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Donati D, Boccolari P, Giorgi F, Berti L, Platano D, Tedeschi R. Breaking the Cycle of Pain: The Role of Graded Motor Imagery and Mirror Therapy in Complex Regional Pain Syndrome. Biomedicines 2024; 12:2140. [PMID: 39335652 PMCID: PMC11428672 DOI: 10.3390/biomedicines12092140] [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: 08/29/2024] [Revised: 09/11/2024] [Accepted: 09/18/2024] [Indexed: 09/30/2024] Open
Abstract
Background: Complex Regional Pain Syndrome (CRPS) is a chronic condition characterized by severe pain and functional impairment. Graded Motor Imagery (GMI) and Mirror Therapy (MT) have emerged as potential non-invasive treatments; this review evaluates the effectiveness of these therapies in reducing pain, improving function, and managing swelling in CRPS patients. Methods: A systematic review was conducted including randomized controlled trials (RCTs) that investigated GMI and MT in CRPS patients. This review was registered in PROSPERO (CRD42024535972) to ensure transparency and adherence to protocols. This review included searches of PubMed, Cochrane, SCOPUS, and Web of Science databases. Out of 81 studies initially screened, 6 were included in the final review. Studies were assessed for quality using the PEDro and RoB-2 scales. The primary outcomes were pain reduction, functional improvement, and swelling reduction. Results: Graded Motor Imagery (GMI) and Mirror Therapy (MT) reduced pain by an average of 20 points on the Neuropathic Pain Scale (NPS) and resulted in functional improvements as measured by the Task-Specific Numeric Rating Scale (NRS). GMI also contributed to some reduction in swelling. MT, particularly in post-stroke CRPS patients, showed significant pain reduction and functional improvements, with additional benefits in reducing swelling in certain studies. However, the included studies had small sample sizes and mixed designs, which limit the generalizability of the findings. The studies varied in sample size and design, with some risk of bias noted. Conclusions: Graded Motor Imagery (GMI) and Mirror Therapy (MT) have proven to be effective interventions for managing Complex Regional Pain Syndrome (CRPS), with significant improvements in pain reduction and functional recovery. These non-invasive treatments hold potential for integration into standard rehabilitation protocols. However, the small sample sizes and variability in study designs limit the generalizability of these findings. Future research should focus on larger, more homogeneous trials to validate the long-term effectiveness of GMI and MT, ensuring more robust clinical application.
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Affiliation(s)
- Danilo Donati
- Physical Therapy and Rehabilitation Unit, Policlinico di Modena, 41125 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Paolo Boccolari
- Physical Therapy and Rehabilitation Unit, Policlinico di Modena, 41125 Modena, Italy
| | - Federica Giorgi
- Pediatric Physical Medicine and Rehabilitation Unit, IRCCS Institute of Neurological Sciences, 40124 Bologna, Italy
| | - Lisa Berti
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Daniela Platano
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
- Physical Medicine and Rehabilitation Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Roberto Tedeschi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
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Liu A, Wang J, Jin T, Jiang Z, Huang S, Li S, Ying Z, Jiang H. Identifying the genetic association between the cerebral cortex and fibromyalgia. Cereb Cortex 2024; 34:bhae318. [PMID: 39106177 DOI: 10.1093/cercor/bhae318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Revised: 07/08/2024] [Indexed: 08/09/2024] Open
Abstract
Fibromyalgia (FM) is a central sensitization syndrome that is strongly associated with the cerebral cortex. This study used bidirectional two-sample Mendelian randomization (MR) analysis to investigate the bidirectional causality between FM and the cortical surface area and cortical thickness of 34 brain regions. Inverse variance weighted (IVW) was used as the primary method for this study, and sensitivity analyses further supported the results. The forward MR analysis revealed that genetically determined thinner cortical thickness in the parstriangularis (OR = 0.0567 mm, PIVW = 0.0463), caudal middle frontal (OR = 0.0346 mm, PIVW = 0.0433), and rostral middle frontal (OR = 0.0285 mm, PIVW = 0.0463) was associated with FM. Additionally, a reduced genetically determined cortical surface area in the pericalcarine (OR = 0.9988 mm2, PIVW = 0.0085) was associated with an increased risk of FM. Conversely, reverse MR indicated that FM was associated with cortical thickness in the caudal middle frontal region (β = -0.0035 mm, PIVW = 0.0265), fusiform region (β = 0.0024 mm, SE = 0.0012, PIVW = 0.0440), the cortical surface area in the supramarginal (β = -9.3938 mm2, PIVW = 0.0132), and postcentral regions (β = -6.3137 mm2, PIVW = 0.0360). Reduced cortical thickness in the caudal middle frontal gyrus is shown to have a significant relationship with FM prevalence in a bidirectional causal analysis.
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Affiliation(s)
- Aihui Liu
- Department of Rheumatology and Immunology, Center for General Practice Medicine, Hangzhou Medical College, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang 310000, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 31000, China
- Rheumatology and Immunology Research Institute, Hangzhou Medical College, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 310000, China
| | - Jing Wang
- Department of Rheumatology and Immunology, Center for General Practice Medicine, Hangzhou Medical College, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang 310000, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 31000, China
- Rheumatology and Immunology Research Institute, Hangzhou Medical College, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 310000, China
| | - Tianyu Jin
- China Rehabilitation Research center, No. 10, Jiaomen North Road, Fengtai District, Beijing 100068, China
| | - Zhaoyu Jiang
- Department of Rheumatology and Immunology, Center for General Practice Medicine, Hangzhou Medical College, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang 310000, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 31000, China
- Rheumatology and Immunology Research Institute, Hangzhou Medical College, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 310000, China
| | - Shan Huang
- Department of Rheumatology and Immunology, Center for General Practice Medicine, Hangzhou Medical College, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang 310000, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 31000, China
- Rheumatology and Immunology Research Institute, Hangzhou Medical College, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 310000, China
| | - Shinan Li
- Department of Rheumatology and Immunology, Center for General Practice Medicine, Hangzhou Medical College, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang 310000, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 31000, China
- Rheumatology and Immunology Research Institute, Hangzhou Medical College, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 310000, China
| | - Zhenhua Ying
- Department of Rheumatology and Immunology, Center for General Practice Medicine, Hangzhou Medical College, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang 310000, China
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 31000, China
- Rheumatology and Immunology Research Institute, Hangzhou Medical College, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 310000, China
| | - Hongyang Jiang
- Zhejiang Provincial Key Laboratory of Traditional Chinese Medicine Cultivation for Arthritis Diagnosis and Treatment, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 31000, China
- Rheumatology and Immunology Research Institute, Hangzhou Medical College, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang Province 310000, China
- Department of Radiology, Center for Rehabilitation Medicine, Hangzhou Medical College, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, No. 158 Shangtang Road, Gongshu District, Hangzhou, Zhejiang 310000, China
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Wiemann M, Zimowski N, Blendow SL, Enax-Krumova E, Naegel S, Fleischmann R, Strauss S. Evidence for converging pathophysiology in complex regional pain-syndrome and primary headache disorders: results from a case-control study. J Neurol 2024; 271:1850-1860. [PMID: 38070030 PMCID: PMC10972976 DOI: 10.1007/s00415-023-12119-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Neuroinflammation and maladaptive neuroplasticity play pivotal roles in migraine (MIG), trigeminal autonomic cephalalgias (TAC), and complex regional pain syndrome (CRPS). Notably, CRPS shares connections with calcitonin gene-related peptide (CGRP) in its pathophysiology. This study aims to assess if the documented links between CRPS and MIG/TAC in literature align with clinical phenotypes and disease progressions. This assessment may bolster the hypothesis of shared pathophysiological mechanisms. METHODS Patients with CRPS (n = 184) and an age-/gender-matched control group with trauma but without CRPS (n = 148) participated in this case-control study. Participant answered well-established questionnaires for the definition of CRPS symptoms, any headache complaints, headache entity, and clinical management. RESULTS Patients with CRPS were significantly more likely to suffer from migraine (OR: 3.23, 95% CI 1.82-5.85), TAC (OR: 8.07, 95% CI 1.33-154.79), or non-classified headaches (OR: 3.68, 95% CI 1.88-7.49) compared to the control group. Patients with MIG/TAC developed CRPS earlier in life (37.2 ± 11.1 vs 46.8 ± 13.5 years), had more often a central CRPS phenotype (60.6% vs. 37.0% overall) and were three times more likely to report allodynia compared to CRPS patients with other types of headaches. Additionally, these patients experienced higher pain levels and more severe CRPS, which intensified with an increasing number of headache days. Patients receiving monoclonal antibody treatment targeting the CGRP pathway for headaches reported positive effects on CRPS symptoms. CONCLUSION This study identified clinically relevant associations of MIG/TAC and CRPS not explained by chance. Further longitudinal investigations exploring potentially mutual pathomechanisms may improve the clinical management of both CRPS and primary headache disorders. TRIAL REGISTRATION German Clinical Trials Register (DRKS00022961).
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Affiliation(s)
- Matthias Wiemann
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Nikolas Zimowski
- Department of Trauma, Reconstructive Surgery and Rehabilitative Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Sarah-Luis Blendow
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Elena Enax-Krumova
- Department of Neurology, BG University Hospital Bergmannsheil gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Steffen Naegel
- Department of Neurology, Martin Luther University Halle-Wittenberg and University Hospital Halle, Halle (Saale), Germany
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
| | - Robert Fleischmann
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Sebastian Strauss
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.
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Mangnus TJP, Dirckx M, Huygen FJPM. Different Types of Pain in Complex Regional Pain Syndrome Require a Personalized Treatment Strategy. J Pain Res 2023; 16:4379-4391. [PMID: 38162406 PMCID: PMC10757771 DOI: 10.2147/jpr.s432209] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating painful state of an extremity that can develop after trauma. CRPS is diagnosed by the new International Association for the Study of Pain (IASP) diagnostic criteria for CRPS. The syndrome is characterized by continuing regional pain with abnormal sensory, motor, sudomotor, vasomotor, edema, and/or trophic signs. The clinical presentation of CRPS can be very heterogeneous because CRPS is a multi-mechanism syndrome. Therefore, mechanism-based subgroups have been suggested to personalize treatment for CRPS. Additionally, the presentation of symptom pain may also be able to identify different subgroups of CRPS. In this review, the types of pain recognized by the IASP-nociceptive, neuropathic, and nociplastic pain-will be discussed as possible subgroups for CRPS. Each pain type should be identified in CRPS patients, with a thorough history taking, physical examination, and diagnostic tests or (novel) biomarkers to optimize treatment effectiveness. Over the course of the syndrome, patients with CRPS probably experience more than one distinct pain type. Therefore, pain specialists should be alert to not only adjust their treatment if underlying pathophysiologic mechanisms tend to change but also to personalize the treatment of the associated type of pain in the CRPS patient.
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Affiliation(s)
- Thomas J P Mangnus
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maaike Dirckx
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank J P M Huygen
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Knudsen L, Santoro L, Bruehl S, Harden N, Brunner F. Subtypes of complex regional pain syndrome-a systematic review of the literature. Pain Rep 2023; 8:e1111. [PMID: 38027463 PMCID: PMC10653603 DOI: 10.1097/pr9.0000000000001111] [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: 07/05/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 12/01/2023] Open
Abstract
To systematically identify and summarize possible subtypes of complex regional pain syndrome (CRPS), we searched MEDLINE, Embase, Cochrane, Scopus, and Web of Science for original studies reporting or investigating at least one subtype within a group of patients with CRPS. The search retrieved 4239 potentially relevant references. Twenty-five studies met our inclusion criteria and were included in the analysis. Complex regional pain syndrome phenotypes were investigated based on the following variables: clinical presentation/sensory disturbances, dystonia, skin temperature, disease duration, onset type, CRPS outcome, and neuropsychological test performance. Support was found for the following CRPS subtypes: CRPS type I, CRPS type II, acute CRPS, chronic CRPS, centralized CRPS, cold CRPS, warm CRPS, inflammatory CRPS, dystonic CRPS, nondystonic CRPS, familial CRPS, and nonfamilial CRPS. It is unclear whether these are distinct or overlapping subtypes. The results of this comprehensive review can facilitate the formulation of well-defined CRPS subtypes based on presumed underlying mechanisms. Our findings provide a foundation for establishing and defining clinically meaningful CRPS subtypes, with the ultimate goal of developing targeted and enhanced treatments for CRPS.
