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Mangnus TJP, Dirckx M, Huygen FJPM. Different Types of Pain in Complex Regional Pain Syndrome Require a Personalized Treatment Strategy. J Pain Res 2023; 16:4379-4391. [PMID: 38162406 PMCID: PMC10757771 DOI: 10.2147/jpr.s432209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating painful state of an extremity that can develop after trauma. CRPS is diagnosed by the new International Association for the Study of Pain (IASP) diagnostic criteria for CRPS. The syndrome is characterized by continuing regional pain with abnormal sensory, motor, sudomotor, vasomotor, edema, and/or trophic signs. The clinical presentation of CRPS can be very heterogeneous because CRPS is a multi-mechanism syndrome. Therefore, mechanism-based subgroups have been suggested to personalize treatment for CRPS. Additionally, the presentation of symptom pain may also be able to identify different subgroups of CRPS. In this review, the types of pain recognized by the IASP-nociceptive, neuropathic, and nociplastic pain-will be discussed as possible subgroups for CRPS. Each pain type should be identified in CRPS patients, with a thorough history taking, physical examination, and diagnostic tests or (novel) biomarkers to optimize treatment effectiveness. Over the course of the syndrome, patients with CRPS probably experience more than one distinct pain type. Therefore, pain specialists should be alert to not only adjust their treatment if underlying pathophysiologic mechanisms tend to change but also to personalize the treatment of the associated type of pain in the CRPS patient.
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Affiliation(s)
- Thomas J P Mangnus
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maaike Dirckx
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank J P M Huygen
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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2
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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: 1] [Impact Index Per Article: 0.3] [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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Sommer C, Klose P, Welsch P, Petzke F, Häuser W. Opioids for chronic non‐cancer neuropathic pain. An updated systematic review and meta‐analysis of efficacy, tolerability and safety in randomized placebo‐controlled studies of at least 4 weeks duration. Eur J Pain 2019; 24:3-18. [DOI: 10.1002/ejp.1494] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 10/16/2019] [Accepted: 10/21/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Claudia Sommer
- Department of Neurology University of Würzburg Würzburg Germany
| | - Petra Klose
- Department Internal and Integrative Medicine Faculty of Medicine University of Duisburg‐Essen Essen Germany
| | - Patrick Welsch
- Health Care Center for Pain Medicine and Mental Health Saarbrücken Germany
| | - Frank Petzke
- Pain Medicine Department of Anesthesiology University Medical Center Göttingen Göttingen Germany
| | - Winfried Häuser
- Health Care Center for Pain Medicine and Mental Health Saarbrücken Germany
- Department Psychosomatic Medicine and Psychotherapy Technische Universit€at München München Germany
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Kaguelidou F, Le Roux E, Mangiarini L, Lundin R, de Leeuw TG, Della Pasqua O, Felisi M, Bonifazi D, Tibboel D, Ceci A, de Wildt SN, Alberti C. Non-inferiority double-blind randomised controlled trial comparing gabapentin versus tramadol for the treatment of chronic neuropathic or mixed pain in children and adolescents: the GABA-1 trial-a study protocol. BMJ Open 2019; 9:e023296. [PMID: 30787078 PMCID: PMC6398794 DOI: 10.1136/bmjopen-2018-023296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Gabapentin is currently used 'off-label' in children and adolescents with chronic neuropathic pain, and reliable evidence of its effects and optimal dosing are lacking. OBJECTIVES The GABA-1 trial aims to compare the efficacy and safety of gabapentin liquid formulation relative to tramadol and to explore the pharmacokinetics of both drugs in the treatment of chronic, neuropathic or mixed pain in the paediatric population. METHODS AND ANALYSIS The trial is a multicentre, double-blind, double-dummy, randomised, active-controlled, non-inferiority trial. Participants aged from 3 months to <18 years of age with moderate to severe (≥4/10 in age-appropriate pain scales) chronic neuropathic or mixed pain will be recruited in 14 clinical sites in eight European countries. A total of 94 subjects will be randomised to receive gabapentin and tramadol placebo or tramadol and gabapentin placebo throughout 16-19 weeks (including 3 weeks of titration [optimisation period], 12 weeks of treatment at a stable dose [maintenance period] and 1-4 weeks of tapering [discontinuation period]). The primary objective is to assess the efficacy of gabapentin relative to tramadol for the treatment of moderate to severe chronic neuropathic or mixed pain by comparing the difference in average pain scores (assessed by age-appropriate pain scales) between intervention arms after 15 weeks of treatment. Secondary objectives include the assessment of the safety, quality of life and global satisfaction with treatment and the description of the pharmacokinetic-pharmacodynamic relationship of gabapentin liquid formulation and tramadol oral drops to validate the recommended paediatric doses. Only rescue pain medication by paracetamol and/or ibuprofen is allowed during the trial. ETHICS AND DISSEMINATION Ethic approval was obtained in the eight participating countries. Results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. TRIAL REGISTRATION NUMBERS 2014-004851-30 and NCT02722603. TRIAL STATUS Ongoing research study, currently recruiting.
