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Paredes Sanchez J, Titmus M, Lawson-Smith H, Di Pietro F. Tactile acuity improves during acute experimental pain of the limb. Pain Rep 2023; 8:e1091. [PMID: 38225958 PMCID: PMC10789456 DOI: 10.1097/pr9.0000000000001091] [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: 10/12/2022] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 01/17/2024] Open
Abstract
Introduction Chronic pain is associated with poor tactile acuity, commonly measured with the 2-point discrimination (TPD) test. Although poor tactile acuity across chronic pain conditions is well established, less is known in acute pain. Objective Recent conflicting findings in experimentally induced neck and back pain led us to conduct a TPD investigation in experimentally induced limb pain. We hypothesised altered TPD during experimental upper limb pain, but we did not speculate on the direction of the change. Methods Thirty healthy subjects immersed their dominant hand in a circulating cold-water bath at 7°C (cold pressor test [CPT]). Two-point discrimination was measured at baseline (pre-CPT), during pain (during-CPT), and after withdrawal from the water (post-CPT) in 3 different sites: (1) the dominant forearm, (2) dominant arm and (3) contralateral forearm. Results Repeated-measures analysis of variance revealed a significant main effect of time (F(2,56) = 4.45, P = 0.02, η p 2 = 0.14) on TPD; in all 3 sites, TPD values decreased (ie, tactile acuity improved) during pain. Interestingly, the contralateral forearm followed a similar pattern to the dominant (ie, painful) forearm, and furthermore was the only site that exhibited any correlation with pain, albeit in an intriguing direction (r = 0.57, P = 0.001), ie, the greater the pain the worse the tactile acuity. Conclusion The improvements in tactile acuity during experimentally induced limb pain may reflect a protective response. The changes in the corresponding site in the contralateral limb may reflect a protective spinal cross talk. Such a response, together with the interesting relationship between tactile acuity and pain, warrant further inquiry.
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Affiliation(s)
| | - Morgan Titmus
- Curtin Medical School, Curtin University, Western Australia, Australia
| | | | - Flavia Di Pietro
- Curtin Medical School, Curtin University, Western Australia, Australia
- Curtin Health and Innovation Research Institute (CHIRI), Curtin University, Western Australia, Australia
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2
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Damercheli S, Buist M, Ortiz-Catalan M. Mindful SensoriMotor Therapy combined with brain modulation for the treatment of pain in individuals with disarticulation or nerve injuries: a single-arm clinical trial. BMJ Open 2023; 13:e059348. [PMID: 36627156 PMCID: PMC9835879 DOI: 10.1136/bmjopen-2021-059348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Neuropathic pain is a complex and demanding medical condition that is often difficult to treat. Regardless of the cause, the impairment, lesion or damage to the nervous system can lead to neuropathic pain, such as phantom limb pain (PLP). No treatment has been found widely effective for PLP, but plasticity-guided therapies have shown the least severe side effects in comparison to pharmacological or surgical interventions. Phantom motor execution (PME) is a plasticity-guided intervention that has shown promising results in alleviating PLP. The potential mechanism underlying the effectiveness of PME can be explained by the Stochastic Entanglement hypothesis for neurogenesis of neuropathic pain resulting from sensorimotor impairment. We have built on this hypothesis to investigate the efficacy of enhancing PME interventions by using phantom motor imagery to facilitate execution and with the addition of sensory training. We refer to this new treatment concept as Mindful SensoriMotor Therapy (MiSMT). In this study, we further complement MiSMT with non-invasive brain modulation, specifically transcranial direct current stimulation (tDCS), for the treatment of neuropathic pain in patients with disarticulation or peripheral nerve injury. METHODS AND ANALYSIS This single-arm clinical trial investigates the efficacy of MiSMT and tDCS as a treatment of neuropathic pain resulting from highly impaired extremity or peripheral nerve injury in eight participants. The study consists of 12 sessions of MiSMT with anodal tDCS in the motor cortex, pretreatment and post-treatment assessments, and follow-up sessions (up to 6 months). The primary outcome is the change in pain intensity as measured by the Pain Rating Index between the first and last treatment sessions. ETHICS AND DISSEMINATION The study is performed under the approval of the governing ethical committee in Sweden (approval number 2020-07157) and in accordance with the Declaration of Helsinki. TRIAL REGISTRATION NUMBER NCT04897425.
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Affiliation(s)
- Shahrzad Damercheli
- Center for Bionics and Pain Research, Mölndal, Sweden
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Mirka Buist
- Center for Bionics and Pain Research, Mölndal, Sweden
- Department of Physiology, Institute of Physiology and Neuroscience, Sahlgrenska Academy, Gothenburg, Sweden
| | - Max Ortiz-Catalan
- Center for Bionics and Pain Research, Mölndal, Sweden
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
- Operational Area 3, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Roma PG, Schneiderman JS, Schorn JM, Whiting SE, Landon LB, Williams TJ. Assessment of Spaceflight Medical Conditions' and Treatments' Potential Impacts on Behavioral Health and Performance. LIFE SCIENCES IN SPACE RESEARCH 2021; 30:72-81. [PMID: 34281667 DOI: 10.1016/j.lssr.2021.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 06/13/2023]
Abstract
Long-duration space exploration missions will pose significant risks to the physical and behavioral health and performance of the crew. We documented the presence and frequency of (1) behavioral health and performance (BHP)-relevant symptoms for each condition in NASA's Exploration Medical Conditions List (EMCL), (2) the BHP-relevant effects of applicable medical treatments in the current International Space Station (ISS) On-Orbit Medication List, (3) the breadth of potential BHP impacts of spaceflight medical treatments, and (4) the likelihood of adverse BHP effects of treating spaceflight medical conditions. BHP symptoms and effects were categorized by the six neurobehavioral domains of the National Institute of Mental Health's Research Domain Criteria (RDoC) framework. Including the cognitive effects of acute and chronic pain (e.g., attention, memory), 94% of spaceflight medical conditions include symptoms relevant to Cognitive Systems (e.g., attention deficits, confusion, psychosis), 36% include symptoms relevant to Negative Valence Systems (e.g., anxiety), 32% include symptoms relevant to Arousal and Regulatory Systems (e.g., sleep disturbances), 22% include symptoms relevant to Sensorimotor Systems (e.g., dizziness), 19% include symptoms relevant to Positive Valence Systems (e.g., mania), and 11% include symptoms relevant to Social Processes (e.g., social withdrawal). Only 2% of spaceflight medical conditions have no documented BHP symptoms. Of the spaceflight medical treatments, 63% affect Arousal and Regulatory Systems, 60% affect Sensorimotor Systems, 59% affect Cognitive Systems, 53% affect Negative Valence Systems, 38% affect Positive Valence Systems, and 31% affect Social Processes. The breadth of potential BHP impacts was bimodal, in that 27% of spaceflight medical treatments had no documented BHP effects; however, 27% of treatments may produce adverse effects across all six neurobehavioral domains. Historical prevalence data on medical conditions, symptoms, and complaints from 14 years of International Space Station operations coupled with documented BHP effects of recommended treatments indicates the potential for up to 481 adverse BHP effects of spaceflight medical treatments per person-year. Assessing the potential BHP impacts of spaceflight medical conditions and their treatments highlights the interactive nature of operational risks, and can provide an enhanced evidence base to support integrated research and countermeasure development strategies for long-duration exploration missions.
