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Maria Frare J, Rodrigues P, Andrighetto Ruviaro N, Trevisan G. Chronic post-ischemic pain (CPIP) model of complex regional pain syndrome (CRPS-I): Role of oxidative stress and inflammation. Biochem Pharmacol 2024:116506. [PMID: 39182734 DOI: 10.1016/j.bcp.2024.116506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 08/17/2024] [Accepted: 08/22/2024] [Indexed: 08/27/2024]
Abstract
Complex regional pain syndrome (CRPS) presents as a persistent and distressing pain condition often stemming from limb trauma or ischemia, manifesting as either CRPS-I (without initial nerve injury) or CRPS-II (accompanied by nerve injury). Despite its prevalence and significant impact on functionality and emotional well-being, standard treatments for CRPS remain elusive. The multifaceted nature of CRPS complicates the identification of its underlying mechanisms. In efforts to elucidate these mechanisms, researchers have turned to animal models such as chronic post-ischemic pain (CPIP), which mirrors the symptoms of CRPS-I. Various mechanisms have been proposed to underlie the acute and chronic pain experienced in CRPS-I, including oxidative stress and inflammation. Traditional treatment approaches often involve antidepressants, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids. However, these methods frequently fall short of providing adequate relief. Accordingly, there is a growing interest in exploring alternative treatments, such as antioxidant supplementation, anti-inflammatory agents, and non-pharmacological interventions. Future research directions should focus on optimizing treatment strategies and addressing remaining gaps in knowledge to improve patient outcomes. This review aims to delve into the pathophysiological mechanisms implicated in the CPIP model, specifically focusing on oxidative stress and inflammation, with the ultimate goal of proposing innovative therapeutic strategies for alleviating the symptoms of CRPS-I.
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Affiliation(s)
- Julia Maria Frare
- Graduated Program in Biological Sciences: Toxicological Biochemistry, Federal University of Santa Maria (UFSM), 97105-900, Santa Maria, RS, Brazil
| | - Patrícia Rodrigues
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil
| | - Náthaly Andrighetto Ruviaro
- Graduated Program in Biological Sciences: Toxicological Biochemistry, Federal University of Santa Maria (UFSM), 97105-900, Santa Maria, RS, Brazil
| | - Gabriela Trevisan
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil; Graduated Program in Biological Sciences: Toxicological Biochemistry, Federal University of Santa Maria (UFSM), 97105-900, Santa Maria, RS, Brazil.
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Zhu H, Wen B, Xu J, Zhang Y, Xu L, Huang Y. Efficacy and Safety of Pharmacological Treatment in Patients with Complex Regional Pain Syndrome: A Systematic Review and Meta-Analysis. Pharmaceuticals (Basel) 2024; 17:811. [PMID: 38931478 PMCID: PMC11206895 DOI: 10.3390/ph17060811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/24/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Complex regional pain syndrome (CRPS) is a disabling condition that usually affects the extremities after trauma or surgery. At present, there is no FDA-approved pharmacological treatment for patients with CRPS. We performed this systematic review and meta-analysis to evaluate the efficacy and safety of pharmacological therapies and determine the best strategy for CRPS. We searched the databases, including PubMed, Embase, Cochrane, Web of Science, Scopus, and ClinicalTrials.gov, for published eligible randomized controlled trials (RCTs) comparing pharmacological treatment with placebo in CRPS patients. Target patients were diagnosed with CRPS according to Budapest Criteria in 2012 or the 1994 consensus-based IASP CRPS criteria. Finally, 23 RCTs comprising 1029 patients were included. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty (confidence in evidence and quality of evidence). Direct meta-analysis showed that using bisphosphonates (BPs) (mean difference [MD] -2.21, 95% CI -4.36--0.06, p = 0.04, moderate certainty) or ketamine (mean difference [MD] -0.78, 95% CI -1.51--0.05, p = 0.04, low certainty) could provide long-term (beyond one month) pain relief. However, there was no statistically significant difference in the efficacy of short-term pain relief. Ketamine (rank p = 0.55) and BPs (rank p = 0.61) appeared to be the best strategies for CRPS pain relief. Additionally, BPs (risk ratio [RR] = 1.86, 95% CI 1.34-2.57, p < 0.01, moderate certainty) and ketamine (risk ratio [RR] = 3.45, 95% CI 1.79-6.65, p < 0.01, moderate certainty) caused more adverse events, which were mild, and no special intervention was required. In summary, among pharmacological interventions, ketamine and bisphosphonate injection seemed to be the best treatment for CRPS without severe adverse events.
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Affiliation(s)
- He Zhu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Bei Wen
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Jijun Xu
- Department of Pain Management, Anesthesiology Institute, Cleveland, OH 44195, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH 44195, USA
- Cleveland Clinic, Case Western Reserve University, Cleveland, OH 44195, USA
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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Shermon S, Fazio KM, Shim R, Abd-Elsayed A, Kim CH. Prescription Trends in Complex Regional Pain Syndrome: A Retrospective Case-Control Study. Brain Sci 2023; 13:1012. [PMID: 37508943 PMCID: PMC10377480 DOI: 10.3390/brainsci13071012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE The objective of this study was to evaluate discrepancies in prescription trends for analgesic medications in complex regional pain syndrome (CRPS) patients based on recommendations in the literature. DESIGN We conducted a retrospective case-control study. SUBJECTS A total of 2510 CRPS patients and 2510 demographic-matched controls participated in this study. METHODS The SlicerDicer feature in Epic was used to find patients diagnosed with CRPS I or II between January 2010 and November 2022. An equal number of age-, gender-, and race-matched controls without a CRPS diagnosis were retracted from Epic. General and CRPS-associated prescription frequencies for the following classes were retrieved for both cases and controls: benzodiazepines, bisphosphonates, calcitonin, capsaicin, neuropathic pain medications, NSAIDs, opioids, and steroids. RESULTS A total of 740 (29%) CRPS patients and 425 (17%) controls were prescribed benzodiazepines (95% CI 0.1-0.15), 154 (6.1%) CRPS patients and 52 (2.1%) controls were prescribed capsaicin (95% CI 0.03-0.05), 1837 (73%) CRPS patients and 927 (37%) controls were prescribed neuropathic pain medications (95% CI 0.05-0.34), 1769 (70%) CRPS patients and 1217 (48%) controls were prescribed opioids (95% CI 0.19-0.25), 1095 (44%) CRPS patients and 1217 (48%) controls were prescribed steroids (95% CI 0.08-0.14), and 1638 (65%) CRPS patients and 1765 (70%) controls were prescribed NSAIDs (95% CI -0.08-0.02), p < 0.001 for all classes. With CRPS-associated prescriptions, (95% CI 0.05-0.16, p < 0.001) more CRPS patients were prescribed opioids (N = 398, 59%) than controls (N = 327, 49%). CONCLUSIONS CRPS is difficult to treat with significant variance in suggested treatment modalities. Based on the results of our study, there is a divergence between some published recommendations and actual practice.
