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Abd-Elsayed A, Stark CW, Topoluk N, Isaamullah M, Uzodinma P, Viswanath O, Gyorfi MJ, Fattouh O, Schlidt KC, Dyara O. A brief review of complex regional pain syndrome and current management. Ann Med 2024; 56:2334398. [PMID: 38569195 PMCID: PMC10993759 DOI: 10.1080/07853890.2024.2334398] [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: 10/31/2023] [Accepted: 02/28/2024] [Indexed: 04/05/2024] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating chronic pain condition that, although exceedingly rare, carries a significant burden for the affected patient population. The complex and ambiguous pathophysiology of this condition further complicates clinical management and therapeutic interventions. Furthermore, being a diagnosis of exclusion requires a diligent workup to ensure an accurate diagnosis and subsequent targeted management. The development of the Budapest diagnostic criteria helped to consolidate existing definitions of CRPS but extensive work remains in identifying the underlying pathways. Currently, two distinct types are identified by the presence (CRPS type 1) or absence (CRPS type 2) of neuronal injury. Current management directed at this disease is broad and growing, ranging from non-invasive modalities such as physical and psychological therapy to more invasive techniques such as dorsal root ganglion stimulation and potentially amputation. Ideal therapeutic interventions are multimodal in nature to address the likely multifactorial pathological development of CRPS. Regardless, a significant need remains for continued studies to elucidate the pathways involved in developing CRPS as well as more robust clinical trials for various treatment modalities.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, University of WI School of Medicine and Public Health, Madison, WI, USA
| | - Cain W. Stark
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Natasha Topoluk
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Mir Isaamullah
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Paul Uzodinma
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Omar Viswanath
- Anesthesiology, LSU Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Michael J. Gyorfi
- Department of Anesthesiology, University of WI School of Medicine and Public Health, Madison, WI, USA
| | - Osama Fattouh
- Department of Neurobiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Kevin C. Schlidt
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Omar Dyara
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
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Ferraro MC, O'Connell NE, Sommer C, Goebel A, Bultitude JH, Cashin AG, Moseley GL, McAuley JH. Complex regional pain syndrome: advances in epidemiology, pathophysiology, diagnosis, and treatment. Lancet Neurol 2024; 23:522-533. [PMID: 38631768 DOI: 10.1016/s1474-4422(24)00076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 04/19/2024]
Abstract
Complex regional pain syndrome (CRPS) is a rare pain disorder that usually occurs in a limb after trauma. The features of this disorder include severe pain and sensory, autonomic, motor, and trophic abnormalities. Research from the past decade has offered new insights into CRPS epidemiology, pathophysiology, diagnosis, and treatment. Early identification of individuals at high risk of CRPS is improving, with several risk factors established and some others identified in prospective studies during the past 5 years. Better understanding of the pathophysiological mechanisms of CRPS has led to its classification as a chronic primary pain disorder, and subtypes of CRPS have been updated. Procedures for diagnosis have also been clarified. Although effective treatment of CRPS remains a challenge, evidence-based integrated management approaches provide new opportunities to improve patient care. Further advances in diagnosis and treatment of CRPS will require coordinated, international multicentre initiatives.
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Affiliation(s)
- Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| | - Claudia Sommer
- University Hospital Würzburg, Department of Neurology, Würzburg, Germany
| | - Andreas Goebel
- Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, and Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Janet H Bultitude
- Centre for Pain Research, Department of Psychology, University of Bath, Bath, UK
| | - Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - G Lorimer Moseley
- IMPACT in Health, University of South Australia, Kaurna Country, Adelaide, SA, Australia
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW, Australia; School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia.
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Bonomo R, Bonomo G, Rubiu E, Iess G, Cammarata G, Innocenti N, Restelli F, Falco J, Porto E, Amato A, Zekaj E, Levi V. Integrative approaches in spinal cord stimulation: Neuropathic pain management and motor recovery in spinal cord injury. A narrative review. BRAIN & SPINE 2024; 4:102781. [PMID: 38601775 PMCID: PMC11004705 DOI: 10.1016/j.bas.2024.102781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/08/2024] [Accepted: 03/01/2024] [Indexed: 04/12/2024]
Abstract
Introduction Spinal cord stimulation is a widespread treatment of chronic neuropathic pain from different conditions. Several novel and improving technologies have been recently developed to increase the effect of neuromodulation in patients refractory to pharmacological therapy. Research question To explore spinal cord stimulation's mechanisms of action, indications, and management. Material and methods The paper initially explores the mechanism of action of this procedure based on the generation of an electric field between electrodes placed on the posterior dural surface of the spinal cord probably interfering with the transmission of pain stimuli to the brain. Subsequently, the most consolidated criteria for selecting patients for surgery, which constitute a major issue of debate, were defined. Thereafter, the fundamental patterns of stimulation were summarized by exploring the advantages and side effects. Lastly, the most common side effects and the related management were discussed. Results Proper selection of the patient is of paramount importance to achieve the best results from this specific neuromodulation treatment. Regarding the different types of stimulation patterns, no definite evidence-based guidelines exist on the most appropriate approach in relation to the specific type of neuropathic pain. Both burst stimulation and high-frequency stimulation are innovative techniques that reduce the risk of paresthesias compared with conventional stimulation. Discussion and conclusion Novel protocols of stimulation (burst stimulation and high frequency stimulation) may improve the trade-off between therapeutic benefits and potential side effects. Likewise, decreasing the rates of hardware-related complications will be also useful to increase the application of neuromodulation in clinical settings.
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Affiliation(s)
- Roberta Bonomo
- Department of Neurology, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- School of Medicine and Surgery, Kore University of Enna, Enna, Italy
| | - Giulio Bonomo
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- Department of Neurological Surgery, Policlinico “G. Rodolico-S. Marco” University Hospital, Catania, Italy
| | - Emanuele Rubiu
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Guglielmo Iess
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Giacomo Cammarata
- Department of Neurological Surgery, Policlinico “G. Rodolico-S. Marco” University Hospital, Catania, Italy
| | - Niccolò Innocenti
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Francesco Restelli
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Jacopo Falco
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Edoardo Porto
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Alessia Amato
- Department of Child Neuropsychiatry, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Edvin Zekaj
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Vincenzo Levi
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
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Rodrigues P, Cassanego GB, Peres DS, Viero FT, Kudsi SQ, Ruviaro NA, Aires KDV, Portela VM, Bauermann LDF, Trevisan G. Alpha-lipoic acid reduces nociception by reducing oxidative stress and neuroinflammation in a model of complex regional pain syndrome type I in mice. Behav Brain Res 2024; 459:114790. [PMID: 38040057 DOI: 10.1016/j.bbr.2023.114790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/27/2023] [Accepted: 11/28/2023] [Indexed: 12/03/2023]
Abstract
Complex regional pain syndrome type I (CRPS-I) is a disabling pain condition without adequate treatment. Chronic post-ischemia pain injury (CPIP) is a model of CRPS-I that causes allodynia, spontaneous pain, inflammation, vascular injury, and oxidative stress formation. Antioxidants, such as alpha lipoic acid (ALA), have shown a therapeutic potential for CRPS-I pain control. Thus, we aim to evaluate if ALA repeated treatment modulates neuroinflammation in a model of CRPS-I in mice. We used male C57BL/6 mice to induce the CPIP model (O-ring torniquet for 2 h in the hindlimb). For the treatment with ALA or vehicle (Veh) mice were randomly separated in four groups and received 100 mg/kg orally once daily for 15 days (CPIP-ALA, CPIP-Veh, Control-ALA, and Control-Veh). We evaluated different behavioral tests including von Frey (mechanical stimulus), acetone (cold thermal stimulus), rotarod, open field, hind paw edema determination, and nest-building (spontaneous pain behavior). Also, hydrogen peroxide (H2O2) levels, NADPH oxidase and superoxide dismutase (SOD) activity in the sciatic nerve and spinal cord, and Iba1, Nrf2, and Gfap in spinal cord were evaluated at 16 days after CPIP or sham induction. Repeated ALA treatment reduced CPIP-induced mechanical and cold allodynia and restored nest-building capacity without causing locomotor or body weight alteration. ALA treatment reduced SOD and NADPH oxidase activity, and H2O2 production in the spinal cord and sciatic nerve. CPIP-induced neuroinflammation in the spinal cord was associated with astrocyte activation and elevated Nfr2, which were reduced by ALA. ALA repeated treatment prevents nociception by reducing oxidative stress and neuroinflammation in a model of CRPS-I in mice.
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Affiliation(s)
- Patrícia Rodrigues
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil
| | - Gabriela Buzatti Cassanego
- Graduated Program in Pharmaceutical Sciences, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil
| | - Diulle Spat Peres
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil
| | - Fernanda Tibolla Viero
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil
| | - Sabrina Qader Kudsi
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil
| | - Náthaly Andrighetto Ruviaro
- Graduated Program in Biochemistry Toxicological Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil
| | - Karine de Vargas Aires
- Graduate Program of Veterinary Medicine, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Valério Marques Portela
- Laboratory of Biotechnology and Animal Reproduction, BioRep, Veterinary Hospital, Federal University of Santa Maria (UFSM), Santa Maria, Brazil
| | - Liliane De Freitas Bauermann
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil; Graduated Program in Pharmaceutical Sciences, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil
| | - Gabriela Trevisan
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil; Graduated Program in Biochemistry Toxicological Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil.
