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Kim CY, Choi SB, Lee ES. Prevalence and predisposing factors of post-stroke complex regional pain syndrome: Retrospective case-control study. J Stroke Cerebrovasc Dis 2024; 33:107522. [PMID: 38141321 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107522] [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: 07/20/2023] [Revised: 11/05/2023] [Accepted: 11/28/2023] [Indexed: 12/25/2023] Open
Abstract
INTRODUCTION Poststroke complex regional pain syndrome (CRPS) is an important complication in stroke survivors. The identification of factors associated with post-stroke CRPS is important for preventive measures and early diagnosis. METHODS A total of 141 first-ever stroke survivors in the subacute stage were retrospectively analyzed. Demographic data, diagnosis time, duration of hospitalization, location of brain lesion, etiology, comorbidities, and blood test findings were investigated. Clinical data included Medical Research Council (MRC) grade, Fugl-Meyer assessment (FMA), National Institute for Health Stroke Scale (NIHSS), Berg Balance Scale (BBS). RESULTS Among 141 patients with subacute stroke, 22 were diagnosed with CRPS, with a prevalence of 15.6 %. The mean time to diagnosis was 38.6 (±16.5) days. The prevalence according to the degree of paralysis was 33.3 % in MRC grades 0 and 1, 8.6 % in grade 2, and 0 % in grade 3 or higher. The incidence rates within 1 month after stroke were 1.42 % and 22.47 % between 1 and 3 months after stroke, respectively. The independent risk factors for CRPS were hospitalization duration and FMA, NIHSS, and BBS scores. The sensitivity and specificity of the NIHSS score for predicting post-stroke CRPS were 86.4 % and 59.7 %, respectively, with an optimal cutoff value of 7.5. CONCLUSIONS CRPS of the affected upper limb in stroke patients is associated with stroke severity, including paralysis, and the incidence increases over time during the subacute phase. Additionally, having sufficient strength to move through a full range of motion against gravity had a protective effect against CRPS.
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Affiliation(s)
- Chan Yong Kim
- Department of Rehabilitation Medicine, Wonkwang University School of Medicine Hospital, Republic of Korea
| | - Seong Bok Choi
- Department of Rehabilitation Medicine, Wonkwang University School of Medicine Hospital, Republic of Korea
| | - Eun Sun Lee
- Department of Rehabilitation Medicine, Wonkwang University School of Medicine Hospital, Republic of Korea.
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Kong ST, Yeo D, Neo EJ, Chen D. Bilateral Upper Limb Complex Regional Pain Syndrome (Type 2) in Cervical Spinal Cord Injury: A Case Report. Cureus 2022; 14:e26440. [PMID: 35915704 PMCID: PMC9338342 DOI: 10.7759/cureus.26440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/05/2022] Open
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Do JG, Choi JH, Park CH, Yoon KJ, Lee YT. Prevalence and Related Factors for Poststroke Complex Regional Pain Syndrome: A Retrospective Cross-Sectional Cohort Study. Arch Phys Med Rehabil 2021; 103:274-281. [PMID: 34480888 DOI: 10.1016/j.apmr.2021.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/19/2021] [Accepted: 08/05/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate the prevalence of poststroke complex regional pain syndrome (CRPS) to estimate related factors for poststroke CRPS in patients with first-ever stroke. DESIGN This was a retrospective cross-sectional cohort study of adult patients (age >18y) with stroke who were admitted to rehabilitation unit from December 2014 to May 2018 in Korea. SETTING Single acute rehabilitation unit of university hospital. PARTICIPANTS Participants (N=313) diagnosed with first-ever stroke were identified from the stroke rehabilitation registry of our institute. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Prevalence of poststroke CRPS based on clinical features and 3-phase bone scintigraphy and the related factors of poststroke CRPS. RESULTS A total of 313 records were analyzed, including demographic, clinical characteristics, and functional variables. Poststroke CRPS was found in 8.94% (28 of 313) patients with first-ever stroke. Logistic regression analysis showed that Fugl Meyer Assessment of Upper Extremity (FMA-UE) score was a significant associated factor for the presence of CRPS (odds ratio, 0.96; 95% confidence interval, 0.94-0.98; P=.003). The cutoff value of 76 points for FMA-UE score yielded moderate accuracy in identifying of poststroke CRPS (92.6% sensitivity, 65.8% specificity, and 0.85 area under the curve). CONCLUSIONS The prevalence of poststroke CRPS was 8.94% in patients with first-ever stroke. The FMA-UE score was associated with the poststroke CRPS. Therefore, in patients with low FMA-UE score, prevention and high suspicion of post-stroke CRPS is necessary.