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Affiliation(s)
- Peter G Roma
- Behavioral Health & Performance Laboratory, Biomedical Research and Environmental Sciences Division, Human Health and Performance Directorate, KBR/NASA Johnson Space Center, Houston, TX, USA.
| | - Jason S Schneiderman
- Behavioral Health & Performance Laboratory, Biomedical Research and Environmental Sciences Division, Human Health and Performance Directorate, KBR/NASA Johnson Space Center, Houston, TX, USA; Department of Psychiatry and Behavioral Health, Stony Brook University, Stony Brook, NY, USA
| | - Julia M Schorn
- Behavioral Health & Performance Laboratory, Biomedical Research and Environmental Sciences Division, Human Health and Performance Directorate, KBR/NASA Johnson Space Center, Houston, TX, USA; Department of Psychology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sara E Whiting
- Behavioral Health & Performance Laboratory, Biomedical Research and Environmental Sciences Division, Human Health and Performance Directorate, KBR/NASA Johnson Space Center, Houston, TX, USA
| | - Lauren Blackwell Landon
- Behavioral Health & Performance Laboratory, Biomedical Research and Environmental Sciences Division, Human Health and Performance Directorate, KBR/NASA Johnson Space Center, Houston, TX, USA
| | - Thomas J Williams
- Human Factors and Behavioral Performance Element, Human Research Program, NASA Johnson Space Center, Houston, TX, USA
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Therrien AS, Howard C, Buxbaum LJ. Aberrant activity in an intact residual muscle is associated with phantom limb pain in above-knee amputees. J Neurophysiol 2021; 125:2135-2143. [PMID: 33949884 DOI: 10.1152/jn.00482.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Many individuals who undergo limb amputation experience persistent phantom limb pain (PLP), but the underlying mechanisms of PLP are unknown. The traditional hypothesis was that PLP resulted from maladaptive plasticity in sensorimotor cortex that degrades the neural representation of the missing limb. However, a recent study of individuals with upper limb amputations has shown that PLP is correlated with aberrant electromyographic (EMG) activity in residual muscles, posited to reflect a retargeting of efferent projections from a preserved representation of a missing limb. Here, we assessed EMG activity in a residual thigh muscle (vastus lateralis, VL) in patients with transfemoral amputations during cyclical movements of a phantom foot. VL activity on the amputated side was compared to that recorded on patients' intact side while they moved both the phantom and intact feet synchronously. VL activity in the patient group was also compared to a sample of control participants with no amputation. We show that phantom foot movement is associated with greater VL activity in the amputated leg than that seen in the intact leg as well as that exhibited by controls. The magnitude of residual VL activity was also positively related to ratings of PLP. These results show that phantom limb movement is associated with aberrant activity in a residual muscle after lower-limb amputation and provide evidence of a positive relationship between this activity and phantom limb pain.NEW & NOTEWORTHY This study is the first to assess residual muscle activity during movement of a phantom limb in individuals with lower limb amputations. We find that phantom foot movement is associated with aberrant recruitment of a residual thigh muscle and that this aberrant activity is related to phantom limb pain.
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Affiliation(s)
| | - Cortney Howard
- Duke Center for Cognitive Neuroscience, Duke Universitygrid.26009.3d, Durham, North Carolina
| | - Laurel J Buxbaum
- Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania.,Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
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Chang C, McDonnell P, Gershwin ME. Complex regional pain syndrome - Autoimmune or functional neurologic syndrome. J Transl Autoimmun 2020; 4:100080. [PMID: 33490941 PMCID: PMC7804982 DOI: 10.1016/j.jtauto.2020.100080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 12/23/2022] Open
Abstract
Complex regional pain syndrome (CRPS) purports to explain extremity pain accompanied by a variety of subjective complaints, including sensitivity to touch, fatigue, burning sensations, allodynia and signs consistent with voluntary immobilization, including skin changes, edema and trophic changes. By its own definition, CRPS pain is disproportionate to any inciting event or underlying pathology, which means that the syndrome describes non-anatomic and exaggerated symptoms. Although CRPS was coined in the early 1990s, physicians have described unexplained exaggerated pain for centuries. Before a small group of researchers assigned this historical phenomenon with the name CRPS, other physicians in various subspecialties investigated the existence of a common pathophysiologic mechanism but found none. The literature was searched for evidence of a reproducible pathologic mechanism for CRPS. Although some have suggested that CRPS is an autoimmune disease, there is a paucity of evidence to support this. While cytokines such as IL-1β, IL-6 and TNF-α have been detected during the early phases of CRPS, this cannot lead to the conclusion that CRPS is an autoimmune disease, nor that it is an autoinflammatory disorder. Moreover, intravenous immunoglobulin has showed inconsistent results in the treatment of CRPS. On the other hand, CRPS has been found to meet at least three out of four criteria of malingering, which was previously a DSM-IV diagnosis; and its diagnostic criteria are virtually identical to current DSM-5 Functional Neurological Disorder ("FND"), and proposed ICD-11 classification, which includes FND as a distinct neurological diagnosis apart from any psychiatric condition. Unfortunately, the creation of CPRS is not merely misguided brand marketing. It has serious social and health issues. At least in part, the existence of CRPS has led to the labeling of many patients with a diagnosis that allows the inappropriate use of invasive surgery, addictive opioids, and ketamine. The CRPS hypothesis also ignores the nature and purpose of pain, as a symptom of some organic or psychological process. Physicians have long encountered patients who voice symptoms that cannot be biologically explained. Terminology historically used to describe this phenomenon have been medically unexplained symptoms ("MUS"), hysterical, somatic, non-organic, psychogenic, conversion disorder, or dissociative symptoms. The more recent trend describes disorders where there is a functional, rather than structural cause of the symptoms, as "functional disorders." Physicians report high success treating functional neurological symptoms with reassurance, physiotherapy, and cognitive behavior therapy measured in terms of functional improvement. The CRPS label, however, neither leads to functional improvement in these patients nor resolution of symptoms. Under principles of evidence-based medicine, the CRPS label should be abandoned and the syndrome should simply be considered a subset of FNDs, specifically Functional Pain Disorder; and treated appropriately.
