Treatment of reflex sympathetic dystrophy of the hand with an active "stress loading" program

Refractory CRPS pain treated with psilocybin: A case report

Psilocybin shows promise as a treatment for CRPS, offering significant pain relief and functional improvement in a patient with refractory symptoms. This case highlights the need for further research into psilocybin's efficacy and optimal dosing for chronic pain management.

Remission of hypersensitivity by simple weight load stimuli in a complex regional pain syndrome mouse model

Painful sensitivity of the hand or foot are the most common and debilitating symptoms of complex regional pain syndrome (CRPS). Physical therapy is standard treatment for CRPS, but evidence supporting its efficacy is minimal and it can be essentially impossible for CRPS patients to actively exercise the painful limb. Using the well-characterized distal tibial fracture CRPS mouse model, we compared the therapeutic effects of several weeks of daily hindlimb loading versus rotarod walking exercise. The effects of loading and exercise were evaluated by weekly testing of hind-paw withdrawal thresholds to von Frey fibers and radiant heat, as well as measurements of paw and ankle edema. At 6 weeks after fracture, the mice were killed and the ipsilateral femur, spinal cord and L4/5 dorsal root ganglia, and hind-paw skin collected for PCR assays and paw skin Immunohistochemistry evaluation. Hindlimb loading reduced hind-paw von Frey allodynia and heat hyperalgesia and edema within a week and these effects persisted for at least a week after discontinuing treatment. These therapeutic effects of loading exceeded the beneficial effects observed with rotarod walking exercise in fracture mice. Levels of nerve growth factor and transient receptor potential vanilloid 1 (TRPV1) immunostaining in the hind-paw skin were increased at 6 weeks after fracture, and both loading and exercise treatment reduced increases. Collectively, these results suggest that loading may be an effective and possibly curative treatment in CRPS patients with sensitivity in the affected limb.

Effect and mechanisms of exercise for complex regional pain syndrome

Complex regional pain syndrome characterized by severe pain and dysfunction seriously affects patients' quality of life. Exercise therapy is gaining attention because it can effectively relieve pain and improve physical function. Based on the previous studies, this article summarized the effectiveness and underlying mechanisms of exercise interventions for complex regional pain syndrome, and described the gradual multistage exercise program. Exercises suitable for patients with complex regional pain syndrome mainly include graded motor imagery, mirror therapy, progressive stress loading training, and progressive aerobic training. In general, exercise training for patients with complex regional pain syndrome not only alleviates pain but also improves physical function and positive mental status. The underlying mechanisms of exercise interventions for complex regional pain syndrome include the remodeling of abnormal central and peripheral nervous system, the regulation of vasodilation and adrenaline levels, the release of endogenous opioids, and the increased anti-inflammatory cytokines. This article provided a clear explanation and summary of the research on exercise for complex regional pain syndrome. In the future, more high-quality studies with sufficient sample sizes may provide more exercise regimens and better evidence of efficacy.

Harmful or safe? Exposure and pain provocation during physiotherapy of complex regional pain syndrome I: a narrative review

BACKGROUND

Complex regional pain syndrome (CRPS) is a clinical diagnosis and an umbrella term for a heterogeneous group of states associated with pain disproportionate to any inciting event, together with a number of signs and symptoms that are manifested mainly in the limbs. There are often concerns among clinicians and patients about the potential harms caused by pain provocation during physiotherapy of CRPS, even though clinical guidelines de-emphasize pain-contingency.

OBJECTIVE

The objective of this narrative review is to summarize current evidence regarding potential harms due to pain provocation during so-called exposure-based therapies in individuals with CRPS.

METHODS

Six studies evaluating exposure-based approach were included (n= 6).

RESULTS

Although only one included study focused primarily on safety and in the rest of the included studies the reporting of harms was insufficient and therefore our certainty in evidence is very low, taken together with outcome measures, available data does not point to any long-term deterioration in symptoms or function, or any major harms associated with pain provocation during physiotherapy of CRPS.

CONCLUSION

There is a great need for higher-quality studies to determine which therapeutic approach is the most appropriate for whom and to evaluate the risks and benefits of different approaches in more detail.

Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition

There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for "better research." This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of "elder statesman" researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the "Budapest" criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient.

Post-arthrolysis rehabilitation in a patient with wrist stiffness secondary to distal radio-ulnar fracture: A case report

BACKGROUND

Arthrolysis is usually performed when stiffness has a disabling effect on quality of life and in cases where physiotherapy has not been effective. This report describes one patient with a chronic stiff wrist who underwent open arthrolysis. The purpose of this case report is to describe the rehabilitation following arthrolysis, in order to illustrate the effects of intensive physiotherapy for this patient.

CASE DESCRIPTION

A 54-year-old woman with chronic wrist stiffness secondary to a radio-ulnar fracture was described. The patient presented severe pain and unsatisfactory wrist range of motion and muscle strength almost 2 years after the traumatic event.

INTERVENTION

Post-arthrolysis rehabilitation was based on edema control, manual therapy, transcutaneous electrical nerve stimulation (TENS), static splinting and strengthening exercises. In addition, graded motor imagery and proprioceptive rehabilitation were included to address impaired motor control. Outcome measures of passive range of motion (PROM), active range of motion (AROM), grip and pinch strength, numeric rating scale (NRS), disability of the arm, shoulder and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) were recorded.

CONCLUSIONS

The outcomes of this case report suggest that arthrolysis combined with immediate and intensive physiotherapy were a suitable option for the treatment of post-traumatic wrist stiffness in this patient. The passive motion measured intraoperatively was maintained, while pain, functional active motion and strength were improved allowing for social reintegration.

