Scintigraphic evaluation of reflex sympathetic dystrophy: comparative study of the course of the disease under two therapeutic regimens

Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition

There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for "better research." This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of "elder statesman" researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the "Budapest" criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient.

Adult Complex Regional Pain Syndrome Type I: A Narrative Review

Complex regional pain syndrome type I (CRPS I) is a multifactorial painful disorder with a complex pathogenesis. Both peripheral and central mechanisms are involved. Acute CRPS I is considered to be an exaggerated inflammatory disorder; however, over time, because of altered function of the sympathetic nervous system and maladaptive neuroplasticity, CRPS I evolves into a neurological disorder. This review thoroughly describes the pathophysiological aspects of CRPS I and summarizes the potential therapeutic options. The mechanisms and targets of the treatment are different in the early and late stages of the disease. This current review builds on a previous review by this author group by deepening the role of the peripheral classic and neuronal inflammatory component in the acute stage of this painful disorder.

LEVEL OF EVIDENCE

Not applicable.

Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition

OBJECTIVE

This is the fourth edition of diagnostic and treatment guidelines for complex regional pain syndrome (CRPS; aka reflex sympathetic dystrophy).

METHODS

Expert practitioners in each discipline traditionally utilized in the treatment of CRPS systematically reviewed the available and relevant literature; due to the paucity of levels 1 and 2 studies, less rigorous, preliminary research reports were included. The literature review was supplemented with knowledge gained from extensive empirical clinical experience, particularly in areas where high-quality evidence to guide therapy is lacking.

RESULTS

The research quality, clinical relevance, and "state of the art" of diagnostic criteria or treatment modalities are discussed, sometimes in considerable detail with an eye to the expert practitioner in each therapeutic area. Levels of evidence are mentioned when available, so that the practitioner can better assess and analyze the modality under discussion, and if desired, to personally consider the citations. Tables provide details on characteristics of studies in different subject domains described in the literature.

CONCLUSIONS

In the humanitarian spirit of making the most of all current thinking in the area, balanced by a careful case-by-case analysis of the risk/cost vs benefit analysis, the authors offer these "practical" guidelines.

The effectiveness and cost evaluation of pain exposure physical therapy and conventional therapy in patients with complex regional pain syndrome type 1. Rationale and design of a randomized controlled trial

BACKGROUND

Pain Exposure Physical Therapy is a new treatment option for patients with Complex Regional Pain Syndrome type 1. It has been evaluated in retrospective as well as in prospective studies and proven to be safe and possibly effective. This indicates that Pain Exposure Physical Therapy is now ready for clinical evaluation. The results of an earlier performed pilot study with an n = 1 design, in which 20 patients with Complex Regional Pain Syndrome type 1 were treated with Pain Exposure Physical Therapy, were used for the design and power calculation of the present study.After completion and evaluation of this phase III study, a multi-centre implementation study will be conducted.The aim of this study is to determine whether Pain Exposure Physical Therapy can improve functional outcomes in patients with Complex Regional Pain Syndrome type 1.

METHODS/DESIGN

This study is designed as a single-blinded, randomized clinical trial. 62 patients will be randomized with a follow-up of 9 months to demonstrate the expected treatment effect. Complex Regional Pain Syndrome type 1 is diagnosed in accordance with the Bruehl/International Association for the Study of Pain criteria. Conventional therapy in accordance with the Dutch guideline will be compared with Pain Exposure Physical Therapy. Primary outcome measure is the Impairment level SumScore, restricted version.

DISCUSSION

This is the first randomized controlled study with single blinding that has ever been planned in patients with Complex Regional Pain Syndrome type 1 and does not focus on a single aspect of the pain syndrome but compares treatment strategies based on completely different pathophysiological and cognitive theories.

Evidence-based interventional pain medicine according to clinical diagnoses. 16. Complex regional pain syndrome

Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy is a pain syndrome with an unclear pathophysiology and unpredictable clinical course. The disease is often therapy resistant, the natural course not always favorable. The diagnosis of CRPS is based on signs and symptoms derived from medical history and physical examination. Pharmacological pain management and physical rehabilitation of limb function are the main pillars of therapy and should be started as early as possible. If, however, there is no improvement of limb function and persistent severe pain, interventional pain management techniques may be considered. Intravenous regional blocks with guanethidine did not prove superior to placebo but frequent side effects occurred.Therefore this technique receives a negative recommendation (2 A-). Sympathetic block is the interventional treatment of first choice and has a 2 B+ rating. Ganglion stellatum (stellate ganglion) block with repeated local anesthetic injections or by radiofrequency denervation after positive diagnostic block is documented in prospective and retrospective trials in patients suffering from upper limb CRPS. Lumbar sympathetic blocks can be performed with repeated local anesthetic injections. For a more prolonged lumbar sympathetic block radiofrequency treatment is preferred over phenol neurolysis because effects are comparable whereas the risk for side effects is lower (2 B+). For patients suffering from CRPS refractory to conventional treatment and sympathetic blocks, plexus brachialis block or continuous epidural infusion analgesia coupled with exercise therapy may be tried (2 C+). Spinal cord stimulation is recommended if other treatments fail to improve pain and dysfunction (2 B+). Alternatively peripheral nerve stimulation can be considered, preferentially in study conditions (2 C+).

