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Batalla MAP, Lewis JS. Cognitive Multisensory Rehabilitation, a novel approach for Complex Regional Pain Syndrome: case series. Physiother Theory Pract 2024:1-15. [PMID: 39267348 DOI: 10.1080/09593985.2024.2393213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 07/25/2024] [Accepted: 08/11/2024] [Indexed: 09/17/2024]
Abstract
INTRODUCTION Effective treatment for Complex Regional Pain Syndrome (CRPS), a chronic pain condition, is challenging. Cognitive Multisensory Rehabilitation (CMR) is a cognitive and sensorimotor treatment approach aimed at restoring function that targets cognitive, somatosensory, and multisensory functions through sensory discrimination tasks. PURPOSE We aimed to apply CMR to treat CRPS within our clinical practice. Clinically, we have found promising results in reducing pain and other common features of CRPS, such as Body Perception Disturbances (BPD). METHODS In this clinical case series, four CRPS patients who participated in a two-week interdisciplinary CRPS rehabilitation program at the National Complex Regional Pain Syndrome Service in Bath, UK received CMR as part of their treatment. A combination of self-reported measures and clinical outcomes were collected pre and post-rehabilitation program. RESULTS Functional improvements and a reduction on BPD were observed in all clinical cases. DISCUSSION We demonstrate how CMR may improve several CRPS-related features that often hinder rehabilitation in people living with CRPS. CONCLUSION Research involving larger cohorts are necessary to provide empirical evidence of the application of CMR in treating CRPS.
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Affiliation(s)
- Marc A Pique Batalla
- National Complex Regional Pain Syndrome Service, Royal United Hospital Bath NHS Trust, Bath, UK
- School of Health and social Wellbeing, University of the West of England, Bristol, UK
| | - Jennifer S Lewis
- National Complex Regional Pain Syndrome Service, Royal United Hospital Bath NHS Trust, Bath, UK
- School of Health and social Wellbeing, University of the West of England, Bristol, UK
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Schneider S, Wertli MM, Henzi A, Hebeisen M, Brunner F. Effect of an interdisciplinary inpatient program for patients with complex regional pain syndrome in reducing disease activity-a single-center prospective cohort study. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:459-467. [PMID: 38530793 PMCID: PMC11224586 DOI: 10.1093/pm/pnae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/02/2024] [Accepted: 03/07/2024] [Indexed: 03/28/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the benefit of inpatient treatment in reducing disease activity in patients with complex regional pain syndrome (CRPS) who have exhausted outpatient options. Furthermore, the study sought to identify patient-related outcome variables that predict a reduction in disease activity. METHODS The primary outcome was disease severity (CRPS Severity Score, range 0-16 points). Secondary outcomes included depression, anxiety, physical function, pain interference, fatigue, sleep disturbance, and the ability to participate in social roles and activities, all of which were assessed using the PROMIS-29. Furthermore, pain catastrophizing, neuropathic pain, quality of life, pain self-efficacy, medication intake, and the patient's global impression of change were examined in accordance with current international agreed recommendations, assessed at discharge, 3-month, and 6-month post-discharge. Mixed-effects models were conducted to identify baseline variables associated with CRPS severity. RESULTS Twenty-five patients completed the program (mean age 49.28 [SD 11.23] years, 92% females, mean symptom duration 8.5 [SD 6.5] months). Results showed a significant reduction between baseline and discharge of disease activity (CSS -2.36, P < .0001), pain (PROMIS-29 pain -0.88, P = .005), and emotional function (PROMIS-29 depression -5.05, P < .001; fatigue -4.63, P = .002). Moderate evidence for a reduction between baseline and discharge could be observed for pain interference (+2.27, P = .05), social participation (PROMIS-29 + 1.93, P = .05), anxiety (PROMIS-29 -3.32, P = .02) and physical function (PROMIS-29 + 1.3, P = .03). On discharge, 92% of patients (23 of 25) reported improvement in their overall condition. In the follow-up period, medication intake could be reduced after 3 (MQS -8.22, P = .002) and 6 months (MQS -8.69, P = .001), and there was further improvement in social participation after 3 months (PROMIS-29 + 1.72, 0.03) and sleep after 6 months (PROMIS-29 + 2.38, 0.008). In the mixed models, it was demonstrated that patients experiencing less pain at baseline also exhibited lower disease activity. CONCLUSION The results of this study confirm that inpatient interdisciplinary treatment of CRPS patients improves disease activity, pain, physical function, emotional function, and social participation. Most improvements were maintained for up to 6 months after discharge. The majority of patients reported that their overall condition had improved during the study period.
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Affiliation(s)
- Stephanie Schneider
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Maria M Wertli
- Department of Internal Medicine, Kantonsspital Baden, 5404 Baden, Switzerland
- Department of General Internal Medicine, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Anna Henzi
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Monika Hebeisen
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, 8001 Zurich, Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, 8008 Zurich, Switzerland
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Kiyomoto K, Emori M, Hanaka M, Teramoto A, Hayakawa H, Takashima K, Yamashita T, Iba K. Remission of hypersensitivity by simple weight load stimuli in a complex regional pain syndrome mouse model. J Orthop Res 2024; 42:1020-1032. [PMID: 38044473 DOI: 10.1002/jor.25750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 06/26/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
Painful sensitivity of the hand or foot are the most common and debilitating symptoms of complex regional pain syndrome (CRPS). Physical therapy is standard treatment for CRPS, but evidence supporting its efficacy is minimal and it can be essentially impossible for CRPS patients to actively exercise the painful limb. Using the well-characterized distal tibial fracture CRPS mouse model, we compared the therapeutic effects of several weeks of daily hindlimb loading versus rotarod walking exercise. The effects of loading and exercise were evaluated by weekly testing of hind-paw withdrawal thresholds to von Frey fibers and radiant heat, as well as measurements of paw and ankle edema. At 6 weeks after fracture, the mice were killed and the ipsilateral femur, spinal cord and L4/5 dorsal root ganglia, and hind-paw skin collected for PCR assays and paw skin Immunohistochemistry evaluation. Hindlimb loading reduced hind-paw von Frey allodynia and heat hyperalgesia and edema within a week and these effects persisted for at least a week after discontinuing treatment. These therapeutic effects of loading exceeded the beneficial effects observed with rotarod walking exercise in fracture mice. Levels of nerve growth factor and transient receptor potential vanilloid 1 (TRPV1) immunostaining in the hind-paw skin were increased at 6 weeks after fracture, and both loading and exercise treatment reduced increases. Collectively, these results suggest that loading may be an effective and possibly curative treatment in CRPS patients with sensitivity in the affected limb.
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Affiliation(s)
- Kenta Kiyomoto
- Department of Musculoskeletal Anti-aging Medicine, Sapporo Medical University, Sapporo, Japan
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
- Division of Occupational Therapy, Department of Rehabilitation, Faculty of Health Science, Japan Healthcare University, Sapporo, Japan
| | - Makoto Emori
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Megumi Hanaka
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Atsushi Teramoto
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hikaru Hayakawa
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kenichi Takashima
- Department of Musculoskeletal Anti-aging Medicine, Sapporo Medical University, Sapporo, Japan
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Toshihiko Yamashita
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kousuke Iba
- Department of Musculoskeletal Anti-aging Medicine, Sapporo Medical University, Sapporo, Japan
- Department of Orthopaedic Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
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Ferraro MC, O'Connell NE, Sommer C, Goebel A, Bultitude JH, Cashin AG, Moseley GL, McAuley JH. Complex regional pain syndrome: advances in epidemiology, pathophysiology, diagnosis, and treatment. Lancet Neurol 2024; 23:522-533. [PMID: 38631768 DOI: 10.1016/s1474-4422(24)00076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 04/19/2024]
Abstract
Complex regional pain syndrome (CRPS) is a rare pain disorder that usually occurs in a limb after trauma. The features of this disorder include severe pain and sensory, autonomic, motor, and trophic abnormalities. Research from the past decade has offered new insights into CRPS epidemiology, pathophysiology, diagnosis, and treatment. Early identification of individuals at high risk of CRPS is improving, with several risk factors established and some others identified in prospective studies during the past 5 years. Better understanding of the pathophysiological mechanisms of CRPS has led to its classification as a chronic primary pain disorder, and subtypes of CRPS have been updated. Procedures for diagnosis have also been clarified. Although effective treatment of CRPS remains a challenge, evidence-based integrated management approaches provide new opportunities to improve patient care. Further advances in diagnosis and treatment of CRPS will require coordinated, international multicentre initiatives.
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Affiliation(s)
- Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Claudia Sommer
- University Hospital Würzburg, Department of Neurology, Würzburg, Germany
| | - Andreas Goebel
- Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, and Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Janet H Bultitude
- Centre for Pain Research, Department of Psychology, University of Bath, Bath, UK
| | - Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - G Lorimer Moseley
- IMPACT in Health, University of South Australia, Kaurna Country, Adelaide, SA, Australia
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
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Lewis JS, Wallace CS, White P, Mottram L, Ockenden G, Rehm K, Walker K. Early versus persistent Complex Regional Pain Syndrome: Is there a difference in patient reported outcomes following rehabilitation? Eur J Pain 2024; 28:464-475. [PMID: 37947050 DOI: 10.1002/ejp.2196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/18/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Expert consensus asserts that early treatment of Complex Regional Pain Syndrome (CRPS) leads to better outcomes. Yet no evidence supports this assumption regarding the recognized gold standard of multidisciplinary functional rehabilitation. To address this, we aimed to establish if there is a difference in outcomes between early CRPS (<1 year symptom duration) and persistent CRPS (= >1 year symptom duration) following rehabilitation and whether any gains are maintained at three months. METHOD Secondary analysis was conducted on previously collected clinical Patient Reported Outcome Measures (PROMS) data from 218 patients attending a residential multidisciplinary rehabilitation programme. Datasets were categorized into early CRPS (n = 40) or persistent CRPS (n = 178) dependent on symptom duration. Function, pain, self-efficacy, kinesiophobia and psychological health domains were compared using repeated measures analysis of covariance for a two group design for group difference post rehabilitation and at three month follow-up. RESULTS Post-rehabilitation, both groups improved in pain, function, kinesiophobia, psychological health and self-efficacy. At three months, the persistent CRPS group maintained improvements in pain and function. This was not achieved in early CRPS. CONCLUSION This exploratory study is the first to empirically test the assumption that those with early CRPS have better outcomes following rehabilitation. Our clinical data challenges this, as both early and persistent CRPS groups improved following rehabilitation. Findings indicate that rehabilitation benefits those with CRPS, regardless of symptom duration. However, unlike early CRPS, those with persistent CRPS sustain gains at follow-up. Further prospective exploration is warranted. SIGNIFICANCE Expert consensus recommends early treatment for Complex Regional Pain Syndrome, yet there is little empirical evidence to support this. Our findings are the first to challenge this assumption by revealing no difference in outcomes between early and persistent CRPS post-rehabilitation. However, those with persistent CRPS maintain gains after three months, unlike people with early CRPS (symptoms < one year). These findings are relevant to clinical practice as they challenge established assumptions, suggesting a focus on improving early CRPS follow-up outcomes.
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Affiliation(s)
- Jennifer S Lewis
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
- National Complex Regional Pain Syndrome Service, Royal United Hospitals NHS Trust, Bath, UK
| | - Chris S Wallace
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Paul White
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Laura Mottram
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Gareth Ockenden
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Kjetil Rehm
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Kate Walker
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
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Osumi M, Sumitani M, Iwatsuki K, Hoshiyama M, Imai R, Morioka S, Hirata H. Resting-state Electroencephalography Microstates Correlate with Pain Intensity in Patients with Complex Regional Pain Syndrome. Clin EEG Neurosci 2024; 55:121-129. [PMID: 37844609 DOI: 10.1177/15500594231204174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
Objective: Severe pain and other symptoms in complex regional pain syndrome (CRPS), such as allodynia and hyperalgesia, are associated with abnormal resting-state brain network activity. No studies to date have examined resting-state brain networks in CRPS patients using electroencephalography (EEG), which can clarify the temporal dynamics of brain networks. Methods: We conducted microstate analysis using resting-state EEG signals to prospectively reveal direct correlations with pain intensity in CRPS patients (n = 17). Five microstate topographies were fitted back to individual CRPS patients' EEG data, and temporal microstate measures were subsequently calculated. Results: Our results revealed five distinct microstates, termed microstates A to E, from resting EEG data in patients with CRPS. Microstates C, D and E were significantly correlated with pain intensity before pain treatment. Particularly, microstates D and E were significantly improved together with pain alleviation after pain treatment. As microstates D and E in the present study have previously been related to attentional networks and the default mode network, improvement in these networks might be related to pain relief in CRPS patients. Conclusions: The functional alterations of these brain networks affected the pain intensity of CRPS patients. Therefore, EEG microstate analyses may be used to identify surrogate markers for pain intensity.
