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Turgeman Dahan N, Vatine JJ, Weissman-Fogel I, Karpin H, Shmuely S, Bar-Shalita T. Quantitative Dynamic Allodynograph-A Standardized Measure for Testing Dynamic Mechanical Allodynia in Chronic Limb Pain. SENSORS (BASEL, SWITZERLAND) 2023; 23:7949. [PMID: 37766006 PMCID: PMC10535773 DOI: 10.3390/s23187949] [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: 07/06/2023] [Revised: 08/18/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Dynamic mechanical allodynia (DMA) is both a symptom and a central sensitization sign, yet no standardized method for quantifying the DMA area has been reported. This study aimed to establish psychometric properties for Quantitative Dynamic Allodynography (QDA), a newly developed protocol measuring the DMA area as a percentage of the body surface. METHODS Seventy-eight patients aged 18-65 diagnosed with chronic complex regional pain syndrome (CRPS) participated in this study. Test-retest reliability was conducted twice, one week apart (N = 20), and inter-rater (N = 3) reliability was conducted on 10 participants. Disease severity (CRPS Severity Score, CSS), pain intensity (VAS), and quality of life (SF-36) measures were utilized to test construct validity. RESULTS High inter-rater reliability (intraclass correlation coefficient (ICC) = 0.96, p < 0.001) and test-retest reliability (r = 0.98, p < 0.001) were found. Furthermore, the QDA score was found to be correlated with the CSS (r = 0.47, p < 0.001), VAS (r = 0.37, p < 0.001), and the SF-36 physical health total (r = -0.47, p < 0.001) scores. CONCLUSION The QDA is the first developed reliable and valid protocol for measuring DMA in a clinical setting and may be used as a diagnostic and prognostic measure in clinics and in research, advancing the pain precision medicine approach.
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Affiliation(s)
- Noy Turgeman Dahan
- Department of Occupational Therapy, School of Health Professions, Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo 69978, Israel;
- Reuth Rehabilitation Hospital, Tel Aviv-Yafo 6772830, Israel; (H.K.); (S.S.)
| | | | - Irit Weissman-Fogel
- Physical Therapy Department, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa 3103301, Israel;
| | - Hana Karpin
- Reuth Rehabilitation Hospital, Tel Aviv-Yafo 6772830, Israel; (H.K.); (S.S.)
- Physical Therapy Department, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa 3103301, Israel;
| | - Sharon Shmuely
- Reuth Rehabilitation Hospital, Tel Aviv-Yafo 6772830, Israel; (H.K.); (S.S.)
| | - Tami Bar-Shalita
- Department of Occupational Therapy, School of Health Professions, Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo 69978, Israel;
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Harden RN, McCabe CS, Goebel A, Massey M, Suvar T, Grieve S, Bruehl S. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S1-S53. [PMID: 35687369 PMCID: PMC9186375 DOI: 10.1093/pm/pnac046] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- R Norman Harden
- Departments of PM&R and Physical Therapy and Human Movement Sciences, Northwestern University
| | - Candida S McCabe
- University of the West of England, Stapleton, Bristol, UK
- Dorothy House Hospice, Bradford-on-Avon, Wilts, UK
| | - Andreas Goebel
- Pain Research Institute, Faculty of Health and Life Science, University of Liverpool, Liverpool, UK
| | - Michael Massey
- CentraCare Neurosciences Pain Center, CentraCare, St. Cloud, Minnesota, USA
| | - Tolga Suvar
- Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Sharon Grieve
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Centers, Nashville, Tennessee, USA
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Mundluru T, Saraghi M. Anesthetic Management of a Complex Regional Pain Syndrome (CRPS) Patient With Ketamine. Anesth Prog 2021; 67:219-225. [PMID: 33393601 DOI: 10.2344/anpr-67-02-07] [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: 05/29/2019] [Accepted: 04/13/2020] [Indexed: 11/11/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a potentially debilitating form of neuropathic pain that may manifest following a traumatic injury or surgery. CRPS is also known as algodystrophy, causalgia, or reflex sympathetic dystrophy (RSD). Patients describe unbearable burning pain from nonnociceptive stimuli, such as when taking a shower or brushing against another object. Regular tactile stimuli encountered during routine dental procedures may not be well-tolerated by a patient with CRPS. Ketamine infusions have been reported to help alleviate acute exacerbations or "flare-ups" of CRPS symptoms. This case report provides a brief overview of CRPS pathophysiology and treatment including data supporting the use of ketamine infusions and a discussion regarding the anesthetic management of a patient with CRPS presenting for dental care under deep sedation utilizing high-dose intravenous ketamine.
