Complex Regional Pain Syndromes: guidelines for therapy

Complex regional pain syndrome: diagnostic challenges and favorable response to prednisolone

Complex regional pain syndrome (CRPS), characterized by severe and disproportionate pain, is a rare and debilitating condition. Due to its rarity, evidence-based treatment guidelines remain limited, creating a challenge for clinicians. We present the case of a 20-year-old female with CRPS type 1 of the right hand. Her pain, initially triggered by a minor trauma, had persisted for three months. The patient demonstrated severe pain, swelling, hyperesthesia, and restricted range of motion. Despite multiple hospital visits, her symptoms did not improve until she was diagnosed with CRPS and treated with oral prednisolone. A dosage of 40 mg daily led to a dramatic response within 10 days. Our report emphasizes the importance of recognizing CRPS and highlights the potential of prednisolone as a treatment option, particularly in resource-limited settings, where more specialized interventions may be unavailable. Further research is essential to establish a stronger evidence base for the use of steroids in CRPS management.

High-intensity swimming alleviates nociception and neuroinflammation in a mouse model of chronic post-ischemia pain by activating the resolvin E1-chemerin receptor 23 axis in the spinal cord

Physical exercise effectively alleviates chronic pain associated with complex regional pain syndrome type-I. However, the mechanism of exercise-induced analgesia has not been clarified. Recent studies have shown that the specialized pro-resolving lipid mediator resolvin E1 promotes relief of pathologic pain by binding to chemerin receptor 23 in the nervous system. However, whether the resolvin E1-chemerin receptor 23 axis is involved in exercise-induced analgesia in complex regional pain syndrome type-I has not been demonstrated. In the present study, a mouse model of chronic post-ischemia pain was established to mimic complex regional pain syndrome type-I and subjected to an intervention involving swimming at different intensities. Chronic pain was reduced only in mice that engaged in high-intensity swimming. The resolvin E1-chemerin receptor 23 axis was clearly downregulated in the spinal cord of mice with chronic pain, while high-intensity swimming restored expression of resolvin E1 and chemerin receptor 23. Finally, shRNA-mediated silencing of chemerin receptor 23 in the spinal cord reversed the analgesic effect of high-intensity swimming exercise on chronic post-ischemic pain and the anti-inflammatory polarization of microglia in the dorsal horn of the spinal cord. These findings suggest that high-intensity swimming can decrease chronic pain via the endogenous resolvin E1-chemerin receptor 23 axis in the spinal cord.

Neurotechnology for Pain

Neurotechnologies for treating pain rely on electrical stimulation of the central or peripheral nervous system to disrupt or block pain signaling and have been commercialized to treat a variety of pain conditions. While their adoption is accelerating, neurotechnologies are still frequently viewed as a last resort, after many other treatment options have been explored. We review the pain conditions commonly treated with electrical stimulation, as well as the specific neurotechnologies used for treating those conditions. We identify barriers to adoption, including a limited understanding of mechanisms of action, inconsistent efficacy across patients, and challenges related to selectivity of stimulation and off-target side effects. We describe design improvements that have recently been implemented, as well as some cutting-edge technologies that may address the limitations of existing neurotechnologies. Addressing these challenges will accelerate adoption and change neurotechnologies from last-line to first-line treatments for people living with chronic pain.

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.

Clinical practice guidelines for the management of patients with chronic regional pain syndrome: a systematic appraisal using the AGREE II instrument

Aim: Chronic regional pain syndrome (CRPS) is a debilitating, painful condition of limbs that often arises after an injury and is associated with significant morbidity. Materials & methods: The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument, used to assess the quality of clinical practice guidelines (CPGs), was used to evaluate seven CRPS management guideline. Results: Out of the seven CPGs evaluated using the AGREE II instrument, only one from Royal College of Physicians was found to have high-quality consensus guidelines for diagnosis and management of CRPS. Conclusion: Future CPGs should be backed by systematic literature searches, focus on guidelines clinical translation into clinical practice and applicability to the desired patient population.