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Affiliation(s)
- Michihiro Osumi
- Graduate School of Health Science, Kio University. 4-2-2 Umaminaka, Kitakatsuragigun, Nara, Japan
- Neurorehabilitation Research Center, Kio University. 4-2-2 Umaminaka, Kitakatsuragigun, Nara, Japan
| | - Masahiko Sumitani
- Department of Pain and Palliative Medicine, The University of Tokyo Hospital. 7-3-1 Hongo, Bunkyo-ku, Tokyo, Japan
| | - Katsuyuki Iwatsuki
- Department of Hand Surgery, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, Japan
| | - Minoru Hoshiyama
- Department of Health Sciences, Faculty of Medicine, Nagoya University, 1-1-20 Daiko-minami, Higashi-ku, Nagoya, Aichi, Japan
| | - Ryota Imai
- School of Rehabilitation, Osaka Kawasaki Rehabilitation University, Kaizuka, Osaka, Japan
| | - Shu Morioka
- Graduate School of Health Science, Kio University. 4-2-2 Umaminaka, Kitakatsuragigun, Nara, Japan
- Neurorehabilitation Research Center, Kio University. 4-2-2 Umaminaka, Kitakatsuragigun, Nara, Japan
| | - Hitoshi Hirata
- Department of Hand Surgery, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, Japan
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Knudsen L, Santoro L, Bruehl S, Harden N, Brunner F. Subtypes of complex regional pain syndrome-a systematic review of the literature. Pain Rep 2023; 8:e1111. [PMID: 38027463 PMCID: PMC10653603 DOI: 10.1097/pr9.0000000000001111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 12/01/2023] Open
Abstract
To systematically identify and summarize possible subtypes of complex regional pain syndrome (CRPS), we searched MEDLINE, Embase, Cochrane, Scopus, and Web of Science for original studies reporting or investigating at least one subtype within a group of patients with CRPS. The search retrieved 4239 potentially relevant references. Twenty-five studies met our inclusion criteria and were included in the analysis. Complex regional pain syndrome phenotypes were investigated based on the following variables: clinical presentation/sensory disturbances, dystonia, skin temperature, disease duration, onset type, CRPS outcome, and neuropsychological test performance. Support was found for the following CRPS subtypes: CRPS type I, CRPS type II, acute CRPS, chronic CRPS, centralized CRPS, cold CRPS, warm CRPS, inflammatory CRPS, dystonic CRPS, nondystonic CRPS, familial CRPS, and nonfamilial CRPS. It is unclear whether these are distinct or overlapping subtypes. The results of this comprehensive review can facilitate the formulation of well-defined CRPS subtypes based on presumed underlying mechanisms. Our findings provide a foundation for establishing and defining clinically meaningful CRPS subtypes, with the ultimate goal of developing targeted and enhanced treatments for CRPS.
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Affiliation(s)
- Lone Knudsen
- National Rehabilitation Center for Neuromuscular Diseases, Aarhus, Denmark
| | - Lana Santoro
- Wheelock College of Education and Human Development, Boston University, Boston, MA, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Zurich, Switzerland
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Griffiths GS, Thompson BL, Snell DL, Dunn JA. Experiences of diagnosis and treatment for upper limb Complex Regional Pain Syndrome: a qualitative analysis. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1355-1363. [PMID: 37584744 PMCID: PMC10690851 DOI: 10.1093/pm/pnad111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/21/2023] [Accepted: 08/10/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Complex Regional Pain Syndrome (CRPS) most frequently affects the upper limb, with high associated disability. Delays to diagnosis and appropriate treatment can adversely impact prognosis and quality of life, but little is known about the healthcare experiences of people with CRPS. This study aimed to explore lived experiences of diagnosis and treatment for people with upper limb CRPS. METHODS Participants were recruited through online support groups and multiple public and private healthcare settings in the Greater Wellington Region, New Zealand. Semi-structured interviews were conducted with participants who had experienced upper limb CRPS for more than three months and less than three years. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. RESULTS Thirteen participants (11 female, 2 male) aged between 43 and 68 years were interviewed. Duration of CRPS ranged from 7 months to 2.5 years. Five themes were identified. Participants initially engaged in healthcare out of a desire to return to being the person they were before having CRPS. Three interacting experiences epitomised the overall healthcare experience: (1) not knowing what is going on, (2) not being taken seriously, and (3) healthcare as adding another layer of load. Meanwhile, participants used multiple approaches in an attempt to not let CRPS stop them from continuing to live their lives. CONCLUSIONS Participants in this study felt that credible information, validation, and simplification from healthcare providers and systems would support their process of navigating towards a meaningful life and self-concept in the presence of CRPS.
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Affiliation(s)
- Grace S Griffiths
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch 8011, New Zealand
| | - Bronwyn L Thompson
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch 8011, New Zealand
| | - Deborah L Snell
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch 8011, New Zealand
| | - Jennifer A Dunn
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch 8011, New Zealand
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Griffiths GS, Thompson BL, Snell DL, Dunn JA. Person-centred management of upper limb complex regional pain syndrome: an integrative review of non-pharmacological treatment. HAND THERAPY 2023; 28:16-32. [PMID: 37904811 PMCID: PMC10584071 DOI: 10.1177/17589983221138610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/25/2022] [Indexed: 11/01/2023]
Abstract
Introduction Complex Regional Pain Syndrome (CRPS) is most common in the upper limb and associated with high disability. The purpose of this review was to critically appraise and synthesise literature exploring non-pharmacological treatment for upper limb CRPS, to guide upper-limb-specific management. Methods Using an integrative review methodology, 13 databases were searched to identify all published studies on non-pharmacological management of upper limb CRPS. The Crowe Critical Appraisal Tool was used to provide quality ratings for included studies, and analysis employed a qualitative descriptive approach. Results From 236 abstracts reviewed, 113 full texts were read, and 38 articles selected for data extraction. Designs included single case (n = 14), randomised controlled trial (n = 8), prospective cohort (n = 8), case series (n = 4), retrospective (n = 3), and mixed methods (n = 1). Interventions were categorised as sensory retraining (n = 13), kinesiotherapy (n = 7), manual therapies (n = 7), physical modalities (n = 6), and interdisciplinary treatment programmes (n = 5). All studies measured pain intensity, and most (n = 24) measured physical parameters such as strength, movement, or perceptual abilities. Few measured patient-rated function (n = 13) or psychological factors (n = 4). Quality ratings ranged from 30% to 93%, with a median of 60%. Conclusion Methodological quality of non-pharmacological treatment approaches for upper limb CRPS is overall poor. Movement, desensitisation, and graded functional activity remain the mainstays of intervention. However, despite the impact of CRPS on wellbeing and function, psychological factors and functional outcomes are infrequently addressed. Further robust research is required to determine which aspects of treatment have the greatest influence on which symptoms, and when and how these should be introduced and progressed.
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Affiliation(s)
- Grace S Griffiths
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Bronwyn L Thompson
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Deborah L Snell
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Jennifer A Dunn
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
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Louis MH, Meyer C, Legrain V, Berquin A. Biological and psychological early prognostic factors in complex regional pain syndrome: A systematic review. Eur J Pain 2023; 27:338-352. [PMID: 36516373 DOI: 10.1002/ejp.2068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 11/14/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Several risk factors for the onset of CRPS have been found, but evidence for prognostic factors associated with the progression of this condition remains sparse. However, the detection and management of these factors are necessary to design secondary prevention strategies. The objective of this systematic review was to identify prognostic factors in adult individuals with early CRPS. DATABASE AND DATA TREATMENT PubMed, Embase, PsycINFO, Cochrane Library and Scopus, were published between January 1990 and November 2021. Two independent investigators selected cross-sectional and longitudinal studies looking at early (<12 weeks from onset) prognostic factors for pain, CRPS severity score, disability, return to work, or quality of life. The quality in prognostic studies (QUIPS) tool was used to assess the risk of bias. A qualitative meta-synthesis was performed. RESULTS Out of 4652 different articles, six studies met the inclusion criteria. We identified 21 early factors associated with a poorer prognosis in type I CRPS. We found moderate evidence to support six of them: higher pain intensity, self-rated disability, anxiety, pain-related fear, being a female and high-energy triggering event. Only two studies had an overall low risk of bias. CONCLUSIONS This study showed an important lack of information on early prognostic factors in CRPS. Only one article investigated the link with psychological characteristics. There is a crucial need for larger studies, with a well-defined population using validated measures. SIGNIFICANCE This systematic review highlights the lack of knowledge about early prognostic factors in CRPS. A few putative prognostic factors were identified. Most of the moderate evidence is related to a single cohort. Future research is required to find out which patients are vulnerable to chronification.
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Affiliation(s)
- Marc-Henri Louis
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
| | - Caroline Meyer
- CHU UCL Namur site Godinne, Department of Physical Medicine and Rehabilitation, Yvoir, Belgium
| | - Valéry Legrain
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
- Psychological Sciences Research Institute, Université catholique de Louvain, Louvain-la-Neuve, Belgium
- Louvain Bionics, Université catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Anne Berquin
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
- Cliniques Universitaires UCL Saint-Luc, Department of Physical and Rehabilitation Medicine, Brussels, Belgium
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Reinhold AK, Kindl GK, Dietz C, Scheu N, Mehling K, Brack A, Birklein F, Rittner HL. Molecular and clinical markers of pain relief in complex regional pain syndrome: An observational study. Eur J Pain 2023; 27:278-288. [PMID: 36440973 DOI: 10.1002/ejp.2058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is marked by disproportionate pain after trauma. Whilst the long-term outcome is crucial to patients, predictors or biomarkers of the course of pain or CRPS symptoms are still lacking. In particular, microRNAs, such as miR-223, decreased in CRPS, have been described only in cross-sectional studies. METHODS In this study, we characterised CRPS patients over a course of 2.5 years of standard treatment. The patient underwent clinical examination including pain measurement, symptom questionnaires, quantitative sensory testing (QST) and blood sampling. Exosomal microRNA levels were measured via qPCR. After follow-up, patients were stratified into 'pain relief' (mean pain reduced by ≥2 numeric rating scale) or 'persistence' (mean pain unchanged or worsened). The primary outcome was miR-223 and miR-939 expression, secondary outcomes were differences in clinical parameters between groups and time points. RESULTS Thirty-nine patients were included, 33 of whom qualified for stratification. Overall, patients reported lower pain and improved clinical characteristics after 2.5 years, but no significant changes in QST or miR-223 and miR-939 expression levels. 16 patients met the criteria for pain relief. This was associated with stable exosomal miR-223 expression, whilst levels further decreased in pain persistence. Clinically, pain relief was marked by shorter disease duration and correlated positively with high initial pain. CONCLUSION We identified progressively reduced miR-223 as a putative biomarker of chronic CRPS pain. Clinically, this study underlines the importance of early diagnosis and treatment showing that high initial pain does not predict an unfavourable outcome. Finally, pain relief and recovery of sensory disturbances seem independent processes.
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Affiliation(s)
- Ann Kristin Reinhold
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Gudrun-Karin Kindl
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Christopher Dietz
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Nathalie Scheu
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Katharina Mehling
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Alexander Brack
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Frank Birklein
- Department of Neurology, Mainz University Hospitals, Mainz, Germany
| | - Heike L Rittner
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
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12
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Li TS, Wang R, Su X, Wang XQ. Effect and mechanisms of exercise for complex regional pain syndrome. Front Mol Neurosci 2023; 16:1167166. [PMID: 37206984 PMCID: PMC10188984 DOI: 10.3389/fnmol.2023.1167166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Complex regional pain syndrome characterized by severe pain and dysfunction seriously affects patients' quality of life. Exercise therapy is gaining attention because it can effectively relieve pain and improve physical function. Based on the previous studies, this article summarized the effectiveness and underlying mechanisms of exercise interventions for complex regional pain syndrome, and described the gradual multistage exercise program. Exercises suitable for patients with complex regional pain syndrome mainly include graded motor imagery, mirror therapy, progressive stress loading training, and progressive aerobic training. In general, exercise training for patients with complex regional pain syndrome not only alleviates pain but also improves physical function and positive mental status. The underlying mechanisms of exercise interventions for complex regional pain syndrome include the remodeling of abnormal central and peripheral nervous system, the regulation of vasodilation and adrenaline levels, the release of endogenous opioids, and the increased anti-inflammatory cytokines. This article provided a clear explanation and summary of the research on exercise for complex regional pain syndrome. In the future, more high-quality studies with sufficient sample sizes may provide more exercise regimens and better evidence of efficacy.