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Affiliation(s)
- Tarun Mundluru
- Resident in Orofacial Pain and Oral Medicine, The Herman Ostrow School of Dentistry at the University of Southern California, Los Angeles, California
| | - Mana Saraghi
- Director, Dental Anesthesiology Residency Program, Jacobi Medical Center Bronx, New York
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Bang S, Kim YS, Lee S, Park U, Kim TK, Choi Y. Prevalence of common causes of neuropathic pain in Korea: population-based observational study. J Int Med Res 2020; 48:300060519888102. [PMID: 31775560 PMCID: PMC7516997 DOI: 10.1177/0300060519888102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 10/22/2019] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To investigate the prevalence of complex regional pain syndrome (CRPS), post-herpetic neuralgia (PHN), trigeminal neuralgia (TN), and diabetic neuropathy (DN), common causes of neuropathic pain encountered in pain clinics. METHODS We investigated the period prevalence rate of CRPS, PHN, TN, and DN using data from a Korean national electronic database from 2009 to 2013. RESULTS The prevalence of CRPS decreased slightly throughout the study period, while the prevalence of PHN increased from 2009 to 2013. The prevalence of TN was reduced over the same period. The prevalence of DN increased from 2009 to 2012 but decreased in 2013. All four neuropathic diseases were more prevalent in individuals aged over 70 years. The prevalence of CRPS, PHN, and TN were more common in women than in men, but DN showed no gender difference. CONCLUSION While the prevalence of CRPS and TN has decreased in Korea, that of PHN and DN has increased. With the exception of DN, the neuropathic diseases were more prevalent in women. Further studies are necessary to investigate the risk factors and socioeconomic burden for each disease, and national efforts are essential to limit the development of these preventable neuropathic diseases.
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Affiliation(s)
- Seunguk Bang
- Daejeon St. Mary's Hospital, College
of Medicine, The Catholic University of Korea, Anesthesiology and Pain Medicine,
Daejeon, Republic of Korea
| | - Yee Suk Kim
- Catholic University of Korea Bucheon
Saint Mary's Hospital, Department of Anesthesiology and Pain Medicine, Bucheon,
Republic of Korea
| | - Soyeon Lee
- Catholic University of Korea Bucheon
Saint Mary's Hospital, Department of Anesthesiology and Pain Medicine, Bucheon,
Republic of Korea
| | - Uijin Park
- Catholic University of Korea Bucheon
Saint Mary's Hospital, Department of Anesthesiology and Pain Medicine, Bucheon,
Republic of Korea
| | - Tae-kwan Kim
- Catholic University of Korea Bucheon
Saint Mary's Hospital, Department of Anesthesiology and Pain Medicine, Bucheon,
Republic of Korea
| | - Yuna Choi
- Catholic University of Korea Bucheon
Saint Mary's Hospital, Department of Anesthesiology and Pain Medicine, Bucheon,
Republic of Korea
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Wu W, Ji X, Zhao Y. Emerging Roles of Long Non-coding RNAs in Chronic Neuropathic Pain. Front Neurosci 2019; 13:1097. [PMID: 31680832 PMCID: PMC6813851 DOI: 10.3389/fnins.2019.01097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/30/2019] [Indexed: 02/06/2023] Open
Abstract
Chronic neuropathic pain, a type of chronic and potentially disabling pain caused by a disease or injury of the somatosensory nervous system, spinal cord injury, or various chronic conditions, such as viral infections (e.g., post-herpetic neuralgia), autoimmune diseases, cancers, and metabolic disorders (e.g., diabetes mellitus), is one of the most intense types of chronic pain, which incurs a major socio-economic burden and is a serious public health issue, with an estimated prevalence of 7–10% in adults throughout the world. Presently, the available drug treatments (e.g., anticonvulsants acting at calcium channels, serotonin-noradrenaline reuptake inhibitors, tricyclic antidepressants, opioids, topical lidocaine, etc.) for chronic neuropathic pain patients are still rare and have disappointing efficacy, which makes it difficult to relieve the patients’ painful symptoms, and, at best, they only try to reduce the patients’ ability to tolerate pain. Long non-coding RNAs (lncRNAs), a type of transcript of more than 200 nucleotides with no protein-coding or limited capacity, were identified to be abnormally expressed in the spinal cord, dorsal root ganglion, hippocampus, and prefrontal cortex under chronic neuropathic pain conditions. Moreover, a rapidly growing body of data has clearly pointed out that nearly 40% of lncRNAs exist specifically in the nervous system. Hence, it was speculated that these dysregulated lncRNAs might participate in the occurrence, development, and progression of chronic neuropathic pain. In other words, if we deeply delve into the potential roles of lncRNAs in the pathogenesis of chronic neuropathic pain, this may open up new strategies and directions for the development of novel targeted drugs to cure this refractory disorder. In this article, we primarily review the status of chronic neuropathic pain and provide a general overview of lncRNAs, the detailed roles of lncRNAs in the nervous system and its related diseases, and the abnormal expression of lncRNAs and their potential clinical applications in chronic neuropathic pain. We hope that through the above description, readers can gain a better understanding of the emerging roles of lncRNAs in chronic neuropathic pain.