Evidence-Based Clinical Guidelines from the American Society of Pain and Neuroscience for the Use of Implantable Peripheral Nerve Stimulation in the Treatment of Chronic Pain

The objective of this peripheral nerve stimulation consensus guideline is to add to the current family of consensus practice guidelines and incorporate a systematic review process. The published literature was searched from relevant electronic databases, including PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from database inception to March 29, 2021. Inclusion criteria encompassed studies that described peripheral nerve stimulation in patients in terms of clinical outcomes for various pain conditions, physiological mechanism of action, surgical technique, technique of placement, and adverse events. Twenty randomized controlled trials and 33 prospective observational studies were included in the systematic review process. There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles; failed back surgery syndrome via subcutaneous peripheral field stimulation; and lower extremity neuropathic and lower extremity post-amputation pain. Evidence from current Level I studies combined with newer technologies facilitating less invasive and easier electrode placement make peripheral nerve stimulation an attractive alternative for managing patients with complex pain disorders. Peripheral nerve stimulation should be used judiciously as an adjunct for chronic and acute postoperative pain following adequate patient screening and positive diagnostic nerve block or stimulation trial.

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.

Ultrasound-guided pulsed radiofrequency of the saphenous nerve in a complex regional pain syndrome patient with lower limb pain

Complex regional pain syndrome is a painful and debilitating syndrome in which the patient presents with disabling pain, edema, and/or vasomotor or sudomotor abnormalities. The mechanism is complex and not well understood. There is no definitive treatment for the condition yet. Pulsed radiofrequency is a minimally invasive, minimal destructive, and safe intervention. It can be used for neuropathic pain. A 40-year-old man with complex regional pain syndrome complained of intractable pain of the lower limb secondary to injury to the saphenous nerve due to a third-degree burn. Conventional medications, epidural block, and sympathetic nerve block provided temporary relief. We performed pulsed radiofrequency of the saphenous nerve for the management of lower limb pain, and the symptoms remained under control at 3 months. To the best of our knowledge, this is the first application of ultrasound-guided pulsed radiofrequency of the saphenous nerve for the management of complex regional pain syndrome.

Orofacial complex regional pain syndrome

Complex regional pain syndrome (CRPS)-an extremely painful primary pain disorder related to trauma-is rare in the orofacial region. The authors describe a case of orofacial CRPS with a clinical phenotype that fits the Budapest diagnostic criteria. A 39-year-old female patient presented with left-side facial pain that had been untreated for 10 months. Symptoms included burning pain and allodynia accompanied by swelling and redness on exposure to cold or stress. The diagnosis was confirmed after stellate ganglion anesthetic block resulted in substantial improvement.

Molecular Aspects of Regional Pain Syndrome

The purpose of this review is to summarize the pathophysiology of complex regional pain syndrome (CRPS), the underlying molecular mechanisms, and potential treatment options for its management. CRPS is a multifactorial pain condition. CRPS is characterized by prolonged or excessive pain and changes in skin color and temperature, and/or swelling in the affected area, and is generally caused by stimuli that lead to tissue damage. An inflammatory response involving various cytokines and autoantibodies is generated in response to acute trauma/stress. Chronic phase pathophysiology is more complex, involving the central and peripheral nervous systems. Various genetic factors involved in the chronicity of pain have been identified in CRPS patients. As with other diseases of complex pathology, CRPS is difficult to treat and no single treatment regimen is the same for two patients. Stimulation of the vagus nerve is a promising technique being tested for different gastrointestinal and inflammatory diseases. CRPS is more frequent in individuals of 61–70 years of age with a female to male ratio of 3 : 1. Menopause, migraine, osteoporosis, and asthma all represent risk factors for CRPS and in smokers the prognosis appears to be more severe. The pathophysiological mechanisms underlying CRPS involve both inflammatory and neurological pathways. Understanding the molecular basis of CRPS is important for its diagnosis, management, and treatment. For instance, vagal nerve stimulation might have the potential for treating CRPS through the cholinergic anti-inflammatory pathway.

