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Schneider S, Wertli MM, Henzi A, Hebeisen M, Brunner F. Effect of an interdisciplinary inpatient program for patients with complex regional pain syndrome in reducing disease activity-a single-center prospective cohort study. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:459-467. [PMID: 38530793 PMCID: PMC11224586 DOI: 10.1093/pm/pnae021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/02/2024] [Accepted: 03/07/2024] [Indexed: 03/28/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the benefit of inpatient treatment in reducing disease activity in patients with complex regional pain syndrome (CRPS) who have exhausted outpatient options. Furthermore, the study sought to identify patient-related outcome variables that predict a reduction in disease activity. METHODS The primary outcome was disease severity (CRPS Severity Score, range 0-16 points). Secondary outcomes included depression, anxiety, physical function, pain interference, fatigue, sleep disturbance, and the ability to participate in social roles and activities, all of which were assessed using the PROMIS-29. Furthermore, pain catastrophizing, neuropathic pain, quality of life, pain self-efficacy, medication intake, and the patient's global impression of change were examined in accordance with current international agreed recommendations, assessed at discharge, 3-month, and 6-month post-discharge. Mixed-effects models were conducted to identify baseline variables associated with CRPS severity. RESULTS Twenty-five patients completed the program (mean age 49.28 [SD 11.23] years, 92% females, mean symptom duration 8.5 [SD 6.5] months). Results showed a significant reduction between baseline and discharge of disease activity (CSS -2.36, P < .0001), pain (PROMIS-29 pain -0.88, P = .005), and emotional function (PROMIS-29 depression -5.05, P < .001; fatigue -4.63, P = .002). Moderate evidence for a reduction between baseline and discharge could be observed for pain interference (+2.27, P = .05), social participation (PROMIS-29 + 1.93, P = .05), anxiety (PROMIS-29 -3.32, P = .02) and physical function (PROMIS-29 + 1.3, P = .03). On discharge, 92% of patients (23 of 25) reported improvement in their overall condition. In the follow-up period, medication intake could be reduced after 3 (MQS -8.22, P = .002) and 6 months (MQS -8.69, P = .001), and there was further improvement in social participation after 3 months (PROMIS-29 + 1.72, 0.03) and sleep after 6 months (PROMIS-29 + 2.38, 0.008). In the mixed models, it was demonstrated that patients experiencing less pain at baseline also exhibited lower disease activity. CONCLUSION The results of this study confirm that inpatient interdisciplinary treatment of CRPS patients improves disease activity, pain, physical function, emotional function, and social participation. Most improvements were maintained for up to 6 months after discharge. The majority of patients reported that their overall condition had improved during the study period.
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Affiliation(s)
- Stephanie Schneider
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Maria M Wertli
- Department of Internal Medicine, Kantonsspital Baden, 5404 Baden, Switzerland
- Department of General Internal Medicine, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Anna Henzi
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Monika Hebeisen
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, 8001 Zurich, Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, 8008 Zurich, Switzerland
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Sobeeh MG, Hassan KA, Silva AG, Bruehl S. Impact of different CRPS phenotypes and diagnostic criteria on quantitative sensory testing outcomes: systematic review and meta-analysis. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:211-225. [PMID: 37930043 DOI: 10.1093/pm/pnad144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES This review and meta-analysis evaluated the impact of diagnostic criteria and clinical phenotypes on quantitative sensory testing (QST) outcomes in patients with complex regional pain syndrome (CRPS). METHODS Eight databases were searched based on a previously published protocol. Forty studies comparing QST outcomes between CRPS-I vs II, warm vs cold CRPS, upper vs lower limb CRPS, males vs females, or using Budapest vs older IASP criteria were included. RESULTS Studies investigating QST differences between CRPS-I vs II (n = 4), between males vs females (n = 2), and between upper and lower limb CRPS (n = 2) showed no significant differences. Four studies compared QST outcomes in warm vs cold CRPS, showing heat hyperalgesia in warm CRPS, with thermal and mechanical sensory loss in cold CRPS. Although CRPS diagnosed using the Budapest criteria (24 studies) vs 1994 IASP criteria (13 studies) showed similar sensory profiles, there was significant heterogeneity and low quality of evidence in the latter. CONCLUSIONS Based on the findings of this review, classifying CRPS according to presence or absence of nerve lesion into CRPS-I and II, location (upper or lower limb) or according to sex might not be clinically relevant as all appear to have comparable sensory profiles that might suggest similar underlying mechanisms. In contrast, warm vs cold phenotypes exhibited clear differences in their associated QST sensory profiles. To the extent that differences in underlying mechanisms might lead to differential treatment responsiveness, it appears unlikely that CRPS-I vs II, CRPS location, or patient sex would prove useful in guiding clinical management.
