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Likar R, Poglitsch R, Bejvančický Š, Carl L, Ferencik M, Klein-Watrycz A, Rieger M, Flores KS, Schumich A, Vlamaki Z, Werner M. The Use of High-Dose Intravenous L-Ascorbate in Pain Therapy: Current Evidence from the Literature. Pain Ther 2024; 13:767-790. [PMID: 38864974 PMCID: PMC11255149 DOI: 10.1007/s40122-024-00622-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/24/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Pain is the most common reason for seeking medical treatment. Despite extensive research efforts and effective analgesics modulating pain, there is still a major therapeutic gap in addressing the root causes of pain. Pain is associated with tissue damage induced by oxidative stress and induction of inflammatory mediators following high consumption of antioxidants. The role of antioxidants in general, and the administration of L-ascorbate in particular, is still controversially discussed and underestimated in the daily clinical practice. METHODS The current literature on the therapeutic effect of L-ascorbate, ascorbic acid, and vitamin C on various pain conditions was evaluated against the background of evidence-based medicine. Those articles, obtained from systematic search in PubMed, were critically assessed and rated in terms of evidence level and methodological quality by two independent experts. The primary purpose of this work was to establish specific pain therapy guidance for intravenous L-ascorbate. RESULTS A PubMed search revealed 14 suitable articles comprising controlled clinical trials and meta-analyses. An additional ten publications could be identified via secondary literature. There is supporting evidence for the efficacy of ascorbate treatment in inflammatory pain conditions, in the complex regional pain syndrome, in post zoster neuralgia, in neuropathic pain, in post-operative pain conditions, and in tumor-related pain. However, the considered studies differ in the type of administration, in dosage, in duration of treatment, as well as in quality of research. Despite all study heterogeneity, it became evident that research of high scientific quality is in support of the efficacy of L-ascorbate in pain treatment. DISCUSSION Oxidative stress is present in almost all pain conditions. Because oral administration of most magistral formulas of vitamin C does not provide biological availability, parenteral administration should be preferred and can be supported by an oral dose with high bioavailability on days without intravenous treatment. L-ascorbate should be preferred for parenteral high dosage, rather than ascorbic acid, as it does not release acid valences under physiological conditions. CONCLUSIONS L-ascorbate is an effective, safe, and economically favorable integrative treatment option for various pain conditions, addressing the root cause of tissue damage and inflammatory mediator burst.
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Affiliation(s)
- Rudolf Likar
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Klagenfurt Am Wörthersee, Chair of Palliative Medicine SFU Vienna, Klagenfurt am Wörthersee, Austria.
| | - Ruth Poglitsch
- Medical Institute Dr. Poglitsch, Pain Medicine, Graz, Austria
| | - Štěpán Bejvančický
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Pilsen, Pilsen, Czech Republic
| | - Ludwig Carl
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Mutterhaus Trier, Johannes Gutenberg University, Mainz, Germany
| | - Miroslav Ferencik
- Department of Algesiology SZU, F. D. Roosevelt University Hospital, Banska Bystrica, Slovakia
| | - Alfred Klein-Watrycz
- Institute of Physical Medicine and Rehabilitation, Hospital Mistelbach, Mistelbach, Austria
| | - Monika Rieger
- Pain Therapy Practice Rieger, Bingen am Rhein, Germany
| | | | - Astrid Schumich
- Private Practice for General Medicine, Orthopaedics, Orthopaedic Surgery and Functional Myodiagnostics, Vienna, Austria
| | - Zoe Vlamaki
- General Surgery and Breast Oncoplastic Surgery, NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Marc Werner
- Clinic for Naturopathy and Integrative Medicine, Evangelische Kliniken Essen-Mitte GmbH, Essen, Germany
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Limerick G, Christo DK, Tram J, Moheimani R, Manor J, Chakravarthy K, Karri J, Christo PJ. Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments. Curr Pain Headache Rep 2023; 27:269-298. [PMID: 37421541 DOI: 10.1007/s11916-023-01130-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW This review presents the most current information about the epidemiology of complex regional pain syndrome (CRPS), classification and diagnostic criteria, childhood CRPS, subtypes, pathophysiology, conventional and less conventional treatments, and preventive strategies. RECENT FINDINGS CRPS is a painful disorder with multifactorial pathophysiology. The data describe sensitization of the central and peripheral nervous systems, inflammation, possible genetic factors, sympatho-afferent coupling, autoimmunity, and mental health factors as contributors to the syndrome. In addition to conventional subtypes (type I and type II), cluster analyses have uncovered other proposed subtypes. Prevalence of CRPS is approximately 1.2%, female gender is consistently associated with a higher risk of development, and substantial physical, emotional, and financial costs can result from the syndrome. Children with CRPS seem to benefit from multifaceted physical therapy leading to a high percentage of symptom-free patients. The best available evidence along with standard clinical practice supports pharmacological agents, physical and occupational therapy, sympathetic blocks for engaging physical restoration, steroids for acute CRPS, neuromodulation, ketamine, and intrathecal baclofen as therapeutic approaches. There are many emerging treatments that can be considered as a part of individualized, patient-centered care. Vitamin C may be preventive. CRPS can lead to progressively painful sensory and vascular changes, edema, limb weakness, and trophic disturbances, all of which substantially erode healthy living. Despite some progress in research, more comprehensive basic science investigation is needed to clarify the molecular mechanisms of the disease so that targeted treatments can be developed for better outcomes. Incorporating a variety of standard therapies with different modes of action may offer the most effective analgesia. Introducing less conventional approaches may also be helpful when traditional treatments fail to provide sufficient improvement.