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Affiliation(s)
- Suzanna Shermon
- MetroHealth Medical Center, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA
| | - Kimberly M Fazio
- MetroHealth Medical Center, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA
| | - Richard Shim
- School of Medicine, Case Western Reserve University, Cleveland, OH 44109, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53706, USA
| | - Chong H Kim
- MetroHealth Medical Center, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA
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Ferraro MC, Cashin AG, Wand BM, Smart KM, Berryman C, Marston L, Moseley GL, McAuley JH, O'Connell NE. Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD009416. [PMID: 37306570 PMCID: PMC10259367 DOI: 10.1002/14651858.cd009416.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a chronic pain condition that usually occurs in a limb following trauma or surgery. It is characterised by persisting pain that is disproportionate in magnitude or duration to the typical course of pain after similar injury. There is currently no consensus regarding the optimal management of CRPS, although a broad range of interventions have been described and are commonly used. This is the first update of the original Cochrane review published in Issue 4, 2013. OBJECTIVES To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the efficacy, effectiveness, and safety of any intervention used to reduce pain, disability, or both, in adults with CRPS. METHODS We identified Cochrane reviews and non-Cochrane reviews through a systematic search of Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, CINAHL, PEDro, LILACS and Epistemonikos from inception to October 2022, with no language restrictions. We included systematic reviews of randomised controlled trials that included adults (≥18 years) diagnosed with CRPS, using any diagnostic criteria. Two overview authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools respectively. We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes quality of life, emotional well-being, and participants' ratings of satisfaction or improvement with treatment. MAIN RESULTS: We included six Cochrane and 13 non-Cochrane systematic reviews in the previous version of this overview and five Cochrane and 12 non-Cochrane reviews in the current version. Using the AMSTAR 2 tool, we judged Cochrane reviews to have higher methodological quality than non-Cochrane reviews. The studies in the included reviews were typically small and mostly at high risk of bias or of low methodological quality. We found no high-certainty evidence for any comparison. There was low-certainty evidence that bisphosphonates may reduce pain intensity post-intervention (standardised mean difference (SMD) -2.6, 95% confidence interval (CI) -1.8 to -3.4, P = 0.001; I2 = 81%; 4 trials, n = 181) and moderate-certainty evidence that they are probably associated with increased adverse events of any nature (risk ratio (RR) 2.10, 95% CI 1.27 to 3.47; number needed to treat for an additional harmful outcome (NNTH) 4.6, 95% CI 2.4 to 168.0; 4 trials, n = 181). There was moderate-certainty evidence that lidocaine local anaesthetic sympathetic blockade probably does not reduce pain intensity compared with placebo, and low-certainty evidence that it may not reduce pain intensity compared with ultrasound of the stellate ganglion. No effect size was reported for either comparison. There was low-certainty evidence that topical dimethyl sulfoxide may not reduce pain intensity compared with oral N-acetylcysteine, but no effect size was reported. There was low-certainty evidence that continuous bupivacaine brachial plexus block may reduce pain intensity compared with continuous bupivacaine stellate ganglion block, but no effect size was reported. For a wide range of other commonly used interventions, the certainty in the evidence was very low and provides insufficient evidence to either support or refute their use. Comparisons with low- and very low-certainty evidence should be treated with substantial caution. We did not identify any RCT evidence for routinely used pharmacological interventions for CRPS such as tricyclic antidepressants or opioids. AUTHORS' CONCLUSIONS Despite a considerable increase in included evidence compared with the previous version of this overview, we identified no high-certainty evidence for the effectiveness of any therapy for CRPS. Until larger, high-quality trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult. Current non-Cochrane systematic reviews of interventions for CRPS are of low methodological quality and should not be relied upon to provide an accurate and comprehensive summary of the evidence.
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Affiliation(s)
- Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Benedict M Wand
- The School of Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Keith M Smart
- UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
- Physiotherapy Department, St Vincent's University Hospital, Dublin, Ireland
| | - Carolyn Berryman
- IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, South Australia, Australia
- School of Biomedicine, The University of Adelaide, Kaurna Country, Adelaide, Australia
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, UK
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, South Australia, Australia
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
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Meshkini A, Sarpoolaki MK, Vafaei A, Mirzaei F, Badripour A, Rafiei E, Khalilzadeh M, Fattahi MR, Iranmehr A. The efficacy of intrathecal methyl-prednisolone for acute spinal cord injury: A pilot study. Heliyon 2023; 9:e15548. [PMID: 37128349 PMCID: PMC10148034 DOI: 10.1016/j.heliyon.2023.e15548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/23/2023] [Accepted: 04/13/2023] [Indexed: 05/03/2023] Open
Abstract
Study design Randomized clinical trial. Objectives To evaluate the safety and effectiveness of intrathecal methyl-prednisolone compared to intravenous methyl-prednisolone in acute spinal cord injuries. Setting Imam Reza Hospital, Tabriz University of Medical Sciences. Methods Patients meeting our inclusion and exclusion criteria were enrolled in the study and divided randomly into two treatment arms: intrathecal and intravenous. Standard spinal cord injury care (including surgery) was given to each patient based on our institutional policy. Patients were then assessed for neurological status (based on ASIA scores, Frankel scores) and complications for six months and compared to baseline status after injury. To better understand the biological bases of methyl-prednisolone on spinal cord injuries, we measured two biomarkers for oxidative stress (serum malondialdehyde and total antioxidant capacity) in these patients at arrival and day three after injury. Results The present study showed no significant difference between the treatment arms in neurological status (sensory scores or motor scores) or complications. However, the within-group analysis showed improvement in neurological status in each treatment arm within six months. Serum malondialdehyde and total antioxidant capacity were analyzed, and no significant difference between the groups was seen. Conclusion This is the first known clinical trial investigating the effect of intrathecal MP in acute SCI patients. Our finding did not show any significant differences in complication rates and neurological outcomes between the two study arms. Further studies should be conducted to define the positive and negative effects of this somehow novel technique in different populations as well.
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Affiliation(s)
- Ali Meshkini
- Neurosurgery Department, Tarbiz University of Medical Sciences, Iran
| | - Mohammad Kazem Sarpoolaki
- Neurological Surgery Department, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences, Iran
| | - Ali Vafaei
- Experimental Medicine Research Center, Department of Pharmacology, Tehran University of Medical Sciences, Iran
| | - Farhad Mirzaei
- Neurosurgery Department, Tarbiz University of Medical Sciences, Iran
| | - Abolfazl Badripour
- Experimental Medicine Research Center, Department of Pharmacology, Tehran University of Medical Sciences, Iran
- Brain and Spinal Cord Injuries Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Iran
| | - Ebrahim Rafiei
- Neurosurgery Department, Tarbiz University of Medical Sciences, Iran
| | | | | | - Arad Iranmehr
- Neurological Surgery Department, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences, Iran
- Sina hospital, Hasanabad, Tehran, Iran
- Corresponding author. Neurological Surgery Department, Imam Khomeini Hospital Complex (IKHC), Tehran University of Medical Sciences, Iran.
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van den Berg C, de Bree PN, Huygen FJPM, Tiemensma J. Glucocorticoid treatment in patients with complex regional pain syndrome: A systematic review. Eur J Pain 2022; 26:2009-2035. [PMID: 35983980 PMCID: PMC9826269 DOI: 10.1002/ejp.2025] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVE The pathophysiology of complex regional pain syndrome (CRPS) is multifactorial, with an exaggerated inflammatory response being the most prominent. Treatment for CRPS is carried out according to the presenting pathophysiological mechanism. Anti-inflammatory treatment with glucocorticoids is therefore an option. The aim of this study was to systematically review the efficacy of glucocorticoids in CRPS. DATABASES AND DATA TREATMENT Embase, Medline, Web of Science and Google Scholar were systematically searched for articles focusing on glucocorticoid treatment and CRPS. Screening based on title and abstract was followed by full-text reading (including reference lists) to determine the final set of relevant articles. Bias was assessed using the revised Cochrane risk-of-bias-tool for randomized trials (Rob2). RESULTS Forty-one studies were included, which reported on 1208 CRPS patients. A wide variety of glucocorticoid administration strategies were applied, with oral being the most frequently chosen. Additionally, researchers found great heterogeneity in outcome parameters, including clinical symptoms, pain relief and range of motion. The use of glucocorticoids caused an improvement of parameters in all but two studies. In particular, improvement in pain relief and range of motion were reported. Using glucocorticoids in CRPS of longer duration (i.e. more than 3 months) appears to be less effective. CONCLUSION Based on the present review, there is evidence to support glucocorticoid treatment in CRPS. However, the ideal administration route and dose remain unclear. We therefore recommend future research via an intervention study, as well as studies on the aetiological mechanisms and corresponding optimal treatment because CRPS pathogenesis is only partially understood. SIGNIFICANCE Several studies point towards CRPS being an inflammatory response after tissue or nerve damage, with higher levels of pro-inflammatory cytokines in serum, plasma, cerebrospinal fluid and artificial skin blisters. Inflammation provides a possible role for glucocorticoids in treating CRPS. This systematic review provides a structured overview of glucocorticoid treatment in patients with CRPS. Improvement in pain and range of motion is shown. Systematic review registration number: PROSPERO-CRD42020144671.