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Frediani JK, Lal AA, Kim E, Leslie SL, Boorman DW, Singh V. The role of diet and non-pharmacologic supplements in the treatment of chronic neuropathic pain: A systematic review. Pain Pract 2024; 24:186-210. [PMID: 37654090 DOI: 10.1111/papr.13291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/01/2023] [Accepted: 08/04/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND/IMPORTANCE Dietary interventions, vitamins, and nutritional supplementation are playing an increasingly important role in the management of neuropathic pain. Current pharmacological treatments are poorly tolerated and ineffective in many cases. OBJECTIVE This systematic review aims to study the efficacy of dietary interventions, vitamins, and nutritional supplementation in the management of chronic neuropathic pain in adults. EVIDENCE REVIEW The review followed PRISMA guidelines and was registered with PROSPERO (#CRD42022300312). Ten databases and gray literature, including Embase.com, MEDLINE and Web of Science, were systematically searched using a combination of keywords and controlled vocabulary related to chronic neuropathic pain and oral non-pharmacological supplements. Studies on adult humans published between 2000 and 2021 were considered for inclusion. The Cochrane Handbook was used to assess risk of bias, and Grading of Recommendations Assessment, Development, and Evaluation was used to determine overall quality of evidence. FINDINGS Forty studies were included in the final review, and results were categorized according to pain type including pain related to chemotherapy-induced peripheral neuropathy (CIPN, 22 studies, including 3 prospective cohorts), diabetic peripheral neuropathy (DPN, 13 studies, including 2 prospective), complex regional pain syndrome (CRPS-I, 3 studies, including 1 prospective), and other (2 studies, both RCT). The CIPN studies used various interventions including goshajinkigan (4 studies), vitamin E (5), vitamin B12 (3), glutamine (3), N-acetyl-cysteine (2), acetyl-l-carnitine (2), guilongtonluofang (1), ninjin'yoeito (1), alpha-lipoic acid (1), l-carnosine (1), magnesium and calcium (1), crocin (1), and antioxidants (1), with some studies involving multiple interventions. All CIPN studies involved varying cancers and/or chemotherapies, advising caution for generalizability of results. Interventions for DPN included alpha-lipoic acid (5 studies), vitamin B12 (3), acetyl-l-carnitine (3), vitamin E (1), vitamin D (2), and a low-fat plant-based diet (1). Vitamin C was studied to treat CRPS-I (3 studies, including 1 prospective). Magnesium (1) and St. John's wort (1) were studied for other or mixed neuropathologies. CONCLUSIONS Based on the review, we cannot recommend any supplement use for the management of CIPN, although further research into N-acetyl-cysteine, l-carnosine, crocin, and magnesium is warranted. Acetyl-l-carnitine was found to be likely ineffective or harmful. Alpha-lipoic acid was not found effective. Studies with goshajinkigan, vitamin B12, vitamin E, and glutamine had conflicting results regarding efficacy, with one goshajinkigan study finding it harmful. Guilongtonluofang, ninjin'yoeito, and antioxidants showed various degrees of potential effectiveness. Regarding DPN, our review supports the use of alpha-lipoic acid, acetyl-l-carnitine, and vitamin D. The early use of vitamin C prophylaxis for the development of CRPS-I also seems promising. Further research is warranted to confirm these findings.
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Affiliation(s)
- Jennifer K Frediani
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Asim A Lal
- Department of Anesthesiology, Emory School of Medicine, Atlanta, Georgia, USA
| | - Esther Kim
- Philadelphia College of Osteopathic Medicine, Suwanee, Georgia, USA
| | - Sharon L Leslie
- Woodruff Health Sciences Center Library, Emory University, Atlanta, Georgia, USA
| | - David W Boorman
- Department of Anesthesiology, Emory School of Medicine, Atlanta, Georgia, USA
| | - Vinita Singh
- Department of Anesthesiology, Emory School of Medicine, Atlanta, Georgia, USA
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6
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Lorente A, Mariscal G, Lorente R. Incidence and risk factors for complex regional pain syndrome in radius fractures: meta-analysis. Arch Orthop Trauma Surg 2023; 143:5687-5699. [PMID: 37209231 DOI: 10.1007/s00402-023-04909-8] [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: 03/18/2023] [Accepted: 05/10/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE This meta-analysis aimed to evaluate the incidence and risk factors for complex regional pain syndrome (CRPS) in radius fractures. METHODS The meta-analysis was performed using the PubMed, Embase, Scopus, and Cochrane Collaboration Library databases. Studies focusing on patients with conservative or surgically treated radius fractures leading to CRPS were included. A control group consisting of patients with radius fractures and no CRPS (-) was included. The outcome measures were incidence and risk factors. Comparative studies were also included. Data were combined using Review Manager 5.4. RESULTS Out of 610 studies, nine studies were included. The incidence of CRPS after radius fractures ranged from 0.19 to 13.63% (95% CI: 11.12-16.15%). Open fractures, high-energy mechanisms in radial head fractures, and associations with ulnar fractures were risk factors for CRPS [(RR: 0.98; 95% CI: 0.97-1.00), (RR: 0.18; 95% CI: 0.07-0.47), and (RR: 1.25; 95% CI: 1.17-1.35), respectively]. Other risk factors were female sex and high body mass index [(RR: 1.20; 95% CI: 1.05-1.37) and (MD: 1.17; 95% CI: 0.45-1.88)]. Psychiatric factors also increased the incidence of CRPS (RR: 2.04; 95% CI: 1.83-2.28). On the other hand, the type of surgery (external fixation or open reduction and internal fixation) and manipulations; associated comorbidities (diabetes and hypertension) together with tobacco and alcohol abuse; marital status, educational level, employment status, and socioeconomic status were not risk factors (p > 0.05). CONCLUSION The incidence of CRPS in radius fractures was 13.63%. Fractures with greater complexity or greater associated tissue damage, female sex, high BMI, and psychiatric disorders were risk factors for the development of CRPS. LEVEL OF EVIDENCE Meta-analysis of cohort and case series studies; II.
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Affiliation(s)
- Alejandro Lorente
- Department of Traumatology and Orthopaedic Surgery, University Hospital Ramón y Cajal, Madrid, Spain
| | - Gonzalo Mariscal
- Institute for Research on Musculoskeletal Disorders, School of Medicine, Valencia Catholic University, Carrer de Quevedo, 2, 46001, València, Valencia, Spain.
- Mediterranean Observatory for Clinical and Health Research, Valencia, Spain.
| | - Rafael Lorente
- Department of Orthopedic Surgery and Traumatology, University Hospital of Badajoz, Badajoz, Spain
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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: 0] [Impact Index Per Article: 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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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: 0] [Impact Index Per Article: 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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Ramón R, Holguín E, Chiriboga JD, Rubio N, Ballesteros C, Ezechieli M. Anti-Inflammatory Effect of Vitamin C during the Postoperative Period in Patients Subjected to Total Knee Arthroplasty: A Randomized Controlled Trial. J Pers Med 2023; 13:1299. [PMID: 37763067 PMCID: PMC10532858 DOI: 10.3390/jpm13091299] [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: 07/23/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Vitamin C, a potent reducing and antioxidant agent, plays an important role in the body, aiding in the growth of cartilage and bones. It is also involved in mechanisms that help reduce inflammation and its effects on the body. In addition, vitamin C decreases pro-inflammatory cytokines, such as IL-6, which produce acute-phase proteins such as CRP and influence inflammatory markers such as ESR. We carried out a study with 110 patients who underwent total knee replacement surgery. We divided the patients into two groups, in which the intervention group received 15 g of parenteral vitamin C during the immediate postoperative period while the control group did not. Patients who received 15 g of vitamin C after total knee replacement surgery had decreased inflammatory markers, specifically CRP and ESR. Overall, administering vitamin C in the post-surgical period results in improved management of inflammation, as evidenced by a decrease in CRP and ESR values. This leads to faster recovery and better healing outcomes for patients undergoing total knee replacement surgery. Furthermore, the beneficial effects of vitamin C in reducing proinflammatory cytokines, reducing the need for opioid analgesics, and its mild adverse effects make it a promising adjuvant in managing postoperative recovery.
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Affiliation(s)
- Ricardo Ramón
- St. Vincenz Hospital Location Salzkotten, 33154 Salzkotten, Germany;
| | | | | | - Newton Rubio
- Ministry of Public Health (MSP), 170702 Quito, Ecuador
| | | | - Marco Ezechieli
- St. Vincenz Hospital Location Salzkotten, 33154 Salzkotten, Germany;
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10
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Alter TH, Noh KJ, Monica JT. Management of Isolated Ulnar Shaft Fractures. JBJS Rev 2023; 11:01874474-202306000-00002. [PMID: 37276269 DOI: 10.2106/jbjs.rvw.22.00254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
» Most isolated ulnar shaft fractures are stable and heal without complication regardless of treatment protocol.» Casting above the elbow may create unwanted stiffness without enhancing union rates.» Defining unstable fractures and determining which injuries would benefit from operative management remain a challenge.» Recent development of intramedullary devices has shown promise in preliminary studies, but more vigorous investigation is needed to determine their role.
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Affiliation(s)
- Todd H Alter
- Department of Orthopaedic Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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11
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Daoust R, Paquet J, Chauny JM, Williamson D, Huard V, Arbour C, Emond M, Rouleau D, Cournoyer A. Impact of vitamin C on the reduction of opioid consumption after an emergency department visit for acute musculoskeletal pain: a double-blind randomised control trial protocol. BMJ Open 2023; 13:e069230. [PMID: 37225265 PMCID: PMC10230879 DOI: 10.1136/bmjopen-2022-069230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/28/2023] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION Recent evidence has shown that vitamin C has some analgesic properties in addition to its antioxidant effect and can, therefore, reduce opioid use during recovery time. Vitamin C analgesic effect has been explored mostly during short-term postoperative context or in disease-specific chronic pain prevention, but never after acute musculoskeletal injuries, which are often seen in the emergency department (ED). The protocol's primary aim is to compare the total morphine 5 mg pills consumed during a 2-week follow-up between patients receiving vitamin C or a placebo after ED discharge for an acute musculoskeletal pain complaint. METHODS AND ANALYSIS We will conduct a two-centre double-blind randomised placebo-controlled trial with 464 participants distributed in two arms, one group receiving 1000 mg of vitamin C two times a day for 14 days and another one receiving a placebo. Participants will be ≥18 years of age, treated in ED for acute musculoskeletal pain present for less than 2 weeks and discharged with an opioid prescription for home pain management. Total morphine 5 mg pills consumed during the 2-week follow-up will be assessed via an electronic (or paper) diary. In addition, patients will report their daily pain intensity, pain relief, side effects and other types of pain medication or other non-pharmacological approach used. Three months after the injury, participants will also be contacted to evaluate chronic pain development. We hypothesised that vitamin C, compared with a placebo, will reduce opioid consumption during a 14-day follow-up for ED discharged patients treated for acute musculoskeletal pain. ETHICS AND DISSEMINATION This study has received approval from the Ethics Review Committee from the 'Comité d'éthique de la recherche du CIUSSS du Nord-de-l'Île-de-Montréal (No 2023-2442)'. Findings will be disseminated through scientific conferences and peer-reviewed journal publication. The data sets generated during the study will be available from the corresponding author on reasonable request. TRIAL REGISTRATION NUMBER NCT05555576 ClinicalTrials.Gov PRS.
