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Watson CPN, Midha R, Ng DW. Causalgia: A Review of Nerve Resection, Amputation, Immunotherapy, and Amputated Limb CRPS II Pathology. Can J Neurol Sci 2024; 51:351-356. [PMID: 37489506 DOI: 10.1017/cjn.2023.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
BACKGROUND Causalgia and complex regional pain syndrome (CRPS) type II with nerve injury can be difficult to treat. Surgical peripheral nerve denervation for causalgia has been largely abandoned by pain clinicians because of a perception that this may aggravate a central component (anesthesia dolorosa). METHODS We selectively searched Pubmed, Cochrane, MEDLINE, EMBASE, CINAHL Plus, and Scopus from 1947 for articles, books, and book chapters for evidence of surgical treatments (nerve resection and amputation) and treatment related to autoimmunity and immune deficiency with CRPS. RESULTS Reviews were found for the treatment of causalgia or CRPS type II (n = 6), causalgia relieved by nerve resection (n = 6), and causalgia and CRPS II treated by amputation (n = 8). Twelve reports were found of autoimmunity with CRPS, one paper of these on associated immune deficiency and autoimmunity, and two were chosen for discussion regarding treatment with immunoglobulin and one by plasma exchange. We document a report of a detailed and unique pathological examination of a CRPS type II affected amputated limb and related successful treatment with immunoglobulin. CONCLUSIONS Nerve resection, with grafting, and relocation may relieve uncomplicated causalgia and CRPS type II in some patients in the long term. However, an unrecognized and treatable immunological condition may underly some CRPS II cases and can lead to the ultimate failure of surgical treatments.
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Affiliation(s)
| | - Rajiv Midha
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Calgary, AB, Canada
| | - Denise W Ng
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
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2
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Russo MA, Georgius P, Pires AS, Heng B, Allwright M, Guennewig B, Santarelli DM, Bailey D, Fiore NT, Tan VX, Latini A, Guillemin GJ, Austin PJ. Novel immune biomarkers in complex regional pain syndrome. J Neuroimmunol 2020; 347:577330. [PMID: 32731051 DOI: 10.1016/j.jneuroim.2020.577330] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 02/07/2023]
Abstract
We investigated serum levels of 29 cytokines and immune-activated kynurenine and tetrahydrobiopterin pathway metabolites in 15 complex regional pain syndrome (CRPS) subjects and 14 healthy controls. Significant reductions in interleukin-37 and tryptophan were found in CRPS subjects, along with positive correlations between kynurenine/tryptophan ratio and TNF-α levels with kinesiophobia, tetrahydrobiopterin levels with McGill pain score, sRAGE, and xanthurenic acid and neopterin levels with depression, anxiety and stress scores. Using machine learning, we identified a set of binary variables, including IL-37 and GM-CSF, capable of distinguishing controls from established CRPS subjects. These results suggest possible involvement of various inflammatory markers in CRPS pathogenesis.
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Affiliation(s)
- Marc A Russo
- Hunter Pain Specialists, 91 Chatham Street, Broadmeadow, NSW, 2292, Australia; Genesis Research Services, 220 Denison St, Broadmeadow, NSW, 2292, Australia
| | - Peter Georgius
- Pain Rehab, Suite 4 Noosa Central, 6 Bottlebrush Avenue, Sunshine Coast, QLD, 4567, Australia
| | - Ananda Staats Pires
- Neuroinflammation Group; Department of Biomedical Sciences, Faculty of Medicine and Health Sciences; Macquarie University, Sydney, NSW, 2109, Australia; Laboratório de Bioenergética e Estresse Oxidativo, LABOX; Departamento de Bioquímica, CCB; Universidade Federal de Santa Catarina; Florianópolis / SC, Brazil
| | - Benjamin Heng
- Neuroinflammation Group; Department of Biomedical Sciences, Faculty of Medicine and Health Sciences; Macquarie University, Sydney, NSW, 2109, Australia
| | - Michael Allwright
- ForeFront, Brain & Mind Centre, The University of Sydney, NSW, 2006, Australia
| | - Boris Guennewig
- ForeFront, Brain & Mind Centre, The University of Sydney, NSW, 2006, Australia
| | | | - Dominic Bailey
- Genesis Research Services, 220 Denison St, Broadmeadow, NSW, 2292, Australia
| | - Nathan T Fiore
- Discipline of Anatomy & Histology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia
| | - Vanessa X Tan
- Neuroinflammation Group; Department of Biomedical Sciences, Faculty of Medicine and Health Sciences; Macquarie University, Sydney, NSW, 2109, Australia
| | - Alexandra Latini
- Laboratório de Bioenergética e Estresse Oxidativo, LABOX; Departamento de Bioquímica, CCB; Universidade Federal de Santa Catarina; Florianópolis / SC, Brazil
| | - Gilles J Guillemin
- Neuroinflammation Group; Department of Biomedical Sciences, Faculty of Medicine and Health Sciences; Macquarie University, Sydney, NSW, 2109, Australia
| | - Paul J Austin
- Discipline of Anatomy & Histology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, NSW, 2006, Australia.