Increased calcium-mediated cerebral processes after peripheral injury: possible role of the brain in complex regional pain syndrome

Background

Among various diseases that accompany pain, complex regional pain syndrome (CRPS) is one of the most frustrating for patients and physicians. Recently, many studies have shown functional and anatomical abnormalities in the brains of patients with CRPS. The calcium-related signaling pathway is important in various physiologic processes via calmodulin (CaM) and calcium-calmodulin kinase 2 (CaMK2). To investigate the cerebral mechanism of CRPS, we measured changes in CaM and CaMK2 expression in the cerebrum in CRPS animal models.

Methods

The chronic post-ischemia pain model was employed for CRPS model generation. After generation of the animal models, the animals were categorized into three groups based on changes in the withdrawal threshold for the affected limb: CRPS-positive (P), CRPS-negative (N), and control (C) groups. Western blot analysis was performed to measure CaM and CaMK2 expression in the rat cerebrum.

Results

Animals with a decreased withdrawal threshold (group P) showed a significant increment in cerebral CaM and CaMK2 expression (P = 0.013 and P = 0.021, respectively). However, groups N and C showed no difference in CaM and CaMK2 expression.

Conclusions

The calcium-mediated cerebral process occurs after peripheral injury in CRPS, and there can be a relationship between the cerebrum and the pathogenesis of CRPS.

Symptom reduction and improved function in chronic CRPS type 1 after 12-week integrated, interdisciplinary therapy

Background and aims Complex Regional Pain Syndrome (CRPS) often recovers spontaneously within the first year, but when it becomes chronic, available rehabilitative therapies (pharmacological management, physiotherapy, and psychological intervention) have limited effectiveness. This study examined the effect of a 12-week intensive outpatient rehabilitation on pain relief and function in chronic CRPS patients. Rehabilitation program included memantine and morphine treatment (added to patient's prior pain medication) and concurrent psychological and physiotherapeutic intervention. Primary outcome measure was a change in CRPS symptom count and secondary outcomes were motor performance, psychological factors, pain intensity, and quality of life. Methods Ten patients with chronic upper limb CRPS I (median 2.9 years, range 8 months to 12 years) were recruited to the study and were assessed before and after the intervention. Hand motor function of the patients was evaluated by an independent physiotherapist. There were standardized questionnaires for depression, pain anxiety, pain acceptance, quality of life, and CRPS symptom count. In addition, psychological factors were evaluated by a semi-structured interview. Severity of experienced pain was rated at movement and at rest. In addition, a video experiment of a hand action observation was conducted pre- and post-intervention to study possible change in neuronal maladaptation. Intervention consisted of pharmacological, psychological and physiotherapeutic treatment. First, 10 mg daily morphine was started and increased gradually to 30 mg daily, if tolerated. After 30 mg/day or tolerated dose of morphine was achieved, 5 mg daily memantine was started and increased gradually to 40 mg, if tolerated. Psychological intervention consisted of weekly group sessions, using cognitive and behavioral methods (relaxation, behavioral activation, and exposure) and acceptance and commitment therapy (ACT) and daily home practice. Physiotherapeutic intervention consisted of graded motor imagery and physiotherapy exercises with weekly group sessions and/or individual guidance by the physiotherapist, and individual exercise of the affected upper limb. Results Multimodal intensive intervention resulted in significant decrease in CRPS symptom count. The effect was strongest in motor and trophic symptoms (19% decrease after intervention) and in sensory symptoms (18% decrease). Additionally, improvement was seen in some, but not all, secondary outcomes (movement pain, motor symptoms, change in perceptions during video experiment of hand actions, and summary index with motor functioning, pain, and psychological factors). There were no dropouts. Conclusions Intensive 12-week multimodal intervention reduced some CRPS symptoms but was not sufficient to alter patients' rest pain, distress, or quality of life. Implications These results support the efficacy of an interdisciplinary rehabilitation program for pain and function in chronic CRPS patients. After intervention, some CRPS symptoms reduced and function improved, but distress and quality of life were unchanged. This may be due to the relatively short duration of this program; to delayed effects; to particular cognitive problems of CPRS patients; and/or to low distress levels at baseline that make statistically significant reduction less likely.

