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Lewis JS, Wallace CS, White P, Mottram L, Ockenden G, Rehm K, Walker K. Early versus persistent Complex Regional Pain Syndrome: Is there a difference in patient reported outcomes following rehabilitation? Eur J Pain 2024; 28:464-475. [PMID: 37947050 DOI: 10.1002/ejp.2196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/18/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Expert consensus asserts that early treatment of Complex Regional Pain Syndrome (CRPS) leads to better outcomes. Yet no evidence supports this assumption regarding the recognized gold standard of multidisciplinary functional rehabilitation. To address this, we aimed to establish if there is a difference in outcomes between early CRPS (<1 year symptom duration) and persistent CRPS (= >1 year symptom duration) following rehabilitation and whether any gains are maintained at three months. METHOD Secondary analysis was conducted on previously collected clinical Patient Reported Outcome Measures (PROMS) data from 218 patients attending a residential multidisciplinary rehabilitation programme. Datasets were categorized into early CRPS (n = 40) or persistent CRPS (n = 178) dependent on symptom duration. Function, pain, self-efficacy, kinesiophobia and psychological health domains were compared using repeated measures analysis of covariance for a two group design for group difference post rehabilitation and at three month follow-up. RESULTS Post-rehabilitation, both groups improved in pain, function, kinesiophobia, psychological health and self-efficacy. At three months, the persistent CRPS group maintained improvements in pain and function. This was not achieved in early CRPS. CONCLUSION This exploratory study is the first to empirically test the assumption that those with early CRPS have better outcomes following rehabilitation. Our clinical data challenges this, as both early and persistent CRPS groups improved following rehabilitation. Findings indicate that rehabilitation benefits those with CRPS, regardless of symptom duration. However, unlike early CRPS, those with persistent CRPS sustain gains at follow-up. Further prospective exploration is warranted. SIGNIFICANCE Expert consensus recommends early treatment for Complex Regional Pain Syndrome, yet there is little empirical evidence to support this. Our findings are the first to challenge this assumption by revealing no difference in outcomes between early and persistent CRPS post-rehabilitation. However, those with persistent CRPS maintain gains after three months, unlike people with early CRPS (symptoms < one year). These findings are relevant to clinical practice as they challenge established assumptions, suggesting a focus on improving early CRPS follow-up outcomes.
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Affiliation(s)
- Jennifer S Lewis
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
- National Complex Regional Pain Syndrome Service, Royal United Hospitals NHS Trust, Bath, UK
| | - Chris S Wallace
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Paul White
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Laura Mottram
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Gareth Ockenden
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Kjetil Rehm
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Kate Walker
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
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Zhou X, Zhou Y, Zhang X, Jiang F. Economic evaluation of management strategies for complex regional pain syndrome (CRPS). Front Pharmacol 2024; 15:1297927. [PMID: 38318140 PMCID: PMC10839065 DOI: 10.3389/fphar.2024.1297927] [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: 09/20/2023] [Accepted: 01/08/2024] [Indexed: 02/07/2024] Open
Abstract
Background: The economic impact of Complex Regional Pain Syndrome (CRPS) on both patients and the global healthcare system continues to escalate. However, the economic implications associated with management interventions for CRPS have received limited attention. Therefore, our objective is to perform a thorough examination of published economic assessments of the various management strategies utilized for CRPS. Methods: A thorough search spanning four general medical databases and three health economic databases to identify full economic evaluations on CRPS management strategies from January 1994 to June 2023 were conducted. The quality of these studies were evaluated by employing the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. To enable cross-study comparisons conducted in different countries, we adjusted the costs reported in the selected studies for inflation and converted them into 2023 US dollars. Results: A total of nine economic evaluations, consisting of eight high-quality and one medium-quality, were identified across five nations during a span of 29 years. The findings suggest that the most economically efficient intervention for CRPS are interventional approaches of Spinal Cord Stimulation (SCS) in comparison to conventional management for long periods of time. Furthermore, in situations where there is a limited time period of less than 1 year, rehabilitation therapies, particularly physical therapy, have been demonstrated to be more effective in terms of both cost and clinical outcomes. Conclusion: The interventional management strategies, particularly for severe and persistent CRPS over long periods, may offer the greatest cost efficiency. In conditions with limited timelines, rehabilitation measures, such as rehabilitation therapies, can be cost-effective. However, insufficient data for other common interventions prevents the formation of a definitive conclusion. Similarly, it is crucial to recognize that the results of these interventions might be affected by the selection of comparator and the threshold for willingness to pay.