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Affiliation(s)
- Mohamed Gomaa Sobeeh
- Department of Physical Therapy for Musculoskeletal Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt
- Department of Physical Therapy for Orthopedic and orthopedic surgery, Faculty of Physical Therapy, Sinai University, Ismailia, Egypt
| | - Karima Abdelaty Hassan
- Department of Physical Therapy for Musculoskeletal Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Anabela G Silva
- CINTESIS.UA@RISE, School of Health Sciences, University of Aveiro, Aveiro, Portugal
| | - Stephen Bruehl
- Vanderbilt University Medical Center, Nashville, TN, United States
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Griffiths GS, Thompson BL, Snell DL, Dunn JA. Person-centred management of upper limb complex regional pain syndrome: an integrative review of non-pharmacological treatment. HAND THERAPY 2023; 28:16-32. [PMID: 37904811 PMCID: PMC10584071 DOI: 10.1177/17589983221138610] [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: 07/05/2022] [Accepted: 10/25/2022] [Indexed: 11/01/2023]
Abstract
Introduction Complex Regional Pain Syndrome (CRPS) is most common in the upper limb and associated with high disability. The purpose of this review was to critically appraise and synthesise literature exploring non-pharmacological treatment for upper limb CRPS, to guide upper-limb-specific management. Methods Using an integrative review methodology, 13 databases were searched to identify all published studies on non-pharmacological management of upper limb CRPS. The Crowe Critical Appraisal Tool was used to provide quality ratings for included studies, and analysis employed a qualitative descriptive approach. Results From 236 abstracts reviewed, 113 full texts were read, and 38 articles selected for data extraction. Designs included single case (n = 14), randomised controlled trial (n = 8), prospective cohort (n = 8), case series (n = 4), retrospective (n = 3), and mixed methods (n = 1). Interventions were categorised as sensory retraining (n = 13), kinesiotherapy (n = 7), manual therapies (n = 7), physical modalities (n = 6), and interdisciplinary treatment programmes (n = 5). All studies measured pain intensity, and most (n = 24) measured physical parameters such as strength, movement, or perceptual abilities. Few measured patient-rated function (n = 13) or psychological factors (n = 4). Quality ratings ranged from 30% to 93%, with a median of 60%. Conclusion Methodological quality of non-pharmacological treatment approaches for upper limb CRPS is overall poor. Movement, desensitisation, and graded functional activity remain the mainstays of intervention. However, despite the impact of CRPS on wellbeing and function, psychological factors and functional outcomes are infrequently addressed. Further robust research is required to determine which aspects of treatment have the greatest influence on which symptoms, and when and how these should be introduced and progressed.
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Affiliation(s)
- Grace S Griffiths
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Bronwyn L Thompson
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Deborah L Snell
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - Jennifer A Dunn
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
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Louis MH, Meyer C, Legrain V, Berquin A. Biological and psychological early prognostic factors in complex regional pain syndrome: A systematic review. Eur J Pain 2023; 27:338-352. [PMID: 36516373 DOI: 10.1002/ejp.2068] [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: 07/04/2022] [Revised: 11/14/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Several risk factors for the onset of CRPS have been found, but evidence for prognostic factors associated with the progression of this condition remains sparse. However, the detection and management of these factors are necessary to design secondary prevention strategies. The objective of this systematic review was to identify prognostic factors in adult individuals with early CRPS. DATABASE AND DATA TREATMENT PubMed, Embase, PsycINFO, Cochrane Library and Scopus, were published between January 1990 and November 2021. Two independent investigators selected cross-sectional and longitudinal studies looking at early (<12 weeks from onset) prognostic factors for pain, CRPS severity score, disability, return to work, or quality of life. The quality in prognostic studies (QUIPS) tool was used to assess the risk of bias. A qualitative meta-synthesis was performed. RESULTS Out of 4652 different articles, six studies met the inclusion criteria. We identified 21 early factors associated with a poorer prognosis in type I CRPS. We found moderate evidence to support six of them: higher pain intensity, self-rated disability, anxiety, pain-related fear, being a female and high-energy triggering event. Only two studies had an overall low risk of bias. CONCLUSIONS This study showed an important lack of information on early prognostic factors in CRPS. Only one article investigated the link with psychological characteristics. There is a crucial need for larger studies, with a well-defined population using validated measures. SIGNIFICANCE This systematic review highlights the lack of knowledge about early prognostic factors in CRPS. A few putative prognostic factors were identified. Most of the moderate evidence is related to a single cohort. Future research is required to find out which patients are vulnerable to chronification.