The efficiency of electromagnetic field treatment in Complex Regional Pain Syndrome Type I

INTRODUCTION

Complex Regional Pain Syndrome Type I is a pathological condition that occurs without evident nerve injury and follows a course characterized by severe pain.

PURPOSE

The aim of this study is to assess whether or not electromagnetic field treatment administered with calcitonin and exercise has positive effects on clinical improvement, scintigraphic assessment and bone markers compared to calcitonin and exercise administration.

METHOD

In this randomized double-blind, placebo-controlled study, 40 patients with Complex Regional Pain Syndrome Type I, that developed after a Colles fracture were included in the assessments and were administered calcitonin and exercise treatment for 6 weeks. In addition to this treatment, half the patients received electromagnetic field treatment, and the other half received placebo treatment. The patients were evaluated at the beginning and end of treatment with clinical parameters, scintigraphic assessment and biochemical markers.

RESULTS

Although we found some significant improvements in our evaluation criteria, we could not find a significant statistical difference between groups.

CONCLUSIONS

The absence of a significant difference between the two groups in the assessment parameters has been interpreted as evidence that electromagnetic field treatment does not provide additional benefit to calcitonin and exercise treatment.

Prognostic value of triple phase bone scanning for reflex sympathetic dystrophy in hemiplegia

Twenty-two patients with cerebral vascular accident (CVA), clinically confirmed by head computed tomography, were observed for symptoms of the reflex sympathetic dystrophy syndrome (RSDS). All patients received triple phase bone scans; 16 scans were positive for RSDS. Patients with negative scans had no symptoms of RSDS. Five patients with positive scans had RSDS symptoms at the time of bone scanning. Seven of 11 patients with positive scans but no symptoms of RSDS at the time of bone scan developed symptoms of RSDS within six months. We found a significant relationship between positive bone scans and the subsequent development of RSDS (p < 0.01). Considering only those patients who were asymptomatic for RSDS at the time of bone scanning, we found bone scanning to be a good predictor for the future development of clinical RSDS. We found the correlation between positive bone scans and the subsequent development of clinical RSDS in previously asymptomatic individuals to be statistically significant (p < 0.05). We conclude that bone scans may be a good predictor of patients at risk for developing clinical RSDS after CVA.

Salmon calcitonin reduces vertebral fracture rate in postmenopausal crush fracture syndrome

The effectiveness of calcitonin on the vertebral fracture rate in postmenopausal osteoporosis was assessed through the skeletal deformity index (SDI) and the new vertebral fracture rate per 100 patient-years in a group of 32 women with postmenopausal osteoporosis treated by us with 100 IU of salmon calcitonin and 500 mg of elemental calcium for 10 consecutive days each month, and in another group of 28 women with postmenopausal osteoporosis treated with 500 mg of elemental calcium only for 10 consecutive days each month. Both groups were age-matched. The follow-up was a retrospective randomized study over 24 months. Thirty of the 32 women of the calcitonin group and 27 of 28 women of the calcium group finished treatment. The SDI was stabilized after six months in the calcitonin group (0.57 +/- 0.13, 0.62 +/- 0.18, 0.63 +/- 0.16 and 0.64 +/- 0.17, at base line, 6, 12 and 24 months respectively). The calcium group showed a significant increase only at 12 months (P less than 0.01) and 24 months (P less than 0.05) (0.61 +/- 0.16, 0.63 +/- 0.16, 0.69 +/- 0.16, and 0.73 +/- 0.15, at base line, 6, 12 and 24 months respectively). At 24 months, the new vertebral fracture rate decreased by 60% (20%, 14% and 8% at 6, 12 and 24 months respectively) in the calcitonin group and increased by 35% (31%, 33% and 42%, at 6, 12 and 24 months respectively) in the calcium group (P less than 0.025). These results show that calcitonin induced a significant reduction in postmenopausal osteoporotic vertebral fractures.

The value of bone scintigraphy in the follow-up of vertebral osteoporosis

In an open study, we have assessed the bone/soft tissue uptake index in recent osteoporotic vertebral collapse using scintigraphy. The evolution of these cases was followed-up at 6 months in 22 patients treated with 100 IU of salmon calcitonin plus 500 mg of elemental calcium/10 days per month and in 18 patients treated with 500 mg of elemental calcium only on a daily basis. There were no index differences between groups prior to treatment. At six months, the group treated with calcitonin plus calcium showed a significant decrease from 10.2 +/- 6.4 to 3.2 +/- 1.1 (p less than 0.001), while the calcium only group did not show any significant changes (12.1 +/- 6.6 vs 9.2 +/- 4.6), considering that there were significant differences between groups (p less than 0.001). On a mid-term basis, these results have shown the values of the bone/soft tissue index in the follow-up of osteoporotic vertebral collapse.