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Shoenfeld Y, Ryabkova VA, Scheibenbogen C, Brinth L, Martinez-Lavin M, Ikeda S, Heidecke H, Watad A, Bragazzi NL, Chapman J, Churilov LP, Amital H. Complex syndromes of chronic pain, fatigue and cognitive impairment linked to autoimmune dysautonomia and small fiber neuropathy. Clin Immunol 2020; 214:108384. [PMID: 32171889 DOI: 10.1016/j.clim.2020.108384] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 12/21/2022]
Abstract
Chronic fatigue syndrome, postural orthostatic tachycardia syndrome, complex regional pain syndrome and silicone implant incompatibility syndrome are a subject of debate among clinicians and researchers. Both the pathogenesis and treatment of these disorders require further study. In this paper we summarize the evidence regarding the role of autoimmunity in these four syndromes with respect to immunogenetics, autoimmune co-morbidities, alteration in immune cell subsets, production of autoantibodies and presentation in animal models. These syndromes could be incorporated in a new concept of autoimmune neurosensory dysautonomia with the common denominators of autoantibodies against G-protein coupled receptors and small fiber neuropathy. Sjogren's syndrome, which is a classical autoimmune disease, could serve as a disease model, illustrating the concept. Development of this concept aims to identify an apparently autoimmune subgroup of the disputable disorders, addressed in the review, which may most benefit from the immunotherapy.
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Affiliation(s)
- Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv, Israel; Laboratory of the Mosaics of Autoimmunity, Saint Petersburg State University, Russia.
| | - Varvara A Ryabkova
- Laboratory of the Mosaics of Autoimmunity, Saint Petersburg State University, Russia
| | - Carmen Scheibenbogen
- Institute for Medical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Louise Brinth
- Department of Nuclear Medicine, Herlev Gentofte Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Manuel Martinez-Lavin
- Rheumatology Department, National Institute of Cardiology, Juan Badiano 1, 14080 Mexico City, Mexico
| | - Shuichi Ikeda
- Intractable Disease Care Center, Shinshu University Hospital, Matsumoto 390-0802, Japan
| | | | - Abdulla Watad
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv, Israel; Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
| | - Nicola L Bragazzi
- Postgraduate School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Joab Chapman
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv, Israel
| | - Leonid P Churilov
- Laboratory of the Mosaics of Autoimmunity, Saint Petersburg State University, Russia
| | - Howard Amital
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Aviv, Israel
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4
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Russo MA, Fiore NT, van Vreden C, Bailey D, Santarelli DM, McGuire HM, Fazekas de St Groth B, Austin PJ. Expansion and activation of distinct central memory T lymphocyte subsets in complex regional pain syndrome. J Neuroinflammation 2019; 16:63. [PMID: 30885223 PMCID: PMC6423749 DOI: 10.1186/s12974-019-1449-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/28/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a debilitating condition where trauma to a limb results in devastating persistent pain that is disproportionate to the initial injury. The pathophysiology of CRPS remains unknown; however, accumulating evidence suggests it is an immunoneurological disorder, especially in light of evidence of auto-antibodies in ~ 30% of patients. Despite this, a systematic assessment of all circulating leukocyte populations in CRPS has never been performed. METHODS We characterised 14 participants as meeting the Budapest clinical criteria for CRPS and assessed their pain ratings and psychological state using a series of questionnaires. Next, we performed immunophenotyping on blood samples from the 14 CRPS participants as well as 14 healthy pain-free controls using mass cytometry. Using a panel of 38 phenotypic and activation markers, we characterised the numbers and intracellular activation status of all major leukocyte populations using manual gating strategies and unsupervised cluster analysis. RESULTS We have shown expansion and activation of several distinct populations of central memory T lymphocytes in CRPS. The number of central memory CD8+ T cells was increased 2.15-fold; furthermore, this cell group had increased phosphorylation of NFkB and STAT1 compared to controls. Regarding central memory CD4+ T lymphocytes, the number of Th1 and Treg cells was increased 4.98-fold and 2.18-fold respectively, with increased phosphorylation of NFkB in both populations. We also found decreased numbers of CD1c+ myeloid dendritic cells, although with increased p38 phosphorylation. These changes could indicate dendritic cell tissue trafficking, as well as their involvement in lymphocyte activation. CONCLUSIONS These findings represent the first mass cytometry immunophenotyping study in any chronic pain state and provide preliminary evidence of an antigen-mediated T lymphocyte response in CRPS. In particular, the presence of increased numbers of long-lived central memory CD4+ and CD8+ T lymphocytes with increased activation of pro-inflammatory signalling pathways may indicate ongoing inflammation and cellular damage in CRPS.