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Affiliation(s)
- Jong Geol Do
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Jae Hyeong Choi
- Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chul-Hyun Park
- Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyung Jae Yoon
- Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yong-Taek Lee
- Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Diagnosis of Complex Regional Pain Syndrome I Following Traumatic Axonal Injury of the Corticospinal Tract in a Patient with Mild Traumatic Brain Injury. Diagnostics (Basel) 2020; 10:diagnostics10020095. [PMID: 32050691 PMCID: PMC7168287 DOI: 10.3390/diagnostics10020095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/07/2020] [Accepted: 02/07/2020] [Indexed: 11/19/2022] Open
Abstract
A 54-year-old male suffered from direct head trauma resulting from a fall while working. At approximately two months after the accident, he began to feel pain (burning sensation) and swelling of the dorsum of the right hand and wrist. He showed the following clinical features among the clinical signs and symptoms of revised diagnostic criteria for complex regional pain syndrome (CRPS): spontaneous pain, mechanical hyperalgesia, vasodilation, skin temperature asymmetries, skin color changes, swelling, motor weakness. No specific lesion was observed on brain MRI taken at ten weeks after onset. Plain X-ray, electromyography, and nerve conduction studies for the right upper extremity detected no abnormality. A three-phase bone scan showed hot uptake in the right wrist in the delayed image. On two-month diffusion tensor tractography, partial tearing of the corticospinal tract (CST) was observed at the subcortical white matter in both hemispheres (much more severe in the left CST). In addition, the fiber number of the right CST was significantly decreased than that of seven normal control subjects. CRPS I of the right hand in this patient appeared to be related to traumatic axonal injury of the left CST following mild traumatic brain injury.
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Jang SH, Kwon YH, Lee SJ. Central Pain Due to Injury of the Spinothalamic Tract Misdiagnosed as Complex Regional Pain Syndrome: A Case Report. Diagnostics (Basel) 2019; 9:diagnostics9040145. [PMID: 31597370 PMCID: PMC6963659 DOI: 10.3390/diagnostics9040145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 01/10/2023] Open
Abstract
Objectives: We report on a patient with whiplash injury who had central pain, due to injury of the spinothalamic tract (STT), but who was misdiagnosed as complex regional pain syndrome (CRPS). Case description: While a minivan in which a 43-year-old female was seated in the passenger seat was stopped for a signal, a truck collided with the minivan from behind, and the minivan then repeatedly collided with trucks in front and behind the minivan. Her head repeatedly struck the minivan seat resulting in whiplash injuries. After onset, she felt pain in both legs with mild motor weakness in all four extremities and memory impairment. Eight years after onset, she was diagnosed at a university hospital as CRPS type 1 with the clinical features of hyperalgesia and mild edema and motor weakness of both legs. She visited another university hospital nine years after onset and complained of pain in the right arm and both legs, constant tingling and burning pain along with allodynia and hyperalgesia. She also showed mild weakness in the four extremities, mild edema of both legs, and memory impairment. On diffusion tensor tractography (DTT), the left spinothalamic tract (STT) showed marked narrowing, and the right STT revealed mild narrowing and partial tearing. In addition, partial tears were observed in both corticospinal tracts and the right corticoreticulospinal tract. Discontinuations were observed in the left corticoreticulospinal tract and the left fornical crus. Conclusion: Injury of the STT was demonstrated on DTT in a patient with central pain following whiplash injury. Previously, the patient was misdiagnosed as CRPS.
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Affiliation(s)
- Sung Ho Jang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Daegu 705-717, Korea
| | - Young Hyeon Kwon
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Daegu 705-717, Korea
| | - Sung Jun Lee
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyungdong, Namku, Daegu 705-717, Korea.