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.

A proposed clinical conceptual model for the physiotherapy management of Complex Regional Pain Syndrome (CRPS)

There are no validated clinical models to show a reliable pathway of guaranteeing an effective recovery for Complex Regional Pain Syndrome (CRPS) with physiotherapy management. An array of medical, psychological and physiotherapy intervention methods show weak benefit. Spearman correlations, with significance p < 0.05, from an observational, prospective, longitudinal, multi-centre study of regional standard physiotherapy CRPS management showed complete recovery to be potentially associated with baseline factors of: better mental health; better functional ability and quality of life; higher scores of extraversion personality trait; lower scores of intraversion personality trait; and interventions such as concurrent prescription of the anticonvulsant secondary analgesia group and a higher intensity of physiotherapy education intervention. These correlations were integrated with the literature evidence and the crux of previously suggested models to conceptualise a clinical model that can contribute to the broader knowledge of physiotherapy management in CRPS that should be tested with future research.

Epidemiology of complex regional pain syndrome in Korea: An electronic population health data study

Chronic regional pain syndrome (CRPS) is an inflammatory and neuropathic pain disorder characterized by the involvement of the autonomic nervous system with sensory, autonomic, motor, skin, and bone changes. At present, universally accepted consensus criteria for CRPS are not yet established, despite the diagnostic criteria proposed by the International Association for the Study of Pain (IASP). Various hypotheses for the pathophysiology of CRPS have been proposed; as a result, current therapeutic modalities are varied. General epidemiological data on CRPS are necessary for effective management. However, recent data on the epidemiology of CRPS in Korea are scarce. The aim of this study was to evaluate the incidence and other epidemiological features of CRPS in the general population in Korea. In this study on the epidemiology of CRPS in Korea, population-based medical data acquired from 51,448,491 subscribers to the National Health Insurance Service (NHIS) from 2011 to 2015 were analyzed, including the incidence, distribution by the CRPS type, regional distribution, monthly distribution, medical costs, and healthcare resource-utilization. The findings indicated that the incidence of CRPS in Korea was 29.0 per 100,000 person-years in 2015 and was correlated with patient age and sex. CRPS types included type I (63%) and type II (37%); moreover, the number of individuals with CRPS I have shown a growing trend since 2011. There was no monthly distribution, but there was regional variation according to the province. The medical departments managing CRPS I the most were orthopedics, internal medicine, anesthesiology and pain medicine, in order; however, patients with CRPS spent more money per visit in the departments of rehabilitation medicine, and anesthesiology and pain medicine. The incidence rate of CRPS in Korea was 29.0 per 100,000 person-years with an increasing trend, which was correlated with patient age in the 70s and female sex. CRPS type I was more common than CRPS type II; in addition, constant increase in medical expenses, regional imbalance, and differences in medical expense among medical specialties should be considered for early management of patients to reduce the disease burden in Korea. Sharing of knowledge about the diagnostic criteria of CRPS are also needed.

Complex Regional Pain Syndrome Type 1: Diagnosis and Management

Diagnosis of Complex regional pain syndrome (CRPS) is made primarily on a clinical basis, and no specific test is known to confirm or exclude CRPS diagnosis. That is, there aren’t specific diagnostic tools and instrumental tests are made only for identifying an etiology at the basis of the CRPS. Numerous therapeutic methods have been introduced, but none have shown definitive results. When symptoms persist, patients experience permanent impairment and disability. Therefore, early recognition of CRPS, along with proper treatment, is important for minimizing permanent loss of function. As there is no gold standard test for CRPS, several clinical diagnostic criteria have been introduced and applied in various studies. However, to date, no formal or standardized diagnostic criteria for CRPS have been widely accepted. However, the Budapest diagnostic criteria have recently increased in popularity and are frequently used in scientific studies. The goal for management of CRPS is the return of normal limb function. No specific technique has been shown to prevent CRPS following surgery, but avoidance of prolonged immobilization may be important. Therefore, initiating early post-surgical rehabilitation, where possible, is important. A multidisciplinary approach would seem to be optimal, above all things objectives of physical and occupational therapy are fulfilled with combination pharmacotherapy due to provide pain relief to facilitate physical rehabilitation. Future research using large randomized controlled trials should focus on collecting strong evidence for the etiology of CRPS, testing pharmacological effects, and determining appropriate combination treatment strategies.

