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Choi EJ, Kim S, Lim D, Jin HS, Hong SM, Lee PB, Nahm FS. Effect duration of lumbar sympathetic ganglion neurolysis in patients with complex regional pain syndrome: a prospective observational study. Sci Rep 2024; 14:12693. [PMID: 38830944 PMCID: PMC11148052 DOI: 10.1038/s41598-024-63732-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 05/31/2024] [Indexed: 06/05/2024] Open
Abstract
Lumbar sympathetic ganglion neurolysis (LSGN) has been used for long-term pain relief in patients with complex regional pain syndrome (CRPS). However, the actual effect duration of LSGN has not been accurately measured. This prospective observational study measured the effect duration of LSGN in CRPS patients and investigated the relationship between temperature change and pain relief. After performing LSGN, the skin temperatures of both the maximum pain site and the plantar area in the affected and unaffected limbs were measured by infrared thermography, and pain intensity was assessed before and at 2 weeks, 1 month, and 3 months. The median time to return to baseline temperature was calculated using survival analysis. The skin temperature increased significantly at all-time points relative to baseline in both regions (maximum pain site: 1.4 °C ± 1.0 °C, plantar region: 1.28 °C ± 0.8 °C, all P < 0.001). The median time to return to baseline temperature was 12 weeks (95% confidence interval [CI] 7.7-16.3) at the maximum pain site and 12 weeks (95% CI 9.4-14.6) at the plantar area. Pain intensity decreased significantly relative to baseline, at all-time points after LSGN. In conclusion, the median duration of the LSGN is estimated to be 12 weeks.
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Affiliation(s)
- Eun Joo Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sunmin Kim
- Department of Anesthesiology and Pain Medicine, Korea University Anam Hospital, Seoul, South Korea
| | - Dongsik Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | | | - Sung Man Hong
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, South Korea
| | - Pyung Bok Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Francis Sahngun Nahm
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea.
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Miner SES, McCarthy MC, Ardern CI, Perry CGR, Toleva O, Nield LE, Manlhiot C, Cantor WJ. The relationships between acetylcholine-induced chest pain, objective measures of coronary vascular function and symptom status. Front Cardiovasc Med 2023; 10:1217731. [PMID: 37719976 PMCID: PMC10501450 DOI: 10.3389/fcvm.2023.1217731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/31/2023] [Indexed: 09/19/2023] Open
Abstract
Background Acetylcholine-induced chest pain is routinely measured during the assessment of microvascular function. Aims The aim was to determine the relationships between acetylcholine-induced chest pain and both symptom burden and objective measures of vascular function. Methods In patients with angina but no obstructive coronary artery disease, invasive studies determined the presence or absence of chest pain during both acetylcholine and adenosine infusion. Thermodilution-derived coronary blood flow (CBF) and index of microvascular resistance (IMR) was determined at rest and during both acetylcholine and adenosine infusion. Patients with epicardial spasm (>90%) were excluded; vasoconstriction between 20% and 90% was considered endothelial dysfunction. Results Eighty-seven patients met the inclusion criteria. Of these 52 patients (60%) experienced chest pain during acetylcholine while 35 (40%) did not. Those with acetylcholine-induced chest pain demonstrated: (1) Increased CBF at rest (1.6 ± 0.7 vs. 1.2 ± 0.4, p = 0.004) (2) Decreased IMR with acetylcholine (acetylcholine-IMR = 29.7 ± 16.3 vs. 40.4 ± 17.1, p = 0.004), (3) Equivalent IMR following adenosine (Adenosine-IMR: 21.1 ± 10.7 vs. 21.8 ± 8.2, p = 0.76), (4) Increased adenosine-induced chest pain (40/52 = 77% vs. 7/35 = 20%, p < 0.0001), (5) Increased chest pain during exercise testing (30/46 = 63% vs. 4/29 = 12%, p < 0.00001) with no differences in exercise duration or electrocardiographic changes, and (6) Increased prevalence of epicardial endothelial dysfunction (33/52 = 63% vs. 14/35 = 40%, p = 0.03). Conclusions After excluding epicardial spasm, acetylcholine-induced chest pain is associated with increased pain during exercise and adenosine infusion, increased coronary blood flow at rest, decreased microvascular resistance in response to acetylcholine and increased prevalence of epicardial endothelial dysfunction. These findings raise questions about the mechanisms underlying acetylcholine-induced chest pain.
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Affiliation(s)
- Steven E. S. Miner
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, ON, Canada
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mary C. McCarthy
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Chris I. Ardern
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
| | - Chris G. R. Perry
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
| | - Olga Toleva
- Department of Cardiology, Emory University, Atlanta, GA, United States
| | - Lynne E. Nield
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cedric Manlhiot
- The Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, United States
| | - Warren J. Cantor
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Fulas OA, Laferriere A, Stein RS, Bohle DS, Coderre TJ. Topical combination of meldonium and N‐acetyl cysteine relieves allodynia in rat models of CRPS‐1 and peripheral neuropathic pain by enhancing NO‐mediated tissue oxygenation. J Neurochem 2020; 152:570-584. [DOI: 10.1111/jnc.14943] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/13/2019] [Accepted: 12/16/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Oli A. Fulas
- Department of Anesthesia McGill University Montreal QC Canada
| | | | - Robin S. Stein
- Department of Chemistry McGill University Montreal QC Canada
| | - D. Scott Bohle
- Department of Chemistry McGill University Montreal QC Canada
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Complex regional pain syndrome: a focus on the autonomic nervous system. Clin Auton Res 2019; 29:457-467. [PMID: 31104164 DOI: 10.1007/s10286-019-00612-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/07/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Although autonomic features are part of the diagnostic criteria for complex regional pain syndrome (CRPS), the role of the autonomic nervous system in CRPS pathophysiology has been downplayed in recent years. The purpose of this review is to redress this imbalance. METHODS We focus in this review on the contribution of the autonomic nervous system to CRPS pathophysiology. In particular, we discuss regional sympathetic and systemic autonomic disturbances in CRPS and the mechanisms which may underlie them, and consider links between these mechanisms, immune disturbances and pain. RESULTS The focused literature research revealed that immune reactions, alterations in receptor populations (e.g., upregulation of adrenoceptors and reduced cutaneous nerve fiber density) and central changes in autonomic drive seem to contribute to regional and systemic disturbances in sympathetic activity and to sympathetically maintained pain in CRPS. CONCLUSIONS We conclude that alterations in the sympathetic nervous system contribute to CRPS pathology. Understanding these alterations may be an important step towards providing appropriate treatments for CRPS.