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Affiliation(s)
- Marc A. Russo
- Hunter Pain Clinic, 91 Chatham Street, Broadmeadow, NSW 2292 Australia
- Genesis Research Services, 220 Denison St, Broadmeadow, NSW 2292 Australia
| | - Nathan T. Fiore
- Discipline of Anatomy & Histology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Room E513, Anderson Stuart Building, Sydney, NSW 2006 Australia
| | - Caryn van Vreden
- Ramaciotti Centre for Human Systems Biology, Charles Perkins Centre, The University of Sydney, Sydney, NSW 2006 Australia
- Sydney Cytometry, Centenary Institute and the Charles Perkins Centre, John Hopkins Drive, Camperdown, NSW 2050 Australia
| | - Dominic Bailey
- Genesis Research Services, 220 Denison St, Broadmeadow, NSW 2292 Australia
| | | | - Helen M. McGuire
- Ramaciotti Centre for Human Systems Biology, Charles Perkins Centre, The University of Sydney, Sydney, NSW 2006 Australia
- Discipline of Pathology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia
| | - Barbara Fazekas de St Groth
- Ramaciotti Centre for Human Systems Biology, Charles Perkins Centre, The University of Sydney, Sydney, NSW 2006 Australia
- Discipline of Pathology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006 Australia
| | - Paul J. Austin
- Discipline of Anatomy & Histology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Room E513, Anderson Stuart Building, Sydney, NSW 2006 Australia
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5
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David Clark J, Tawfik VL, Tajerian M, Kingery WS. Autoinflammatory and autoimmune contributions to complex regional pain syndrome. Mol Pain 2018; 14:1744806918799127. [PMID: 30124090 PMCID: PMC6125849 DOI: 10.1177/1744806918799127] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a highly enigmatic syndrome typically developing after injury or surgery to a limb. Severe pain and disability are common among those with chronic forms of this condition. Accumulating evidence suggests that CRPS may involve both autoinflammatory and autoimmune components. In this review article, evidence for dysfunction of both the innate and adaptive immune systems in CRPS is presented. Findings from human studies in which cytokines and other inflammatory mediators were measured in the skin of affected limbs are discussed. Additional results from studies of mediator levels in animal models are evaluated in this context. Similarly, the evidence from human, animal, and translational studies of the production of autoantibodies and the potential targets of those antibodies is reviewed. Compelling evidence of autoinflammation in skin and muscle of the affected limb has been collected from CRPS patients and laboratory animals. Cytokines including IL-1β, IL-6, TNFα, and others are reliably identified during the acute phases of the syndrome. More recently, autoimmune contributions have been suggested by the discovery of self-directed pain-promoting IgG and IgM antibodies in CRPS patients and model animals. Both the autoimmune and the autoinflammatory components of CRPS appear to be regulated by neuropeptide-containing peripheral nerve fibers and the sympathetic nervous system. While CRPS displays a complex neuroimmunological pathogenesis, therapeutic interventions could be designed targeting autoinflammation, autoimmunity, or the neural support for these phenomena.
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Affiliation(s)
- J David Clark
- 1 Anesthesiology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.,2 Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Vivianne L Tawfik
- 2 Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Maral Tajerian
- 2 Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Wade S Kingery
- 3 Palo Alto Veterans Institute for Research, Palo Alto, CA, USA
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6
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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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7
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Reilly JM, Dharmalingam B, Marsh SJ, Thompson V, Goebel A, Brown DA. Effects of serum immunoglobulins from patients with complex regional pain syndrome (CRPS) on depolarisation-induced calcium transients in isolated dorsal root ganglion (DRG) neurons. Exp Neurol 2015; 277:96-102. [PMID: 26708558 DOI: 10.1016/j.expneurol.2015.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 12/10/2015] [Accepted: 12/15/2015] [Indexed: 12/28/2022]
Abstract
Complex regional pain syndrome (CRPS) is thought to have an auto-immune component. One such target recently proposed from the effects of auto-immune IgGs on Ca(2+) transients in cardiac myocytes and cell lines is the α1-adrenoceptor. We have tested whether such IgGs exerted comparable effects on nociceptive sensory neurons isolated from rat dorsal root ganglia. Depolarisation-induced [Ca(2+)]i transients were generated by applying 30 mM KCl for 2 min and monitored by Fura-2 fluorescence imaging. No IgGs tested (including 3 from CRPS patients) had any significant effect on these [Ca(2+)]i transients. However, IgG from one CRPS patient consistently and significantly reduced the K(+)-induced response of cells that had been pre-incubated for 24h with a mixture of inflammatory mediators (1 μM histamine, 5-hydroxytryptamine, bradykinin and PGE2). Since this pre-incubation also appeared to induce a comparable inhibitory response to the α1-agonist phenylephrine, this is compatible with the α1-adrenoceptor as a target for CRPS auto-immunity. A mechanism whereby this might enhance pain is suggested.