Bodily Sensory Inputs and Anomalous Bodily Experiences in Complex Regional Pain Syndrome: Evaluation of the Potential Effects of Sound Feedback

Neuroscientific studies have shown that human's mental body representations are not fixed but are constantly updated through sensory feedback, including sound feedback. This suggests potential new therapeutic sensory approaches for patients experiencing body-perception disturbances (BPD). BPD can occur in association with chronic pain, for example in Complex Regional Pain Syndrome (CRPS). BPD often impacts on emotional, social, and motor functioning. Here we present the results from a proof-of-principle pilot study investigating the potential value of using sound feedback for altering BPD and its related emotional state and motor behavior in those with CRPS. We build on previous findings that real-time alteration of the sounds produced by walking can alter healthy people's perception of their own body size, while also resulting in more active gait patterns and a more positive emotional state. In the present study we quantified the emotional state, BPD, pain levels and gait of twelve people with CRPS Type 1, who were exposed to real-time alteration of their walking sounds. Results confirm previous reports of the complexity of the BPD linked to CRPS, as participants could be classified into four BPD subgroups according to how they mentally visualize their body. Further, results suggest that sound feedback may affect the perceived size of the CRPS affected limb and the pain experienced, but that the effects may differ according to the type of BPD. Sound feedback affected CRPS descriptors and other bodily feelings and emotions including feelings of emotional dominance, limb detachment, position awareness, attention and negative feelings toward the limb. Gait also varied with sound feedback, affecting the foot contact time with the ground in a way consistent with experienced changes in body weight. Although, findings from this small pilot study should be interpreted with caution, they suggest potential applications for regenerating BDP and its related bodily feelings in a clinical setting for patients with chronic pain and BPD.

Treatment of complex regional pain syndrome with stellate ganglion local anesthetic blockade: a case report of one patient's experiences with traditional bupivacaine HCl and liposome bupivacaine

Complex regional pain syndrome (CRPS) is a poorly understood, debilitating disorder characterized by severe chronic pain in an affected limb or region of the body. This case presentation is the first to describe the effectiveness and prolonged duration of the effect of liposome bupivacaine in stellate ganglion block for CRPS.

Intravenous Therapies for Complex Regional Pain Syndrome: A Systematic Review

Complex regional pain syndrome (CRPS) remains a challenging clinical pain condition. Multidisciplinary approaches have been advocated for managing CRPS. Compared with spinal cord stimulation and intrathecal targeted therapy, IV treatments are less invasive and less costly. We aimed to systemically review the literature on IV therapies and determine the level of evidence to guide the management of CRPS. We searched PubMed, Embase, Scopus, and the Cochrane databases for articles published on IV therapies of CRPS up through February 2015. The search yielded 299 articles, of which 101 were deemed relevant by reading the titles and 63 by reading abstracts. All these 63 articles were retrieved for analysis and discussion. We evaluated the relevant studies and provided recommendations according to the level of evidence. We conclude that there is evidence to support the use of IV bisphosphonates, immunoglobulin, ketamine, or lidocaine as valuable interventions in selected patients with CRPS. However, high-quality studies are required to further evaluate the safety, efficacy, and cost-effectiveness of IV therapies for CRPS.

Immediate Return to Ambulation and Improved Functional Capacity for Rehabilitation in Complex Regional Pain Syndrome following Early Implantation of a Spinal Cord Stimulation System

Complex regional pain syndrome (CRPS) is a neuropathic pain condition that is characterized by vasomotor, sensory, sudomotor, and motor symptoms. Spinal cord stimulation (SCS) has been successfully utilized for the treatment of pain refractory to conventional therapies. We present a case of a previously highly functioning 54-year-old female who developed a rarely reported case of idiopathic CRPS of the right ankle which spontaneously occurred four months after an uncomplicated anterior cervical disc fusion. This condition resulted in severe pain and functional impairment that was unresponsive to pharmacological management. The patient's rehabilitation was severely stymied by her excruciating pain. However, with the initiation of spinal cord stimulation, her pain was adequately controlled allowing for progression to full unassisted ambulation, advancing functional capacity, and improving quality of life. This case report supports the concept that rapid progression to neuromodulation, rather than delays that occur due to attempts at serial sympathetic blocks, may better control symptoms leading allowing for a more meaningful recovery.