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Bellon G, Venturin A, Masiero S, Del Felice A. Intra-articular botulinum toxin injection in complex regional pain syndrome: Case report and review of the literature. Toxicon 2019; 159:41-44. [DOI: 10.1016/j.toxicon.2019.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 12/29/2018] [Accepted: 01/02/2019] [Indexed: 01/05/2023]
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Stanton-Hicks MD. CRPS: what’s in a name? Taxonomy, epidemiology, neurologic, immune and autoimmune considerations. Reg Anesth Pain Med 2019; 44:376-387. [DOI: 10.1136/rapm-2018-100064] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 09/25/2018] [Accepted: 10/03/2018] [Indexed: 12/26/2022]
Abstract
This account of the condition now termed complex regional pain syndrome (CRPS) spans approximately 462 years since a description embodying similar clinical features was described by Ambroise Paré in 1557. While reviewing its historical origins, the text describes why it became necessary to change the taxonomies of two clinical syndromes with similar pathophysiologies to one which acknowledges this aspect but does not introduce any mechanistic overtones. Discussed at length is the role of the sympathetic component of the autonomic nervous system (ANS) and why its dysfunction has both directly and indirectly influenced our understanding of the inflammatory aspects of CRPS. As the following article will show, our knowledge has expanded in an exponential fashion to include musculoskeletal, immune, autoimmune, central and peripheral nervous system and ANS dysfunction, all of which increase the complexity of its clinical management. A burgeoning literature is beginning to shed light on the mechanistic aspects of these syndromes and the increasing evidence of a genetic influence on such factors as autoimmunity, and its importance is also discussed at length. An important aspect that has been missing from the diagnostic criteria is a measure of disease severity. The recent validation of a CRPS Severity Score is also included.
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A new hypothesis for the pathophysiology of complex regional pain syndrome. Med Hypotheses 2018; 119:41-53. [DOI: 10.1016/j.mehy.2018.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/18/2018] [Accepted: 07/27/2018] [Indexed: 12/21/2022]
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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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Adult Complex Regional Pain Syndrome Type I: A Narrative Review. PM R 2016; 9:707-719. [PMID: 27890578 DOI: 10.1016/j.pmrj.2016.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 11/06/2016] [Accepted: 11/15/2016] [Indexed: 12/19/2022]
Abstract
Complex regional pain syndrome type I (CRPS I) is a multifactorial painful disorder with a complex pathogenesis. Both peripheral and central mechanisms are involved. Acute CRPS I is considered to be an exaggerated inflammatory disorder; however, over time, because of altered function of the sympathetic nervous system and maladaptive neuroplasticity, CRPS I evolves into a neurological disorder. This review thoroughly describes the pathophysiological aspects of CRPS I and summarizes the potential therapeutic options. The mechanisms and targets of the treatment are different in the early and late stages of the disease. This current review builds on a previous review by this author group by deepening the role of the peripheral classic and neuronal inflammatory component in the acute stage of this painful disorder. LEVEL OF EVIDENCE Not applicable.
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Bilgili A, Çakır T, Doğan ŞK, Erçalık T, Filiz MB, Toraman F. The effectiveness of transcutaneous electrical nerve stimulation in the management of patients with complex regional pain syndrome: A randomized, double-blinded, placebo-controlled prospective study. J Back Musculoskelet Rehabil 2016; 29:661-671. [PMID: 26922847 DOI: 10.3233/bmr-160667] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the effect of transcutaneous electrical nerve stimulation (TENS) on clinical recovery in the management of patients with complex regional pain syndrome Type I (CRPS Type I). MATERIAL AND METHOD The study included 30 patients with stage 1 and 2 CRPS Type I in the upper extremities. The patients were randomly assigned into 2 groups, group 1 (n= 15) received conventional TENS therapy for 20 minutes, and group 2 (n= 15) received sham TENS therapy. The standard physical therapy program, which included contrast bath for 20 minutes; whirlpool bath for 15 minutes; assisted active and passive range of motion, and static stretching exercises up to the pain threshold, was also conducted in both groups. Therapy was scheduled for 15 sessions. A visual analogue scale (VAS) was used to assess spontaneous pain. The Leeds Assessment of Neuropathic Signs and Symptoms (LANSS) scale and the Douleur Neuropathique en 4 Questions (DN-4) were used to assess neuropathic pain. In addition, range of motion (ROM) was measured using a goniometer and volumetric measurements were taken to assess edema. Functional capacity was assessed using a hand dynamometer and the Duruöz Hand Index (DHI). All measurements were performed at baseline and after therapy. RESULTS Significant improvements were achieved in spontaneous and neuropathic pain scores, edema, ROM, and functional capacity in both groups (p< 0.05). However, improvement was found to be significantly greater in group 1 regarding pain intensity, neuropathic pain assessed using LANNS, edema, and in the 2nd-3rd finger ROM measurements (p< 0.05). No significant difference was detected between groups regarding improvements in 4th-5th finger and wrist ROM measurements, grip strength, and DN4 and DHI scores (p> 0.05). CONCLUSION The addition of TENS to the physical therapy program was seen to make a significant contribution to clinical recovery in CRPS Type 1.
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Affiliation(s)
- Adem Bilgili
- Physical Medicine and Rehabilitation Clinics, Iğdır State Hospital, Iğdır, Turkey
| | - Tuncay Çakır
- Physical Medicine and Rehabilitation Clinics, Antalya Training & Research Hospital, Antalya, Turkey
| | - Şebnem Koldaş Doğan
- Physical Medicine and Rehabilitation Clinics, Antalya Training & Research Hospital, Antalya, Turkey
| | - Tülay Erçalık
- Department of Algologia, Physical Medicine and Rehabilitation Clinics, School of Medicine, Marmara University, Istanbul, Turkey
| | - Meral Bilgilisoy Filiz
- Physical Medicine and Rehabilitation Clinics, Antalya Training & Research Hospital, Antalya, Turkey
| | - Füsun Toraman
- Physical Medicine and Rehabilitation Clinics, Antalya Training & Research Hospital, Antalya, Turkey
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Sikandar S, Aasvang EK, Dickenson AH. Scratching the surface: the processing of pain from deep tissues. Pain Manag 2016; 6:95-102. [PMID: 26974398 DOI: 10.2217/pmt.15.50] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Although most pain research focuses on skin, muscles, joints and viscerae are major sources of pain. We discuss the mechanisms of deep pains arising from somatic and visceral structures and how this can lead to widespread manifestations and chronification. We include how both altered peripheral and central sensory neurotransmission lead to deep pain states and comment on key areas such as top-down modulation where little is known. It is vital that the clinical characterization of deep pain in patients is improved to allow for back translation to preclinical models so that the missing links can be ascertained. The contribution of deeper somatic and visceral tissues to various chronic pain syndromes is common but there is much we need to know.