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Affiliation(s)
- Florentia Kaguelidou
- Department of Paediatric Pharmacology and Pharmacogenetics, AP-HP, Hôpital Robert Debré, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Inserm, CIC 1426, F-75019, Paris, France
| | - Enora Le Roux
- AP-HP, Hôpital Robert Debré, Unité d’Epidémiologie Clinique, Paris, France
- UMR-1123 ECEVE, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | | | | | - Thomas G de Leeuw
- Department of Anaesthesia, Erasmus MC Sophia Children’s Hospital & Center for Pain Medicine Rotterdam, Rotterdam, The Netherlands
| | - Oscar Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, London, UK
| | - Mariagrazia Felisi
- PHARM – Pharmaceutical Research Management SRL, Lodi, Italy
- CVBF–Consorzio per le Valutazioni Biologiche e Farmacologiche, Pavia, Italy
| | - Donato Bonifazi
- PHARM – Pharmaceutical Research Management SRL, Lodi, Italy
- CVBF–Consorzio per le Valutazioni Biologiche e Farmacologiche, Pavia, Italy
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Adriana Ceci
- Fondazione per la Ricerca Farmacologica Gianni Benzi onlus, Valenzano, Italy
| | - Saskia N de Wildt
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Pharmacology and Toxicology, Radboud Universiteit Faculteit der Rechtsgeleerdheid, Nijmegen, The Netherlands
| | - Corinne Alberti
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- AP-HP, Hôpital Robert Debré, Unité d’Epidémiologie Clinique, Paris, France
- Inserm, U1123 and CICEC 1426, F-75019, Paris, France
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Castelnuovo G, Giusti EM, Manzoni GM, Saviola D, Gabrielli S, Lacerenza M, Pietrabissa G, Cattivelli R, Spatola CAM, Rossi A, Varallo G, Novelli M, Villa V, Luzzati F, Cottini A, Lai C, Volpato E, Cavalera C, Pagnini F, Tesio V, Castelli L, Tavola M, Torta R, Arreghini M, Zanini L, Brunani A, Seitanidis I, Ventura G, Capodaglio P, D'Aniello GE, Scarpina F, Brioschi A, Bigoni M, Priano L, Mauro A, Riva G, Di Lernia D, Repetto C, Regalia C, Molinari E, Notaro P, Paolucci S, Sandrini G, Simpson S, Wiederhold BK, Gaudio S, Jackson JB, Tamburin S, Benedetti F. What Is the Role of the Placebo Effect for Pain Relief in Neurorehabilitation? Clinical Implications From the Italian Consensus Conference on Pain in Neurorehabilitation. Front Neurol 2018; 9:310. [PMID: 29867723 PMCID: PMC5968866 DOI: 10.3389/fneur.2018.00310] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/19/2018] [Indexed: 12/12/2022] Open
Abstract
Background It is increasingly acknowledged that the outcomes of medical treatments are influenced by the context of the clinical encounter through the mechanisms of the placebo effect. The phenomenon of placebo analgesia might be exploited to maximize the efficacy of neurorehabilitation treatments. Since its intensity varies across neurological disorders, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCP) summarized the studies on this field to provide guidance on its use. Methods A review of the existing reviews and meta-analyses was performed to assess the magnitude of the placebo effect in disorders that may undergo neurorehabilitation treatment. The search was performed on Pubmed using placebo, pain, and the names of neurological disorders as keywords. Methodological quality was assessed using a pre-existing checklist. Data about the magnitude of the placebo effect were extracted from the included reviews and were commented in a narrative form. Results 11 articles were included in this review. Placebo treatments showed weak effects in central neuropathic pain (pain reduction from 0.44 to 0.66 on a 0-10 scale) and moderate effects in postherpetic neuralgia (1.16), in diabetic peripheral neuropathy (1.45), and in pain associated to HIV (1.82). Moderate effects were also found on pain due to fibromyalgia and migraine; only weak short-term effects were found in complex regional pain syndrome. Confounding variables might have influenced these results. Clinical implications These estimates should be interpreted with caution, but underscore that the placebo effect can be exploited in neurorehabilitation programs. It is not necessary to conceal its use from the patient. Knowledge of placebo mechanisms can be used to shape the doctor-patient relationship, to reduce the use of analgesic drugs and to train the patient to become an active agent of the therapy.
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Affiliation(s)
- Gianluca Castelnuovo