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Affiliation(s)
- Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA.,Division of Immunology, Allergy and Rheumatology, Joe DiMaggio Children's Hospital and Memorial Healthcare System, 1131 N 35th Avenue, Suite 220, Hollywood, FL, 33021, USA
| | | | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA
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Di Pietro F, Lee B, Henderson LA. Altered resting activity patterns and connectivity in individuals with complex regional pain syndrome. Hum Brain Mapp 2020; 41:3781-3793. [PMID: 32510695 PMCID: PMC7416050 DOI: 10.1002/hbm.25087] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 12/20/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic neuropathic pain disorder that typically occurs in the limbs, usually the upper limb. CRPS usually develops from a peripheral event but its maintenance relies on changes within the central nervous system. While functional abnormalities in the thalamus and primary somatosensory cortex (S1) of the brain are some of the most consistently reported brain findings in CRPS, the mechanisms are yet to be explored in full, not least of all how these two regions interact and how they might relate to clinical deficits, such as the commonly reported poor tactile acuity in this condition. This study recruited 15 upper‐limb CRPS subjects and 30 healthy controls and used functional magnetic resonance imaging (fMRI) to investigate infra‐slow oscillations (ISOs) in critical pain regions of the brain in CRPS. As hypothesised, we found CRPS was associated with increases in resting signal intensity ISOs (0.03–0.06 Hz) in the thalamus contralateral to the painful limb in CRPS subjects. Interestingly, there was no such difference between groups in S1, however CRPS subjects displayed stronger thalamo‐S1 functional connectivity than controls, and this was related to pain. As predicted, CRPS subjects displayed poor tactile acuity on the painful limb which, interestingly, was also related to thalamo‐S1 functional connectivity strength. Our findings provide novel evidence of altered patterns of resting activity and connectivity in CRPS which may underlie altered thalamocortical loop dynamics and the constant perception of pain.
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Affiliation(s)
- Flavia Di Pietro
- Department of Anatomy and Histology, Brain and Mind Centre, University of Sydney, Sydney, Australia.,School of Pharmacy and Biomedical Sciences, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Barbara Lee
- Department of Anatomy and Histology, Brain and Mind Centre, University of Sydney, Sydney, Australia
| | - Luke A Henderson
- Department of Anatomy and Histology, Brain and Mind Centre, University of Sydney, Sydney, Australia
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CRPS Is Not Associated with Altered Sensorimotor Cortex GABA or Glutamate. eNeuro 2020; 7:ENEURO.0389-19.2020. [PMID: 31980452 PMCID: PMC7029188 DOI: 10.1523/eneuro.0389-19.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 12/18/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating chronic pain disorder typically in the upper or lower limbs. While CRPS usually develops from a peripheral event, it is likely maintained by CNS changes. Indeed, CRPS is reported to be associated with sensorimotor cortex changes, or functional “reorganization,” as well as deficits such as poor tactile acuity. While the mechanisms underpinning cortical reorganization in CRPS are unknown, some have hypothesized that it involves disinhibition (i.e., a reduction in GABA activity). In this study, we addressed this hypothesis by using edited magnetic resonance spectroscopy to determine sensorimotor GABA and glutamate concentrations in 16 humans with CRPS and 30 matched control subjects and the relationship of these concentrations with tactile acuity. We found that individuals with upper limb CRPS displayed reduced tactile acuity in the painful hand, compared with the nonpainful hand and pain-free control subjects. Despite this acuity deficit, CRPS was not associated with altered GABA or glutamate concentrations within the sensorimotor cortex on either the side that represents the affected or unaffected hand. Furthermore, there was no significant relationship between sensorimotor GABA or glutamate concentrations and tactile acuity in CRPS subjects or control subjects. Although our sample was small, these data suggest that CRPS is not associated with altered total sensorimotor GABA or glutamate concentrations. While these results are at odds with the sensorimotor cortex disinhibition hypothesis, it is possible that GABAergic mechanisms other than total GABA concentration may contribute to such disinhibition.
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Abstract
In this chapter, we provide an overview of neuroimaging studies in chronic pain. We start with an introduction about the phenomenology of pain. In the following section, the application of functional and structural imaging techniques is shown in selected chronic pain syndromes (chronic back pain, fibromyalgia syndrome (FMS), phantom limb pain, and complex regional pain syndrome (CRPS)), and commonalities and peculiarities of imaging correlates across different types of chronic pain are discussed. We conclude this chapter with implications for treatments, with focus on behavioral interventions, sensory and motor trainings, and mirror and motor imagery trainings.
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Affiliation(s)
- Martin Diers
- Clinical and Experimental Behavioral Medicine, Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr University Bochum, Alexandrinenstrasse 1-3, 44791, Bochum, Germany.
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Stanton-Hicks MD. CRPS: what’s in a name? Taxonomy, epidemiology, neurologic, immune and autoimmune considerations. Reg Anesth Pain Med 2019; 44:376-387. [DOI: 10.1136/rapm-2018-100064] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/25/2018] [Accepted: 10/03/2018] [Indexed: 12/26/2022]
Abstract
This account of the condition now termed complex regional pain syndrome (CRPS) spans approximately 462 years since a description embodying similar clinical features was described by Ambroise Paré in 1557. While reviewing its historical origins, the text describes why it became necessary to change the taxonomies of two clinical syndromes with similar pathophysiologies to one which acknowledges this aspect but does not introduce any mechanistic overtones. Discussed at length is the role of the sympathetic component of the autonomic nervous system (ANS) and why its dysfunction has both directly and indirectly influenced our understanding of the inflammatory aspects of CRPS. As the following article will show, our knowledge has expanded in an exponential fashion to include musculoskeletal, immune, autoimmune, central and peripheral nervous system and ANS dysfunction, all of which increase the complexity of its clinical management. A burgeoning literature is beginning to shed light on the mechanistic aspects of these syndromes and the increasing evidence of a genetic influence on such factors as autoimmunity, and its importance is also discussed at length. An important aspect that has been missing from the diagnostic criteria is a measure of disease severity. The recent validation of a CRPS Severity Score is also included.