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Affiliation(s)
- Raoul Daoust
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Jean Paquet
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
| | - Jean-Marc Chauny
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
| | - David Williamson
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Vérilibe Huard
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Caroline Arbour
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Faculté des sciences infirmières, Université de Montréal, Montréal, Québec, Canada
| | - Marcel Emond
- Department of Family and Emergency Medicine, Universite Laval, Quebec, Quebec, Canada
| | - Dominique Rouleau
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Alexis Cournoyer
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
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12
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Trauma-Related Clinical Practice Variation in Dutch Emergency Departments. Healthcare (Basel) 2023; 11:healthcare11050748. [PMID: 36900752 PMCID: PMC10000928 DOI: 10.3390/healthcare11050748] [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: 01/25/2023] [Revised: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Structural insights in the use of protocols and the extent of practice variation in EDs are lacking. The objective is to determine the extent of practice variation in EDs in The Netherlands, based on specified common practices. We performed a comparative study on Dutch EDs that employed emergency physicians to determine practice variation. Data on practices were collected via a questionnaire. Fifty-two EDs across The Netherlands were included. Thrombosis prophylaxis was prescribed for below-knee plaster immobilization in 27% of EDs. Vitamin C was prescribed in 50% of EDs after a wrist fracture. Splitting of applied casts to the upper or lower limb was performed in one-third of the EDs. Analysis of the cervical spine after trauma was performed by the NEXUS criteria (69%), the Canadian C-spine Rule (17%) or otherwise. The imaging modality for cervical spine trauma in adults was a CT scan (98%). The cast used for scaphoid fractures was divided between the short arm cast (46%) and the navicular cast (54%). Locoregional anaesthesia for femoral fractures was applied in 54% of the EDs. EDs in The Netherlands showed considerable practice variation in treatments among the subjects studied. Further research is warranted to gain a full understanding of the variation in practice in EDs and the potential to improve quality and efficiency.
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13
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Li R, Yu S, Liang X, Li Y, Lai KP. Vitamin C exerts anti-cadmium induced fracture functions/targets: bioinformatic and biostructural findings. FOOD SCIENCE AND HUMAN WELLNESS 2022. [DOI: 10.1016/j.fshw.2022.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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14
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Stretton B, Kovoor JG, Vanlint A, Maddern G, Thompson CH. Perioperative micronutrients, macroscopic benefits? J Perioper Pract 2022; 33:92-98. [PMID: 35445613 DOI: 10.1177/17504589221091058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
'Micronutrients' are vitamins and minerals vital for healthy metabolic function, wound healing and disease and infection prevention. Micronutrients may play a role in significantly improving postoperative recovery and indices of patient comfort; however, minimal research exists for surgical patients. Furthermore, current guidelines on perioperative nutrition have a macronutrient focus which may fail to guide detection and treatment of the subclinical micronutrient deficiency in a patient who is not obviously malnourished. Limited research into supplementation of some micronutrient deficiencies shows favourable results; however, given the financial implications of wound care, the prevalence of micronutrient deficiency and possible benefits from attention to micronutrition for postoperative recovery, further research into this area is urgently warranted. Interventions to guide optimal future clinical practice are suggested.
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Affiliation(s)
- Brandon Stretton
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Joshua G Kovoor
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, SA, Australia
| | - Andrew Vanlint
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Guy Maddern
- Discipline of Surgery, The Queen Elizabeth Hospital, The University of Adelaide, Adelaide, SA, Australia
| | - Campbell H Thompson
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
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15
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Bruehl S, Milne G, Schildcrout J, Shi Y, Anderson S, Shinar A, Polkowski G, Mishra P, Billings FT. Oxidative stress is associated with characteristic features of the dysfunctional chronic pain phenotype. Pain 2022; 163:786-794. [PMID: 34382610 PMCID: PMC8807797 DOI: 10.1097/j.pain.0000000000002429] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT The dysfunctional chronic pain (Dysfunctional CP) phenotype is an empirically identifiable CP subtype with unclear pathophysiological mechanisms that cuts across specific medical CP diagnoses. This study tested whether the multidimensional pain and psychosocial features that characterize the dysfunctional CP phenotype are associated broadly with elevated oxidative stress (OS). Measures of pain intensity, bodily extent of pain, catastrophizing cognitions, depression, anxiety, sleep disturbance, pain interference, and function were completed by 84 patients with chronic osteoarthritis before undergoing total knee arthroplasty. Blood samples were obtained at the initiation of surgery before incision or tourniquet placement. Plasma levels of F2-isoprostanes and isofurans, the most highly specific measures of in vivo OS, were quantified using gas chromatography/negative ion chemical ionization mass spectrometry. The results indicated that controlling for differences in age, sex, and body mass index, higher overall OS (mean of isoprostanes and isofurans) was associated with significantly (P < 0.05) greater pain intensity, more widespread pain, greater depressive symptoms and pain catastrophizing, higher pain interference, and lower function. OS measures were not significantly associated with sleep disturbance or anxiety levels (P >0.10). The results build on prior case-control findings suggesting that presence of a CP diagnosis is associated with elevated OS, highlighting that it may specifically be individuals displaying characteristics of the dysfunctional CP phenotype who are characterized by elevated OS. Clinical implications of these findings remain to be determined.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ginger Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic T. Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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16
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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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17
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Sane RM, Samant PD, Butala RR. Effectiveness of prophylactic vitamin C supplementation in the prevention of complex regional pain syndrome after distal end radius fractures in the aging population. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2021. [DOI: 10.1177/22104917211056946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background/purpose Vitamin C has been proposed to prevent the incidence of complex regional pain syndrome, but the results are conflicting. We evaluated the effectiveness of vitamin C in the prevention of complex regional pain syndrome-1 after distal end radius fractures in the aging population. Methods This was a prospective, randomized study. Patients treated with either conservative or surgical management for distal end radius fracture received Vitamin C (500 mg/day) plus standard therapy or standard therapy alone for a period of 3 months. The presence of complex regional pain syndrome-1 was assessed with Budapest criteria. Results The complex regional pain syndrome-I occurred in 11.3% in Vitamin C plus Standard in compared to 26% in Standard therapy alone. Vitamin C was significantly associated with a reduction in the likelihood of exhibiting complex regional pain syndrome-1. Conclusion Vitamin C (500 mg/day) supplementation was effective and associated with a lower occurrence of acute complex regional pain syndrome-1. It can be a promising prophylactic option for the prevention of complex regional pain syndrome-1 after distal end radius fracture.
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Affiliation(s)
- Rohit M Sane
- Department of Orthopaedics, D Y Patil University School of Medicine, India
| | - Prakash D Samant
- Department of Orthopaedics, D Y Patil University School of Medicine, India
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18
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Taylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, Carlson T, Myrcik D, Varrassi G, Viswanath O. Complex Regional Pain Syndrome: A Comprehensive Review. Pain Ther 2021; 10:875-892. [PMID: 34165690 PMCID: PMC8586273 DOI: 10.1007/s40122-021-00279-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/03/2021] [Indexed: 12/22/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain condition often involving hyperalgesia and allodynia of the extremities. CRPS is divided into CRPS-I and CRPS-II. Type I occurs when there is no confirmed nerve injury. Type II is when there is known associated nerve injury. Female gender is a risk factor for developing CRPS. Other risk factors include fibromyalgia and rheumatoid arthritis. Unfortunately, the pathogenesis of CRPS is not yet clarified. Some studies have demonstrated different potential pathways. Neuropathic inflammation, specifically activation of peripheral nociceptors of C-fibers, has been shown to play a critical role in developing CRPS. The autonomic nervous system (ANS) is involved. Depending on whether it is acute or chronic CRPS, norepinephrine levels are either decreased or increased, respectively. Some studies have suggested the importance of genetics in developing CRPS. More consideration is being given to the role of psychological factors. Some association between a history of depression and/or post-traumatic stress disorder (PTSD) and the diagnosis of CRPS has been demonstrated. Treatment modalities available range from physical therapy, pharmacotherapy, and interventional techniques. Physical and occupational therapies include mirror therapy and graded motor imagery. Medical management with non-steroidal anti-inflammatory drugs (NSAIDs) has not shown significant improvement. There have been supporting findings in the use of short-course steroids, bisphosphonates, gabapentin, and ketamine. Antioxidant treatment has also shown some promise. Other pharmacotherapies include low-dose naltrexone and Botulinum toxin A (BTX-A). Sympathetic blocks are routinely used, even if their short- and long-term effects are not clear. Finally, spinal cord stimulation (SCS) has been used for decades. In conclusion, CRPS is a multifactorial condition that still requires further studying to better understand its pathogenesis, epidemiology, genetic involvement, psychological implications, and treatment options. Future studies are warranted to better understand this syndrome. This will provide an opportunity for better prevention, diagnosis, and treatment of CRPS.
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Affiliation(s)
- Samantha-Su Taylor
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Nazir Noor
- Department of Anesthesiology, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33130, USA.
| | - Ivan Urits
- grid.492905.3Southcoast Physician Group Pain Medicine, Southcoast Health, North Dartmouth, MA USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA
| | - Antonella Paladini
- grid.158820.60000 0004 1757 2611Department of MESVA, University of L’Aquila, 67100 L’Aquila, Italy
| | - Monica Sri Sadhu
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Clay Gibb
- grid.260024.2Midwestern University Chicago College of Osteopathic Medicine, Chicago, IL USA
| | - Tyler Carlson
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Dariusz Myrcik
- grid.411728.90000 0001 2198 0923Department of Internal Medicine, Medical University of Silesia, 42-600 Katowice, Bytom Poland
| | | | - Omar Viswanath
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA ,Valley Pain Consultants-Envision Physician Services, Phoenix, AZ USA ,grid.254748.80000 0004 1936 8876Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE USA
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19
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Rask DMG, Puntel MR, Patzkowski JC, Patzkowski MS. Multivitamin Use in Enhanced Recovery After Surgery Protocols: A Cost Analysis. Mil Med 2021; 186:e1024-e1028. [PMID: 33242075 DOI: 10.1093/milmed/usaa505] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/14/2020] [Accepted: 11/05/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Enhanced Recovery After Surgery (ERAS) protocols have shown significant benefits in multiple areas including early mobilization, improved pain control, and early oral intake. Deficient nutritional states may compromise the operative outcomes. Several essential vitamins, e.g., B12, C, D, and E, have demonstrated anti-inflammatory properties and may promote wound healing. Given the low risk of oral multivitamin supplementation and the potential benefits, we hypothesized that adding a multivitamin to our institution's ERAS protocols would be a low-cost perioperative intervention accounting for a very small fraction of the annual pharmacy budget. METHODS A cost analysis for vitamin supplementation for all adult orthopedic surgical cases for the fiscal year 2018 was conducted. To assess the potential cost for multivitamin supplementation in the perioperative period, the fiscal year 2018 pharmacy budget and current costs of multivitamins were obtained from the hospital pharmacy. Medication costs were obtained from the medical logistics ordering system at per unit (i.e., bottle) and per tablet levels for all formulary oral multivitamins. We also determined the number of adult orthopedic surgical cases for our facility in the fiscal year 2018 from our surgery scheduling system. The cost for supplementation for a single day (day of surgery), 1 week (first postoperative week), 6 weeks plus 1 week preop, and 6 months plus 1 week preop for all cases was then calculated. RESULTS Our institution's pharmacy budget for the fiscal year 2018 was $123 million dollars with two oral multivitamins on formulary. Prenatal tablets, containing vitamins A-E, calcium, iron, and zinc, cost $1.52 per bottle of 100 tablets and $0.0152 per tablet, while renal formulation tablets, containing water-soluble vitamins B and C, cost $2.79 per bottle of 100 tablets and $0.0279 per tablet. For one fiscal year, the medication cost to supplement every adult orthopedic surgery patient with an oral multivitamin for 1 day, 1 week, 6 weeks plus 1 week preop, and 6 months plus 1 week preop would range from $60.47 to $110.99, from $423.29 to $776.93, from $2,963.03 to $5,438.51, and from $10,582.25 to $19,423.25, respectively, depending on which multivitamin was prescribed. These costs would represent between 0.00005% and 0.00009% of the annual pharmacy budget for 1 day, between 0.0003% and 0.0006% for 1 week, between 0.00245% and 0.441% for 6 weeks plus 1 week preop, and between 0.00875% and 1.575% for 6 months plus 1 week preop, respectively. DISCUSSION/CONCLUSIONS The relative nutrient-deficient state in the perioperative patient from decreased oral intake contributes to the metabolic derangements resulting from the surgery. The current ERAS protocols help to mitigate this with early feeding, and the addition of multivitamin supplementation may enhance this process. Multivitamins are safe, widely accessible, and inexpensive, and early investigations of pain control and healing have shown encouraging results. Further prospective studies are needed for incorporating multivitamins into ERAS protocols in order to elucidate the effective dosages, duration of treatment, and effect on outcomes.