Pain Phenotypes in Rare Musculoskeletal and Neuromuscular Diseases

For patients diagnosed with a rare musculoskeletal or neuromuscular disease, pain may transition from acute to chronic; the latter yielding additional challenges for both patients and care providers. We assessed the present understanding of pain across a set of ten rare, noninfectious, noncancerous disorders; Osteogenesis Imperfecta, Ehlers-Danlos Syndrome, Achondroplasia, Fibrodysplasia Ossificans Progressiva, Fibrous Dysplasia/McCune-Albright Syndrome, Complex Regional Pain Syndrome, Duchenne Muscular Dystrophy, Infantile- and Late-Onset Pompe disease, Charcot-Marie-Tooth Disease, and Amyotrophic Lateral Sclerosis. Through the integration of natural history, cross-sectional, retrospective, clinical trials, & case studies we described pathologic and genetic factors, pain sources, phenotypes, and lastly, existing therapeutic approaches. We highlight that while rare diseases possess distinct core pathologic features, there are a number of shared pain phenotypes and mechanisms that may be prospectively examined and therapeutically targeted in a parallel manner. Finally, we describe clinical and research approaches that may facilitate more accurate diagnosis, monitoring, and treatment of pain as well as elucidation of the evolving nature of pain phenotypes in rare musculoskeletal or neuromuscular illnesses.

Complex Regional Pain Syndrome: Current Diagnostic and Treatment Considerations

Complex Regional Pain Syndrome is a severe complication of extremity fracture or other injury. Patients who develop this show marked hyperalgesia and allodynia, altered vasomotor, sudomotor and trophic changes. The condition affects women more than men and is most common in those between the ages of 50 and 70 years but can be seen in younger athletes. The diagnosis is made clinically, and treatment is directed at functional recovery using medications, occupational and physical therapy, and psychological interventions. Prognosis for complete recovery is variable and unpredictable.

Mechanism-specific rehabilitation management of complex regional pain syndrome: Proposed recommendations from evidence synthesis

STUDY DESIGN

Narrative review.

INTRODUCTION

There are a variety of treatments with demonstrated effectiveness for the management of complex regional pain syndrome (CRPS). However given the variability in symptom presentation in this population, therapists may be unsure what treatments would be most effective for individual clients.

PURPOSE OF THE STUDY

To present a brief synthesis of the literature and propose a rehabilitation version of a mechanism-specific management algorithm to guide personalized treatment of CRPS.

METHODS

A systematic search of the literature was conducted to identify all randomized controlled trials, systematic reviews, and clinical practice guidelines addressing rehabilitation of CRPS. Results were reviewed independently by 2 reviewers and final selection of articles was reached by consensus, Data was extracted using standardized forms, and a single rater gave quality ratings. Both reviewers then used the extracted data to present a synthesis of the evidence categorized by the proposed mechanisms of effect.

RESULTS

A total of 111 articles were retrieved and reviewed for inclusion; 49 were selected for data extraction. A synthesis of the key recommendations was compiled into a rehabilitation-specific version of the mechanism-based management algorithm proposed by Gierthmühlen et al (2014).

CONCLUSIONS

Consideration of mechanism-appropriate rehabilitation interventions may assist therapists to select the most appropriate and effective treatments from the body of evidence supporting rehabilitation of CRPS.

Rehabilitation of distal radioulnar joint instability

Distal radioulnar joint (DRUJ) instabilities are common and often combined with other injuries of the interosseous membrane and/or the proximal radioulnar joint. Once they are diagnosed and the treatment is chosen, physiotherapists have limited choices due to the lack of validated protocols. The benefits of proprioception and neuromuscular rehabilitation have been brought to light for the shoulder, knee and ankle joints, among others. However, no program has been described for the DRUJ. The purpose of this article is to study the muscular elements responsible for active DRUJ stability, and to propose a proprioceptive rehabilitation program suited to this condition.

Rehabilitation strategies for wrist sensorimotor control impairment: From theory to practice

This clinical review discusses the organization, neuroanatomy, assessment, clinical relevance, and rehabilitation of sensorimotor (SM) control impairment after wrist trauma. The wrist SM control system encompasses complex SM pathways that control normal wrist active range of motion and mediate wrist joint neuromuscular stability for maintaining joint function. Among various known assessment methods of wrist SM control impairment, the active wrist joint position sense test is determined to be a clinically meaningful and responsive measure for wrist SM control impairment after wrist fracture. Wrist trauma may involve significant soft tissue injury (ie, skin, ligament, muscle), which could disrupt the generation and transmission of adequate proprioceptive input from wrist mechanoreceptors, thus leading to significant joint SM impairment. Various clinical examples of wrist trauma (eg, distal radius fracture, scapholunate joint injury) along with known prognostic factors (eg, pain) that may influence wrist SM control impairment recovery are discussed to illustrate this point. This article proposes promising rehabilitation strategies toward restoring wrist joint conscious and unconscious SM control impairments, integrating current research evidence with clinical practice. These strategies require more rigorous evaluation in clinical trials.

LEVEL OF EVIDENCE

5.