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Affiliation(s)
- Tian-Shu Li
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Rui Wang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
| | - Xuan Su
- Department of Rehabilitation Medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai, China
- Xuan Su,
| | - Xue-Qiang Wang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
- Shanghai Shangti Orthopaedic Hospital, Department of Rehabilitation Medicine, Shanghai, China
- *Correspondence: Xue-Qiang Wang,
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13
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Karpin H, Vatine JJ, Bachar Kirshenboim Y, Markezana A, Weissman-Fogel I. Central Sensitization and Psychological State Distinguishing Complex Regional Pain Syndrome from Other Chronic Limb Pain Conditions: A Cluster Analysis Model. Biomedicines 2022; 11:89. [PMID: 36672597 PMCID: PMC9856064 DOI: 10.3390/biomedicines11010089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/23/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023] Open
Abstract
Complex regional pain syndrome (CRPS) taxonomy has been updated with reported subtypes and is defined as primary pain alongside other chronic limb pain (CLP) conditions. We aimed at identifying CRPS clinical phenotypes that distinguish CRPS from other CLP conditions. Cluster analysis was carried out to classify 61 chronic CRPS and 31 CLP patients based on evoked pain (intensity of hyperalgesia and dynamic allodynia, allodynia area, and after-sensation) and psychological (depression, kinesiophobia, mental distress, and depersonalization) measures. Pro-inflammatory cytokine IL-6 and TNF-α serum levels were measured. Three cluster groups were created: ‘CRPS’ (78.7% CRPS; 6.5% CLP); ‘CLP’ (64.5% CLP; 4.9% CRPS), and ‘Mixed’ (16.4% CRPS; 29% CLP). The groups differed in all measures, predominantly in allodynia and hyperalgesia (p < 0.001, η² > 0.58). ‘CRPS’ demonstrated higher psychological and evoked pain measures vs. ‘CLP’. ‘Mixed’ exhibited similarities to ‘CRPS’ in psychological profile and to ‘CLP’ in evoked pain measures. The serum level of TNF-αwas higher in the ‘CRPS’ vs. ‘CLP’ (p < 0.001) groups. In conclusion, pain hypersensitivity reflecting nociplastic pain mechanisms and psychological state measures created different clinical phenotypes of CRPS and possible CRPS subtypes, which distinguishes them from other CLP conditions, with the pro-inflammatory TNF-α cytokine as an additional potential biomarker.
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Affiliation(s)
- Hana Karpin
- Physical Therapy Department, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa 3498838, Israel
- Reuth Rehabilitation Hospital, Tel Aviv 6772829, Israel
| | - Jean-Jacques Vatine
- Reuth Rehabilitation Hospital, Tel Aviv 6772829, Israel
- Physical Medicine and Rehabilitation Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Yishai Bachar Kirshenboim
- Reuth Rehabilitation Hospital, Tel Aviv 6772829, Israel
- Department of Occupational Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Aurelia Markezana
- Goldyne Savad Institute of Gene Therapy, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel
| | - Irit Weissman-Fogel
- Physical Therapy Department, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa 3498838, Israel
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14
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Melf-Marzi A, Böhringer B, Wiehle M, Hausteiner-Wiehle C. Modern Principles of Diagnosis and Treatment in Complex Regional Pain Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:879-886. [PMID: 36482756 PMCID: PMC10011717 DOI: 10.3238/arztebl.m2022.0358] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 04/21/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Background: Complex regional pain syndrome (CRPS) is a relatively common complication, occurring in 5% of cases after injury or surgery, particularly in the limbs. The incidence of CPRS is around 5-26/100 000. The latest revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) now categorizes CRPS as a primary pain condition of multifactorial origin, rather than a disease of the skeletal system or the autonomic nervous system. METHODS Method: Based on a selective search of the literature, we summarize current principles for the diagnosis and treatment of CRPS. RESULTS Results: Regional findings in CRPS are accompanied by systemic symptoms, especially by neurocognitive disorders of body perception and of symptom processing. The therapeutic focus is shifting from predominantly passive peripheral measures to early active treatments acting both centrally and peripherally. The treatment is centered on physiotherapy and occupational therapy to improve sensory perception, strength, (fine) motor skills, and sensorimotor integration/ body perception. This is supported by stepped psychological interventions to reduce anxiety and avoidance behavior, medication to decrease inflammation and pain, passive physical measures for reduction of edema and of pain, and medical aids to improve functioning in daily life. Interventional procedures should be limited to exceptional cases and only be performed in specialized centers. Spinal cord and dorsal root ganglion stimulation, respectively, are the interventions with the best evidence. CONCLUSION Conclusion: The modern principles for the diagnosis and treatment of CRPS consider both, physiological and psychological mechanisms, with the primary goal of restoring function and participation. More research is needed to strengthen the evidence base in this field.
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Affiliation(s)
- Alexandra Melf-Marzi
- Department for BG Rehabilitation; Outpatient CRPS Clinic; BG Trauma Center Murnau; Department for Anesthesiology, Intensive Care Medicine and Pain Therapy; Multimodal Pain Therapy; BG Trauma Center Murnau; Department for Neurology, Clinical Neurophysiology and Stroke Unit; BG Trauma Center Murnau; Clinic and Polyclinic for Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich
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15
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Varenna M, Gatti D, Zucchi F, Crotti C, Braga V, Iolascon G, Frediani B, Nannipieri F, Rossini M. Long-term efficacy and safety of neridronate treatment in patients with complex regional pain syndrome type 1: a pre-specified, open-label, extension study. Ther Adv Musculoskelet Dis 2022; 14:1759720X221142274. [PMID: 36569491 PMCID: PMC9772942 DOI: 10.1177/1759720x221142274] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/14/2022] [Indexed: 12/23/2022] Open
Abstract
Background No data on the permanent and curative effect of bisphosphonate treatment in patients with complex regional pain syndrome type-1 (CRPS-1) are currently available. The aim of this pre-specified, open-label, observational study was to evaluate the long-term efficacy and safety of neridronate treatment. Design A pre-specified, open-label, extension study. Methods Patients treated with intramuscular (IM) placebo in the double-blind phase of the study were assigned to 100 mg intravenous (IV) neridronate treatment administered 4 times over 10 days. These patients, together with those previously treated with 400 mg IM neridronate, were followed for 1 year. Efficacy was assessed using a visual analogue scale (VAS) pain score. Changes in clinical signs and symptoms, quality of life (QoL) using the Short Form Health Survey (SF-36), and the McGill Pain Questionnaire were also assessed. Results Benefits on pain, clinical and functional measures were maintained and further improved over 12 months in most patients treated with neridronate administered either IM or IV. In IM-treated patients, the percentage of those defined as responders (VAS score reduction ≥ 50%) progressively increased up to day 360 to 32 of 35 patients (91.4%). Among the 27 patients referred to as responders at the end of the double-blind phase, 26 reported the same result at day 360 (96.3%). In IV-treated patients, a responder rate of 88% (22 out 25) was found at day 360 (p = 0.66 between groups). Consistent improvements were also observed for all clinical signs and functional questionnaire. No drug-related adverse events were reported during the study. Conclusion In patients with acute CRPS-1, the benefit in pain, clinical, and functional measures observed a few weeks after neridronate treatment administered either IM or IV is maintained and further improved over 12 months. Parenteral neridronate induces permanent disease remission preventing chronic pain and motor dysfunction. Trial registration EU Clinical Trials Register (EudraCT Number): 2014-001156-28.
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Affiliation(s)
| | - Davide Gatti
- Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy
| | - Francesca Zucchi
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | - Chiara Crotti
- Bone Diseases Unit, Department of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | | | - Giovanni Iolascon
- Department of Medical and Surgical Specialties, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | | | | | - Maurizio Rossini
- Rheumatology Unit, Department of Medicine, University of Verona, Verona, Italy
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16
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Kavka T. Harmful or safe? Exposure and pain provocation during physiotherapy of complex regional pain syndrome I: a narrative review. J Back Musculoskelet Rehabil 2022; 36:565-576. [PMID: 36530077 DOI: 10.3233/bmr-220081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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17
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Terkelsen AJ, Birklein F. Complex Regional Pain Syndrome or Limb Pain: A Plea for a Critical Approach. J Pain Res 2022; 15:1915-1923. [PMID: 35837543 PMCID: PMC9275500 DOI: 10.2147/jpr.s351099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Most frequently, complex regional pain syndrome (CRPS) develops after a trauma and affects distal parts of the limbs. Early recognition and initiation of adequate treatment is crucial for a favorable outcome. On the other hand, misdiagnosing other disorders as CRPS is detrimental because more appropriate treatment may be withheld from the patients. Despite intensive research, a specific biomarker or paraclinical measure for CRPS diagnosis is still lacking. Instead, clinical criteria approved by the International Association for the Study of Pain (IASP) and latest adapted in 2019 are central for diagnosing CPRS. Thus, the CRPS diagnosis remains challenging with the risk of a “deliberate diagnosis” for unexplained pain, while at the same time a delayed CRPS diagnosis prevents early treatment and full recovery. CRPS is a diagnosis of exclusion. To clinically diagnose CRPS, a vigorous exclusion of “other diseases that would better explain the signs and symptoms” are needed before the patients should be referred to tertiary centers for specific pain treatment. We highlight red flags that suggest “non-CRPS” limb pain despite clinical similarity to CRPS. Clinical and neurological examination and paraclinical evaluation of a probably CRPS patient are summarized. Finally, we pinpoint common differential diagnoses for CRPS. This perspective might help CRPS researchers and caregivers to reach a correct diagnosis and choose the right treatment, regardless whether for CRPS mimics or CRPS itself.
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Affiliation(s)
- Astrid Juhl Terkelsen
- Department of Neurology, Aarhus University Hospital and Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Frank Birklein
- University Medical Centre Mainz, Department of Neurology, Mainz, Germany
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18
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Reinhold AK, Salvador E, Förster CY, Birklein F, Rittner HL. Microvascular Barrier Protection by microRNA-183 via FoxO1 Repression: A Pathway Disturbed in Neuropathy and Complex Regional Pain Syndrome. THE JOURNAL OF PAIN 2022; 23:967-980. [PMID: 34974173 DOI: 10.1016/j.jpain.2021.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/14/2021] [Accepted: 12/17/2021] [Indexed: 06/14/2023]
Abstract
Blood nerve barrier disruption and edema are common in neuropathic pain as well as in complex regional pain syndrome (CRPS). MicroRNAs (miRNA) are epigenetic multitarget switches controlling neuronal and non-neuronal cells in pain. The miR-183 complex attenuates hyperexcitability in nociceptors, but additional non-neuronal effects via transcription factors could contribute as well. This study explored exosomal miR-183 in CRPS and murine neuropathy, its effect on the microvascular barrier via transcription factor FoxO1 and tight junction protein claudin-5, and its antihyperalgesic potential. Sciatic miR-183 decreased after CCI. Substitution with perineural miR-183 mimic attenuated mechanical hypersensitivity and restored blood nerve barrier function. In vitro, serum from CCI mice und CRPS patients weakened the microvascular barrier of murine cerebellar endothelial cells, increased active FoxO1 and reduced claudin-5, concomitant with a lack of exosomal miR-183 in CRPS patients. Cellular stress also compromised the microvascular barrier which was rescued either by miR-183 mimic via FoxO1 repression or by prior silencing of Foxo1. PERSPECTIVE: Low miR-183 leading to barrier impairment via FoxO1 and subsequent claudin-5 suppression is a new aspect in the pathophysiology of CRPS and neuropathic pain. This pathway might help untangle the wide symptomatic range of CRPS and nurture further research into miRNA mimics or FoxO1 inhibitors.