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Emanuele Maria Giusti
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Gian Mauro Manzoni
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Faculty of Psychology, eCampus University, Novedrate, Italy
| | - Donatella Saviola
- Cardinal Ferrari Rehabilitation Center, Santo Stefano Rehabilitation Istitute, Fontanellato, Italy
| | | | - Marco Lacerenza
- Pain Medicine Center, San Pio X Clinic, Humanitas, Milan, Italy
| | - Giada Pietrabissa
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Roberto Cattivelli
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Chiara Anna Maria Spatola
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Alessandro Rossi
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy
| | - Giorgia Varallo
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy
| | - Margherita Novelli
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy
| | - Valentina Villa
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy
| | | | | | - Carlo Lai
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Eleonora Volpato
- Department of Psychology, Catholic University of Milan, Milan, Italy.,HD Respiratory Rehabilitation Unit, IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Cesare Cavalera
- Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Francesco Pagnini
- Department of Psychology, Catholic University of Milan, Milan, Italy.,Department of Psychology, Harvard University, Cambridge, MA, United States
| | | | - Lorys Castelli
- Department of Psychology, University of Turin, Turin, Italy
| | - Mario Tavola
- Anesthesia and Intensive Care, ASST Lecco, Lecco, Italy
| | - Riccardo Torta
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Marco Arreghini
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Loredana Zanini
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Amelia Brunani
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Ionathan Seitanidis
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Giuseppe Ventura
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Paolo Capodaglio
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Guido Edoardo D'Aniello
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Federica Scarpina
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy
| | - Andrea Brioschi
- Istituto Auxologico Italiano IRCCS, Department of Neurology and Neurorehabilitation, San Giuseppe Hospital, Verbania, Italy
| | - Matteo Bigoni
- Istituto Auxologico Italiano IRCCS, Department of Neurology and Neurorehabilitation, San Giuseppe Hospital, Verbania, Italy
| | - Lorenzo Priano
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,Istituto Auxologico Italiano IRCCS, Department of Neurology and Neurorehabilitation, San Giuseppe Hospital, Verbania, Italy
| | - Alessandro Mauro
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,Istituto Auxologico Italiano IRCCS, Department of Neurology and Neurorehabilitation, San Giuseppe Hospital, Verbania, Italy
| | - Giuseppe Riva
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Daniele Di Lernia
- Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Claudia Repetto
- Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Camillo Regalia
- Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Enrico Molinari
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Paolo Notaro
- Pain Medicine, Anesthesiology Department, A.O. Ospedale Niguarda ca Granda, Milan, Italy
| | | | - Giorgio Sandrini
- C. Mondino National Neurological Institute, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Susan Simpson
- University of South Australia, Adelaide, SA, Australia.,Regional Eating Disorders Unit, NHS Lothian, Livingston, United Kingdom
| | | | - Santino Gaudio
- Department of Neuroscience, Functional Pharmacology, Uppsala University, Uppsala, Sweden
| | | | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Fabrizio Benedetti
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
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Lee YH, Lee KM, Kim HG, Kang SK, Auh QS, Hong JP, Chun YH. Orofacial complex regional pain syndrome: pathophysiologic mechanisms and functional MRI. Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 124:e164-e170. [PMID: 28522185 DOI: 10.1016/j.oooo.2017.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 02/27/2017] [Accepted: 03/03/2017] [Indexed: 01/29/2023]
Abstract