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Affiliation(s)
- Marc-Henri Louis
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
| | - Caroline Meyer
- CHU UCL Namur site Godinne, Department of Physical Medicine and Rehabilitation, Yvoir, Belgium
| | - Valéry Legrain
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
- Psychological Sciences Research Institute, Université catholique de Louvain, Louvain-la-Neuve, Belgium
- Louvain Bionics, Université catholique de Louvain, Louvain-la-Neuve, Belgium
| | - Anne Berquin
- Institute of Neuroscience, Université catholique de Louvain, Brussels, Belgium
- Cliniques Universitaires UCL Saint-Luc, Department of Physical and Rehabilitation Medicine, Brussels, Belgium
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Reinhold AK, Kindl GK, Dietz C, Scheu N, Mehling K, Brack A, Birklein F, Rittner HL. Molecular and clinical markers of pain relief in complex regional pain syndrome: An observational study. Eur J Pain 2023; 27:278-288. [PMID: 36440973 DOI: 10.1002/ejp.2058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is marked by disproportionate pain after trauma. Whilst the long-term outcome is crucial to patients, predictors or biomarkers of the course of pain or CRPS symptoms are still lacking. In particular, microRNAs, such as miR-223, decreased in CRPS, have been described only in cross-sectional studies. METHODS In this study, we characterised CRPS patients over a course of 2.5 years of standard treatment. The patient underwent clinical examination including pain measurement, symptom questionnaires, quantitative sensory testing (QST) and blood sampling. Exosomal microRNA levels were measured via qPCR. After follow-up, patients were stratified into 'pain relief' (mean pain reduced by ≥2 numeric rating scale) or 'persistence' (mean pain unchanged or worsened). The primary outcome was miR-223 and miR-939 expression, secondary outcomes were differences in clinical parameters between groups and time points. RESULTS Thirty-nine patients were included, 33 of whom qualified for stratification. Overall, patients reported lower pain and improved clinical characteristics after 2.5 years, but no significant changes in QST or miR-223 and miR-939 expression levels. 16 patients met the criteria for pain relief. This was associated with stable exosomal miR-223 expression, whilst levels further decreased in pain persistence. Clinically, pain relief was marked by shorter disease duration and correlated positively with high initial pain. CONCLUSION We identified progressively reduced miR-223 as a putative biomarker of chronic CRPS pain. Clinically, this study underlines the importance of early diagnosis and treatment showing that high initial pain does not predict an unfavourable outcome. Finally, pain relief and recovery of sensory disturbances seem independent processes.
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Affiliation(s)
- Ann Kristin Reinhold
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Gudrun-Karin Kindl
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Christopher Dietz
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Nathalie Scheu
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Katharina Mehling
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Alexander Brack
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Frank Birklein
- Department of Neurology, Mainz University Hospitals, Mainz, Germany
| | - Heike L Rittner
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
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Sobeeh MG, Hassan KA, da Silva AG, Youssef EF, Fayaz NA, Mohammed MM. Pain mechanisms in complex regional pain syndrome: a systematic review and meta-analysis of quantitative sensory testing outcomes. J Orthop Surg Res 2023; 18:2. [PMID: 36593515 PMCID: PMC9806919 DOI: 10.1186/s13018-022-03461-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a chronic condition following inciting events such as fractures or surgeries with sensorimotor and autonomic manifestations and poor prognosis. This review aimed to provide conclusive evidence about the sensory phenotype of CRPS based on quantitative sensory testing (QST) to understand the underlying pain mechanisms and guide treatment strategies. DATABASES Eight databases were searched based on a previously published protocol. Forty studies comparing QST outcomes (thermal, mechanical, vibration, and electric detection thresholds, thermal, mechanical, pressure, and electric pain thresholds, wind-up ratio, mechanical pain sensitivity, allodynia, flare area, area after pinprick hyperalgesia, pleasantness after C-tactile stimulation, and pain ratings) in chronic CRPS (adults and children) versus healthy controls were included. RESULTS From 37 studies (14 of low quality, 22 of fair quality, and 1 of good quality), adults with CRPS showed: (i) significant loss of thermal, mechanical, and vibration sensations, significant gain of thermal and mechanical pain thresholds, significant elevation of pain ratings, and no difference in wind-up ratio; (ii) significant reduction of pleasantness levels and increased area of pinprick hyperalgesia, in the affected limb. From three fair-quality studies, adolescents and children with CRPS showed loss of cold detection with cold hyperalgesia in the affected limb. There was moderate to substantial overall heterogeneity. CONCLUSION Diffuse thermal and mechanical hypoesthesia with primary and secondary hyperalgesia, enhanced pain facilitation evidenced by increased area of pinprick hyperalgesia, and elevated pain ratings are dominant in adults with CRPS. Adolescents and children with CRPS showed less severe sensory abnormalities.