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Affiliation(s)
- Ann-Kristin Reinhold
- University Hospital Würzburg, Department of Anesthesiology, Intensive Care, Emergency Care and Pain Management, Center for Interdisciplinary Pain Medicine, Würzburg, Germany
| | - Ellaine Salvador
- University Hospital Würzburg, Department of Anesthesiology, Intensive Care, Emergency Care and Pain Management, Center for Interdisciplinary Pain Medicine, Würzburg, Germany; University Hospital Würzburg, Department of Neurosurgery, Tumorbiology Laboratory, Würzburg, Germany
| | - Carola Y Förster
- University Hospital Würzburg, Department of Anesthesiology, Intensive Care, Emergency Care and Pain Management, Center for Interdisciplinary Pain Medicine, Würzburg, Germany
| | - Frank Birklein
- Mainz University Hospitals, Department of Neurology, Mainz, Germany
| | - Heike L Rittner
- University Hospital Würzburg, Department of Anesthesiology, Intensive Care, Emergency Care and Pain Management, Center for Interdisciplinary Pain Medicine, Würzburg, Germany.
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19
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Moore E, Braithwaite FA, Stanton TR, Bellan V, Moseley GL, Berryman C. What do I need to know? Essential educational concepts for complex regional pain syndrome. Eur J Pain 2022; 26:1481-1498. [PMID: 35598314 PMCID: PMC9542775 DOI: 10.1002/ejp.1976] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/01/2022] [Accepted: 05/07/2022] [Indexed: 11/12/2022]
Abstract
Background Methods Results Conclusion Significance
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Affiliation(s)
- E. Moore
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - F. A. Braithwaite
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - T. R. Stanton
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - V. Bellan
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - G. L. Moseley
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
- Neuroscience Research Australia, Randwick Sydney Australia
| | - C. Berryman
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
- Brain Stimulation, Imaging and Cognition Group School of Medicine The University of Adelaide, Kaurna Country Adelaide Australia
- Corresponding author. Carolyn Berryman, Level 7 Centenary Building University of South Australia Kaurna Country, Adelaide, Australia, 5005
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20
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Johnson S, Cowell F, Gillespie S, Goebel A. Complex regional pain syndrome what is the outcome? - a systematic review of the course and impact of CRPS at 12 months from symptom onset and beyond. Eur J Pain 2022; 26:1203-1220. [PMID: 35435302 PMCID: PMC9324966 DOI: 10.1002/ejp.1953] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/28/2022] [Accepted: 04/03/2022] [Indexed: 11/21/2022]
Abstract
Background and Objective To improve CRPS treatment, it is imperative to understand the nature, degree and relative importance of ongoing problems associated with CRPS. The objective of this systematic review was to summarize the published data concerning measures of function and impact including occupational parameters, of CRPS at 12 months from symptom onset and beyond. Databases and Data Treatment MEDLINE, EmBase and PsychINFO were searched (inception to May 2021). Study cohorts were eligible if they included; adult patients with the primary complaint of CRPS ≥12 months duration, outcomes that reported change in CRPS signs and symptoms, and physical and social function. Prospero registration: CRD42021241785. Results Twenty‐two included studies suggest that pain and motor dysfunction are the most dominant long‐term features of CRPS, persisting for 51%–89% of patients at ≥12 months. On average for all patients who had CRPS at baseline, grip strength was found to be reduced by 25%–66%, and range of motion reduced by 20%–25% at ≥12 months. Such losses were associated with physical and social disability. Thirty to forty percent of all patients did not return to work and a further 27%–35% of persons returned to work but required some form of workplace adaptation, although the quality of this data was poor. Quality assessment highlighted limitations in the literature, such as high attrition bias and variations in diagnostic criteria. Conclusions Results provide first‐time quantitative data including specific evidence about losses to motor function and long‐term compromises to work status. Results demonstrate that the ongoing impact of one episode of CRPS on limb function and work status is relatively high. Significance This review provides first‐time clarity in relation to outcomes of limb function and work status associated with an episode of CRPS, beyond 12 months from onset. Results demonstrate that the long‐term impact of an episode of CRPS on these outcomes is much larger than previously described, and thus also illustrates how the wider health economic impact of CRPS is not yet fully understood. We additionally highlight the need for future research that identifies long‐term predictors, and treatments that can foster good functional and occupational recovery.
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Affiliation(s)
- Selina Johnson
- Walton Centre NHS Foundation Trust, Liverpool, UK.,Pain Research Institute, Faculty of health and life Sciences, University of Liverpool, Liverpool, UK
| | - Fiona Cowell
- Liverpool University Hospitals Foundation Trust (LUHFT), UK
| | | | - Andreas Goebel
- Walton Centre NHS Foundation Trust, Liverpool, UK.,Pain Research Institute, Faculty of health and life Sciences, University of Liverpool, Liverpool, UK
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21
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Fallico N, Padmanabhan R, Rahman S, Somma F, Spagnoli AM. A randomised placebo-controlled clinical trial on the efficacy of local lidocaine injections and oral citalopram for the treatment of complex regional pain syndrome. J Plast Reconstr Aesthet Surg 2021; 75:970-979. [PMID: 34903493 DOI: 10.1016/j.bjps.2021.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 10/31/2021] [Accepted: 11/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a neuropathic pain condition with no universally recognised treatment. The study evaluates the efficacy of a therapeutic protocol consisting of oral citalopram and lidocaine injections in patients affected by CRPS. METHODS Between January 2010 and December 2014, 150 consecutive patients with CRPS were enrolled in the study and randomly assigned into three groups: group one - lidocaine injection and oral citalopram; group two - lidocaine injection and oral placebo; and group three - injective and oral placebo. The Impairment Sum Score (ISS) was used to assess the severity of CRPS before, as well as at regular intervals after treatment commenced. Statistical significance (p < 0.05) was determined by paired t-tests. RESULTS The combined treatment proved to be more effective (ISS 47.6 to 12.6) than local anaesthetic alone (ISS 47.5 to 21.5) and to placebo (ISS 47.2 to 29.9). CONCLUSION This study indicates that CRPS may be managed with well-tolerated association of oral citalopram and lidocaine injections.
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Affiliation(s)
- Nefer Fallico
- "Sapienza" University of Rome, Department of Plastic and Reconstructive Surgery, Rome, Italy; Guy's and St Thomas' Hospital, Department of Plastic Surgery, London, UK
| | | | - Shakeel Rahman
- Guy's and St Thomas' Hospital, Department of Plastic Surgery, London, UK
| | - Francesco Somma
- "Sapienza" University of Rome, Department of Plastic and Reconstructive Surgery, Rome, Italy
| | - Anna Maria Spagnoli
- "Sapienza" University of Rome, Department of Plastic and Reconstructive Surgery, Rome, Italy
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22
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Lewis JS, Newport R, Taylor G, Smith M, McCabe CS. Visual illusions modulate body perception disturbance and pain in Complex Regional Pain Syndrome: A randomized trial. Eur J Pain 2021; 25:1551-1563. [PMID: 33759278 DOI: 10.1002/ejp.1766] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/14/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Effective treatment of longstanding Complex Regional Pain Syndrome (CRPS) is a challenge, as causal mechanisms remain elusive. People with CRPS frequently report distorted subjective perceptions of their affected limb. Evidence of pain reduction when the affected limb is visually altered in size suggests that visual illusions used to target central processing could restore coherence of this disrupted limb representation. We hypothesized that using virtual reality that alters hand image to match the patient's desired hand appearance would improve body perception disturbance and pain. Also, repeated exposure would maintain any therapeutic effect. METHODS A blinded randomized controlled trial of 45 participants with refractory upper-limb CRPS and body perception disturbance (BPD) viewed a digital image of their affected hand for 1 min. The image was digitally altered according to the patient's description of how they desired their hand to look in the experimental group and unaltered in the control group. BPD and pain were measured pre- and post-intervention. A subgroup was followed up 2 weeks after a course of repeated interventions. RESULTS BPD (mean-6, ±SD 7.9, p = 0.036, effect size [ES] = 0.6) and pain intensity (mean-0.43, ±SD 1.3, p = 0.047, ES = 0.5) reduced in 23 participants after single exposure compared to controls (n = 22). At follow-up, the subgroup (experimental n = 21; control n = 18) showed sustained pain reduction only (p = 0.037, ±SD 1.9, ES = 0.7), with an overall 1.2 decrease on an 11-point scale. CONCLUSIONS Visually changing the CRPS hand to a desired appearance modulates BPD and pain suggesting therapeutic potential for those with refractory CRPS. Further research to optimize this therapeutic effect is required. SIGNIFICANCE Visual bodily illusions that change the shape and appearance of the painful CRPS hand to that desired by the patient result in a rapid amelioration of pain and body perception disturbance in people with longstanding CRPS. These findings highlight the future potential of this drug-free approach in the treatment of refractory CRPS.
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Affiliation(s)
- Jennifer S Lewis
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Trust, Bath, UK
- University of the West of England, Bristol, UK
| | - Roger Newport
- University of Nottingham, Nottingham, UK
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | | | - Mike Smith
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Trust, Bath, UK
| | - Candida S McCabe
- University of the West of England, Bristol, UK
- Florence Nightingale Foundation, London, UK
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23
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Dietz C, Reinhold AK, Escolano-Lozano F, Mehling K, Forer L, Kress M, Üçeyler N, Sommer C, Dimova V, Birklein F, Rittner HL. Complex regional pain syndrome: role of contralateral sensitisation. Br J Anaesth 2021; 127:e1-e3. [PMID: 33941363 DOI: 10.1016/j.bja.2021.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/03/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Christopher Dietz
- Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, University Hospital of Würzburg, Würzburg, Germany
| | - Ann-Kristin Reinhold
- Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, University Hospital of Würzburg, Würzburg, Germany
| | | | - Katharina Mehling
- Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, University Hospital of Würzburg, Würzburg, Germany
| | - Lukas Forer
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michaela Kress
- Division of Physiology, Department of Physiology and Medical Physics, University of Innsbruck, Innsbruck, Austria
| | - Nurcan Üçeyler
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Claudia Sommer
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Violeta Dimova
- Department of Neurology, University Hospital of Mainz, Mainz, Germany
| | - Frank Birklein
- Department of Neurology, University Hospital of Mainz, Mainz, Germany
| | - Heike L Rittner
- Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, University Hospital of Würzburg, Würzburg, Germany.
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Complex regional pain syndrome patient immunoglobulin M has pronociceptive effects in the skin and spinal cord of tibia fracture mice. Pain 2021; 161:797-809. [PMID: 31815913 DOI: 10.1097/j.pain.0000000000001765] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
It has been proposed that complex regional pain syndrome (CRPS) is a post-traumatic autoimmune disease. Previously, we observed that B cells are required for the full expression of CRPS-like changes in a mouse tibia fracture model and that serum immunoglobulin M (IgM) antibodies from fracture mice have pronociceptive effects in muMT fracture mice lacking B cells. The current study evaluated the pronociceptive effects of injecting CRPS patient serum or antibodies into muMT fracture mice by measuring hind paw allodynia and unweighting changes. Complex regional pain syndrome serum binding was measured against autoantigens previously identified in the fracture mouse model. Both CRPS patient serum or IgM antibodies had pronociceptive effects in the fracture limb when injected systemically in muMT fracture mice, but normal subject serum and CRPS patient IgG antibodies had no effect. Furthermore, CRPS serum IgM antibodies had pronociceptive effects when injected into the fracture limb hind paw skin or intrathecally in the muMT fracture mice. Early (1-12 months after injury) CRPS patient (n = 20) sera were always pronociceptive after systemic injection, and chronic (>12 months after injury) CRPS sera were rarely pronociceptive (2/20 patients), while sera from normal subjects (n = 20) and from patients with uncomplicated recoveries from orthopedic surgery and/or fracture (n = 15) were never pronociceptive. Increased CRPS serum IgM binding was observed for keratin 16, histone 3.2, gamma actin, and alpha enolase autoantigens. We postulate that CRPS patient IgM antibodies bind to neoantigens in the fracture mouse skin and spinal cord to initiate a regionally restricted pronociceptive complement response potentially contributing to the CRPS disease process.