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Affiliation(s)
- Wei Wu
- College of Food Science and Engineering, Qingdao Agricultural University, Qingdao, China
| | - Xiaojun Ji
- Department of Neurology, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yang Zhao
- Department of Anesthesiology, Affiliated Hospital to Qingdao University, Qingdao, China
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Adult Complex Regional Pain Syndrome Type I: A Narrative Review. PM R 2016; 9:707-719. [PMID: 27890578 DOI: 10.1016/j.pmrj.2016.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 11/06/2016] [Accepted: 11/15/2016] [Indexed: 12/19/2022]
Abstract
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.
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Abstract
Although fibromyalgia and complex regional pain syndrome (CRPS) have distinct clinical phenotypes, they do share many other features. Pain, allodynia and dysaesthesia occur in each condition and seem to exist on a similar spectrum. Fibromyalgia and CRPS can both be triggered by specific traumatic events, although fibromyalgia is most commonly associated with psychological trauma and CRPS is most often associated with physical trauma, which is frequently deemed routine or minor by the patient. Fibromyalgia and CRPS also seem to share many pathophysiological mechanisms, among which the most important are those involving central effects. Nonetheless, peripheral effects, such as neurogenic neuroinflammation, are also important contributors to the clinical features of each of these disorders. This Review highlights the differing degrees to which neurogenic neuroinflammation might contribute to the multifactorial pathogenesis of both fibromyalgia and CRPS, and discusses the evidence suggesting that this mechanism is an important link between the two disorders, and could offer novel therapeutic targets.
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8
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Blaes F, Dharmalingam B, Tschernatsch M, Feustel A, Fritz T, Kohr D, Singh P, Kaps M, Szalay G. Improvement of complex regional pain syndrome after plasmapheresis. Eur J Pain 2014; 19:503-7. [DOI: 10.1002/ejp.572] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2014] [Indexed: 11/10/2022]
Affiliation(s)
- F. Blaes
- Department of Neurology; Justus Liebig University; Giessen Germany
- Department of Neurology; Gummersbach Hospital; Gummersbach Germany
| | - B. Dharmalingam
- Department of Neurology; Justus Liebig University; Giessen Germany
| | - M. Tschernatsch
- Department of Neurology; Justus Liebig University; Giessen Germany
| | - A. Feustel
- Department of Internal Medicine; Justus Liebig University; Giessen Germany
| | - T. Fritz
- Department of Anaesthesiology; Justus Liebig University; Giessen Germany
| | - D. Kohr
- Department of Neurology; Justus Liebig University; Giessen Germany
| | - P. Singh
- Department of Neurology; Justus Liebig University; Giessen Germany
| | - M. Kaps
- Department of Neurology; Justus Liebig University; Giessen Germany
| | - G. Szalay
- Department of Trauma Surgery; Justus Liebig University; Giessen Germany
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9
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Koh TT, Daly A, Howard W, Tan C, Hardidge A. Complex Regional Pain Syndrome. JBJS Rev 2014; 2:01874474-201407000-00005. [PMID: 27490060 DOI: 10.2106/jbjs.rvw.m.00085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Thuan-Tzen Koh
- Departments of Orthopaedic Surgery (T.-T.K. and A.H.), Physiotherapy (A.D.), and Anaesthesia (W.H. and C.T.) and Pain Services (W.H.), Austin Hospital, 145 Studley Road, P.O. Box 5555, Heidelberg, Victoria, Australia
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10
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11
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Vasudeva K, Andersen K, Zeyzus-Johns B, Hitchens TK, Patel SK, Balducci A, Janjic JM, Pollock JA. Imaging neuroinflammation in vivo in a neuropathic pain rat model with near-infrared fluorescence and ¹⁹F magnetic resonance. PLoS One 2014; 9:e90589. [PMID: 24587398 PMCID: PMC3938771 DOI: 10.1371/journal.pone.0090589] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 02/03/2014] [Indexed: 12/21/2022] Open
Abstract
Chronic neuropathic pain following surgery represents a serious worldwide health problem leading to life-long treatment and the possibility of significant disability. In this study, neuropathic pain was modeled using the chronic constriction injury (CCI). The CCI rats exhibit mechanical hypersensitivity (typical neuropathic pain symptom) to mechanical stimulation of the affected paw 11 days post surgery, at a time when sham surgery animals do not exhibit hypersensitivity. Following a similar time course, TRPV1 gene expression appears to rise with the hypersensitivity to mechanical stimulation. Recent studies have shown that immune cells play a role in the development of neuropathic pain. To further explore the relationship between neuropathic pain and immune cells, we hypothesize that the infiltration of immune cells into the affected sciatic nerve can be monitored in vivo by molecular imaging. To test this hypothesis, an intravenous injection of a novel perfluorocarbon (PFC) nanoemulsion, which is phagocytosed by inflammatory cells (e.g. monocytes and macrophages), was used in a rat CCI model. The nanoemulsion carries two distinct imaging agents, a near-infrared (NIR) lipophilic fluorescence reporter (DiR) and a ¹⁹F MRI (magnetic resonance imaging) tracer, PFC. We demonstrate that in live rats, NIR fluorescence is concentrated in the area of the affected sciatic nerve. Furthermore, the ¹⁹FF MRI signal was observed on the sciatic nerve. Histological examination of the CCI sciatic nerve reveals significant infiltration of CD68 positive macrophages. These results demonstrate that the infiltration of immune cells into the sciatic nerve can be visualized in live animals using these methods.