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Affiliation(s)
- Corinne van den Berg
- Department of AnesthesiologyCentre for Pain MedicineErasmus MCRotterdamThe Netherlands
| | - Pim N. de Bree
- Department of AnesthesiologyCentre for Pain MedicineErasmus MCRotterdamThe Netherlands
| | - Frank J. P. M. Huygen
- Department of AnesthesiologyCentre for Pain MedicineErasmus MCRotterdamThe Netherlands
| | - Jitske Tiemensma
- Department of AnesthesiologyCentre for Pain MedicineErasmus MCRotterdamThe Netherlands
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Harden RN, McCabe CS, Goebel A, Massey M, Suvar T, Grieve S, Bruehl S. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S1-S53. [PMID: 35687369 PMCID: PMC9186375 DOI: 10.1093/pm/pnac046] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/23/2022]
Abstract
There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for "better research." This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of "elder statesman" researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the "Budapest" criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient.
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Affiliation(s)
- R Norman Harden
- Departments of PM&R and Physical Therapy and Human Movement Sciences, Northwestern University
| | - Candida S McCabe
- University of the West of England, Stapleton, Bristol, UK
- Dorothy House Hospice, Bradford-on-Avon, Wilts, UK
| | - Andreas Goebel
- Pain Research Institute, Faculty of Health and Life Science, University of Liverpool, Liverpool, UK
| | - Michael Massey
- CentraCare Neurosciences Pain Center, CentraCare, St. Cloud, Minnesota, USA
| | - Tolga Suvar
- Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Sharon Grieve
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Centers, Nashville, Tennessee, USA
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From a Symptom-Based to a Mechanism-Based Pharmacotherapeutic Treatment in Complex Regional Pain Syndrome. Drugs 2022; 82:511-531. [PMID: 35247200 PMCID: PMC9016036 DOI: 10.1007/s40265-022-01685-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 02/06/2023]
Abstract
Complex regional pain syndrome (CRPS) is a debilitating painful condition of a distal extremity that can develop after tissue damage. CRPS is thought to be a multimechanism syndrome and ideally the most prominent mechanism(s) should be targeted by drugs in an individually tailored manner. This review gives an overview of the action and evidence of current and future pharmacotherapeutic options for CRPS. The available options are grouped in four categories by their therapeutic actions on the CRPS mechanisms, i.e. inflammation, central sensitisation, vasomotor disturbances and motor disturbances. More knowledge about the underlying mechanisms of CRPS helps to specifically target important CRPS mechanisms. In the future, objective biomarkers could potentially aid in selecting appropriate mechanism-based drugs in order to increase the effectiveness of CRPS treatment. Using this approach, current and future pharmacotherapeutic options for CRPS should be studied in multicentre trials to prove their efficacy. The ultimate goal is to shift the symptom-based selection of therapy into a mechanism-based selection of therapy in CRPS.
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9
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Okumo T, Takayama Y, Maruyama K, Kato M, Sunagawa M. Senso-Immunologic Prospects for Complex Regional Pain Syndrome Treatment. Front Immunol 2022; 12:786511. [PMID: 35069559 PMCID: PMC8767061 DOI: 10.3389/fimmu.2021.786511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain syndrome that occurs in tissue injuries as the result of surgery, trauma, or ischemia. The clinical features of this severely painful condition include redness and swelling of the affected skin. Intriguingly, it was recently suggested that transient receptor potential ankyrin 1 (TRPA1) is involved in chronic post-ischemia pain, a CRPS model. TRPA1 is a non-selective cation channel expressed in calcitonin gene-related peptide (CGRP)-positive primary nociceptors that becomes highly activated in ischemic conditions, leading to the generation of pain. In this review, we summarize the history of TRPA1 and its involvement in pain sensation, inflammation, and CRPS. Furthermore, bone atrophy is also thought to be a characteristic clinical sign of CRPS. The altered bone microstructure of CRPS patients is thought to be caused by aggravated bone resorption via enhanced osteoclast differentiation and activation. Although TRPA1 could be a target for pain treatment in CRPS patients, we also discuss the paradoxical situation in this review. Nociceptor activation decreases the risk of bone destruction via CGRP secretion from free nerve endings. Thus, TRPA1 inhibition could cause severe bone atrophy. However, the suitable therapeutic strategy is controversial because the pathologic mechanisms of bone atrophy in CRPS are unclear. Therefore, we propose focusing on the remission of abnormal bone turnover observed in CRPS using a recently developed concept: senso-immunology.
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Affiliation(s)
- Takayuki Okumo
- Department of Physiology, Showa University School of Medicine, Shinagawa, Japan
| | - Yasunori Takayama
- Department of Physiology, Showa University School of Medicine, Shinagawa, Japan
| | - Kenta Maruyama
- Department of Physiology, Showa University School of Medicine, Shinagawa, Japan.,Division of Cell Signaling, National Institute for Physiological Sciences, Natural Institutes for Natural Sciences, Okazaki, Japan
| | - Mami Kato
- Department of Physiology, Showa University School of Medicine, Shinagawa, Japan.,Department of Molecular and System Pharmacology, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Masataka Sunagawa
- Department of Physiology, Showa University School of Medicine, Shinagawa, Japan
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10
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OUP accepted manuscript. Rheumatology (Oxford) 2022; 61:3534-3546. [DOI: 10.1093/rheumatology/keac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 11/14/2022] Open
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Shim H, Rose J, Halle S, Shekane P. Complex regional pain syndrome: a narrative review for the practising clinician. Br J Anaesth 2019; 123:e424-e433. [PMID: 31056241 DOI: 10.1016/j.bja.2019.03.030] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/25/2019] [Accepted: 03/22/2019] [Indexed: 12/15/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a life-altering condition that usually affects the extremities after a trauma or nerve injury. The physiologic changes that occur as a result of the inciting injury are complex, as the name of the syndrome implies. The pain and disability associated with CRPS often lead to psychological co-morbidities that create a vicious cycle of pain, isolation, and depression. We review recent developments in the understanding of CRPS and advancements in management of this syndrome. Further research in targeting specific mechanisms involved in the pathophysiology of CRPS should lead to prevention of this condition.
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Affiliation(s)
- H Shim
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA
| | - J Rose
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA
| | - S Halle
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA
| | - P Shekane
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA.
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The Blind Leading the Not-So-Blind: A Meta-Analysis of Blinding in Pharmacological Trials for Chronic Pain. THE JOURNAL OF PAIN 2019; 20:489-500. [DOI: 10.1016/j.jpain.2018.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/08/2018] [Accepted: 09/06/2018] [Indexed: 01/09/2023]
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Li L, Han Y, Li T, Zhou J, Sun C, Xue Y. The analgesic effect of intravenous methylprednisolone on acute neuropathic pain with allodynia due to central cord syndrome: a retrospective study. J Pain Res 2018; 11:1231-1238. [PMID: 29983586 PMCID: PMC6025778 DOI: 10.2147/jpr.s160463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Central cord syndrome (CCS) may be associated with severe neuropathic pain that often resists to conventional pain therapy regimens and affects the patients’ quality of life (QoL) seriously. Current treatments for CCS-associated neuropathic pain have limited evidence of efficacy. This retrospective study was performed to present the effects of early treatment with methylprednisolone (MP) on acute neuropathic pain relief and the QoL in CCS patients. Patients and methods Data were collected from the medical records of CCS patients who suffered from acute neuropathic pain with allodynia. All the patients received intravenous MP treatment for up to 1 week. Patients were evaluated with standard measures of efficacy: neuropathic pain intensity, the area of allodynia, and the QoL at baseline, daily treatment, and at 1 and 3 months after the end of MP treatment. Results Thirty-four eligible patients were enrolled in our study. By the end of MP treatment, the proportion of patients who gained total or major (visual analog scale [VAS] score decreased by 50% or more) allodynia relief from the treatment was 91.18%, and a decrease in spontaneous pain was also observed. Moreover, this study showed MP could significantly improve the QoL of patients based on McGill Pain Questionnaire Short Form and EuroQol Five Dimensions Questionnaire. Four patients (11.76%) during MP treatment experienced mild or moderate side effects. None of the patients manifested CCS-associated neuropathic pain recurrence and MP-associated side effects at follow-up. Conclusion The current results suggested that MP offered an effective therapeutic alternative for relieving CCS-associated acute neuropathic pain with allodynia. Given the encouraging results of this study, it would be worthwhile to confirm these results in randomized placebo-controlled clinical trials.