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Affiliation(s)
- Lone Knudsen
- National Rehabilitation Center for Neuromuscular Diseases, Aarhus, Denmark
| | - Lana Santoro
- Wheelock College of Education and Human Development, Boston University, Boston, MA, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Zurich, Switzerland
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Harnik MA, Kesselring P, Ott A, Urman RD, Luedi MM. Complex Regional Pain Syndrome (CRPS) and the Value of Early Detection. Curr Pain Headache Rep 2023; 27:417-427. [PMID: 37410335 PMCID: PMC10462545 DOI: 10.1007/s11916-023-01124-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE OF REVIEW The goal of this narrative review is to describe the current understanding of the pathology of Complex Regional Pain Syndrome (CRPS), as well as diagnostic standards and therapeutic options. We will then make the case for early recognition and management. RECENT FINDINGS CRPS remains an enigmatic pain syndrome, comprising several subtypes. Recent recommendations clarify diagnostic ambiguities and emphasize the importance of standardized assessment and therapy. Awareness of CRPS should be raised to promote prevention, early detection, and rapid escalation of therapy in refractory cases. Comorbidities and health costs (i.e., the socioeconomic impact) must also be addressed early to prevent negative consequences for patients.
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Affiliation(s)
- Michael Alexander Harnik
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pascal Kesselring
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Ott
- Department of Anaesthesiology and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Richard D. Urman
- Department of Anaesthesiology, College of Medicine, The Ohio State University, Columbus, OH 43210 USA
| | - Markus M. Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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Paredes Sanchez J, Titmus M, Lawson-Smith H, Di Pietro F. Tactile acuity improves during acute experimental pain of the limb. Pain Rep 2023; 8:e1091. [PMID: 38225958 PMCID: PMC10789456 DOI: 10.1097/pr9.0000000000001091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 01/17/2024] Open
Abstract
Introduction Chronic pain is associated with poor tactile acuity, commonly measured with the 2-point discrimination (TPD) test. Although poor tactile acuity across chronic pain conditions is well established, less is known in acute pain. Objective Recent conflicting findings in experimentally induced neck and back pain led us to conduct a TPD investigation in experimentally induced limb pain. We hypothesised altered TPD during experimental upper limb pain, but we did not speculate on the direction of the change. Methods Thirty healthy subjects immersed their dominant hand in a circulating cold-water bath at 7°C (cold pressor test [CPT]). Two-point discrimination was measured at baseline (pre-CPT), during pain (during-CPT), and after withdrawal from the water (post-CPT) in 3 different sites: (1) the dominant forearm, (2) dominant arm and (3) contralateral forearm. Results Repeated-measures analysis of variance revealed a significant main effect of time (F(2,56) = 4.45, P = 0.02, η p 2 = 0.14) on TPD; in all 3 sites, TPD values decreased (ie, tactile acuity improved) during pain. Interestingly, the contralateral forearm followed a similar pattern to the dominant (ie, painful) forearm, and furthermore was the only site that exhibited any correlation with pain, albeit in an intriguing direction (r = 0.57, P = 0.001), ie, the greater the pain the worse the tactile acuity. Conclusion The improvements in tactile acuity during experimentally induced limb pain may reflect a protective response. The changes in the corresponding site in the contralateral limb may reflect a protective spinal cross talk. Such a response, together with the interesting relationship between tactile acuity and pain, warrant further inquiry.
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Affiliation(s)
| | - Morgan Titmus
- Curtin Medical School, Curtin University, Western Australia, Australia
| | | | - Flavia Di Pietro
- Curtin Medical School, Curtin University, Western Australia, Australia
- Curtin Health and Innovation Research Institute (CHIRI), Curtin University, Western Australia, Australia
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Limerick G, Christo DK, Tram J, Moheimani R, Manor J, Chakravarthy K, Karri J, Christo PJ. Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments. Curr Pain Headache Rep 2023; 27:269-298. [PMID: 37421541 DOI: 10.1007/s11916-023-01130-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW This review presents the most current information about the epidemiology of complex regional pain syndrome (CRPS), classification and diagnostic criteria, childhood CRPS, subtypes, pathophysiology, conventional and less conventional treatments, and preventive strategies. RECENT FINDINGS CRPS is a painful disorder with multifactorial pathophysiology. The data describe sensitization of the central and peripheral nervous systems, inflammation, possible genetic factors, sympatho-afferent coupling, autoimmunity, and mental health factors as contributors to the syndrome. In addition to conventional subtypes (type I and type II), cluster analyses have uncovered other proposed subtypes. Prevalence of CRPS is approximately 1.2%, female gender is consistently associated with a higher risk of development, and substantial physical, emotional, and financial costs can result from the syndrome. Children with CRPS seem to benefit from multifaceted physical therapy leading to a high percentage of symptom-free patients. The best available evidence along with standard clinical practice supports pharmacological agents, physical and occupational therapy, sympathetic blocks for engaging physical restoration, steroids for acute CRPS, neuromodulation, ketamine, and intrathecal baclofen as therapeutic approaches. There are many emerging treatments that can be considered as a part of individualized, patient-centered care. Vitamin C may be preventive. CRPS can lead to progressively painful sensory and vascular changes, edema, limb weakness, and trophic disturbances, all of which substantially erode healthy living. Despite some progress in research, more comprehensive basic science investigation is needed to clarify the molecular mechanisms of the disease so that targeted treatments can be developed for better outcomes. Incorporating a variety of standard therapies with different modes of action may offer the most effective analgesia. Introducing less conventional approaches may also be helpful when traditional treatments fail to provide sufficient improvement.
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Affiliation(s)
- Gerard Limerick
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Dana K Christo
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jennifer Tram
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | | | - John Manor
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Jay Karri
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.
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Arcidiacono UA, Armocida D, Pesce A, Maiotti M, Proietti L, D’Andrea G, Santoro A, Frati A. Complex Regional Pain Syndrome after Spine Surgery: A Rare Complication in Mini-Invasive Lumbar Spine Surgery: An Updated Comprehensive Review. J Clin Med 2022; 11:7409. [PMID: 36556025 PMCID: PMC9781971 DOI: 10.3390/jcm11247409] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a postoperative, misdiagnosed condition highlighted only by pain therapists after numerous failed attempts at pain control by the treating surgeon in the case of prolonged pain after surgery. It only occurs rarely after spine surgery, causing the neurosurgeon's inappropriate decision to resort to a second surgical treatment. METHODS We performed a systematic review of the literature reporting and analyzing all recognized and reported cases of CRPS in patients undergoing spinal surgery to identify the best diagnostic and therapeutic strategies for this unusual condition. We compare our experience with the cases reported through a review of the literature. RESULTS We retrieve 20 articles. Most of the papers are clinical cases showing the disorder's rarity after spine surgery. Most of the time, the syndrome followed uncomplicated lumbar spine surgery involving one segment. The most proposed therapy was chemical sympathectomy and spinal cord stimulation. CONCLUSION CRPS is a rare pathology and is rarer after spine surgery. However, it is quite an invalidating disorder. Early therapy and resolution, however, require a rapid diagnosis of the syndrome. In our opinion, since CRPS occurs relatively rarely following spinal surgery, it should not have a substantial impact on the indications for and timing of these operations. Therefore, it is essential to diagnose this rare occurrence and treat it promptly and appropriately.
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Affiliation(s)
| | - Daniele Armocida
- Human Neurosciences Department, Neurosurgery Division, “Sapienza” University, 00185 Rome, Italy
- IRCCS “Neuromed”, 86077 Pozzilli, Italy
| | - Alessandro Pesce
- Neurosurgery Unit, Santa Maria Goretti Hospital, Via Guido Reni 1, 04100 Latina, Italy
| | - Marco Maiotti
- Villa Stuart Hospital, Orthopedic Clinic, 00135 Roma, Italy
| | - Luca Proietti
- Division of Spinal Surgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Institute of Orthopaedics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | | | - Antonio Santoro
- Human Neurosciences Department, Neurosurgery Division, “Sapienza” University, 00185 Rome, Italy
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Akcay S, Koskderelioglu A, Ince B, Elif Saka F, Eskut N, Goksel Karatepe A. Is the left/right judgment task performance altered in unilateral carpal tunnel syndrome: And associated with symptom severity? Musculoskelet Sci Pract 2022; 62:102641. [PMID: 35961062 DOI: 10.1016/j.msksp.2022.102641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/11/2022] [Accepted: 07/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Left/right judgment task performance (LRJT) is impaired in severe neuropathic pain conditions. However, comparison of LRJT performance in patients with carpal tunnel syndrome (CTS) with a control group with similar cognitive functions has not been investigated. OBJECTIVE The aim of the study was to compare the LRJT performance of CTS patients with healthy controls and the unaffected side. METHODS Seventy-five CTS patients with dominant, right-hand involvement and 75 control subjects were included in the study. The Recognize® tablet application was used for LRJT performance. Tactile acuity (Two-point discrimination) and handgrip strength; pain severity (Visual Analog Scale) and neuropathic component of pain (Pain Detect Questionnaire); symptom severity and functional impact of CTS (Boston CTS Assessment Test) were evaluated. Mixed-design ANOVAs and correlation analyses were used for data analysis. DESIGN Cross-sectional study. RESULTS Analysis of variance showed that there was no significant effect of side (affected versus unaffected) or group (CTS versus control group) on recognition accuracy or time. Significant group*site interactions were found for the two-point discrimination F (1,148) = 6.388, p = 0.013; and for handgrip strength F (1,148) = 17.552, p < 0.01. A statistically significant negative correlation was found between recognition accuracy and symptom duration and a significant positive correlation was found between recognition accuracy and handgrip strength in CTS patients (r = -0.267, p = 0.020; r = 0.290, p = 0.012). CONCLUSION CTS patients recognize the affected side as accurately and quickly as the unaffected side and control group. Further research is needed to clarify the relationship between LRJT performance in the severely affected CTS group. GOV REGISTRATION NUMBER NCT04967144 CLINICALTRIALS. GOV REGISTRATION DATE 19 July 2021.
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Affiliation(s)
- Seniz Akcay
- University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Department of Physical Medicine and Rehabilitation, Izmir, Turkey.
| | - Asli Koskderelioglu
- University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Department of Neurology, Izmir, Turkey.
| | - Bugra Ince
- University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Department of Physical Medicine and Rehabilitation, Izmir, Turkey.
| | - Fikriye Elif Saka
- University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Department of Physical Medicine and Rehabilitation, Izmir, Turkey.
| | - Neslihan Eskut
- University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Department of Neurology, Izmir, Turkey.
| | - Altinay Goksel Karatepe
- University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Department of Physical Medicine and Rehabilitation, Izmir, Turkey.
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11
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Acapo S, Osinski T, Rulleau T, Dupeyron A, Nizard J. Assessment of body perception disturbances in complex regional pain syndrome: A systematic review using the COSMIN guideline. Eur J Pain 2022; 26:2060-2073. [PMID: 36065635 PMCID: PMC9826130 DOI: 10.1002/ejp.2032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 04/19/2022] [Accepted: 09/02/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To conduct a systematic review to identify which tools are being used to assess body perception disturbances in Complex Regional Pain Syndrome (CRPS) and to provide an evidence-based recommendation in the selection of an assessment tool, based on measurement properties. DATABASES AND DATA TREATMENT Five electronic databases (EMBASE, Pubmed, PsycInfo, Science Direct and Web of Science) were searched for English or French written articles, with no time restrictions. All original articles using a body perception assessment tool with adult patients with CRPS were selected, regardless of their design (controlled trials, single case, qualitative study). Two investigators screened abstracts, selected full articles and extracted data independently. RESULTS Thirty-eight full-text papers were obtained and three main methods to evaluate body perception disturbances were identified: The Bath Body Perception Disturbance Scale, the Neglect-like Symptoms questionnaire adapted from Galer and the patient's body perception description. No full psychometric assessments were found. The Limb Laterality Recognition Task was also used in conjunction with another method. CONCLUSIONS Three main assessment methods for CRPS body perception disturbances are currently used. Full psychometric evaluation has not been completed for any of the assessment methods. As a consequence, we could not fully apply the COSMIN guideline. To date, there is no agreement concerning the use of a specific questionnaire or scale. The results indicate a need for further research such as psychometric properties of these questionnaires. SIGNIFICANCE This systematic review identified body perception disturbances assessment methods and their the psychometric properties in order to provide help and guidance to researchers and clinicians to investigate those clinical features.