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Affiliation(s)
- Dawn M G Rask
- San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Matthew R Puntel
- San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Jeanne C Patzkowski
- San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Michael S Patzkowski
- San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
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20
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Marchesi N, Govoni S, Allegri M. Non-drug pain relievers active on non-opioid pain mechanisms. Pain Pract 2021; 22:255-275. [PMID: 34498362 DOI: 10.1111/papr.13073] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This review is aimed to summarize the pain-relieving effect of non-drug substances, mostly prescribed as integrators in treatment of pain, including especially in chronic postoperative pain (CPSP) and in chronic back pain after acute episodes. Their use reflects the fact that the current treatments for these syndromes continue to pose problems of unsatisfactory responses in a significant portion of patients and/or of an excess of side effects like those noted in the present opioid crisis. As integrators are frequently introduced into the market without adequate clinical testing, this review is aimed to collect the present scientific evidence either preclinical or clinical for their effectiveness. In particular, we reviewed the data on the use of: B vitamins; vitamin C; vitamin D; alpha lipoic acid (ALA); N-acetylcysteine; acetyl L-carnitine; curcumin; boswellia serrata; magnesium; coenzyme Q10, and palmitoylethanolamide. The combination of preclinical findings and clinical observations strongly indicate that these compounds deserve more careful attention, some of them having interesting clinical potentials also in preventing chronic pain after an acute episode. In particular, examining their putative mechanisms of action it emerges that combinations of few of them may exert an extraordinary spectrum of activities on a large variety of pain-associated pathways and may be eventually used in combination with more traditional pain killers in order to extend the duration of the effect and to lower the doses. Convincing examples of effective combinations against pain are vitamin B complex plus gabapentin for CPSP, including neuropathic pain; vitamin B complex plus diclofenac against low back pain and also in association with gabapentin, and ALA for burning mouth syndrome. These as well as other examples need, however, careful controlled independent clinical studies confirming their role in therapy.
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Affiliation(s)
| | - Stefano Govoni
- Department of Drug Sciences, University of Pavia, Pavia, Italy
| | - Massimo Allegri
- Pain Therapy Service, Policlinico Monza, Monza, Italy.,Italian Pain Group, Monza-Brianza, Italy
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21
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Faggiani M, Piccato A, Baroni C, Risitano S, Conforti LG. Intravenous treatment with biphosphates in Complex Regional Pain Syndrome. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021190. [PMID: 34487084 PMCID: PMC8477097 DOI: 10.23750/abm.v92i4.11194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Complex Regional Pain Syndrome (CRPS) is a pathological persistence of spontaneous or evoked disproportionate pain. Several drugs are employed, but only bisphosphonates seem to have good outcomes. The purpose of our research is to analyze the characteristics of the cases victims of CRPS and study the beneficial effect of the intravenous nerindronic acid sodium salt (Nerixia®), in an attempt to improve the results in this disabling disease. Materials and methods: We retrospectively examined 30 cases of CRPS that had undergone intravenous nerindronic acid sodium salt therapy in our center. The patients were contacted after 12 months from the start of therapy and their clinical situation was assessed with Quick DASH Score. Results: The average age of our group was 59,76 years (span, 42-78), and female subjects were 84% (p-value <0.05). 72% of all cases were complications of wrist fractures.). The Quick DASH Score (19 points are the best result, 95 the worst outcome) average was 41,1 points. The values of Quick DASH Score differed significantly (p-value <0.001) according to the age of the patient. In addition, the DASH Score values were related to the sex of the patient (p-value <0.001). Male subjects have obtained a better score. After 12 months of intravenous therapy, 52% of cases reports that they still have joint stiffness. The DASH values differed significantly depending on the onset of intravenous treatment (p-value <0.001). Conclusion: Our study showed that the CRPS affects a population between 42 and 78 years, especially women. Treatment with intravenous bisphosphonates seems to lead to an improvement in CRPS symptoms, in particular administration between 3 and 6 months after the onset of the disease. In particular, women over 61 years of age seem to have a lower improvement in symptomatology after treatment. 52% of cases report that they still have joint stiffness.
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Affiliation(s)
- Marianna Faggiani
- Department of Orthopaedic Surgery and Traumatology. "Maggiore" Hospital of Chieri. Turin. Italy.
| | - Alice Piccato
- Department of Orthopaedic Surgery and traumatology. "Edoardo Agnelli" Hospital - Pinerolo. Italy.
| | - Chiara Baroni
- Department of Orthopaedic Surgery and Traumatology. "Maggiore" Hospital of Chieri. Turin. Italy.
| | - Salvatore Risitano
- Department of Orthopaedic Surgery and Traumatology. "Maggiore" Hospital of Chieri. Turin. Italy.
| | - Luigi Giulio Conforti
- Department of Orthopaedic Surgery and Traumatology. "Maggiore" Hospital of Chieri. Turin. Italy.
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22
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Hernigou J, Labadens A, Ghistelinck B, Bui Quoc E, Maes R, Bhogal H, Callewier A, Bath O, Chahidi E, Safar A. Vitamin C prevention of complex regional pain syndrome after foot and ankle surgery: a prospective randomized study of three hundred and twenty nine patients. INTERNATIONAL ORTHOPAEDICS 2021; 45:2453-2459. [PMID: 34347132 DOI: 10.1007/s00264-021-05159-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/17/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Complex regional pain syndrome (CRPS) after foot and ankle surgery has a significant impact on the ability to walk. As the symptomatic treatment of this disaster complication is poor and has low efficacy, a preventive treatment would be beneficial. Vitamin C has been reported to be efficient in preventing CRPS in elective scheduled surgery. Few authors explored this efficiency in foot and ankle surgery. We, therefore, evaluated the efficacy of vitamin C in preventing this complication after foot and ankle surgeries for both trauma and elective surgery. MATERIAL AND METHODS Between January 2018 and December 2019, 329 patients were included in the study. We conducted a prospective randomized study on the efficiency of vitamin C (one group with and one without vitamin C) to prevent CRPS risk in patients operated in our institution on foot or ankle surgery. The incidence of CRPS after foot and ankle surgery was evaluated in both groups; the diagnostic of CRPS was made using the Budapest criteria associated with three-phase bone scintigraphy. RESULTS Among the 329 patients included in the study (232 women and 97 men), 121 patients were included in the vitamin C group and 208 in the control group (without vitamin C). Vitamin C was statistically linked with a decreased risk of CRPS (OR 0.19; CI 95% from 0.05 to 0.8; p = 0.021). Alcoholism and cast immobilization were increased risks factors of CRPS (respectively p = 0.001 and p = 0.034). CONCLUSION Taking 1 g per day of vitamin C during 40 days after a foot or ankle surgery reduces the risk of CRPS.
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Affiliation(s)
- Jacques Hernigou
- Department of Orthopaedics and Traumatology, Centre Hospitalier EpiCURA, Sites Hornu/Baudour, Hainaut, Belgium.
| | - Adeline Labadens
- Department of Orthopaedics and Traumatology, Centre Hospitalier EpiCURA, Sites Hornu/Baudour, Hainaut, Belgium.,Université Libre de Bruxelles, Brussels, Belgium
| | - Barbara Ghistelinck
- Department of Orthopaedics and Traumatology, Centre Hospitalier EpiCURA, Sites Hornu/Baudour, Hainaut, Belgium.,Université Libre de Bruxelles, Brussels, Belgium
| | - Emilie Bui Quoc
- Department of Anesthesia, Centre Hospitalier EpiCURA, Hainaut, Belgium
| | - Renaud Maes
- Department of Orthopaedics and Traumatology, Centre Hospitalier EpiCURA, Sites Hornu/Baudour, Hainaut, Belgium
| | - Harkirat Bhogal
- Department of Orthopaedics and Traumatology, Centre Hospitalier EpiCURA, Sites Hornu/Baudour, Hainaut, Belgium
| | - Antoine Callewier
- Department of Orthopaedics and Traumatology, Centre Hospitalier EpiCURA, Sites Hornu/Baudour, Hainaut, Belgium
| | - Olivier Bath
- Department of Orthopaedics and Traumatology, Centre Hospitalier EpiCURA, Sites Hornu/Baudour, Hainaut, Belgium
| | - Esfandiar Chahidi
- Department of Orthopaedics and Traumatology, Centre Hospitalier EpiCURA, Sites Hornu/Baudour, Hainaut, Belgium.,Université Libre de Bruxelles, Brussels, Belgium
| | - Adonis Safar
- Department of Orthopaedics and Traumatology, Centre Hospitalier EpiCURA, Sites Hornu/Baudour, Hainaut, Belgium
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Safran T, Dionisopoulos T. Enhanced Recovery Protocol in Prepectoral Direct-to-Implant Reconstruction. Plast Reconstr Surg 2021; 148:332e-334e. [PMID: 34233339 DOI: 10.1097/prs.0000000000008148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Tyler Safran
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Division of Plastic and Reconstructive Surgery, Jewish General Hospital, Montreal, Quebec, Canada
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Vitamin C Could Prevent Complex Regional Pain Syndrome Type I in Trauma and Orthopedic Care? A Systematic Review of the Literature and Current Findings. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2021; 55:139-145. [PMID: 34349587 PMCID: PMC8298085 DOI: 10.14744/semb.2021.82335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/22/2021] [Indexed: 11/20/2022]
Abstract
The aim of this systematic review is to evaluate the efficacy of Vitamin C (VC) in preventing Complex Regional Pain Syndrome type I (CRPS-I) in fractures or surgery of the upper and lower extremities. During December 2020, Scopus and PubMed search was performed to analyze VC supplementation in preventing CRPS-I after trauma and orthopedic care, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guideline. Patient, Intervention, Comparison, Outcomes, Study Design model, and a modified version of the Coleman Methodology Score were used to analyze the included studies. The research was limited from 1990 to December 2020. Initial screening results identified 649 studies. After reviewing each study, six clinical studies were included in the study. A total of 2026 patients of whom 632 male and 1394 female were collected in our systematic review. During the entire follow-up period, the occurrence of CRPS-I was evaluated in 1939 patients. Five of the six analyzed studies were favoring prophylactic use of the 500-1000 mg daily dose of VC for 45-50 days after orthopedic or trauma care for prevention of CRPS-I. Only one study found no benefit in VC supplementation compared with placebo to prevent CRPS-I. Analysis of the literature suggests that a daily 500-1000 mg VC supplementation may reduce the onset of CRPS-I in trauma of upper/lower extremities and in orthopedic surgery.