Complex regional pain syndrome (CRPS) is one of the most challenging chronic pain conditions and is characterized by burning pain, allodynia, hyperalgesia, autonomic changes, trophic changes, edema, and functional loss involving mainly the extremities. Until recently, very few reports have been published concerning CRPS involving the orofacial area. We report on a 50-year-old female patient who presented with unbearable pain in all of her teeth and hypersensitivity of the facial skin. She also reported intractable pain in both extremities accompanied by temperature changes and orofacial pain that increased when the other pains were aggravated. In the case of CRPS with trigeminal neuropathic pain, protocols for proper diagnosis and prompt treatment have yet to be established in academia or in the clinical field. We performed functional magnetic resonance imaging for a thorough analysis of the cortical representation of the affected orofacial area immediately before and immediately after isolated light stimulus of the affected hand and foot and concluded that CRPS can be correlated with trigeminal neuropathy in the orofacial area. Furthermore, the patient was treated with carbamazepine administration and stellate ganglion block, which can result in a rapid improvement of pain in the trigeminal region.
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Affiliation(s)
- Yeon-Hee Lee
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
| | - Kyung Mi Lee
- Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, Korea.
| | - Hyug-Gi Kim
- Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Soo-Kyung Kang
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
| | - Q-Schick Auh
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
| | - Jyung-Pyo Hong
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
| | - Yang-Hyun Chun
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
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Inflammatory arthritis mimicking Complex Regional Pain Syndrome (CRPS) in a child: A case report. North Clin Istanb 2017; 3:131-134. [PMID: 28058400 PMCID: PMC5206463 DOI: 10.14744/nci.2015.33043] [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: 05/10/2015] [Accepted: 10/28/2015] [Indexed: 11/29/2022] Open
Abstract
Joint complaints in childhood are seen frequently and differential diagnosis can be difficult. Juvenile idiopathic arthritis (JIA) is the most common rheumatological disease of childhood. It involves peripheral joint arthritis, chronic synovitis, and extra-articular manifestations. Accurate diagnosis can take a long time and sometimes multiple diagnoses are used while following the patient until a final diagnosis can be reached. Arthritis may be triggered by trauma and confused with other diseases like complex regional pain syndrome (CRPS), in which trauma plays a role in the etiology. In the present case, ankle pain in an 8-year-old girl was misdiagnosed as CRPS.
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9
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Bussa M, Guttilla D, Lucia M, Mascaro A, Rinaldi S. Complex regional pain syndrome type I: a comprehensive review. Acta Anaesthesiol Scand 2015; 59:685-97. [PMID: 25903457 DOI: 10.1111/aas.12489] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 11/25/2014] [Accepted: 01/06/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Complex regional pain syndrome type I (CRPS I), formerly known as reflex sympathetic dystrophy (RSD), is a chronic painful disorder that usually develops after a minor injury to a limb. This topical review gives a synopsis of CRPS I and discusses the current concepts of our understanding of CRPS I in adults, the diagnosis, and treatment options based on the limited evidence found in medical literature. CRPS I is a multifactorial disorder. Possible pathophysiological mechanisms of CRPS I are classic and neurogenic inflammation, and maladaptive neuroplasticity. At the level of the central nervous system, it has been suggested that an increased input from peripheral nociceptors alters the central processing mechanisms. METHODS A literature search was conducted using, as electronic bibliographic database, Medline from 1980 until 2014. RESULTS An early diagnosis and multidisciplinary treatment are necessary to prevent permanent disability. CONCLUSIONS The pharmacological treatment of CRPS I is empirical and insufficiently effective. Further research is needed regarding the therapeutic modalities discussed in the guidelines. Physical therapy is widely recommended as a first-line treatment. The efficacy of local anesthetic sympathetic blockade as treatment for CRPS I is questionable.