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Affiliation(s)
- Joanne M Reilly
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Backialakshmi Dharmalingam
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, WC1E 6BT, UK; Pain Research Institute, Department of Translational Medicine, University of Liverpool, Liverpool, L9 7AL, UK
| | - Stephen J Marsh
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Victoria Thompson
- Pain Research Institute, Department of Translational Medicine, University of Liverpool, Liverpool, L9 7AL, UK
| | - Andreas Goebel
- Pain Research Institute, Department of Translational Medicine, University of Liverpool, Liverpool, L9 7AL, UK.
| | - David A Brown
- Department of Neuroscience, Physiology and Pharmacology, University College London, Gower Street, London, WC1E 6BT, UK
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8
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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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9
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Huygen F, Verschueren K, McCabe C, Stegmann JU, Zima J, Mahaux O, Van Holle L, Angelo MG. Investigating Reports of Complex Regional Pain Syndrome: An Analysis of HPV-16/18-Adjuvanted Vaccine Post-Licensure Data. EBioMedicine 2015; 2:1114-21. [PMID: 26501109 PMCID: PMC4587999 DOI: 10.1016/j.ebiom.2015.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/30/2015] [Accepted: 07/01/2015] [Indexed: 12/03/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain disorder that typically follows trauma or surgery. Suspected CRPS reported after vaccination with human papillomavirus (HPV) vaccines led to temporary suspension of proactive recommendation of HPV vaccination in Japan. We investigated the potential CRPS signal in relation to HPV-16/18-adjuvanted vaccine (Cervarix®) by database review of CRPS cases with independent expert confirmation; a disproportionality analysis and analyses of temporality; an observed versus expected analysis using published background incidence rates; systematic reviews of aggregate safety data, and a literature review. The analysis included 17 case reports of CRPS: 10 from Japan (0.14/100,000 doses distributed) and seven from the United Kingdom (0.08/100,000). Five cases were considered by independent experts to be confirmed CRPS. Quantitative analyses did not suggest an association between CRPS and HPV-16/18-adjuvanted vaccine. Observed CRPS incidence after HPV-16/18 vaccination was statistically significantly below expected rates. Systematic database reviews using search terms varying in specificity and sensitivity did not identify new cases. No CRPS was reported during clinical development and no unexpected results found in the literature. There is not sufficient evidence to suggest an increased risk of developing CRPS following vaccination with HPV-16/18-adjuvanted vaccine. Post-licensure safety surveillance confirms the acceptable benefit-risk of HPV-16/18 vaccination. GSK investigated a potential safety signal after suspected CRPS cases were reported following HPV vaccination in Japan Little is known of CRPS. We used database reviews and statistical methods to maximise case detection and reduce uncertainty There is not sufficient evidence to suggest an increased risk of CRPS following HPV-16/18-adjuvanted vaccine
In 2013 the Japanese health authority temporarily suspended proactive recommendation of HPV vaccination after reports of a chronic pain condition (CRPS) in Japan. GSK, who manufactures one of the two available HPV vaccines (Cervarix®), investigated this potential safety issue by reviewing its safety database for all cases of CRPS ever reported after HPV vaccination, and by various statistical analyses. None of the reviews or analyses suggested a safety concern. The observed rate of CRPS after vaccination was lower than what might be expected by chance. At this time there is not enough evidence to suggest that Cervarix® causes CRPS.
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Affiliation(s)
- Frank Huygen
- Center for Pain Medicine, Erasmus MC, University Hospital, Rotterdam 3000CA, The Netherlands
- Corresponding author at: Center for Pain Medicine, Erasmus MC, University Hospital, PO Box 2040, Rotterdam 3000CA, The Netherlands.
| | - Kristin Verschueren
- Safety Evaluation and Risk Management, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| | - Candida McCabe
- Bath Centre for Pain Services, Royal National Hospital for Rheumatic Diseases, Bath, BA1 1RL, United Kingdom
- University of the West of England, Bristol, BS16 1DD, United Kingdom
| | - Jens-Ulrich Stegmann
- Vaccines Clinical Safety and Pharmacovigilance, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| | - Julia Zima
- Safety Evaluation and Risk Management, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| | - Olivia Mahaux
- Vaccines Safety and Research Group, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| | - Lionel Van Holle
- Vaccines Safety and Research Group, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
| | - Maria-Genalin Angelo
- Safety Evaluation and Risk Management, GSK Vaccines, 20 Avenue Fleming, B-1300 Wavre, Belgium
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10
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The prevalence of autoantibodies in complex regional pain syndrome type I. Mediators Inflamm 2015; 2015:718201. [PMID: 25741131 PMCID: PMC4337272 DOI: 10.1155/2015/718201] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 01/25/2015] [Accepted: 01/26/2015] [Indexed: 01/22/2023] Open
Abstract
Autoimmunity has been suggested as one of the pathophysiologic mechanisms that may underlie complex regional pain syndrome (CRPS). Screening for antinuclear antibodies (ANA) is one of the diagnostic tests, which is usually performed if a person is suspected to have a systemic autoimmune disease. Antineuronal antibodies are autoantibodies directed against antigens in the central and/or peripheral nervous system. The aim of this study was to compare the prevalence of these antibodies in CRPS patients with the normal values of those antibodies in the healthy population.