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Small KM, Adler RS, Shah SH, Roberts CC, Bencardino JT, Appel M, Gyftopoulos S, Metter DF, Mintz DN, Morrison WB, Subhas N, Thiele R, Towers JD, Tynus KM, Weissman BN, Yu JS, Kransdorf MJ. ACR Appropriateness Criteria ® Shoulder Pain-Atraumatic. J Am Coll Radiol 2019; 15:S388-S402. [PMID: 30392607 DOI: 10.1016/j.jacr.2018.09.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/07/2018] [Indexed: 01/25/2023]
Abstract
Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | | | - Shaan H Shah
- Research Author, Brigham & Women's Hospital, Boston, Massachusetts
| | | | - Jenny T Bencardino
- Panel Vice-Chair, New York University School of Medicine, New York, New York
| | - Marc Appel
- James J. Peters VA Medical Center, Bronx, New York; American Academy of Orthopaedic Surgeons
| | | | - Darlene F Metter
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | | | | | - Ralf Thiele
- University of Rochester School of Medicine and Dentistry, Rochester, New York; American College of Rheumatology
| | - Jeffrey D Towers
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katherine M Tynus
- Northwestern Memorial Hospital, Chicago, Illinois; American College of Physicians
| | | | - Joseph S Yu
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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Amini B, Beckmann NM, Beaman FD, Wessell DE, Bernard SA, Cassidy RC, Czuczman GJ, Demertzis JL, Greenspan BS, Khurana B, Lee KS, Lenchik L, Motamedi K, Sharma A, Walker EA, Kransdorf MJ. ACR Appropriateness Criteria ® Shoulder Pain-Traumatic. J Am Coll Radiol 2019; 15:S171-S188. [PMID: 29724420 DOI: 10.1016/j.jacr.2018.03.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 02/08/2023]
Abstract
Traumatic shoulder pain is pain directly attributed to a traumatic event, either acute or chronic. This pain may be the result of either fracture (the clavicle, scapula, or proximal humerus) or soft-tissue injury (most commonly of the rotator cuff, acromioclavicular ligaments, or labroligamentous complex). Imaging assessment of traumatic shoulder pain begins with conventional radiography and, depending on physical examination findings, will require MRI or MR arthrography for assessment of soft-tissue injuries and CT for delineation of fracture planes. Ultrasound excels in assessment of rotator cuff injuries but has limited usefulness for assessment of the deep soft-tissues. CT angiography and conventional arteriography are helpful for assessment of vascular injury, and bone scintigraphy can be used in assessment of complex regional pain syndrome after traumatic shoulder injury. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Behrang Amini
- Principal Author, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | | | | | | | | | - R Carter Cassidy
- UK Healthcare Spine and Total Joint Service, Lexington, Kentucky; American Academy of Orthopaedic Surgeons
| | | | | | | | | | - Kenneth S Lee
- University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Leon Lenchik
- Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Kambiz Motamedi
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; and Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Wertli MM, Brunner F, Steurer J, Held U. Usefulness of bone scintigraphy for the diagnosis of Complex Regional Pain Syndrome 1: A systematic review and Bayesian meta-analysis. PLoS One 2017; 12:e0173688. [PMID: 28301606 PMCID: PMC5354289 DOI: 10.1371/journal.pone.0173688] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 02/24/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Since 2007, the Budapest criteria are recommended for the diagnosis of Complex Regional Pain Syndrome (CRPS) 1. The usefulness of bone scintigraphy (BS, index test) for the diagnosis of CRPS 1 remains controversial. Imperfect reference tests (RT) result in underestimation of the diagnostic accuracy of BS. Further, biased results can occur when a dependency between the RT and BS exists. The objective was to assess the impact of different RTs, specifically the Budapest criteria, and the assumed imperfect nature of the RT on the diagnostic accuracy of BS. Further, we analyzed the association between baseline characteristics and positive BS in patients with CRPS 1. METHODS Systematic literature review and Bayesian meta-analysis to assess the test accuracy of BS with and without accounting for the imperfect nature of the RT. We examined correlations (Spearman correlation coefficients / Wilcoxon tests) between baseline characteristics and the proportion of positive BS in patients with CRPS 1. RESULTS The pooled sensitivity was 0.804 (95% credible interval (CI) 0.225-1.0, 21 studies) and specificity 0.853 (95%CI 0.278-1.00). Sensitivity and specificity of BS increased when accounting for the imperfect nature of the RT. However, in studies using Budapest criteria as reference, the sensitivity decreased (0.551; 95% CI 0.046-1) and the specificity increased (0.935; 95% CI 0.306-1). Shorter disease duration and a higher proportion of males were associated with a higher proportion of positive BS (27 studies, disease duration <52 weeks Wilcoxon test p = 0.047, female proportion Spearman correlation -0.63, p = 0.009). CONCLUSION Compared to the accepted Budapest diagnostic criteria BS cannot be used to rule-in the diagnosis of CRPS 1. In patients with negative BS CRPS 1 is less likely the underlying illness. Studies using older or no diagnostic criteria should not be used to evaluate the diagnostic accuracy of BS in CRPS 1.