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Affiliation(s)
- Liandong Li
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China,
| | - Yawei Han
- Department of Histology and Embryology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Tengshuai Li
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China,
| | - Jiaming Zhou
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China,
| | - Chao Sun
- Department of Orthopaedics Surgery, Tianjin Metabolic Diseases Hospital & Tianjin Institution of Endocrinology, Tianjin, China.,Key Lab of Hormones and Development (National Health and Family Planning Commission of the PRC), Tianjin Key Laboratory of Metabolic Diseases, Tianjin, China
| | - Yuan Xue
- Department of Orthopaedics Surgery, Tianjin Medical University General Hospital, Tianjin, China,
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Duong S, Bravo D, Todd KJ, Finlayson RJ, Tran DQ. Treatment of complex regional pain syndrome: an updated systematic review and narrative synthesis. Can J Anaesth 2018; 65:658-684. [PMID: 29492826 DOI: 10.1007/s12630-018-1091-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 10/17/2022] Open
Abstract
PURPOSE Although multiple treatments have been advocated for complex regional pain syndrome (CRPS), the levels of supportive evidence are variable and sometimes limited. The purpose of this updated review is to provide a critical analysis of the evidence pertaining to the treatment of CRPS derived from recent randomized-controlled trials (RCTs). SOURCE The MEDLINE, EMBASE, Psychinfo, and CINAHL databases were searched to identify relevant RCTs conducted on human subjects and published in English between 1 May 2009 and 24 August 2017. PRINCIPAL FINDINGS The search yielded 35 RCTs of variable quality pertaining to the treatment of CRPS. Published trials continue to support the use of bisphosphonates and short courses of oral steroids in the setting of CRPS. Although emerging evidence suggests a therapeutic role for ketamine, memantine, intravenous immunoglobulin, epidural clonidine, intrathecal clonidine/baclofen/adenosine, aerobic exercise, mirror therapy, virtual body swapping, and dorsal root ganglion stimulation, further confirmatory RCTs are warranted. Similarly, trials also suggest an expanding role for peripheral sympathetic blockade (i.e., lumbar/thoracic sympathetic, stellate ganglion, and brachial plexus blocks). CONCLUSIONS Since our prior systematic review article (published in 2010), 35 RCTs related to CRPS have been reported. Nevertheless, the quality of trials remains variable. Therefore, further research is required to continue investigating possible treatments for CRPS.
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Affiliation(s)
- Silvia Duong
- Jewish General Hospital, Herzl Family Medicine Center, Montreal, QC, Canada
| | - Daniela Bravo
- Department of Anesthesia, Hospital Clínico Universidad de Chile, University of Chile, Santiago, Chile
| | - Keith J Todd
- Jewish General Hospital, Herzl Family Medicine Center, Montreal, QC, Canada
| | - Roderick J Finlayson
- Department of Anesthesia, Montreal General Hospital, McGill University, 1650 Ave Cedar, D10-144, Montreal, QC, H3G 1A4, Canada
| | - De Q Tran
- Department of Anesthesia, Montreal General Hospital, McGill University, 1650 Ave Cedar, D10-144, Montreal, QC, H3G 1A4, Canada.
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15
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Rijsdijk M, Agalave NM, van Wijck AJM, Kalkman CJ, Ramachandran R, Baharpoor A, Svensson CI, Yaksh TL. Effect of intrathecal glucocorticoids on the central glucocorticoid receptor in a rat nerve ligation model. Scand J Pain 2017; 16:1-9. [PMID: 28850381 DOI: 10.1016/j.sjpain.2016.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 12/30/2016] [Accepted: 12/31/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Despite widespread use, the efficacy of neuraxial glucocorticoids for neuropathic pain is subject to debate. Since most glucocorticoid actions are mediated through its receptor, we explored the effects of intrathecal methylprednisolone acetate (MPA) on total glucocorticoid receptor (tGR) levels and activation of the glucocorticoid receptor (phosphorylated state=pGR) within the spinal dorsal horn (SDH) and dorsal root ganglion (DRG) in a spinal nerve ligation (SNL) model in rats. METHODS Rats received unilateral ligation of the L5/L6 spinal nerves and were treated with two intrathecal doses of either 400μg MPA or 0.9% saline with a 72-h interval. Plantar tactile thresholds were measured over time. Seven days after drug treatment, DRG and SDH were harvested to assess tGR and pGR levels using immunohistochemistry and qPCR. RESULTS Allodynia, defined by lowered tactile withdrawal thresholds after SNL, was unaltered by intrathecal MPA. In saline controls, mRNA levels of tGR did not change after SNL in the DRGs or SDH. tGR and pGR protein levels in the SDH however, significantly increased on the ipsilateral side of SNL compared to the contralateral side and to naïve tissue. When treating rats with MPA, tGR mRNA levels were significantly reduced in the SDH compared to saline controls. tGR and pGR protein levels, however were not significantly lower compared to saline controls. CONCLUSIONS In intrathecal MPA treated rats, tGR mRNA levels decreased after SNL. However this did not result in lower tGR and pGR protein levels compared to saline controls, and did not decrease ligation-induced mechanical hypersensitivity. IMPLICATIONS Intrathecal MPA treatment after SNL did not result in lower tGR and pGR levels within the SDH and DRG compared to saline controls. In present study we did not differentiate between the various isoforms of the GR which might clarify this finding.
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Affiliation(s)
- Mienke Rijsdijk
- Department of Anesthesiology, University Medical Center Utrecht, The Netherlands.
| | - Nilesh M Agalave
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Albert J M van Wijck
- Department of Anesthesiology, University Medical Center Utrecht, The Netherlands
| | - Cornelis J Kalkman
- Department of Anesthesiology, University Medical Center Utrecht, The Netherlands
| | | | - Azar Baharpoor
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Camilla I Svensson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Tony L Yaksh
- Department of Anesthesiology, University of California, San Diego, USA
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Barbalinardo S, Loer SA, Goebel A, Perez RSGM. The Treatment of Longstanding Complex Regional Pain Syndrome with Oral Steroids. PAIN MEDICINE 2017; 17:337-43. [PMID: 26814238 DOI: 10.1093/pm/pnv002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Evaluate the effectiveness of oral steroids in relieving pain in patients with Complex Regional Pain Syndrome (CRPS) of more than 3 months duration. DESIGN Service evaluation/Open label uncontrolled trial. SETTING Two pain outpatient clinics specialized in CRPS diagnosis and treatment in the period 2009-2012. SUBJECTS Thirty-one patients diagnosed with CRPS with the Budapest criteria in two specialized centers, with a disease duration of more than 3 months and not responsive to standard treatment were included. METHODS Patients were treated with oral prednisolone in both centers [100 mg daily tapered by 25 mg every 4 days to zero (Σ1g) at center 1 (C1) and 60 mg daily for 2 weeks lowered 20 mg every 4 days to zero (Σ1.06g) at center 2 (C2)]. The average pain intensity was recorded by patients using a numeric rating scale before the treatment start, and 6 weeks after treatment onset (treatment duration was respectively 16 days and 22 days at the two centers). RESULTS Overall the authors observed no significant reduction in the average pain intensity (P = 0.059), but 2 patients had a consistent reduction in pain intensity with return to baseline pain levels 9 weeks after treatment onset, and 1 patient had ongoing stable pain relief of >50%. CONCLUSIONS This study provides indications that the efficacy of oral corticosteroids is limited in treating CRPS of more than 3 months duration who did not respond to previous treatment. Randomized controlled studies (with enriched designs), or single subject designs would be required to identify the possible existence of a patient subgroup with a specific disease profile that may benefit from a steroid treatment.