Short- and long-term results of an inpatient programme to manage Complex Regional Pain Syndrome in children and adolescents

The aim of this retrospective study was to determine whether an inpatient approach and the use of regional anaesthesia techniques can accelerate the recovery to normal functions in children with Complex Regional Pain Syndrome (CRPS). This study looked at the data of patients admitted to the rehabilitation unit with a diagnosis of CRPS from January 2010 to April 2015. Variables such as hospital stay, medications administered, regional anaesthesia procedures, changes in functional status prior to treatment and at the time of discharge, psychological evaluation and diagnosis were evaluated. A total of 31 patients (21 females and 10 males) were admitted with a diagnosis of CRPS 1 and 2. In all, 97% of the patients received a peripheral or central nerve catheter for an average of 4 days with pain scores of Verbal Numeric Scale (VNS) score = 1.0 ± 0.7 and an average length of hospital stay of 8.2 ± 2.6 days. The modified Functional Independence Measure for Children (WeeFIM) scores and Canadian Association of Occupational Therapists tests significantly improved at the time of hospital discharge, as well as their pain scores, which decreased from 8.2 ± 2 to 1.6 ± 3. In conclusion, these data suggest that the use of regional anaesthesia techniques and an intensive inpatient rehabilitation programme could accelerate the recovery of children with CRPS.

Hyperalgesia in an immobilized rat hindlimb: effect of treadmill exercise using non-immobilized limbs

Cast immobilization of limbs causes hyperalgesia, which is a decline of the threshold of mechanical and thermal mechanical stimuli. The immobilization-induced hyperalgesia (IIH) can disturb rehabilitation and activities of daily living in patients with orthopedic disorders. However, it is unclear what therapeutic and preventive approaches can be used to alleviate IIH. Exercise that activates the descending pain modulatory system may be effective for IIH. The purpose of this study was to investigate the effects of treadmill exercise during the immobilization period, using the non-immobilized limbs, on IIH. Thirty-six 8-week-old Wistar rats were randomly divided into (1) control, (2) immobilization (Im), and (3) immobilization and treadmill exercise (Im+Ex) groups. In the Im and Im+Ex groups, the right ankle joints of each rat were immobilized in full plantar flexion with a plaster cast for an 8-week period. In the Im+Ex group, treadmill exercise (15 m/min, 30 min/day, 5 days/week) was administered during the immobilization period while the right hindlimb was kept immobilized. Mechanical hyperalgesia was measured using von Frey filaments every week. To investigate possible activation of the descending pain modulatory system, beta-endorphin expression levels in hypothalamus and midbrain periaqueductal gray were analyzed. Although IIH clearly occurred in the Im group, the hyperalgesia was partially but significantly reduced in the Im+Ex group. Beta-endorphin, which is one of the endogenous opioids, was selectively increased in the hypothalamus and midbrain periaqueductal gray of the Im+Ex group. Our data suggest that treadmill running using the non-immobilized limbs reduces the amount of hyperalgesia induced in the immobilized limb even if it is not freed. This ameliorating effect might be due to the descending pain modulatory system being activated by upregulation of beta-endorphin in the brain.

Informed Decision-Making Regarding Amputation for Complex Regional Pain Syndrome Type I

BACKGROUND

Literature on complex regional pain syndrome type I (CRPS-I) discussing the decision to amputate or not, the level of amputation, or the timing of the amputation is scarce. We evaluated informed decision-making regarding amputation for CRPS-I.

METHODS

We describe our findings in a retrospective study of the decision-making process of thirty-six patients who underwent amputation for CRPS-I at our university medical center from 2000 to 2012. Additionally, we present the incidents preceding the CRPS-I, the reasons for and the levels of the amputation, and the outcomes after the amputations.

RESULTS

Team members and the patient decided together whether or not to amputate and the level of amputation. Issues such as level of pain or allodynia, infection, desired length of the residual limb, joint range of motion, strength of all extremities, ability to use walking aids, and psychological "green, yellow, and red flags" were weighed in this process. There were no complications during the amputation surgery, a 22% rate of complications (infection in all but one patient) immediately postoperatively (reamputation not required), a 72% rate of phantom pain immediately after or within the first three months after the amputation, and a 77% rate of phantom pain more than one year after the amputation.

CONCLUSIONS

Informed decision-making regarding amputation for CRPS-I remains a complex process for which little evidence is available to support patient choices; patient-specific outcomes are not predictable. However, amputation should not be ignored as a treatment option for long-standing therapy-resistant CRPS-I.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Complex regional pain syndrome: From diagnosis to rehabilitation

Complex regional pain syndrome (CRPS) is a debilitating pathology characterised by intense chronic pain associated with vasomotor, sensory and motor dysfunction of the affected limb. Although the pathophysiology of CRPS is not fully understood, it is recognised that inflammatory processes and autonomic dysfunction are involved. These processes are associated with peripheral and central sensitisation as well as changes in brain structure and function, and are reflected in the clinical presentation of CRPS. CRPS management requires an interdisciplinary team and requires the therapeutic approach to be individualised. With regard to pharmacological treatment, bisphosphonates, corticosteroids, ketamine and anticonvulsants have been demonstrated to be effective for CRPS management. Psychotherapy, including cognitive-behavioural therapy, has produced promising results but more studies are needed to confirm its efficacy. Among rehabilitation interventions, there is evidence of the efficacy of physiotherapy and occupational therapy in diminishing CRPS symptoms and achieving a higher level of functioning. In this regard, the rehabilitation modality that seems the most promising according to the actual literature is graded motor imagery, which can help to reverse the maladaptive neuroplasticity occurring in CRPS.

Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition

OBJECTIVE

This is the fourth edition of diagnostic and treatment guidelines for complex regional pain syndrome (CRPS; aka reflex sympathetic dystrophy).