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Affiliation(s)
- Maria M. Wertli
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, Zurich, Switzerland
- Division of General Internal Medicine, Bern University Hospital, Bern University, Freiburgstrasse 8, Bern, Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Forchstrasse 340, Zurich, Switzerland
| | - Johann Steurer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, Zurich, Switzerland
| | - Ulrike Held
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, Zurich, Switzerland
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Held U, Brunner F, Steurer J, Wertli MM. Bayesian meta-analysis of test accuracy in the absence of a perfect reference test applied to bone scintigraphy for the diagnosis of complex regional pain syndrome. Biom J 2016; 57:1020-37. [PMID: 26479506 DOI: 10.1002/bimj.201400155] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 05/26/2015] [Accepted: 06/07/2015] [Indexed: 11/06/2022]
Abstract
There is conflicting evidence about the accuracy of bone scintigraphy (BS) for the diagnosis of complex regional pain syndrome 1 (CRPS 1). In a meta-analysis of diagnostic studies, the evaluation of test accuracy is impeded by the use of different imperfect reference tests. The aim of our study is to summarize sensitivity and specificity of BS for CRPS 1 and to identify factors to explain heterogeneity. We use a hierarchical Bayesian approach to model test accuracy and threshold, and we present different models accounting for the imperfect nature of the reference tests, and assuming conditional dependence between BS and the reference test results. Further, we include disease duration as explanatory variable in the model. The models are compared using summary ROC curves and the deviance information criterion (DIC). Our results show that those models which account for different imperfect reference tests with conditional dependence and inclusion of the covariate are the ones with the smallest DIC. The sensitivity of BS was 0.87 (95% credible interval 0.73-0.97) and the overall specificity was 0.87 (0.73-0.95) in the model with the smallest DIC, in which missing values of the covariate are imputed within the Bayesian framework. The estimated effect of duration of symptoms on the threshold parameter was 0.17 (-0.25 to 0.57). We demonstrate that the Bayesian models presented in this paper are useful to address typical problems occurring in meta-analysis of diagnostic studies, including conditional dependence between index test and reference test, as well as missing values in the study-specific covariates.
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Affiliation(s)
- Ulrike Held
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland
| | - Florian Brunner
- Department of Rheumatology, University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Johann Steurer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland
| | - Maria M Wertli
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland
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Sensitization of the Nociceptive System in Complex Regional Pain Syndrome. PLoS One 2016; 11:e0154553. [PMID: 27149519 PMCID: PMC4858201 DOI: 10.1371/journal.pone.0154553] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 04/17/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Complex regional pain syndrome type I (CRPS-I) is characterized by sensory, motor and autonomic abnormalities without electrophysiological evidence of a nerve lesion. OBJECTIVE Aims were to investigate how sensory, autonomic and motor function change in the course of the disease. METHODS 19 CRPS-I patients (17 with acute, 2 with chronic CRPS, mean duration of disease 5.7±8.3, range 1-33 months) were examined with questionnaires (LANSS, NPS, MPI, Quick DASH, multiple choice list of descriptors for sensory, motor, autonomic symptoms), motor and autonomic tests as well as quantitative sensory testing according to the German Research Network on Neuropathic Pain at two visits (baseline and 36±10.6, range 16-53 months later). RESULTS CRPS-I patients had an improvement of sudomotor and vasomotor function, but still a great impairment of sensory and motor function upon follow-up. Although pain and mechanical detection improved upon follow-up, thermal and mechanical pain sensitivity increased, including the contralateral side. Increase in mechanical pain sensitivity and loss of mechanical detection were associated with presence of ongoing pain. CONCLUSIONS The results demonstrate that patients with CRPS-I show a sensitization of the nociceptive system in the course of the disease, for which ongoing pain seems to be the most important trigger. They further suggest that measured loss of function in CRPS-I is due to pain-induced hypoesthesia rather than a minimal nerve lesion. In conclusion, this article gives evidence for a pronociceptive pain modulation profile developing in the course of CRPS and thus helps to assess underlying mechanisms of CRPS that contribute to the maintenance of patients' pain and disability.