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Guo TZ, Shi X, Li W, Wei T, Kingery WS, Clark JD. Dimethyl Fumarate Reduces Oxidative Stress and Pronociceptive Immune Responses in a Murine Model of Complex Regional Pain Syndrome. Anesth Analg 2021; 132:1475-1485. [PMID: 33646995 PMCID: PMC8049952 DOI: 10.1213/ane.0000000000005440] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a highly disabling cause of pain often precipitated by surgery or trauma to a limb. Both innate and adaptive immunological changes contribute to this syndrome. Dimethyl fumarate (DMF) works through the nuclear factor erythroid 2-related factor 2 (Nrf2) transcription factor and other targets to activate antioxidant systems and to suppress immune system activation. We hypothesized that DMF would reduce nociceptive, functional, and immunological changes measured in a model of CRPS. METHODS Male C57BL/6 mice were used in the well-characterized tibial fracture model of CRPS. Some groups of mice received DMF 25 mg/kg/d orally, per os for 3 weeks after fracture versus vehicle alone. Homozygous Nrf2 null mutant mice were used as test subjects to address the need for this transcription factor for DMF activity. Allodynia was assessed using von Frey filaments and hindlimb weight-bearing data were collected. The markers of oxidative stress malondialdehyde (MDA) and 4-hydroxynonenal (4-HNE) were quantified in the skin of the fractured mice using immunoassays along with the innate immune system cytokines IL-1β and IL-6. The accumulation of IgM in the fractured limbs and lymph node hypertrophy were used as indexes of adaptive immune system activation, and the passive transfer of serum from wildtype fractured mice to B cell-deficient fractured muMT mice (mice lacking B cells and immunoglobulin) helped to assess the pronociceptive activity of humoral factors. RESULTS We observed that oral DMF administration strongly prevented nociceptive sensitization and reduced uneven hindlimb weight bearing after fracture. DMF was also very effective in reducing the accumulation of markers of oxidative stress, activation of innate immune mediator production, lymph node hypertrophy, and the accumulation of IgM in fractured limbs. The sera of fractured vehicle-treated but not DMF-treated mice conferred pronociceptive activity to recipient mice. Unexpectedly, the effects of DMF were largely unchanged in the Nrf2 null mutant mice. CONCLUSIONS Oxidative stress and immune system activation are robust after hindlimb fracture in mice. DMF strongly reduces activation of those systems, and the Nrf2 transcription factor is not required. DMF or drugs working through similar mechanisms might provide effective therapy for CRPS or other conditions where oxidative stress causes immune system activation.
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Affiliation(s)
- Tian-zhi Guo
- Palo Alto Veterans Institute for Research, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Xiaoyou Shi
- Anesthesiology Service, Veterans Affairs Palo Alto Health Care System Palo Alto, CA, United States
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, United States
| | - Wenwu Li
- Anesthesiology Service, Veterans Affairs Palo Alto Health Care System Palo Alto, CA, United States
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, United States
| | - Tzuping Wei
- Palo Alto Veterans Institute for Research, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - Wade S. Kingery
- Palo Alto Veterans Institute for Research, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States
| | - J. David Clark
- Anesthesiology Service, Veterans Affairs Palo Alto Health Care System Palo Alto, CA, United States
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, United States
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Dutton LK, Rhee PC. Complex Regional Pain Syndrome and Distal Radius Fracture: Etiology, Diagnosis, and Treatment. Hand Clin 2021; 37:315-322. [PMID: 33892884 DOI: 10.1016/j.hcl.2021.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by a constellation of signs and symptoms including pain out of proportion to the injury or insult, autonomic dysfunction, trophic changes, and impaired function. CRPS may occur following either conservative or surgical management of distal radius fractures and can significantly complicate the trajectory of a patient's recovery. Although the incidence, diagnosis, prevention, and treatment of this condition have been extensively studied, optimal methods to identify, prevent, and treat this condition remain controversial. This article reviews the available literature on the diagnosis and treatment of CRPS in distal radius fractures.
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Affiliation(s)
- Lauren Kate Dutton
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Peter Charles Rhee
- Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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A meta-analysis of randomized clinical trials on the impact of oral vitamin C supplementation on first-year outcomes in orthopedic patients. Sci Rep 2021; 11:9225. [PMID: 33927326 PMCID: PMC8085077 DOI: 10.1038/s41598-021-88864-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/16/2021] [Indexed: 12/17/2022] Open
Abstract
This meta-analysis aimed at investigating the impact of oral vitamin C supplementation on the post-procedural recovery of orthopedic patients, including functional outcomes and complex regional pain syndrome type I (CRPS I). Literature search using the Medline, Cochrane Library, and Embase databases from inception till March 2021 identified seven eligible randomized controlled trials with 1,361 participants. Forest plot revealed no significant difference in the functional outcomes at 6–12 months [standardized mean difference (SMD) = −0.00, 95% CI − 0.19 to 0.18, 467 patients], risk of overall complications (RR = 0.98, 95% CI 0.68 to 1.39, 426 patients), and pain severity at 3–6 months (SMD = − 0.18, 95% CI − 0.49 to 0.12, 486 patients) between patients with and without oral vitamin C supplementation. Pooled analysis showed that vitamin C treatment reduced the risk of CRPS I regardless of dosage (RR = 0.46, 95% CI 0.25 to 0.85, 1143 patients). In conclusion, the current meta-analysis demonstrated that oral vitamin C supplementation may reduce the risk of complex regional pain syndrome type I but did not improve the functional outcomes in orthopedic patients. Nevertheless, because of the small number of trials included in the present study, further large-scale clinical studies are warranted to support our findings.
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Prospective randomized study of the vitamin C effect on pain and complex pain regional syndrome after total knee arthroplasty. INTERNATIONAL ORTHOPAEDICS 2021; 45:1155-1162. [PMID: 33438072 DOI: 10.1007/s00264-020-04936-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Complex regional pain syndrome (CRPS) type I, formerly known as reflex sympathetic dystrophy (RSD) or algodystrophy, is a condition with chronic pain condition following a trauma or surgery. The physiopathology of this syndrome remained incompletely known. Due to the lack of effective curative treatment, prevention of this complication is important. Therefore, we evaluated the efficacy of vitamin C in preventing this complication. MATERIAL AND METHODS Between January 2018 and July 2019, we conducted a prospective randomized study on the efficiency of vitamin C (one group with and one without vitamin C) on prevention of CRPS risk in patients operated in our institution with TKA. Patients with a VAS pain score > 4 performed a three-phase bone scintigraphy. The diagnostic of CRPS was made by using the Budapest criteria associated to a bone scintigraphy. Statistical significance was set at p < 0.05 RESULTS: One hundred fifty-three patients were included in the vitamin C group, 139 in the control group without vitamin C. For the entire cohort, the prevalence of complex regional pain syndrome was 7.9% (23 of 292). The prevalence of complex regional pain syndrome was 3.9% (six of 153) in the vitamin C group and 12.2% (seventeen of 139) in the control group (p = 0.008). After multivariate regression, vitamin C was found to be an independent preventive factor of CRPS and there was a significant difference between the vitamin C group and the control group (relative risk, 0.27; 95% confidence interval, 0.1-0.8; p = 0.015). CONCLUSION Taking 1 g per day of vitamin C during 40 days after a TKA reduces the risk of CRPS.
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Intravenous Administration of Vitamin C in the Treatment of Herpes Zoster-Associated Pain: Two Case Reports and Literature Review. Pain Res Manag 2020; 2020:8857287. [PMID: 33335639 PMCID: PMC7723478 DOI: 10.1155/2020/8857287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/16/2020] [Indexed: 01/28/2023]
Abstract
Background Herpes zoster (HZ) is an acute inflammatory neurocutaneous disease caused by the reactivation of varicella-zoster virus. It is estimated that the incidence of postherpetic neuralgia following HZ is 10–20%. The leading risk factors of the prognosis are aging and immunity dysfunction. Vitamin C plays a pivoted role in enhancing white blood cell function. Epidemiological evidence and clinical studies have indicated an association between pain and suboptimal vitamin C status. At present, vitamin C has been used as an additional option in the treatment of HZ-associated pain. Despite the current controversy, case reports and randomized controlled studies have indicated that both acute- and postherpetic neuralgia can be dramatically alleviated following intravenous vitamin C infusions. Case Presentation. Two patients (male aged 72 and female 78 years) with HZ did not respond well to antiviral therapy and analgesics. Skin lesions in the right groin and front thigh healed after early antiviral therapy, but the outbreak of pain persisted in the male patient. The female patient presented to our clinic with clusters of rashes in the right forehead with severe edema of her right upper eyelid. Because nerve blockade could not be conducted for both patients, intravenous infusion of vitamin C was applied and resulted in an immediate remission of the breakthrough pain in the male patient and cutaneous lesions in the female patient. Conclusions The use of vitamin C appears to be an emerging treatment alternative for attenuating HZ and PHN pain. Hence, we recommend the addition of concomitant use of intravenously administered vitamin C into therapeutic strategies in the treatment of HZ-associated pain, especially for therapy-resistant cases. Furthermore, animal studies are required to determine analgesic mechanisms of vitamin C, and more randomized clinical trials are essential to further determine the optimal dose and timing of administration of vitamin C.