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Gatti D, Rossini M, Adami S. Management of patients with complex regional pain syndrome type I. Osteoporos Int 2016; 27:2423-31. [PMID: 26928187 DOI: 10.1007/s00198-016-3531-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/05/2016] [Indexed: 01/26/2023]
Abstract
Complex regional pain syndrome type I (CRPS-I) includes different conditions characterized by regional pain and sensory, motor, sudomotor, vasomotor, and/or trophic findings, affecting a peripheral limb usually after a noxious event, such as a trauma or surgery. The pathophysiology is still poorly understood. Limited data are available on the incidence of CRPS-I, and the disease is underestimated and under-diagnosed. The disease shows a female preponderance approximately 3:1 with a peak age of incidence around the 5th and 6th decade. The available diagnostic criteria for CRPS-I rely on clinical criteria that are unfortunately focused on the signs and symptoms of the chronic and late disease, while little emphasis is given to the typical imaging (X-rays, bone scintigraphy, MRI) findings of the early phase. Over the last decades, several therapies have been proposed but the few studies available are often too small to be conclusive and rarely evolved to randomized controlled trials (RCTs). On the basis of the results of a few RCTs, only short courses of high bisphosphonate doses appear to provide substantial benefits. The best results are seen in patients in the early phase of the disease, often with the persistent remission or complete healing of the conditions. Since the only accredited mechanism of action of bisphosphonates is the suppression of osteoclastic bone resorption, it is likely the initial dramatic bone loss plays a role in the maintenance and evolution of CRPS-I. Short courses of high doses of bisphosphonates should be considered the treatment of choice for patients with CRPS-I.
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Affiliation(s)
- D Gatti
- Rheumatology Unit, University of Verona, Policlinico Borgo Roma, Piazzale Scuro, 10, 37134, Verona, Italy.
| | - M Rossini
- Rheumatology Unit, University of Verona, Policlinico Borgo Roma, Piazzale Scuro, 10, 37134, Verona, Italy
| | - S Adami
- Rheumatology Unit, University of Verona, Policlinico Borgo Roma, Piazzale Scuro, 10, 37134, Verona, Italy
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18
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Rijsdijk M, Svensson CI, van Wijck AJ, Kalkman CJ, Yaksh TL. Analgesic properties of intrathecal glucocorticoids in three well established preclinical pain models. Scand J Pain 2016; 10:90-102. [PMID: 28361779 DOI: 10.1016/j.sjpain.2015.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS Glucocorticoids, a group of anti-inflammatory agents, are frequently administered in pain medicine. Of interest is the reported activity after intrathecal delivery in patients with neuropathic pain syndromes such as postherpetic neuralgia, though its efficacy is controversial. After the publication of two randomized clinical trials in postherpetic neuralgia patients treated with similar intrathecal methylprednisolone acetate (MPA) dosing regimes with conflicting results; one showing significant pain reduction (Kotani N, Kushikata T, Hashimoto H, Kimura F, Muraoka M, Yodono M, Asai M, Matsuki A: Intrathecal methylprednisolone for intractable postherpetic neuralgia. N Engl J Med 2000;23: 1514-9), the other increased pain sensations (Rijsdijk M, van Wijck AJ, Meulenhoff PC, Kavelaars A, van der Tweel I, Kalkman CJ: No beneficial effect of intrathecal methylprednisolone acetate in postherpetic neuralgia patients. Eur J Pain 2013;38: 175-200), we decided additional research was warranted. Present study sought to determine effects of intrathecally delivered methylprednisolone on pain-like behaviour and pain-associated markers in three well established rodent pain models: (1) intraplantar carrageenan, (2) intraplantar formalin, and (3) ligation of L5/L6 spinal nerves (SNL model). METHODS Male rats with intrathecal catheters were examined for (1) tactile allodynia after unilateral hindpaw intraplantar carrageenan injection (2%), (2) flinching and subsequent long term tactile allodynia after unilateral hindpaw intraplantar formalin injection (2.5%) or (3) tactile allodynia after unilateral ligation of the L5 and L6 spinal nerves. Rats were treated with the maximum tolerable intrathecal dose of the soluble methylprednisolone sodium succinate (MP) or the particulate methylprednisolone acetate (MPA). Dorsal root ganglia and spinal cords were harvested for immunohistochemistry to assess markers of neuronal damage (ATF3) and glial activation (GFAP, Iba1). RESULTS During dose finding, severe generalized allodynia was observed with high intrathecal doses of both MPA and MP in naive rats. MPA had no effect upon tactile allodynia after carrageenan. MP and MPA did not reverse tactile allodynia in the SNL model, and did not reduce flinching in the formalin model. MP and MPA prevented the delayed (7-day) tactile allodynia otherwise observed in the formalin-injected paw. Systemic MP or perineural MP or MPA did not reduce pain-like behaviour in the SNL model. No reduction of neuronal injury (ATF3) in the dorsal root ganglion or astrocyte activation (GFAP) in the spinal dorsal horn with intrathecal MP or MPA was observed. There was a decrease in microglial activation (Iba1) in the spinal dorsal horn with MPA after SNL. CONCLUSION Severe generalized allodynia was observed after high intrathecal doses of MP and MPA in naive rats. No acute analgesic effects with intrathecal glucocorticoids were observed in three well established pain models. Only a late antiallodynic effect was present in the formalin model, 7 days after formalin injection and drug treatment. IMPLICATIONS Our results do not support use of intrathecal methylprednisolone in the treatment of pain.