METHODS

Expert practitioners in each discipline traditionally utilized in the treatment of CRPS systematically reviewed the available and relevant literature; due to the paucity of levels 1 and 2 studies, less rigorous, preliminary research reports were included. The literature review was supplemented with knowledge gained from extensive empirical clinical experience, particularly in areas where high-quality evidence to guide therapy is lacking.

RESULTS

The research quality, clinical relevance, and "state of the art" of diagnostic criteria or treatment modalities are discussed, sometimes in considerable detail with an eye to the expert practitioner in each therapeutic area. Levels of evidence are mentioned when available, so that the practitioner can better assess and analyze the modality under discussion, and if desired, to personally consider the citations. Tables provide details on characteristics of studies in different subject domains described in the literature.

CONCLUSIONS

In the humanitarian spirit of making the most of all current thinking in the area, balanced by a careful case-by-case analysis of the risk/cost vs benefit analysis, the authors offer these "practical" guidelines.

Complex [corrected] regional pain syndrome: what specialized rehabilitation services do patients require?

Complex [corrected] regional pain syndrome (CRPS) is a complex disorder, the optimal treatment of which requires an interdisciplinary approach encompassing medical, interventional, psychological, and rehabilitation services that emphasize the role of physical and occupational therapies. The central focus of treatment is the restoration of function, utilizing a systematic, coordinated, and progressive set of therapeutic strategies. The poorly delineated pathophysiology and variable course of CRPS suggest that individualized strategies are required for optimal management, but also mean that carefully controlled trials of physiotherapy are difficult to conduct. This article presents a brief review of the nature and pathophysiology of CRPS, the medical and psychological approaches that have been found to be effective, and a review of the current trends in rehabilitation.

The effectiveness and cost evaluation of pain exposure physical therapy and conventional therapy in patients with complex regional pain syndrome type 1. Rationale and design of a randomized controlled trial

BACKGROUND

Pain Exposure Physical Therapy is a new treatment option for patients with Complex Regional Pain Syndrome type 1. It has been evaluated in retrospective as well as in prospective studies and proven to be safe and possibly effective. This indicates that Pain Exposure Physical Therapy is now ready for clinical evaluation. The results of an earlier performed pilot study with an n = 1 design, in which 20 patients with Complex Regional Pain Syndrome type 1 were treated with Pain Exposure Physical Therapy, were used for the design and power calculation of the present study.After completion and evaluation of this phase III study, a multi-centre implementation study will be conducted.The aim of this study is to determine whether Pain Exposure Physical Therapy can improve functional outcomes in patients with Complex Regional Pain Syndrome type 1.

METHODS/DESIGN

This study is designed as a single-blinded, randomized clinical trial. 62 patients will be randomized with a follow-up of 9 months to demonstrate the expected treatment effect. Complex Regional Pain Syndrome type 1 is diagnosed in accordance with the Bruehl/International Association for the Study of Pain criteria. Conventional therapy in accordance with the Dutch guideline will be compared with Pain Exposure Physical Therapy. Primary outcome measure is the Impairment level SumScore, restricted version.

DISCUSSION

This is the first randomized controlled study with single blinding that has ever been planned in patients with Complex Regional Pain Syndrome type 1 and does not focus on a single aspect of the pain syndrome but compares treatment strategies based on completely different pathophysiological and cognitive theories.

Safety of "pain exposure" physical therapy in patients with complex regional pain syndrome type 1

"Pain exposure" physical therapy (PEPT) is a new treatment for patients with complex regional pain syndrome type 1 (CRPS-1) that consists of a progressive-loading exercise program and management of pain-avoidance behavior without the use of specific CRPS-1 medication or analgesics. The aim of this study was to investigate primarily whether PEPT could be applied safely in patients with CRPS-1. Twenty patients with CRPS-1 were consecutively enrolled in the study after giving informed consent. The diagnosis of CRPS-1 was defined using the Bruehl and Harden/IASP diagnostic criteria. CRPS-1 was diagnosed between 3 and 18 months after the inciting event (trauma). According to a multiple single-case design (baseline [A1], treatment [B], follow-up [A2]), multiple baseline and follow-up measurements were performed to evaluate changes in CRPS signs and symptoms and to assess functional parameters. When comparing the baseline with the follow-up phase, patients improved significantly with respect to pain on the visual analogue scale (57%), pain intensity (48%), muscle strength (52%), arm/shoulder/hand disability (36%), 10-meter walking speed (29%), pain disability index (60%), kinesiophobia (18%), and the domains of perceived health change in the SF-36 survey (269%). Three patients initially showed increased vegetative signs but improved in all other CRPS parameters and showed good functional recovery at follow-up. We conclude that PEPT is a safe and effective treatment for patients with CRPS-1. A progressive-loading exercise program and management of pain-avoidance behavior without the use of specific medication ("pain exposure" physical therapy) is safe and effective for patients with complex regional pain syndrome.

Validation of proposed diagnostic criteria (the "Budapest Criteria") for Complex Regional Pain Syndrome

Current IASP diagnostic criteria for CRPS have low specificity, potentially leading to overdiagnosis. This validation study compared current IASP diagnostic criteria for CRPS to proposed new diagnostic criteria (the "Budapest Criteria") regarding diagnostic accuracy. Structured evaluations of CRPS-related signs and symptoms were conducted in 113 CRPS-I and 47 non-CRPS neuropathic pain patients. Discriminating between diagnostic groups based on presence of signs or symptoms meeting IASP criteria showed high diagnostic sensitivity (1.00), but poor specificity (0.41), replicating prior work. In comparison, the Budapest clinical criteria retained the exceptional sensitivity of the IASP criteria (0.99), but greatly improved upon the specificity (0.68). As designed, the Budapest research criteria resulted in the highest specificity (0.79), again replicating prior work. Analyses indicated that inclusion of four distinct CRPS components in the Budapest Criteria contributed to enhanced specificity. Overall, results corroborate the validity of the Budapest Criteria and suggest they improve upon existing IASP diagnostic criteria for CRPS.

