the 596 participants, 42 (7.0%) were diagnosed with CRPS1 according to the Harden and Bruehl criteria, 289 (48.5%) according to the International Association for the Study of Pain criteria, and 127 (21.3%) according to the criteria of Veldman. An analysis of the medical and demographic differences revealed that patients in whom CRPS1 later developed more often had intra-articular fractures, fracture dislocations, rheumatoid arthritis, or musculoskeletal comorbidities. An ankle fracture, dislocation, and an intra-articular fracture contributed significantly to the prediction of the development of CRPS1. No CRPS1 patients were symptom free at 12 months (T3). At baseline, patients with CRPS1 had significantly more pain than patients without CRPS1 (P<.001). The incidence of the diagnosis of CRPS1 after a single fracture depends to a large extent on the diagnostic criteria used. After a fracture, 7% of the patients developed CRPS1 and none of the patients were free of symptoms at 1-year follow-up.     

Clinical expression profiles of complex regional pain syndrome,fibromyalgia and a-specific repetitive strain injury: More common denominators than pain?

Purpose.?To systematically evaluate and compare the clinical manifestations, disease course, risk factors and demographic characteristics of Complex Regional Pain Syndrome type 1 (CRPS), fibromyalgia (FM) and a-specific Repetitive Strain Injury (RSI).

Method.?A literature search was performed using terms related to the aforementioned topics and diseases. Only original clinical studies that included at least 20 subjects were eligible.

Results.?Fifty-nine studies on CRPS, 73 on FM and 7 on a-specific RSI were identified. The diseases show similarities in age distribution, male-female ratio, pain characteristics and sensory signs and symptoms. Motor, autonomic and trophic changes are frequently reported in CRPS, but only occasionally in FM and RSI. Systemic symptoms are found in patients with CRPS and FM, and in a subgroup of patients with RSI. In all three disorders, symptoms usually start locally, but may spread to other body regions later, which, in the case of FM, is a prerequisite for diagnosis. Disease onset is always, usually, or occasionally of traumatic origin in RSI, CRPS and FM, respectively. Anxiety and depression are more frequent in patients compared to controls, but probably not very different from patients with other pain conditions or chronic diseases.

Conclusions.?Apart from some obvious differences between CRPS, FM and RSI, the similarities are conspicuous. The common features of CRPS, FM and a-specific RSI may suggest that a common pathway is involved, but until patients with these type of symptoms are assessed with a uniform assessment procedure, a thorough comparison cannot be made. A systematic evaluation of patients with a suspected diagnosis of CRPS, FM or RSI, may lead to a better appreciation of the differences and similarities in these diseases and help to unravel the underlying mechanisms.     

Clinical expression profiles of complex regional pain syndrome, fibromyalgia and a-specific repetitive strain injury: more common denominators than pain?

Purpose. To systematically evaluate and compare the clinical manifestations, disease course, risk factors and demographic characteristics of Complex Regional Pain Syndrome type 1 (CRPS), fibromyalgia (FM) and a-specific Repetitive Strain Injury (RSI).

Method. A literature search was performed using terms related to the aforementioned topics and diseases. Only original clinical studies that included at least 20 subjects were eligible.

Results. Fifty-nine studies on CRPS, 73 on FM and 7 on a-specific RSI were identified. The diseases show similarities in age distribution, male-female ratio, pain characteristics and sensory signs and symptoms. Motor, autonomic and trophic changes are frequently reported in CRPS, but only occasionally in FM and RSI. Systemic symptoms are found in patients with CRPS and FM, and in a subgroup of patients with RSI. In all three disorders, symptoms usually start locally, but may spread to other body regions later, which, in the case of FM, is a prerequisite for diagnosis. Disease onset is always, usually, or occasionally of traumatic origin in RSI, CRPS and FM, respectively. Anxiety and depression are more frequent in patients compared to controls, but probably not very different from patients with other pain conditions or chronic diseases.

Conclusions. Apart from some obvious differences between CRPS, FM and RSI, the similarities are conspicuous. The common features of CRPS, FM and a-specific RSI may suggest that a common pathway is involved, but until patients with these type of symptoms are assessed with a uniform assessment procedure, a thorough comparison cannot be made. A systematic evaluation of patients with a suspected diagnosis of CRPS, FM or RSI, may lead to a better appreciation of the differences and similarities in these diseases and help to unravel the underlying mechanisms.     

A systematic literature review of psychological characteristics as determinants of outcome for spinal cord stimulation therapy

Psychological factors are deemed important when considering patients for suitability for Spinal Cord Stimulation (SCS). However, there is to date no consensus on which psychological characteristics or tests to undertake. This review analyses the literature to determine findings concerning the psychological characteristics observed and their impact on SCS efficacy for chronic pain. A search in the databases Cochrane, EBSCOhost (CINAHL, MEDLINE, PsycINFO and PsycARTICLES) and a hand search of reference lists from selected articles were performed, resulting in nine relevant articles. The Minnesota Multiphasic Personality Inventory was the most commonly used tool for assessing psychological factors. Only one study used a semi-structured interview instead of questionnaires. Studies lacked long term followup. Depression was identified in six studies as a factor that reduces efficacy, also as a characteristic that can improve after successful SCS by two studies. One study did not include patients with depression, due to previous research indicating depression as a contra-indication. Hypochondriasis and hysteria had conflicting results for prediction of efficacy. Mania was predicted by only two studies as a positive indicator for success. Further long term studies of psychological factors on outcome from SCS are needed.     

Spinal cord stimulation for complex regional pain syndrome: an evidence-based medicine review of the literature

OBJECTIVES: The purpose of this investigation is to assess the evidence for efficacy of SCS in the management of pain in patients with CRPS. METHODS: Search strategy: Electronic databases such as Medline and Cochrane Library were queried using key words such as "spinal cord stimulation," "reflex sympathetic dystrophy (RSD)," and "complex regional pain syndrome (CRPS)."Selection criteria: Relevant published randomized controlled trials (RCT), cohort studies, case-control studies, case series, and case reports that described SCS as the primary treatment modality for patients with CRPS were eligible for inclusion.Data collection and analysis: Data extracted from qualified studies were summarized in sections of methodology, demographics, SCS equipment, primary and secondary outcomes, and complications. RESULTS: Thirteen studies using the primary search strategy and 7 studies from their reference lists were considered. Five of these 20 studies were discarded. One RCT, 2 prospective observational, and 12 retrospective observational studies were eventually considered. The methodological quality of all studies was poor except for the single RCT study. DISCUSSION: Although limited in quality and quantity, available evidence from the examined literature suggests that SCS is effective in the management of pain in patients with CRPS (grade B/C). Clinically useful information extracted from the available studies is very limited in guiding clinicians in the rational use of SCS for pain management in CRPS patients. Future attempts to investigate the efficacy of SCS in CRPS patients should involve methodologically robust designs such as randomized studies that have sufficient power.