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Affiliation(s)
- Mienke Rijsdijk
- Pain Clinic, Department of Anesthesiology, University Medical Center Utrecht, UtrechtThe Netherlands
| | - Camilla I Svensson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Albert J van Wijck
- Pain Clinic, Department of Anesthesiology, University Medical Center Utrecht, UtrechtThe Netherlands
| | - Cornelis J Kalkman
- Pain Clinic, Department of Anesthesiology, University Medical Center Utrecht, UtrechtThe Netherlands
| | - Tony L Yaksh
- Department of Anesthesiology, University of California, San Diego, USA
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McCormick ZL, Gagnon CM, Caldwell M, Patel J, Kornfeld S, Atchison J, Stanos S, Harden RN, Calisoff R. Short-Term Functional, Emotional, and Pain Outcomes of Patients with Complex Regional Pain Syndrome Treated in a Comprehensive Interdisciplinary Pain Management Program. PAIN MEDICINE 2015; 16:2357-67. [DOI: 10.1111/pme.12817] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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20
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Affiliation(s)
- Andreas Goebel
- Senior Lecturer and Honorary Consultant in Pain Medicine, Pain Research Group and Centre for Immune Studies in Pain, University Liverpool and The Walton Centre NHS Trust, Liverpool Clinical Sciences Centre, University Hospital Aintree, Liverpool L9 7AL 0151 529 5822
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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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Grieve S, Jones L, Walsh N, McCabe C. What outcome measures are commonly used for Complex Regional Pain Syndrome clinical trials? A systematic review of the literature. Eur J Pain 2015; 20:331-40. [PMID: 26075938 DOI: 10.1002/ejp.733] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2015] [Indexed: 11/10/2022]
Affiliation(s)
- S. Grieve
- Royal National Hospital for Rheumatic Diseases; Bath UK
- Faculty of Health and Applied Sciences; University of the West of England; Bristol UK
| | - L. Jones
- Faculty of Health and Applied Sciences; University of the West of England; Bristol UK
| | - N. Walsh
- Faculty of Health and Applied Sciences; University of the West of England; Bristol UK
| | - C. McCabe
- Royal National Hospital for Rheumatic Diseases; Bath UK
- Faculty of Health and Applied Sciences; University of the West of England; Bristol UK
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Mbizvo GK, Nolan SJ, Nurmikko TJ, Goebel A. Placebo Responses in Long-Standing Complex Regional Pain Syndrome: A Systematic Review and Meta-Analysis. THE JOURNAL OF PAIN 2015; 16:99-115. [DOI: 10.1016/j.jpain.2014.11.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 10/25/2014] [Accepted: 11/05/2014] [Indexed: 12/19/2022]
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Abstract
Complex regional pain syndrome (CRPS) is the current consensus-derived name for a syndrome usually triggered by limb trauma. Required elements include prolonged, disproportionate distal-limb pain and microvascular dysregulation (e.g., edema or color changes) or altered sweating. CRPS-II (formerly "causalgia") describes patients with identified nerve injuries. CRPS-I (formerly "reflex sympathetic dystrophy") describes most patients who lack evidence of specific nerve injuries. Diagnosis is clinical and the pathophysiology involves combinations of small-fiber axonopathy, microvasculopathy, inflammation, and brain plasticity/sensitization. Females have much higher risk and workplace accidents are a well-recognized cause. Inflammation and dysimmunity, perhaps facilitated by injury to the blood-nerve barrier, may contribute. Most patients, particularly the young, recover gradually, but treatment can speed healing. Evidence of efficacy is strongest for rehabilitation therapies (e.g., graded-motor imagery), neuropathic pain medications, and electric stimulation of the spinal cord, injured nerve, or motor cortex. Investigational treatments include ketamine, botulinum toxin, immunoglobulins, and transcranial neuromodulation. Nonrecovering patients should be re-evaluated for neurosurgically treatable causal lesions (nerve entrapment, impingement, infections, or tumors) and treatable potentiating medical conditions, including polyneuropathy and circulatory insufficiency. Earlier impressions that CRPS represents malingering or psychosomatic illness have been replaced by evidence that CRPS is a rare complication of limb injury in biologically susceptible individuals.
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Affiliation(s)
- Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston, MA, USA.
| | - Steven H Horowitz
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, School of Medicine, Tufts University, Boston, MA, USA
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McKeown A, Gewandter JS, McDermott MP, Pawlowski JR, Poli JJ, Rothstein D, Farrar JT, Gilron I, Katz NP, Lin AH, Rappaport BA, Rowbotham MC, Turk DC, Dworkin RH, Smith SM. Reporting of sample size calculations in analgesic clinical trials: ACTTION systematic review. THE JOURNAL OF PAIN 2014; 16:199-206.e1-7. [PMID: 25481494 DOI: 10.1016/j.jpain.2014.11.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 11/10/2014] [Accepted: 11/13/2014] [Indexed: 11/29/2022]
Abstract
UNLABELLED Sample size calculations determine the number of participants required to have sufficiently high power to detect a given treatment effect. In this review, we examined the reporting quality of sample size calculations in 172 publications of double-blind randomized controlled trials of noninvasive pharmacologic or interventional (ie, invasive) pain treatments published in European Journal of Pain, Journal of Pain, and Pain from January 2006 through June 2013. Sixty-five percent of publications reported a sample size calculation but only 38% provided all elements required to replicate the calculated sample size. In publications reporting at least 1 element, 54% provided a justification for the treatment effect used to calculate sample size, and 24% of studies with continuous outcome variables justified the variability estimate. Publications of clinical pain condition trials reported a sample size calculation more frequently than experimental pain model trials (77% vs 33%, P < .001) but did not differ in the frequency of reporting all required elements. No significant differences in reporting of any or all elements were detected between publications of trials with industry and nonindustry sponsorship. Twenty-eight percent included a discrepancy between the reported number of planned and randomized participants. This study suggests that sample size calculation reporting in analgesic trial publications is usually incomplete. Investigators should provide detailed accounts of sample size calculations in publications of clinical trials of pain treatments, which is necessary for reporting transparency and communication of pre-trial design decisions. PERSPECTIVE In this systematic review of analgesic clinical trials, sample size calculations and the required elements (eg, treatment effect to be detected; power level) were incompletely reported. A lack of transparency regarding sample size calculations may raise questions about the appropriateness of the calculated sample size.
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Affiliation(s)
- Andrew McKeown
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Jennifer S Gewandter
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Joseph R Pawlowski
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Joseph J Poli
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Daniel Rothstein
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - John T Farrar
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Gilron
- Queen's University, Kingston, Ontario, Canada
| | - Nathaniel P Katz
- Analgesic Solutions, Natick, Massachusetts; Department of Anesthesiology, Tufts University, Boston, Massachusetts
| | - Allison H Lin
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland
| | - Bob A Rappaport
- Center for Drug Evaluation and Research, United States Food and Drug Administration, Silver Spring, Maryland
| | | | - Dennis C Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York; Department of Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Shannon M Smith
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York.
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Rocha RDO, Teixeira MJ, Yeng LT, Cantara MG, Faria VG, Liggieri V, Loduca A, Müller BM, Souza AC, de Andrade DC. Thoracic sympathetic block for the treatment of complex regional pain syndrome type I: A double-blind randomized controlled study. Pain 2014; 155:2274-81. [DOI: 10.1016/j.pain.2014.08.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 08/12/2014] [Accepted: 08/13/2014] [Indexed: 01/21/2023]
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Gierthmühlen J, Binder A, Baron R. Mechanism-based treatment in complex regional pain syndromes. Nat Rev Neurol 2014; 10:518-28. [DOI: 10.1038/nrneurol.2014.140] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Rijsdijk M, van Wijck AJM, Kalkman CJ, Yaksh TL. The effects of glucocorticoids on neuropathic pain: a review with emphasis on intrathecal methylprednisolone acetate delivery. Anesth Analg 2014; 118:1097-112. [PMID: 24781577 DOI: 10.1213/ane.0000000000000161] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Methylprednisolone acetate (MPA) has a long history of use in the treatment of sciatic pain and other neuropathic pain syndromes. In several of these syndromes, MPA is administered in the epidural space. On a limited basis, MPA has also been injected intrathecally in patients suffering from postherpetic neuralgia and complex regional pain syndrome. The reports on efficacy of intrathecal administration of MPA in neuropathic pain patients are contradictory, and safety is debated. In this review, we broadly consider mechanisms whereby glucocorticoids exert their action on spinal cascades relevant to the pain arising after nerve injury and inflammation. We then focus on the characteristics of the actions of MPA in pharmacokinetics, efficacy, and safety when administered in the intrathecal space.
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Affiliation(s)
- Mienke Rijsdijk
- From the *Department of Anesthesiology, Pain Clinic, University Medical Center Utrecht, Utrecht, The Netherlands; and †Department of Anesthesiology, University of California San Diego, San Diego, California
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Meissner A, van der Plas AA, van Dasselaar NT, Deelder AM, van Hilten JJ, Mayboroda OA. 1H-NMR metabolic profiling of cerebrospinal fluid in patients with complex regional pain syndrome-related dystonia. Pain 2013; 155:190-196. [PMID: 24120462 DOI: 10.1016/j.pain.2013.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 10/01/2013] [Accepted: 10/04/2013] [Indexed: 11/26/2022]
Abstract
In complex regional pain syndrome (CRPS)-related dystonia, compelling evidence points to the involvement of the central nervous system, but the underpinning pathobiology is still unclear. Thus, to enable a hypothesis-free, unbiased view of the problem and to obtain new insight into the pathobiology of dystonia in CRPS, we applied an exploratory metabolomics analysis of cerebrospinal fluid (CSF) of patients with CRPS-related dystonia. (1)H-NMR spectroscopy in combination with multivariate modeling were used to investigate metabolic profiles of a total of 105 CSF samples collected from patients with CRPS-related dystonia and controls. We found a significantly different metabolic profile of CSF in CRPS patients compared to controls. The differences were already reflected in the first two principal components of the principal component analysis model, which is an indication that the variance associated with CRPS is stronger than variance caused by such classical confounders as gender, age, or individual differences. A supervised analysis generated a strong model pinpointing the most important metabolites contributed to the metabolic signature of patients with CRPS-related dystonia. From the set of identified discriminators, the most relevant metabolites were 2-keto-isovalerate, glucose, glutamine, and lactate, which all showed increased concentrations, and urea, which showed decreased concentration in CRPS subjects. Our findings point at a catabolic state in chronic CRPS patients with dystonia that is likely associated with inflammation.