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Szynkowicz P, Petrucci A. Chiropractic Care of a Patient With Complex Regional Pain Syndrome Type 1 (CRPS-1): A Case Report. J Chiropr Med 2020; 19:145-151. [PMID: 33318733 DOI: 10.1016/j.jcm.2020.05.001] [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: 08/29/2018] [Revised: 05/12/2020] [Accepted: 05/20/2020] [Indexed: 11/27/2022] Open
Abstract
Objective The purpose of this case report is to describe the evaluation and treatment of a patient presenting with left upper extremity pain and neck pain after a slip and fall. Clinical Features A 56-year-old woman sustained a left distal radius fracture secondary to a slip-and-fall accident. She was placed in a cast for 6 weeks, and after the removal of her cast she developed excruciating left forearm, wrist, hand, and finger pain. The patient was diagnosed with complex regional pain syndrome type 1 utilizing the modified (Budapest) International Association for the Study of Pain criteria. Intervention and Outcome The patient did not respond positively to initial management, which included the application of a cast after closed reduction of the distal radius fracture, 8 weeks of physical/occupational therapy, and the use of a brace which kept her left wrist, hand, and fingers in a flexed position. Subsequently, the patient presented to the University of Bridgeport College of Chiropractic outpatient clinic, where she was evaluated and treated. She received a total of 36 chiropractic treatments between her initial office visit in January 2018 and the follow-up in June 2018. The patient reported and demonstrated amelioration of her presenting complaints, decreased pain, increased ranges of motion, and increased function. Conclusion This case report underscores the importance of a rapid, accurate, initial diagnosis of complex regional pain syndrome type 1, during the acute (warm) stage.
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Affiliation(s)
- Peter Szynkowicz
- University of Bridgeport College of Chiropractic Outpatient Clinic, Bridgeport, Connecticut
| | - Anthony Petrucci
- University of Bridgeport College of Chiropractic Outpatient Clinic, Bridgeport, Connecticut
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Regional vitamin C in Bier block reduces the incidence of CRPS-1 following distal radius fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:689-693. [PMID: 33119790 DOI: 10.1007/s00590-020-02821-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Systemic vitamin C supplementation after wrist fracture has been suggested to reduce the incidence of complex regional pain syndrome (CRPS). This study aimed to evaluate the effect of regional vitamin C in Bier block in the early phase of fracture on CRPS occurrence following surgery for distal radius fractures. METHODS Seventy-four patients with isolated extra-articular distal radius fracture with the plan of fixation under Bier block were enrolled. Patients were assigned randomly into two groups: receiving either 500 mg vitamin C or sterile water as a Bier block adjuvant. Both groups received 500 mg of oral vitamin C for six weeks. The patients were evaluated for CRPS signs and symptoms at 2, 4, 6, and 12 weeks post-surgery. RESULTS The overall incidence of CRPS 12 weeks after surgery in the vitamin C group was significantly less than the controls (22.9% vs 45.5%, p = 0.04). Logistic regression analysis showed that the only significant contribution in predicting the incidence of CRPS came from the intervention variable (OR 0.26, CI95% 0.08-0.85; P = 0.027). CONCLUSIONS The findings suggest that adding vitamin C 500 mg to the local anesthetic in Bier block significantly reduces the incidence of CRPS following distal radius fractures.
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DNA methylation profiles are associated with complex regional pain syndrome after traumatic injury. Pain 2020; 160:2328-2337. [PMID: 31145213 DOI: 10.1097/j.pain.0000000000001624] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Factors contributing to development of complex regional pain syndrome (CRPS) are not fully understood. This study examined possible epigenetic mechanisms that may contribute to CRPS after traumatic injury. DNA methylation profiles were compared between individuals developing CRPS (n = 9) and those developing non-CRPS neuropathic pain (n = 38) after undergoing amputation following military trauma. Linear Models for Microarray (LIMMA) analyses revealed 48 differentially methylated cytosine-phosphate-guanine dinucleotide (CpG) sites between groups (unadjusted P's < 0.005), with the top gene COL11A1 meeting Bonferroni-adjusted P < 0.05. The second largest differential methylation was observed for the HLA-DRB6 gene, an immune-related gene linked previously to CRPS in a small gene expression study. For all but 7 of the significant CpG sites, the CRPS group was hypomethylated. Numerous functional Gene Ontology-Biological Process categories were significantly enriched (false discovery rate-adjusted q value <0.15), including multiple immune-related categories (eg, activation of immune response, immune system development, regulation of immune system processes, and antigen processing and presentation). Differentially methylated genes were more highly connected in human protein-protein networks than expected by chance (P < 0.05), supporting the biological relevance of the findings. Results were validated in an independent sample linking a DNA biobank with electronic health records (n = 126 CRPS phenotype, n = 19,768 non-CRPS chronic pain phenotype). Analyses using PrediXcan methodology indicated differences in the genetically determined component of gene expression in 7 of 48 genes identified in methylation analyses (P's < 0.02). Results suggest that immune- and inflammatory-related factors might confer risk of developing CRPS after traumatic injury. Validation findings demonstrate the potential of using electronic health records linked to DNA for genomic studies of CRPS.
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De Logu F, De Prá SDT, de David Antoniazzi CT, Kudsi SQ, Ferro PR, Landini L, Rigo FK, de Bem Silveira G, Silveira PCL, Oliveira SM, Marini M, Mattei G, Ferreira J, Geppetti P, Nassini R, Trevisan G. Macrophages and Schwann cell TRPA1 mediate chronic allodynia in a mouse model of complex regional pain syndrome type I. Brain Behav Immun 2020; 88:535-546. [PMID: 32315759 DOI: 10.1016/j.bbi.2020.04.037] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/27/2020] [Accepted: 04/15/2020] [Indexed: 12/21/2022] Open
Abstract
Complex regional pain syndrome type I (CRPS-I) is characterized by intractable chronic pain. Poor understanding of the underlying mechanisms of CRPS-I accounts for the current unsatisfactory treatment. Antioxidants and antagonists of the oxidative stress-sensitive channel, the transient receptor potential ankyrin 1 (TRPA1), have been found to attenuate acute nociception and delayed allodynia in models of CRPS-I, evoked by ischemia and reperfusion (I/R) of rodent hind limb (chronic post ischemia pain, CPIP). However, it is unknown how I/R may lead to chronic pain mediated by TRPA1. Here, we report that the prolonged (day 1-15) mechanical and cold allodynia in the hind limb of CPIP mice was attenuated permanently in Trpa1-/- mice and transiently after administration of TRPA1 antagonists (A-967079 and HC-030031) or an antioxidant (α-lipoic acid). Indomethacin treatment was, however, ineffective. We also found that I/R increased macrophage (F4/80+ cell) number and oxidative stress markers, including 4-hydroxynonenal (4-HNE), in the injured tibial nerve. Macrophage-deleted MaFIA (Macrophage Fas-Induced Apoptosis) mice did not show I/R-evoked endoneurial cell infiltration, increased 4-HNE and mechanical and cold allodynia. Furthermore, Trpa1-/- mice did not show any increase in macrophage number and 4-HNE in the injured nerve trunk. Notably, in mice with selective deletion of Schwann cell TRPA1 (Plp1-CreERT;Trpa1fl/fl mice), increases in macrophage infiltration, 4-HNE and mechanical and cold allodynia were attenuated. In the present mouse model of CRPS-I, we propose that the initial oxidative stress burst that follows reperfusion activates a feed forward mechanism that entails resident macrophages and Schwann cell TRPA1 of the injured tibial nerve to sustain chronic neuroinflammation and allodynia. Repeated treatment one hour before and for 3 days after I/R with a TRPA1 antagonist permanently protected CPIP mice against neuroinflammation and allodynia, indicating possible novel therapeutic strategies for CRPS-I.
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Affiliation(s)
- Francesco De Logu
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Samira Dal-Toé De Prá
- Graduate Program in Health Sciences, University of the Extreme South of Santa Catarina (Unesc), 88006-000 Criciúma (SC), Brazil
| | | | - Sabrina Qader Kudsi
- Graduate Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria (RS), Brazil
| | - Paula Ronsani Ferro
- Graduate Program in Health Sciences, University of the Extreme South of Santa Catarina (Unesc), 88006-000 Criciúma (SC), Brazil
| | - Lorenzo Landini
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Flávia Karine Rigo
- Graduate Program in Health Sciences, University of the Extreme South of Santa Catarina (Unesc), 88006-000 Criciúma (SC), Brazil
| | - Gustavo de Bem Silveira
- Graduate Program in Health Sciences, University of the Extreme South of Santa Catarina (Unesc), 88006-000 Criciúma (SC), Brazil
| | - Paulo Cesar Lock Silveira
- Graduate Program in Health Sciences, University of the Extreme South of Santa Catarina (Unesc), 88006-000 Criciúma (SC), Brazil
| | - Sara Marchesan Oliveira
- Graduate Program in Biological Sciences: Toxicological Biochemistry, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria (RS), Brazil
| | - Matilde Marini
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Gianluca Mattei
- Department of Information Engineering, University of Florence, 50139 Florence, Italy
| | - Juliano Ferreira
- Graduate Program in Pharmacology, Federal University of Santa Catarina, 88040-900 Florianopolis (SC), Brazil
| | - Pierangelo Geppetti
- Department of Health Sciences, University of Florence, 50139 Florence, Italy
| | - Romina Nassini
- Department of Health Sciences, University of Florence, 50139 Florence, Italy.
| | - Gabriela Trevisan
- Department of Health Sciences, University of Florence, 50139 Florence, Italy; Graduate Program in Health Sciences, University of the Extreme South of Santa Catarina (Unesc), 88006-000 Criciúma (SC), Brazil; Graduate Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria (RS), Brazil.
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Knackstedt R, Oliver J, Gatherwright J. Evidence-Based Perioperative Nutrition Recommendations: Optimizing Results and Minimizing Risks. Plast Reconstr Surg 2020; 146:423-435. [PMID: 32740600 DOI: 10.1097/prs.0000000000007004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Plastic surgery patients span the nutritional spectrum from generally healthy, nutritionally competent patients to inherently catabolic, nutritionally deficient, and chronic wound patients. Therefore, plastic and reconstructive surgery affords the opportunity to investigate the impact of nutrition across a heterogeneous patient population following a wide variety of procedures. Although patients may be nutritionally deficient in certain vitamins warranting perioperative repletion, other supplements have the potential to benefit all patients, regardless of nutritional status. Despite these putative benefits, there is a dearth of information regarding nutritional optimization, with the limited, available literature focusing mostly on herbal supplements and their potential side effects. A significant barrier to supplement use is the lack of education and available supporting information regarding the indications, contraindications, and physiology of these adjuncts. The goal of this article is to provide a comprehensive, evidence-based review of available nutritional supplements that can be considered for the plastic surgery patient in the perioperative period to optimize surgical outcomes while minimizing risk. Prospective, well-designed studies using validated, high-quality supplements will be critical in determining the significance that perioperative supplementation can have for surgical outcomes. Until well-done prospective studies are performed, the supplement, dose, and duration should be determined on an individual, patient-per-patient basis at the discretion of the operating surgeon.
