Besides scientific evidence, other aspects are important in the formulation of guidelines, such as patient perspectives, availability of special techniques or expertise, organisational aspects, social consequences and costs. For the present guidelines these considerations were for a part based on Dutch perspectives. The conclusions based on scientific publications were set into the context of daily practice, and advantages and disadvantages of the various possible policies considered. The final recommendations are the result of the evidence available in combination with these considerations. This procedure followed in the present guideline development provides the opportunity to incorporate the debate between project group members in the formulation of recommendations, in order to make the guideline transparent and bring the recommendations in line with general practice.
Based on the presented evidence based evaluation of CRPS-I literature, in combination with additional considerations with regard to availability of treatment methods, side-effects, cost-benefits and consequences for organisation of care, recommendations endorsed by the participating professional societies were formulated, described additional file 3. In addition to these guidelines the task force is of the opinion that regular consultation between practitioners is desirable in order to provide uniform and clear information to the patient. In line with these observations, the task force advocates that patients should be actively informed about CRPS-I and possible consequences of this complaint, whereby verbal as well as written information should be provided. Although there is no evidence of for specific psychological profile or predisposition for patients with CRPS-I, there may be reasons to carry out further psychological investigation. Possible psychological factors maintaining and/or aggravating the syndrome need to be determined.
A limitation of the guidelines presented in this article is that only articles published up to 2006 were included, and possible relevant findings published after this date couldn't be incorporated in the present guidelines as a consequence of the formal procedure (see method section), involving the approval of participating professional societies. An additional search based on the search string used for these guidelines, revealed 45 additional articles [108–152], possibly providing information that could lead to amendment of this guideline. These articles comprised one retrospective chart review , one prospective cohort , six case series [117, 125, 127, 128, 132, 133], 14 clinical trials [109, 111, 112, 119, 122, 123, 126, 131, 135, 138, 140, 146, 147, 150], two controlled clinical trials [130, 136], 16 RCT's [108, 113, 114, 116, 124, 129, 134, 137, 139, 141, 143, 145, 146, 148, 149, 152], four systematic reviews/meta analyses [110, 115, 142, 144], and one treatment guideline . Interventions evaluated therein were piroxicam , gabapentin , intrathecal baclofen , sympathetic blockade (lumbar, stellate ganglion and intravenous) (n = 5) [122, 123, 134, 143, 149], corticosteroids (n = 3) [114, 119, 135], calcium regulating medication (bisphosphonates, calcitonin) (n = 4) [110, 116, 138, 142], NMDA antagonists (magnesium sulphate, ketamine, memantine) (n = 9) [111, 121, 125, 131, 140, 146–148, 152], free radical scavengers (mannitol, vitamin C) (n = 3) [129,135.137], nitric oxide regulating medication (n = 3) [133, 141, 151], spinal cord stimulation (n = 5) [112, 115, 120, 128, 132], regional anaesthesia (n = 2) [113, 117], physiotherapy and rehabilitation medicine (physiotherapy, mirror therapy, manual lymph drainage, vibratory stimulation, functional restoration, sensorimotor retuning, behavioural therapy, occlusional splints) (n = 11) [108, 109, 124, 126, 127, 130, 136, 139, 144, 145, 150]. Fifteen studies evaluated a combination of interventions, and four controlled studies used an active control. Two studies addressed primary prevention of CRPS I [117, 129]. These studies will have to be evaluated in the next formal adaptation of these guidelines. In addition, since the publication of these guidelines information provided in two studies included in these guidelines [100, 101] has been retracted due to scientific misconduct of the author. Recommendations based on these data (i.e. secondary prevention using pre-, per- and postoperative pain control and regional blockades with clonidine) therefore have to be regarded with caution.
Based on the identified literature and the extent of evidence found therein for therapeutic interventions for CRPS-I, we can conclude that further research is needed into each of the modalities discussed in these guidelines. This includes specifically treatment approaches recommended (or not advised) in these guidelines based on expert opinion, such as the use of botulin toxin and tricyclic antidepressants. Scientific data is also lacking with respect to treatment-related aspects, such as the role of the multidisciplinary approach, problems relating to work and communication with the patient and his or her family and close friends.
The project group considers that particular attention needs to be paid to further development of the diagnostic process. This development must be accompanied by research into possible underlying pathophysiological mechanisms (such as genetic factors) associated with CRPS-I, with particular attention being paid to possible sub-groups of the condition related to these underlying mechanisms.
With regard to drug treatment, further investigation is needed into the efficacy of pain medication and the percutaneous sympathetic blockade. More research is also needed into the use of drugs and invasive treatment with children suffering from CRPS-I.
In terms of paramedical treatment, the emphasis must be placed on the difference between pain contingent and a time contingent approach. Research is needed into the effects of various interventions on more long-standing (chronic) CRPS-I and into a multidisciplinary approach to CRPS-I.