Treatment of complex regional pain syndrome type 1 in a pediatric patient using the lidocaine patch 5%: a case report

BACKGROUND

Successful treatment of complex regional pain syndrome type 1 (CRPS-1) requires a coordinated, multidisciplinary approach. Physical rehabilitation is an important component of long-term treatment. Unfortunately, patients with significant allodynia or hyperalgesia characteristic of CRPS-1 often have difficulty progressing through a physical therapy (PT) regimen. In most adults with CRPS-1, the treatment of choice is PO opioids.

OBJECTIVE

This article presents a case report of the use of the lidocaine patch 5%, a targeted peripheral analgesic, in a pediatric patient and its effects on reducing pain, improving the patient's overall attitude, and facilitating compliance with ongoing PT.

RESULTS

A 10-year-old girl developed CRPS-1 after arthroscopic surgery for a sprained ankle. Attempts at PT were unsuccessful due to inadequate pain relief from various treatment modalities. Therapy with the lidocaine patch 5% was initiated and resulted in significant pain relief, improvements in the patient's attitude, and progress with PT.

CONCLUSION

This case report of a child with CRPS-1 showed that therapy with lidocaine patch 5% may be efficacious in treating children with pain resulting from CRPS-1, thereby increasing the success of PT.

Pulsed radiofrequency treatment of complex regional pain syndrome: a case series

BACKGROUND

Various forms of sympathetic chain neurolysis (sympathectomy) have, at one time or another, held promise as effective treatment options for complex regional pain syndrome (CRPS). Complications, such as worsening pain and the development of new pain syndromes, have prevented sympathectomy from emerging as a standard intervention. In an effort to avoid poor outcomes associated with neurolysis, pulsed radiofrequency (PRF) has been proposed as a potential treatment alternative for a number of chronic neuropathic pain states, including some forms of CRPS.

METHODS

The present report describes three cases in which patients diagnosed with lower extremity CRPS type I obtained substantial and lasting intervals of pain relief following PRF of the lumbar sympathetic chain. Over a period of four years, 14 fluoroscopically guided procedures using PRF lesioning of the lumbar sympathetic chain at L2, L3 and L4 were performed in three individuals with CRPS type I of the lower limb. Outcome measures included pre- and post-treatment self-reported pain and medication requirements.

RESULTS

Substantial pain relief (>50%) was achieved in 91.7% of PRF applications at three months and 83.3% at six months, with some treatments resulting in persistent relief well beyond 12 months. Medication use decreased to a comparable degree, with discontinuation of opiates after all but three treatments.

CONCLUSIONS

PRF lesioning of the lumbar sympathetic chain can be an effective treatment for patients with CRPS type I of the lower extremity, with the potential to provide ≥6 months of substantial pain relief.

Role of rehabilitation medicine and physical agents in the treatment of cancer-associated pain

PURPOSE

To provide an overview of rehabilitation medicine- and physical modality-based approaches to cancer pain management, and to highlight the fact that these approaches are generally used in conjunction and that a majority are focused on minimizing pain during periods of mobility and the performance of activities of daily living.

METHODS

We performed a nonsystematic literature review and provide a description of the current standard of care.

RESULTS

Rehabilitative and physical modalities used to manage pain can be grouped into four categories: those that modulate nociception, stabilize or unload painful structures, influence physiological processes that indirectly influence nociception, or alleviate pain arising from the overloading of muscles and connective tissues that often occurs after surgery or with sarcopenia in late-stage cancer. Most modalities have been pragmatically refined over the years, and many have an evidence base, although few have been explicitly validated in the oncologic setting. With few exceptions, they are patient controlled and free of adverse effects.