Twenty seven (33%) of the 82 CRPS patients of whom serum was available showed a positive ANA test. This prevalence is significantly higher than in the general population. Six patients (7.3%) showed a positive result for typical antineuronal antibodies. This proportion, however, does not deviate from that in the general population. Our findings suggest that autoantibodies may be associated with the pathophysiology of CRPS, at least in a subset of patients. Further research is needed into defining this subset and into the role of autoantibodies in the pathogenesis of CRPS.
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11
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Dalakas MC, Löscher WN. 7th International Immunoglobulin Conference: Interlaken Leadership Awards. Clin Exp Immunol 2014; 178 Suppl 1:124-6. [PMID: 25546789 DOI: 10.1111/cei.12538] [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: 11/26/2022] Open
Abstract
The Interlaken Leadership Awards (ILAs), established in 2010, are monetary grants pledged annually by CSL Behring to fund research into the use of immunoglobulin (Ig) therapy, especially into its use in neurological disorders. Five recipients of the 2011/2012 Awards were invited to present their research at the 7th International Immunoglobulin Conference. Dr Honnorat reports on paraneoplastic neurological syndromes (PNS). His multi-centre Phase II trial, currently under way, will assess the efficacy of IVIg therapy in treating PNS in the first 3 months of treatment. Dr Geis shows improved disease scores after IVIg treatment in a mouse model of neuromyelitis optica (NMO). It is hoped that these promising results will translate well into human NMO. Dr Schmidt studied IVIg therapy in an mdx mouse model for Duchenne muscular dystrophy (DMD). He reports that motor function improved and myopathic changes in skeletal muscles and creatine kinase release were decreased. Dr Gamez presents the design and rationale for a Phase II clinical trial investigating the preoperative use of IVIg therapy in myasthenia gravis patients to prevent post-operative myasthenic crisis. Dr Goebel reports results from studies elucidating the immune-mediated pathogenesis of complex regional pain syndrome (CRPS), the successful IVIg therapy in a proportion of CRPS patients, and the development of a model for predicting which patients are more likely to respond to Ig therapy.
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Affiliation(s)
- M C Dalakas
- University of Athens Medical School, Athens, Greece; Thomas Jefferson University, Philadelphia, PA, USA
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12
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Goebel A. Cellular and behavioural models to predict responses to immunoglobulin G treatment in complex regional pain syndrome. Clin Exp Immunol 2014; 178 Suppl 1:136-7. [PMID: 25546794 DOI: 10.1111/cei.12543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- A Goebel
- The Walton Centre and University of Liverpool, Liverpool, UK
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13
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Longstanding complex regional pain syndrome is associated with activating autoantibodies against alpha-1a adrenoceptors. Pain 2014; 155:2408-17. [DOI: 10.1016/j.pain.2014.09.022] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/09/2014] [Accepted: 09/16/2014] [Indexed: 11/22/2022]
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14
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Blaes F, Dharmalingam B, Tschernatsch M, Feustel A, Fritz T, Kohr D, Singh P, Kaps M, Szalay G. Improvement of complex regional pain syndrome after plasmapheresis. Eur J Pain 2014; 19:503-7. [DOI: 10.1002/ejp.572] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2014] [Indexed: 11/10/2022]
Affiliation(s)
- F. Blaes
- Department of Neurology; Justus Liebig University; Giessen Germany
- Department of Neurology; Gummersbach Hospital; Gummersbach Germany
| | - B. Dharmalingam
- Department of Neurology; Justus Liebig University; Giessen Germany
| | - M. Tschernatsch
- Department of Neurology; Justus Liebig University; Giessen Germany
| | - A. Feustel
- Department of Internal Medicine; Justus Liebig University; Giessen Germany
| | - T. Fritz
- Department of Anaesthesiology; Justus Liebig University; Giessen Germany
| | - D. Kohr
- Department of Neurology; Justus Liebig University; Giessen Germany
| | - P. Singh
- Department of Neurology; Justus Liebig University; Giessen Germany
| | - M. Kaps
- Department of Neurology; Justus Liebig University; Giessen Germany
| | - G. Szalay
- Department of Trauma Surgery; Justus Liebig University; Giessen Germany
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15
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Schlereth T, Drummond PD, Birklein F. Inflammation in CRPS: role of the sympathetic supply. Auton Neurosci 2013; 182:102-7. [PMID: 24411269 DOI: 10.1016/j.autneu.2013.12.011] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/11/2013] [Indexed: 12/21/2022]
Abstract
Acute Complex Regional Pain Syndrome (CRPS) is associated with signs of inflammation such as increased skin temperature, oedema, skin colour changes and pain. Pro-inflammatory cytokines (tumour necrosis factor-α (TNF-α), interleukin-2 (IL-2), IL-1beta, IL-6) are up-regulated, whereas anti-inflammatory cytokines (IL-4, IL-10) are diminished. Adaptive immunity seems to be involved in CRPS pathophysiology as many patients have autoantibodies directed against β2 adrenergic and muscarinic-2 receptors. In an animal tibial fracture model changes in the innate immune response such as up-regulation of keratinocytes are also found. Additionally, CRPS is accompanied by increased neurogenic inflammation which depends mainly on neuropeptides such as CGRP and Substance P. Besides inflammatory signs, sympathetic nervous system involvement in CRPS results in cool skin, increased sweating and sympathetically-maintained pain. The norepinephrine level is lower in the CRPS-affected than contralateral limb, but sympathetic sprouting and up-regulation of alpha-adrenoceptors may result in an adrenergic supersensitivity. The sympathetic nervous system and inflammation interact: norepinephrine influences the immune system and the production of cytokines. There is substantial evidence that this interaction contributes to the pathophysiology and clinical presentation of CRPS, but this interaction is not straightforward. How inflammation in CRPS might be exaggerated by sympathetic transmitters requires further elucidation.