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Affiliation(s)
- Rebecca Knackstedt
- From the Department of Plastic Surgery, Cleveland Clinic; the Mayo Medical School; and the Division of Plastic Surgery, MetroHealth
| | - Jeremie Oliver
- From the Department of Plastic Surgery, Cleveland Clinic; the Mayo Medical School; and the Division of Plastic Surgery, MetroHealth
| | - James Gatherwright
- From the Department of Plastic Surgery, Cleveland Clinic; the Mayo Medical School; and the Division of Plastic Surgery, MetroHealth
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Abstract
The vitamin status of a child depends on many factors and most of the clinical studies do not take into account the different access to adequate nutrition of children coming from different countries and the consequent major differences in micronutrients or vitamin deficits between low-income and high-income countries. Vitamin supplements are included in the general field of dietary supplements. There is a large amount of not always factual material concerning vitamin supplements, and this may sometimes create confusion in clinicians and patients. Inadequate information may lead to the risk of attributing beneficial properties leading to their over-use or misuse in the paediatric field. Vitamin supplementation is indicated in all those conditions in which a vitamin deficiency is found, either because of a reduced intake due to reduced availability of certain foods, restrictive diets or inadequate absorption. The lack of guidelines in these fields may lead paediatricians to an improper use of vitamins, both in terms of excessive use or inadequate use. This is due to the fact that vitamin supplementation is often intended as a therapy of support rather than an essential therapeutic tool able to modify disease prognosis. In fact, various vitamins and their derivatives have therapeutic potential in the prevention and treatment of many diseases, especially in emerging conditions of paediatric age such as type 2 diabetes and the metabolic syndrome. The aim of the present article is to analyse the state of the art and consider new perspectives on the role of vitamin supplements in children.
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Abstract
In the recent years, treatment of distal radius fractures (DRF) has advanced considerably. Surgical fixation with palmar angular stable plate has gained popularity, due to a reported lower complication rate when compared to dorsal fixation. The type of trauma or injury, surgical procedure and impaired bone quality are all contributors to complications in DRF. The main aim of this review is to summarize the most common complications and possible therapeutic solutions. In addition, strategies for minimizing these complications will be discussed.
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García-Cepeda I, Aguado-Maestro I, De Blas-Sanz I, Quintanilla-García A, García-Alonso M. Radiological results of surgical management of fracture of the distal radius treated with volar locking plates. Injury 2020; 51 Suppl 1:S42-S47. [PMID: 32113738 DOI: 10.1016/j.injury.2020.02.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/15/2020] [Accepted: 02/19/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Distal radius fracture (DRF) is the most common upper extremity fracture. The incidence of complications after surgical treatment still remains high. The objective of our study was to assess functional and radiological results of DRF treated with volar locking plate. METHODS We conducted a retrospective study including DRF treated by open reduction and internal fixation with a volar locking plate during a period of 8 years (2010-2018). Data were collected from clinical records and included patient demographics, fracture characteristics, radiological parameters (radial inclination, palmar tilt, ulnar variance, articular step-off), range of motion (ROM), complications and reinterventions. RESULTS A total of 170 patients (63.5% female) met the inclusion criteria with a mean age of 55.9 years [24.1-83.7; 13.76]. High energy injuries were more frequent in younger patients (25.56% vs 3.95%; p < 0.0001). AO classification was: 2R3A: 23.5%, 2R3B: 24.1% and 2R3C: 52.4%. Time until surgery was 8.5 days, longer in extraarticular fractures (AO-2R3A: 12.22 days, AO-2R3B: 7.97 days, AO-2R3C: 7.04 days, p = 0.018). Younger patients had better radial inclination (excellent in 85.1% vs 59.21%, p = 0.001) and radial shortening (excellent in 100% vs 88.15%, p = 0.001). ROM was: flexion 63° [0-90°; 19.73], extension 57.67° [5-90°; 21.61], pronation 78.94° [40-90°] and supination 81.76° [38-90°; 8.87]. We found a weak correlation between ROM in flexion-extension and radial shortening (r = 0.218; p = 0.001) and articular step-off (r = -0.269; p = 0.002). We had 39 complications (21.18% of patients). 10.6% of patients needed a re-operation, being the most frequent hardware removal (6.5%) and tendinous disruptions repairs (2.4%). Reintervention rate was higher in younger patients (14.9% vs 5.3%; p = 0.042), complete articular fractures (AO-2R3A: 2.5%; AO-2R3B: 7.3%; AO-2R3C: 15.7%; p = 0.037) and high energy injuries (8.4% vs 22.2%; p = 0.044). Patients undergoing reintervention had a decreased flexion-extension (94.44° vs 123.83°, p = 0.007). CONCLUSION Radial shortening and articular step-off seem the most important predictors for postoperative range of motion. Worse radiological outcomes are observed in complete articular fractures and those affecting elder population. Although radiological and functional results are good or excellent in most of cases, the incidence of complications and need for reintervention still remains noticeable. Re-operations were more frequent in younger patients, complete articular fractures and high energy injuries, and it worsened functional outcomes.
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Affiliation(s)
- I García-Cepeda
- Traumatology and Orthopaedic Surgery Department, Hospital Universitario del Río Hortega, C Dulzaina 2, Valladolid 47009, Spain
| | - I Aguado-Maestro
- Traumatology and Orthopaedic Surgery Department, Hospital Universitario del Río Hortega, C Dulzaina 2, Valladolid 47009, Spain.
| | - I De Blas-Sanz
- Traumatology and Orthopaedic Surgery Department, Hospital Universitario del Río Hortega, C Dulzaina 2, Valladolid 47009, Spain
| | - A Quintanilla-García
- Traumatology and Orthopaedic Surgery Department, Hospital Universitario del Río Hortega, C Dulzaina 2, Valladolid 47009, Spain
| | - M García-Alonso
- Traumatology and Orthopaedic Surgery Department, Hospital Universitario del Río Hortega, C Dulzaina 2, Valladolid 47009, Spain
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Response to "Reply to 'Integrative Medicine in Plastic Surgery: A Systematic Review of Our Literature'". Ann Plast Surg 2020; 85:457-458. [PMID: 32118632 DOI: 10.1097/sap.0000000000002247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Motoji H, To M, Hidaka K, Matsuo M. Vitamin C and eggshell membrane facilitate orthodontic tooth movement and induce histological changes in the periodontal tissue. J Oral Biosci 2020; 62:80-87. [DOI: 10.1016/j.job.2020.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/16/2020] [Accepted: 01/17/2020] [Indexed: 12/15/2022]
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Reply to "Integrative Medicine in Plastic Surgery: A Review of our Literature". Ann Plast Surg 2020; 85:456-457. [PMID: 32032117 DOI: 10.1097/sap.0000000000002246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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What Is the Effect of Vitamin C on Finger Stiffness After Distal Radius Fracture? A Double-blind, Placebo-controlled Randomized Trial. Clin Orthop Relat Res 2019; 477:2278-2286. [PMID: 32142501 PMCID: PMC6999927 DOI: 10.1097/corr.0000000000000807] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is proposed that vitamin C administration can reduce disproportionate pain and stiffness after distal radius fracture; however, randomized trials that tested this hypothesis have had inconsistent results. QUESTIONS/PURPOSES (1) Is administering vitamin C after distal radius fracture associated with better ROM, patient-reported upper extremity function, and pain scores? (2) What factors are associated with post-fracture finger stiffness and worse upper extremity function? METHODS This is a double-blind, randomized, placebo-controlled, noncrossover study. Between August 2014 and July 2017, we approached 204 consecutive patients, of which 195 were eligible, and 134 chose to participate. Participants were randomized to receive once-daily 500 mg vitamin C (67 participants) or placebo (67 participants) within 2 weeks after distal radius fracture. All patients received usual care at the discretion of their surgeon. The mean age of participants was 49 ± 17 years, 99 patients (74%) were women, and 83 (62%) were treated nonoperatively. The primary outcome was the distance between the fingertip and distal palmar crease 6 weeks after fracture. This measure is easy to obtain and previously has been shown to correlate with aggregate ROM of all finger joints. The secondary outcomes were total active finger motion, total active thumb motion, upper extremity-specific limitations, and pain intensity.An a priori power analysis suggested 126 patients would provide 80% power to detect a difference of 2 cm (SD 4.0) fingertip distance to palmar crease with α set at 0.05 using a two-tailed Student's t-test. Accounting for 5% lost to followup, we included 134 patients.All analyses were intention-to-treat. Ten participants of the intervention group and five of the placebo group were lost to followup. Their missing data were addressed by multiple imputation, after which we performed linear regression analysis for our outcome variables. RESULTS Administration of vitamin C was not associated with ROM, function, or pain scores at 6 weeks (distance to palmar crease: β -0.23; 95% CI -1.7 to 1.2; p = 0.754; finger ROM: β 4.9; 95% CI, -40 to 50; p = 0.829; thumb ROM: β 0.98; 95% CI, -18 to 20; p = 0.918, Patient-Reported Outcomes Measurement Information System [PROMIS] score: β 0.32; 95% CI, -2.6 to 3.2; p = 0.828; pain score: β -0.62; 95% CI, -0.62 to 0.89; p = 0.729) nor at 6 months (PROMIS score: β -0.21; 95% CI, -3.7 to 3.3; p = 0.904; pain score: β 0.31; 95% CI, -0.74 to 1.4; p = 0.559). At 6 weeks, we found that more finger stiffness was mildly associated with greater age (β -1.5; 95% CI, -2.8 to -0.083; p = 0.038). Thumb stiffness was mildly associated with greater age (β -0.72; 95% CI, -1.3 to -0.18; p = 0.009) and strongly associated with operative treatment (β -32; 95% CI, -50 to -13; p = 0.001). Greater pain interference was modestly associated with greater functional limitations at 6 weeks (β -0.32; 95% CI, -0.52 to -0.12; p = 0.002) and 6 months (β -0.36; 95% CI, -0.60 to -0.11; p = 0.004). CONCLUSIONS Vitamin C does not seem to facilitate recovery after distal radius fracture, but amelioration of maladaptation to nociception (pain interference) merits greater attention. LEVEL OF EVIDENCE Level I, therapeutic study.