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Sampath S, Mittal BR, Arun S, Sood A, Bhattacharya A, Sharma A. Usefulness of asymmetry score on quantitative three-phase bone scintigraphy in the evaluation of complex regional pain syndrome. Indian J Nucl Med 2013; 28:11-6. [PMID: 24019668 PMCID: PMC3764684 DOI: 10.4103/0972-3919.116798] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Introduction: Complex regional pain syndrome (CRPS) is primarily a clinical diagnosis. Diagnostic imaging in CRPS can be used, especially to exclude other disorders. The sensitivity and specificity of three phase bone scintigraphy (TPBS) for the diagnosis of CRPS is variable throughout the literature. Aim: To establish a simple and effective quantitative approach to help in the diagnosis of CRPS by TPBS. Materials and Methods: TPBS done in patients (n = 68) with suspected CRPS was analyzed retrospectively. They were classified into bone scan positive group (BSP), bone scan negative group (BSN) and non-CRPS group based on diffusely increased periarticular uptake, symmetrical uptake, and focal uptake respectively. Asymmetry score (AS) was also measured between the affected and unaffected side. Results: 16 patients showed focal uptake, 37 were in BSP group with mean AS score of 1.57 ± 0.5 and 15 were in BSN group with mean AS score of 1.01 ± 0.05. The mean AS was significantly different (P < 0.0001). AS of 1.06 had sensitivity and specificity of 96.43% and 100% respectively (P = 0.0001). There was a trend of negative correlation between the AS and the duration, r = −0.21; however, it was not statistically significant (P = 0.28). Conclusion: TPBS should be considered in the evaluation of CRPS to rule out patients who have focal involvement, not diagnostic of CRPS (~24% in this study). Quantitative AS of 1.06 can be included to support visual interpretation in the delayed phase.
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Affiliation(s)
- Santhosh Sampath
- Department of Nuclear Medicine and Positron Emission Tomography, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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AlSharif A, Akel AY, Sheikh-Ali RF, Juweid ME, Hawamdeh ZM, Ajlouni JM, Abdulsahib AS, AlHadidi FA, ElHadidy ST. Is there a correlation between symptoms and bone scintigraphic findings in patients with complex regional pain syndrome? Ann Nucl Med 2012; 26:665-9. [PMID: 22797817 DOI: 10.1007/s12149-012-0623-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Accepted: 06/18/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is characterized by pain in combination with sensory, vasomotor, sudomotor, trophic and motor abnormalities. The diagnosis of CRPS is based primarily on clinical criteria and the presence of distinct signs and symptoms. The role of bone scintigraphy in the diagnosis of these patients has been limited by its variable sensitivity. In this study, we aim to look if the presence of specific symptoms or symptom subgroups in patients with clinically diagnosed CRPS correlates with scintigraphic findings in bone scan. MATERIALS AND METHODS We retrospectively reviewed clinical records of patients referred for bone scintigraphy with the clinical diagnosis of CRPS during the period December 2006 until February 2011. Patients were classified into 4 distinct subgroups according to the presence of specific symptoms namely sensory subgroup, sudomotor and/or edema subgroup, vasomotor subgroup and finally motor and/or trophic changes subgroup. We looked specifically for the correlation between these specific symptoms and scintigraphic bone findings. RESULTS 37 patients were referred for bone scintigraphy with the clinical diagnosis of CRPS and were enrolled in the study. The presence of vasomotor symptoms and (motor and/or trophic changes) was significantly higher in patients with positive bone scintigraphy (P value 0.0133, 0.018 respectively). There was no other statistically significant correlation between the presence of specific symptoms or symptom subgroups on one hand and the result of bone scintigraphy on the other hand. CONCLUSIONS The probability of positive bone scintigraphy increased significantly in patients with vasomotor symptoms and in patients with motor and/or trophic changes. This may contribute to the reported variability of the diagnostic performance of bone scintigraphy in CRPS patients.
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Affiliation(s)
- Abedallatif AlSharif
- Nuclear Medicine Section, Radiology and Nuclear Medicine Department, Faculty of Medicine, Jordan University Hospital, University of Jordan, Queen Rania Street, Al-Jubeiha, P.O.Box 13046, 11942, Amman, Jordan.