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Affiliation(s)
- Shafaq Sikandar
- Department of Neuroscience, Physiology & Pharmacology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Eske Kvanner Aasvang
- Section for Surgical Pathophysiology, Julianne Marie Centre, Rigshospitalet, Copenhagen University, Copenhagen 2100 KBH Ø, Denmark
| | - Anthony H Dickenson
- Department of Neuroscience, Physiology & Pharmacology, University College London, Gower Street, London, WC1E 6BT, UK
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McCormick ZL, Gagnon CM, Caldwell M, Patel J, Kornfeld S, Atchison J, Stanos S, Harden RN, Calisoff R. Short-Term Functional, Emotional, and Pain Outcomes of Patients with Complex Regional Pain Syndrome Treated in a Comprehensive Interdisciplinary Pain Management Program. PAIN MEDICINE 2015; 16:2357-67. [DOI: 10.1111/pme.12817] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Proteomic identification of altered cerebral proteins in the complex regional pain syndrome animal model. BIOMED RESEARCH INTERNATIONAL 2014; 2014:498410. [PMID: 25313364 PMCID: PMC4182003 DOI: 10.1155/2014/498410] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 08/14/2014] [Accepted: 08/25/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a rare but debilitating pain disorder. Although the exact pathophysiology of CRPS is not fully understood, central and peripheral mechanisms might be involved in the development of this disorder. To reveal the central mechanism of CRPS, we conducted a proteomic analysis of rat cerebrum using the chronic postischemia pain (CPIP) model, a novel experimental model of CRPS. MATERIALS AND METHODS After generating the CPIP animal model, we performed a proteomic analysis of the rat cerebrum using a multidimensional protein identification technology, and screened the proteins differentially expressed between the CPIP and control groups. Results. A total of 155 proteins were differentially expressed between the CPIP and control groups: 125 increased and 30 decreased; expressions of proteins related to cell signaling, synaptic plasticity, regulation of cell proliferation, and cytoskeletal formation were increased in the CPIP group. However, proenkephalin A, cereblon, and neuroserpin were decreased in CPIP group. CONCLUSION Altered expression of cerebral proteins in the CPIP model indicates cerebral involvement in the pathogenesis of CRPS. Further study is required to elucidate the roles of these proteins in the development and maintenance of CRPS.
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Gierthmühlen J, Binder A, Baron R. Mechanism-based treatment in complex regional pain syndromes. Nat Rev Neurol 2014; 10:518-28. [DOI: 10.1038/nrneurol.2014.140] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Mainka T, Bischoff FS, Baron R, Krumova EK, Nicolas V, Pennekamp W, Treede RD, Vollert J, Westermann A, Maier C. Comparison of muscle and joint pressure-pain thresholds in patients with complex regional pain syndrome and upper limb pain of other origin. Pain 2014; 155:591-597. [DOI: 10.1016/j.pain.2013.12.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 11/15/2013] [Accepted: 12/09/2013] [Indexed: 01/30/2023]
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Borchers A, Gershwin M. Complex regional pain syndrome: A comprehensive and critical review. Autoimmun Rev 2014; 13:242-65. [DOI: 10.1016/j.autrev.2013.10.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2013] [Indexed: 12/19/2022]
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Krämer HH, Hofbauer LC, Szalay G, Breimhorst M, Eberle T, Zieschang K, Rauner M, Schlereth T, Schreckenberger M, Birklein F. Osteoprotegerin: a new biomarker for impaired bone metabolism in complex regional pain syndrome? Pain 2014; 155:889-895. [PMID: 24447513 DOI: 10.1016/j.pain.2014.01.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 12/14/2013] [Accepted: 01/14/2014] [Indexed: 10/25/2022]
Abstract
Osteoprotegerin (OPG) is important for bone remodeling and may contribute to complex regional pain syndrome (CRPS) pathophysiology. We aimed to assess the value of OPG as a biomarker for CRPS and a possible correlation with radiotracer uptake in 3-phase bone scintigraphy (TPBS). OPG levels were analyzed in 23 CRPS patients (17 women; mean age 50±9.0 years; disease duration: 12 weeks [IQR 8-24]), 10 controls (6 women; mean age 58±9.6 years) and 21 patients after uncomplicated fractures (12 women; mean age: 43±15 years; time after fracture: 15 weeks [IQR: 6-22]). The CRPS and control patients also underwent TPBS. OPG in CRPS patients was significantly increased by comparison with both control groups (P=0.001; Kruskal-Wallis test; CRPS patients: 74.1 pg/mL [IQR: 47.1-100.7]; controls: 46.7 pg/mL [IQR: 35.5-55.0]; P=0.004; fracture patients: 45.9 pg/mL [IQR: 37.5-56.7]; P=0.001). As a diagnostic test for CRPS, OPG had a sensitivity of 0.74, specificity of 0.80, positive predictive value of 68% and negative predictive value of 84%. Receiver operating characteristic curve analysis showed an area under the curve of 0.80 (CI: 0.68-0.91). For the CRPS-affected hand, a significant correlation between OPG and TPBS region of interest analysis in phase III was detected (carpal bones; r=0.391; P=0.03). The persistent OPG increase in CRPS indicates enhanced osteoblastic activity shown by increased radiotracer uptake in TPBS phase III. A contribution of bone turnover to CRPS pathophysiology is likely. OPG might be useful as a biomarker for CRPS.
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Affiliation(s)
- Heidrun H Krämer
- Department of Neurology, Justus Liebig University, Giessen, Germany Department of Neurology, University Medical Center, Johannes Gutenberg University, Mainz, Germany Department of Medicine III, Dresden Technical University Medical Center, Dresden, Germany Department of Trauma Surgery, Justus Liebig University, Giessen, Germany Department of Nuclear Medicine, University Medical Center, Johannes Gutenberg University, Mainz, Germany
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Schlereth T, Drummond PD, Birklein F. Inflammation in CRPS: role of the sympathetic supply. Auton Neurosci 2013; 182:102-7. [PMID: 24411269 DOI: 10.1016/j.autneu.2013.12.011] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/11/2013] [Indexed: 12/21/2022]
Abstract
Acute Complex Regional Pain Syndrome (CRPS) is associated with signs of inflammation such as increased skin temperature, oedema, skin colour changes and pain. Pro-inflammatory cytokines (tumour necrosis factor-α (TNF-α), interleukin-2 (IL-2), IL-1beta, IL-6) are up-regulated, whereas anti-inflammatory cytokines (IL-4, IL-10) are diminished. Adaptive immunity seems to be involved in CRPS pathophysiology as many patients have autoantibodies directed against β2 adrenergic and muscarinic-2 receptors. In an animal tibial fracture model changes in the innate immune response such as up-regulation of keratinocytes are also found. Additionally, CRPS is accompanied by increased neurogenic inflammation which depends mainly on neuropeptides such as CGRP and Substance P. Besides inflammatory signs, sympathetic nervous system involvement in CRPS results in cool skin, increased sweating and sympathetically-maintained pain. The norepinephrine level is lower in the CRPS-affected than contralateral limb, but sympathetic sprouting and up-regulation of alpha-adrenoceptors may result in an adrenergic supersensitivity. The sympathetic nervous system and inflammation interact: norepinephrine influences the immune system and the production of cytokines. There is substantial evidence that this interaction contributes to the pathophysiology and clinical presentation of CRPS, but this interaction is not straightforward. How inflammation in CRPS might be exaggerated by sympathetic transmitters requires further elucidation.