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Affiliation(s)
- Sessi Acapo
- EA 4391 Excitabilité Nerveuse et TherapeutiqueUniversité Paris EstCréteilFrance
| | - Thomas Osinski
- UR 20201 ERPHANUniversité Versailles Saint QuentinGarchesFrance
- IFMKFondation EFOM Boris DoltoParisFrance
| | | | - Arnaud Dupeyron
- Physical Medicine and Rehabilitation Department, CHU NîmesUniversity of MontpellierNîmesFrance
- EuroMov Digital Health in MotionUniversity of Montpellier, IMT Mines AlesMontpellierFrance
| | - Julien Nizard
- EA 4391 Excitabilité Nerveuse et TherapeutiqueUniversité Paris EstCréteilFrance
- UIC 22 Multidisciplinary Pain, Palliative and Supportive Care DepartmentNantes University HospitalNantesFrance
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12
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Functional MRI in Radiology—A Personal Review. Healthcare (Basel) 2022; 10:healthcare10091646. [PMID: 36141258 PMCID: PMC9498519 DOI: 10.3390/healthcare10091646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
We, here, provide a personal review article on the development of a functional MRI in the radiology departments of two German university medicine units. Although the international community for human brain mapping has met since 1995, the researchers fascinated by human brain function are still young and innovative. However, the impact of functional magnetic resonance imaging (fMRI) on prognosis and treatment decisions is restricted, even though standardized methods have been developed. The tradeoff between the groundbreaking studies on brain function and the attempt to provide reliable biomarkers for clinical decisions is large. By describing some historical developments in the field of fMRI, from a personal view, the rise of this method in clinical neuroscience during the last 25 years might be understandable. We aim to provide some background for (a) the historical developments of fMRI, (b) the establishment of two research units for fMRI in the departments of radiology in Germany, and (c) a description of some contributions within the selected fields of systems neuroscience, clinical neurology, and behavioral psychology.
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13
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Glomus Tumor of the Lower Extremity Previously Misdiagnosed as Complex Regional Pain Syndrome in Close Proximity to a Myxofibrosarcoma: A Case Report. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202207000-00002. [PMID: 35797605 PMCID: PMC9263485 DOI: 10.5435/jaaosglobal-d-21-00311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/09/2022] [Indexed: 11/18/2022]
Abstract
Complex regional pain syndrome (CRPS) is a potentially devastating condition that can result in severe psychological and social morbidity. It is a diagnosis of exclusion, and other pathologic entities must be ruled out first. Glomus tumors are exquisitely painful benign vascular tumors that are most common in the hand and are rarely found in the lower extremity. Here, we present a case of a patient who developed a focus of severe anterior knee pain and tenderness a few months after a car accident that had been misdiagnosed as CRPS for 15 years. She coincidentally developed a sarcoma of her ipsilateral leg distal to this site. Magnetic resonance imaging of the sarcoma included the area of knee pain where, interestingly, it identified a separate small soft-tissue mass. A glomus tumor was diagnosed histologically in a needle biopsy specimen from this mass, which was resected along with the sarcoma. For the first time in 15 years, despite the additional sarcoma surgery, she reported relief of her pain and complete resolution of her “CRPS.”
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14
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Vittersø AD, Halicka M, Buckingham G, Proulx MJ, Bultitude JH. The sensorimotor theory of pathological pain revisited. Neurosci Biobehav Rev 2022; 139:104735. [PMID: 35705110 DOI: 10.1016/j.neubiorev.2022.104735] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/13/2022] [Accepted: 06/07/2022] [Indexed: 01/31/2023]
Abstract
Harris (1999) proposed that pain can arise in the absence of tissue damage because changes in the cortical representation of the painful body part lead to incongruences between motor intention and sensory feedback. This idea, subsequently termed the sensorimotor theory of pain, has formed the basis for novel treatments for pathological pain. Here we review the evidence that people with pathological pain have changes to processes contributing to sensorimotor function: motor function, sensory feedback, cognitive representations of the body and its surrounding space, multisensory processing, and sensorimotor integration. Changes to sensorimotor processing are most evident in the form of motor deficits, sensory changes, and body representations distortions, and for Complex Regional Pain Syndrome (CRPS), fibromyalgia, and low back pain. Many sensorimotor changes are related to cortical processing, pain, and other clinical characteristics. However, there is very limited evidence that changes in sensorimotor processing actually lead to pain. We therefore propose that the theory is more appropriate for understanding why pain persists rather than how it arises.
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Affiliation(s)
- Axel D Vittersø
- Centre for Pain Research, University of Bath, Bath, Somerset, United Kingdom; Department of Psychology, University of Bath, Bath, Somerset, United Kingdom; Department of Sport & Health Sciences, University of Exeter, Exeter, Devon, United Kingdom; Department of Psychology, Oslo New University College, Oslo, Norway.
| | - Monika Halicka
- Centre for Pain Research, University of Bath, Bath, Somerset, United Kingdom; Department of Psychology, University of Bath, Bath, Somerset, United Kingdom
| | - Gavin Buckingham
- Department of Sport & Health Sciences, University of Exeter, Exeter, Devon, United Kingdom
| | - Michael J Proulx
- Department of Psychology, University of Bath, Bath, Somerset, United Kingdom; Centre for Real and Virtual Environments Augmentation Labs, Department of Computer Science, University of Bath, Bath, Somerset, United Kingdom
| | - Janet H Bultitude
- Centre for Pain Research, University of Bath, Bath, Somerset, United Kingdom; Department of Psychology, University of Bath, Bath, Somerset, United Kingdom
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15
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Lotze M, Moseley GL. Clinical and Neurophysiological Effects of Progressive Movement Imagery Training for Pathological Pain. THE JOURNAL OF PAIN 2022; 23:1480-1491. [PMID: 35504569 DOI: 10.1016/j.jpain.2022.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/17/2022] [Accepted: 04/11/2022] [Indexed: 01/04/2023]
Abstract
Movement limitation is a common characteristic of chronic pain such that pain prevents the very movement and activity that is most likely to promote recovery. This is particularly the case for pathological pain states such as complex regional pain syndrome (CRPS). One clinical approach to CRPS that has growing evidence of efficacy involves progressive movement imagery training. Graded Motor Imagery (GMI) targets clinical and neurophysiological effects through a stepwise progression through implicit and explicit movement imagery training, mirror therapy and then functional tasks. Here we review experiences from over 20 years of clinical and research experience with GMI. We situate GMI in terms of its historical underpinnings, the benefits and outstanding challenges of its implementation, its potential application beyond CRPS. We then review the neuropathological targets of GMI and current thought on its effects on neurophysiological biomarkers. Perspective This article provides an overview of our experiences with graded motor imagery training over the last 20 years focussing on the treatment of CRPS. It does both cover the theoretical underpinnings for this treatment approach, biomarkers which indicate potential changes driven by GMI, and experiences for achieving optimal treatment results.
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Affiliation(s)
- Martin Lotze
- Functional Imaging Unit. Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany.
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, Australia
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16
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Lee B, Di Pietro F, Henderson LA, Austin PJ. Altered basal ganglia infraslow oscillation and resting functional connectivity in complex regional pain syndrome. J Neurosci Res 2022; 100:1487-1505. [PMID: 35441738 PMCID: PMC9543905 DOI: 10.1002/jnr.25057] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 11/06/2022]
Abstract
Complex regional pain syndrome (CRPS) is a painful condition commonly accompanied by movement disturbances and often affects the upper limbs. The basal ganglia motor loop is central to movement, however, non-motor basal ganglia loops are involved in pain, sensory integration, visual processing, cognition, and emotion. Systematic evaluation of each basal ganglia functional loop and its relation to motor and non-motor disturbances in CRPS has not been investigated. We recruited 15 upper limb CRPS and 45 matched healthy control subjects. Using functional magnetic resonance imaging, infraslow oscillations (ISO) and resting-state functional connectivity in motor and non-motor basal ganglia loops were investigated using putamen and caudate seeds. Compared to controls, CRPS subjects displayed increased ISO power in the putamen contralateral to the CRPS affected limb, specifically, in contralateral putamen areas representing the supplementary motor area hand, motor hand, and motor tongue. Furthermore, compared to controls, CRPS subjects displayed increased resting connectivity between these putaminal areas as well as from the caudate body to cortical areas such as the primary motor cortex, supplementary and cingulate motor areas, parietal association areas, and the orbitofrontal cortex. These findings demonstrate changes in basal ganglia loop function in CRPS subjects and may underpin motor disturbances of CRPS.
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Affiliation(s)
- Barbara Lee
- School of Medical Sciences and Brain and Mind Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Flavia Di Pietro
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia.,Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
| | - Luke A Henderson
- School of Medical Sciences and Brain and Mind Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Paul J Austin
- School of Medical Sciences and Brain and Mind Centre, University of Sydney, Camperdown, New South Wales, Australia
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17
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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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18
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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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19
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Halicka M, Vittersø AD, Proulx MJ, Bultitude JH. Attention upturned: Bias toward and away from the affected side of the body and near space in a case of complex regional pain syndrome. Neuropsychologia 2021; 163:108079. [PMID: 34740614 DOI: 10.1016/j.neuropsychologia.2021.108079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/24/2021] [Accepted: 10/29/2021] [Indexed: 10/19/2022]
Abstract
People with Complex Regional Pain Syndrome (CRPS) following limb injury can show neuropsychological symptoms in the absence of observable brain pathologies. These can include sensory changes, distorted body representation, and inattention to their affected limb and its surrounding space, resembling post-stroke hemispatial neglect. The precise nature and mechanisms of these neuropsychological symptoms are unclear, however insights could be gained by testing for dissociations and associations that have been observed in stroke patients. Drawing from clinical and experimental methods for investigating spatial attention bias and related symptoms in stroke patients, we conducted a detailed investigation of neuropsychological symptoms in a woman with CRPS of her left arm who initially presented to us with pronounced inattention to her affected side. The patient showed visual and tactile neglect and extinction on her affected side on confrontation tests, but no attention deficits on "bedside" tests of neglect. On sensitive computer-based measures, attention biases were found in the patient's body and near space (in Temporal Order Judgements), but not far or imagined space (on the Greyscales task and Mental Number Line Bisection). Unique to the current literature, the patient showed a reversal in her Temporal Order Judgement bias across time, from inattention (first and second session) to hyperattention (third session) to her affected side. In contrast, pain and self-reported body representation distortion were similar across the three sessions. The patient had reduced central and peripheral visual acuity, however these deficits were near symmetrical and therefore could not explain her performance on the visual attention tasks. Given that spatial attention bias has been linked to imbalance in relative activation of the two cerebral hemispheres, we administered a Global-Local processing task to test for hemispheric asymmetry. This revealed no difference in global compared to local interference refuting any hemispheric imbalance. Instead, the patient showed impaired performance (compared to controls) on incongruent trials regardless of trial type, consistent with executive impairment. We conclude that spatial attention bias in CRPS can generalize across different sensory modalities and extend beyond the affected limb to the external space around it, independent of any low-level sensory disturbances. This bias is not necessarily directed away from the affected side or stable over time. People with CRPS can also demonstrate more generalized neuropsychological changes in sensory and executive functions. Our observations refute several existing theories about the mechanisms of attention bias in CRPS, and their relationship to pain, and have potential implications for treatment.
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Affiliation(s)
- Monika Halicka
- Centre for Pain Research, University of Bath, Bath, United Kingdom; Department of Psychology, University of Bath, Bath, United Kingdom.
| | - Axel D Vittersø
- Centre for Pain Research, University of Bath, Bath, United Kingdom; Department of Psychology, University of Bath, Bath, United Kingdom; Department of Sport and Health Sciences, University of Exeter, Exeter, United Kingdom
| | - Michael J Proulx
- Department of Psychology, University of Bath, Bath, United Kingdom; Centre for Reality & Virtual Environments Augmentation Labs, Department of Computer Science, University of Bath, Bath, United Kingdom
| | - Janet H Bultitude
- Centre for Pain Research, University of Bath, Bath, United Kingdom; Department of Psychology, University of Bath, Bath, United Kingdom; Centre for Functional Magnetic Resonance Imaging of the Brain (FMRIB), University of Oxford, Oxford, United Kingdom
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20
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Strauss S, Barby S, Härtner J, Pfannmöller JP, Neumann N, Moseley GL, Lotze M. Graded motor imagery modifies movement pain, cortical excitability and sensorimotor function in complex regional pain syndrome. Brain Commun 2021; 3:fcab216. [PMID: 34661105 PMCID: PMC8514858 DOI: 10.1093/braincomms/fcab216] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/17/2021] [Accepted: 08/12/2021] [Indexed: 11/14/2022] Open
Abstract
Patients with complex regional pain syndrome suffer from chronic neuropathic pain and also show a decrease in sensorimotor performance associated with characteristic central and peripheral neural system parameters. In the brain imaging domain, these comprise altered functional sensorimotor representation for the affected hand side. With regard to neurophysiology, a decrease in intracortical inhibition for the sensorimotor cortex contralateral to the affected hand has been repetitively verified, which might be related to increased primary somatosensory cortex functional activation for the affected limb. Rare longitudinal intervention studies in randomized controlled trials have demonstrated that a decrease in primary somatosensory cortex functional MRI activation coincided with pain relief and recovery in sensorimotor performance. By applying a randomized wait-list control crossover study design, we tested possible associations of clinical, imaging and neurophysiology parameters in 21 patients with complex regional pain syndrome in the chronic stage (>6 months). In more detail, we applied graded motor imagery over 6 weeks to relieve movement pain of the affected upper limb. First, baseline parameters were tested between the affected and the non-affected upper limb side and age-matched healthy controls. Second, longitudinal changes in clinical and testing parameters were associated with neurophysiological and imaging parameters. During baseline short intracortical inhibition, as assessed with transcranial magnetic stimulation, was decreased only for hand muscles of the affected hand side. During movement of the affected limb, primary somatosensory cortex functional MRI activation was increased. Hand representation area size for somatosensory stimulation in functional MRI was smaller on the affected side with longer disease duration. Graded motor imagery intervention but not waiting, resulted in a decrease of movement pain. An increase of somatosensory hand representation size over graded motor imagery intervention was related to movement pain relief. Over graded motor imagery intervention, pathological parameters like the increased primary somatosensory cortex activation during fist movement or decreased short intracortical inhibition were modified in the same way as movement pain and hand performance improved. No such changes were observed during the waiting period. Overall, we demonstrated characteristic changes in clinical, behaviour and neuropathology parameters applying graded motor imagery in patients with upper limb complex regional pain syndrome, which casts light on the effects of graded motor imagery intervention on biomarkers for chronic neuropathic pain.