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Allegri N, Mennuni S, Rulli E, Vanacore N, Corli O, Floriani I, De Simone I, Allegri M, Govoni S, Vecchi T, Sandrini G, Liccione D, Biagioli E. Systematic Review and Meta‐Analysis on Neuropsychological Effects of Long‐Term Use of Opioids in Patients With Chronic Noncancer Pain. Pain Pract 2018; 19:328-343. [DOI: 10.1111/papr.12741] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 09/05/2018] [Accepted: 10/05/2018] [Indexed: 01/03/2023]
Affiliation(s)
- Nicola Allegri
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
| | | | - Eliana Rulli
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Nicola Vanacore
- IRCCS Mondino Foundation Pavia Italy
- National Centre of Epidemiology National Institute of Health Rome Italy
| | - Oscar Corli
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Irene Floriani
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Irene De Simone
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
| | - Massimo Allegri
- Pain Therapy Service Policlinico Monza Monza Italy
- Italian Pain Group Milan Italy
| | - Stefano Govoni
- Department of Drug Sciences University of Pavia Pavia Italy
| | - Tomaso Vecchi
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
- IRCCS Mondino Foundation Pavia Italy
| | - Giorgio Sandrini
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
- IRCCS Mondino Foundation Pavia Italy
| | - Davide Liccione
- Department of Brain and Behavioral Science University of Pavia Pavia Italy
| | - Elena Biagioli
- IRCCS‐Istituto di Ricerche Farmacologiche Mario Negri Milan Italy
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Birklein F, Ibrahim A, Schlereth T, Kingery WS. The Rodent Tibia Fracture Model: A Critical Review and Comparison With the Complex Regional Pain Syndrome Literature. THE JOURNAL OF PAIN 2018; 19:1102.e1-1102.e19. [PMID: 29684510 PMCID: PMC6163066 DOI: 10.1016/j.jpain.2018.03.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/28/2018] [Accepted: 03/30/2018] [Indexed: 12/23/2022]
Abstract
Distal limb fracture is the most common cause of complex regional pain syndrome (CRPS), thus the rodent tibia fracture model (TFM) was developed to study CRPS pathogenesis. This comprehensive review summarizes the published TFM research and compares these experimental results with the CRPS literature. The TFM generated spontaneous and evoked pain behaviors, inflammatory symptoms (edema, warmth), and trophic changes (skin thickening, osteoporosis) resembling symptoms in early CRPS. Neuropeptides, inflammatory cytokines, and nerve growth factor (NGF) have been linked to pain behaviors, inflammation, and trophic changes in the TFM model and proliferating keratinocytes were identified as the primary source of cutaneous cytokines and NGF. Tibia fracture also activated spinal glia and upregulated spinal neuropeptide, cytokine, and NGF expression, and in the brain it changed dendritic architecture. B cell-expressed immunoglobulin M antibodies also contributed to pain behavior, indicating a role for adaptive immunity. These results modeled many findings in early CRPS, but significant differences were also noted. PERSPECTIVE Multiple neuroimmune signaling mechanisms contribute to the pain, inflammation, and trophic changes observed in the injured limb of the rodent TFM. This model replicates many of the symptoms, signs, and pathophysiology of early CRPS, but most post-fracture changes resolve within 5 months and may not contribute to perpetuating chronic CRPS.
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Affiliation(s)
- Frank Birklein
- University Medical Center of the Johannes Gutenberg University Mainz, Department of Neurology, Mainz, Germany
| | - Alaa Ibrahim
- University Medical Center of the Johannes Gutenberg University Mainz, Department of Neurology, Mainz, Germany
| | - Tanja Schlereth
- University Medical Center of the Johannes Gutenberg University Mainz, Department of Neurology, Mainz, Germany
| | - Wade S Kingery
- Palo Alto Veterans Institute for Research, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
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Maldonato NM, Sperandeo R, Caiazzo G, Cioffi V, Cozzolino P, De Santo RM, Fusco ML, Iorio VS, Gigante E, Marone P, Nascivera N, Scognamiglio C. Keep moving without hurting: The interaction between physical activity and pain in determining cognitive function at the population level. PLoS One 2018; 13:e0197745. [PMID: 29856761 PMCID: PMC5983501 DOI: 10.1371/journal.pone.0197745] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/08/2018] [Indexed: 01/12/2023] Open
Abstract
Background A number of studies have evaluated the association between cognitive function, pain, and physical activity. To our knowledge, however, no previous studies have evaluated these factors at the population level. Aims To evaluate the association between cognitive function in the elderly with pain, physical activity, and the interaction between these variables. Estimates are generated for the United States population. Methods We made use of the NHANES database (1999–2002), making adjustments so that our results represent the United States population. Cognitive function was evaluated through the Digit Symbol Substitution Test. Our main predictors were (1) pain, defined as soreness of either the shoulder, neck, lower back and joint, or a severe headache (2) physical activity, measured as the performance while performing tasks at home, physical activity intensity, walking, bicycle riding, and muscle strengthening. Results Most individual pain sites were not significantly associated with cognitive function, while all physical activity factors were associated with an increase in cognitive function. When evaluating the sample subset of those with cognitive scores lower than the median, a combination of more pain and less physical activity was consistently associated with lower cognitive scores when compared to those performing more physical activity with or without pain. When evaluating individuals with cognitive scores above the median, a similar association pattern was perceived. Conclusions Among the population of individuals above the age of 60, higher cognitive levels are associated with more physical activity and less with pain, although both factors might impact cognition. Public policy resources should be commensurate with these findings when targeting cognitive function among the aging population.
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Affiliation(s)
- Nelson Mauro Maldonato
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
- * E-mail:
| | | | - Giovanni Caiazzo
- SiPGI, School of Specialization in Integrated Gestalt Psychotherapy, Torre Annunziata, Naples, Italy
| | - Valeria Cioffi
- SiPGI, School of Specialization in Integrated Gestalt Psychotherapy, Torre Annunziata, Naples, Italy
| | - Pasquale Cozzolino
- SiPGI, School of Specialization in Integrated Gestalt Psychotherapy, Torre Annunziata, Naples, Italy
| | - Rosa Maria De Santo
- SiPGI, School of Specialization in Integrated Gestalt Psychotherapy, Torre Annunziata, Naples, Italy
| | - Maria Luigia Fusco
- SiPGI, School of Specialization in Integrated Gestalt Psychotherapy, Torre Annunziata, Naples, Italy
| | - Vittoria Silviana Iorio
- SiPGI, School of Specialization in Integrated Gestalt Psychotherapy, Torre Annunziata, Naples, Italy
| | - Elena Gigante
- SiPGI, School of Specialization in Integrated Gestalt Psychotherapy, Torre Annunziata, Naples, Italy
| | - Patrizia Marone
- SiPGI, School of Specialization in Integrated Gestalt Psychotherapy, Torre Annunziata, Naples, Italy
| | - Nicole Nascivera
- SiPGI, School of Specialization in Integrated Gestalt Psychotherapy, Torre Annunziata, Naples, Italy
| | - Chiara Scognamiglio
- SiPGI, School of Specialization in Integrated Gestalt Psychotherapy, Torre Annunziata, Naples, Italy
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Falling C, Mani R. Regional asymmetry, obesity and gender determines tactile acuity of the knee regions: A cross-sectional study. ACTA ACUST UNITED AC 2016; 26:150-157. [DOI: 10.1016/j.math.2016.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 05/23/2016] [Accepted: 08/01/2016] [Indexed: 01/11/2023]
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Abstract
Many chronic pain syndromes are characterized by enhanced perception of painful stimuli as well as alterations in cortical processing in sensory and motor regions. In this review article the alterations in muscle pain and neuropathic pain are described. Alterations in patients with fibromyalgia and chronic back pain are described as examples for musculoskeletal pain and also in patients with phantom limb pain after amputation and complex regional pain syndrome as examples for neuropathic pain. In addition to altered pain perception, cumulative evidence on alterations in the processing of reward and the underlying mechanisms in chronic pain has been described. A description is given of what is known on how pain and reward interact and affect each other. The relevance of such interactions for chronic pain is discussed. The implications of these findings for therapeutic approaches are delineated with respect to sensorimotor training and behavioral therapy, focusing on the effectiveness of these approaches, mechanisms and future developments. In particular, we discuss operant behavioral therapy in patients with chronic back pain and fibromyalgia as well as prosthesis training in patients with phantom limb pain and discrimination, mirror and imaginary training in patients with phantom limb pain and complex regional pain syndrome. With respect to the processing of reward, the focus of the discussion is on the role of reward and associated learning in pain therapy.