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Affiliation(s)
- Tanja Schlereth
- Department of Neurology, Langenbeckstr, 1, D-55131 Mainz, Germany.
| | - Peter D Drummond
- School of Psychology and Exercise Science, Murdoch University, 6150 Western Australia, Australia
| | - Frank Birklein
- Department of Neurology, Langenbeckstr, 1, D-55131 Mainz, Germany
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Goebel A, Blaes F. Complex regional pain syndrome, prototype of a novel kind of autoimmune disease. Autoimmun Rev 2013; 12:682-6. [DOI: 10.1016/j.autrev.2012.10.015] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2012] [Indexed: 11/28/2022]
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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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Beerthuizen A, Stronks DL, Van't Spijker A, Yaksh A, Hanraets BM, Klein J, Huygen FJPM. Demographic and medical parameters in the development of complex regional pain syndrome type 1 (CRPS1): prospective study on 596 patients with a fracture. Pain 2012; 153:1187-1192. [PMID: 22386473 DOI: 10.1016/j.pain.2012.01.026] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 01/20/2012] [Accepted: 01/26/2012] [Indexed: 02/08/2023]
Abstract
Limited data are available on the incidence of complex regional pain syndrome type 1 (CRPS1) and on demographic and medical risk factors for the development of CRPS1. The objective of this study was to investigate the incidence of CRPS1 in patients with a fracture using 3 sets of diagnostic criteria and to evaluate the association between demographic/medical factors and the development of CRPS1 diagnosed with the Harden and Bruehl criteria. A prospective multicenter cohort study of 596 patients (ages 18 years and older) with a single fracture of the wrist, scaphoid, ankle, or metatarsal V, recruited patients from the emergency rooms of 3 Dutch hospitals. Of the 596 participants, 42 (7.0%) were diagnosed with CRPS1 according to the Harden and Bruehl criteria, 289 (48.5%) according to the International Association for the Study of Pain criteria, and 127 (21.3%) according to the criteria of Veldman. An analysis of the medical and demographic differences revealed that patients in whom CRPS1 later developed more often had intra-articular fractures, fracture dislocations, rheumatoid arthritis, or musculoskeletal comorbidities. An ankle fracture, dislocation, and an intra-articular fracture contributed significantly to the prediction of the development of CRPS1. No CRPS1 patients were symptom free at 12 months (T3). At baseline, patients with CRPS1 had significantly more pain than patients without CRPS1 (P<.001). The incidence of the diagnosis of CRPS1 after a single fracture depends to a large extent on the diagnostic criteria used. After a fracture, 7% of the patients developed CRPS1 and none of the patients were free of symptoms at 1-year follow-up.
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Affiliation(s)
- Annemerle Beerthuizen
- Department of Medical Psychology and Psychotherapy, Erasmus MC, Rotterdam, The Netherlands Department of Anesthesiology and Pain Management, Erasmus MC, Rotterdam, The Netherlands Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Ludwig J, Gorodetskaya N, Schattschneider J, Jänig W, Baron R. Behavioral and sensory changes after direct ischemia-reperfusion injury in rats. Eur J Pain 2012; 11:677-84. [PMID: 17174127 DOI: 10.1016/j.ejpain.2006.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2006] [Revised: 10/10/2006] [Accepted: 10/22/2006] [Indexed: 11/30/2022]
Abstract
Complex regional pain syndromes (CRPS) are disabling pain syndromes that can develop after trauma or minor tissue injury affecting a limb. Characteristics of CRPS are sensory signs and symptoms, autonomic abnormalities, trophic changes and an impaired motor function. Pathophysiological mechanisms for the development of CRPS are still a matter of investigation. Based on clinical data and investigations of CRPS patients it is hypothesized that tissue hypoxia and inflammation are important for the development of CRPS. The aim of the current study was therefore to examine if direct ischemia-reperfusion injury can induce behavior in rats with symptoms present in patients with CRPS. After baseline behavior measurements the femoral artery of Wistar rats was ligated for 3h with consecutive reperfusion. Sham-operated rats underwent the same preparation except ligation of the artery. Subsequent behavioral testing (observations of spontaneous pain behavior, paw withdrawal to mechanical, noxious mechanical, cold and heat stimuli) was performed up to two months after surgery. Both in rats that underwent ischemia and in sham-operated rats no obvious changes of hindpaw tissue were observed after ischemia-reperfusion injury (trophic changes, edema, differences in skin color or temperature). In behavioral tests only minor changes were observed, these being not different between postischemic rats and sham-operated rats. Using Wistar rats, our data do not support the idea that an ischemia-reperfusion injury can play a major role in the development of CRPS.