CONCLUSION

Physical modalities and rehabilitation medicine offer a range of pain management approaches that may serve as beneficial adjuncts to the conventional systemic and interventional analgesic strategies used to control cancer-related pain. These approaches may be particularly beneficial to patients with movement-associated pain and those who are ambivalent regarding pharmacoanalgesia.

Spinal cord stimulator placement in a patient with complex regional pain syndrome and ankylosing spondylitis: a novel approach with dual benefits

Spinal cord stimulation is a treatment modality used to treat various chronic pain conditions, including complex regional pain syndrome (CRPS). We present a case in which spinal cord stimulation was used for the treatment of lower extremity CRPS in a patient with ankylosing spondylitis. Preoperative imaging demonstrated fusion of the lumbothoracic spine with obliteration of the interlaminar spaces. The sacral hiatus remained open and was used to access the epidural space, facilitating the placement of 2 thoracic epidural electrodes. The resulting stimulation controlled not only the patient's lower extremity CRPS pain but also alleviated his chronic axial pain secondary to ankylosing spondylitis.

Complex regional pain syndrome in a young athlete with von Willebrand disease

A 17-year-old female with type 1 Von Willebrand Disease (vWD) developed left medial calf pain while running track. Over the next 6 months, orthopedic surgery, sports medicine, vascular surgery, and neurology treated her under various working diagnoses; however, the pain, allodynia, coldness, and pale skin color worsened. She was admitted to a tertiary pediatric hospital for intractable pain where PM&R diagnosed her with complex regional pain syndrome (CRPS) type 1, began gabapentin, and initiated an aggressive inpatient rehabilitation program. During her 3 weeks of inpatient rehabilitation, passive range of motion of knee extension improved from 40° from extension to full extension, and ankle dorsiflexion improved from 15° from neutral to a consistent range of motion beyond neutral. Additional outcome measures were distance of ambulation and assistive device usage; from admission to inpatient rehabilitation to 2 months postdischarge, her weight-bearing tolerance progressed from nonweight-bearing to partial weight-bearing, and ambulation improved from 20 feet with a three-point crutch gait to unlimited distances with a four-point crutch gait. This is the first known case of a bleeding disorder as the likely underlying microvascular pathology associated with CRPS, a theory exposed in 2010.

EMDR as a Therapeutic Treatment for Complex Regional Pain Syndrome: A Case Report

Complex regional pain syndrome (CRPS) is characterized by ongoing pain, swelling, and stiffness following an acute injury. CRPS is difficult to diagnose, significantly impacts functioning, and is frequently incurable. Current treatments are pharmacotherapy, surgery, and physiotherapy. This case report describes the use of eye movement desensitization and reprocessing (EMDR) in the psychotherapeutic treatment of a woman diagnosed with CRPS in 2009 as a result of injuries sustained during an assault in 2004. This article reports on EMDR treatment provided 1–2 years after her diagnosis. At initial assessment, the client was debilitated and suicidal, unable to work or care for her children, and dependent on her family for financial support because of CRPS. Two phases of 7 EMDR sessions were provided; the first focused on past traumatic experiences; the second addressed her pain with Grant’s (2009) EMDR chronic pain protocol. At the end of treatment, the client reported decreased pain, decreased substance dependence, improved mood and outlook, and was able to resume part-time work. Results were maintained at 8-month follow-up and suggest that EMDR was helpful for this client in reducing the symptoms associated with 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.