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Affiliation(s)
- M. Bussa
- O.U. of Anesthesia, Intensive Care and Pain Therapy of Sant'Antonio Abate Hospital; Casa Santa Erice Trapani Italy
| | - D. Guttilla
- O.U. of Anesthesia, Intensive Care and Pain Therapy of Sant'Antonio Abate Hospital; Casa Santa Erice Trapani Italy
| | - M. Lucia
- O.U. of Anesthesia, Intensive Care and Pain Therapy of Azienda Ospedaliera Ospedali Riuniti Villa Sofia Cervello; Palermo Italy
| | - A. Mascaro
- Anaesthesiology, Intensive Care and Pain Therapy Department; Catholic University; Medical School; Rome Italy
| | - S. Rinaldi
- Plastic and Reconstructive Surgery Department; University ‘Sapienza’ of Rome; Rome Italy
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Dong J, Yang L, Tang J, Zheng J. Dexmedetomidine alleviates rat post-ischemia induced allodynia through GRK2 upregulation in superior cervical ganglia. Auton Neurosci 2014; 187:76-83. [PMID: 25466829 DOI: 10.1016/j.autneu.2014.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 10/14/2014] [Accepted: 10/25/2014] [Indexed: 10/24/2022]
Abstract
A transient decrease in G protein-coupled receptor kinase 2 (GRK2) in nociceptors can produce long-lasting neuroplastic changes in nociceptor function, eventually enhancing and prolonging inflammatory hyperalgesia. Here, we investigated the effects of selective α2-adrenoceptor agonist dexmedetomidine (DMED) on GRK2 expression in superior cervical ganglion (SCG) in a rat model of complex regional pain syndrome type I (CRPS-I). The ipsilateral 50% paw withdrawal thresholds (PWTs) to mechanical stimuli decreased significantly starting from 24 h after ischemia-reperfusion (I/R) injury, and lasted for over 3 weeks; the ipsilateral cold allodynia scores, GRK2 protein and mRNA levels in SCGs all increased significantly. No significant differences were found in the contralateral side except GRK2 mRNA reduced significantly after 48 h I/R injury, but still higher than those in the ipsilateral side. Following daily injection of 10 μg/kg of DMED for a maximum of 7 days, the ipsilateral PWTs on days 1, 2, 7, 14, and 21 after DMED administration were significantly higher than those in control group; the GRK2 protein and mRNA expressions in the ipsilateral SCGs were also significantly upregulated; the ipsilateral cold allodynia scores were significantly reduced. No significant differences were found in the contralateral 50%PWTs, cold allodynia scores, and GRK2 protein level except GRK2 mRNA levels increased significantly on days 1 to 7 after DMED administration. Therefore, a transient decrease of GRK2 expression in SCG neurons might be involved in the development and maintenance of allodynia in CRPS-I and DMED might alleviate this allodynia through GRK2 upregulation in SCG neurons.
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Affiliation(s)
- Jing Dong
- Department of Anesthesiology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Department of Anesthesiology, Shanghai First People's Hospital, Shanghai Jiaotong University affiliated Shanghai First People's Hospital, Shanghai 201620, China.
| | - Li Yang
- Department of Anesthesiology, Jinshan Hospital, Fudan University, Shanghai, China.
| | - Jun Tang
- Department of Anesthesiology, Jinshan Hospital, Fudan University, Shanghai, China.
| | - Jijian Zheng
- Department of Anesthesiology, Shanghai First People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Department of Anesthesiology, Shanghai First People's Hospital, Shanghai Jiaotong University affiliated Shanghai First People's Hospital, Shanghai 201620, China.
