Abstract: We included 18 RCTs (739 participants) that tested the effectiveness of a broad range of physiotherapy-based interventions. Overall, there was a paucity of high quality evidence concerning physiotherapy treatment for pain and disability in people with CRPS I. Most included trials were at 'high' risk of bias (15 trials) and the remainder were at 'unclear' risk of bias (three trials). The quality of the evidence was very low or low for all comparisons, according to the GRADE approach. We found very low quality evidence that graded motor imagery (GMI; two trials, 49 participants) may be useful for improving pain (0 to 100 VAS) (mean difference (MD) −21.00, 95% CI −31.17 to −10.83) and functional disability (11-point numerical rating scale) (MD 2.30, 95% CI 1.12 to 3.48), at long-term (six months) follow-up, in people with CRPS I compared to usual care plus physiotherapy; very low quality evidence that multimodal physiotherapy (one trial, 135 participants) may be useful for improving 'impairment' at long-term (12 month) follow-up compared to a minimal 'social work' intervention; and very low quality evidence that mirror therapy (two trials, 72 participants) provides clinically meaningful improvements in pain (0 to 10 VAS) (MD 3.4, 95% CI −4.71 to −2.09) and function (0 to 5 functional ability subscale of the Wolf Motor Function Test) (MD −2.3, 95% CI −2.88 to −1.72) at long-term (six month) follow-up in people with CRPS I post stroke compared to placebo (covered mirror). There was low to very low quality evidence that tactile discrimination training, stellate ganglion block via ultrasound and pulsed electromagnetic field therapy compared to placebo, and manual lymphatic drainage combined with and compared to either anti-inflammatories and physical therapy or exercise are not effective for treating pain in the short-term in people with CRPS I. Laser therapy may provide small clinically insignificant, short-term, improvements in pain compared to interferential current therapy in people with CRPS I. Adverse events were only rarely reported in the included trials. No trials including participants with CRPS II met the inclusion criteria of this review. The best available data show that GMI and mirror therapy may provide clinically meaningful improvements in pain and function in people with CRPS I although the quality of the supporting evidence is very low. Evidence of the effectiveness of multimodal physiotherapy, electrotherapy and manual lymphatic drainage for treating people with CRPS types I and II is generally absent or unclear. Large scale, high quality RCTs are required to test the effectiveness of physiotherapy-based interventions for treating pain and disability of people with CRPS I and II. Implications for clinical practice and future research are considered.

Plain-language summary: We searched for clinical trials of physiotherapy up to 12 February 2015. We included 18 trials that had 739 participants with CRPS I. In most of these trials the participants had CRPS I of the arm and hand. We did not find any clinical trials that included participants with CRPS II. Overall we did not find any good quality clinical trials of physiotherapy aimed at reducing the pain and disability of CRPS I in adults. Most included trials were not well designed and contained only small numbers of patients. We did find some low quality trials suggesting that two broadly similar types of rehabilitation training, known as 'graded motor imagery' (GMI) and 'mirror therapy', might be useful for reducing the pain and disability associated with CRPS I after traumatic events or surgery or a stroke. From the limited evidence available it appears that some types of electrotherapy, such as ultrasound and pulsed electromagnetic field therapy, as well as a type of massage therapy known as manual lymphatic drainage, are not effective. Most studies did not report on adverse events and so we do not know if these treatments have any harmful side-effects. On the whole, because of the limited number and low quality of available trials for the various physiotherapy treatments, we cannot be sure if any of the physiotherapy treatments we evaluated are effective for treating the pain and disability of CRPS I in adults. It is possible that some treatments, such as GMI or mirror therapy, might be effective. Further high quality clinical trials of physiotherapy are needed in order to find out if any of the different types of physiotherapy treatment are effective at improving pain and disability in people with CRPS.