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Affiliation(s)
- Kiran Vasudeva
- Biological Sciences, Bayer School of Natural and Environmental Sciences, and Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
| | - Karl Andersen
- Biological Sciences, Bayer School of Natural and Environmental Sciences, and Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
| | - Bree Zeyzus-Johns
- Biological Sciences, Bayer School of Natural and Environmental Sciences, and Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
| | - T. Kevin Hitchens
- NMR Center for Biomedical Research, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | - Sravan Kumar Patel
- Graduate School of Pharmaceutical Sciences, Mylan School of Pharmacy, and Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
| | - Anthony Balducci
- Department of Research and Development, Celsense, Inc., Pittsburgh, Pennsylvania, Unite States of America
| | - Jelena M. Janjic
- Graduate School of Pharmaceutical Sciences, Mylan School of Pharmacy, and Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
| | - John A. Pollock
- Biological Sciences, Bayer School of Natural and Environmental Sciences, and Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
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Abstract
Complex regional pain syndrome (CRPS) is a disabling pain condition poorly understood by medical professionals. Because CRPS is particularly enigmatic, and has significant impact on patient function, researchers have examined psychological processes present among patients with this diagnosis. This systematic review examines psychosocial factors associated with CRPS, both predictors and sequelae. Our conclusions are that CRPS is associated with negative outcomes, both psychological (e.g., increased depression and anxiety) and psychosocial (e.g., reduced quality of life, impaired occupational function) in nature. However, research does not reveal support for specific personality or psychopathology predictors of the condition.
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13
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Lenz M, Üçeyler N, Frettlöh J, Höffken O, Krumova EK, Lissek S, Reinersmann A, Sommer C, Stude P, Waaga-Gasser AM, Tegenthoff M, Maier C. Local cytokine changes in complex regional pain syndrome type I (CRPS I) resolve after 6 months. Pain 2013; 154:2142-2149. [DOI: 10.1016/j.pain.2013.06.039] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 06/02/2013] [Accepted: 06/24/2013] [Indexed: 01/18/2023]
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14
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Harden RN, Oaklander AL, Burton AW, Perez RSGM, Richardson K, Swan M, Barthel J, Costa B, Graciosa JR, Bruehl S. Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. PAIN MEDICINE 2013; 14:180-229. [PMID: 23331950 DOI: 10.1111/pme.12033] [Citation(s) in RCA: 292] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- R Norman Harden
- Center for Pain Studies, Rehabilitation Institute of Chicago, Illinois 60611, USA.
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Heir GM, Nasri-Heir C, Thomas D, Puchimada BP, Khan J, Eliav E, Benoliel R. Complex regional pain syndrome following trigeminal nerve injury: report of 2 cases. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114:733-9. [DOI: 10.1016/j.oooo.2012.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 05/29/2012] [Accepted: 06/01/2012] [Indexed: 11/27/2022]
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Stanton-Hicks MD, Burton AW, Bruehl SP, Carr DB, Harden RN, Hassenbusch SJ, Lubenow TR, Oakley JC, Racz GB, Raj PP, Rauck RL, Rezai AR. Validation of proposed diagnostic criteria (the "Budapest Criteria") for Complex Regional Pain Syndrome. Pain Pract 2010; 2:1-16. [PMID: 17134466 DOI: 10.1046/j.1533-2500.2002.02009.x] [Citation(s) in RCA: 220] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Current IASP diagnostic criteria for CRPS have low specificity, potentially leading to overdiagnosis. This validation study compared current IASP diagnostic criteria for CRPS to proposed new diagnostic criteria (the "Budapest Criteria") regarding diagnostic accuracy. Structured evaluations of CRPS-related signs and symptoms were conducted in 113 CRPS-I and 47 non-CRPS neuropathic pain patients. Discriminating between diagnostic groups based on presence of signs or symptoms meeting IASP criteria showed high diagnostic sensitivity (1.00), but poor specificity (0.41), replicating prior work. In comparison, the Budapest clinical criteria retained the exceptional sensitivity of the IASP criteria (0.99), but greatly improved upon the specificity (0.68). As designed, the Budapest research criteria resulted in the highest specificity (0.79), again replicating prior work. Analyses indicated that inclusion of four distinct CRPS components in the Budapest Criteria contributed to enhanced specificity. Overall, results corroborate the validity of the Budapest Criteria and suggest they improve upon existing IASP diagnostic criteria for CRPS.