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Affiliation(s)
- Gerard Limerick
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Dana K Christo
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jennifer Tram
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | | | - John Manor
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Jay Karri
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.
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Seth I, Bulloch G, Seth N, Siu A, Clayton S, Lower K, Roshan S, Nara N. Effect of Perioperative Vitamin C on the Incidence of Complex Regional Pain Syndrome: A Systematic Review and Meta-Analysis. J Foot Ankle Surg 2022; 61:748-754. [PMID: 34961681 DOI: 10.1053/j.jfas.2021.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023]
Abstract
Complex regional pain syndrome type 1 (CRPS-I) is a complex complication that occurs after limb extremity surgeries. Controversy exists regarding the effectiveness of vitamin C in reducing that condition. Therefore, we conducted this systematic review and meta-analysis to assess the role of vitamin C on CRPS-I and functional outcomes after distal radius, wrist, foot, and ankle surgeries. We searched Medline (via PubMed), Embase, the Cochrane Library, Clinicaltrial.gov, and Google Scholar for relevant studies comparing perioperative vitamin C versus placebo after distal radius, wrist, foot, and ankle surgeries from infinity to May 2021. Continuous data such as functional outcomes and pain scores were pooled as mean differences, while dichotomous variables such as the incidence of complex regional pain syndrome and complications were pooled as odds ratios, with 95% confidence interval, using R software (meta package, version 4.9-0) for Windows. Eight studies were included. The timeframe for vitamin C administration in each study ranged from 42 to 50 days postinjury and/or surgical fixation. The effect size showed that vitamin C was associated with a decreased rate of CRPS-1 than placebo (odds ratio 0.33, 95% confidence interval [0.17, 0.63]). No significant difference was found between vitamin C and placebo in terms of complications (odds ratio 1.90, 95% confidence interval [0.99, 3.65]), functional outcomes (mean difference 6.37, 95% confidence interval [-1.40, 14.15]), and pain scores (mean difference -0.14, 95% confidence interval [-1.07, 0.79]). Overall, vitamin C was associated with a decreased rate of CRPS-I than placebo, while no significant difference was found regarding complications, functional outcomes, and pain scores. These results hold true when stratifying fracture type (distal radius, ankle, and foot surgeries) and vitamin C dose (500 mg or 1 g).
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Affiliation(s)
- Ishith Seth
- Bendigo Base Hospital, Bendigo, Victoria, Australia; Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, New South Wales, Australia.
| | - Gabriella Bulloch
- Faculty of Science, Medicine and Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Nimish Seth
- Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Adrian Siu
- Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Stephanie Clayton
- Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Kirk Lower
- Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Sasha Roshan
- Department of Orthopaedic Surgery, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Naveen Nara
- Department of Orthopaedic Surgery, Ballarat Base Hospital, Ballarat, Victoria, Australia
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Bruehl S, Milne G, Schildcrout J, Shi Y, Anderson S, Shinar A, Polkowski G, Mishra P, Billings FT. Oxidative stress is associated with characteristic features of the dysfunctional chronic pain phenotype. Pain 2022; 163:786-794. [PMID: 34382610 PMCID: PMC8807797 DOI: 10.1097/j.pain.0000000000002429] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT The dysfunctional chronic pain (Dysfunctional CP) phenotype is an empirically identifiable CP subtype with unclear pathophysiological mechanisms that cuts across specific medical CP diagnoses. This study tested whether the multidimensional pain and psychosocial features that characterize the dysfunctional CP phenotype are associated broadly with elevated oxidative stress (OS). Measures of pain intensity, bodily extent of pain, catastrophizing cognitions, depression, anxiety, sleep disturbance, pain interference, and function were completed by 84 patients with chronic osteoarthritis before undergoing total knee arthroplasty. Blood samples were obtained at the initiation of surgery before incision or tourniquet placement. Plasma levels of F2-isoprostanes and isofurans, the most highly specific measures of in vivo OS, were quantified using gas chromatography/negative ion chemical ionization mass spectrometry. The results indicated that controlling for differences in age, sex, and body mass index, higher overall OS (mean of isoprostanes and isofurans) was associated with significantly (P < 0.05) greater pain intensity, more widespread pain, greater depressive symptoms and pain catastrophizing, higher pain interference, and lower function. OS measures were not significantly associated with sleep disturbance or anxiety levels (P >0.10). The results build on prior case-control findings suggesting that presence of a CP diagnosis is associated with elevated OS, highlighting that it may specifically be individuals displaying characteristics of the dysfunctional CP phenotype who are characterized by elevated OS. Clinical implications of these findings remain to be determined.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ginger Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic T. Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Efficacy and safety of perioperative vitamin C in patients undergoing noncardiac surgery: a systematic review and meta-analysis of randomised trials. Br J Anaesth 2022; 128:664-678. [DOI: 10.1016/j.bja.2021.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
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