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Affiliation(s)
- S Becker
- Institut für Neuropsychologie und Klinische Psychologie, Zentralinstitut für Seelische Gesundheit, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - M Diers
- Klinik für Psychosomatische Medizin und Psychotherapie, LWL-Universitätsklinikum, Ruhr-Universität Bochum, Alexandrinenstr. 1-3, 44791, Bochum, Deutschland.
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Abstract
Despite the severe pain and disability associated with complex regional pain syndrome (CRPS), the lack of understanding of the pathophysiological mechanisms supporting this enigmatic condition prevents the rational design of new therapies, a situation that is frustrating to both the physician and the patient. The review highlights some of the mechanisms thought to be involved in the pathophysiology of CRPS in preclinical models and CRPS patients, with the ultimate goal that understanding these mechanisms will lead to the design of efficacious, mechanism-based treatments available to the clinic.
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Affiliation(s)
- Maral Tajerian
- Veterans Affairs Palo Alto Health Care System Palo Alto, CA, USA,Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA
| | - J David Clark
- Veterans Affairs Palo Alto Health Care System Palo Alto, CA, USA,Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA,Corresponding author: J David Clark, MD, PhD., Anesthesia Service, Veterans Affairs Palo Alto Health Care, System, 3801 Miranda Ave., Palo Alto, CA 94304, USA, Tel: 650-493-5000 ext. 60479, Fax: 650-852-3423,
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David M, Dinse HR, Mainka T, Tegenthoff M, Maier C. High-Frequency Repetitive Sensory Stimulation as Intervention to Improve Sensory Loss in Patients with Complex Regional Pain Syndrome I. Front Neurol 2015; 6:242. [PMID: 26635719 PMCID: PMC4648023 DOI: 10.3389/fneur.2015.00242] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 10/30/2015] [Indexed: 11/13/2022] Open
Abstract
Achieving perceptual gains in healthy individuals or facilitating rehabilitation in patients is generally considered to require intense training to engage neuronal plasticity mechanisms. Recent work, however, suggested that beneficial outcome similar to training can be effectively acquired by a complementary approach in which the learning occurs in response to mere exposure to repetitive sensory stimulation (rSS). For example, high-frequency repetitive sensory stimulation (HF-rSS) enhances tactile performance and induces cortical reorganization in healthy subjects and patients after stroke. Patients with complex regional pain syndrome (CRPS) show impaired tactile performance associated with shrinkage of cortical maps. We here investigated the feasibility and efficacy of HF-rSS, and low-frequency rSS (LF-rSS) to enhance tactile performance and reduce pain intensity in 20 patients with CRPS type I. Intermittent high- or low-frequency electrical stimuli were applied for 45 min/day to all fingertips of the affected hand for 5 days. Main outcome measures were spatial two-point-discrimination thresholds and mechanical detection thresholds measured on the tip of the index finger bilaterally. Secondary endpoint was current pain intensity. All measures were assessed before and on day 5 after the last stimulation session. HF-rSS applied in 16 patients improved tactile discrimination on the affected hand significantly without changes contralaterally. Current pain intensity remained unchanged on average, but decreased in four patients by ≥30%. This limited pain relief might be due to the short stimulation period of 5 days only. In contrast, after LF-rSS, tactile discrimination was impaired in all four patients, while detection thresholds and pain were not affected. Our data suggest that HF-rSS could be used as a novel approach in CRPS treatment to improve sensory loss. Longer treatment periods might be required to induce consistent pain relief.
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Affiliation(s)
- Marianne David
- Department of Pain Medicine, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-University Bochum , Bochum , Germany
| | - Hubert R Dinse
- Neural Plasticity Laboratory, Institute for Neuroinformatics, Ruhr-University Bochum , Bochum , Germany ; Department of Neurology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-University Bochum , Bochum , Germany
| | - Tina Mainka
- Department of Pain Medicine, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-University Bochum , Bochum , Germany ; Department of Neurology, University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Martin Tegenthoff
- Department of Neurology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-University Bochum , Bochum , Germany
| | - Christoph Maier
- Department of Pain Medicine, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Ruhr-University Bochum , Bochum , Germany
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Associative fear learning and perceptual discrimination: A perceptual pathway in the development of chronic pain. Neurosci Biobehav Rev 2015; 51:118-25. [DOI: 10.1016/j.neubiorev.2015.01.009] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 12/11/2014] [Accepted: 01/09/2015] [Indexed: 12/30/2022]
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Brain neuroplastic changes accompany anxiety and memory deficits in a model of complex regional pain syndrome. Anesthesiology 2014; 121:852-65. [PMID: 25093591 DOI: 10.1097/aln.0000000000000403] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a painful condition with approximately 50,000 annual new cases in the United States. It is a major cause of work-related disability, chronic pain after limb fractures, and persistent pain after extremity surgery. Additionally, CRPS patients often experience cognitive changes, anxiety, and depression. The supraspinal mechanisms linked to these CRPS-related comorbidities remain poorly understood. METHODS The authors used a previously characterized mouse model of tibia fracture/cast immobilization showing the principal stigmata of CRPS (n = 8 to 20 per group) observed in humans. The central hypothesis was that fracture/cast mice manifest changes in measures of thigmotaxis (indicative of anxiety) and working memory reflected in neuroplastic changes in amygdala, perirhinal cortex, and hippocampus. RESULTS The authors demonstrate that nociceptive sensitization in these mice is accompanied by altered thigmotactic behaviors in the zero maze but not open field assay, and working memory dysfunction in novel object recognition and social memory but not in novel location recognition. Furthermore, the authors found evidence of structural changes and synaptic plasticity including changes in dendritic architecture and decreased levels of synaptophysin and brain-derived neurotrophic factor in specific brain regions. CONCLUSIONS The study findings provide novel observations regarding behavioral changes and brain plasticity in a mouse model of CRPS. In addition to elucidating some of the supraspinal correlates of the syndrome, this work supports the potential use of therapeutic interventions that not only directly target sensory input and other peripheral mechanisms, but also attempt to ameliorate the broader pain experience by modifying its associated cognitive and emotional comorbidities.