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Affiliation(s)
- Xiaofeng Zhou
- Department of Pain, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yi Zhou
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xiaofei Zhang
- Department of Neuro-Critical Care Medicine, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Feng Jiang
- Department of Ophthalmology, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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Rahman S, Kidwai A, Rakhamimova E, Elias M, Caldwell W, Bergese SD. Clinical Diagnosis and Treatment of Chronic Pain. Diagnostics (Basel) 2023; 13:3689. [PMID: 38132273 PMCID: PMC10743062 DOI: 10.3390/diagnostics13243689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 12/23/2023] Open
Abstract
More than 600 million people globally are estimated to be living with chronic pain. It is one of the most common complaints seen in an outpatient setting, with over half of patients complaining of pain during a visit. Failure to properly diagnose and manage chronic pain is associated with substantial morbidity and mortality, especially when opioids are involved. Furthermore, it is a tremendous financial strain on the healthcare system, as over USD 100 billion is spent yearly in the United States on healthcare costs related to pain management and opioids. This exceeds the costs of diabetes, heart disease, and cancer-related care combined. Being able to properly diagnose, manage, and treat chronic pain conditions can substantially lower morbidity, mortality, and healthcare costs in the United States. This review will outline the current definitions, biopsychosocial model, subclassifications, somatosensory assessments, imaging, clinical prediction models, and treatment modalities associated with chronic pain.
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Affiliation(s)
| | | | | | | | | | - Sergio D. Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (S.R.); (A.K.); (E.R.); (M.E.); (W.C.)
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Canfora F, Ottaviani G, Calabria E, Pecoraro G, Leuci S, Coppola N, Sansone M, Rupel K, Biasotto M, Di Lenarda R, Mignogna MD, Adamo D. Advancements in Understanding and Classifying Chronic Orofacial Pain: Key Insights from Biopsychosocial Models and International Classifications (ICHD-3, ICD-11, ICOP). Biomedicines 2023; 11:3266. [PMID: 38137487 PMCID: PMC10741077 DOI: 10.3390/biomedicines11123266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
In exploring chronic orofacial pain (COFP), this review highlights its global impact on life quality and critiques current diagnostic systems, including the ICD-11, ICOP, and ICHD-3, for their limitations in addressing COFP's complexity. Firstly, this study outlines the global burden of chronic pain and the importance of distinguishing between different pain types for effective treatment. It then delves into the specific challenges of diagnosing COFP, emphasizing the need for a more nuanced approach that incorporates the biopsychosocial model. This review critically examines existing classification systems, highlighting their limitations in fully capturing COFP's multifaceted nature. It advocates for the integration of these systems with the DSM-5's Somatic Symptom Disorder code, proposing a unified, multidisciplinary diagnostic approach. This recommendation aims to improve chronic pain coding standardization and acknowledge the complex interplay of biological, psychological, and social factors in COFP. In conclusion, here, we highlight the need for a comprehensive, universally applicable classification system for COFP. Such a system would enable accurate diagnosis, streamline treatment strategies, and enhance communication among healthcare professionals. This advancement holds potential for significant contributions to research and patient care in this challenging field, offering a broader perspective for scientists across disciplines.
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Affiliation(s)
- Federica Canfora
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, 5 Via Pansini, 80131 Naples, Italy; (F.C.); (D.A.)
| | - Giulia Ottaviani
- Department of Surgical, Medical and Health Sciences, University of Trieste, 447 Strada di Fiume, 34149 Trieste, Italy
| | - Elena Calabria
- Dentistry Unit, Department of Health Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy
| | - Giuseppe Pecoraro
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, 5 Via Pansini, 80131 Naples, Italy; (F.C.); (D.A.)
| | - Stefania Leuci
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, 5 Via Pansini, 80131 Naples, Italy; (F.C.); (D.A.)
| | - Noemi Coppola
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, 5 Via Pansini, 80131 Naples, Italy; (F.C.); (D.A.)
| | - Mattia Sansone
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, 5 Via Pansini, 80131 Naples, Italy; (F.C.); (D.A.)
| | - Katia Rupel
- Department of Surgical, Medical and Health Sciences, University of Trieste, 447 Strada di Fiume, 34149 Trieste, Italy
| | - Matteo Biasotto
- Department of Surgical, Medical and Health Sciences, University of Trieste, 447 Strada di Fiume, 34149 Trieste, Italy
| | - Roberto Di Lenarda
- Department of Surgical, Medical and Health Sciences, University of Trieste, 447 Strada di Fiume, 34149 Trieste, Italy
| | - Michele Davide Mignogna
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, 5 Via Pansini, 80131 Naples, Italy; (F.C.); (D.A.)
| | - Daniela Adamo
- Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, 5 Via Pansini, 80131 Naples, Italy; (F.C.); (D.A.)