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Affiliation(s)
- Mohamed Gomaa Sobeeh
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt ,grid.442728.f0000 0004 5897 8474Faculty of Physical Therapy, Sinai University, Ismailia, Egypt
| | - Karima Abdelaty Hassan
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Anabela Gonçalves da Silva
- grid.7311.40000000123236065CINTESIS.UA@RISE, School of Health Sciences, University of Aveiro, Aveiro, Portugal
| | - Enas Fawzy Youssef
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Nadia Abdelazim Fayaz
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Maha Mostafa Mohammed
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
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Ehrenbrusthoff K, Ryan CG, Martin DJ, Milnik V, Dinse HR, Grüneberg C. Low test–retest reliability of a protocol for assessing somatosensory cortex excitability generated from sensory nerves of the lower back. Front Hum Neurosci 2022; 16:898759. [PMID: 36082228 PMCID: PMC9445117 DOI: 10.3389/fnhum.2022.898759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
In people with chronic low back pain (CLBP), maladaptive structural and functional changes on a cortical level have been identified. On a functional level, somatosensory cortical excitability has been shown to be reduced in chronic pain conditions, resulting in cortical disinhibition. The occurrence of structural and/or functional maladaptive cortical changes in people with CLBP could play a role in maintaining the pain. There is currently no measurement protocol for cortical excitability that employs stimulation directly to the lower back. We developed a protocol for the measurement of single pulse somatosensory evoked potential (SEP) waveforms and paired-pulse behavior (PPB) generated from sensory nerves of the lower back and quantified its test–retest reliability in a sample of 30 healthy individuals to gain insights into the normal variability of cortical responses, which could then be compared to results from people with CLBP. We investigated cortical excitability by measuring SEPs and PPB. PPB was defined as the ratio of the amplitude of the second cortical response (A2s) divided by the first cortical response (A1). A2s was determined by subtracting the response to single-pulse stimuli from the paired pulse stimuli response to account for linear superposition effects. The test–retest reliability of the protocol was very poor with no evidence of systematic bias but a high amount of random variability between sessions. There was no significant difference in the right side PPB for session 1 (Mean ratio A2s/A1 = 0.66, SD = 0.54) and session 2 (Mean ratio A2s/A1 = 0.94, SD = 1.56); mean session difference [(95% CI) = −0.44 (−1.23 to 0.34); t (22) = −1.17, p = 0.26]. The ICC3.1 (absolute agreement) for the outlier-removed right side PPB were 0.19 (95% CI: −0.84 to 0.66) and 0.43 for left side PPB (95% CI: −0.37 to 0.76). This finding potentially has wider implications for PPB protocols. If these findings were replicated in other groups and other nerves, it would question the validity of this measure more generally. However, these findings are restricted to healthy people and sensory nerves of the lower back and may not be generalizable.
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Affiliation(s)
- Katja Ehrenbrusthoff
- Department of Applied Health Sciences, Hochschule für Gesundheit, Bochum, Germany
- *Correspondence: Katja Ehrenbrusthoff,
| | - Cormac G. Ryan
- School of Health & Life Sciences, Teesside University, Middlesbrough, United Kingdom
| | - Denis J. Martin
- School of Health & Life Sciences, Teesside University, Middlesbrough, United Kingdom
| | | | - Hubert R. Dinse
- Department of Neurology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH, Ruhr-University Bochum, Bochum, Germany
- Institute for Neuroinformatics, Neural Plasticity Lab, Ruhr-University of Bochum, Bochum, Germany
| | - Christian Grüneberg
- Department of Applied Health Sciences, Hochschule für Gesundheit, Bochum, Germany
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Habig K, Lautenschläger G, Maxeiner H, Birklein F, Krämer HH, Seddigh S. Low mechano-afferent fibers reduce thermal pain but not pain intensity in CRPS. BMC Neurol 2021; 21:272. [PMID: 34243742 PMCID: PMC8268451 DOI: 10.1186/s12883-021-02304-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Human hairy (not glabrous skin) is equipped with a subgroup of C-fibers, the C-tactile (CT) fibers. Those do not mediate pain but affective aspects of touch. CT-fiber-activation reduces experimental pain if they are intact. In this pilot study we investigated pain modulating capacities of CT-afferents in CRPS. Methods 10 CRPS-patients (mean age 33 years, SEM 3.3) and 11 healthy controls (mean age 43.2 years, SEM 3.9) participated. CT-targeted-touch (brush stroking, velocity: 3 cm/s) was applied on hairy and glabrous skin on the affected and contralateral limb. Patients rated pleasantness of CT-targeted-touch (anchors: 1 “not pleasant”—4 “very pleasant”) twice daily on 10 days. Pain intensity (NRS: 0 “no pain” – 10 “worst pain imaginable”) was assessed before, 0, 30, 60 and 120 min after each CT-stimulation. To assess sensory changes, quantitative-sensory-testing was performed at the beginning and the end of the trial period. Results CT-targeted-touch was felt more pleasant on the healthy compared to the affected limb on hairy (p < 0.001) and glabrous skin (p 0.002), independent of allodynia. In contrast to healthy controls patients felt no difference between stimulating glabrous and hairy skin on the affected limb. Thermal pain thresholds increased after CT-stimulation on the affected limb (cold-pain-threshold: p 0.016; heat-pain-threshold: p 0.033). Conclusions CT-stimulation normalizes thermal pain thresholds but has no effect on the overall pain in CRPS. Therefore, pain modulating properties of CT-fibers might be too weak to alter chronic pain in CRPS. Moreover, CT-fibers appear to lose their ability to mediate pleasant aspects of touch in CRPS.