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Catley MJ, O'Connell NE, Berryman C, Ayhan FF, Moseley GL. Is Tactile Acuity Altered in People With Chronic Pain? A Systematic Review and Meta-analysis. THE JOURNAL OF PAIN 2014; 15:985-1000. [DOI: 10.1016/j.jpain.2014.06.009] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 06/10/2014] [Accepted: 06/17/2014] [Indexed: 01/28/2023]
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Becerra L, Sava S, Simons LE, Drosos AM, Sethna N, Berde C, Lebel AA, Borsook D. Intrinsic brain networks normalize with treatment in pediatric complex regional pain syndrome. Neuroimage Clin 2014; 6:347-69. [PMID: 25379449 PMCID: PMC4218937 DOI: 10.1016/j.nicl.2014.07.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/17/2014] [Accepted: 07/29/2014] [Indexed: 12/22/2022]
Abstract
Pediatric complex regional pain syndrome (P-CRPS) offers a unique model of chronic neuropathic pain as it either resolves spontaneously or through therapeutic interventions in most patients. Here we evaluated brain changes in well-characterized children and adolescents with P-CRPS by measuring resting state networks before and following a brief (median = 3 weeks) but intensive physical and psychological treatment program, and compared them to matched healthy controls. Differences in intrinsic brain networks were observed in P-CRPS compared to controls before treatment (disease state) with the most prominent differences in the fronto-parietal, salience, default mode, central executive, and sensorimotor networks. Following treatment, behavioral measures demonstrated a reduction of symptoms and improvement of physical state (pain levels and motor functioning). Correlation of network connectivities with spontaneous pain measures pre- and post-treatment indicated concomitant reductions in connectivity in salience, central executive, default mode and sensorimotor networks (treatment effects). These results suggest a rapid alteration in global brain networks with treatment and provide a venue to assess brain changes in CRPS pre- and post-treatment, and to evaluate therapeutic effects.
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Affiliation(s)
- Lino Becerra
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA ; Department of Anesthesiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA ; Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Simona Sava
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Laura E Simons
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA ; Department of Anesthesiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Athena M Drosos
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Navil Sethna
- Department of Anesthesiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Charles Berde
- Department of Anesthesiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - Alyssa A Lebel
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA ; Department of Anesthesiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
| | - David Borsook
- Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA ; Department of Anesthesiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA 02115, USA
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The relationship among psychological factors, neglect-like symptoms and postoperative pain after total knee arthroplasty. Pain Res Manag 2014; 19:251-6. [PMID: 25101335 PMCID: PMC4197752 DOI: 10.1155/2014/471529] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neglect-like symptoms have been defined as a loss of perception of a limb, with pain and excessive effort necessary to move the limb. This phenomenon has been studied in patients with complex regional pain syndrome, but has not been assessed in patients who have undergone orthopedic procedures such as total knee arthroplasty. The authors of this study assessed neglect-like symptoms in a group of 90 patients three and six weeks after total knee arthroplasty. BACKGROUND: Persistent postoperative pain has a significant relationship with patient health and satisfaction. OBJECTIVES: To investigate the prevalence and association of neglect-like symptoms (NLS) and other psychological factors on postoperative pain in patients following total knee arthroplasty (TKA). NLS are defined as the loss of perception of the limb with pain and excessive effort required to move the limb. The authors hypothesized that NLS were an important contributor to postoperative pain. METHODS: The factors influencing pain were investigated using a longitudinal study with assessments at three and six weeks postsurgery. The relationships among demographic factors (age, body weight, body mass index), psychological factors (State-Trait Anxiety Inventory and Pain Catastrophizing Scale [PCS]) and NLS with postoperative pain were investigated in 90 patients after TKA. The associations among motor functions (muscle strength of knee extension, range of motion), sensory functions (joint position sense and two-point discrimination in the thigh) and NLS were also investigated. RESULTS: At three and six weeks after surgery, 36% and 19% of patients, respectively, experienced NLS. In hierarchical multiple regression analysis, NLS and PCS scores were significantly associated with postoperative pain, while joint position sense and range of motion were significantly associated with NLS. CONCLUSIONS: These results suggest that facilitation of sensory integration is important in rehabilitation after TKA because NLS appears to result from impaired sensory integration. The association of PCS scores with postoperative pain and NLS suggests the need to provide appropriate postoperative education to reduce persistent negative thoughts regarding future pain.
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Di Pietro F, McAuley JH, Parkitny L, Lotze M, Wand BM, Moseley GL, Stanton TR. Primary Motor Cortex Function in Complex Regional Pain Syndrome: A Systematic Review and Meta-Analysis. THE JOURNAL OF PAIN 2013; 14:1270-88. [DOI: 10.1016/j.jpain.2013.07.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 06/25/2013] [Accepted: 07/02/2013] [Indexed: 02/09/2023]
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Erpelding N, Sava S, Simons LE, Lebel A, Serrano P, Becerra L, Borsook D. Habenula functional resting-state connectivity in pediatric CRPS. J Neurophysiol 2013; 111:239-47. [PMID: 24155006 DOI: 10.1152/jn.00405.2013] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The habenula (Hb) is a small brain structure located in the posterior end of the medial dorsal thalamus and through medial (MHb) and lateral (LHb) Hb connections, it acts as a conduit of information between forebrain and brainstem structures. The role of the Hb in pain processing is well documented in animals and recently also in acute experimental pain in humans. However, its function remains unknown in chronic pain disorders. Here, we investigated Hb resting-state functional connectivity (rsFC) in patients with complex regional pain syndrome (CRPS) compared with healthy controls. Twelve pediatric patients with unilateral lower-extremity CRPS (9 females; 10-17 yr) and 12 age- and sex-matched healthy controls provided informed consent to participate in the study. In healthy controls, Hb functional connections largely overlapped with previously described anatomical connections in cortical, subcortical, and brainstem structures. Compared with controls, patients exhibited an overall Hb rsFC reduction with the rest of the brain and, specifically, with the anterior midcingulate cortex, dorsolateral prefrontal cortex, supplementary motor cortex, primary motor cortex, and premotor cortex. Our results suggest that Hb rsFC parallels anatomical Hb connections in the healthy state and that overall Hb rsFC is reduced in patients, particularly connections with forebrain areas. Patients' decreased Hb rsFC to brain regions implicated in motor, affective, cognitive, and pain inhibitory/modulatory processes may contribute to their symptomatology.