Neuropathic pain

Neuropathic pain is a clinical entity that presents unique diagnostic and therapeutic challenges. This chapter addresses the classification, epidemiology, pathophysiology, diagnosis, and treatment of neuropathic pain syndrome. Neuropathic pain can be distinguished from nociceptive pain based on clinical signs and symptoms. Although neuropathic pain presents a significant burden to individuals and society, a more accurate assessment of resource utilization, costs, and impairments associated with neuropathic pain would facilitate appropriate planning of healthcare policies. The underlying pathophysiology of neuropathic pain is not well defined. Several theories regarding the mechanism of neuropathic pain have been proposed, including central and peripheral nervous system sensitization, deafferentation, neurogenic inflammation, and the wind up theory. Neuropathic pain is a clinical diagnosis and requires a systematic approach to assessment, including a detailed history, physical examination, and appropriate diagnostic testing. The mainstay of treatment for neuropathic pain is pharmacological, including the use of antidepressants, antiepileptics, topical anesthetics, and opioids. Nonpharmacological treatments include psychological approaches, physical therapy, interventional therapy, spinal cord stimulation, and surgical procedures. Neuropathic pain is difficult to treat, but a combination of therapies may be more effective than monotherapy. Clinical practice guidelines provide an evidence-based approach to the treatment of neuropathic pain.

A day-hospital approach to treatment of pediatric complex regional pain syndrome: initial functional outcomes

OBJECTIVES

To examine clinical outcomes of an interdisciplinary day-hospital treatment program (comprised of physical, occupational, and cognitive-behavioral therapies with medical and nursing services) for pediatric complex regional pain syndrome (CRPS).

METHODS

The study is a longitudinal case series of consecutive patients treated in a day-hospital pediatric pain rehabilitation program. Participants were 56 children and adolescents with ages 8 to 18 years (median=14 y) with CRPS spectrum conditions who failed to progress sufficiently with a previous outpatient and/or inpatient treatments. Patients participated in daily physical therapy, occupational therapy, and psychological treatment and received nursing and medical care as necessary. The model places equal emphasis on physical and cognitive-behavioral approaches to pain management. Median duration of stay was 3 weeks. Outcome measures included assessments of physical, occupational, and psychological functioning at program admission, discharge, and at posttreatment follow-up at a median of 10 months after discharge. Scores at discharge and follow-up were compared with measures on admission by Wilcoxon tests, paired t tests, or analysis of variance as appropriate, with corrections for multiple comparisons.

RESULTS

Outcomes demonstrate clinically and statistically significant improvements from admission to discharge in pain intensity (P<0.001), functional disability (P<0.001), subjective report of limb function (P<0.001), timed running (P<0.001), occupational performance (P<0.001), medication use (P<0.01), use of assistive devices (P<0.001), and emotional functioning (anxiety, P<0.001; depression, P<0.01). Functional gains were maintained or further improved at follow-up.

DISCUSSION

A day-hospital interdisciplinary rehabilitation approach seems effective in reducing disability and improving physical and emotional functioning and occupational performance among children and adolescents with CRPSs that have failed to improve with outpatient treatment.

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.

[Efficacy of a topical treatment protocol with dimethyl sulfoxide 50% in type 1 complex regional pain syndrome]

OBJECTIVE

Evaluate the efficacy of a topical treatment protocol with DMSO 50% to alleviate inflammatory processes in type 1 complex regional pain syndrome (CRPS) with a course of less than 1 year.

METHOD

Retrospective study performed in a traumatology hospital on patients with type 1 CRPS for whom a standard treatment algorithm was prescribed with stepwise administration of oral drugs and interventional techniques. Patients also received topical DMSO 50% cream as a magistral formula. The follow-up period, lasting until patient discharge, or during 1 year for persistent cases, included 6 visits: baseline, 15 days, 1 month, 3 months, 6 months, and 1 year. The evaluation was performed using a visual analogue scale (VAS) as the main efficacy variable. Secondary variables were the Likert scale for quality of life and the limb capacity variable (range of motion, strength, overall limb function). A questionnaire designed for the study was also given.

RESULTS

Overall decrease in VAS score in the 29 patients was 3.09 points. The Likert scale score increased by 1.36 points. The scores measuring limb capacity increased to 12.03 for range of motion and to 3 in strength with overall function rated «moderate».

CONCLUSIONS

Topical application of DMSO 50% associated with a treatment algorithm decreased pain intensity according to the VAS score with results approaching absence of pain, and led to higher scores on the quality of life questionnaire. Topical DMSO 50% is an additional tool for use in treating CRPS I. Its side effects are scarce and it provides an overall sense of relief and lessens rigidity.