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Affiliation(s)
- Michael D Stanton-Hicks
- Division of Anesthesiology, Pain Management and Research, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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17
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Motor cortex electrical stimulation applied to patients with complex regional pain syndrome. Pain 2009; 147:91-8. [PMID: 19793621 DOI: 10.1016/j.pain.2009.08.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Revised: 07/02/2009] [Accepted: 08/18/2009] [Indexed: 11/21/2022]
Abstract
Motor cortex stimulation (MCS) is useful to treat patients with neuropathic pain syndromes, unresponsive to medical treatment. Complex regional pain syndrome (CRPS) is a segmentary disease treated successfully by spinal cord stimulation (SCS). However, CRPS often affects large body segments difficult to cover by SCS. This study analyzed the MCS efficacy in patients with CRPS affecting them. Five patients with CRPS of different etiologies underwent a small craniotomy for unilateral 20-grid-contact implantation on MC, guided by craniometric landmarks. Neurophysiological and clinical tests were performed to identify the contacts position and the best analgesic responses to MCS. The grid was replaced by a definitive 4-contacts-electrode connected to an internalized system. Pain was evaluated by international scales. Changes in sympathetic symptoms, including temperature, perspiration, color and swelling were evaluated. Pre-operative and post-operative monthly evaluations were performed during one year. A double-blind maneuver was introduced assigning two groups. One had stimulators turned OFF from day 30-60 and the other from day 60-90. Four patients showed important decrease in pain, sensory and sympathetic changes during the therapeutic trial, while one patient did not have any improvement and was rejected for implantation. VAS and McGill pain scales diminished significantly (p<0.01) throughout the follow-up, accompanied by disappearance of the sensory (allodynea and hyperalgesia) and sympathetic signs. MCS is effective not only to treat pain, but also improve the sympathetic changes in CPRS. Mechanism of action is actually unclear, but seems to involve sensory input at the level of the spinal cord.
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18
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Schwenkreis P, Maier C, Tegenthoff M. Functional imaging of central nervous system involvement in complex regional pain syndrome. AJNR Am J Neuroradiol 2009; 30:1279-84. [PMID: 19386737 DOI: 10.3174/ajnr.a1630] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
SUMMARY In complex regional pain syndrome (CRPS), functional imaging studies gave evidence for an important role of the central nervous system (CNS) in the pathogenesis of the disease. Especially, reorganization in central somatosensory and motor networks was demonstrated, leading to an altered central processing of tactile and nociceptive stimuli, as well as to an altered cerebral organization of movement. These findings may explain a number of clinical signs and symptoms occurring in the course of the disease and seem to be closely related to chronic pain in CRPS. Neurorehabilitative strategies, which target cortical areas and aim to restore impaired sensorimotor function in patients with CRPS, therefore, may be effective not only in restoring impaired function but also in pain reduction. This article reviews findings of functional imaging studies, which have been conducted to clarify CNS involvement in the course of CRPS.
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Affiliation(s)
- P Schwenkreis
- Department of Neurology, BG-Universitatsklinikum Bergmannsheil, Ruhr-University Bochum, Germany.
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19
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Hald A. Spinal Astrogliosis in Pain Models: Cause and Effects. Cell Mol Neurobiol 2009; 29:609-19. [DOI: 10.1007/s10571-009-9390-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 03/09/2009] [Indexed: 01/25/2023]
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Farid IS, Heiner EJ. Intrathecal Local Anesthetic Infusion as a Treatment for Complex Regional Pain Syndrome in a Child. Anesth Analg 2007; 104:1078-80, tables of contents. [PMID: 17456655 DOI: 10.1213/01.ane.0000260563.39299.9c] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Diagnosis and treatment of complex regional pain syndrome in children is one of the most challenging clinical pain problems encountered in the chronic pain setting. Despite the intense and debilitating nature of the pain, referral to appropriate specialists often comes too late, thereby prolonging an already arduous (and controversial) course of treatment and risking long-term disability. On the contrary, full recovery can be expected with early diagnosis and prompt treatment. The following case study describes a novel and successful use of intrathecal catheter administration of ropivacaine in a child with early, rapidly progressing, and debilitating complex regional pain syndrome.