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van Rooijen DE, Marinus J, Schouten AC, Noldus LP, van Hilten JJ. Muscle Hyperalgesia Correlates With Motor Function in Complex Regional Pain Syndrome Type 1. THE JOURNAL OF PAIN 2013; 14:446-54. [DOI: 10.1016/j.jpain.2012.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 11/20/2012] [Accepted: 12/10/2012] [Indexed: 01/21/2023]
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Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a painful disorder without a known unifying mechanism. There are little data on which to base evaluation and treatment decisions, and what data are available come from studies involving adults; however, even that literature is relatively sparse. Developing robust research for CRPS in children is essential for the progress toward optimal treatment. OBJECTIVES To determine potential avenues of research in pediatric CRPS based on a review of the literature. Areas of concern include diagnostic criteria, peripheral mechanisms, central nervous system mechanisms, the role of the autonomic nervous system, possible risk factors, options for prevention and potential avenues of treatment. METHODS A literature review was performed and the results applied to form the hypotheses posited in the form of research questions. RESULTS AND CONCLUSIONS CRPS is a complicated entity that is more than a painful sensory condition. There is evidence for peripheral inflammatory and neurological changes, and reorganization in both sensory and motor cortexes. In addition, a significant motor component is frequently observed and there appear to be tangible risk factors. Many of these pieces of evidence suggest options for prevention, treatment and monitoring progress and outcome. Most of the data are derived from adult studies and need to be replicated in children. Furthermore, there may be factors unique to pediatrics due to developmental changes in neuroplasticity as well as somatic, endocrinological and emotional growth. Some of these developmental factors may shed light on the adult condition.
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KURITA GP, DE MATTOS PIMENTA CA, BRAGA PE, FRICH L, JØRGENSEN MM, NIELSEN PR, HØJSTED J, SJØGREN P. Cognitive function in patients with chronic pain treated with opioids: characteristics and associated factors. Acta Anaesthesiol Scand 2012; 56:1257-66. [PMID: 22946710 DOI: 10.1111/j.1399-6576.2012.02760.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2012] [Indexed: 01/14/2023]
Abstract
BACKGROUND The paucity of studies regarding cognitive function in patients with chronic pain, and growing evidence regarding the cognitive effects of pain and opioids on cognitive function prompted us to assess cognition via neuropsychological measurement in patients with chronic non-cancer pain treated with opioids. METHODS In this cross-sectional study, 49 patients were assessed by Continuous Reaction Time, Finger Tapping, Digit Span, Trail Making Test-B and Mini-mental State Examination tests. Linear regressions were applied. RESULTS Patients scored poorly in the Trail Making Test-B (mean = 107.6 s, SD = 61.0, cut-off = 91 s); and adequately on all other tests. Several associations among independent variables and cognitive tests were observed. In the multiple regression analyses, the variables associated with statistically significant poor cognitive performance were female sex, higher age, lower annual income, lower schooling, anxiety, depression, tiredness, lower opioid dose, and more than 5 h of sleep the night before assessment (P < 0.05). CONCLUSIONS Patients with chronic pain may have cognitive dysfunction related to some reversible factors, which can be optimized by therapeutic interventions.
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Affiliation(s)
| | | | - P. E. BRAGA
- School of Nursing; University of Sao Paulo; Sao Paulo; Brazil
| | - L. FRICH
- Palliative Care Unit; Bispebjerg Hospital; Copenhagen; Denmark
| | - M. M. JØRGENSEN
- Multidisciplinary Pain Centre; Rigshospitalet; Copenhagen; Denmark
| | - P. R. NIELSEN
- Multidisciplinary Pain Centre; Rigshospitalet; Copenhagen; Denmark
| | - J. HØJSTED
- Multidisciplinary Pain Centre; Rigshospitalet; Copenhagen; Denmark
| | - P. SJØGREN
- Section of Palliative Medicine; Rigshospitalet; Copenhagen; Denmark
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Reiswich J, Krumova EK, David M, Stude P, Tegenthoff M, Maier C. Intact 2D-form recognition despite impaired tactile spatial acuity in complex regional pain syndrome type I. Pain 2012; 153:1484-1494. [DOI: 10.1016/j.pain.2012.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 03/27/2012] [Accepted: 04/05/2012] [Indexed: 12/01/2022]
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Lewis J, Schweinhardt P. Perceptions of the painful body: The relationship between body perception disturbance, pain and tactile discrimination in complex regional pain syndrome. Eur J Pain 2012; 16:1320-30. [DOI: 10.1002/j.1532-2149.2012.00120.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2012] [Indexed: 01/22/2023]
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Abstract
OBJECTIVES A mixture of sensory loss and gain is a hallmark of neuropathic pain. But hypesthesia and hyperalgesia also occur with experimentally induced acute pain. Here, we assessed sensory profiles in chronic non-neuropathic pain (osteoarthritis, OA) using the quantitative sensory testing (QST) protocol of the German Research Network on Neuropathic Pain (DFNS). METHODS Twenty individuals with OA [mean pain intensity on the numerical rating scale (NRS, 0-10): 5.6±1.5] were tested on the painful and contralateral hand and compared with 20 healthy volunteers matched for age, sex, and handedness. RESULTS In the OA group, analysis of variance revealed increased detection thresholds to tactile stimuli bilaterally and to thermal stimuli restricted to the more painful hand (all P<0.05). Pin-prick hypoalgesia was present restricted to the patients' more affected hand. Neither hyperalgesia nor allodynia was found. QST parameters were correlated with average pain intensity (r between 0.48 and 0.51). CONCLUSIONS These results suggest that chronic non-neuropathic pain may induce slight sensory impairment for large fiber function (bilateral) and small fiber function (ipsilateral). However, all changes are within the normal range, in contrast to patients with neuropathy. Inhibition of central pathways by nociceptive input and altered sensory processing due to disuse of the hand are possible mechanisms. These functional sensory alterations do not interfere with the diagnosis of neuropathy.