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Impaired Pain Processing at a Brainstem Level Is Involved in Maladaptive Neuroplasticity in Patients with Chronic Complex Regional Pain Syndrome. Int J Mol Sci 2022; 23:ijms232315368. [PMID: 36499694 PMCID: PMC9740440 DOI: 10.3390/ijms232315368] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Neuroinflammatory mechanisms and maladaptive neuroplasticity underlie the progression of complex regional pain syndrome (CRPS), which is prototypical of central neuropathic pain conditions. While cortical maladaptive alterations are well described, little is known about the contribution of the brainstem to the pathophysiology. This study investigates the role of pain-modulatory brainstem pathways in CRPS using the nociceptive blink reflex (nBR), which not only provides a direct read-out of brainstem excitability and habituation to painful stimuli but may also be suitable for use as a diagnostic biomarker for CRPS. Thirteen patients with CRPS and thirteen healthy controls (HCs) participated in this prospective case-control study investigating the polysynaptic trigemino-cervical (R2) nBR response. The R2 area and its habituation were assessed following repeated supraorbital electrical stimulation. Between-group comparisons included evaluations of diagnostic characteristics as a potential biomarker for the disease. Patients with CRPS showed a substantial decrease in habituation on the stimulated (Cohen's d: 1.3; p = 0.012) and the non-stimulated side (Cohen's d: 1.1; p = 0.04). This is the first study to reveal altered nBR habituation as a pathophysiological mechanism and potential diagnostic biomarker in CRPS. We confirmed previous findings of altered nBR excitability, but the diagnostic accuracy was inferior. Future studies should investigate the nBR as a marker of progression to central mechanisms in CRPS and as a biomarker to predict treatment response or prognosis.
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Wang Y, Jiang M, Dai X, Zhang Q. Determinants of Complex Regional Pain Syndrome Type I among Radial Head Fracture Patients with Unilateral Arthroplasty. Orthop Surg 2022; 14:1395-1403. [PMID: 35673902 PMCID: PMC9251304 DOI: 10.1111/os.13320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 05/07/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aims to assess the proportions of complex regional pain syndrome type I (CRPS I) in radial head fracture patients undergoing unilateral arthroplasty and to explore associated factors. METHODS This is a prospective observational study. From March 2016 to May 2019, a total of 221 adult patients with radial head fracture patients were included in consecutive studies and completed the 1-year follow-up. All patients were treated by unilateral arthroplasty. At each follow-up visit, the visual analogue scale was used to measure patients' pain level. Occurrence of CRPS I, which was diagnosed by Budapest criteria, was the main outcome collected at baseline and the 1-, 3-, 6-, and 9-month follow-ups. The baseline data were collected before surgery and included demographic and clinical data. Independent t-tests and χ2 tests were used as univariate analyses to compare the baseline data of patients with and without CRPS I. Multivariate analysis (Backword-Wald) was used to identify factors independently associated with CRPS I. RESULTS The proportion of CRPS I cases among radial head fracture patients undergoing unilateral arthroplasty was 11% (n = 24). A total of 19 (79%) patients were diagnosed with CRPS I within 1 month after surgery. Multivariable logistic regression analysis revealed that female gender (odds ratios [OR]: 1.537; 95% confidence interval [CI]: 1.138-2.072), age younger than 60 years (OR: 1.682; 95% CI: 1.246-2.267), moderate and severe Mayo Elbow Performance Score (MEPS) pain (OR: 3.229; 95% CI: 2.392-4.351) and anxiety (OR: 83.346; 95% CI: 61.752-112.320) were independently associated with CRPS I. CONCLUSIONS This exploratory study reported that the incidence of CRPS I developing after radial head arthroplasty was 11%. Female sex, younger age, moderate and severe MEPS pain and anxiety patients seems more likely to develop CRPS I.
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Affiliation(s)
- Ye Wang
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Menglu Jiang
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China.,Soochow University, Soochow, China
| | - Xu Dai
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Qin Zhang
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China
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Relative Prevalence and Associated Factors of Complex Regional Pain Syndrome Type I in Patients with Radial Head Fractures Treated with Open Reduction and Internal Fixation: A Cross-Sectional Study. Pain Res Manag 2022; 2022:9214404. [PMID: 35646200 PMCID: PMC9135570 DOI: 10.1155/2022/9214404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/07/2022] [Accepted: 05/04/2022] [Indexed: 11/26/2022]
Abstract
Objective This cross-sectional study aimed to examine the incidence and associated factors of complex regional pain syndrome type I (CRPS I) in patients who underwent open reduction and internal fixation (ORIF) for radial head fractures. Methods The study enrolled 601 radial head fracture patients treated with ORIF, 523 of which completed the 1-year follow-up. The incidence of CRPS I in those patients was assessed using the Budapest criteria. Patients were then divided into 2 groups: patients with CRPS I (n = 28) and patients without CRPS I (n = 495). The patients' demographic and clinical data before the operation were prospectively collected by our team. Independent t-tests and χ2 tests were used as univariate analyses to compare the demographic and clinical data between the two groups. Meanwhile, multivariate regression analysis was conducted to identify the associated risk factors for CRPS I. Results The incidence of CRPS I in patients with radial head fractures treated with ORIF was 5.5% during the first year following surgery. Significant differences were observed in age, gender, type of trauma, modified Mason Classification, and depressive personality disorders. The logistic regression analysis revealed that the female gender, modified Mason type III fractures, and depressive patients were significantly more likely to develop CRPS I (p=0.021, 0.023, and 0.025, respectively). Conclusions The incidence of CRPS I among radial head fracture patients undergoing ORIF was 5.5%. In addition, early detection of CRPS I and providing adequate intervention will likely result in greater benefits for those patients.