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Affiliation(s)
- Kathrin Habig
- Department of Neurology, Justus Liebig University, 35392, Giessen, Germany.
| | | | - Hagen Maxeiner
- Department of Anaesthesiology, Justus Liebig University, 35392, Giessen, Germany
| | - Frank Birklein
- Department of Neurology, University Medical Center, Johannes Gutenberg-University, Langenbeckstr. 1, 56101, Mainz, Germany
| | - Heidrun H Krämer
- Department of Neurology, Justus Liebig University, 35392, Giessen, Germany
| | - Susann Seddigh
- Department of Neurology, BG Klinikum Duisburg, 47249, Duisburg, Germany
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9
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Reinersmann A, Skinner IW, Lücke T, Massy-Westropp N, Rudolf H, Moseley GL, Stanton TR. Intact tactile anisotropy despite altered hand perception in complex regional pain syndrome: rethinking the role of the primary sensory cortex in tactile and perceptual dysfunction. PeerJ 2021; 9:e11156. [PMID: 33986983 PMCID: PMC8101475 DOI: 10.7717/peerj.11156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 03/04/2021] [Indexed: 01/18/2023] Open
Abstract
Complex Regional Pain Syndrome (CRPS) is characterised by pain, autonomic, sensory and motor abnormalities. It is associated with changes in the primary somatosensory cortex (S1 representation), reductions in tactile sensitivity (tested by two-point discrimination), and alterations in perceived hand size or shape (hand perception). The frequent co-occurrence of these three phenomena has led to the assumption that S1 changes underlie tactile sensitivity and perceptual disturbances. However, studies underpinning such a presumed relationship use tactile sensitivity paradigms that involve the processing of both non-spatial and spatial cues. Here, we used a task that evaluates anisotropy (i.e., orientation-dependency; a feature of peripheral and S1 representation) to interrogate spatial processing of tactile input in CRPS and its relation to hand perception. People with upper limb CRPS (n = 14) and controls with (n = 15) or without pain (n = 19) judged tactile distances between stimuli-pairs applied across and along the back of either hand to provide measures of tactile anisotropy. Hand perception was evaluated using a visual scaling task and questionnaires. Data were analysed with generalised estimating equations. Contrary to our hypotheses, tactile anisotropy was bilaterally preserved in CRPS, and the magnitude of anisotropic perception bias was comparable between groups. Hand perception was distorted in CRPS but not related to the magnitude of anisotropy or bias. Our results suggest against impairments in spatial processing of tactile input, and by implication S1 representation, as the cause of distorted hand perception in CRPS. Further work is warranted to elucidate the mechanisms of somatosensory dysfunction and distorted hand perception in CRPS.