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Affiliation(s)
- Sebastian Strauss
- Functional Imaging Unit, Center for Diagnostic Radiology, University Medicine Greifswald, Greifswald, Germany.,Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Silke Barby
- Functional Imaging Unit, Center for Diagnostic Radiology, University Medicine Greifswald, Greifswald, Germany
| | - Jonas Härtner
- Functional Imaging Unit, Center for Diagnostic Radiology, University Medicine Greifswald, Greifswald, Germany
| | - Jörg Peter Pfannmöller
- Functional Imaging Unit, Center for Diagnostic Radiology, University Medicine Greifswald, Greifswald, Germany.,Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA
| | - Nicola Neumann
- Functional Imaging Unit, Center for Diagnostic Radiology, University Medicine Greifswald, Greifswald, Germany
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Adelaide 5000, Australia
| | - Martin Lotze
- Functional Imaging Unit, Center for Diagnostic Radiology, University Medicine Greifswald, Greifswald, Germany
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21
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Zangrandi A, Allen Demers F, Schneider C. Complex Regional Pain Syndrome. A Comprehensive Review on Neuroplastic Changes Supporting the Use of Non-invasive Neurostimulation in Clinical Settings. FRONTIERS IN PAIN RESEARCH 2021; 2:732343. [PMID: 35295500 PMCID: PMC8915550 DOI: 10.3389/fpain.2021.732343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Complex regional pain syndrome (CRPS) is a rare debilitating disorder characterized by severe pain affecting one or more limbs. CRPS presents a complex multifactorial physiopathology. The peripheral and sensorimotor abnormalities reflect maladaptive changes of the central nervous system. These changes of volume, connectivity, activation, metabolism, etc., could be the keys to understand chronicization, refractoriness to conventional treatment, and developing more efficient treatments. Objective: This review discusses the use of non-pharmacological, non-invasive neurostimulation techniques in CRPS, with regard to the CRPS physiopathology, brain changes underlying chronicization, conventional approaches to treat CRPS, current evidence, and mechanisms of action of peripheral and brain stimulation. Conclusion: Future work is warranted to foster the evidence of the efficacy of non-invasive neurostimulation in CRPS. It seems that the approach has to be individualized owing to the integrity of the brain and corticospinal function. Non-invasive neurostimulation of the brain or of nerve/muscles/spinal roots, alone or in combination with conventional therapy, represents a fertile ground to develop more efficient approaches for pain management in CRPS.
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Affiliation(s)
- Andrea Zangrandi
- Noninvasive Neurostimulation Laboratory (NovaStim), Quebec City, QC, Canada
- Neuroscience Division of Centre de Recherche du CHU of Québec, Université Laval, Quebec City, QC, Canada
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Fannie Allen Demers
- Noninvasive Neurostimulation Laboratory (NovaStim), Quebec City, QC, Canada
- Neuroscience Division of Centre de Recherche du CHU of Québec, Université Laval, Quebec City, QC, Canada
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Cyril Schneider
- Noninvasive Neurostimulation Laboratory (NovaStim), Quebec City, QC, Canada
- Neuroscience Division of Centre de Recherche du CHU of Québec, Université Laval, Quebec City, QC, Canada
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
- Department Rehabilitation, Université Laval, Quebec City, QC, Canada
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22
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Tompra N, van Dieën JH, Plinsinga ML, Coppieters MW. Left/right discrimination is not impaired in people with unilateral chronic Achilles tendinopathy. Musculoskelet Sci Pract 2021; 54:102388. [PMID: 33965774 DOI: 10.1016/j.msksp.2021.102388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 03/01/2021] [Accepted: 04/20/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Impaired left/right discrimination of an affected body part has been observed in various chronic pain states. This study aimed to examine whether people with unilateral chronic Achilles tendinopathy also present with impaired left/right discrimination. DESIGN Cross-sectional study. METHODS Nineteen runners with persistent unilateral Achilles tendinopathy and 19 matched healthy volunteers performed a left/right discrimination task in a laboratory setting. Participants were shown pictures of feet, hands and Shepard-Metzler figures and were asked to decide as accurately and as fast as possible whether the body part belonged to the left or right side of the body, or whether the Shepard-Metzler figures were rotated or mirrored. Performance was evaluated in terms of accuracy and response time. Data were analysed with mixed-design ANOVAs. RESULTS The decline in left/right discrimination ability at group level, if present, between affected and unaffected side, or compared to healthy participants, was negligible for both accuracy (<1.5%) and response time (<50 ms). There was no significant effect of side (affected versus unaffected side) or group (people with Achilles tendinopathy versus healthy) for accuracy (p > 0.36) or response time (p > 0.69). CONCLUSIONS People with Achilles tendinopathy recognised the affected side as accurately and as fast as the non-affected side and their performance was comparable to healthy participants. The absence of impaired left/right discrimination despite the chronicity of the condition may be attributable to the typical intermittent nature of Achilles tendinopathy pain and/or maintained sports activity.
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Affiliation(s)
- Nefeli Tompra
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands. https://twitter.com/NefeliTompra
| | - Jaap H van Dieën
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands. https://twitter.com/DieenJaap
| | - Melanie L Plinsinga
- Menzies Health Institute Queensland, Griffith University, Brisbane & Gold Coast, Australia. https://twitter.com/Melaniielp
| | - Michel W Coppieters
- Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, 1081 BT Amsterdam, The Netherlands; Menzies Health Institute Queensland, Griffith University, Brisbane & Gold Coast, Australia.
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23
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Defina S, Niedernhuber M, Shenker N, Brown CA, Bekinschtein TA. Attentional modulation of neural dynamics in tactile perception of complex regional pain syndrome patients. Eur J Neurosci 2021; 54:5601-5619. [PMID: 34250660 DOI: 10.1111/ejn.15387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 06/21/2021] [Accepted: 07/07/2021] [Indexed: 01/10/2023]
Abstract
Body perceptual disturbances are an increasingly acknowledged set of symptoms and possible clinical markers of complex regional pain syndrome (CRPS), but the neurophysiological and neurocognitive changes that underlie them are still far from being clear. We adopted a multivariate and neurodynamical approach to the analysis of EEG modulations evoked by touch to highlight differences between patients and healthy controls, between affected and unaffected side of the body, and between "passive" (i.e., no task demands and equiprobable digit stimulation) and "active" tactile processing (i.e., where a digit discrimination task was administered and spatial probability manipulated). When correct identifications are considered, an early reduction in cortical decodability (28-56 ms) distinguishes CRPS patients from healthy volunteers. However, when error trials are included in the classifier's training, there is an unexpected increased decodability in the CRPS group compared with healthy volunteers (280-320 ms). These group differences in neural processing seemed to be driven by the affected rather than the unaffected side. We corroborated these findings with several exploratory analyses of neural representation dynamics and behavioural modelling, highlighting the need for single participant analyses. Although several limitations impacted the robustness and generalizability of these comparisons, the proposed analytical approach yielded promising insights (as well as possible biomarkers based on neural dynamics) into the relatively unexplored alterations of tactile decision-making and attentional control mechanisms in chronic CRPS.
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Affiliation(s)
- Serena Defina
- Consciousness and Cognition Lab, Department of Psychology, University of Cambridge, Cambridge, UK
| | - Maria Niedernhuber
- Consciousness and Cognition Lab, Department of Psychology, University of Cambridge, Cambridge, UK
| | - Nicholas Shenker
- Department of Rheumatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Christopher A Brown
- Department of Rheumatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Tristan A Bekinschtein
- Consciousness and Cognition Lab, Department of Psychology, University of Cambridge, Cambridge, UK
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24
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Fuchs X, Diers M, Trojan J, Kirsch P, Milde C, Bekrater-Bodmann R, Rance M, Foell J, Andoh J, Becker S, Flor H. Phantom limb pain after unilateral arm amputation is associated with decreased heat pain thresholds in the face. Eur J Pain 2021; 26:114-132. [PMID: 34288253 DOI: 10.1002/ejp.1842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The mechanisms underlying chronic phantom limb pain (PLP) are complex and insufficiently understood. Altered sensory thresholds are often associated with chronic pain but quantitative sensory testing (QST) in PLP has so far been inconclusive due to large methodological variation between studies and small sample sizes. METHODS In this study, we applied QST in 37 unilateral upper-limb amputees (23 with and 14 without PLP) and 19 healthy controls. We assessed heat pain (HPT), pressure pain, warmth detection and two-point discrimination thresholds at the residual limb, a homologous point and the thenar of the intact limb as well as both corners of the mouth. RESULTS We did not find significant differences in any of the thresholds between the groups. However, PLP intensity was negatively associated with HPT at all measured body sites except for the residual limb, indicating lower pain thresholds with higher PLP levels. Correlations between HPT and PLP were strongest in the contralateral face (r = -0.65, p < 0.001). Facial HPT were specifically associated with PLP, independent of residual limb pain (RLP) and various other covariates. HPT at the residual limb, however, were significantly associated with RLP, but not with PLP. CONCLUSION We conclude that the association between PLP and, especially facial, HPT could be related to central mechanisms. SIGNIFICANCE Phantom limb pain (PLP) is still poorly understood. We show that PLP intensity is associated with lower heat pain thresholds, especially in the face. This finding could be related to central nervous changes in PLP.
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Affiliation(s)
- Xaver Fuchs
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Biopsychology and Cognitive Neuroscience, Faculty of Psychology and Sports Science, Bielefeld University, Bielefeld, Germany
| | - Martin Diers
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Department of Psychosomatic Medicine and Psychotherapy, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| | - Jörg Trojan
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Pinar Kirsch
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christopher Milde
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Department of Psychology, University of Koblenz-Landau, Landau, Germany
| | - Robin Bekrater-Bodmann
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Mariela Rance
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jens Foell
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Department of Psychology, Florida State University, Tallahassee, Florida, USA
| | - Jamila Andoh
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Heidelberg, Germany
| | - Susanne Becker
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Integrative Spinal Research, Research Chiropractic, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Herta Flor
- Institute of Cognitive and Clinical Neuroscience, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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25
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Lee D, Choi SH, Noh E, Lee WJ, Jang JH, Moon JY, Kang DH. Impaired Performance in Mental Rotation of Hands and Feet and Its Association with Social Cognition in Patients with Complex Regional Pain Syndrome. PAIN MEDICINE 2021; 22:1411-1419. [PMID: 33749758 PMCID: PMC8185560 DOI: 10.1093/pm/pnaa482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objectives. So far, dysfunction in mental rotation has been assessed in relation to the left- or right-sided CRPS. Here we examined mental rotation in patients with upper or lower limb CRPS. Considering the potential role of socio-emotional functioning on the perception of body image, we further investigated the association between performance on mental rotation and socio-emotional characteristics. Methods. We examined the performance of 36 patients with upper or lower limb CRPS on the limb laterality recognition. Accuracy and response times for pictures of hands and feet at 4 rotation angles were evaluated. Socio-emotional functioning was measured by the Interpersonal Reactivity Scale and the Toronto Alexithymia Scale. Results. Patients with upper limb pain showed longer RTs to recognize the laterality of hands than feet (P = 0.002), whereas patients with lower limb pain showed longer RTs for feet than hands (P = 0.039). Exploratory correlation analyses revealed that RTs for feet were negatively correlated with the levels of empathic ability to take another’s perspective (P = 0.006) and positively correlated with the level of emotional difficulty in identifying feelings (P = 0.006). Conclusions. This study is the first to report selectively impaired mental rotation of hands vs feet in patients with upper or lower limb CRPS. The findings suggest that impaired mental rotation derives from relative deficits in the representation of the affected limb. Correlations between impaired mental rotation and socio-emotional inability indicate that an altered body schema may be closely associated with impaired social cognitive aspects in CRPS patients.