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Gong H, Zhao G, Liu Y, Lu Z. Determinants of complex regional pain syndrome type I in patients with scaphoid waist fracture- a multicenter prospective observational study. BMC Musculoskelet Disord 2022; 23:34. [PMID: 34986822 PMCID: PMC8734294 DOI: 10.1186/s12891-021-04977-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this prospective study was to assess the incidence of complex regional pain syndrome type I (CRPS I) in patients with scaphoid waist fracture and to explore associated factors. Methods This was a multicenter, prospective observational study. Demographic, imaging indicators and clinical data were collected before the conservative treatment of scaphoid waist fracture patients. The occurrence of CRPS I and pain condition were the main outcomes. To explore the factors associated with CRPS I, multivariate logistic regression model was used. Results A total of 493 scaphoid waist fracture participants undergoing conservative treatment were recruited for this study. The incidence of CRPS I was 20% (n = 87). The average time between injury and the onset of CRPS I was 6.7 ± 2.1 weeks. Multivariable logistic regression analysis revealed that female sex (odds ratio (OR): 1.669; 95% confidence interval (CI): 1.189–2.338), diabetes mellitus (OR: 3.206; 95% CI: 2.284–4.492), and severe pain condition before treatment (visual analog scale (VAS) score more than 4 cm) (OR: 27.966; 95% CI: 19.924–39.187) were independently associated with CRPS I. Conclusions Patients suffering from scaphoid waist fracture may be at a higher risk of CRPS I, especially in women with diabetes mellitus who report severe pain before treatment. Early screening and regular follow up evaluation are recommended in these patients.
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Affiliation(s)
- Hao Gong
- Department of Hand Surgery, Wuxi Ninth People's Hospital, Wuxi, Jiangsu, China.,Department of Medicine, Soochow University, Suzhou, China
| | - Gang Zhao
- Department of Hand Surgery, Wuxi Ninth People's Hospital, Wuxi, Jiangsu, China
| | - Yuzhou Liu
- Department of Hand Surgery, Wuxi Ninth People's Hospital, Wuxi, Jiangsu, China
| | - Zhengfeng Lu
- Department of Hand Surgery, Wuxi Ninth People's Hospital, Wuxi, Jiangsu, China.
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Wetzel-Weaver A, Revaz S, Konzelmann M, Luthi F. Going toe-to-toe with a rare case of a complex regional pain syndrome limited to the hallux. BMJ Case Rep 2021; 14:14/8/e242781. [PMID: 34433527 PMCID: PMC8388269 DOI: 10.1136/bcr-2021-242781] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report the first case of a complex regional pain syndrome (CRPS) limited to the hallux using the Budapest criteria. Limited forms of CRPS are scarce in the literature and probably overlooked. There is currently no consensus to define these forms. Due to the particular metameric topography, common to the hand and the foot, we suggest the term ‘metameric’ CRPS to describe them. A uniform nomenclature would promote future research to study its prevalence and specific treatment in more detail.
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Affiliation(s)
- Audrey Wetzel-Weaver
- Department of Research, Clinique romande de readaptation, Sion, Switzerland .,Department of Physical and Rehabilitation Medicine, Hopital Fribourgeois, Villars-sur-Glâne, Fribourg, Switzerland
| | - Sylvie Revaz
- Department of Rheumatology and Expertise, Clinique romande de readaptation, Sion, Switzerland
| | - Michel Konzelmann
- Department of Research, Clinique romande de readaptation, Sion, Switzerland.,Department of Musculoskeletal Rehabilitation, Clinique romande de readaptation, Sion, Switzerland
| | - Francois Luthi
- Department of Research, Clinique romande de readaptation, Sion, Switzerland.,Department of Physical and Rehabilitation Medicine, Lausanne University Hospital, Lausanne, Switzerland
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