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Affiliation(s)
- Ibrahim S Farid
- Division of Pain Medicine, Akron Children's Hospital, Akron, Ohio 44308, USA.
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22
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Binder A, Schattschneider J, Baron R. Complex Regional Pain Syndrome Type I (Reflex Sympathetic Dystrophy). Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50030-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Pleger B, Ragert P, Schwenkreis P, Förster AF, Wilimzig C, Dinse H, Nicolas V, Maier C, Tegenthoff M. Patterns of cortical reorganization parallel impaired tactile discrimination and pain intensity in complex regional pain syndrome. Neuroimage 2006; 32:503-10. [PMID: 16753306 DOI: 10.1016/j.neuroimage.2006.03.045] [Citation(s) in RCA: 211] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Revised: 01/22/2006] [Accepted: 03/21/2006] [Indexed: 11/25/2022] Open
Abstract
In the complex regional pain syndrome (CRPS), several theories proposed the existence of pathophysiological mechanisms of central origin. Recent studies highlighted a smaller representation of the CRPS-affected hand on the primary somatosensory cortex (SI) during non-painful stimulation of the affected side. We addressed the question whether reorganizational changes can also be found in the secondary somatosensory cortex (SII). Moreover, we investigated whether cortical changes might be accompanied by perceptual changes within associated skin territories. Seventeen patients with CRPS of one upper limb without the presence of peripheral nerve injuries (type I) were subjected to functional magnetic resonance imaging (fMRI) during electrical stimulation of both index fingers (IFs) in order to assess hemodynamic signals of the IF representation in SI and SII. As a marker of tactile perception, we tested 2-point discrimination thresholds on the tip of both IFs. Cortical signals within SI and SII were significantly reduced contralateral to the CRPS-affected IF as compared to the ipsilateral side and to the representation of age- and sex-matched healthy controls. In parallel, discrimination thresholds of the CRPS-affected IF were significantly higher, giving rise to an impairment of tactile perception within the corresponding skin territory. Mean sustained, but not current pain levels were correlated with the amount of sensory impairment and the reduction in signal strength. We conclude that patterns of cortical reorganization in SI and SII seem to parallel impaired tactile discrimination. Furthermore, the amount of reorganization and tactile impairment appeared to be linked to characteristics of CRPS pain.
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Affiliation(s)
- Burkhard Pleger
- Department of Neurology, BG-Kliniken Bergmannsheil, Buerkle-de-la-Camp-Platz 1, 44789 Bochum, Germany; University College London, UK.
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24
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Abstract
OBJECTIVES Complex regional pain syndromes (CRPS) can be relieved by sympathetic blockade. Different sympathetic efferent output channels innervate distinct effector organs (ie, cutaneous vasoconstrictor, muscle vasoconstrictor. and sudomotor neurons, as well as neurons innervating deep somatic tissues like bone, joints, and tendons). The aim of the present study was to elucidate in CRPS patients the sympathetically maintained pain (SMP) component that exclusively depends on cutaneous sympathetic activity compared with the SMP depending on the sympathetic innervation of deep somatic tissues. METHODS The sympathetic outflow to the painful skin was modulated selectively in awake humans. High and low cutaneous vasoconstrictor activity was produced in 12 CRPS type 1 patients by whole-body cooling and warming (thermal suit). Spontaneous pain was quantified during high and low cutaneous vasoconstrictor activity. By comparing the cutaneous SMP component with the change in pain that was achieved by modulation of the entire sympathetic outflow (sympathetic ganglion block), the SMP component originating in deep somatic structures was estimated. RESULTS The relief of spontaneous pain after sympathetic blockade was more pronounced than changes in spontaneous pain that could be induced by selective sympathetic cutaneous modulation. The entire SMP component (cutaneous and deep) changes considerably over time. It is most prominent in the acute stages of CRPS. CONCLUSIONS Sympathetic afferent coupling takes place in the skin and in the deep somatic tissues, but especially in the acute stages of CRPS, the pain component that is influenced by the sympathetic innervation of deep somatic structures is more important than the cutaneous activation. The entire sympathetic maintained pain component is not constant in the course of the disease but decreases over time.