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Johnston-Devin C, Oprescu F, Gray M, Wallis M. Patients Describe their Lived Experiences of Battling to Live with Complex Regional Pain Syndrome. THE JOURNAL OF PAIN 2021; 22:1111-1128. [PMID: 33892156 DOI: 10.1016/j.jpain.2021.03.151] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/27/2021] [Accepted: 03/16/2021] [Indexed: 11/16/2022]
Abstract
Complex regional pain syndrome (CRPS) has never comprehensively been examined from a lived experience perspective. Patients generally have a poorer quality of life than people with other chronic pain conditions. This study aimed to understand the essence of living with CRPS. Data were collected from 17 patients via in-depth interviews. Hermeneutic discussions with four health professionals generated deeper insights. Internet blogs and a book containing patient stories were included for theme verification and triangulation. CRPS is seen as a war-like experience and five themes were identified within the battle: "dealing with the unknown enemy", "building an armoury against a moving target", "battles within the war", "developing battle plans with allies" and "warrior or prisoner of war". Patients live with a chronic pain condition and experience problems unique to CRPS such as fear of pain extending to other parts of their body. Use of the model generated by this research may assist patient/clinician interactions and guide therapeutic discussions. Support for people living with CRPS does not always exist, and some healthcare professionals require additional education about the condition. Better health outcomes are experienced by patients when their personal situation and experiences are heard and understood by health care professionals. PERSPECTIVE: This article presents the lived experience of CRPS. This information and the model generated can help clinicians to better understand their patients and deliver appropriate patient-centered care.
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Affiliation(s)
- Colleen Johnston-Devin
- School of Health and Sport Science, University of the Sunshine Coast, Sippy Downs, QLD, Australia; School of Nursing, Midwifery and Social Sciences, CQUniversity Australia, Brisbane, QLD, Australia.
| | - Florin Oprescu
- School of Health and Sport Science, University of the Sunshine Coast, Sippy Downs, QLD, Australia
| | - Marion Gray
- School of Health and Sport Science, University of the Sunshine Coast, Sippy Downs, QLD, Australia; School of Health and Wellbeing, University of Southern Queensland, Ipswich, QLD, Australia
| | - Marianne Wallis
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sippy Downs, QLD, Australia; School of Health and Human Sciences, Southern Cross University, Bilinga, QLD, Australia
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26
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Lunden LK, Jorum E. The challenge of recognizing severe pain and autonomic abnormalities for early diagnosis of CRPS. Scand J Pain 2021; 21:548-559. [PMID: 33838088 DOI: 10.1515/sjpain-2021-0036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 03/14/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Complex regional pain syndrome (CRPS) is a disabling usually post-traumatic pain condition. International guidelines emphasize early diagnosis for treatment and improved outcome. Early intense and persistent pain along with features of autonomic dysfunction in the first week's post-injury are early warning signs for development of CRPS. We have previously reported a delayed diagnosis of CRPS. The main purpose of the present study was to investigate possible causes of a delayed diagnosis, with a special focus of recognition of risk factors. METHODS A total of 52 CRPS 1 (without detectable nerve damage) and CRPS 2 (with evidence of nerve lesion) patients were included in the study. When examined at OUS-Rikshospitalet, we retrospectively asked the patients on the development of pain and autonomic abnormalities from the time of the eliciting injury, performed a thorough clinical investigation with an emphasis on signs of autonomic failure and compared symptoms and clinical findings with such information in previous medical records. We also evaluated symptoms and signs according to the type of injury they had suffered. RESULTS Of a total of 52 patients (30 women and 22 men, mean age 39.0 years at the time of injury), 34 patients had CRPS type 1 (65.4%) and 18 CRPS type 2 (34.6%), 25 patients with pain in the upper and 27 in the lower extremity. A total of 35 patients (67.3%) were diagnosed with CRPS (following mean 2.1 years) prior to the investigation at OUS-Rikshospitalet (mean 4.86 years following injury). Mean time from injury to diagnosis was 33.5 months (SD 30.6) (2.8 years) for all patients. In retrospect, all 17 patients first diagnosed at OUS met the CRPS diagnosis at an earlier stage. All patients retrospectively reported intense pain (numeric rating scale > 7) from the time of injury with a large discrepancy to previous medical records which only stated intense pain in 29.4% of patients with CRPS type 1 and 44.4% of patients with CRPS type 2 within the first four months. While the patients reported an early onset of autonomic dysfunction, present in 67.3 and 94.2% of the patients within one week and one month, respectively, reports of autonomic abnormalities within the first four months was far less (maximum in 51.7% of patients with CRPS type 1 and in 60% in CRPS 2). In 10 patients with CRPS type 1, no symptom nor sign of autonomic abnormalities was reported. CONCLUSIONS We still find a significant delay in the diagnosis of CRPS. There is a large discrepancy between both self-reporting of intense, disproportionate pain, as well as symptoms of autonomic abnormalities from the time of injury, and documentation in previous medical records. Our findings suggest a lack of awareness of risk factors for the development of CRPS, such as early intense pain and autonomic abnormalities without recovery, contributing to delayed diagnosis. The present results suggest causes of delayed CRPS-diagnosis. An increased attention to early warning signs/risk factors may improve diagnosis of CRPS.
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Affiliation(s)
- Lars Kristian Lunden
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ellen Jorum
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Herlyn P. [41/m-Where does the pain come from? : Preparation for the medical specialist examination: part 68]. Unfallchirurg 2021; 124:190-193. [PMID: 33651114 DOI: 10.1007/s00113-021-00966-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Philipp Herlyn
- Klinik für Unfall‑, Wiederherstellungs- und Handchirurgie, Städtisches Klinikum Dresden, Standort Friedrichstraße, Friedrichstr. 41, 01067, Dresden, Deutschland.
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Antunovich DR, Horne JC, Tuck NL, Bean DJ. Are Illness Perceptions Associated with Pain and Disability in Complex Regional Pain Syndrome? A Cross-Sectional Study. PAIN MEDICINE 2020; 22:100-111. [DOI: 10.1093/pm/pnaa320] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Abstract
Objective
Complex regional pain syndrome (CRPS) is a complex and often poorly understood condition, and people with CRPS will have diverse beliefs about their symptoms. According to the self-regulation model, these beliefs (termed “illness perceptions”) influence health behaviors and outcomes. Previous studies have found that psychological factors influence CRPS outcomes, but few studies have investigated CRPS patients’ illness perceptions specifically. The present study examined whether illness perceptions were related to pain intensity and other relevant outcomes in people with CRPS.
Methods
In this cross-sectional study, 53 patients with CRPS (type 1 and type 2) completed questionnaires assessing illness perceptions, pain, disability, and psychological factors. Multiple regression analyses were used to determine whether illness perceptions were associated with pain intensity, disability, depression, and kinesiophobia, after controlling for possible covariates (including clinical and demographic factors, pain catastrophizing, and negative affect).
Results
Negative illness perceptions were associated with greater pain, disability, and kinesiophobia, but not depression. Specifically, attributing more symptoms to CRPS (more negative illness identity perceptions) was associated with greater pain intensity, and reporting a poorer understanding of CRPS (lower illness coherence scores) was associated with greater disability and kinesiophobia.
Conclusions
Patients with CRPS with more negative illness perceptions (particularly perceptions indicating a poor understanding of their condition) also experience greater pain, disability, and kinesiophobia. Future research could investigate whether altering CRPS patients’ illness perceptions influences clinical outcomes.
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Affiliation(s)
- Dana R Antunovich
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Juliette C Horne
- The Auckland Regional Pain Service, Auckland District Health Board, Auckland, New Zealand
| | - Natalie L Tuck
- The Auckland Regional Pain Service, Auckland District Health Board, Auckland, New Zealand
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
- Chronic Pain Service, Department of Anaesthesia and Perioperative Medicine, Waitematā District Health Board, Auckland, New Zealand
| | - Debbie J Bean
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
- The Auckland Regional Pain Service, Auckland District Health Board, Auckland, New Zealand
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
- Chronic Pain Service, Department of Anaesthesia and Perioperative Medicine, Waitematā District Health Board, Auckland, New Zealand
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Benchouk S, Buchard PA, Luthi F. Complex regional pain syndrome and bone marrow oedema syndrome: family ties potentially closer than expected. BMJ Case Rep 2020; 13:13/8/e234600. [PMID: 32847873 PMCID: PMC7451491 DOI: 10.1136/bcr-2020-234600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Complex regional pain syndrome (CRPS) and bone marrow edema syndrome (BMES) are two rare conditions that are still being discussed. They are generally considered as two distinct entities, yet they share similarities such as a homogeneous bone marrow edema is also often found in the early phase of CRPS. We present the case of a 41-year-old man with CRPS after a foot fracture followed by the development of painful BMES of the ipsilateral knee and hip a few weeks later. The search for another pathology was negative. After pamidronate infusions, the evolution was spectacular: the disappearance of hip pain at 1 month and more than 50% reduction in knee and foot pain at 2 months. At final follow-up (1 year), the patient was asymptomatic. This case reinforces the idea of a possible link between CRPS and BMES probably through similar trabecular bone involvement. Imaging remains useful in diagnosis of CRPS.
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Affiliation(s)
- Samy Benchouk
- Department for Musculoskeletal Rehabilitation, Clinique Romande de Réadaptation, Sion, Switzerland
| | | | - François Luthi
- Department of Medical Research, Clinique romande de readaptation, Sion, VS, Switzerland.,Department of Physical Medicine and Rehabilitation, Orthopaedic Hospital, Lausanne University Hospital, Lausanne, Switzerland
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Lee WJ, Jung CH, Hwang JY, Seong SJ, Han CH, Park JW, Jang JH, Lee D, Kang DH. Prognostic Factors in Complex Regional Pain Syndrome Type 1 Occurring in the Korean Army. PAIN MEDICINE 2020; 20:1989-1996. [PMID: 30986307 DOI: 10.1093/pm/pnz076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES In Korea, patients diagnosed with complex regional pain syndrome (CRPS) in the army are typically discharged from the army; however, the course of the disease after discharge is not known. The purpose of this study was to investigate the course of CRPS that occurred in the army and to identify the influences of various clinical and psychosocial factors immediately before discharge on the disease course. METHODS Clinical profiles and psychosocial status were collected from the medical records of 16 patients with CRPS type 1 who were discharged during the period between March 2017 and April 2018. The degree of improvement after discharge was assessed by follow-up evaluation through telephone contact. Cox proportional hazards regression was performed to identify clinical and psychosocial predictors for the rate of recovery. RESULTS The median time to recovery after discharge was 39 weeks (95% confidence interval [CI] = 8.8-69.2 weeks). The sole predictor for time to recovery after discharge was the time period from the onset of pain to discharge. Each one-week increase in the duration of pain experienced in the military was associated with a 18.2% (95% CI = 5.3%-29.5%) reduction in the rate of recovery after discharge (P = 0.007). CONCLUSIONS Patients who experienced a short period of pain in the military demonstrated a relatively good prognosis after discharge. This may show how prolonged pain in the army could affect the experience of pain from a social point of view, in that it shows the disease course after a change in the social environment.
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Affiliation(s)
- Won Joon Lee
- Department of Psychiatry, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea.,Department of Psychiatry, Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Cheol Hee Jung
- Department of Anesthesiology and Pain Medicine, Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Jae Yeon Hwang
- Department of Psychiatry, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Su-Jeong Seong
- Department of Psychiatry, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Chang Hwan Han
- Department of Psychiatry, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Jin Woo Park
- Department of Orthopedic Surgery, Kangwon National University College of Medicine, Chuncheon, Republic of Korea
| | - Joon Hwan Jang
- Department of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Dasom Lee
- Emotional Information and Communication Technology Association, Seoul, Republic of Korea
| | - Do-Hyung Kang
- Emotional Information and Communication Technology Association, Seoul, Republic of Korea
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Li WW, Yang Y, Shi XY, Guo TZ, Guang Q, Kingery WS, Herzenberg LA, Clark JD. Germinal center formation, immunoglobulin production and hindlimb nociceptive sensitization after tibia fracture. Brain Behav Immun 2020; 88:725-734. [PMID: 32413559 PMCID: PMC7416484 DOI: 10.1016/j.bbi.2020.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/22/2020] [Accepted: 05/09/2020] [Indexed: 12/12/2022] Open
Abstract
Emerging evidence suggests that Complex Regional Pain Syndrome (CRPS) is in part a post-traumatic autoimmune disease mediated by an adaptive immune response after limb injuries. We previously observed in a murine tibial fracture model of CRPS that pain-related behaviors were dependent upon adaptive immune mechanisms including the neuropeptide-dependent production of IgM for 5 months after injury. However, the time course of induction of this immune response and the demonstration of germinal center formation in lymphoid organs has not been evaluated. Using the murine fracture model, we employed behavioral tests of nociceptive sensitization and limb dysfunction, serum passive transfer techniques, western blot analysis of IgM accumulation, fluorescence-activated cell sorting (FACS) of lymphoid tissues and immunohistochemistry to follow the temporal activation of the adaptive immune response over the first 3 weeks after fracture. We observed that: 1) IgM protein levels in the skin of the fractured mice were elevated at 3 weeks post fracture, but not at earlier time points, 2) serum from fracture mice at 3 weeks, but not 1 and 2 weeks post fracture, had pro-nociceptive effects when passively transferred to fractured muMT mice lacking B cells, 3) fracture induced popliteal lymphadenopathy occurred ipsilateral to fracture beginning at 1 week and peaking at 3 weeks post fracture, 4) a germinal center reaction was detected by FACS analysis in the popliteal lymph nodes from injured limbs by 3 weeks post fracture but not in other lymphoid tissues, 5) germinal center formation was characterized by the induction of T follicular helper cells (Tfh) and germinal center B cells in the popliteal lymph nodes of the injured but not contralateral limbs, and 6) fracture mice treated with the Tfh signaling inhibitor FK506 had impaired germinal center reactions, reduced IgM levels, reduced nociceptive sensitization, and no pronociceptive serum effects after administration to fractured muMT mice. Collectively these data demonstrate that tibia fracture induces an adaptive autoimmune response characterized by popliteal lymph node germinal center formation and Tfh cell dependent B cell activation, resulting in nociceptive sensitization within 3 weeks.