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Pickering AE, McCabe CS. Prolonged ketamine infusion as a therapy for complex regional pain syndrome: synergism with antagonism? Br J Clin Pharmacol 2014; 77:233-8. [PMID: 23701138 PMCID: PMC3992840 DOI: 10.1111/bcp.12157] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 04/28/2013] [Indexed: 12/18/2022] Open
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He L, Üçeyler N, Krämer HH, Colaço MN, Lu B, Birklein F, Sommer C. Methylprednisolone prevents nerve injury-induced hyperalgesia in neprilysin knockout mice. Pain 2013; 155:574-580. [PMID: 24333776 DOI: 10.1016/j.pain.2013.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 11/16/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022]
Abstract
The pathophysiology of the complex regional pain syndrome involves enhanced neurogenic inflammation mediated by neuropeptides. Neutral endopeptidase (neprilysin, NEP) is a key enzyme in neuropeptide catabolism. Our previous work revealed that NEP knock out (ko) mice develop more severe hypersensitivity to thermal and mechanical stimuli after chronic constriction injury (CCI) of the sciatic nerve than wild-type (wt) mice. Because treatment with glucocorticoids is effective in early complex regional pain syndrome, we investigated whether methylprednisolone (MP) reduces pain and sciatic nerve neuropeptide content in NEP ko and wt mice with nerve injury. After CCI, NEP ko mice developed more severe thermal and mechanical hypersensitivity and hind paw edema than wt mice, confirming previous findings. Hypersensitivity was prevented by MP treatment in NEP ko but not in wt mice. MP treatment had no effect on protein levels of calcitonin-gene related peptide, substance P, and bradykinin in sciatic nerves of NEP ko mice. Endothelin-1 (ET-1) levels were higher in naïve and nerve-injured NEP ko than in wt mice, without an effect of MP treatment. Gene expression of the ET-1 receptors ETAR and ETBR was not different between genotypes and was not altered after CCI, but was increased after additional MP treatment. The ETBR agonist IRL-1620 was analgesic in NEP ko mice after CCI, and the ETBR antagonist BQ-788 showed a trend to reduce the analgesic effect of MP. The results provide evidence that MP reduces CCI-induced hyperalgesia in NEP ko mice, and that this may be related to ET-1 via analgesic actions of ETBR.
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Affiliation(s)
- Lan He
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany Department of Neurology, Johannes Gutenberg University Mainz, Mainz, Germany Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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13
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Wilsey B, Marcotte T, Deutsch R, Gouaux B, Sakai S, Donaghe H. Low-dose vaporized cannabis significantly improves neuropathic pain. THE JOURNAL OF PAIN 2013; 14:136-48. [PMID: 23237736 PMCID: PMC3566631 DOI: 10.1016/j.jpain.2012.10.009] [Citation(s) in RCA: 187] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 08/26/2012] [Accepted: 10/21/2012] [Indexed: 12/30/2022]
Abstract
UNLABELLED We conducted a double-blind, placebo-controlled, crossover study evaluating the analgesic efficacy of vaporized cannabis in subjects, the majority of whom were experiencing neuropathic pain despite traditional treatment. Thirty-nine patients with central and peripheral neuropathic pain underwent a standardized procedure for inhaling medium-dose (3.53%), low-dose (1.29%), or placebo cannabis with the primary outcome being visual analog scale pain intensity. Psychoactive side effects and neuropsychological performance were also evaluated. Mixed-effects regression models demonstrated an analgesic response to vaporized cannabis. There was no significant difference between the 2 active dose groups' results (P > .7). The number needed to treat (NNT) to achieve 30% pain reduction was 3.2 for placebo versus low-dose, 2.9 for placebo versus medium-dose, and 25 for medium- versus low-dose. As these NNTs are comparable to those of traditional neuropathic pain medications, cannabis has analgesic efficacy with the low dose being as effective a pain reliever as the medium dose. Psychoactive effects were minimal and well tolerated, and neuropsychological effects were of limited duration and readily reversible within 1 to 2 hours. Vaporized cannabis, even at low doses, may present an effective option for patients with treatment-resistant neuropathic pain. PERSPECTIVE The analgesia obtained from a low dose of delta-9-tetrahydrocannabinol (1.29%) in patients, most of whom were experiencing neuropathic pain despite conventional treatments, is a clinically significant outcome. In general, the effect sizes on cognitive testing were consistent with this minimal dose. As a result, one might not anticipate a significant impact on daily functioning.