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Affiliation(s)
- Jörn Schattschneider
- Klinik für Neurologie, Sektion für Schmerzforschung und therapie, Univeritätsklinikum Schleswig-Holstein, Campus Kiel, Germany
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25
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Nambi-Joseph P, Stanton-Hicks M, Sferra JJ. Interventional modalities in the treatment of complex regional pain syndrome. Foot Ankle Clin 2004; 9:405-17. [PMID: 15165590 DOI: 10.1016/j.fcl.2004.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Complex regional pain syndrome (CRPS) applies to a variety of conditions in which symptoms such as allodynia and hyperalgesia predominate along with hyperpathia and vasomotor/sudomotor disturbances. The incidence of CRPS in the chronic pain population varies and is difficult to determine, though it appears to affect women more than men. Treatment is multidisciplinary, and recovery of function and the reduction of pain are the main goals of treatment;this article addresses some of the interventional modalities that are used.
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Affiliation(s)
- Pushpa Nambi-Joseph
- Section of Foot & Ankle Surgery, Department of Pain Management, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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27
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Pleger B, Tegenthoff M, Schwenkreis P, Janssen F, Ragert P, Dinse HR, Völker B, Zenz M, Maier C. Mean sustained pain levels are linked to hemispherical side-to-side differences of primary somatosensory cortex in the complex regional pain syndrome I. Exp Brain Res 2004; 155:115-9. [PMID: 15064892 DOI: 10.1007/s00221-003-1738-4] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2003] [Accepted: 11/29/2003] [Indexed: 02/08/2023]
Abstract
Chronic back pain as well as phantom-limb pain is characterized by a close relationship between the amount of cortical reorganization and the magnitude of pain. In patients with positively assessed complex regional pain syndrome type I (CRPS I), we found a positive correlation between representational changes of primary somatosensory cortex (SI) and mean sustained pain levels. We investigated seven right-handed patients with CRPS I of one upper limb by means of somatosensory evoked potential (SSEP) mapping. Cortical representation of the CRPS-affected hand was significantly smaller than that of the contralateral healthy hand, giving rise to a substantial side difference. Subjective pain levels experienced over the last 4 weeks were estimated according to the visual analogue scale (VAS). Individual expansion of hand representation contralateral to the CRPS-affected limb was significantly correlated with mean pain intensity. Accordingly, low pain levels were linked to small representational side-to-side differences, while subjects with a distinctive hemispherical asymmetry reported the highest pain levels. Follow-up studies using functional imaging methods might be instrumental in providing a better understanding of this issue.
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Affiliation(s)
- Burkhard Pleger
- Department of Neurology, BG-Kliniken Bergmannsheil, Ruhr University Bochum, Buerkle-de-la-Camp Platz 1, 44789, Bochum, Germany
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28
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Baron R. Chapter 4 Reflex sympathetic dystrophy and causalgia. ACTA ACUST UNITED AC 2004; 57:24-38. [PMID: 16106603 DOI: 10.1016/s1567-424x(09)70340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Ralf Baron
- Universitätsklinikum Schleswig-Holstein, Campus Kiel, Klinik für Neurologie, Schittenhelmstrasse 10, D-24105 Kiel, Germany.
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29
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Abstract
Three cases are presented in which electroconvulsive therapy (ECT) for depression led to the relief of comorbid complex regional pain syndrome as well as depression. In one of the cases, concomitant fibromyalgia was not relieved during 2 separate series of ECT. The literature regarding the role of ECT in the management of chronic pain is reviewed and discussed in light of recent findings about ECT and changes in neurotransmission associated with seizures.
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Affiliation(s)
- William W McDaniel
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
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30
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Abstract
As suggested by this article, considerable advances in clinical management and research have taken place during the past 20 years. Although mechanisms underlying the pain syndrome CRPS I and CRPS II remain far from one's understanding, glimpses of the pathophysiology are beginning to take shape. There is now strong evidence that these syndromes exemplify a complex neurologic disease involving the brain at several integrated levels. The changes that occur in CRPS I patients involve somatosensory, sympathetic, and somatomotor systems. The diagnostic criteria have helped to focus on aspects of these foregoing systems and whereas there is no specific laboratory test for CRPS, enough is now known about the pathophysiology to use the following tests: quantitative sensory testing (QST), autonomic testing that include quantitative sudomotor axon reflex test (QSART) for sweating abnormalities, the cold pressor test in conjunction with thermographic imaging to observe the vasoconstrictor response, and laser Doppler flowmetry to monitor background vasomotor control. Recognition of a motor disorder requires accurate documentation and may be a component of the diagnostic criteria in the future. Until a better understanding of mechanistic overtones that would help to put in place mechanism-based therapeutic strategies, current management is built around a rehabilitation model. For this to be successful, as described in the foregoing pages, different non-interventional and interventional modalities are applied in a time-restricted manner to facilitate those modalities that favor progress in the treatment algorithm. As has been described, it is important when using physiotherapeutic maneuvers to minimize joint movement in the affected region to reduce the mechanorecpetor barrage and its increase in perceived pain to encourage and maintain a patient's compliance with their rehabilitation. Finally, of greater significance is the understanding that sympatholysis per se is not a "diagnostic" test for CRPS, but rather a useful procedure that may facilitate treatment for pain that is sympathetically maintained.