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Affiliation(s)
- Tanja Schlereth
- Department of Neurology, Langenbeckstr, 1, D-55131 Mainz, Germany.
| | - Peter D Drummond
- School of Psychology and Exercise Science, Murdoch University, 6150 Western Australia, Australia
| | - Frank Birklein
- Department of Neurology, Langenbeckstr, 1, D-55131 Mainz, Germany
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Han EY, Jung HY, Kim MO. Absent median somatosensory evoked potential is a predictor of type I complex regional pain syndrome after stroke. Disabil Rehabil 2013; 36:1080-4. [PMID: 24050813 DOI: 10.3109/09638288.2013.829530] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE The objective was to determine whether the abnormal finding of somatosensory evoked potentials (SEPs) associated with the development of type I complex regional pain syndrome (CRPS) after stroke. METHODS This was a retrospective study conducted from January, 2003, to December, 2007. Seventy patients were confirmed as CRPS type I, and one hundred and eighty-two patients were assigned to the control group. The initial clinical data were reviewed including age, gender, main type of stroke, lateralization and location of the lesion, presence of glenohumeral subluxation, and the development of CRPS. Somatosensory evoked potentials tests (SEP) in median nerve (N20) and posterior tibial nerve (P37) were performed. RESULTS CRPS groups revealed significantly higher incidence of the absent and abnormal hemiplegic median SEP, hemorrhagic stroke, and glenohumeral subluxation (GHS). Binary logistic regression analysis indicated that GHS (exp.(B)=4.083, p<0.01) with the absent median SEP (exp.(B)=3.246, p<0.01) were significant independent predictors of CRPS onset. CONCLUSIONS In conclusion, GHS and the absent median SEP at sub-acute phase of stroke were primary predictors of the onset of post-stoke CRPS. Implications for Rehabilitation Recent investigations have suggested that autonomic, motor and somatosensory abnormalities of CRPS are impairments involving the central nervous system (CNS) as well as the peripheral neurogenic inflammatory process. However, the understanding of the pathophysiology of CRPS is still far from complete. The absence of SEP at the sub-acute stage of stroke correlated with the onset of post-stroke CRPS type I. The SEP evaluation at the sub-acute period after stroke might be generally used for predicting the concomitant development of post-stroke CRPS type I as well as functional recovery after stroke.
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Affiliation(s)
- Eun Young Han
- Department of Rehabilitation Medicine, Jeju National University Hospital, University of Jeju College of Medicine , Jeju , Republic of Korea and
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Kang S, Lee D, Theusch BE, Arpey CJ, Brennan TJ. Wound hypoxia in deep tissue after incision in rats. Wound Repair Regen 2013; 21:730-9. [PMID: 23926943 PMCID: PMC3776009 DOI: 10.1111/wrr.12081] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 06/01/2013] [Indexed: 11/30/2022]
Abstract
Our previous studies using rat models of incisional pain have shown that tissue lactate levels increase and pH decreases for several days after incision, suggesting the presence of an ischemic-like condition. The purpose of this study was to evaluate the time course and the extent of tissue hypoxia that develops in incised muscle and skin. We directly measured oxygen tension at several time points after incisions of the gastrocnemius muscle, the paraspinal skin, and the plantar hindpaw in anesthetized rats using an oxygen-sensitive microelectrode. In vivo hypoxia of the incised tissues was also evaluated immunohistochemically using a hypoxia marker, pimonidazole hydrochloride. To minimize intersubject variability, unincised contralateral tissues were used as a control. Tissue oxygen tension was decreased in both skeletal muscle and skin compared with control, for several days after incision. When measured directly, oxygen tension decreased immediately and remained low for several days after incisions. Pimonidazole immunostaining revealed hypoxic areas in incised muscle and skin for several days. By postoperative day 10, tissue oxygen tension recovered to that of control tissue. These results support the evidence that a hypoxic condition is present in deep tissue after incisions and that an ischemic-like mechanism may contribute to postoperative pain.
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Affiliation(s)
- Sinyoung Kang
- Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Dongchul Lee
- Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Brett E. Theusch
- Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Christopher J. Arpey
- Department of Dermatology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Timothy J. Brennan
- Department of Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Department of Pharmacology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, Iowa
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Abstract
Complex regional pain syndrome, formally known as reflex sympathetic dystrophy, is a poorly understood condition that describes a collection of clinical symptoms and signs occurring in the peripheries most commonly after trauma. Pain is the main problem. It is generally out of proportion to the degree of injury and can be unresponsive to narcotics. In addition joint stiffness, temperature and colour changes, and swelling occur. The diagnosis and treatment are challenging for any clinician and a multidisciplinary approach is often necessary with physiotherapy, occupational therapy, and the pain team. The hand surgeon is involved for two reasons, firstly as the upper limb is the most frequently involved, and secondly because the condition may be a complication of the patient's surgery and result in a much prolonged recovery. This review elucidates the recent advances in the knowledge of the aetiology, classification and treatment of this fascinating condition.
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Affiliation(s)
- J Field
- Cheltenham General Hospital, Cheltenham, UK.
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23
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Goebel A. Management of adult patients with long-standing complex regional pain syndrome. Pain Manag 2013; 3:137-46. [DOI: 10.2217/pmt.13.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
SUMMARY Approximately 15% of patients with complex regional pain syndrome will experience no improvement in their condition within the first 12 months. This group should be considered as having a long-term condition. Recently published clinical studies and national guidelines can support clinicians to devise rational approaches to the management of this group; however, conclusive evidence is still lacking for almost all aspects of care. A multidisciplinary approach to managing long-standing complex regional pain syndrome appears best suited to ensure high-quality care. This should allow effective functional rehabilitation. Unfortunately, however, meaningful pain relief is often not achieved with currently available treatment methods. Recently published novel treatment approaches will probably provide more patients with long-term pain relief in the future, but confirmatory trials are required.