Pain exposure physical therapy may be a safe and effective treatment for longstanding complex regional pain syndrome type 1: a case series

OBJECTIVE

To determine if treatment of longstanding complex regional pain syndrome type 1, focusing on functional improvement only while neglecting pain, results in clinical improvement of this syndrome.

DESIGN

Prospective description of a case series of 106 patients.

SETTING

Outpatient clinic for rehabilitation.

INTERVENTIONS

Physical therapy of the affected limb directed at a functional improvement only while neglecting the pain, was performed following an extensive explanation. Normal use of the limb between the treatments was encouraged despite pain. A maximum of five of these sessions were performed in three months.

MEASURES

Radboud Skills Test was used to monitor functional improvement of the arms. Speed and walking distance was used as the measure of outcome for the legs.

RESULTS

The function of the affected arm or leg improved in 95 patients. Full functional recovery was experienced in 49 (46%) of them. A reduction in pain presented in 75 patients. In 23 patients functional recovery was reached despite an increase in pain. Four patients stopped early due to pain increase.

CONCLUSIONS

Our results suggest that 'pain exposure physical therapy' is effective and safe for patients who are unresponsive to accepted standard therapies. Avoiding the use of a limb due to pain will result in loss of function. Forced usage of limbs restores the function, reverses these adaptive processes and leads to regain of control by practice with a reduction of pain in most cases.

Complex regional pain syndromes in children and adolescents

BACKGROUND

The purpose of the present paper was to assess efficiency of treatment and long-term functional outcome of complex regional pain syndromes (CRPS) in children who were treated in the chronic pain clinic at a major tertiary hospital in Israel.

METHODS

The files of 14 children with CRPS were analyzed retrospectively. Demographic data, initiating event, referring source, time needed for referral to pain clinic, clinical evaluation, treatment, recurrence and complications were recorded.

RESULTS

Fourteen children with CRPS types I and II were included in the study. Girls were affected in 71%. Lower extremities were affected in 57%. The median time from onset of symptoms to seeking medical help was 4.46 weeks (range 2-82 weeks). The median time to referral to pain clinic was 24.51 weeks (range 1.2-94). In 45% the referral source was the pediatrician. A total of 85.8% of patients were referred to various consultations before the pain clinic. Most children had reduced pain and improved function on non-invasive treatment approach. Invasive treatments were used in 28.5%. Full or partial recovery was accomplished in 93%. Recurrence was observed in 29%.

CONCLUSIONS

CRPS in children and adolescents is still underdiagnosed, although many of the epidemiologic features of pediatric CRPS are similar in different countries/cultures. Early recognition and management is the major factor in improving outcome and preventing resistant CRPS, but even children with delayed diagnosis still have a good outcome. The management of this disease by an experienced multidisciplinary team is recommended. Because psychosocial factors play an important role, it is recommended to provide psychological evaluation and cognitive behavioral treatment as soon as possible.

Does evidence support physiotherapy management of adult Complex Regional Pain Syndrome Type One? A systematic review

OBJECTIVE

To source and critically evaluate the evidence on the effectiveness of Physiotherapy to manage adult CRPS-1.

DESIGN

Systematic literature review.

METHODS

Electronic databases, conference proceedings, clinical guidelines and text books were searched for quantitative studies on CRPS-1 in adults where Physiotherapy was a sole or significant component of the intervention. Data were extracted according to predefined criteria by two independent reviewers. Methodological quality was assessed using the Critical Review Form.

RESULTS

The search strategy identified 1320 potential articles. Of these, 14 articles, representing 11 studies, met inclusion criteria. There were five randomised controlled trials, one comparative study and five case series. Methodological quality was dependent on study type, with randomised controlled trials being higher in quality. Physiotherapy treatments varied between studies and were often provided in combination with medical management. This did not allow for the 'stand-alone' value of Physiotherapy to be determined. Heterogeneity across the studies, with respect to participants, interventions evaluated and outcome measures used, prevented meta-analysis. Narrative synthesis of the results, based on effect size, found there was good to very good quality level II evidence that graded motor imagery is effective in reducing pain in adults with CRPS-1, irrespective of the outcome measure used. No evidence was found to support treatments frequently recommended in clinical guidelines, such as stress loading.

CONCLUSIONS

Graded motor imagery should be used to reduce pain in adult CRPS-1 patients. Further, the results of this review should be used to update CRPS-1 clinical guidelines.

Report of a focus group survey of current practice in the therapeutic treatment of Complex Regional Pain Syndrome in the United Kingdom

Complex Regional Pain Syndrome (CRPS) typically affects the hand following trauma. It is characterised by pain, altered sensation, motor disturbance, oedema, functional limitation and psychological disturbance. There is no definitive curative treatment for CRPS and controversy exists regarding the most effective combination of interventions for the treatment of this syndrome (Siddiqui et al 2001).

A study was commissioned in 2006 to explore the therapeutic interventions being implemented with patients with CRPS in the UK. Sixty therapists at the British Association of Hand Therapists annual conference consented to participate in focus group discussions. Categories were established to identify all therapeutic modalities currently used by participants. Therapists utilised the following therapeutic techniques: functional activity, exercise, education, support, sensory re-education, desensitisation, stress loading, pressure garments, mirror visual feedback, splints and psychological strategies, amongst others.