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Affiliation(s)
- Janne Ludwig
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Schittenhelmstrasse 10, Kiel, Germany.
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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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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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The passive transfer of immunoglobulin G serum antibodies from patients with longstanding Complex Regional Pain Syndrome. Eur J Pain 2010; 15:504.e1-6. [PMID: 21075025 DOI: 10.1016/j.ejpain.2010.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 10/18/2010] [Accepted: 10/18/2010] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aetiology of Complex Regional Pain Syndrome (CRPS) is unknown. Recent evidence suggests that there may be autoantibodies directed against peripheral nerves, but it is unclear whether such autoantibodies are merely biomarkers or whether they cause or contribute to the underlying pathology. The transfer of disease after injection of a patient's serum or IgG fraction into mice ('passive transfer') is the classic way to demonstrate a functional role of autoantibodies. AIMS Based on previous preliminary results, we wished to investigate whether the transfer of IgG antibodies affected mouse behaviour or produced signs of CRPS. METHODS We injected purified serum-IgG from 12 patients and 12 controls into groups of 6-10 mice (∼ 17 mg/mouse intraperitoneally) on 2 consecutive days and looked for any evidence for altered behaviour or signs of CRPS. The observer, blinded as to test or control group, measured behaviour in the open field, stimulus-evoked pain and motor coordination, and inspected limbs for autonomic CRPS signs. RESULTS Stimulus-evoked pain and autonomic signs were not detected, but CRPS-IgG induced significant depression of rearing behaviour (17.9 rears/3 min (n = 84) vs. 22.1 rears/3 min (n = 83), p = 0.0004), confirming previous observations in a single case study. Moreover, motor impairment, one of the four cardinal signs of CRPS, was evident in the three CRPS-IgG injected groups tested with a sensitive rota-rod protocol (p < 0.0001 vs. control-IgG injected groups). CONCLUSIONS These results lend support to a pathophysiological role for IgG autoantibodies in CRPS.
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Muthuraman A, Sood S. Pharmacological evaluation of tacrolimus (FK-506) on ischemia reperfusion induced vasculatic neuropathic pain in rats. J Brachial Plex Peripher Nerve Inj 2010; 5:13. [PMID: 20529260 PMCID: PMC2890670 DOI: 10.1186/1749-7221-5-13] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Accepted: 06/07/2010] [Indexed: 01/09/2023] Open
Abstract
Background Ischemia reperfusion (I/R) is common in various pathological conditions like diabetic complication, rheumatic arthritis, necrotizing vascular occlusive disease and trauma. Methods We have evaluated the effect of tacrolimus (1, 2 and 3 mg/kg, p.o. for 10 consecutive days) on femoral arterial ischemic reperfusion (I/R) induced neuropathic pain in rats. Behavioral parameters (i.e. hot plate, radiant heat, acetone drop, tail heat hyperalgesia, tail flick and tail cold allodynia tests) were assessed at different time intervals (i.e. 0, 1, 4, 7, 10, 13 and 16th day) and biochemical analysis in serum and tissue samples were also performed along with histopathological studies. Results Behavioral pain assessment revealed increase in the paw and tail withdrawal threshold in tacrolimus treated groups against hyperalgesic and allodynic stimuli as compared to the sham control group. We observed a decrease in the serum nitrate and thiobarbituric acid reactive substance (TBARS) levels along with reduction in tissue myeloperoxidase (MPO) and total calcium levels, whereas, rise in tissue reduced glutathione levels in tacrolimus treated groups. However, significant results were obtained in medium and high dose treated group as compared to sham control group. Histopathological study had revealed the increase in the neuronal edema and axonal degeneration in the I/R group whereas, tacrolimus ameliorate these effects. Conclusion Our results indicate the anti-oxidative, anti-inflammatory and calcium modulatory actions of tacrolimus. Therefore, it can be used as a therapeutic agent for the treatment of vascular inflammatory related neuropathic pain.
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Affiliation(s)
- Arunachalam Muthuraman
- Rayat institute of pharmacy, Ropar campus, Nawanshahr district, Railmajra, Near Ropar-144533, Punjab, India.