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Influence of vitamin C on the incidence of CRPS-I after subacromial shoulder surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:221-226. [PMID: 31541301 DOI: 10.1007/s00590-019-02542-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 08/29/2019] [Indexed: 01/14/2023]
Abstract
PURPOSE The primary aim of this study was to determine whether postoperative administration of vitamin C (VC) is associated with reduced risk of complex regional pain syndrome type I (CRPS-I) after subacromial shoulder surgery (SaSS). The secondary objective of the study was to identify risk factor for the development of CRPS-I after SaSS. MATERIALS AND METHODS A retrospective cohort study was performed to evaluate 542 patients undergoing SaSS from January 2015 to December 2016. The cohort was divided into two groups based on VC administration [Group I (no VC) and Group II (500 mg/day oral VC for 50 days postoperatively)]. The relationship between VC administration and development of CRPS-I was assessed. Demographics, preoperative clinical parameters, and operative variables were evaluated to determine their effect on the incidence of CRPS-I. RESULTS A total of 267 patients (Group II) undergoing SaSS received VC, and 266 patients (Group I) did not. The incidence of CRPS-I was significantly different between two groups (36(13%) vs 18(7%), p = 0.009). Multivariable regression, however, demonstrated that VC reduced the risk of CRPS-I after SaSS by > 50% (aOR = 0.49; 95% CI 0.27-0.91). Patients undergoing open surgery (aOR = 2.19; 95% CI 1.2-4.0) were more likely to develop CRPS-I postoperatively. Higher preoperative Constant score (aOR = 0.94; 95% CI 0.91-0.98) was associated with lower risk for CRPS-I development. CONCLUSIONS The present study found that VC administered prophylactically for 50 days postoperatively is effective in preventing CRPS-I development after SaSS. CRPS-I is a common complication following SaSS, especially in the setting of an open approach. The authors recommend preventive management with VC and arthroscopic approaches when possible for SaSS. LEVEL OF EVIDENCE III Retrospective comparative study.
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Keef T, Keef S. The Efficacy of Vitamin C in the Prevention of Complex Regional Pain Syndrome After Distal Radius Fractures: A Synthesis. J Pain Palliat Care Pharmacother 2019; 32:208-211. [PMID: 30998426 DOI: 10.1080/15360288.2019.1598530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The current recommendation is to use daily doses of vitamin C to prevent the occurrence of the complex regional pain syndrome (CRPS) following a distal radius fracture. The study is a synthesis of the four primary studies that examine this issue. These studies have been previously examined in the meta-analysis literature. The incidence of CRPS is lower in patients treated with the vitamin C protocol compared with the control. The significance of the difference varies from P = .02 to P = .13. Our analysis points to the fact that the relative efficacy of vitamin C has decreased over the past 15 years (P < .001). In 2014, the incidence of CRPS in the vitamin C cohort is not statistically different from the incidence in the control group (P = .76). Vitamin C has lost its relative efficacy.
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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: 32] [Impact Index Per Article: 6.4] [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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Hodel S, Schraner C, Oehme F, van Leeuwen R, Link BC, Babst R, Beeres FJP. Factors predicting adverse outcome in complete intra-articular distal radius fractures. Eur J Trauma Emerg Surg 2019; 46:1413-1419. [PMID: 30820598 DOI: 10.1007/s00068-019-01102-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/25/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine risk factors associated with adverse functional and radiological outcome in complete intra-articular distal radius fractures (AO 23 C2-3) with a minimum follow-up of 1 year. METHODS Retrospective case series of 87 consecutive patients with a complete intra-articular distal radius fracture (AO/OTA 23 C2-3) and a minimum follow-up of 1 year between 2012 and 2016. Risk factors for adverse clinical [using the Patient-Rated Wrist Evaluation (PRWE) score] and radiological outcome (positive ulnar variance 1 year postoperative) were analysed in a linear regression model. RESULTS PRWE scored a median of 4.5 points (range 0-72.5) after a median follow-up of 31 months (range 12-70 months). A concomitant polytrauma was associated with a worse PRWE (β = 23.34, p < 0.01) and was also significantly associated with the use of a temporary external fixator (χ2 = 11.93; p < 0.01) and high-energy trauma (χ2 = 19.39; p < 0.01). Radiological outcome measures 1 year postoperative did not correlate with clinical outcome measures. CONCLUSION This cohort of complete intra-articular distal radius fractures (AO/OTA 23 C2-3) shows a good clinical outcome at medium-term follow-up independent of the radiological outcome. A concomitant polytrauma was associated with worse functional outcome and a higher complication rate. This is most likely due to the associated injury severity. These factors help the treating physician in decision-making and informing patients when treating displaced intra-articular radius fractures.
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Affiliation(s)
- Sandro Hodel
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland.
| | - Christian Schraner
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
| | - Florian Oehme
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
| | - Robbert van Leeuwen
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, 6000, Lucerne, Switzerland
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Pecoraro L, Martini L, Antoniazzi F, Piacentini G, Pietrobelli A. Vitamin C: should daily administration keep the paediatrician away? Int J Food Sci Nutr 2018; 70:513-517. [PMID: 30513006 DOI: 10.1080/09637486.2018.1540557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Vitamin C is an organic compound that is almost ubiquitous in the daily diet of individuals. There are clear indications of supplementation when secondary deficiency is detected related with reduced dietary intake or reduced absorption. On the other hand, indications for supplementation concerning an increased need are controversial. Several authors have studied the role of vitamin C as an adjuvant in the treatment of diseases that may affect children and adolescents. These diseases affect all organs and systems: specifically, vitamin C supplementation could play a role in respiratory, neurological, psychiatric, oncohematological, nephrological, ophthalmological and nutritional disorders. In paediatric age, a significant benefit of vitamin C supplementation has been observed in depressive pathology, iron-deficiency anaemia and chronic renal failure related to haemodialysis. No evidence was found with vitamin C supplementation on mortality, cognitive performance, quality of life, eye diseases, infections, cardiovascular diseases and tumours. This evidence may be related to the fact that in developed countries, vitamin C is almost ubiquitous in the daily diet of each individual. In conclusion, studies on non-industrialised populations in which there could be a real benefit from such supplementation, have yet to be conducted.
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Affiliation(s)
- Luca Pecoraro
- a Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics , University of Verona , Verona , Italy
| | - Lucia Martini
- a Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics , University of Verona , Verona , Italy
| | - Franco Antoniazzi
- a Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics , University of Verona , Verona , Italy
| | - Giorgio Piacentini
- a Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics , University of Verona , Verona , Italy
| | - Angelo Pietrobelli
- a Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics , University of Verona , Verona , Italy.,b Pennington Biomedical Research Center , Baton Rouge , LA , USA
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Alter TH, Ilyas AM. Complications Associated with Volar Locking Plate Fixation of Distal Radial Fractures. JBJS Rev 2018; 6:e7. [DOI: 10.2106/jbjs.rvw.18.00004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Chaitanya NC, Muthukrishnan A, Krishnaprasad CMS, Sanjuprasanna G, Pillay P, Mounika B. An Insight and Update on the Analgesic Properties of Vitamin C. J Pharm Bioallied Sci 2018; 10:119-125. [PMID: 30237682 PMCID: PMC6142887 DOI: 10.4103/jpbs.jpbs_12_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Pain is an unpleasant subjective feeling having implications on both physical and mental realm. Multiple dimensions of pain involving behavioral, spiritual, emotional, and cognitive changes have been studied and pathways elucidated. It is stressed that the nature in which pain is modulated and perceived at a higher center is a complex phenomenon. One of the main goals of pain modulation is to modify pain to a more tolerable level, rather than its complete eradication. Different pain management interventions were tried but have effects that are more adverse. Till date, the only reliable pain blockers are analgesics and anti-inflammatory drugs in the form of opioids and non-opioids. Despite this, most of the drugs are ineffective at various levels, furthermore, adding to complications. Thus, there is an urgent need for effective intervention with minimal side effects. Ascorbic acid, popularly known as vitamin C, has shown to exhibit promising analgesic properties. The literature is sparse with the usage of the drug in various forms of pain. This review focuses on the dynamics and kinetics of vitamin C and its usage in various forms of pain. With minimal adverse effects, the drug is shown to perform well in different types of pain disorders, thus paving way for alternative interventional agent for pain management.
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Affiliation(s)
- Nallan Csk Chaitanya
- Department of Oral Medicine and Radiology, Research Scholar of Saveetha university, Saveetha University, Thandalam, India
| | - Arvind Muthukrishnan
- Department of Oral Medicine and Radiology, Saveetha Dental College, Chennai, Tamil Nadu, India
| | - C M S Krishnaprasad
- Department of Orthodontics and Dentofacial Orthopedics, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
| | - Gali Sanjuprasanna
- Department of Oral Medicine and Radiology, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
| | - Poojaragini Pillay
- Department of Oral Medicine and Radiology, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
| | - Balmoori Mounika
- Department of Oral Medicine and Radiology, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
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Carr AC, McCall C. The role of vitamin C in the treatment of pain: new insights. J Transl Med 2017; 15:77. [PMID: 28410599 PMCID: PMC5391567 DOI: 10.1186/s12967-017-1179-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 04/05/2017] [Indexed: 02/07/2023] Open
Abstract
The vitamin C deficiency disease scurvy is characterised by musculoskeletal pain and recent epidemiological evidence has indicated an association between suboptimal vitamin C status and spinal pain. Furthermore, accumulating evidence indicates that vitamin C administration can exhibit analgesic properties in some clinical conditions. The prevalence of hypovitaminosis C and vitamin C deficiency is high in various patient groups, such as surgical/trauma, infectious diseases and cancer patients. A number of recent clinical studies have shown that vitamin C administration to patients with chronic regional pain syndrome decreases their symptoms. Acute herpetic and post-herpetic neuralgia is also diminished with high dose vitamin C administration. Furthermore, cancer-related pain is decreased with high dose vitamin C, contributing to enhanced patient quality of life. A number of mechanisms have been proposed for vitamin C’s analgesic properties. Herein we propose a novel analgesic mechanism for vitamin C; as a cofactor for the biosynthesis of amidated opioid peptides. It is well established that vitamin C participates in the amidation of peptides, through acting as a cofactor for peptidyl-glycine α-amidating monooxygenase, the only enzyme known to amidate the carboxy terminal residue of neuropeptides and peptide hormones. Support for our proposed mechanism comes from studies which show a decreased requirement for opioid analgesics in surgical and cancer patients administered high dose vitamin C. Overall, vitamin C appears to be a safe and effective adjunctive therapy for acute and chronic pain relief in specific patient groups.
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Affiliation(s)
- Anitra C Carr
- Department of Pathology, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand.
| | - Cate McCall
- Centre for Postgraduate Nursing Studies, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand
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