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Affiliation(s)
- Andreas Goebel
- Pain Research Institute & Centre for Immune Studies in Pain, Department of Translational Medicine, Liverpool University, Liverpool, UK and The Walton Centre NHS Foundation Trust, Liverpool, UK
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Goebel A, Lawson A, Allen S, Glynn C. Buprenorphine injection to the stellate ganglion in the treatment of upper body chronic pain syndromes. Eur J Pain 2012; 12:266-74. [PMID: 17638583 DOI: 10.1016/j.ejpain.2007.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Revised: 04/07/2007] [Accepted: 05/26/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND The injection of low dose buprenorphine to the sympathetic ganglia, termed "GLOA", Ganglionide Local Opioid Analgesia, is used to treat chronic pain in several European centres. It is not known whether the clinically observed GLOA effect in chronic pain syndromes is due to a specific effect of buprenorphine at the ganglia. We assessed whether GLOA, plus intramuscular saline, was more efficacious than the reverse, saline injection to the stellate plus intramuscular buprenorphine, termed SSB. METHODS We devised a randomized, double-blinded, controlled crossover trial to treat patients with chronic upper body pain syndromes. Patients first received either GLOA or SSB. Pain was assessed using pain diaries both before injection and over the first 8h and 6days afterwards, and was expressed as relative pain intensity post versus pre-injection pain. RESULTS The median relative pain intensity after injections did not differ between GLOA and SSB. Four patients reported a low, <50%, relative pain level over the first 8h after SSB only. Four patients did not complete the trial and were excluded. One patient with cardiomyopathy became acutely diaphoretic and fatigued after GLOA, his vital signs however remained stable. CONCLUSIONS We failed to show a superiority of GLOA over SSB. Our results suggest it unlikely that the clinically observed effect after a single GLOA injection is due to a specific action of buprenorphine at the stellate ganglion. The efficacy of GLOA is hereby questioned. The use of GLOA in patients with cardiomyopathy should be cautioned. TRIAL REGISTRATION ISRCTN59287260; http://www.controlled-trials.com/
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Affiliation(s)
- Andreas Goebel
- The Pain Relief Unit, Churchill Hospital, Oxford OX3 7LJ, United Kingdom.
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25
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26
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El Sawy NAEH, Hamid MMA, El Sawy MM, Hussein NAMM. Complex regional pain syndromes: Clinical characteristics and pathophysiological factors. THE EGYPTIAN RHEUMATOLOGIST 2011; 33:121-129. [DOI: 10.1016/j.ejr.2011.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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27
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Abstract
Complex regional pain syndrome (CRPS) is a highly painful, limb-confined condition, which arises usually after trauma. It is associated with a particularly poor quality of life, and large health-care and societal costs. The causes of CRPS remain unknown. The condition's distinct combination of abnormalities includes limb-confined inflammation and tissue hypoxia, sympathetic dysregulation, small fibre damage, serum autoantibodies, central sensitization and cortical reorganization. These features place CRPS at a crossroads of interests of several disciplines including rheumatology, pain medicine and neurology. Significant scientific and clinical advances over the past 10 years hold promise both for an improved understanding of the causes of CRPS, and for more effective treatments. This review summarizes current concepts of our understanding of CRPS in adults. Based on the results from systematic reviews, treatment approaches are discussed within the context of these concepts. The treatment of CRPS is multidisciplinary and aims to educate about the condition, sustain or restore limb function, reduce pain and provide psychological intervention. Results from recent randomized controlled trials suggest that it is possible that some patients whose condition was considered refractory in the past can now be effectively treated, but confirmatory trials are required. The review concludes with a discussion of the need for additional research.
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Affiliation(s)
- Andreas Goebel
- Pain Research Group and Centre for Immune Studies in Pain, Department of Translational Medicine, University of Liverpool, UK.
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28
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Buscher HCJL, van Goor H, Sweep CGJ, Lenders JWM, Wilder-Smith OHG. Increased sympathetic activity in chronic pancreatitis patients is associated with hyperalgesia. J Pain Palliat Care Pharmacother 2011; 24:362-6. [PMID: 21133744 DOI: 10.3109/15360288.2010.519762] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pain treatment in chronic pancreatitis patients is difficult, with pain frequently relapsing or persisting. Recent studies suggest that altered central nervous system pain processing underlies the chronic pain state in these patients. There is evidence that increased sympathetic activity may also play a role in some chronic pain syndromes. This study assessed sympathetic nervous system activity and its relation to pain processing in patients with severe painful chronic pancreatitis. The authors postulated that chronic pancreatitis patients with more sympathetic activity exhibit more generalized hyperalgesia. In 16 chronic pancreatitis patients, sympathetic activity was measured via venous plasma norepinephrine (NE) levels (supine, standing). Pain processing was quantified via pressure pain tolerance thresholds (PPTs) in dermatomes T10 (pancreatic area), C5, T4, L1. Five patients showed increased supine plasma NE levels (NE ≥ 3.0 nmol/L). PPTs were lower in patients with increased NE levels (INE) compared with patients with normal NE (NNE) (means [95% confidence interval]: INE 402 kPa [286-517] versus NNE 522 kPa [444-600]; P = .042). In severe chronic pancreatitis patients, increased sympathetic activity and hyperalgesia appear associated, suggesting that sympathetic activity may also play a role in these patients' pain.
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Affiliation(s)
- H C J L Buscher
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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29
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Coderre TJ, Bennett GJ. A hypothesis for the cause of complex regional pain syndrome-type I (reflex sympathetic dystrophy): pain due to deep-tissue microvascular pathology. PAIN MEDICINE 2011; 11:1224-38. [PMID: 20704671 DOI: 10.1111/j.1526-4637.2010.00911.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Complex regional pain syndrome-type I (CRPS-I; reflex sympathetic dystrophy) is a chronic pain condition that usually follows a deep-tissue injury such as fracture or sprain. The cause of the pain is unknown. We have developed an animal model (chronic post-ischemia pain) that creates CRPS-I-like symptomatology. The model is produced by occluding the blood flow to one hind paw for 3 hours under general anesthesia. Following reperfusion, the treated hind paw exhibits an initial phase of hyperemia and edema. This is followed by mechano-hyperalgesia, mechano-allodynia, and cold-allodynia that lasted for at least 1 month. Light microscopic analyses and electron microscopic analyses of the nerves at the site of the tourniquet show that the majority of these animals have no sign of injury to myelinated or unmyelinated axons. However, electron microscopy shows that the ischemia-reperfusion injury produces a microvascular injury, slow-flow/no-reflow, in the capillaries of the hind paw muscle and digital nerves. We propose that the slow-flow/no-reflow phenomenon initiates and maintains deep-tissue ischemia and inflammation, leading to the activation of muscle nociceptors, and the ectopic activation of sensory afferent axons due to endoneurial ischemia and inflammation. These data, and a large body of clinical evidence, suggest that in at least a subset of CRPS-I patients, the fundamental cause of the abnormal pain sensations is ischemia and inflammation due to microvascular pathology in deep tissues, leading to a combination of inflammatory and neuropathic pain processes. Moreover, we suggest a unifying idea that relates the pathogenesis of CRPS-I to that of CRPS-II. Lastly, our hypothesis suggests that the role of the sympathetic nervous system in CRPS-I is a factor that is not fundamentally causative, but may have an important contributory role in early-stage disease.
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Affiliation(s)
- Terence J Coderre
- Department of Anesthesia, Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada.