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Ringer R, Wertli M, Bachmann LM, Buck FM, Brunner F. Concordance of qualitative bone scintigraphy results with presence of clinical complex regional pain syndrome 1: meta-analysis of test accuracy studies. Eur J Pain 2012; 16:1347-56. [PMID: 22473897 DOI: 10.1002/j.1532-2149.2012.00137.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2012] [Indexed: 11/05/2022]
Abstract
BACKGROUND To date, no attempt has been made to investigate the agreement between qualitative bone scintigraphy (BS) and the presence of complex regional pain syndrome 1 (CRPS 1) and the agreement between a negative BS in the absence of CRPS 1. AIMS To summarize the existing evidence quantifying the concordance of qualitative BS in the presence or absence of clinical CRPS 1. DATA SOURCES We searched Medline, Embase, Dare and the Cochrane Library and screened bibliographies of all included studies. STUDY ELIGIBILITY CRITERIA We selected diagnostic studies investigating the association between qualitative BS results and the clinical diagnosis of CRPS 1. The minimum requirement for inclusion was enough information to fill the two-by-two tables. RESULTS Twelve studies met our inclusion criteria and were included in the meta-analysis. The pooled mean sensitivity of 12 two-by-two tables was 0.87 (95% CI, 0.68-0.97) and specificity was 0.69 (95% CI, 0.47-0.85). The pooled mean sensitivity for the subgroup with clearly defined diagnostic criteria (seven two-by-two tables) was 0.80 (95% CI, 0.44-0.95) and specificity was 0.73 (95% CI, 0.40-0.91). CONCLUSIONS Based on this study, clinicians must be advised that a positive BS is not necessarily concordant with presence of absence or CRPS 1. Given the moderate level of concordance between a positive BS in the absence of clinical CRPS 1, discordant results potentially impede the diagnosis of CRPS 1.
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Affiliation(s)
- R Ringer
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Zurich, Switzerland
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Moon J, Park S, Kim Y, Lee S, Nahm F, Kim J, Kim H, Oh S. Analysis of patterns of three-phase bone scintigraphy for patients with complex regional pain syndrome diagnosed using the proposed research criteria (the ‘Budapest Criteria’). Br J Anaesth 2012; 108:655-61. [DOI: 10.1093/bja/aer500] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Diagnostic performance of three-phase bone scan for complex regional pain syndrome type 1 with optimally modified image criteria. Nucl Med Mol Imaging 2011; 45:261-7. [PMID: 24900016 DOI: 10.1007/s13139-011-0104-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 02/17/2011] [Accepted: 08/15/2011] [Indexed: 10/17/2022] Open
Abstract
PURPOSE Although the three-phase bone scan (TBPS) is one of the widely used imaging studies for diagnosing complex regional pain syndrome type I (CRPS-1), there is some controversy regarding the TPBS image criteria for CRPS-1. In this study, we modified the image criteria using image pattern and quantitative analysis in the patients diagnosed using the most recent consensus clinical diagnostic criteria. MATERIALS AND METHODS The study included 140 patients with suspected CRPS-1 (CRPS-1, n = 79; non-CRPS, n = 61; mean age 39 ± 15 years) who underwent TPBS. The clinical diagnostic criteria for CRPS-1 revised by the Budapest consensus group were used for confirmative diagnosis. Patients were classified according to flow/pool and delayed uptake (DU) image patterns, and the time interval between the initiating event and TPBS (TIevent-scan). Quantitative analysis for lesion-to-contralateral ratio (LCR) was performed. Modified TPBS image criteria were created and evaluated for optimal diagnostic performance. RESULTS Both increased and decreased periarticular DU were significant image findings for CRPS-1 (CRPS-1 positive-rate = 73% in the increased DU group, 75% in the decreased DU group). The TIevent-scan did not differ significantly between the different image pattern groups. Quantitative analysis revealed an LCR of 1.43 was the optimal cutoff value for CRPS-1 and diagnostic performance was significantly improved in the increased DU group (area under the curve = 0.732). Given the modified image criteria, the sensitivity and specificity of TPBS for diagnosing CRPS-1 were 80% and 72%, respectively. CONCLUSIONS Optimally modified TPBS image criteria for CRPS-1 were suggested using image pattern and quantitative analysis. With the criteria, TPBS is an effective imaging study for CRPS-1 even with the most recent consensus clinical diagnostic criteria.
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