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Affiliation(s)
- Dasom Lee
- Emotional Information and Communication Technology Industrial Association, Seoul, Republic of Korea
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soo-Hee Choi
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Psychiatry and Institute of Human Behavioral Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eunchung Noh
- Interdisciplinary Program in Neuroscience, Seoul National University, Seoul, Republic of Korea
| | - Won Joon Lee
- Department of Psychiatry, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Joon Hwan Jang
- Department of Psychiatry, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jee Youn Moon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Do-Hyung Kang
- Emotional Information and Communication Technology Industrial Association, Seoul, Republic of Korea
- Correspondence to: Do-Hyung Kang, MD, PhD, Emotional Information and Communication Technology Industrial Association, 06168, Samseong-ro 508, Gangnam-gu, Seoul, Republic of Korea. Tel: +82-42-860-1648; Fax: +82-50-7083-6323; E-mail:
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26
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Strauss S, Barby S, Härtner J, Neumann N, Moseley GL, Lotze M. Modifications in fMRI Representation of Mental Rotation Following a 6 Week Graded Motor Imagery Training in Chronic CRPS Patients. THE JOURNAL OF PAIN 2021; 22:680-691. [PMID: 33421590 DOI: 10.1016/j.jpain.2020.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/23/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
Complex regional pain syndrome (CRPS) is a neuropathic pain condition that is difficult to treat. For behavioral interventions, graded motor imagery (GMI) showed relevant effects, but underlying neural substrates in patient groups have not been investigated yet. A previous study investigating differences in the representation of a left/right hand judgment task demonstrated less recruitment of subcortical structures, such as the putamen, in CRPS patients than in healthy controls. In healthy volunteers, the putamen activity increased after a hand judgment task training. In order to test for longitudinal effects of GMI training, we investigated 20 CRPS patients in a wait-list crossover design with 3 evaluation time points. Patients underwent a 6 week GMI treatment and a 6 week waiting period in a randomized group assignment and treatment groups were evaluated by a blinded rater. When compared to healthy matched controls at baseline, CRPS patients showed less functional activation in areas processing visual input, left sensorimotor cortex, and right putamen. Only GMI treatment, but not the waiting period showed an effect on movement pain and hand judgment task performance. Regression analyses revealed positive associations of movement pain with left anterior insula activation at baseline. Right intraparietal sulcus activation change during GMI was associated with a gain in performance of the hand judgment task. The design used here is reliable for investigating the functional representation of the hand judgment task in an intervention study. PERSPECTIVE: Twenty chronic CRPS patients underwent a 6 week GMI intervention in a randomized wait-list crossover design. functional MRI was tested pre and post for the hand lateralization task which improved over GMI but not over WAITING. Performance gain was positively related to right parietal functional MRI activation.
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Affiliation(s)
- Sebastian Strauss
- Functional Imaging Unit, Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Germany; Department of Neurology, University Medicine Greifswald, Germany
| | - Silke Barby
- Functional Imaging Unit, Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Germany
| | - Jonas Härtner
- Functional Imaging Unit, Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Germany
| | - Nicola Neumann
- Functional Imaging Unit, Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Germany
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Adelaide, Australia
| | - Martin Lotze
- Functional Imaging Unit, Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Germany.
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27
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Reinersmann A, Skinner IW, Lücke T, Massy-Westropp N, Rudolf H, Moseley GL, Stanton TR. Intact tactile anisotropy despite altered hand perception in complex regional pain syndrome: rethinking the role of the primary sensory cortex in tactile and perceptual dysfunction. PeerJ 2021; 9:e11156. [PMID: 33986983 PMCID: PMC8101475 DOI: 10.7717/peerj.11156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 03/04/2021] [Indexed: 01/18/2023] Open
Abstract
Complex Regional Pain Syndrome (CRPS) is characterised by pain, autonomic, sensory and motor abnormalities. It is associated with changes in the primary somatosensory cortex (S1 representation), reductions in tactile sensitivity (tested by two-point discrimination), and alterations in perceived hand size or shape (hand perception). The frequent co-occurrence of these three phenomena has led to the assumption that S1 changes underlie tactile sensitivity and perceptual disturbances. However, studies underpinning such a presumed relationship use tactile sensitivity paradigms that involve the processing of both non-spatial and spatial cues. Here, we used a task that evaluates anisotropy (i.e., orientation-dependency; a feature of peripheral and S1 representation) to interrogate spatial processing of tactile input in CRPS and its relation to hand perception. People with upper limb CRPS (n = 14) and controls with (n = 15) or without pain (n = 19) judged tactile distances between stimuli-pairs applied across and along the back of either hand to provide measures of tactile anisotropy. Hand perception was evaluated using a visual scaling task and questionnaires. Data were analysed with generalised estimating equations. Contrary to our hypotheses, tactile anisotropy was bilaterally preserved in CRPS, and the magnitude of anisotropic perception bias was comparable between groups. Hand perception was distorted in CRPS but not related to the magnitude of anisotropy or bias. Our results suggest against impairments in spatial processing of tactile input, and by implication S1 representation, as the cause of distorted hand perception in CRPS. Further work is warranted to elucidate the mechanisms of somatosensory dysfunction and distorted hand perception in CRPS.
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Affiliation(s)
- Annika Reinersmann
- Neuropediatric Department, Children's University Hospital St. Josef, Ruhr-Universität Bochum, Bochum, North-Rhine Westphalia, Germany.,School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Ian W Skinner
- Neuroscience Research Australia, NEURA, University of New South Wales, Sydney, New South Wales, Australia
| | - Thomas Lücke
- Neuropediatric Department, Children's University Hospital St. Josef, Ruhr-Universität Bochum, Bochum, North-Rhine Westphalia, Germany
| | - Nicola Massy-Westropp
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-Universität Bochum, Bochum, Germany
| | - G Lorimer Moseley
- Neuroscience Research Australia, NEURA, University of New South Wales, Sydney, New South Wales, Australia.,School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Tasha R Stanton
- Neuroscience Research Australia, NEURA, University of New South Wales, Sydney, New South Wales, Australia.,School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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28
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Abstract
Complex regional pain syndrome (CRPS) develops after-limb injury, with persistent pain and deficits in movement frequently co-occurring. The striatum is critical for mediating multiple mechanisms that are often aberrant in CRPS, which includes sensory and pain processing, motor function, and goal-directed behaviors associated with movement. Yet, much remains unknown with regards to the morphological and functional properties of the striatum and its subregions in this disease. Thus, we investigated 20 patients (15 female, age 58 ± 9 years, right-handed) diagnosed with chronic (6+ months of pain duration) CRPS in the right hand and 20 matched, healthy controls with anatomical and resting-state, functional magnetic resonance imaging. In addition, a comprehensive clinical and behavioral evaluation was performed, where each participant's pain, motor function, and medical history were assessed. Complex regional pain syndrome patients harbored significant abnormalities in hand coordination, dexterity, and strength. These clinical pain- and movement-related findings in CRPS patients were concomitant with bilateral decreases in gray matter density in the putamen as well as functional connectivity increases and decreases among the putamen and pre-/postcentral gyri and cerebellum, respectively. Importantly, higher levels of clinical pain and motor impairment were associated with increased putamen-pre-/postcentral gyri functional connectivity strengths. Collectively, these findings suggest that putaminal alterations, specifically the functional interactions with sensorimotor structures, may underpin clinical pain and motor impairment in chronic CRPS patients.
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29
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Olthof NA, Harvie DS, Henderson C, Thompson B, Sharp R, Craig-Ward L, Weermeijer JD, Sterling M, Moseley GL, Coppieters MW. Description and psychometric properties of a prototype to test tactile acuity in the neck. Musculoskelet Sci Pract 2021; 51:102259. [PMID: 33023867 DOI: 10.1016/j.msksp.2020.102259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Clinical tools assessing tactile acuity in people with persistent pain have limitations. Therefore, a novel and semi-automated tool was developed: The Imprint Tactile Acuity Device (iTAD). AIM To describe the iTAD prototype and present the psychometric properties of its tactile acuity assessments: the localisation test, the orientation test and the overall score (mean of both tests). METHOD A test-retest design with fifty healthy participants was used to assess intra-rater reliability (ICC(2.1)), internal consistency (ICC(2.4)) and measurement error (SEM) of the three assessments (0-100% accuracy scores each) performed at the neck. Using a known-group comparison design, balanced by age and sex, scores of thirty individuals with persistent neck pain were compared to thirty healthy controls to determine construct validity. RESULTS The ICC(2,1) and ICC(2,4) were 0.60 and 0.78 for the localisation test, 0.66 and 0.77 for the orientation test, and 0.73 and 0.84 for the overall score. The SEMs were 9.0%, 8.1% and 6.0%, respectively. No fixed or proportional bias, or signs of heteroscedasticity were observed. Overall, no between group differences were observed (p = 0.49). In the male subgroup, however, the overall score was lower for people with neck pain than for healthy participants (mean difference (SE); 7.6% (2.5); p = 0.008). DISCUSSION The tactile acuity assessments of the iTAD demonstrate moderate reliability and good internal consistency. Measurement errors appear comparable to currently preferred methods. Clear construct validity was not established, but results may be biased by design issues of the prototype. Taken together, the iTAD shows promise but further fine-tuning is needed.
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Affiliation(s)
- Nick A Olthof
- School of Allied Health Sciences, Griffith University, Brisbane and Gold Coast, Australia; Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia
| | - Daniel S Harvie
- School of Allied Health Sciences, Griffith University, Brisbane and Gold Coast, Australia; Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia.
| | - Courtney Henderson
- School of Allied Health Sciences, Griffith University, Brisbane and Gold Coast, Australia
| | - Brendan Thompson
- School of Allied Health Sciences, Griffith University, Brisbane and Gold Coast, Australia
| | - Robert Sharp
- School of Allied Health Sciences, Griffith University, Brisbane and Gold Coast, Australia
| | - Lauren Craig-Ward
- School of Allied Health Sciences, Griffith University, Brisbane and Gold Coast, Australia
| | - Jeroen D Weermeijer
- Center for Contextual Psychiatry, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Michele Sterling
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Australia; NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Australia
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Adelaide, Australia
| | - Michel W Coppieters
- Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia; Amsterdam Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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30
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Chang C, McDonnell P, Gershwin ME. Complex regional pain syndrome - Autoimmune or functional neurologic syndrome. J Transl Autoimmun 2020; 4:100080. [PMID: 33490941 PMCID: PMC7804982 DOI: 10.1016/j.jtauto.2020.100080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 12/23/2022] Open
Abstract
Complex regional pain syndrome (CRPS) purports to explain extremity pain accompanied by a variety of subjective complaints, including sensitivity to touch, fatigue, burning sensations, allodynia and signs consistent with voluntary immobilization, including skin changes, edema and trophic changes. By its own definition, CRPS pain is disproportionate to any inciting event or underlying pathology, which means that the syndrome describes non-anatomic and exaggerated symptoms. Although CRPS was coined in the early 1990s, physicians have described unexplained exaggerated pain for centuries. Before a small group of researchers assigned this historical phenomenon with the name CRPS, other physicians in various subspecialties investigated the existence of a common pathophysiologic mechanism but found none. The literature was searched for evidence of a reproducible pathologic mechanism for CRPS. Although some have suggested that CRPS is an autoimmune disease, there is a paucity of evidence to support this. While cytokines such as IL-1β, IL-6 and TNF-α have been detected during the early phases of CRPS, this cannot lead to the conclusion that CRPS is an autoimmune disease, nor that it is an autoinflammatory disorder. Moreover, intravenous immunoglobulin has showed inconsistent results in the treatment of CRPS. On the other hand, CRPS has been found to meet at least three out of four criteria of malingering, which was previously a DSM-IV diagnosis; and its diagnostic criteria are virtually identical to current DSM-5 Functional Neurological Disorder ("FND"), and proposed ICD-11 classification, which includes FND as a distinct neurological diagnosis apart from any psychiatric condition. Unfortunately, the creation of CPRS is not merely misguided brand marketing. It has serious social and health issues. At least in part, the existence of CRPS has led to the labeling of many patients with a diagnosis that allows the inappropriate use of invasive surgery, addictive opioids, and ketamine. The CRPS hypothesis also ignores the nature and purpose of pain, as a symptom of some organic or psychological process. Physicians have long encountered patients who voice symptoms that cannot be biologically explained. Terminology historically used to describe this phenomenon have been medically unexplained symptoms ("MUS"), hysterical, somatic, non-organic, psychogenic, conversion disorder, or dissociative symptoms. The more recent trend describes disorders where there is a functional, rather than structural cause of the symptoms, as "functional disorders." Physicians report high success treating functional neurological symptoms with reassurance, physiotherapy, and cognitive behavior therapy measured in terms of functional improvement. The CRPS label, however, neither leads to functional improvement in these patients nor resolution of symptoms. Under principles of evidence-based medicine, the CRPS label should be abandoned and the syndrome should simply be considered a subset of FNDs, specifically Functional Pain Disorder; and treated appropriately.