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Affiliation(s)
- Wen-Wu Li
- Veterans Affairs Palo Alto Health Care System 3801 Miranda Ave., Palo Alto, California 94304,Department of Anesthesiology, Stanford University School of Medicine, 300 Pasture Drive, Stanford, California 94304
| | - Yang Yang
- Department of Genetics, Stanford University School of Medicine, 300 Pasture Drive, Stanford, CA 94304, United States.
| | - Xiao-you Shi
- Veterans Affairs Palo Alto Health Care System 3801 Miranda Ave., Palo Alto, California 94304,Department of Anesthesiology, Stanford University School of Medicine, 300 Pasture Drive, Stanford, California 94304
| | - Tian-Zhi Guo
- Veterans Affairs Palo Alto Health Care System 3801 Miranda Ave., Palo Alto, California 94304,Veterans Affairs Institute for Research, 3801 Miranda Ave., Palo Alto, California 94304
| | - Qin Guang
- Department of Genetics, Stanford University School of Medicine, 300 Pasture Drive, Stanford, California 94304
| | - Wade S. Kingery
- Veterans Affairs Palo Alto Health Care System 3801 Miranda Ave., Palo Alto, California 94304,Veterans Affairs Institute for Research, 3801 Miranda Ave., Palo Alto, California 94304
| | - Leonore A. Herzenberg
- Department of Genetics, Stanford University School of Medicine, 300 Pasture Drive, Stanford, California 94304
| | - J. David Clark
- Veterans Affairs Palo Alto Health Care System 3801 Miranda Ave., Palo Alto, California 94304,Department of Anesthesiology, Stanford University School of Medicine, 300 Pasture Drive, Stanford, California 94304
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Elomaa M, Hotta J, de C Williams AC, Forss N, Äyräpää A, Kalso E, Harno H. Symptom reduction and improved function in chronic CRPS type 1 after 12-week integrated, interdisciplinary therapy. Scand J Pain 2020; 19:257-270. [PMID: 30789827 DOI: 10.1515/sjpain-2018-0098] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/29/2018] [Indexed: 12/22/2022]
Abstract
Background and aims Complex Regional Pain Syndrome (CRPS) often recovers spontaneously within the first year, but when it becomes chronic, available rehabilitative therapies (pharmacological management, physiotherapy, and psychological intervention) have limited effectiveness. This study examined the effect of a 12-week intensive outpatient rehabilitation on pain relief and function in chronic CRPS patients. Rehabilitation program included memantine and morphine treatment (added to patient's prior pain medication) and concurrent psychological and physiotherapeutic intervention. Primary outcome measure was a change in CRPS symptom count and secondary outcomes were motor performance, psychological factors, pain intensity, and quality of life. Methods Ten patients with chronic upper limb CRPS I (median 2.9 years, range 8 months to 12 years) were recruited to the study and were assessed before and after the intervention. Hand motor function of the patients was evaluated by an independent physiotherapist. There were standardized questionnaires for depression, pain anxiety, pain acceptance, quality of life, and CRPS symptom count. In addition, psychological factors were evaluated by a semi-structured interview. Severity of experienced pain was rated at movement and at rest. In addition, a video experiment of a hand action observation was conducted pre- and post-intervention to study possible change in neuronal maladaptation. Intervention consisted of pharmacological, psychological and physiotherapeutic treatment. First, 10 mg daily morphine was started and increased gradually to 30 mg daily, if tolerated. After 30 mg/day or tolerated dose of morphine was achieved, 5 mg daily memantine was started and increased gradually to 40 mg, if tolerated. Psychological intervention consisted of weekly group sessions, using cognitive and behavioral methods (relaxation, behavioral activation, and exposure) and acceptance and commitment therapy (ACT) and daily home practice. Physiotherapeutic intervention consisted of graded motor imagery and physiotherapy exercises with weekly group sessions and/or individual guidance by the physiotherapist, and individual exercise of the affected upper limb. Results Multimodal intensive intervention resulted in significant decrease in CRPS symptom count. The effect was strongest in motor and trophic symptoms (19% decrease after intervention) and in sensory symptoms (18% decrease). Additionally, improvement was seen in some, but not all, secondary outcomes (movement pain, motor symptoms, change in perceptions during video experiment of hand actions, and summary index with motor functioning, pain, and psychological factors). There were no dropouts. Conclusions Intensive 12-week multimodal intervention reduced some CRPS symptoms but was not sufficient to alter patients' rest pain, distress, or quality of life. Implications These results support the efficacy of an interdisciplinary rehabilitation program for pain and function in chronic CRPS patients. After intervention, some CRPS symptoms reduced and function improved, but distress and quality of life were unchanged. This may be due to the relatively short duration of this program; to delayed effects; to particular cognitive problems of CPRS patients; and/or to low distress levels at baseline that make statistically significant reduction less likely.
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Affiliation(s)
- Minna Elomaa
- Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jaakko Hotta
- Clinical Neurosciences, Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Neuroscience and Biomedical Engineering, Aalto University, Espoo, Finland
| | - Amanda C de C Williams
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Nina Forss
- Clinical Neurosciences, Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Department of Neuroscience and Biomedical Engineering, Aalto University, Espoo, Finland
| | - Anni Äyräpää
- Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Internal Medicine and Rehabilitation, Physiotherapy, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Eija Kalso
- Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanno Harno
- Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Pain Clinic, Department of Clinical Neurosciences, Neurology, Helsinki University Hospital and University of Helsinki, P.O Box 140, 00029 HUS, Helsinki, Finland, Phone: +358504639469, Fax: +358947175641
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Prednisone for Acute Complex Regional Pain Syndrome: A Retrospective Cohort Study. Pain Res Manag 2020; 2020:8182569. [PMID: 32184912 PMCID: PMC7060858 DOI: 10.1155/2020/8182569] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/04/2020] [Indexed: 12/27/2022]
Abstract
Objective The objective of this study was to evaluate prednisone effectiveness on complex regional pain syndrome (CRPS) features in a community-based outpatient rehabilitation setting. Design A single-centre, retrospective inception cohort design was used. Inclusion criteria were CRPS diagnosis according to the Budapest criteria, involvement of multiple joints, treatment with prednisone, and duration of symptoms less than one year. Typical prednisone treatment was 28-day taper regimen with 60 mg. Patient symptoms and signs were compared before and after treatment. Results There were 39 patients who met inclusion criteria for analysis. Duration of symptoms before treatment was 80.8 ± 67.7 days. Following treatment, 19 (48.7%) patients reported complete pain resolution, 19 (48.7%) patients reported decreased pain permitting functional use, and 1 (2.6%) patient reported no improvement. All symptoms and signs decreased significantly following oral prednisone treatment (p < 0.001). Range of motion (ROM) deficits persisted in 19 (49%) patients. However, 17 of these patients reported functional ROM recovery. Degree of ROM recovery and time-to-treatment had low positive correlation (r = 0.354, p < 0.001). Range of motion (ROM) deficits persisted in 19 (49%) patients. However, 17 of these patients reported functional ROM recovery. Degree of ROM recovery and time-to-treatment had low positive correlation (. Conclusions These data support short-course prednisone treatment for acute and subacute CRPS with multijoint involvement in a community rehabilitation setting. The association between time-to-treatment and ROM recovery suggests earlier treatment may result in improved ROM outcomes.
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Atkinson L, Vile A. Unravelling the Complex Regional Pain Syndrome Enigma. PAIN MEDICINE 2020; 21:225-229. [PMID: 31348512 DOI: 10.1093/pm/pnz150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Dimova V, Herrnberger MS, Escolano-Lozano F, Rittner HL, Vlckova E, Sommer C, Maihöfner C, Birklein F. Clinical phenotypes and classification algorithm for complex regional pain syndrome. Neurology 2019; 94:e357-e367. [DOI: 10.1212/wnl.0000000000008736] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 07/18/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveWe pursued the hypothesis that complex regional pain syndrome (CRPS) signs observed by neurologic examination display a structure allowing for alignment of patients to particular phenotype clusters.MethodsClinical examination data were obtained from 3 independent samples of 444, 391, and 202 patients with CRPS. The structure among CRPS signs was analyzed in sample 1 and validated with sample 2 using hierarchical clustering. For patients with CRPS in sample 3, an individual phenotype score was submitted to k-means clustering. Pain characteristics, quantitative sensory testing, and psychological data were tested in this sample as descriptors for phenotypes.ResultsA 2-cluster structure emerged in sample 1 and was replicated in sample 2. Cluster 1 comprised minor injury eliciting CRPS, motor signs, allodynia, and glove/stocking-like sensory deficits, resembling a CRPS phenotype most likely reflecting a CNS pathophysiology (the central phenotype). Cluster 2, which consisted of edema, skin color changes, skin temperature changes, sweating, and trophic changes, probably represents peripheral inflammation, the peripheral phenotype. In sample 3, individual phenotype scores were calculated as the sum of the mean values of signs from each cluster, where signs from cluster 1 were coded with 1 and from cluster 2 with −1. A k-means algorithm separated groups with 78, 36, and 88 members resembling the peripheral, central, and mixed phenotypes, respectively. The central phenotype was characterized by cold hyperalgesia at the affected limb.ConclusionsStatistically determined CRPS phenotypes may reflect major pathophysiologic mechanisms of peripheral inflammation and central reorganization.
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Grieve S, Llewellyn A, Jones L, Manns S, Glanville V, McCabe CS. Complex regional pain syndrome: An international survey of clinical practice. Eur J Pain 2019; 23:1890-1903. [PMID: 31376299 DOI: 10.1002/ejp.1463] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/21/2019] [Accepted: 07/28/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Sharon Grieve
- CRPS Service Royal United Hospitals Bath NHS Foundation Trust Bath UK
- Faculty of Health and Applied Sciences University of the West of England Bristol UK
| | - Alison Llewellyn
- CRPS Service Royal United Hospitals Bath NHS Foundation Trust Bath UK
- Faculty of Health and Applied Sciences University of the West of England Bristol UK
| | - Louise Jones
- Faculty of Health and Applied Sciences University of the West of England Bristol UK
| | - Sarah Manns
- Faculty of Health and Applied Sciences University of the West of England Bristol UK
| | - Victoria Glanville
- Therapies service Gloucestershire Hospitals NHS Foundation Trust Gloucestershire UK
| | - Candida S. McCabe
- CRPS Service Royal United Hospitals Bath NHS Foundation Trust Bath UK
- Faculty of Health and Applied Sciences University of the West of England Bristol UK
- The Florence Nightingale Foundation London UK
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Packham TL, Bean D, Johnson MH, MacDermid JC, Grieve S, McCabe CS, Harden RN. Measurement Properties of the SF-MPQ-2 Neuropathic Qualities Subscale in Persons with CRPS: Validity, Responsiveness, and Rasch Analysis. PAIN MEDICINE 2019; 20:799-809. [PMID: 30346579 DOI: 10.1093/pm/pny202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The purpose of this study was to conduct classical psychometric evaluation and Rasch analysis on the Neuropathic Qualities subscale of the Short-Form McGill Pain Questionnaire-2 utilizing scores from persons with complex regional pain syndrome to consider reliability and person separation, validity (including unidimensionality), and responsiveness in this population. METHODS Secondary analysis of longitudinal data from persons with acute complex regional pain syndrome was utilized for analysis of the psychometric properties and fit to the Rasch model of the Neuropathic Qualities subscale. We followed an iterative process of Rasch analysis to evaluate and address data fitting challenges. RESULTS Repeated measures from 59 persons meeting the Budapest criteria were used for analysis. Both item-total correlations and unidimensionality analyses supported theoretical construct validity; all convergent construct validity hypotheses were also supported. Responsiveness was demonstrated comparing baseline and one-year data at d = 0.92, with a standardized response mean of 0.97. Data were able to fit the Rasch model, but all Neuropathic Qualities items had disordered thresholds that required rescoring. Additionally, local dependency and differential item function were addressed by "bundling," suggesting that no further item reduction would be possible. CONCLUSIONS This study provided preliminary support for the validity and responsiveness of the Neuropathic Qualities subscale in persons with complex regional pain syndrome. Rasch analysis further endorses use of the Neuropathic Qualities subscale as a "stand-alone" measure for neuropathic features, but with substantial background data transformations. Replication with larger samples is recommended to increase confidence in these findings.