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30
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Wasner G. Vasomotor disturbances in complex regional pain syndrome--a review. PAIN MEDICINE 2011; 11:1267-73. [PMID: 20704675 DOI: 10.1111/j.1526-4637.2010.00914.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Complex regional pain syndromes (CRPS) are characterized by vascular disturbances primary affecting the microcirculation in the distal part of the involved extremity. In the acute stage inhibited sympathetic vasoconstriction and exaggerated neurogenic inflammation driven by central and peripheral mechanisms, respectively, seem to be the major pathophysiological mechanisms inducing vasodilation. During the chronic course of the disease as well as early in some patients vasoconstriction dominates the clinical picture induced by changes in the microcirculation itself such as endothelial dysfunction or vascular hyperreactivity, whereas sympathetic vasoconstrictor activity returns and neurogenic inflammation is less severe. It can be suggested that the interaction between different mechanisms underlying vasomotor disturbances as well as the severity of each single mechanism in the individual patient have a great impact on the variety of the overall clinical picture in CRPS. Irrespective of the underlying pathophysiology, measurements of skin temperature differences between the affected and the contralateral extremity can serve as a diagnostic tool in CRPS, in particular when sensitivity and specificity is increased by considering dynamic alterations in skin temperature asymmetries.
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Affiliation(s)
- Gunnar Wasner
- Department of Neurology, Division of Neurological Pain Research and Therapy, University Clinic of Schleswig-Holstein, Kiel, Germany.
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31
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Binder A, Schattschneider J, Baron R. Complex Regional Pain Syndrome Type I (Reflex Sympathetic Dystrophy). Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Stanton-Hicks M. Plasticity of Complex Regional Pain Syndrome (CRPS) in Children. PAIN MEDICINE 2010; 11:1216-23. [DOI: 10.1111/j.1526-4637.2010.00910.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Different activation of opercular and posterior cingulate cortex (PCC) in patients with complex regional pain syndrome (CRPS I) compared with healthy controls during perception of electrically induced pain: a functional MRI study. Clin J Pain 2010; 26:339-47. [PMID: 20393270 DOI: 10.1097/ajp.0b013e3181cb4055] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Although the etiology of complex regional pain syndrome type 1 (CRPS 1) is still debated, many arguments favor central maladaptive changes in pain processing as an important causative factor. METHODS To look for the suspected alterations, 10 patients with CRPS affecting the left hand were explored with functional magnetic resonance imaging during graded electrical painful stimulation of both hands subsequently and compared with healthy participants. RESULTS Activation of the anterior insula, posterior cingulate cortex (PCC), and caudate nucleus was seen in patients during painful stimulation. Compared with controls, CRPS patients had stronger activation of the PCC during painful stimulation of the symptomatic hand. The comparison of insular/opercular activation between controls and patients with CRPS I during painful stimulation showed stronger (posterior) opercular activation in controls than in patients. DISCUSSION Stronger PCC activation during painful stimulation may be interpreted as a correlate of motor inhibition during painful stimuli different from controls. Also, the decreased opercular activation in CRPS patients shows less sensory-discriminative processing of painful stimuli.These results show that changed cerebral pain processing in CRPS patients is less sensory-discriminative but more motor inhibition during painful stimuli. These changes are not limited to the diseased side but show generalized alterations of cerebral pain processing in chronic pain patients.
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34
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Sensitivity and Specificity of 3-phase Bone Scintigraphy in the Diagnosis of Complex Regional Pain Syndrome of the Upper Extremity. Clin J Pain 2010; 26:182-9. [PMID: 20173431 DOI: 10.1097/ajp.0b013e3181c20207] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Jänig W. The fascination of complex regional pain syndrome. Exp Neurol 2009; 221:1-4. [PMID: 19799902 DOI: 10.1016/j.expneurol.2009.09.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Revised: 09/21/2009] [Accepted: 09/23/2009] [Indexed: 10/20/2022]
Abstract
Complex regional pain syndrome (CRPS) is a pain disorder involving the somatosensory, the somatomotor and the sympathetic nervous systems. Based on experiments conducted by Bove (2009), it is suggested that changes in impulse activity in small-diameter afferents and postganglionic axons generated by neuritis can contribute to signs of early CRPS. The potential mechanisms involved are discussed. These mechanisms include the possibility that CRPS, a disorder of the central nervous system, may be caused by a nerve inflammation.
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Affiliation(s)
- Wilfrid Jänig
- Physiologisches Institut, Christian-Albrechts-Universität zu Kiel, Kiel, Germany.
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36
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Groeneweg G, Huygen FJPM, Coderre TJ, Zijlstra FJ. Regulation of peripheral blood flow in complex regional pain syndrome: clinical implication for symptomatic relief and pain management. BMC Musculoskelet Disord 2009; 10:116. [PMID: 19775468 PMCID: PMC2758836 DOI: 10.1186/1471-2474-10-116] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2009] [Accepted: 09/23/2009] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND During the chronic stage of Complex Regional Pain Syndrome (CRPS), impaired microcirculation is related to increased vasoconstriction, tissue hypoxia, and metabolic tissue acidosis in the affected limb. Several mechanisms may be responsible for the ischemia and pain in chronic cold CPRS. DISCUSSION The diminished blood flow may be caused by either sympathetic dysfunction, hypersensitivity to circulating catecholamines, or endothelial dysfunction. The pain may be of neuropathic, inflammatory, nociceptive, or functional nature, or of mixed origin. SUMMARY The origin of the pain should be the basis of the symptomatic therapy. Since the difference in temperature between both hands fluctuates over time in cold CRPS, when in doubt, the clinician should prioritize the patient's report of a persistent cold extremity over clinical tests that show no difference. Future research should focus on developing easily applied methods for clinical use to differentiate between central and peripheral blood flow regulation disorders in individual patients.
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Affiliation(s)
- George Groeneweg
- Department of Anesthesiology, Subdivision Pain Treatment Centre, Erasmus MC, Rotterdam, the Netherlands.
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37
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Groeneweg JG, Huygen FJPM, Niehof SP, Wesseldijk F, Bussmann JBJ, Schasfoort FC, Stronks DL, Zijlstra FJ. No recovery of cold complex regional pain syndrome after transdermal isosorbide dinitrate: a small controlled trial. J Pain Symptom Manage 2009; 38:401-8. [PMID: 19515530 DOI: 10.1016/j.jpainsymman.2008.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 10/03/2008] [Accepted: 10/08/2008] [Indexed: 10/20/2022]
Abstract
The microcirculation appears to be impaired in cold chronic complex regional pain syndrome (CRPS). This double-blind, placebo-controlled, randomized trial investigated the effect of the nitric oxide (NO) donor isosorbide dinitrate (ISDN) on the peripheral blood flow in patients with chronic CRPS. Twenty-four patients received 1% ISDN in Vaseline or a placebo ointment applied to the dorsum of the affected hand four times daily for 10 weeks. The patients participated in a physical therapy program to improve activity. The primary outcome measure was blood distribution in the affected extremity, which was determined by measuring the skin temperature using videothermography. We also measured NO and endothelin-1 concentrations in blister fluid, pain using the visual analog scale, and activity limitations using an upper limb activity monitor and the Disabilities of Arm Shoulder and Hand Questionnaire. ISDN failed to produce a significant improvement in temperature asymmetry in chronic cold CRPS patients, and it did not result in the expected reduction in pain and increase in activity compared with placebo either. There may be other central or peripheral factors contributing to the disturbed vasodynamics in cold chronic CRPS that are not influenced by NO substitution. This study does not show an improvement of the regional blood distribution by ISDN in the involved extremity of patients with cold-type CRPS.