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Affiliation(s)
- Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA.,Division of Immunology, Allergy and Rheumatology, Joe DiMaggio Children's Hospital and Memorial Healthcare System, 1131 N 35th Avenue, Suite 220, Hollywood, FL, 33021, USA
| | | | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA
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31
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Doménech-García V, Palsson TS, Boudreau SA, Bellosta-López P, Herrero P, Graven-Nielsen T. Healthy Pain-Free Individuals with a History of Distal Radius Fracture Demonstrate an Expanded Distribution of Experimental Referred Pain Toward the Wrist. PAIN MEDICINE 2020; 21:2850-2862. [PMID: 33146396 DOI: 10.1093/pm/pnaa228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Nociception caused by injuries may sensitize central mechanisms causing expanded pain areas. After recovery, the status of such pain distribution and sensitivity mechanisms is unknown. The present study investigated whether individuals who have fully recovered from a distal radius fracture demonstrate increased pain sensitivity and expanded distribution of pressure-induced pain. DESIGN Cross-sectional single-blinded study. SETTING Clinical setting. SUBJECTS Twenty-three pain-free individuals with a history of painful distal radius fracture and 22 nonfractured, age/gender-matched controls participated in two experimental sessions (day 0, day 1) 24 hours apart. METHODS Pressure pain thresholds (PPTs) were recorded bilaterally at the extensor carpi radialis longus (ECRL), infraspinatus, and gastrocnemius muscles. Spatial distribution of pain was assessed following 60-second painful pressure stimulation at the ECRL (bilateral) and the infraspinatus muscles on the fractured or dominant side. Participants drew pain areas on a body map. After day 0 assessments, prolonged pain was induced by eccentric exercise of wrist extensors on the fractured/dominant side. RESULTS Compared with controls, pressure-induced ECRL pain in the fracture group referred more frequently toward the distal forearm (P < 0.005) on day 0. Both groups showed larger pain areas on day 1 compared with day 0 (P < 0.005), although the fracture group showed a larger relative change between days (P < 0.005). The fracture group showed larger pain areas on the fracture side compared with the contralateral side on both days (P < 0.005). CONCLUSIONS Prolonged pain and recovered prior painful injuries like fractures may sensitize pain mechanisms manifested as expanded pain distribution. Pressure-induced referred pain can be a simple pain biomarker for clinical use.
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Affiliation(s)
- Víctor Doménech-García
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Universidad San Jorge, Campus Universitario, Villanueva de Gállego, Zaragoza, Spain
| | - Thorvalur S Palsson
- Department of Health Science and Technology, SMI, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Shellie A Boudreau
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Pablo Bellosta-López
- Universidad San Jorge, Campus Universitario, Villanueva de Gállego, Zaragoza, Spain
| | - Pablo Herrero
- Universidad San Jorge, Campus Universitario, Villanueva de Gállego, Zaragoza, Spain
| | - Thomas Graven-Nielsen
- Center for Neuroplasticity and Pain (CNAP), SMI, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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Breckenridge JD, McAuley JH, Ginn KA. Motor Imagery Performance and Tactile Spatial Acuity: Are They Altered in People with Frozen Shoulder? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17207464. [PMID: 33066655 PMCID: PMC7602509 DOI: 10.3390/ijerph17207464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/09/2020] [Accepted: 10/11/2020] [Indexed: 12/24/2022]
Abstract
Frozen shoulder (adhesive capsulitis) is a severe chronic pain condition that is not well understood and current treatment is suboptimal. In several other chronic pain conditions motor imagery and tactile acuity deficits are present, which are thought to represent associated neuroplastic changes. The aims of this study were to determine if motor imagery performance assessed by the left/right judgement task, and tactile acuity assessed by two-point discrimination, are altered in people with unilateral frozen shoulder. In this cross-sectional, prospective study eighteen adults diagnosed with frozen shoulder in a physiotherapy clinic setting completed a left/right judgement task, response times (RT) and accuracy for the left/right judgement task were determined. Next, tactile acuity over both shoulders was assessed with a novel, force-standardised two-point discrimination test. Results corresponding to the affected side were compared to the pain free shoulder; Left/right judgement task: mean RT (SD) corresponding to the affected shoulder was significantly slower than RT for the healthy shoulder (p = 0.031). There was no side-to-side difference in accuracy (p > 0.05). Neither RT nor accuracy was related to pain/disability scores or duration of symptoms (p > 0.05). Two-point discrimination: mean two-point discrimination threshold of the affected shoulder was significantly larger than the contralateral healthy shoulder (p < 0.001). Two-point discrimination threshold was not related to pain/disability scores or pain duration (p > 0.05); One explanation for these findings is altered sensorimotor processing and/or disrupted sensorimotor cortex representations of the affected shoulder. A case then exists for the use of treatments aimed at reversing these changes, training the brain to reduce chronic shoulder pain.
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Affiliation(s)
- John D. Breckenridge
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
- The Clinical Research Institute, Sydney 2145, Australia
- Correspondence: ; Tel.: +61-2-9672-3511
| | - James H. McAuley
- Neuroscience Research Australia (NeuRA), Hospital Rd, Randwick 2013, Australia;
- School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney 2033, Australia
| | - Karen A. Ginn
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
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Hirakawa Y, Imai R, Shigetoh H, Morioka S. Intervention Using Body Shadow to Evoke Loading Imagery in a Patient with Complex Regional Pain Syndrome in the Foot: A Case Report. Brain Sci 2020; 10:brainsci10100718. [PMID: 33050227 PMCID: PMC7600743 DOI: 10.3390/brainsci10100718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 11/30/2022] Open
Abstract
We present the case of a female patient who developed complex regional pain syndrome (CRPS) after a right-foot injury. The patient had pain from the right knee to the toes and showed severe disgust at the appearance of the affected limb. Consequently, the affected limb was not fully loaded, and the patient had difficulty walking. General interventions, such as mirror therapy, were attempted, but the effect was limited. We hypothesized that this was due to the disgust toward the affected limb, and we implemented a body-shadow intervention that we developed. This reduced the disgust for the affected limb and improved pain, but neither changed the anticipated pain of loading the affected limb nor improved the patient’s walking ability. The reason for this was considered to be that the previous interventions using the body shadow utilized the third-person perspective, denoting that the image of the load sensation on the sole of the foot during walking was insufficient; therefore, we attempted a first-person body-shadow intervention. The results showed improvement in the patient’s walking ability. In CRPS of the foot, it is important to use interventions that evoke images of loading without causing anticipatory pain, pointing to the effectiveness of body-shadow interventions.
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Affiliation(s)
- Yoshiyuki Hirakawa
- Department of Rehabilitation, Fukuoka Rehabilitation Hospital, Fukuoka City, Fukuoka 819-8551, Japan
- Correspondence: ; Tel.: +81-(092)-812-1555
| | - Ryota Imai
- School of Rehabilitation Osaka Kawasaki Rehabilitation University, Kaizuka City, Osaka 597-0104, Japan;
| | - Hayato Shigetoh
- Miura Internal Medicine Michiko Pediatrics Clinic, Kagawa 763-0082, Japan;
- Department of Neurorehabilitation, Graduate School of Health Sciences, Kio University, Nara City, Nara 635-0832, Japan;
| | - Shu Morioka
- Department of Neurorehabilitation, Graduate School of Health Sciences, Kio University, Nara City, Nara 635-0832, Japan;
- Neurorehabilitation Research Centre, Kio University, Nara City, Nara 635-0832, Japan
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Breckenridge JD, McAuley JH, Moseley GL, Ginn KA. Is implicit motor imagery altered in people with shoulder pain? The shoulder left/right judgement task. Musculoskelet Sci Pract 2020; 48:102159. [PMID: 32250837 DOI: 10.1016/j.msksp.2020.102159] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Implicit motor imagery performance is altered in a variety of chronic pain conditions, but it is not known whether this is the case in shoulder pain. OBJECTIVES The aim of this study was to assess implicit motor imagery performance, using a valid and reliable shoulder left/right judgement task in people with shoulder pain. DESIGN Cross-sectional observational study. METHODS Participants with (n = 369) and without (n = 747) shoulder pain completed the shoulder left/right judgement task (LRJT). Response times (RT), accuracy were determined. Age, gender, hand dominance, current pain intensity, Shoulder Pain and Disability Index (SPADI) and pain duration recorded. Planned analysis included ANOVAs for current pain, RT and accuracy. RESULTS Gender and hand dominance distribution were similar between groups (p > 0.5). The shoulder pain participants were older, mean age (SD); 47(14)years, than the control group; 41(14)years, p < 0.01. Participants with shoulder pain were slower, mean RT(SD); 1809(746)ms than the controls; 1701(749)ms; p = 0.02, but no different in accuracy, mean % (SD); 93.2(8.5)% to controls; 94.1(9.4)%; p = 0.13. The differences in RT were resolved when age was entered as a covariate (p = 0.83). Regression of the data from the shoulder pain group only found that current pain was positively related to RT (B = 43.97) and negatively to accuracy (B = -0.70). CONCLUSIONS Participants with shoulder pain do not demonstrate poorer implicit motor imagery performance than people who are pain-free. However, more intense shoulder pain is associated with poorer implicit motor imagery performance. We recommend further research utilising the LRJT in well-defined clinically homogenous groups, with verified pain severity, functional disability, and chronicity.
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Affiliation(s)
- John D Breckenridge
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Australia; The Clinical Research Institute, Sydney, Australia.
| | - James H McAuley
- Neuroscience Research Australia (NeuRA), Hospital Rd, Randwick, 2013, Australia; School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Adelaide, 5000, Australia
| | - Karen A Ginn
- School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Australia
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Di Pietro F, Lee B, Henderson LA. Altered resting activity patterns and connectivity in individuals with complex regional pain syndrome. Hum Brain Mapp 2020; 41:3781-3793. [PMID: 32510695 PMCID: PMC7416050 DOI: 10.1002/hbm.25087] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 12/20/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic neuropathic pain disorder that typically occurs in the limbs, usually the upper limb. CRPS usually develops from a peripheral event but its maintenance relies on changes within the central nervous system. While functional abnormalities in the thalamus and primary somatosensory cortex (S1) of the brain are some of the most consistently reported brain findings in CRPS, the mechanisms are yet to be explored in full, not least of all how these two regions interact and how they might relate to clinical deficits, such as the commonly reported poor tactile acuity in this condition. This study recruited 15 upper‐limb CRPS subjects and 30 healthy controls and used functional magnetic resonance imaging (fMRI) to investigate infra‐slow oscillations (ISOs) in critical pain regions of the brain in CRPS. As hypothesised, we found CRPS was associated with increases in resting signal intensity ISOs (0.03–0.06 Hz) in the thalamus contralateral to the painful limb in CRPS subjects. Interestingly, there was no such difference between groups in S1, however CRPS subjects displayed stronger thalamo‐S1 functional connectivity than controls, and this was related to pain. As predicted, CRPS subjects displayed poor tactile acuity on the painful limb which, interestingly, was also related to thalamo‐S1 functional connectivity strength. Our findings provide novel evidence of altered patterns of resting activity and connectivity in CRPS which may underlie altered thalamocortical loop dynamics and the constant perception of pain.
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Affiliation(s)
- Flavia Di Pietro
- Department of Anatomy and Histology, Brain and Mind Centre, University of Sydney, Sydney, Australia.,School of Pharmacy and Biomedical Sciences, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Barbara Lee
- Department of Anatomy and Histology, Brain and Mind Centre, University of Sydney, Sydney, Australia
| | - Luke A Henderson
- Department of Anatomy and Histology, Brain and Mind Centre, University of Sydney, Sydney, Australia
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Hirakawa Y, Fujiwara A, Imai R, Hiraga Y, Morioka S. Clinical Intervention Using Body Shadows for a Patient with Complex Regional Pain Syndrome Who Reported Severe Pain and Self-Disgust Toward the Affected Site: A Case Report. J Pain Res 2020; 13:971-977. [PMID: 32440203 PMCID: PMC7213788 DOI: 10.2147/jpr.s236786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 04/10/2020] [Indexed: 11/27/2022] Open
Abstract
A woman in her thirties developed complex regional pain syndrome in her left shoulder due to a traffic accident. She demonstrated autonomic nervous symptoms (swelling, sweating, and skin color asymmetry) in her left hand, severe allodynia, neglect-like symptoms (NLS), impaired body image associated with impaired body awareness, and functional impairment of the left shoulder and elbow. She also reported physical self-disgust toward her affected limb, describing it as “reptilian,” as well as aversion to touching others; this body awareness exacerbated her pain and NLS. We therefore conducted stepwise interventions using body shadows. The intervention did not trigger physical self-disgust, enabling formation of body ownership and a body image unaccompanied by pain. Consequently, the patient showed improvements in pain, NLS, and autonomic nervous symptoms.