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Affiliation(s)
- Barth Wilsey
- VA Northern California Health Care System, and Department of Physical Medicine and Rehabilitation, University of California, Davis Medical Center, Sacramento, California 95817, USA.
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14
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Segall SK, Maixner W, Belfer I, Wiltshire T, Seltzer Z, Diatchenko L. Janus molecule I: dichotomous effects of COMT in neuropathic vs nociceptive pain modalities. CNS & NEUROLOGICAL DISORDERS-DRUG TARGETS 2012; 11:222-35. [PMID: 22483297 DOI: 10.2174/187152712800672490] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 10/27/2011] [Accepted: 10/28/2012] [Indexed: 01/02/2023]
Abstract
The enzyme catechol-O-methyltransferase (COMT) has been shown to play a critical role in pain perception by regulating levels of epinephrine (Epi) and norepinephrine (NE). Although the key contribution of catecholamines to the perception of pain has been recognized for a long time, there is a clear dichotomy of observations. More than a century of research has demonstrated that increasing adrenergic transmission in the spinal cord decreases pain sensitivity in animals. Equally abundant evidence demonstrates the opposite effect of adrenergic signaling in the peripheral nervous system, where adrenergic signaling increases pain sensitivity. Viewing pain processing within spinal and peripheral compartments and determining the directionality of adrenergic signaling helps clarify the seemingly contradictory findings of the pain modulatory properties of adrenergic receptor agonists and antagonists presented in other reviews. Available evidence suggests that adrenergic signaling contributes to pain phenotypes through α(1/2) and β(2/3) receptors. While stimulation of α(2) adrenergic receptors seems to uniformly produce analgesia, stimulation of α(1) or β receptors produces either analgesic or hyperalgesic effects. Establishing the directionality of adrenergic receptor modulation of pain processing, and related COMT activity in different pain models are needed to bring meaning to recent human molecular genetic findings. This will enable the translation of current findings into meaningful clinical applications such as diagnostic markers and novel therapeutic targets for complex human pain conditions.
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Affiliation(s)
- S K Segall
- Center for Neurosensory Disorders, University of North Carolina, Chapel Hill, USA.
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Munisamy R, Uppalu H, Raghavendra R, Venkata NPS, Harshita S, Janarthanam SV. Type-I complex regional pain syndrome of umbilical port site: An unforeseen complication of laparoscopic surgery. J Minim Access Surg 2012; 8:50-3. [PMID: 22623826 PMCID: PMC3353613 DOI: 10.4103/0972-9941.95535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 06/30/2011] [Indexed: 11/18/2022] Open
Abstract
Many complications have been observed after laparoscopic surgery. Persisting pain in the umbilical port site is due to infection, hernia, endometriosis, metastasis, etc. There is no case report due to neuralgic complex regional pain syndrome, and we have dealt a case which is described with relevant literature review and etiopathogenesis.
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Affiliation(s)
- Ragavan Munisamy
- Department of Pediatric Surgery, Narayana Medical College and Super-Speciality Hospital, Nellore, Andhra Pradesh, India
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16
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Backonja MM, Walk D. QST in peripheral nerve injury pain disorders. Pain 2012; 153:736-737. [PMID: 22386893 DOI: 10.1016/j.pain.2012.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 02/11/2012] [Accepted: 02/11/2012] [Indexed: 10/28/2022]
Affiliation(s)
- Miroslav Misha Backonja
- LifeTree Clinical Research, University of Wisconsin-Madison, USA University of Minnesota, MMC 295, 420 Delaware St S.E., Minneapolis, MN 55455, USA
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Walker S, Drummond PD. Implications of a Local Overproduction of Tumor Necrosis Factor-α in Complex Regional Pain Syndrome. PAIN MEDICINE 2011; 12:1784-807. [DOI: 10.1111/j.1526-4637.2011.01273.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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