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Peltz E, Seifert F, Lanz S, Müller R, Maihöfner C. Impaired hand size estimation in CRPS. THE JOURNAL OF PAIN 2011; 12:1095-101. [PMID: 21741321 DOI: 10.1016/j.jpain.2011.05.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 04/21/2011] [Accepted: 05/12/2011] [Indexed: 02/07/2023]
Abstract
UNLABELLED A triad of clinical symptoms, ie, autonomic, motor and sensory dysfunctions, characterizes complex regional pain syndromes (CRPS). Sensory dysfunction comprises sensory loss or spontaneous and stimulus-evoked pain. Furthermore, a disturbance in the body schema may occur. In the present study, patients with CRPS of the upper extremity and healthy controls estimated their hand sizes on the basis of expanded or compressed schematic drawings of hands. In patients with CRPS we found an impairment in accurate hand size estimation; patients estimated their own CRPS-affected hand to be larger than it actually was when measured objectively. Moreover, overestimation correlated significantly with disease duration, neglect score, and increase of two-point-discrimination-thresholds (TPDT) compared to the unaffected hand and to control subjects' estimations. In line with previous functional imaging studies in CRPS patients demonstrating changes in central somatotopic maps, we suggest an involvement of the central nervous system in this disruption of the body schema. Potential cortical areas may be the primary somatosensory and posterior parietal cortices, which have been proposed to play a critical role in integrating visuospatial information. PERSPECTIVE CRPS patients perceive their affected hand to be bigger than it is. The magnitude of this overestimation correlates with disease duration, decreased tactile thresholds, and neglect-score. Suggesting a disrupted body schema as the source of this impairment, our findings corroborate the current assumption of a CNS involvement in CRPS.
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Affiliation(s)
- Elena Peltz
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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Abstract
We sought to elucidate the existence of neuropsychological subtypes in Complex Regional Pain Syndrome (CRPS). One hundred thirty seven patients with CRPS were administered tests that assess executive control, naming/lexical retrieval, and declarative memory. A 2-step cluster analysis that does not require any a priori specification regarding the number of clusters, classified patients into three groups. Group 1 obtained scores that were in the average range on all tests (n = 48; normal CRSP group). Group 2 (n = 58; dysexecutive CRSP group) presented with mild impairment or statistically low average test performance on working memory/verbal fluency tests. Group 3 (n = 31; global CRSP group) produced scores in the statistically low average/borderline range on all tests with particularly reduced scores on naming/declarative memory tests. Between-group analyses found that the CRPS group 1 obtained higher scores than CRPS groups 2 and 3 on all tests. However, groups 2 and 3 were equally impaired on executive tests. CRPS group 3 was impaired on tests of naming/memory tests compared to the other groups. Significant neuropsychological deficits are present in 65% of patients, with many patients presenting with elements of a dysexecutive syndrome and some patients presenting with global cognitive impairment.
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Maihöfner C, Seifert F, Markovic K. Complex regional pain syndromes: new pathophysiological concepts and therapies. Eur J Neurol 2010; 17:649-60. [PMID: 20180838 DOI: 10.1111/j.1468-1331.2010.02947.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Complex regional pain syndrome (CRPS), formerly known as Sudeck's dystrophy and causalgia, is a disabling and distressing pain syndrome. We here provide a review based on the current literature concerning the epidemiology, etiology, pathophysiology, diagnosis, and therapy of CRPS. CRPS may develop following fractures, limb trauma or lesions of the peripheral or CNS. The clinical picture comprises a characteristic clinical triad of symptoms including autonomic (disturbances of skin temperature, color, presence of sweating abnormalities), sensory (pain and hyperalgesia), and motor (paresis, tremor, dystonia) disturbances. Diagnosis is mainly based on clinical signs. Several pathophysiological concepts have been proposed to explain the complex symptoms of CRPS: (i) facilitated neurogenic inflammation; (ii) pathological sympatho-afferent coupling; and (iii) neuroplastic changes within the CNS. Furthermore, there is accumulating evidence that genetic factors may predispose for CRPS. Therapy is based on a multidisciplinary approach. Non-pharmacological approaches include physiotherapy and occupational therapy. Pharmacotherapy is based on individual symptoms and includes steroids, free radical scavengers, treatment of neuropathic pain, and finally agents interfering with bone metabolism (calcitonin, biphosphonates). Invasive therapeutic concepts include implantation of spinal cord stimulators. This review covers new aspects of pathophysiology and therapy of CRPS.
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Affiliation(s)
- C Maihöfner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage, Erlangen, Germany.
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Affiliation(s)
- Marissa de Mos
- Erasmus University Medical Center, Pharmaco-epidemiology Unit, Departments of Medical Informatics and Epidemiology & Biostatistics, Rotterdam, The Netherlands.
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Geha PY, Baliki MN, Harden RN, Bauer WR, Parrish TB, Apkarian AV. The brain in chronic CRPS pain: abnormal gray-white matter interactions in emotional and autonomic regions. Neuron 2009; 60:570-81. [PMID: 19038215 DOI: 10.1016/j.neuron.2008.08.022] [Citation(s) in RCA: 358] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2008] [Revised: 08/12/2008] [Accepted: 08/15/2008] [Indexed: 12/11/2022]
Abstract
Chronic complex regional pain syndrome (CRPS) is a debilitating pain condition accompanied by autonomic abnormalities. We investigated gray matter morphometry and white matter anisotropy in CRPS patients and matched controls. Patients exhibited a disrupted relationship between white matter anisotropy and whole-brain gray matter volume; gray matter atrophy in a single cluster encompassing right insula, right ventromedial prefrontal cortex (VMPFC), and right nucleus accumbens; and a decrease in fractional anisotropy in the left cingulum-callosal bundle. Reorganization of white matter connectivity in these regions was characterized by branching pattern alterations, as well as increased (VMPFC to insula) and decreased (VMPFC to basal ganglion) connectivity. While regional atrophy differentially related to pain intensity and duration, the strength of connectivity between specific atrophied regions related to anxiety. These abnormalities encompass emotional, autonomic, and pain perception regions, implying that they likely play a critical role in the global clinical picture of CRPS.
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Affiliation(s)
- Paul Y Geha
- Department of Physiology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
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Cortical changes in complex regional pain syndrome (CRPS). Eur J Pain 2008; 13:902-7. [PMID: 19101181 DOI: 10.1016/j.ejpain.2008.11.010] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 10/31/2008] [Accepted: 11/11/2008] [Indexed: 11/21/2022]
Abstract
Recent research suggests that changes in cortical structures can contribute to the pathophysiology of Complex Regional Pain Syndrome (CRPS). This review provides an overview of studies showing cortical involvement in CRPS, including mislocalizations of tactile stimuli, changes in size and organization of the somatosensory map, changes in motor cortex representation and body perception disturbances. In addition, we review experimental treatment approaches, such as mirror therapy and motor imagery programs, aimed at restoring the integrity of neural processing in the sensory-motor cortex in individuals with CRPS. The intervention effects are promising and can be theoretically motivated on the basis of established principles of neural organization, although important questions concerning the precise neural mechanisms of action remain unanswered.
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Lebel A, Becerra L, Wallin D, Moulton EA, Morris S, Pendse G, Jasciewicz J, Stein M, Aiello-Lammens M, Grant E, Berde C, Borsook D. fMRI reveals distinct CNS processing during symptomatic and recovered complex regional pain syndrome in children. Brain 2008; 131:1854-79. [DOI: 10.1093/brain/awn123] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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