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Affiliation(s)
- Annika Reinersmann
- Neuropediatric Department, Children's University Hospital St. Josef, Ruhr-Universität Bochum, Bochum, North-Rhine Westphalia, Germany.,School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Ian W Skinner
- Neuroscience Research Australia, NEURA, University of New South Wales, Sydney, New South Wales, Australia
| | - Thomas Lücke
- Neuropediatric Department, Children's University Hospital St. Josef, Ruhr-Universität Bochum, Bochum, North-Rhine Westphalia, Germany
| | - Nicola Massy-Westropp
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-Universität Bochum, Bochum, Germany
| | - G Lorimer Moseley
- Neuroscience Research Australia, NEURA, University of New South Wales, Sydney, New South Wales, Australia.,School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Tasha R Stanton
- Neuroscience Research Australia, NEURA, University of New South Wales, Sydney, New South Wales, Australia.,School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Meyer-Frießem CH, Attal N, Baron R, Bouhassira D, Finnerup NB, Freynhagen R, Gierthmühlen J, Haanpää M, Hansson P, Jensen TS, Kemp H, Kennedy D, Leffler AS, Rice ASC, Segerdahl M, Serra J, Sindrup S, Solà R, Tölle T, Schuh-Hofer S, Treede RD, Pogatzki-Zahn E, Maier C, Vollert J. Pain thresholds and intensities of CRPS type I and neuropathic pain in respect to sex. Eur J Pain 2020; 24:1058-1071. [PMID: 32096888 DOI: 10.1002/ejp.1550] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 01/19/2020] [Accepted: 02/18/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND AIMS Healthy women have generally been found to have increased experimental pain perception and chronic pain has a higher prevalence in female as compared to male patients. However, no study has investigated whether pain intensity and pain perception thresholds are distinct or similar between sexes within various chronic pain entities. We investigated whether average pain intensities and pain thresholds assessed using quantitative sensory testing (QST) differed between women and men suffering from three distinct chronic pain conditions: Complex Regional Pain Syndrome (CRPS type I), peripheral nerve injury (PNI) or polyneuropathy (PNP), as compared to paired healthy volunteers. METHODS QST data of 1,252 patients (669 female, 583 male) with PNI (n = 342), PNP (n = 571) or CRPS (n = 339), and average pain intensity reports from previously published studies were included. Absolute and z-values (adjusted for age and body region) of cold, heat, pressure (PPT) and pinprick pain thresholds were compared in generalized linear models with aetiology, duration of underlying pain disease and average pain intensity as fixed effects. RESULTS Average pain intensity during the past four weeks did not differ between women and men, in both mean and range. In women absolute pain thresholds for cold, heat and pinprick were lower than in males across all diagnoses (p < .05). However, after z-transformation these differences disappeared except for PPT in CRPS (p = .001). DISCUSSION Pain thresholds in patients show only minor sex differences. However, these differences mimic those observed in healthy subjects and do not seem to be linked to specific pathophysiological processes. SIGNIFICANCE Female healthy participants and female patients with neuropathic pain conditions or CRPS I report lower pain thresholds compared to males, but pain intensity is similar and there is no sex difference in the extent to which the thresholds are altered in neuropathic pain or CRPS. Thus, the sex differences observed in various chronic pain conditions mimic those obtained in healthy participants, indicating that these differences are not linked to specific pathophysiological processes and are of minor clinical relevance.
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Affiliation(s)
- Christine H Meyer-Frießem
- Department of Anesthesiology, Intensive Care, Palliative and Pain Medicine, University Hospital Bergmannsheil Bochum, Bochum, Germany.,Department of Pain Medicine, BG University Hospital Bergmannsheil GmbH, Ruhr-University Bochum, Bochum, Germany
| | - Nadine Attal
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, CHU Ambroise Paré, Boulogne-Billancourt, France.,Université Versailles-Saint-Quentin, Versailles, France
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Didier Bouhassira
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, CHU Ambroise Paré, Boulogne-Billancourt, France.,Université Versailles-Saint-Quentin, Versailles, France
| | - Nanna B Finnerup
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rainer Freynhagen
- Department of Anaesthesiology, Critical Care Medicine, Pain Therapy & Palliative Care, Pain Center Lake Starnberg, Benedictus Hospital Tutzing, Tutzing, Germany.,Anaesthesiological Clinic, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Janne Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Maija Haanpää
- Department of Helsinki University Central Hospital, Helsinki, Finland.,Etera Mutual Pension Insurance Company Helsinki, Helsinki, Finland
| | - Per Hansson
- Division of Emergencies and Critical Care, Department of Pain Management and Research, Oslo University Hospital, Oslo, Norway.,Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Troels S Jensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark.,Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Harriet Kemp
- Pain Research, Department of Surgery and Cancer, Imperial College, London, UK
| | - Donna Kennedy
- Pain Research, Department of Surgery and Cancer, Imperial College, London, UK
| | - Anne-Sofie Leffler
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Imperial College, London, UK
| | - Märta Segerdahl
- H. Lundbeck A/S, Copenhagen, Denmark.,Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Jordi Serra
- Neuroscience Technologies, Ltd., Barcelona, Spain