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Affiliation(s)
- Yoshiyuki Hirakawa
- Department of Rehabilitation, Fukuoka Rehabilitation Hospital, Fukuoka City, Fukuoka, Japan
| | - Akira Fujiwara
- Department of Orthopedics, Fukuoka Reha Orthopedic Clinic, Fukuoka City, Fukuoka, Japan
| | - Ryota Imai
- School of Rehabilitation, Osaka Kawasaki Rehabilitation University, Kaizuka City, Osaka, Japan.,Department of Occupational Therapy, International Univesrity of Health and Welfare, Okawa,Fukuoka, Japan
| | - Yuki Hiraga
- Department of Rehabilitation, Fukuoka Rehabilitation Hospital, Fukuoka City, Fukuoka, Japan.,Neurorehabilitation Research Centre, Kio University, Nara, City, Nara, Japan
| | - Shu Morioka
- Department of Occupational Therapy, International Univesrity of Health and Welfare, Okawa,Fukuoka, Japan.,Department of Neurorehabilitation, Graduate School of Health Sciences, Kio University, Nara City, Nara, Japan
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37
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Nahm FS, Lee JS, Lee PB, Choi E, Han WK, Nahm SS. Increased calcium-mediated cerebral processes after peripheral injury: possible role of the brain in complex regional pain syndrome. Korean J Pain 2020; 33:131-137. [PMID: 32235013 PMCID: PMC7136292 DOI: 10.3344/kjp.2020.33.2.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/28/2020] [Accepted: 03/05/2020] [Indexed: 11/23/2022] Open
Abstract
Background Among various diseases that accompany pain, complex regional pain syndrome (CRPS) is one of the most frustrating for patients and physicians. Recently, many studies have shown functional and anatomical abnormalities in the brains of patients with CRPS. The calcium-related signaling pathway is important in various physiologic processes via calmodulin (CaM) and calcium-calmodulin kinase 2 (CaMK2). To investigate the cerebral mechanism of CRPS, we measured changes in CaM and CaMK2 expression in the cerebrum in CRPS animal models. Methods The chronic post-ischemia pain model was employed for CRPS model generation. After generation of the animal models, the animals were categorized into three groups based on changes in the withdrawal threshold for the affected limb: CRPS-positive (P), CRPS-negative (N), and control (C) groups. Western blot analysis was performed to measure CaM and CaMK2 expression in the rat cerebrum. Results Animals with a decreased withdrawal threshold (group P) showed a significant increment in cerebral CaM and CaMK2 expression (P = 0.013 and P = 0.021, respectively). However, groups N and C showed no difference in CaM and CaMK2 expression. Conclusions The calcium-mediated cerebral process occurs after peripheral injury in CRPS, and there can be a relationship between the cerebrum and the pathogenesis of CRPS.
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Affiliation(s)
- Francis Sahngun Nahm
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - Jae-Sung Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Pyung-Bok Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - Eunjoo Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Woong Ki Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Soep Nahm
- Department of Veterinary Medicine, College of Veterinary Medicine, Konkuk University, Seoul, Korea
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38
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Altered updating of bodily and spatial representations after tool-use in complex regional pain syndrome. Pain 2020; 161:1609-1628. [DOI: 10.1097/j.pain.0000000000001845] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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CRPS Is Not Associated with Altered Sensorimotor Cortex GABA or Glutamate. eNeuro 2020; 7:ENEURO.0389-19.2020. [PMID: 31980452 PMCID: PMC7029188 DOI: 10.1523/eneuro.0389-19.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 12/18/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating chronic pain disorder typically in the upper or lower limbs. While CRPS usually develops from a peripheral event, it is likely maintained by CNS changes. Indeed, CRPS is reported to be associated with sensorimotor cortex changes, or functional “reorganization,” as well as deficits such as poor tactile acuity. While the mechanisms underpinning cortical reorganization in CRPS are unknown, some have hypothesized that it involves disinhibition (i.e., a reduction in GABA activity). In this study, we addressed this hypothesis by using edited magnetic resonance spectroscopy to determine sensorimotor GABA and glutamate concentrations in 16 humans with CRPS and 30 matched control subjects and the relationship of these concentrations with tactile acuity. We found that individuals with upper limb CRPS displayed reduced tactile acuity in the painful hand, compared with the nonpainful hand and pain-free control subjects. Despite this acuity deficit, CRPS was not associated with altered GABA or glutamate concentrations within the sensorimotor cortex on either the side that represents the affected or unaffected hand. Furthermore, there was no significant relationship between sensorimotor GABA or glutamate concentrations and tactile acuity in CRPS subjects or control subjects. Although our sample was small, these data suggest that CRPS is not associated with altered total sensorimotor GABA or glutamate concentrations. While these results are at odds with the sensorimotor cortex disinhibition hypothesis, it is possible that GABAergic mechanisms other than total GABA concentration may contribute to such disinhibition.
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40
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Neuropsychological Changes in Complex Regional Pain Syndrome (CRPS). Behav Neurol 2020; 2020:4561831. [PMID: 32399082 PMCID: PMC7201816 DOI: 10.1155/2020/4561831] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/24/2019] [Accepted: 12/11/2019] [Indexed: 01/18/2023] Open
Abstract
Complex Regional Pain Syndrome (CRPS) is a poorly understood chronic pain condition of multifactorial origin. CRPS involves sensory, motor, and autonomic symptoms primarily affecting one extremity. Patients can also present with neuropsychological changes such as reduced attention to the CRPS-affected extremity, reminiscent of hemispatial neglect, yet in the absence of any brain lesions. However, this "neglect-like" framework is not sufficient to characterise the range of higher cognitive functions that can be altered in CRPS. This comprehensive literature review synthesises evidence of neuropsychological changes in CRPS in the context of potential central mechanisms of the disorder. The affected neuropsychological functions constitute three distinct but not independent groups: distorted body representation, deficits in lateralised spatial cognition, and impairment of non-spatially-lateralised higher cognitive functions. We suggest that many of these symptoms appear to be consistent with a broader disruption to parietal function beyond merely what could be considered "neglect-like." Moreover, the extent of neuropsychological symptoms might be related to the clinical signs of CRPS, and rehabilitation methods that target the neuropsychological changes can improve clinical outcomes in CRPS and other chronic pain conditions. Based on the limitations and gaps in the reviewed literature, we provide several suggestions to improve further research on neuropsychological changes in chronic pain.
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41
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Kaas A, Goebel R, Valente G, Sorger B. Topographic Somatosensory Imagery for Real-Time fMRI Brain-Computer Interfacing. Front Hum Neurosci 2019; 13:427. [PMID: 31920588 PMCID: PMC6915074 DOI: 10.3389/fnhum.2019.00427] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/18/2019] [Indexed: 11/23/2022] Open
Abstract
Real-time functional magnetic resonance imaging (fMRI) is a promising non-invasive method for brain-computer interfaces (BCIs). BCIs translate brain activity into signals that allow communication with the outside world. Visual and motor imagery are often used as information-encoding strategies, but can be challenging if not grounded in recent experience in these modalities, e.g., in patients with locked-in-syndrome (LIS). In contrast, somatosensory imagery might constitute a more suitable information-encoding strategy as the somatosensory function is often very robust. Somatosensory imagery has been shown to activate the somatotopic cortex, but it has been unclear so far whether it can be reliably detected on a single-trial level and successfully classified according to specific somatosensory imagery content. Using ultra-high field 7-T fMRI, we show reliable and high-accuracy single-trial decoding of left-foot (LF) vs. right-hand (RH) somatosensory imagery. Correspondingly, higher decoding accuracies were associated with greater spatial separation of hand and foot decoding-weight patterns in the primary somatosensory cortex (S1). Exploiting these novel neuroscientific insights, we developed-and provide a proof of concept for-basic BCI communication by showing that binary (yes/no) answers encoded by somatosensory imagery can be decoded with high accuracy in simulated real-time (in 7 subjects) as well as in real-time (1 subject). This study demonstrates that body part-specific somatosensory imagery differentially activates somatosensory cortex in a topographically specific manner; evidence which was surprisingly still lacking in the literature. It also offers proof of concept for a novel somatosensory imagery-based fMRI-BCI control strategy, with particularly high potential for visually and motor-impaired patients. The strategy could also be transferred to lower MRI field strengths and to mobile functional near-infrared spectroscopy. Finally, given that communication BCIs provide the BCI user with a form of feedback based on their brain signals and can thus be considered as a specific form of neurofeedback, and that repeated use of a BCI has been shown to enhance underlying representations, we expect that the current BCI could also offer an interesting new approach for somatosensory rehabilitation training in the context of stroke and phantom limb pain.
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Affiliation(s)
- Amanda Kaas
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Center, Maastricht University, Maastricht, Netherlands
| | - Rainer Goebel
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Center, Maastricht University, Maastricht, Netherlands
| | - Giancarlo Valente
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Center, Maastricht University, Maastricht, Netherlands
| | - Bettina Sorger
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
- Maastricht Brain Imaging Center, Maastricht University, Maastricht, Netherlands
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42
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Pelletier R, Paquette É, Bourbonnais D, Higgins J, Harris PG, Danino MA. Bilateral sensory and motor as well as cognitive differences between persons with and without musculoskeletal disorders of the wrist and hand. Musculoskelet Sci Pract 2019; 44:102058. [PMID: 31542683 DOI: 10.1016/j.msksp.2019.102058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 08/11/2019] [Accepted: 09/12/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Sensory and motor disturbances are characteristic of musculoskeletal injuries and conditions. Rehabilitation interventions aimed at remediating these disturbances are traditionally exclusively targeted to the affected area. However, there is some evidence of bilateral changes in sensory and motor function associated with unilateral injuries and conditions suggesting central changes. Deficits on specific cognitive tasks have also been documented in persons with chronic pain. PURPOSE The purpose of the present study was to determine if participants with unilateral pain arising from heterogeneous wrist/hand injuries and conditions demonstrate bilateral changes in sensory and motor functions as well as cognitive deficits. DESIGN/METHODS Sensory (Pressure Pain Thresholds, Two Point Orientation Discrimination), Motor (grip strength and Purdue Pegboard), and Cognitive function (Stroop test and mental rotation task) were measured in 30 participants with wrist/hand pain and 30 healthy control participants in an observational cross-sectional study. RESULTS Participants with unilateral wrist/hand pain demonstrated differences in cognitive function measured with the Stroop test (p = 0.03). They also demonstrated bilateral sensorimotor differences in pressure pain thresholds (p = 0.03), grip strength (p = 0.00) and Purdue pegboard test (p = 0.03) results compared to healthy control participants. CONCLUSION Cognitive as well as bilateral alterations in sensory and motor function in participants with musculoskeletal injuries and conditions suggest central changes are involved in their pathophysiology. These findings in persons with heterogeneous injuries/conditions suggest that these changes are not specific to an injury/condition. Bilateral sensorimotor changes have important implications with regards to the pathophysiology of musculoskeletal disorders of the wrist/hand, for rehabilitative interventions and research.
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Affiliation(s)
- René Pelletier
- Sciences de la réadaptation, École de réadaptation, Faculté de Médecine, Université de Montréal, Montréal, Québec, H3C 3J7, Canada.
| | - Élyssa Paquette
- Sciences de la réadaptation, École de réadaptation, Faculté de Médecine, Université de Montréal, Montréal, Québec, H3C 3J7, Canada.
| | - Daniel Bourbonnais
- École de réadaptation, Faculté de médecine, Université de Montréal, C.P. 6128, succursale Centre-ville, Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, H3C 3J7, Québec, Canada.
| | - Johanne Higgins
- École de réadaptation, Faculté de médecine, Université de Montréal, C.P. 6128, succursale Centre-ville, Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montréal, H3C 3J7, Québec, Canada.
| | - Patrick G Harris
- Département de chirurgie Université de Montréal, Chef département de chirurgie du Centre Hospitalier de l'Université de Montréal (CHUM), 1000, rue Saint-Denisx, H2X 0C1, Québec, Canada.
| | - Michel Alain Danino
- Université de Montréal, Chef du service de chirurgie plastique du Centre Hospitalier Université de Montréal (CHUM), 850, rue St-Denis Pav. S - local S02-128, H2X 0A9, Montréal, Québec, Canada.
