# Effectiveness of Decision Support to Treat Complex Regional Pain Syndrome
## 3 Results  
During the first two months, patients underwent rehabilitative treatment three times a week; eventually, sessions were reduced to twice a week. Once ROM was almost completely restored and the pain disappeared, hand rehabilitative treatment occurred once a week until complete resolution (Figure 2). After an initial evaluation, the rehabilitative protocol started for all the patients with active hand mobilization, together with paraffin thermal therapy (Path A) (Figures 2 and 3). Once VAS was reduced to <7, rehabilitation progressed to A1, where musculature strengthening exercises were performed. When VAS was further lowered to <5, proprioceptive exercises were also performed (A2) in order to obtain a full functional recovery (Figure 4). Figure 2: Flowchart to illustrate the decision tree rehabilitation protocol. Both the stages (paths) of the rehabilitation process and the criteria for the progression throughout the stages are reported. However, if patients did not seem to improve at the end of the second rehabilitative week with Path A, they were redirected to either Path B or Path C depending on their prevalent symptomatology (Figure 2). In detail, if the patients presented pain as the predominant symptom, VAS \(\geq\) 7, and DASH \(\geq\) 30, they underwent Path B consisting of TENS, desensitization techniques, and mirror therapy (Figure 5); while patients who still presented pronounced edema, VAS \(\geq\) 7, and hand volunteer measure \(\geq\) 300 cc underwent Path C consisting of therapeutic massage and compressing bandaging to be kept for four hours each day. Once patients improved (VAS \(<\) 7, plus DASH \(<\) 25 for Path B; hand volunteer measure \(<\) 250 for Path C), they were re-directed to Path A1, as previously described. Figure 4: Illustration of sessions of musculature strengthening and proprioceptive exercises performed within Path A1 and Path A2 rehabilitative protocol. Figure 5: Illustration of a session of transcutaneous electrical nerve stimulation (TENS) performed within Path B rehabilitative protocol. Figure 3: Illustration of a session of paraffin thermal therapy performed within Path A rehabilitative protocol. If no significant improvement could be achieved after one month of rehabilitation and the patients still presented with VAS \(\geq\) 5 and DASH \(\geq\) 20, they underwent Path D, where static custom-made braces with thermo-modeling materials were made for hand protection while at rest, and dynamic ones were also made to increase the articular ROM. In order to progress from Path D to Path A1, patients had to present with VAS \(\leq\) 3, DASH \(\leq\) 20, and hand volunteer measure \(\leq\) 200 cc (Figure 2). CRPS always followed hand immobilization as a consequence of direct trauma with either conservative (n = 137, 76.11%) or (n = 43, 23.88%) surgical management (117 radiolunar joint fractures, 10 phalangeal fractures, 15 carpal tunnel syndromes, 24 metacarpal fractures, 12 distortive traumas, 1 deep flexor tendon injury, and 5 Dupuytren). The mean hand immobilization time was 30.68 days (SD \(\pm\) 7.22). The time elapsed between the trauma and the diagnosis of CRPS was 2.67 months on average (SD \(\pm\) 1.17), while the required rehabilitative therapy had a mean duration of 7.21 months (SD \(\pm\) 1.41) (Table 1). Natecal D3\({}^{\otimes}\) was administered to 157 patients (87.22%) together with e.v. administration of bisphosphonate, while 90 patients (50%) required biophysical stimulation with a portable device for 6-8 consecutive hours each day for 1 month. Ninety-six patients (53.33%) underwent Path A only and had a mean duration of 6.94 months (SD \(\pm\) 1.24). Thirteen patients (7.22%) underwent Path A + B with a mean duration of 6.31 months (SD \(\pm\) 1.25), while 10 patients (5.55%) underwent Path A + B + D with a mean duration of 8.2 months (SD \(\pm\) 0.79). Twenty-four patients (13.33%) underwent Path A + C, while 37 patients (20.55%) underwent Path A + C + D with a mean duration of 7.83 (SD \(\pm\) 0.87) and 7.59 months (SD \(\pm\) 0.64), respectively (Table 1).