| | - Soeren Sindrup
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Roma Solà
- Neuroscience Technologies, Ltd., Barcelona, Spain
| | - Thomas Tölle
- Department of Neurology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Sigrid Schuh-Hofer
- Center of Biomedicine and Medical Technology Mannheim CBTM, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Rolf-Detlef Treede
- Center of Biomedicine and Medical Technology Mannheim CBTM, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Christoph Maier
- Department of Pain Medicine, BG University Hospital Bergmannsheil GmbH, Ruhr-University Bochum, Bochum, Germany
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College, London, UK.,Center of Biomedicine and Medical Technology Mannheim CBTM, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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11
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Sensory Function and Pain Experience in Arthritis, Complex Regional Pain Syndrome, Fibromyalgia Syndrome, and Pain-Free Volunteers. Clin J Pain 2019; 35:894-900. [DOI: 10.1097/ajp.0000000000000751] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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12
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Salgado ASI, Stramosk J, Ludtke DD, Kuci ACC, Salm DC, Ceci LA, Petronilho F, Florentino D, Danielski LG, Gassenferth A, Souza LR, Rezin GT, Santos ARS, Mazzardo-Martins L, Reed WR, Martins DF. Manual Therapy Reduces Pain Behavior and Oxidative Stress in a Murine Model of Complex Regional Pain Syndrome Type I. Brain Sci 2019; 9:brainsci9080197. [PMID: 31405150 PMCID: PMC6721404 DOI: 10.3390/brainsci9080197] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/08/2019] [Accepted: 08/08/2019] [Indexed: 01/24/2023] Open
Abstract
Complex regional pain syndrome type I (CRPS-I) is a chronic painful condition. We investigated whether manual therapy (MT), in a chronic post-ischemia pain (CPIP) model, is capable of reducing pain behavior and oxidative stress. Male Swiss mice were subjected to ischemia-reperfusion (IR) to mimic CRPS-I. Animals received ankle joint mobilization 48h after the IR procedure, and response to mechanical stimuli was evaluated. For biochemical analyses, mitochondrial function as well as oxidative stress thiobarbituric acid reactive substances (TBARS), protein carbonyls, antioxidant enzymes superoxide dismutase (SOD) and catalase (CAT) levels were determined. IR induced mechanical hyperalgesia which was subsequently reduced by acute MT treatment. The concentrations of oxidative stress parameters were increased following IR with MT treatment preventing these increases in malondialdehyde (MDA) and carbonyls protein. IR diminished the levels of SOD and CAT activity and MT treatment prevented this decrease in CAT but not in SOD activity. IR also diminished mitochondrial complex activity, and MT treatment was ineffective in preventing this decrease. In conclusion, repeated sessions of MT resulted in antihyperalgesic effects mediated, at least partially, through the prevention of an increase of MDA and protein carbonyls levels and an improvement in the antioxidant defense system.
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Affiliation(s)
- Afonso S I Salgado
- Coordinator of Integrative Physical Therapy Residency-Philadelphia University Center, Londrina 86020-000, Paraná, Brazil
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-270, Santa Catarina, Brazil
| | - Juliana Stramosk
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-270, Santa Catarina, Brazil
| | - Daniela D Ludtke
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-270, Santa Catarina, Brazil
- Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça 88137-270, Santa Catarina, Brazil
| | - Ana C C Kuci
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-270, Santa Catarina, Brazil
| | - Daiana C Salm
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-270, Santa Catarina, Brazil
- Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça 88137-270, Santa Catarina, Brazil
| | - Lisandro A Ceci
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-270, Santa Catarina, Brazil
- Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça 88137-270, Santa Catarina, Brazil
| | - Fabricia Petronilho
- Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Tubarão 88704-900, Santa Catarina, Brazil
| | - Drielly Florentino
- Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Tubarão 88704-900, Santa Catarina, Brazil
| | - Lucineia G Danielski
- Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Tubarão 88704-900, Santa Catarina, Brazil
| | - Aline Gassenferth
- Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Centre of Biological Sciences, University Federal of Santa Catarina, Florianópolis 88040-900, Santa Catarina, Brazil
| | - Luana R Souza
- Postgraduate Program in Neuroscience, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis 88040-900, Santa Catarina, Brazil
| | - Gislaine T Rezin
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL 35294-1212, USA
| | - Adair R S Santos
- Laboratory of Neurobiology of Pain and Inflammation, Department of Physiological Sciences, Centre of Biological Sciences, University Federal of Santa Catarina, Florianópolis 88040-900, Santa Catarina, Brazil
- Postgraduate Program in Neuroscience, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis 88040-900, Santa Catarina, Brazil
| | - Leidiane Mazzardo-Martins
- Postgraduate Program in Neuroscience, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis 88040-900, Santa Catarina, Brazil
| | - William R Reed
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL 35294-1212, USA
| | - Daniel F Martins
- Coordinator of Integrative Physical Therapy Residency-Philadelphia University Center, Londrina 86020-000, Paraná, Brazil.
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-270, Santa Catarina, Brazil.