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Kohr D, Tschernatsch M, Schmitz K, Singh P, Kaps M, Schäfer KH, Diener M, Mathies J, Matz O, Kummer W, Maihöfner C, Fritz T, Birklein F, Blaes F. Autoantibodies in complex regional pain syndrome bind to a differentiation-dependent neuronal surface autoantigen. Pain 2009; 143:246-251. [DOI: 10.1016/j.pain.2009.03.009] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2008] [Revised: 03/03/2009] [Accepted: 03/10/2009] [Indexed: 11/24/2022]
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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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IVIg in other autoimmune neurological disorders: current status and future prospects. J Neurol 2008; 255 Suppl 3:12-6. [DOI: 10.1007/s00415-008-3004-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Blaes F, Tschernatsch M, Braeu ME, Matz O, Schmitz K, Nascimento D, Kaps M, Birklein F. Autoimmunity in complex-regional pain syndrome. Ann N Y Acad Sci 2007; 1107:168-73. [PMID: 17804544 DOI: 10.1196/annals.1381.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Complex regional pain syndrome (CRPS) is an etiologically unclear syndrome with the main symptoms being pain, trophic and autonomic disturbances, and functional impairment that develops after limb trauma or operation and is located at the distal site of the affected limb. Because autoantibodies against nervous system structures have been described in these patients, an autoimmune etiology of CRPS is discussed. These autoantibodies bind to the surface of peripheral autonomic neurons. Using a competitive binding assay, it can be shown that at least some of the CRPS sera bind to the same neuronal epitope. Autoimmune etiology of CRPS is a new pathophysiological concept and may have severe impact on the treatment of this often chronic disease.
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Affiliation(s)
- F Blaes
- Department of Neurology, Justus-Liebig-University, Giessen, Germany.
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Binder A, Schattschneider J, Baron R. Complex Regional Pain Syndrome Type I (Reflex Sympathetic Dystrophy). Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50030-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Dalakas MC. Role of IVIg in autoimmune, neuroinflammatory and neurodegenerative disorders of the central nervous system: present and future prospects. J Neurol 2006; 253 Suppl 5:V25-32. [PMID: 16998751 DOI: 10.1007/s00415-006-5004-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Although IVIg is highly effective in several autoimmune neuromuscular disorders (neuropathies, myopathies and neuromuscular junction disorders), its effectiveness in autoimmune or neuroinflammatory CNS diseases, with the exception of multiple sclerosis, has not been explored. Emerging data suggest that IVIg may have a role not only in certain antibody-mediated CNS diseases but also in some neurodegenerative disorders associated with "neuroinflammation" mediated by proinflammatory cytokines. METHODS Data from a previously reported controlled study conducted in patients with stiff person syndrome (SPS) are presented as a paradigm of a CNS disorder associated with specific autoantibodies responding to IVIg. Emerging data using IVIg in various neuroinflammatory and neurodegenerative conditions such as Alzheimers disease, postpolio syndrome (PPS), fibrotic disorders, chronic painful conditions and narcoplepsy are summarized. RESULTS On the basis of a double-blind placebo-controlled trial conducted in SPS patients with high anti-GAD antibodies, IVIg was shown to be effective resulting in improvement of stiffness and heightened sensitivity scores and increasing the patients' ability to carry out daily activities. In SPS, IVIg also suppressed the anti-GAD antibodies titers probably via an anti-idiotypic effect. A controlled study in patients with PPS, showed reduction in cytokines in serum and CSF with concomitant improvement in the patients' strength and ability to carry out their daily activities. The effect of IVIg in a small number of patients with Alzheimer's disease was promising by reducing the ADAS-cog scores, suggesting a reversal of disease progression. IVIg has been shown to have an effect on tissue fibrosis and in certain subacute painful conditions by suppressing cytokines that mediate fibrosis or pain. In another uncontrolled study, IVIg reduced the number of cataplectic attacks in narcolepsy patients. CONCLUSIONS IVIg is effective in anti-GAD-positive patients with SPS. Whether it is also effective in other GAD-positive CNS disorders such as epilepsies, cerebellar degenerations or Batten's disease need to be studied in control trials. Emerging data suggest that IVIg, by suppressing proinflammatory cytokines, may exert a beneficial effect in patients with Alzheimer's disease, postpolio syndrome, chronic pain syndromes, fibrotic disorders and narcolepsy. Controlled studies are being planned or conducted to substantiate the benefit of IVIg in neurodegenerative disorders.
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Affiliation(s)
- Marinos C Dalakas
- Neuromuscular Diseases Section, NINDS, National Institutes of Health, Building 10, Room 4N248, 10 Center Drive MSC, Bethesda, MD 20892-1382, USA.
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Schwartzman RJ, Alexander GM, Grothusen J. Pathophysiology of complex regional pain syndrome. Expert Rev Neurother 2006; 6:669-81. [PMID: 16734515 DOI: 10.1586/14737175.6.5.669] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Complex regional pain syndrome (CRPS) most often follows injury to peripheral nerves or their endings in soft tissue. A combination of prostanoids, kinins and cytokines cause peripheral nociceptive sensitization. In time, the Mg(2+) block of the N-methyl-D-aspartate receptor is removed, pain transmission neurons (PTN) are altered by an influx of Ca(2+) that activates kinases for excitation and phosphatases for depression, activity-dependent plasticity that alters the firing of PTN. In time, these neurons undergo central sensitization that lead to a major physiological change of the autonomic, pain and motor systems. The role of the immune system and the sickness response is becoming clearer as microglia are activated following injury and can induce central sensitization while astrocytes may maintain the process.
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Affiliation(s)
- Robert J Schwartzman
- Drexel University College of Medicine, Department of Neurology, 245 N. 15 Street, MS 423 Philadelphia, PA 19102, USA.
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