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43
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Mancini F, Wang AP, Schira MM, Isherwood ZJ, McAuley JH, Iannetti GD, Sereno MI, Moseley GL, Rae CD. Fine-Grained Mapping of Cortical Somatotopies in Chronic Complex Regional Pain Syndrome. J Neurosci 2019; 39:9185-9196. [PMID: 31570533 PMCID: PMC6855684 DOI: 10.1523/jneurosci.2005-18.2019] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/13/2019] [Accepted: 08/19/2019] [Indexed: 01/21/2023] Open
Abstract
It has long been thought that severe chronic pain conditions, such as complex regional pain syndrome (CRPS), are not only associated with, but even maintained by a reorganization of the somatotopic representation of the affected limb in primary somatosensory cortex (S1). This notion has driven treatments that aim to restore S1 representations in CRPS patients, such as sensory discrimination training and mirror therapy. However, this notion is based on both indirect and incomplete evidence obtained with imaging methods with low spatial resolution. Here, we used fMRI to characterize the S1 representation of the affected and unaffected hand in humans (of either sex) with unilateral CRPS. The cortical area, location, and geometry of the S1 representation of the CRPS hand were largely comparable with those of both the unaffected hand and healthy controls. We found no differential relation between affected versus unaffected hand map measures and clinical measures (pain severity, upper limb disability, disease duration). Thus, if any map reorganization occurs, it does not appear to be directly related to pain and disease severity. These findings compel us to reconsider the cortical mechanisms underlying CRPS and the rationale for interventions that aim to "restore" somatotopic representations to treat pain.SIGNIFICANCE STATEMENT This study shows that the spatial map of the fingers in somatosensory cortex is largely preserved in chronic complex regional pain syndrome (CRPS). These findings challenge the treatment rationale for restoring somatotopic representations in complex regional pain syndrome patients.
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Affiliation(s)
- Flavia Mancini
- Computational and Biological Learning, Department of Engineering, University of Cambridge, Cambridge CB2 1PZ, United Kingdom,
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, United Kingdom
| | - Audrey P Wang
- Neuroscience Research Australia, Sydney, New South Wales 2031, Australia
- Faculty of Medicine and Health and Faculty of Health Sciences, University of Sydney, Sydney, New South Wales 2145, Australia
| | - Mark M Schira
- Neuroscience Research Australia, Sydney, New South Wales 2031, Australia
- School of Psychology, University of Wollongong, Wollongong, New South Wales 2522, Australia
| | - Zoey J Isherwood
- School of Psychology, University of Wollongong, Wollongong, New South Wales 2522, Australia
| | - James H McAuley
- Neuroscience Research Australia, Sydney, New South Wales 2031, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales 2052, Australia
| | - Giandomenico D Iannetti
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, United Kingdom
- Neuroscience and Behaviour Laboratory, Istituto Italiano di Tecnologia, Rome 00161, Italy
| | - Martin I Sereno
- Department of Psychology, University College London, London WC1E 6BT, United Kingdom
- Department of Psychology, San Diego State University, San Diego, California 92182, and
| | - G Lorimer Moseley
- Neuroscience Research Australia, Sydney, New South Wales 2031, Australia
- IMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
| | - Caroline D Rae
- Neuroscience Research Australia, Sydney, New South Wales 2031, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales 2052, Australia
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44
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Suboptimal learning of tactile-spatial predictions in patients with complex regional pain syndrome. Pain 2019; 161:369-378. [DOI: 10.1097/j.pain.0000000000001730] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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45
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Lewis JS, Kellett S, McCullough R, Tapper A, Tyler C, Viner M, Palmer S. Body Perception Disturbance and Pain Reduction in Longstanding Complex Regional Pain Syndrome Following a Multidisciplinary Rehabilitation Program. PAIN MEDICINE 2019; 20:2213-2219. [PMID: 31373373 DOI: 10.1093/pm/pnz176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
Clinical guidelines for the treatment of complex regional pain syndrome recommend multidisciplinary rehabilitation, yet limited evidence exists to support the effectiveness of this approach. Body perception disturbance, a common and debilitating feature of complex regional pain syndrome, is recommended by guidelines as important to treat. However, no study has yet explored whether disturbances change in response to multidisciplinary rehabilitation. We aimed to determine whether there is a change in body perception disturbance and pain following a two-week multidisciplinary rehabilitation program for complex regional pain syndrome.
Methods
Retrospective clinical data from complex regional pain syndrome patients who completed the program between September 2014 and December 2016 were extracted and anonymized. Data collected pre- and post rehabilitation comprising the Bath Body Perception Disturbance scale and a pain intensity numerical rating scale were analyzed.
Results
Thirty complete data sets were analyzed from a sample of 50 consecutive patient records. After the program, there was a significant reduction in body perception disturbance (P < 0.0001), strength of negative emotional feelings (P < 0.0001), and pain (P = 0.0038). There was a significant correlation between a change in disturbance and pain (r = 0.44, P = 0.024). No relationship was found between the duration of symptoms and changes in disturbance (r = 0.04, P = 0.82).
Conclusions
This study provides evidence that both body perception disturbance and pain reduce after rehabilitation. Findings suggest that targeting these disturbances may be important in reducing pain and may be a potentially useful measure for recovery. Controlled trials are required to confirm the effectiveness of rehabilitation and determine what factors are responsible for these reductions.
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Affiliation(s)
- Jennifer S Lewis
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals Bath NHS Trust, Bath, UK
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Sara Kellett
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Ryan McCullough
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Ashley Tapper
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Chelsey Tyler
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Maria Viner
- Department of Allied Health Professions, University of the West of England, Bristol, UK
| | - Shea Palmer
- Department of Allied Health Professions, University of the West of England, Bristol, UK
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46
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Windsor RB, Tham SW, Adams TL, Anderson A. The Use of Opioids for Treatment of Pediatric Neuropathic Pain: A Literature Review. Clin J Pain 2019; 35:509-514. [PMID: 30985402 DOI: 10.1097/ajp.0000000000000712] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pediatric neuropathic pain is caused by a spectrum of disorders that are generally challenging to treat. Many of the underlying altered neurological processes are being elucidated through mechanistic studies. Few randomized control trials have evaluated the use of opioids for the treatment of adult neuropathic pain conditions, and there have been none in pediatric populations. With sparse data to provide guidance and an incomplete understanding of the underlying mechanisms, the use of opioids remains unclear. Our clinical experience and typical risk versus benefit considerations suggest a limited, if any, role for using opioids to treat pediatric neuropathic pain. In this literature review, we review the available adult and pediatric data and provide general guidance on this subject matter.
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Affiliation(s)
- Robert B Windsor
- Departments of Pediatrics and Anesthesiology, University of South Carolina School of Medicine Greenville
- Department of Pediatrics, Children's Hospital of Prisma Health-Upstate, Greenville, SC
| | - See Wan Tham
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA
| | - Trevor L Adams
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA
| | - Annette Anderson
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, WA
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47
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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: 99] [Impact Index Per Article: 19.8] [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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48
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Popkirov S, Hoeritzauer I, Colvin L, Carson AJ, Stone J. Complex regional pain syndrome and functional neurological disorders - time for reconciliation. J Neurol Neurosurg Psychiatry 2019; 90:608-614. [PMID: 30355604 DOI: 10.1136/jnnp-2018-318298] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/17/2022]
Abstract
There have been many articles highlighting differences and similarities between complex regional pain syndrome (CRPS) and functional neurological disorders (FND) but until now the discussions have often been adversarial with an erroneous focus on malingering and a view of FND as 'all in the mind'. However, understanding of the nature, frequency and treatment of FND has changed dramatically in the last 10-15 years. FND is no longer assumed to be only the result of 'conversion' of psychological conflict but is understood as a complex interplay between physiological stimulus, expectation, learning and attention mediated through a Bayesian framework, with biopsychosocial predisposing, triggering and perpetuating inputs. Building on this new 'whole brain' perspective of FND, we reframe the debate about the 'psychological versus physical' basis of CRPS. We recognise how CRPS research may inform mechanistic understanding of FND and conversely, how advances in FND, especially treatment, have implications for improving understanding and management of CRPS.
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Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Ingrid Hoeritzauer
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Lesley Colvin
- Division of Population Health Sciences and Genomics, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
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49
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Galambos A, Szabó E, Nagy Z, Édes AE, Kocsel N, Juhász G, Kökönyei G. A systematic review of structural and functional MRI studies on pain catastrophizing. J Pain Res 2019; 12:1155-1178. [PMID: 31114299 PMCID: PMC6489670 DOI: 10.2147/jpr.s192246] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 02/18/2019] [Indexed: 12/25/2022] Open
Abstract
Objectives: Pain catastrophizing is reliably associated with pain reports during experimental pain in healthy, pain-free subjects and in people with chronic pain. It also correlates with self-reports of clinical pain intensity/severity in a variety of disorders characterized by chronic pain in adults, adolescents and children. However, processes, through which it exerts its effects are yet unclear. In this paper, our primary aim was to synthesize neuroimaging research to open a window to possible mechanisms underlying pain catastrophizing in both chronic pain patients and healthy controls. We also aimed to compare whether the neural correlates of pain catastrophizing are similar in these two groups. Methods: PubMed and the Web of Science were searched for magnetic resonance imaging (MRI) studies that explored neural correlates of pain catastrophizing. Results: Twenty articles met the inclusion criteria. The results of our review show a connection between pain catastrophizing and brain areas tightly connected to pain perception (including the somatosensory cortices, anterior insula, anterior cingulate cortex and thalamus) and/or modulation (eg, the dorsolateral prefrontal cortex). Our results also highlight that these processes - in relation to pain catastrophizing - are more pronounced in chronic pain patients, suggesting that structural and functional brain alterations (and perhaps mechanisms) related to pain catastrophizing may depend on prior and/or relatively stable/constant pain experience. However, we also found methodological issues and differences that could lead to divergent results. Discussion: Based on our results, pain catastrophizing might be related to salience detection, pain processing, and top-down attentional processes. More research is recommended to explore neural changes to specific types of catastrophizing thoughts (eg, experimentally induced and/or state). Furthermore, we provide ideas regarding pain catastrophizing studies in the future for a more standardized approach.
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Affiliation(s)
- Attila Galambos
- Doctoral School of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,MTA-SE Neuropsychopharmacology and Neurochemistry Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary
| | - Edina Szabó
- Doctoral School of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,MTA-SE Neuropsychopharmacology and Neurochemistry Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary
| | - Zita Nagy
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Andrea Edit Édes
- SE-NAP2 Genetic Brain Imaging Migraine Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary.,Department of Pharmacodynamics, Faculty of Pharmacy, Semmelweis University, Budapest, Hungary
| | - Natália Kocsel
- Doctoral School of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,SE-NAP2 Genetic Brain Imaging Migraine Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary
| | - Gabriella Juhász
- SE-NAP2 Genetic Brain Imaging Migraine Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary.,Department of Pharmacodynamics, Faculty of Pharmacy, Semmelweis University, Budapest, Hungary.,Neuroscience and Psychiatry Unit, The University of Manchester, Manchester, United Kingdom and Manchester Academic Health Sciences Centre, Manchester, United Kingdom
| | - Gyöngyi Kökönyei
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary.,SE-NAP2 Genetic Brain Imaging Migraine Research Group, Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary.,Department of Pharmacodynamics, Faculty of Pharmacy, Semmelweis University, Budapest, Hungary
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50
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Misidou C, Papagoras C. Complex Regional Pain Syndrome: An update. Mediterr J Rheumatol 2019; 30:16-25. [PMID: 32185338 PMCID: PMC7045919 DOI: 10.31138/mjr.30.1.16] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/06/2019] [Accepted: 01/21/2019] [Indexed: 12/18/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a perplexing painful syndrome of the extremities usually following a harmful event. It is distinguished in two types, mainly depending on the presence of nerve injury. Although its prevalence may vary depending on social and ethnic factors, middle-aged women seem to suffer most often and the upper limb is the most commonly affected extremity. Apart from pain, which is the dominating feature, the clinical picture unfolds across several domains: sensory, motor, autonomic and trophic. This syndrome develops in two phases, the acute (warm) phase, with the classic symptoms of inflammation, and the chronic (cold) phase, often characterized by trophic changes of the soft tissues and even bones. Although the syndrome has been studied for over two decades, no imaging or laboratory test has been established for the diagnosis and recently proposed diagnostic criteria have not yet been validated and are only occasionally applied. Its pathophysiology is still quite obscure, although the most likely mechanisms involve the classic and neurogenic paths of inflammation mediated by cytokines and neuropeptides, intertwined with changes of the autonomic and central nervous system, psychological mechanisms and, perhaps, autoimmunity. Although plenty of treatment modalities have been tried, none has been proven unequivocally efficacious. Apart from information and education, which should be offered to all patients, the most effective pharmacological treatments seem to be bisphosphonates, glucocorticoids and vasoactive mediators, while physical therapy and rehabilitation therapy also make part of the treatment.
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Affiliation(s)
- Christina Misidou
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Charalampos Papagoras
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
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