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13
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Kumowski N, Hegelmaier T, Kolbenschlag J, Mainka T, Michel-Lauter B, Maier C. Short-Term Glucocorticoid Treatment Normalizes the Microcirculatory Response to Remote Ischemic Conditioning in Early Complex Regional Pain Syndrome. Pain Pract 2018; 19:168-175. [PMID: 30269438 DOI: 10.1111/papr.12730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/13/2018] [Accepted: 08/31/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The early phase of complex regional pain syndrome (CRPS) is characterized by an inflammatory state and therefore often treated with anti-inflammatory acting glucocorticoids. Recently, we demonstrated that remote ischemic conditioning (RIC), a cyclic application of nondamaging ischemia on a remote extremity, reduces blood flow and increases oxygen extraction in the CRPS-affected extremity. AIM The aim of the presented study was to analyze the effect of short-term pain treatment including glucocorticoid pulse treatment on the RIC-induced perfusion parameters. METHOD Independently from the study, pain treatment was started with an oral glucocorticoid pulse (180 to 360 mg prednisolone) in 12 patients with CRPS (disease duration < 1 year). RIC was conducted before and after pulse treatment. Three cycles of 5 minutes ischemia and 10 minutes reperfusion were applied to the contralateral limb. Blood flow, tissue oxygenation, and oxygen extraction fraction were assessed ipsilateral before and during RIC. Current pain was assessed on the numeric rating scale (0 to 10), and finger-palm distance was measured. RESULTS Pain level (5.8 ± 1.5 vs. 3.1 ± 1.1) and finger-palm distance (5 ± 1.9 cm vs. 3.7 ± 1.9 cm) were decreased significantly by the treatment. RIC decreased blood flow by 32.8% ± 42.8% (P < 0.05) and increased oxygen extraction fraction by 8.5% ± 10.3% (P < 0.05) solely before the treatment. After treatment, all parameters remained unchanged after RIC (P < 0.05 vs. before), comparable to healthy subjects. CONCLUSION Confirming previous results, RIC presumably unmasks luxury perfusion in untreated CRPS patients. In accordance with the clinical improvement, the short-term pain treatment with glucocorticoids as major component normalizes impaired perfusion. These results might underline the rationale for anti-inflammatory treatment in early-phase CRPS.
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Affiliation(s)
- Nina Kumowski
- Department of Pain Medicine, BG University Hospital Bergmannsheil GmbH, Ruhr University, Bochum, Germany
| | - Tobias Hegelmaier
- Department of Pain Medicine, BG University Hospital Bergmannsheil GmbH, Ruhr University, Bochum, Germany.,Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany
| | - Jonas Kolbenschlag
- Department of Hand-, Plastic, Reconstructive and Burn Surgery, BG Trauma Center Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Tina Mainka
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Beate Michel-Lauter
- Department of Pain Medicine, BG University Hospital Bergmannsheil GmbH, Ruhr University, Bochum, Germany
| | - Christoph Maier
- Department of Pain Medicine, BG University Hospital Bergmannsheil GmbH, Ruhr University, Bochum, Germany
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14
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Walston Z, Hernandez L, Yake D. Utilization of manual therapy to the lumbar spine in conjunction with traditional conservative care for individuals with bilateral lower extremity complex regional pain syndrome: A case series. Physiother Theory Pract 2018; 36:241-248. [PMID: 29873592 DOI: 10.1080/09593985.2018.1482392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Background and purpose: Conservative therapies for complex regional pain syndrome (CRPS) have traditionally focused on exercise and desensitization techniques targeted at the involved extremity. The primary purpose of this case series is to report on the potential benefit of utilizing manual therapy to the lumbar spine in conjunction with traditional conservative care when treating patients with lower extremity CRPS.Case description: Two patients with the diagnosis of lower extremity CRPS were treated with manual therapy to the lumbar spine in conjunction with education, exercise, desensitization, and soft tissue techniques for the extremity.Outcomes: Patient 1 received 13 sessions over 6 weeks resulting in a 34-point improvement in oswestry disability index (ODI) and 35-point improvement in lower extremity functional scale (LEFS). Patient 2 received 21 sessions over 12 weeks resulting in a 28-point improvement in ODI and a 41-point improvement in LEFS.Discussion: Both patients exhibited reductions in pain and clinically meaningful improvements in function. Manual therapies when applied to the lumbar spine in these patients as part of a comprehensive treatment plan resulted in improved spinal mobility, decreased pain, and reduction is distal referred symptoms. Although one cannot infer a cause and effect relationship from a case series, this report identifies meaningful clinical outcomes potentially associated with manual physical therapy to the lumbar spine for two patients with complex regional pain syndrome type 1.
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Affiliation(s)
| | | | - Dale Yake
- PT Solutions Physical Therapy, Atlanta, GA, USA
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