The identified interventions were then reviewed against evidence in the recent literature. There is insufficient evidence to support the use of a single set of multidisciplinary interventions (Stanton-Hicks et al 2002) to address the primary long-term goals of functional restoration and pain relief. This study has, however, highlighted that this is achieved through the treatment of individual symptoms, using multiple therapeutic interventions and algorithms in a multidisciplinary approach.

How effective is physiotherapy in the treatment of complex regional pain syndrome type I? A review of the literature

Complex regional pain syndrome (CRPS) is a debilitating pain disorder for which patients commonly receive physiotherapy. The objective of this literature review is to assess how effective physiotherapy is in the management of adult and childhood CRPS type I. An electronic literature search was performed of the databases AMED, Cinahl, Embase, Ovid Medline, Pubmed, PEDro and PsycINFO, from their inception to November 2004. Human subjects clinical trials, written in English, which could assist in answering the research question were included. Twenty-five (of 748) papers met the inclusion criteria and were reviewed. The review suggests that exercise, motor imagery and mirror feedback exercises, relaxation techniques, acupuncture, electroacupuncture, transcutaneous nerve stimulation and combined treatment programmes may help in the treatment of CRPS type I. However, since numerous methodological weaknesses (e.g. small sample sizes, not employing control groups, not evaluating findings against statistical tests) littered the limited literature, it was not possible to determine the effectiveness of individual treatments. Recommendations are made to develop the evidence base.

Treatment of complex regional pain syndrome: functional restoration

In this review, the authors discuss the development of consensus-based treatment guidelines in 1997. They also synthesize the recommendations of a closed workshop held in Budapest in late 2004 that reexamined these treatment guidelines and made further and more detailed recommendations. They explore and develop the rationale for making functional restoration the pivotal treatment algorithm in the management of complex regional pain syndrome, around which all other treatments, such as psychotherapy, drugs, and interventions, revolve. The authors discuss in detail the process of functional restoration and the modalities appropriate to accomplishing that--specifically, the role of the occupational therapist, physical therapist, recreational therapist, and vocational rehabilitation specialist. Medications, interventions, and psychotherapy will be covered in other sections of this series.

The Challenge to Manage Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome

The challenge to understand reflex sympathetic dystrophy/complex regional pain syndrome may require a better understanding of the complex relationship between the central and peripheral nervous systems. There is no comprehensive hypothesis that clearly explains the etiology and no uniformly successful treatment method. This brief summary of the challenge reviews some of what is known, hypothesizes a possible etiologic mechanism, and proposes 10 common-sense principles for management that recognizes the handicap of limited knowledge.

Friction of the gliding surface. Implications for tendon surgery and rehabilitation

Finger flexor tendon rehabilitation has come a long way, but further advances are possible. Ideally, a healing tendon should move, but under the minimum load necessary to achieve motion. It is possible to design suture repairs that minimize the friction between tendon and sheath while simultaneously maintaining adequate strength to provide a wide margin of safety during therapy. A looped, four-strand modified Kessler repair is a good example of this type of high-strength, low-friction repair. At the same time, rehabilitation methods can also be optimized. A new modified synergistic motion protocol is described in which wrist flexion and finger extension is alternated with wrist and metacarpophalangeal joint extension and finger interphalangeal joint flexion. Based on evidence from basic science studies, the authors hypothesize that this new protocol will deliver more effective proximal tension on the tendon repair than either passive flexion/active extension or synergistic protocols, and may be useful in patients who are not ready for, or are not reliable with, active motion or place and hold protocols. The scientific basis for these new methods is reviewed, and the concept of the "safe zone" for tendon loading, in which tendon motion occurs without gapping of the repair site, is developed.

Complex regional pain syndrome

As suggested by this article, considerable advances in clinical management and research have taken place during the past 20 years. Although mechanisms underlying the pain syndrome CRPS I and CRPS II remain far from one's understanding, glimpses of the pathophysiology are beginning to take shape. There is now strong evidence that these syndromes exemplify a complex neurologic disease involving the brain at several integrated levels. The changes that occur in CRPS I patients involve somatosensory, sympathetic, and somatomotor systems. The diagnostic criteria have helped to focus on aspects of these foregoing systems and whereas there is no specific laboratory test for CRPS, enough is now known about the pathophysiology to use the following tests: quantitative sensory testing (QST), autonomic testing that include quantitative sudomotor axon reflex test (QSART) for sweating abnormalities, the cold pressor test in conjunction with thermographic imaging to observe the vasoconstrictor response, and laser Doppler flowmetry to monitor background vasomotor control. Recognition of a motor disorder requires accurate documentation and may be a component of the diagnostic criteria in the future. Until a better understanding of mechanistic overtones that would help to put in place mechanism-based therapeutic strategies, current management is built around a rehabilitation model. For this to be successful, as described in the foregoing pages, different non-interventional and interventional modalities are applied in a time-restricted manner to facilitate those modalities that favor progress in the treatment algorithm. As has been described, it is important when using physiotherapeutic maneuvers to minimize joint movement in the affected region to reduce the mechanorecpetor barrage and its increase in perceived pain to encourage and maintain a patient's compliance with their rehabilitation. Finally, of greater significance is the understanding that sympatholysis per se is not a "diagnostic" test for CRPS, but rather a useful procedure that may facilitate treatment for pain that is sympathetically maintained.