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Affiliation(s)
- Tara L Packham
- Michael G. DeGroote Institute for Pain Research and Care, Hamilton, Ontario, Canada.,School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Debbie Bean
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand.,Auckland District Health Board, The Auckland Regional Pain Service (TARPS), Auckland, New Zealand
| | - Malcolm H Johnson
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand.,Auckland District Health Board, The Auckland Regional Pain Service (TARPS), Auckland, New Zealand
| | - Joy C MacDermid
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sharon Grieve
- Royal United Hospitals NHS Foundation Trust, Bath & University of the West of England, Bristol, UK
| | - Candida S McCabe
- Royal United Hospitals NHS Foundation Trust, Bath & University of the West of England, Bristol, UK
| | - R Norman Harden
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
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Mouraux D, Lenoir C, Tuna T, Brassinne E, Sobczak S. The long-term effect of complex regional pain syndrome type 1 on disability and quality of life after foot injury. Disabil Rehabil 2019; 43:967-975. [PMID: 31411910 DOI: 10.1080/09638288.2019.1650295] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE To study the long-term evolution of patients with lower-limb Complex Regional Pain Syndrome (CRPS), focusing on functional and proprioceptive aspects and quality of life. METHODS In 20 patients suffering from chronic distal lower-limb CRPS diagnosed using Budapest criteria, we assessed joint position sense and strength of the knee muscles at the CRPS and unaffected leg, functional exercise capacity, pain, CRPS severity score, quality of life and kinesiophobia. Similar assessments were performed in 20 age-matched controls. RESULTS The joint position performance (at 45°) was significantly lower for the CRPS leg as compared to controls. The knee extensor strength of the CRPS leg was significantly reduced as compared to the unaffected leg (-27%) and controls (-42%). CRPS patients showed significantly reduced performance at the 6 min-walk test as compared to their age group predicted value and controls. Patients suffering from CRPS for 3.8 years in average still exhibit high pain, severity and kinesiophobia scores. CONCLUSIONS Long-term deficits in strength and proprioceptive impairments are observed at the knee joint of the CRPS leg. This persistent functional disability has significant repercussions on the quality of life. We highlight the importance of including strength and proprioceptive exercises in the therapeutic approaches for CPRS patients.IMPLICATIONS FOR REHABILITATIONThe long-term evolution of patients suffering from lower-limb Complex Regional Pain Syndrome is associated with persistent disability, pain and impacts the quality of life.Strength, proprioceptive, functional and subjective assessments are necessary to better identify deficits.Rehabilitation should focus on the overall deficit of the affected and contralateral limb.
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Affiliation(s)
- Dominique Mouraux
- Department of Physical Therapy and Rehabilitation, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Department of Physiotherapy, Faculté Des Sciences de la Motricité, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Cédric Lenoir
- Department of Neuroscience, Physiology and Pharmacology, University College, London, UK.,Institut of Neuroscience, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Turgay Tuna
- Department of Anaesthesiology, Pain Clinic, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Eric Brassinne
- Department of Physical Therapy and Rehabilitation, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Department of Physiotherapy, Faculté Des Sciences de la Motricité, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Stéphane Sobczak
- Département D'anatomie, Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, Canada.,Groupe de Recherche Sur Les Affections Neuro-Musculo-Squelettiques (GRAN), Université du Québec à Trois-Rivières (UQTR), Trois-Rivières, Canada
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Abstract
The acute phase of complex regional pain syndrome (CRPS) is pathophysiologically characterized by an activation of the immune system and its associated inflammatory response. During the course of CRPS, central nervous symptoms like mechanical hyperalgesia, loss of sensation, and body perception disorders develop. Psychological factors such as pain-related anxiety and traumatic events might have a negative effect on the treatment outcome. While the visible inflammatory symptoms improve, the pain often persists. A stage adapted, targeted treatment could improve the prognosis. Effective multidisciplinary treatment includes the following: pharmacotherapy with steroids, bisphosphonates, or dimethylsulfoxide cream (acute phase), and antineuropathic analgesics (all phases); physiotherapy and behavioral therapy for pain-related anxiety and avoidance of movement; and interventional treatment like spinal cord or dorsal root ganglion stimulation if noninvasive options failed.
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Affiliation(s)
- V Dimova
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55101, Mainz, Deutschland.
| | - F Birklein
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55101, Mainz, Deutschland
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40
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Lewis JS, Kellett S, McCullough R, Tapper A, Tyler C, Viner M, Palmer S. Body Perception Disturbance and Pain Reduction in Longstanding Complex Regional Pain Syndrome Following a Multidisciplinary Rehabilitation Program. PAIN MEDICINE 2019; 20:2213-2219. [PMID: 31373373 DOI: 10.1093/pm/pnz176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
Clinical guidelines for the treatment of complex regional pain syndrome recommend multidisciplinary rehabilitation, yet limited evidence exists to support the effectiveness of this approach. Body perception disturbance, a common and debilitating feature of complex regional pain syndrome, is recommended by guidelines as important to treat. However, no study has yet explored whether disturbances change in response to multidisciplinary rehabilitation. We aimed to determine whether there is a change in body perception disturbance and pain following a two-week multidisciplinary rehabilitation program for complex regional pain syndrome.
Methods
Retrospective clinical data from complex regional pain syndrome patients who completed the program between September 2014 and December 2016 were extracted and anonymized. Data collected pre- and post rehabilitation comprising the Bath Body Perception Disturbance scale and a pain intensity numerical rating scale were analyzed.
Results
Thirty complete data sets were analyzed from a sample of 50 consecutive patient records. After the program, there was a significant reduction in body perception disturbance (P < 0.0001), strength of negative emotional feelings (P < 0.0001), and pain (P = 0.0038). There was a significant correlation between a change in disturbance and pain (r = 0.44, P = 0.024). No relationship was found between the duration of symptoms and changes in disturbance (r = 0.04, P = 0.82).
Conclusions
This study provides evidence that both body perception disturbance and pain reduce after rehabilitation. Findings suggest that targeting these disturbances may be important in reducing pain and may be a potentially useful measure for recovery. Controlled trials are required to confirm the effectiveness of rehabilitation and determine what factors are responsible for these reductions.
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Affiliation(s)
- Jennifer S Lewis
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Trust, Bath, UK
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Sara Kellett
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Ryan McCullough
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Ashley Tapper
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Chelsey Tyler
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Maria Viner
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Shea Palmer
- Department of Allied Health Professions, University of the West of England, Bristol, UK
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Bar-Shalita T, Granovsky Y, Parush S, Weissman-Fogel I. Sensory Modulation Disorder (SMD) and Pain: A New Perspective. Front Integr Neurosci 2019; 13:27. [PMID: 31379526 PMCID: PMC6659392 DOI: 10.3389/fnint.2019.00027] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/01/2019] [Indexed: 01/17/2023] Open
Abstract
Sensory modulation disorder (SMD) affects sensory processing across single or multiple sensory systems. The sensory over-responsivity (SOR) subtype of SMD is manifested clinically as a condition in which non-painful stimuli are perceived as abnormally irritating, unpleasant, or even painful. Moreover, SOR interferes with participation in daily routines and activities (Dunn, 2007; Bar-Shalita et al., 2008; Chien et al., 2016), co-occurs with daily pain hyper-sensitivity, and reduces quality of life due to bodily pain. Laboratory behavioral studies have confirmed abnormal pain perception, as demonstrated by hyperalgesia and an enhanced lingering painful sensation, in children and adults with SMD. Advanced quantitative sensory testing (QST) has revealed the mechanisms of altered pain processing in SOR whereby despite the existence of normal peripheral sensory processing, there is enhanced facilitation of pain-transmitting pathways along with preserved but delayed inhibitory pain modulation. These findings point to central nervous system (CNS) involvement as the underlying mechanism of pain hypersensitivity in SOR. Based on the mutual central processing of both non-painful and painful sensory stimuli, we suggest shared mechanisms such as cortical hyper-excitation, an excitatory-inhibitory neuronal imbalance, and sensory modulation alterations. This is supported by novel findings indicating that SOR is a risk factor and comorbidity of chronic non-neuropathic pain disorders. This is the first review to summarize current empirical knowledge investigating SMD and pain, a sensory modality not yet part of the official SMD realm. We propose a neurophysiological mechanism-based model for the interrelation between pain and SMD. Embracing the pain domain could significantly contribute to the understanding of this condition’s pathogenesis and how it manifests in daily life, as well as suggesting the basis for future potential mechanism-based therapies.
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Affiliation(s)
- Tami Bar-Shalita
- Department of Occupational Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Yelena Granovsky
- Laboratory of Clinical Neurophysiology, Department of Neurology, Faculty of Medicine, Technion-Israel Institute of Technology, Rambam Health Care Campus, Haifa, Israel
| | - Shula Parush
- School of Occupational Therapy, Faculty of Medicine of Hadassah, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Irit Weissman-Fogel
- Physical Therapy Department, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
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42
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Goebel A, Barker C, Birklein F, Brunner F, Casale R, Eccleston C, Eisenberg E, McCabe CS, Moseley GL, Perez R, Perrot S, Terkelsen A, Thomassen I, Zyluk A, Wells C. Standards for the diagnosis and management of complex regional pain syndrome: Results of a European Pain Federation task force. Eur J Pain 2019; 23:641-651. [PMID: 30620109 PMCID: PMC6593444 DOI: 10.1002/ejp.1362] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 11/25/2022]
Abstract
Background Complex regional pain syndrome is a painful and disabling post‐traumatic primary pain disorder. Acute and chronic complex regional pain syndrome (CRPS) are major clinical challenges. In Europe, progress is hampered by significant heterogeneity in clinical practice. We sought to establish standards for the diagnosis and management of CRPS. Methods The European Pain Federation established a pan‐European task force of experts in CRPS who followed a four‐stage consensus challenge process to produce mandatory quality standards worded as grammatically imperative (must‐do) statements. Results We developed 17 standards in 8 areas of care. There are 2 standards in diagnosis, 1 in multidisciplinary care, 1 in assessment, 3 for care pathways, 1 in information and education, 4 in pain management, 3 in physical rehabilitation and 2 on distress management. The standards are presented and summarized, and their generation and consequences were discussed. Also presented are domains of practice for which no agreement on a standard could be reached. Areas of research needed to improve the validity and uptake of these standards are discussed. Conclusion The European Pain Federation task force present 17 standards of the diagnosis and management of CRPS for use in Europe. These are considered achievable for most countries and aspirational for a minority of countries depending on their healthcare resource and structures. Significance This position statement summarizes expert opinion on acceptable standards for CRPS care in Europe.