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Affiliation(s)
- Axel Meissner
- Center for Proteomics and Metabolomics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands Department of Neurology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands Department of Anesthesiology, Reinier de Graaf Gasthuis, PO Box 5011, 2600 GA Delft, The Netherlands
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Abstract
Inflammation is the process by which an organism responds to tissue injury involving both immune cell recruitment and mediator release. Diverse causes of neuropathic pain are associated with excessive inflammation in both the peripheral and central nervous system which may contribute to the initiation and maintenance of persistent pain. Chemical mediators, such as cytokines, chemokines, and lipid mediators, released during an inflammatory response have the undesired effect of sensitizing and stimulating nociceptors, their central synaptic targets or both. These changes can promote long-term maladaptive plasticity resulting in persistent neuropathic pain. This review aims to provide an overview of inflammatory mechanisms at differing levels of the sensory neuroaxis with a focus on neuropathic pain. We will compare and contrast neuropathic pain states such as traumatic nerve injury which is associated with a vigorous inflammatory response and chemotherapy induced pain in which the inflammatory response is much more modest. Targeting excessive inflammation in neuropathic pain provides potential therapeutic opportunities and we will discuss some of the opportunities but also the clinical challenges in such an approach.
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Affiliation(s)
- A Ellis
- King's College London, Wolfson Wing, Hodgkin Building, Guy's Campus, London SE1 1UL, UK.
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31
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O'Connell NE, Wand BM, McAuley J, Marston L, Moseley GL. Interventions for treating pain and disability in adults with complex regional pain syndrome. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [PMID: 23633371 DOI: 10.1002/14651858.cd009416] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is currently no strong consensus regarding the optimal management of complex regional pain syndrome although a multitude of interventions have been described and are commonly used. OBJECTIVES To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the effectiveness of any therapeutic intervention used to reduce pain, disability or both in adults with complex regional pain syndrome (CRPS). METHODS We identified Cochrane reviews and non-Cochrane reviews through a systematic search of the following databases: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Ovid MEDLINE, Ovid EMBASE, CINAHL, LILACS and PEDro. We included non-Cochrane systematic reviews where they contained evidence not covered by identified Cochrane reviews. The methodological quality of reviews was assessed using the AMSTAR tool.We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes of quality of life, emotional well being and participants' ratings of satisfaction or improvement. Only evidence arising from randomised controlled trials was considered. We used the GRADE system to assess the quality of evidence. MAIN RESULTS We included six Cochrane reviews and 13 non-Cochrane systematic reviews. Cochrane reviews demonstrated better methodological quality than non-Cochrane reviews. Trials were typically small and the quality variable.There is moderate quality evidence that intravenous regional blockade with guanethidine is not effective in CRPS and that the procedure appears to be associated with the risk of significant adverse events.There is low quality evidence that bisphosphonates, calcitonin or a daily course of intravenous ketamine may be effective for pain when compared with placebo; graded motor imagery may be effective for pain and function when compared with usual care; and that mirror therapy may be effective for pain in post-stroke CRPS compared with a 'covered mirror' control. This evidence should be interpreted with caution. There is low quality evidence that local anaesthetic sympathetic blockade is not effective. Low quality evidence suggests that physiotherapy or occupational therapy are associated with small positive effects that are unlikely to be clinically important at one year follow up when compared with a social work passive attention control.For a wide range of other interventions, there is either no evidence or very low quality evidence available from which no conclusions should be drawn. AUTHORS' CONCLUSIONS There is a critical lack of high quality evidence for the effectiveness of most therapies for CRPS. Until further larger trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult.
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Affiliation(s)
- Neil E O'Connell
- Centre for Research in Rehabilitation, School of Health Sciences and Social Care, Brunel University, Uxbridge, UK.
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O'Connell NE, Wand BM, McAuley J, Marston L, Moseley GL. Interventions for treating pain and disability in adults with complex regional pain syndrome. Cochrane Database Syst Rev 2013; 2013:CD009416. [PMID: 23633371 PMCID: PMC6469537 DOI: 10.1002/14651858.cd009416.pub2] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is currently no strong consensus regarding the optimal management of complex regional pain syndrome although a multitude of interventions have been described and are commonly used. OBJECTIVES To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the effectiveness of any therapeutic intervention used to reduce pain, disability or both in adults with complex regional pain syndrome (CRPS). METHODS We identified Cochrane reviews and non-Cochrane reviews through a systematic search of the following databases: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Ovid MEDLINE, Ovid EMBASE, CINAHL, LILACS and PEDro. We included non-Cochrane systematic reviews where they contained evidence not covered by identified Cochrane reviews. The methodological quality of reviews was assessed using the AMSTAR tool.We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes of quality of life, emotional well being and participants' ratings of satisfaction or improvement. Only evidence arising from randomised controlled trials was considered. We used the GRADE system to assess the quality of evidence. MAIN RESULTS We included six Cochrane reviews and 13 non-Cochrane systematic reviews. Cochrane reviews demonstrated better methodological quality than non-Cochrane reviews. Trials were typically small and the quality variable.There is moderate quality evidence that intravenous regional blockade with guanethidine is not effective in CRPS and that the procedure appears to be associated with the risk of significant adverse events.There is low quality evidence that bisphosphonates, calcitonin or a daily course of intravenous ketamine may be effective for pain when compared with placebo; graded motor imagery may be effective for pain and function when compared with usual care; and that mirror therapy may be effective for pain in post-stroke CRPS compared with a 'covered mirror' control. This evidence should be interpreted with caution. There is low quality evidence that local anaesthetic sympathetic blockade is not effective. Low quality evidence suggests that physiotherapy or occupational therapy are associated with small positive effects that are unlikely to be clinically important at one year follow up when compared with a social work passive attention control.For a wide range of other interventions, there is either no evidence or very low quality evidence available from which no conclusions should be drawn. AUTHORS' CONCLUSIONS There is a critical lack of high quality evidence for the effectiveness of most therapies for CRPS. Until further larger trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult.
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Affiliation(s)
- Neil E O'Connell
- Centre for Research in Rehabilitation, School of Health Sciences and Social Care, Brunel University, Uxbridge, UK.
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Goebel A. Management of adult patients with long-standing complex regional pain syndrome. Pain Manag 2013; 3:137-46. [DOI: 10.2217/pmt.13.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
SUMMARY Approximately 15% of patients with complex regional pain syndrome will experience no improvement in their condition within the first 12 months. This group should be considered as having a long-term condition. Recently published clinical studies and national guidelines can support clinicians to devise rational approaches to the management of this group; however, conclusive evidence is still lacking for almost all aspects of care. A multidisciplinary approach to managing long-standing complex regional pain syndrome appears best suited to ensure high-quality care. This should allow effective functional rehabilitation. Unfortunately, however, meaningful pain relief is often not achieved with currently available treatment methods. Recently published novel treatment approaches will probably provide more patients with long-term pain relief in the future, but confirmatory trials are required.