The treatment of complex regional pain syndrome (CRPS) involving upper extremity with continuous sensory analgesia

Continuous sensory analgesia of brachial plexus (CSA BP) was only occasionally reported to have been used in the treatment of CRPS. In the past four years, we have treated 21 patients with a working diagnosis of CRPS. The treatment was instituted one to six months after inciting injury. All patients were admitted to hospital. In the first two days, the therapy consisted of elevation, cryotherapy, and active exercises. Five patients responded well to this initial physiotherapy (5/21). In 16 cases, no evident improvement was observed and CSA BP was introduced. At follow-up (3-36 months), the results were: 13/16 (81%) had at least good results (excellent 2, good without any sequelae 5, good with sequelae of initial injury 6, and poor 3). The results were judged as follows: excellent (completely normal hand); good (only temporary pain up to 2 on a 0-10 numeric rating scale; no signs of dysfunction of sympathetic nervous system; ROM of wrist over 50% of normal hand; ROM of fingers excellent or good; and the strength of hand grasp and key pinch over 50% of normal hand measured with dynamometer) and if any of the former criteria was missing, the result was defined as poor.

Complex regional pain syndrome: a review of evidence-supported treatment options

Complex regional pain syndrome consists of pain and other symptoms that are unexpectedly severe or protracted after an injury. In type II complex regional pain syndrome, major nerve injury, often with motor involvement, is the cause; in complex regional pain syndrome I, the culprit is a more occult lesion, often a lesser injury that predominantly affects unmyelinated axons. In florid form, disturbances of vasoregulation (eg, edema) and abnormalities of other innervated tissues (skin, muscle, bone) can appear. Because of these various symptoms and the difficulty in identifying causative lesions, complex regional pain syndrome is difficult to treat or cure. Complex regional pain syndrome has not been systematically investigated; there are few controlled treatment trials for established complex regional pain syndrome. This article reviews the existing studies (even if preliminary) to direct clinicians toward the best options. Treatments for other neuropathic pain syndromes that may be efficacious for complex regional pain syndrome also are discussed. Some common treatments (eg, local anesthetic blockade of sympathetic ganglia) are not supported by the aggregate of published studies and should be used less frequently. Other treatments with encouraging published results (eg, neural stimulators) are not used often enough. We hope to encourage clinicians to rely more on evidence-supported treatments for complex regional pain syndrome.

Scaphotrapeziotrapezoid arthrodesis: a follow-up study

PURPOSE

The purpose of this study was to review the results of 800 scaphotrapeziotrapezoid fusions performed over a 27-year period.

METHODS

The patients were evaluated for postoperative range of motion, grip and pinch strength, pain, return to work, arthritis, and complications.

RESULTS

The overall range of motion was 70% to 80% of the nonoperated side and strength was 69% to 89%. Of the patients 88% returned to previous employment. Arthritis developed in 1.8% of the patients. The overall complication rate was 13.4%.

CONCLUSIONS

Scaphotrapeziotrapezoid fusion is a viable treatment option especially for a high-functional-demand young population with significant wrist pathology. Complications, specifically nonunion, can be minimized with careful technique.

Functional improvement after physiotherapy with a continuous infusion of local anaesthetics in patients with complex regional pain syndrome

Three patients were referred to our pain clinic with evidence of complex regional pain syndrome in their extremities. Two presented at the atrophic stage with joint contractures. Multiple analgesics had been prescribed without long-lasting relief. Physiotherapy was required to improve physical activity but was severely limited by pain. We instituted local anaesthetic infusion with the possibility of self-supplementation to facilitate physiotherapy; two via brachial plexus catheters for hand pain and one via epidural catheter for knee pain. Although their resultant pain scores were variable after cessation of local anaesthetic infusion, all the affected joints exhibited marked improvement in range of movement. We propose that this technique is a useful option for patients in all stages of complex regional pain syndrome where the emphasis is now directed toward functional improvement.

Lunotriquetral arthrodesis using cancellous bone graft

Previous reports of lunotriquetral arthrodesis suggest relatively low rates of primary fusion without the use of permanent fixation and/or prolonged immobilization. We performed 26 lunotriquetral arthrodeses in 24 patients with a technique using cancellous bone graft to fill a biconcave space created in the adjoining bones with parallel K-wire fixation. The indications included symptomatic lunotriquetral instability and degenerative arthritis. All patients received conservative treatment before surgery. Primary fusion was achieved in all wrists in an average of 50 days. Postoperative wrist flexion/extension averaged 77%/80% of unaffected sides. Radial/ulnar deviation averaged 95%/91% of unaffected sides. Pain relief was good or very good in 83%. Eight-eight percent returned to the workforce. This study shows reliable, effective results with a technique that adheres to the principles of intercarpal arthrodesis and avoids permanent internal fixation.

One thousand intercarpal arthrodeses

Limited wrist arthrodesis is a useful method for treating specific carpal disorders that maximizes residual wrist motion and strength while eliminating pain. Selective fusion of specific carpal units can be used in degenerative arthritis, rotary subluxation of the scaphoid, midcarpal instability, scaphoid nonunion, Kienbock's disease, and congenital synchondrosis or partial fusion of specific carpal joints. This report presents our experience with more than 1000 limited wrist arthrodeses, and provides a review of the indications and technical considerations for specific intercarpal fusions, and subsequent results. To date this is the largest series of intercarpal arthrodeses and the study has demonstrated that these techniques are reliable and effective in dealing with a wide range of wrist disorders.