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Affiliation(s)
- Andreas Goebel
- Walton Centre NHS Foundation Trust, Liverpool, UK.,Pain Research Institute, University of Liverpool, Liverpool, UK
| | - Chris Barker
- Walton Centre NHS Foundation Trust, Liverpool, UK.,Pain Research Institute, University of Liverpool, Liverpool, UK
| | - Frank Birklein
- Department of Neurology, University of Mainz, Mainz, Germany
| | - Florian Brunner
- Physical Medicine and Rheumatology, Balgrist University Hospital, Zurich, Switzerland
| | - Roberto Casale
- Pain Rehabilitation Unit, Habilita Hospitals, Zingonia di Ciserano, Italy
| | - Chris Eccleston
- Centre for Pain Research, The University of Bath, Bath, Uk.,Department of Clinical and Health Psychology, Ghent University, Ghent, Belgium.,European Pain Federation, Brussels, Belgium
| | - E Eisenberg
- Rambam Health Care Campus, Institute of Pain Medicine, Haifa, Israel
| | - Candy S McCabe
- Florence Nightingale Foundation Clinical Professor of Nursing, University of West of England, Bristol & Royal United Hospitals NHS Foundation Trust, Bath, UK
| | | | - R Perez
- Department of Anaesthesiology, VU University Medical Center, Amsterdam, Netherlands
| | - Serge Perrot
- Pain Center, Cochin Hospital, Paris Descartes University, Paris, France
| | - Astrid Terkelsen
- Danish Pain Research Center and Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Andrzey Zyluk
- Department of General and Hand Surgery, Pomeranian Medical University, Szczecin, Poland
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44
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Schrier E, Dijkstra P, Zeebregts C, Wolff A, Geertzen J. Decision making process for amputation in case of therapy resistant complex regional pain syndrome type-I in a Dutch specialist centre. Med Hypotheses 2018; 121:15-20. [DOI: 10.1016/j.mehy.2018.08.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 08/28/2018] [Indexed: 12/13/2022]
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45
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Birklein F, Ibrahim A, Schlereth T, Kingery WS. The Rodent Tibia Fracture Model: A Critical Review and Comparison With the Complex Regional Pain Syndrome Literature. THE JOURNAL OF PAIN 2018; 19:1102.e1-1102.e19. [PMID: 29684510 PMCID: PMC6163066 DOI: 10.1016/j.jpain.2018.03.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/28/2018] [Accepted: 03/30/2018] [Indexed: 12/23/2022]
Abstract
Distal limb fracture is the most common cause of complex regional pain syndrome (CRPS), thus the rodent tibia fracture model (TFM) was developed to study CRPS pathogenesis. This comprehensive review summarizes the published TFM research and compares these experimental results with the CRPS literature. The TFM generated spontaneous and evoked pain behaviors, inflammatory symptoms (edema, warmth), and trophic changes (skin thickening, osteoporosis) resembling symptoms in early CRPS. Neuropeptides, inflammatory cytokines, and nerve growth factor (NGF) have been linked to pain behaviors, inflammation, and trophic changes in the TFM model and proliferating keratinocytes were identified as the primary source of cutaneous cytokines and NGF. Tibia fracture also activated spinal glia and upregulated spinal neuropeptide, cytokine, and NGF expression, and in the brain it changed dendritic architecture. B cell-expressed immunoglobulin M antibodies also contributed to pain behavior, indicating a role for adaptive immunity. These results modeled many findings in early CRPS, but significant differences were also noted. PERSPECTIVE Multiple neuroimmune signaling mechanisms contribute to the pain, inflammation, and trophic changes observed in the injured limb of the rodent TFM. This model replicates many of the symptoms, signs, and pathophysiology of early CRPS, but most post-fracture changes resolve within 5 months and may not contribute to perpetuating chronic CRPS.
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Affiliation(s)
- Frank Birklein
- University Medical Center of the Johannes Gutenberg University Mainz, Department of Neurology, Mainz, Germany
| | - Alaa Ibrahim
- University Medical Center of the Johannes Gutenberg University Mainz, Department of Neurology, Mainz, Germany
| | - Tanja Schlereth
- University Medical Center of the Johannes Gutenberg University Mainz, Department of Neurology, Mainz, Germany
| | - Wade S Kingery
- Palo Alto Veterans Institute for Research, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
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46
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Herlyn P. [Complex regional pain syndrome]. Unfallchirurg 2018; 121:825-838. [PMID: 30218165 DOI: 10.1007/s00113-018-0544-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Complex regional pain syndrome (CRPS) is not a very common yet typical complication of extremity trauma in the daily practice of a trauma surgeon. The pathophysiology of this puzzling disease is still not completely understood and its impact on the patient cannot be overestimated. However, advantages have been made in diagnostics and therapy. While a multitude of different diagnostic systems has led to confusion in the past, we now have an internationally accepted, validated and easy to reproduce diagnostic algorithm in the form of the Budapest criteria. The adequate therapy is still a field for debate, but there is now a broad choice of conservative and interventional treatments for the out- and inpatient setting.
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Affiliation(s)
- Philipp Herlyn
- Abteilung für Unfall‑, Hand- & Wiederherstellungschirurgie, Klinik und Poliklinik für Chirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
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47
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David Clark J, Tawfik VL, Tajerian M, Kingery WS. Autoinflammatory and autoimmune contributions to complex regional pain syndrome. Mol Pain 2018; 14:1744806918799127. [PMID: 30124090 PMCID: PMC6125849 DOI: 10.1177/1744806918799127] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a highly enigmatic syndrome typically developing after injury or surgery to a limb. Severe pain and disability are common among those with chronic forms of this condition. Accumulating evidence suggests that CRPS may involve both autoinflammatory and autoimmune components. In this review article, evidence for dysfunction of both the innate and adaptive immune systems in CRPS is presented. Findings from human studies in which cytokines and other inflammatory mediators were measured in the skin of affected limbs are discussed. Additional results from studies of mediator levels in animal models are evaluated in this context. Similarly, the evidence from human, animal, and translational studies of the production of autoantibodies and the potential targets of those antibodies is reviewed. Compelling evidence of autoinflammation in skin and muscle of the affected limb has been collected from CRPS patients and laboratory animals. Cytokines including IL-1β, IL-6, TNFα, and others are reliably identified during the acute phases of the syndrome. More recently, autoimmune contributions have been suggested by the discovery of self-directed pain-promoting IgG and IgM antibodies in CRPS patients and model animals. Both the autoimmune and the autoinflammatory components of CRPS appear to be regulated by neuropeptide-containing peripheral nerve fibers and the sympathetic nervous system. While CRPS displays a complex neuroimmunological pathogenesis, therapeutic interventions could be designed targeting autoinflammation, autoimmunity, or the neural support for these phenomena.
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Affiliation(s)
- J David Clark
- 1 Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.,2 Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Vivianne L Tawfik
- 2 Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Maral Tajerian
- 2 Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Wade S Kingery
- 3 Palo Alto Veterans Institute for Research, Palo Alto, CA, USA
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Brun C, Giorgi N, Pinard AM, Gagné M, McCabe CS, Mercier C. Exploring the Relationships Between Altered Body Perception, Limb Position Sense, and Limb Movement Sense in Complex Regional Pain Syndrome. THE JOURNAL OF PAIN 2018; 20:17-27. [PMID: 30099211 DOI: 10.1016/j.jpain.2018.07.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 06/25/2018] [Accepted: 07/17/2018] [Indexed: 11/19/2022]
Abstract
Chronic pain is often accompanied by patient-reported distorted body perception and an altered kinesthesia (referring to the senses of limb position and limb movement), but the association between these deficits is unknown. The objectives of this study were to assess body perception and the senses of limb position and limb movement in complex regional pain syndrome (CRPS) and to test whether these variables are related to each other and to pain intensity. Thirteen patients with upper limb CRPS (mean pain intensity, 4.2 ± 2.4 out of 10) and 13 controls were recruited. Body perception was self-reported with a questionnaire, and the senses of limb position (task 1) and of limb movement (task 2) were assessed with a robotic system combined with a 2D virtual reality display. The results showed altered kinesthesia in the patients with CRPS compared with controls (all P < .05). Moreover, in the CRPS group, greater pain intensity was associated with lower performance on task 2 (r = -.60; P < .05). Although alterations in participants' sense of limb position and limb movement were associated with each other (r = -.70, P < .01), they were not related to the altered body perception (all P > .26). Therefore, the results suggest that kinesthesia and body perception should be considered and evaluated separately in patients with CRPS. PERSPECTIVE: Senses of limb position and movement rely on sensorimotor integration. Both are altered in complex regional pain syndrome. However, they are not related to the subjective perception of the painful limb, and thus they should be assessed separately in rehabilitation.
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Affiliation(s)
- Clémentine Brun
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec, QC, Canada.; Departments of Rehabilitation, Laval University, Quebec, QC, Canada
| | - Nicolas Giorgi
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec, QC, Canada.; Departments of Medicine, Laval University, Quebec, QC, Canada
| | - Anne-Marie Pinard
- Departments of Anesthesiology, Laval University, Quebec, QC, Canada.; Departments of Anesthesiology, University Hospital of Quebec, Quebec, QC, Canada
| | - Martin Gagné
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec, QC, Canada
| | - Candida S McCabe
- Royal National Hospital for Rheumatic Diseases, Bath, United Kingdom.; Departments of Nursing and Midwifery, University of the West of England, Bristol, United Kingdom
| | - Catherine Mercier
- Center for Interdisciplinary Research in Rehabilitation and Social Integration, Quebec, QC, Canada.; Departments of Rehabilitation, Laval University, Quebec, QC, Canada..
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Bar-Shalita T, Livshitz A, Levin-Meltz Y, Rand D, Deutsch L, Vatine JJ. Sensory modulation dysfunction is associated with Complex Regional Pain Syndrome. PLoS One 2018; 13:e0201354. [PMID: 30091986 PMCID: PMC6084887 DOI: 10.1371/journal.pone.0201354] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 07/14/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Complex Regional Pain Syndrome (CRPS), a chronic pain condition, develops mainly after limb trauma and severely inhibits function. While early diagnosis is essential, factors for CRPS onset are elusive. Therefore, identifying those at risk is crucial. Sensory modulation dysfunction (SMD), affects the capacity to regulate responses to sensory input in a graded and adaptive manner and was found associated with hyperalgesia in otherwise healthy individuals, suggestive of altered pain processing. AIM To test SMD as a potential risk factor for CRPS. METHODS In this cross-sectional study, forty-four individuals with CRPS (29.9±11 years, 27 men) and 204 healthy controls (27.4±3.7 years, 105 men) completed the Sensory Responsiveness Questionnaire-Intensity Scale (SRQ-IS). A physician conducted the CRPS Severity Score (CSS), testing individuals with CRPS. RESULTS Thirty-four percent of the individuals with CRPS and twelve percent of the healthy individuals were identified to have SMD (χ2 (1) = 11.95; p<0.001). Logistic regression modeling revealed that the risk of CRPS is 2.68 and 8.21 times higher in individuals with sensory over- and sensory under-responsiveness, respectively, compared to non-SMD individuals (p = 0.03 and p = 0.01, respectively). CONCLUSIONS SMD, particularly sensory under-responsiveness, might serve as a potential risk factor for CRPS and therefore screening for SMD is recommended. This study provides the risk index probability clinical tool a simple evaluation to be applied by clinicians in order to identify those at risk for CRPS immediately after injury. Further research is needed.
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Affiliation(s)
- Tami Bar-Shalita
- Department of Occupational Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Anatoly Livshitz
- Center for Rehabilitation of Pain Syndromes, Reuth Rehabilitation Hospital, Tel Aviv, Israel
| | - Yulia Levin-Meltz
- Center for Rehabilitation of Pain Syndromes, Reuth Rehabilitation Hospital, Tel Aviv, Israel
| | - Debbie Rand
- Department of Occupational Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lisa Deutsch
- BioStats Statistical Consulting Ltd, Modiin, Israel
| | - Jean-Jacques Vatine
- Center for Rehabilitation of Pain Syndromes, Reuth Rehabilitation Hospital, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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50
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Complex regional pain syndrome - phenotypic characteristics and potential biomarkers. Nat Rev Neurol 2018; 14:272-284. [PMID: 29545626 DOI: 10.1038/nrneurol.2018.20] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Complex regional pain syndrome (CRPS) is a pain condition that usually affects a single limb, often following an injury. The underlying pathophysiology seems to be complex and probably varies between patients. Clinical diagnosis is based on internationally agreed-upon criteria, which consider the reported symptoms, presence of signs and exclusion of alternative causes. Research into CRPS biomarkers to support patient stratification and improve diagnostic certainty is an important scientific focus, and recent progress in this area provides an opportunity for an up-to-date topical review of measurable disease-predictive, diagnostic and prognostic parameters. Clinical and biochemical attributes of CRPS that may aid diagnosis and determination of appropriate treatment are delineated. Findings that predict the development of CRPS and support the diagnosis include trauma-related factors, neurocognitive peculiarities, psychological markers, and local and systemic changes that indicate activation of the immune system. Analysis of signatures of non-coding microRNAs that could predict the treatment response represents a new line of research. Results from the past 5 years of CRPS research indicate that a single marker for CRPS will probably never be found; however, a range of biomarkers might assist in clinical diagnosis and guide prognosis and treatment.
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