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Affiliation(s)
- Andreas Goebel
- Pain Research Institute & Centre for Immune Studies in Pain, Department of Translational Medicine, Liverpool University, Liverpool, UK and The Walton Centre NHS Foundation Trust, Liverpool, UK
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Levy RM. Evidence-Based Review of Neuromodulation for Complex Regional Pain Syndrome: A Conflict Between Faith and Science? Neuromodulation 2012. [DOI: 10.1111/j.1525-1403.2012.00531.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Robert M. Levy
- Neuromodulation: Technology at the Neural Interface; 655 West 8th Street; Jacksonville ; FL; 32209; USA
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Cossins L, Okell RW, Cameron H, Simpson B, Poole HM, Goebel A. Treatment of complex regional pain syndrome in adults: a systematic review of randomized controlled trials published from June 2000 to February 2012. Eur J Pain 2012; 17:158-73. [PMID: 23042687 DOI: 10.1002/j.1532-2149.2012.00217.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2012] [Indexed: 12/17/2022]
Abstract
Complex regional pain syndrome (CRPS) is a disabling pain condition with sensory, motor and autonomic manifestations. Uncertainty remains about how CRPS can be effectively managed. We conducted a systematic review of randomized controlled trials (RCTs) for treatment and prophylactic interventions for CRPS published during the period 2000-2012, building on previous work by another group reviewing the period 1966-2000. Bibliographic database searches identified 173 papers which were filtered by three reviewers. This process generated 29 trials suitable for further analysis, each of which was reviewed and scored by two independent reviewers for methodological quality using a 15-item checklist. A number of novel and potentially effective treatments were investigated. Analysing the results from both review periods in combination, there was a steep rise in the number of published RCTs per review decade. There is evidence for the efficacy of 10 treatments (3× strong--bisphosphonates, repetitive transcranial magnetic stimulation and graded motor imagery, 1× moderate and 6× limited evidence), and against the efficacy of 15 treatments (1× strong, 1× moderate and ×13 limited). The heterogeneity of trialled interventions and the pilot nature of many trials militate against drawing clear conclusions about the clinical usefulness of most interventions. This and the observed phenomenon of excellent responses in CRPS subgroups would support the case for a network- and multi-centre approach in the conduct of future clinical trials. Most published trials in CRPS are small with a short follow-up period, although several novel interventions investigated from 2000 to 2012 appear promising.
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Affiliation(s)
- L Cossins
- Pain Research Institute, Clinical Sciences Centre, University Hospital Aintree, Liverpool, UK
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Calvo M, Dawes JM, Bennett DLH. The role of the immune system in the generation of neuropathic pain. Lancet Neurol 2012; 11:629-42. [PMID: 22710756 DOI: 10.1016/s1474-4422(12)70134-5] [Citation(s) in RCA: 314] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Persistent pain is a sequela of several neurological conditions with a primary immune basis, such as Guillain-Barré syndrome and multiple sclerosis. Additionally, diverse forms of injury to the peripheral or the central nervous systems--whether traumatic, metabolic, or toxic--result in substantial recruitment and activation of immune cells. This response involves the innate immune system, but evidence also exists of T-lymphocyte recruitment, and in some patient cohorts antibodies to neuronal antigens have been reported. Mediators released by immune cells, such as cytokines, sensitise nociceptive signalling in the peripheral and central nervous systems. Preclinical data suggest an immune pathogenesis of neuropathic pain, but clinical evidence of a central role of the immune system is less clear. An important challenge for the future is to establish to what extent this immune response initiates or maintains neuropathic pain in patients and thus whether it is amenable to therapy.
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Affiliation(s)
- Margarita Calvo
- Department of Neurorestoration, Wolfson CARD, King's College London, London, UK
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37
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Abstract
PURPOSE OF REVIEW To address the issues of the scale and diversity of chronic pain in neurological disorders and the evidence for effective treatment of pain in these conditions. RECENT FINDINGS Contemporary literature supports the notion that pain in neurological conditions is common and has tended to be underestimated. SUMMARY Pain in neurological disease displays great diversity in putative mechanisms and clinical presentation. Rational management requires an analysis of likely mechanisms of pain generation as a guide to treatment. Some common neurological disorders are briefly discussed, primarily to provide an indication of the range of pain phenotypes observed across the spectrum of neurological disease. Treatments are reviewed with an emphasis on systemic drugs and the current best evidence for their use.
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Effect of immunomodulating medications in complex regional pain syndrome: a systematic review. Clin J Pain 2012; 28:355-63. [PMID: 22001668 DOI: 10.1097/ajp.0b013e31822efe30] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Different mechanisms are involved in a complex network of interactions resulting in the painful and impairing disorder, complex regional pain syndrome (CRPS). There is convincing evidence that inflammation plays a pivotal role in the pathophysiology of CRPS. Immunomodulating medication reduces the manifestation of inflammation by acting on the mediators of inflammation. Therefore, as inflammation is involved in the pathophysiology of CRPS, immunomodulating medication in CRPS patients may prove beneficial. OBJECTIVES To describe the current empirical evidence for the efficacy of administering the most commonly used immunomodulating medication (ie, glucocorticoids, tumor necrosis factor-α antagonists, thalidomide, bisphosphonates, and immunoglobulins) in CRPS patients. METHODS PubMed was searched for original articles that investigated CRPS and the use of one of the abovementioned immunomodulating agents. RESULTS The search yielded 39 relevant articles: from these, information on study design, sample size, duration of disease, type and route of medication, primary outcome measures, and results was examined. DISCUSSION Theoretically, the use of immunomodulating medication could counteract the ongoing inflammation and might be an important step in improving a disabled hand or foot, leading to further recovery. However, more high-quality intervention studies are needed.
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Abstract
Complex regional pain syndrome (CRPS) is a highly painful, limb-confined condition, which arises usually after trauma. It is associated with a particularly poor quality of life, and large health-care and societal costs. The causes of CRPS remain unknown. The condition's distinct combination of abnormalities includes limb-confined inflammation and tissue hypoxia, sympathetic dysregulation, small fibre damage, serum autoantibodies, central sensitization and cortical reorganization. These features place CRPS at a crossroads of interests of several disciplines including rheumatology, pain medicine and neurology. Significant scientific and clinical advances over the past 10 years hold promise both for an improved understanding of the causes of CRPS, and for more effective treatments. This review summarizes current concepts of our understanding of CRPS in adults. Based on the results from systematic reviews, treatment approaches are discussed within the context of these concepts. The treatment of CRPS is multidisciplinary and aims to educate about the condition, sustain or restore limb function, reduce pain and provide psychological intervention. Results from recent randomized controlled trials suggest that it is possible that some patients whose condition was considered refractory in the past can now be effectively treated, but confirmatory trials are required. The review concludes with a discussion of the need for additional research.
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Affiliation(s)
- Andreas Goebel
- Pain Research Group and Centre for Immune Studies in Pain, Department of Translational Medicine, University of Liverpool, UK.
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40
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Binder A, Schattschneider J, Baron R. Complex Regional Pain Syndrome Type I (Reflex Sympathetic Dystrophy). Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Goebel A, DuToit N, Perez J, Huygen F. Anesthesiologists' Views on Using Immune Modulating Drugs in Pain Medicine. Pain Pract 2010; 11:344-52. [DOI: 10.1111/j.1533-2500.2010.00433.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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42
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Hansson P. Comment on the commentary by H. Breivik. Eur J Pain 2010; 14:456. [DOI: 10.1016/j.ejpain.2010.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Accepted: 03/26/2010] [Indexed: 10/19/2022]
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Breivik H. Merits of publishing a negative and prematurely ended study on intrathecal methylprednisolone for severe and longstanding complex regional pain syndrome (CRPS-I). Eur J Pain 2010; 14:453-5. [PMID: 20231108 DOI: 10.1016/j.ejpain.2010.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 02/13/2010] [Indexed: 01/23/2023]
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