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Affiliation(s)
- Michael Stanton-Hicks
- Division of Anesthesiology for Pain Management and Research, The Cleveland Clinic, 9500 Euclid Avenue, Desk C-25, Cleveland, OH 44195, USA.
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31
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Abstract
Complex regional pain syndrome (CRPS) is the result of changes to the somatosensory systems that process noxious, tactile, and thermal information; to the sympathetic systems that innervate skin (blood vessels, sweat glands); and to the somatomotor systems. The changes suggest that the CNS representations of the systems have been altered. Patients with CRPS also have peripheral changes (eg, oedema, signs of inflammation, sympathetic-afferent coupling [the basis for sympathetically maintained pain], and trophic changes) that cannot be explained by central changes. On the basis of clinical observation and research in human beings and animals, we hypothesise that CRPS is a systemic disease involving the CNS and peripheral nervous system. The most important question for future research is what causes CRPS? In this article, we suggest a change to the focus of research efforts and treatment. We also suggest there be diagnostic reclassification and redefinition of CRPS.
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Affiliation(s)
- Wilfrid Jänig
- Department of Physiology, Christian-Albrechts-University of Kiel, Kiel, Germany.
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32
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Abstract
In dealing with human nervous system, the sensation of pain is as sophisticated as other physiological phenomena. To obtain an acceptable model of the pain, physiology of the pain has been analysed in the present paper. Pain mechanisms are explained in block diagram representation form. Because of the nonlinear interactions existing among different sections in the diagram, artificial neural networks (ANNs) have been exploited. The basic patterns associated with chronic and acute pain have been collected and then used to obtain proper features for training the neural networks. Both static and dynamic representations of the ANNs were used in this regard. The trained networks then were employed to predict response of the body when it is exposed to special excitations. These excitations have not been used in the training phase and their behavior is interesting from the physiological view. Some of these predictions can be inferred from clinical experimentations. However, more clinical tests have to be accomplished for some of the predictions.
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Affiliation(s)
- M Haeri
- Electrical Engineering Department, Sharif University of Technology, Azadi Avenue, P.O. Box 11365-9363, Tehran, Iran.
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Analgesic Effects of Ketamine Ointment in Patients with Complex Regional Pain Syndrome Type 1. Reg Anesth Pain Med 2002. [DOI: 10.1097/00115550-200209000-00017] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Baron R, Schattschneider J, Binder A, Siebrecht D, Wasner G. Relation between sympathetic vasoconstrictor activity and pain and hyperalgesia in complex regional pain syndromes: a case-control study. Lancet 2002; 359:1655-60. [PMID: 12020526 DOI: 10.1016/s0140-6736(02)08589-6] [Citation(s) in RCA: 197] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Complex regional pain syndromes can be relieved by sympathetic blockage. The mechanisms of sympathetically maintained pain (SMP) are unclear. We aimed to establish the effect of physiological sympathetic cutaneous vasoconstrictor activity on pain and hyperalgesia in patients with complex regional pain syndromes. METHODS High and low cutaneous vasoconstrictor activity was produced by whole-body cooling and warming (thermal suit) in 13 patients with type I disease and in ten controls. The degree of cutaneous vasoconstrictor discharge was monitored by measurement of skin blood flow and temperature at the arm and leg. Local skin temperature at the affected region was fixed at 35 degrees C. Pain was quantified during high and low cutaneous vasoconstrictor activity (intensity of spontaneous pain, area of mechanical hyperalgesias, heat-pain thresholds). Furthermore, pain was measured before and after diagnostic sympathetic blockage to identify patients with SMP and sympathetically independent pain. FINDINGS In patients with SMP, intensity of spontaneous pain significantly increased, by 22%, and spatial distribution of mechanical dynamic and punctate hyperalgesia increased by 42% and 27%, respectively, during high sympathetic activity compared with low activity. Heat-pain thresholds did not differ during high and low cutaneous vasoconstrictor activity (cold and warm state, 43.6 degrees C vs 44.6 degrees C). Pain relief after sympathetic blockage correlated with augmentation of spontaneous pain after experimental stimulation of cutaneous vasoconstrictor activity (r=0.6, p=0.0244). INTERPRETATION We have shown that in complex regional pain syndromes with SMP, physiological activation of cutaneous vasoconstrictor neurons projecting to the painful arm or leg enhances spontaneous pain and hyperalgesia. We postulate that there is a pathological interaction between sympathetic and afferent neurons within the skin.
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Affiliation(s)
- R Baron
- Klinik für Neurologie Christian-Albrechts-Universität Kiel, Kiel, Germany.
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