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Affiliation(s)
- J George Groeneweg
- Pain Treatment Centre, Erasmus Medical Center, Rotterdam, The Netherlands.
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38
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No Impaired Hemoglobin Oxygenation in Forearm Muscles of Patients With Chronic CRPS-1. Clin J Pain 2009; 25:513-9. [DOI: 10.1097/ajp.0b013e31819d19bc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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39
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Oaklander AL, Fields HL. Is reflex sympathetic dystrophy/complex regional pain syndrome type I a small-fiber neuropathy? Ann Neurol 2009; 65:629-38. [DOI: 10.1002/ana.21692] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Li WW, Sabsovich I, Guo TZ, Zhao R, Kingery WS, Clark DJ. The role of enhanced cutaneous IL-1beta signaling in a rat tibia fracture model of complex regional pain syndrome. Pain 2009; 144:303-313. [PMID: 19473768 DOI: 10.1016/j.pain.2009.04.033] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2009] [Revised: 04/22/2009] [Accepted: 04/28/2009] [Indexed: 12/20/2022]
Abstract
Tibia fracture in rats initiates a syndrome resembling the complex regional pain syndrome type I. Accumulating evidence indicates that IL-1beta is involved in the modulation of nociceptive information and it acts as an intermediate inflammatory mediator via up-regulation of NGF. We hypothesized that IL-1beta signaling might mediate the development of the CRPS-like changes after tibial fracture, either directly or by stimulating NGF expression. Rats underwent distal tibia fracture and casting for 4 weeks and were chronically treated with an IL-1 receptor antagonist (IL-1ra). Nociceptive testing and assessment of edema and hindpaw warmth were performed at baseline and after cast removal. Bone microarchitecture was evaluated by micro-computed tomography. Confocal immunofluorescence and in situ hybridization techniques were used to evaluate changes in the cutaneous expression of IL-1beta at 4 weeks post-fracture. The nociceptive and vascular effects of intraplantar IL-1beta injections were evaluated in intact rats at different time points after injection. We found that: (1) IL-1ra reduced fracture-induced nociceptive sensitization, but did not decrease hindpaw edema or warmth, (2) fracture chronically up-regulated IL-1beta mRNA and protein expression in hindpaw skin keratinocytes, (3) IL-1beta intraplantar injection induced mechanical allodynia in a dose-dependent manner and stimulated keratinocyte NGF expression in the hindpaw skin, and (4) intraplantar injection of NGF-induced nociceptive sensitization. Collectively, these results indicate that cutaneous IL-1beta signaling can contribute to chronic regional nociceptive sensitization after fracture, possibly by stimulating NGF over-expression in keratinocytes. Our data also highlight the importance of the keratinocyte as the primary source of post-traumatic IL-1beta over-expression.
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Affiliation(s)
- Wen-Wu Li
- Physical Medicine and Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA Anesthesiology Service, Veterans Affairs Palo Alto Health Care System Palo Alto, CA, USA Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA, USA
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41
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Affiliation(s)
- Marissa de Mos
- Erasmus University Medical Center, Pharmaco-epidemiology Unit, Departments of Medical Informatics and Epidemiology & Biostatistics, Rotterdam, The Netherlands.
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42
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43
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Danielson P, Andersson G, Alfredson H, Forsgren S. Marked sympathetic component in the perivascular innervation of the dorsal paratendinous tissue of the patellar tendon in arthroscopically treated tendinosis patients. Knee Surg Sports Traumatol Arthrosc 2008; 16:621-6. [PMID: 18418576 DOI: 10.1007/s00167-008-0530-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Accepted: 03/14/2008] [Indexed: 01/04/2023]
Abstract
During the recent years, a few studies have shed new light on the innervation patterns of the human patellar tendon, but the area of the loose paratendinous connective tissue dorsal to the proximal tendon proper has yet not been investigated. That is a drawback, since this is the area targeted in promising treatment regimens of chronic painful patellar tendinosis, namely sclerosing Polidocanol injection therapy, and a new surgical method conforming to ultrasound and color Doppler guided arthroscopic shaving, directed at neovessels found in the region. The present study thus aimed at investigating the paratendinous area dorsal to the proximal patellar tendon proper in seven patients being operated for tendinosis. Biopsies were collected through the new arthroscopic technique, approaching the tendon from the dorsal side. Samples were investigated using immunohistochemistry with antibodies delineating general (PGP 9.5), sensory (SP/CGRP), and sympathetic (TH/NPY) nerve patterns, and also antibodies against alpha1- and alpha2A-adrenoreceptors. Both small and large blood vessels had a marked perivascular innervation (PGP 9.5). Surprisingly, this perivascular innervation was found only to a very limited extent to correspond to sensory nerves, while there were marked immunoreactions for sympathetic markers. Adrenoreceptor immunoreactions frequently occurred in blood vessel walls. In conclusion, this study demonstrates, for the first time, the innervation patterns of the area dorsal to the patellar tendon in man. It shows that the area investigated is under marked influence by the sympathetic nervous system. Thus, sympathetic effects are likely to occur for blood vessels of the area, which is interesting since color Doppler has revealed that vessels of this area ("neovessels") display a pathologically high blood flow in tendinosis. The findings are discussed in relation to aspects of vascular regulation, and to pain symptoms of tendinosis.
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Affiliation(s)
- Patrik Danielson
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, 901 87, Umeå, Sweden.
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Vasodilative effect of isosorbide dinitrate ointment in complex regional pain syndrome type 1. Clin J Pain 2008; 24:89-92. [PMID: 18180642 DOI: 10.1097/ajp.0b013e318156db3b] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In complex regional pain syndrome type 1 (CRPS1) vascular changes occur from the initial, inflammatory event onto the trophic signs during chronicity of the disease, resulting in blood flow disturbances and marked temperature changes. Pharmacotherapeutic treatment is generally inadequate. AIM To determine whether local application of the nitric oxide donor isosorbide dinitrate (ISDN) could cause vasodilation and thereby improve tissue blood distribution in the affected extremity. METHODS In a pilot study, 5 female patients with CRPS1 in one hand were treated with ISDN ointment 4 times daily during 10 weeks. As a primary objective videothermography was used to monitor changes in blood distribution in both the involved and contralateral extremities. RESULTS Patients treated with ISDN showed an increase of 4 degrees C to 6 degrees C in mean skin temperature of the cold CRPS1 hands, reaching values similar to that of the contralateral extremities within 2 to 4 weeks time, suggesting normalization of blood distribution. This was confirmed by an improvement in skin color. In 3 patients the Visual Analog Scale pain declined, whereas in the other 2 patients the Visual Analog Scale pain was unchanged over time. CONCLUSIONS In this pilot study, topical application of ISDN seems to be beneficial to improve symptoms for patients with cold type CRPS1, but further study is needed.