New developments in rehabilitation of neuropathic pain syndromes

The common medical treatments of neuropathic pain, medication and nerve blocks, are often only partially effective in providing significant and long-term pain relief. Patients suffering chronic pain often fall prey to associated emotional suffering, functional impairment, and difficulties in multiple areas of their lives, including family disruption, social withdrawal, and vocational disability. An interdisciplinary approach to pain management draws on the skills of physical and occupational therapists, pain psychologists, biofeedback specialists, and vocational counselors. It focuses on both pain management and functional restoration, and should be considered standard treatment for chronically painful conditions. Interdisciplinary pain management views the patient as an active agent, responsible for learning and applying self-management techniques for controlling pain, with the staff assuming a teaching and consulting role. Although much more labor intensive, interdisciplinary pain management is more effective over time in managing chronic pain, in preventing unnecessary emotional and physical impairment, and in controlling overall medical costs.

Reflex sympathetic dystrophy: the clinician's perspective

Theories on the etiology of reflex sympathetic dystrophy (RSD) are reviewed and presented in three categories: peripheral, spinal, and supraspinal. The peripheral pathophysiology involves a prolonged inflammatory, response to injury due to the axon reflex with release of vasoactive neuropeptides and sensitized nociceptors. The spinal component of RSD genesis involves nociceptive spinal cord neurons with lowered thresholds due to chronic pain input. These sensitized spinal neurons respond in turn by signaling pain reflexes through the sympathetic system. A physical-emotional diathesis may predispose individuals to respond to stress through autonomic arousal. Autonomic arousal, coupled with injury, signals the supraspinal influence on this syndrome. Since the puzzle of RSD remains to be solved, measurement and treatment strategies are suggested to provide intervention at each level. Measurement techniques should include a battery of static tests and stress tests. Static tests are used to quantify a physiological parameter at one point in time. Stress tests access physiological response to various neuro-vaso-motor challenges. A "hands off" treatment regime is presented that includes pain control, methods to reset sensory thresholds, vasomotor challenges, and an active motion program.

Complications following surgical treatment for Dupuytren's contracture

Dupuytren's disease is a proliferative fibroplasia that can lead to a significant contracture of the metacarpophalangeal (MCP) and interphalangeal (IP) joints, causing a functional disability. Surgical excision of the Dupuytren's tissue and release of the contracted joints may be necessary to restore function. Most patients require hand therapy postoperatively. Postoperative complications have been reported at 17%. These include excessive inflammation, hematoma, ischemic skin necrosis, infection, granuloma formation, transient paresthesia, scar contracture, persistent proximal interphalangeal (PIP) flexion contracture, distal interphalangeal (DIP) hyperextension deformity, joint stiffness, poor flexion and grip strength, pain, and reflex sympathetic dystrophy (RSD). The hand therapist plays a vital role in the early detection and treatment of many of these complications.

The cooling effects of electroacupuncture on the skin temperature of the hand

Electroacupuncture (EA) has been reported to induce changes in skin temperature; however, it is not clear whether high- and low-frequency EA produce similar effects. Therefore, the purpose of this study was to investigate the effects of EA on the skin temperature of the hand and finger in normal subjects. Twenty-one subjects received high-frequency EA (100 Hz) and low-frequency EA (4 Hz) at the Large Intestine 4 and Small Intestine 3 acupuncture points, as well as a no-treatment control condition. The results showed that the skin temperature following high- and low-frequency EA produced significant cooling effects at both sites as compared with the no-treatment control condition during the stimulation period (p < 0.05). These data show that EA produces significant changes in skin temperature that may be of benefit in pathologic conditions that are accompanied by an increase in local circulation.

Long-term results of peripheral nerve stimulation for reflex sympathetic dystrophy

This prospective, consecutive series describes peripheral nerve stimulation (PNS) for treatment of severe reflex sympathetic dystrophy (RSD) or complex regional pain syndrome, in patients with symptoms entirely or mainly in the distribution of one major peripheral nerve. Plate-type electrodes were placed surgically on affected nerves and tested for 2 to 4 days. Programmable generators were implanted if 50% or more pain reduction and objective improvement in physical changes were achieved. Patients were followed for 2 to 4 years and a disinterested third-party interviewer performed final patient evaluations. Of 32 patients tested, 30 (94%) underwent permanent PNS placement. Long-term good or fair relief was experienced in 19 (63%) of 30 patients. In successfully treated patients, allodynic and spontaneous pain was reduced on a scale of 10 from 8.3 +/- 0.3 preimplantation to 3.5 +/- 0.4 (mean +/- standard error of the mean) at latest follow up (p<0.001). Changes in vasomotor tone and patient activity levels were markedly improved but motor weakness and trophic changes showed less improvement. Six (20%) of the 30 patients undergoing PNS placement returned to part-time or full-time work after being unemployed prestimulator implantation. Initial involvement of more than one major peripheral nerve correlated with a poor or no relief rating (p<0.01). Operative modifications that minimize technical complications are described. This study indicates that PNS can provide good relief for RSD that is limited to the distribution of one major nerve.

Nerve entrapment and reflex sympathetic dystrophy after fractures of the distal radius

In a series of 542 conservatively-treated fractures of the distal radius 30 patients (5,5%) developed compression neuropathy: of the median nerve (n = 23), of the ulnar nerve (n = 5), and of the radial nerve (n = 2). Three patients required decompression of the carpal tunnel, and one patient's ulnar symptoms were relieved after shortening osteotomy of the ulna. The remaining neuropathies resolved spontaneously over a period of three months. Five patients developed typical reflex sympathetic dystrophy with diffuse pain, loss of hand function, and significant autonomic dysfunction. None of them had specific signs of compression neuropathy anteceding the development of reflex dystrophy. All five had their joints mobilised under regional intravenous block combined with regional perfusion of soluble corticosteroid.