Harmful or safe? Exposure and pain provocation during physiotherapy of complex regional pain syndrome I: a narrative review

BACKGROUND: Complex regional pain syndrome (CRPS) is a clinical diagnosis and an umbrella term for a heterogeneous group of states associated with pain disproportionate to any inciting event, together with a number of signs and symptoms that are manifested mainly in the limbs. There are often concerns among clinicians and patients about the potential harms caused by pain provocation during physiotherapy of CRPS, even though clinical guidelines de-emphasize pain-contingency. OBJECTIVE: The objective of this narrative review is to summarize current evidence regarding potential harms due to pain provocation during so-called exposure-based therapies in individuals with CRPS. METHODS: Six studies evaluating exposure-based approach were included (n = 6). RESULTS: Although only one included study focused primarily on safety and in the rest of the included studies the reporting of harms was insufficient and therefore our certainty in evidence is very low, taken together with outcome measures, available data does not point to any long-term deterioration in symptoms or function, or any major harms associated with pain provocation during physiotherapy of CRPS. CONCLUSION: There is a great need for higher-quality studies to determine which therapeutic approach is the most appropriate for whom and to evaluate the risks and benefits of different approaches in more detail.