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Mogilevsky M, Jänig W, Baron R, Harden RN. Complex Regional Pain Syndrome—A Multifaceted Disorder Requiring Multidimensional Care: Case Study. THE JOURNAL OF PAIN 2007; 8:677-81. [PMID: 17652030 DOI: 10.1016/j.jpain.2007.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mila Mogilevsky
- Northwestern University, Rehabilitation Institute of Chicago, Chicago, IL, USA
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Jørum E, Ørstavik K, Schmidt R, Namer B, Carr RW, Kvarstein G, Hilliges M, Handwerker H, Torebjörk E, Schmelz M. Catecholamine-induced excitation of nociceptors in sympathetically maintained pain. Pain 2007; 127:296-301. [PMID: 16997471 DOI: 10.1016/j.pain.2006.08.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Revised: 08/09/2006] [Accepted: 08/21/2006] [Indexed: 11/16/2022]
Abstract
Sympathetically maintained pain could either be mediated by ephaptic interactions between sympathetic efferent and afferent nociceptive fibers or by catecholamine-induced activation of nociceptive nerve endings. We report here single fiber recordings from C nociceptors in a patient with sympathetically maintained pain, in whom sympathetic blockade had repeatedly eliminated the ongoing pain in both legs. We classified eight C-fibers as mechano-responsive and six as mechano-insensitive nociceptors according to their mechanical responsiveness and activity-dependent slowing of conduction velocity (latency increase of 0.5+/-1.1 vs. 7.1+/-2.0 ms for 20 pulses at 0.125 Hz). Two C-fibers were activated with a delay of several seconds following strong endogenous sympathetic bursts; they were also excited for about 3 min following the injection of norepinephrine (10 microl, 0.05%) into their innervation territory. In these two fibers, a prolonged activation by injection of low pH solution (phosphate buffer, pH 6.0, 10 microl) and sensitization of their heat response following prostaglandin E2 injection were recorded, evidencing their afferent nature. Moreover, their activity-dependent slowing was typical for mechano-insensitive nociceptors. We conclude that sensitized mechano-insensitive nociceptors can be activated by endogenously released catecholamines and thereby may contribute to sympathetically maintained pain. No evidence for ephaptic interaction between sympathetic efferent and nociceptive afferent fibers was found.
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Affiliation(s)
- Ellen Jørum
- Laboratory of Clinical Neurophysiology, Department of Neurology, Rikshospitalet University Hospital, Oslo, Norway Department of Physiology and Experimental Pathophysiology, University of Erlangen/Nürnberg, Germany Department of Clinical Neurophysiology, University Hospital, Uppsala, Sweden Department of Basic Oral Sciences, Karolinska Institute, Huddinge, Sweden Department of Anesthesiology, Rikshospitalet University Hospital, Oslo, Norway Department of Anesthesiology and Operative Intensive Care, Mannheim, University Heidelberg, Germany
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Binder A, Schattschneider J, Baron R. Complex Regional Pain Syndrome Type I (Reflex Sympathetic Dystrophy). Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50030-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Passatore M, Roatta S. Influence of sympathetic nervous system on sensorimotor function: whiplash associated disorders (WAD) as a model. Eur J Appl Physiol 2006; 98:423-49. [PMID: 17036216 DOI: 10.1007/s00421-006-0312-8] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2006] [Indexed: 12/26/2022]
Abstract
There is increasing interest about the possible involvement of the sympathetic nervous system (SNS) in initiation and maintenance of chronic muscle pain syndromes of different aetiology. Epidemiological data show that stresses of different nature, e.g. work-related, psychosocial, etc., typically characterised by SNS activation, may be a co-factor in the development of the pain syndrome and/or negatively affect its time course. In spite of their clear traumatic origin, whiplash associated disorders (WAD) appear to share many common features with other chronic pain syndromes affecting the musculo-skeletal system. These features do not only include symptoms, like type of pain or sensory and motor dysfunctions, but possibly also some of the pathophysiological mechanisms that may concur to establish the chronic pain syndrome. This review focuses on WAD, particular emphasis being devoted to sensorimotor symptoms, and on the actions exerted by the sympathetic system at muscle level. Besides its well-known action on muscle blood flow, the SNS is able to affect the contractility of muscle fibres, to modulate the proprioceptive information arising from the muscle spindle receptors and, under certain conditions, to modulate nociceptive information. Furthermore, the activity of the SNS itself is in turn affected by muscle conditions, such as its current state of activity, fatigue and pain signals originating in the muscle. The possible involvement of the SNS in the development of WAD is discussed in light of the several positive feedback loops in which it is implicated.
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Affiliation(s)
- Magda Passatore
- Department of Neuroscience, Physiology Division, University of Torino Medical School, Corso Raffaello 30, 10125, Torino, Italy.
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Pertovaara A. Noradrenergic pain modulation. Prog Neurobiol 2006; 80:53-83. [PMID: 17030082 DOI: 10.1016/j.pneurobio.2006.08.001] [Citation(s) in RCA: 395] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Revised: 08/25/2006] [Accepted: 08/30/2006] [Indexed: 11/18/2022]
Abstract
Norepinephrine is involved in intrinsic control of pain. Main sources of norepinephrine are sympathetic nerves peripherally and noradrenergic brainstem nuclei A1-A7 centrally. Peripheral norepinephrine has little influence on pain in healthy tissues, whereas in injured tissues it has variable effects, including aggravation of pain. Its peripheral pronociceptive effect has been associated with injury-induced expression of novel noradrenergic receptors, sprouting of sympathetic nerve fibers, and pronociceptive changes in the ionic channel properties of primary afferent nociceptors, while an interaction with the immune system may contribute in part to peripheral antinociception induced by norepinephrine. In the spinal cord, norepinephrine released from descending pathways suppresses pain by inhibitory action on alpha-2A-adrenoceptors on central terminals of primary afferent nociceptors (presynaptic inhibition), by direct alpha-2-adrenergic action on pain-relay neurons (postsynaptic inhibition), and by alpha-1-adrenoceptor-mediated activation of inhibitory interneurons. Additionally, alpha-2C-adrenoceptors on axon terminals of excitatory interneurons of the spinal dorsal horn possibly contribute to spinal control of pain. At supraspinal levels, the pain modulatory effect by norepinephrine and noradrenergic receptors has varied depending on many factors such as the supraspinal site, the type of the adrenoceptor, the duration of the pain and pathophysiological condition. While in baseline conditions the noradrenergic system may have little effect, sustained pain induces noradrenergic feedback inhibition of pain. Noradrenergic systems may also contribute to top-down control of pain, such as induced by a change in the behavioral state. Following injury or inflammation, the central as well as peripheral noradrenergic system is subject to various plastic changes that influence its antinociceptive efficacy.
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Affiliation(s)
- Antti Pertovaara
- Biomedicum Helsinki, Institute of Biomedicine/Physiology, PO Box 63, University of Helsinki, FIN-00014 Helsinki, Finland.
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