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Casadei M, Miguel B, Rubione J, Fiore E, Mengelle D, Guerri-Guttenberg RA, Montaner A, Villar MJ, Constandil-Córdova L, Romero-Sandoval AE, Brumovsky PR. Mesenchymal Stem Cell Engagement Modulates Neuroma Microenviroment in Rats and Humans and Prevents Postamputation Pain. THE JOURNAL OF PAIN 2024; 25:104508. [PMID: 38484854 PMCID: PMC11283994 DOI: 10.1016/j.jpain.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/11/2024]
Abstract
Postamputation pain is currently managed unsatisfactorily with neuron-targeted pharmacological and interventional therapies. Non-neuronal pain mechanisms have emerged as crucial factors in the development and persistence of postamputation pain. Consequently, these mechanisms offer exciting prospects as innovative therapeutic targets. We examined the hypothesis that engaging mesenchymal stem cells (MSCs) would foster local neuroimmune interactions, leading to a potential reduction in postamputation pain. We utilized an ex vivo neuroma model from a phantom limb pain patient to uncover that the oligodeoxynucleotide IMT504 engaged human primary MSCs to promote an anti-inflammatory microenvironment. Reverse translation experiments recapitulated these effects. Thus, in an in vivo rat model, IMT504 exhibited strong efficacy in preventing autotomy (self-mutilation) behaviors. This effect was linked to a substantial accumulation of MSCs in the neuroma and associated dorsal root ganglia and the establishment of an anti-inflammatory phenotype in these compartments. Centrally, this intervention reduced glial reactivity in the dorsal horn spinal cord, demonstrating diminished nociceptive activity. Accordingly, the exogenous systemic administration of MSCs phenocopied the behavioral effects of IMT504. Our findings underscore the mechanistic relevance of MSCs and the translational therapeutic potential of IMT504 to engage non-neuronal cells for the prevention of postamputation pain. PERSPECTIVE: The present study suggests that IMT504-dependent recruitment of endogenous MSCs within severely injured nerves may prevent post-amputation pain by modifying the inflammatory scenario at relevant sites in the pain pathway. Reinforcing data in rat and human tissues supports the potential therapeutic value of IMT504 in patients suffering postamputation pain.
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Affiliation(s)
- Mailín Casadei
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Bernardo Miguel
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Julia Rubione
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Esteban Fiore
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | - Diego Mengelle
- Hospital Universitario Austral, Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | | | - Alejandro Montaner
- Instituto de Ciencia y Tecnología “César Milstein”, CONICET-Fundación Pablo Cassará, Buenos Aires, Argentina, C1440FFX
| | - Marcelo J. Villar
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
| | | | | | - Pablo R. Brumovsky
- Instituto de Investigaciones en Medicina Traslacional, CONICET-Universidad Austral, Buenos Aires, Argentina, B1629AHJ
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Early application of cryoanalgesia to the brachial plexus prevents development of phantom limb pain after traumatic forequarter amputation: A case report. Trauma Case Rep 2022; 41:100678. [PMID: 35864840 PMCID: PMC9294552 DOI: 10.1016/j.tcr.2022.100678] [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] [Accepted: 07/11/2022] [Indexed: 11/20/2022] Open
Abstract
Background Amputation of an extremity frequently results in significant phantom limb pain. The etiology of which is not well understood. Central and peripheral factors appear to play a role. Pain relief interventions often are attempted several weeks to months later. Peripheral nerve injury can rapidly result in cortical somatosensory changes potentially making early intervention important in preventing any permanent changes in nerve pathways. Case report We present a case of traumatic forequarter (interscapulothoracic) amputation treated with cryoanalgesia of the brachial plexus for pain control <72 h after injury. The patient denied painful phantom limb pain and postoperative pain at the surgical site immediately following surgery and over a six month follow up period. Conclusion Cryoanalgesia facilitates extended duration of pain control of the affected peripheral nerve which may be of particular benefit in patients sustaining either surgical or traumatic amputations, particularly when applied early to prevent the transmission of noxious signals to the central nervous system.
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Ilfeld BM, Khatibi B, Maheshwari K, Madison SJ, Ali Sakr Esa W, Mariano ER, Kent ML, Hanling S, Sessler DI, Eisenach JC, Cohen SP, Mascha EJ, Yang D, Padwal JA, Turan A. Immediate Effects of a Continuous Peripheral Nerve Block on Postamputation Phantom and Residual Limb Pain: Secondary Outcomes From a Multicenter Randomized Controlled Clinical Trial. Anesth Analg 2021; 133:1019-1027. [PMID: 34314392 DOI: 10.1213/ane.0000000000005673] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND We recently reported that a 6-day continuous peripheral nerve block reduced established postamputation phantom pain 3 weeks after treatment ended. However, the immediate effects of perineural infusion (secondary outcomes) have yet to be reported. METHODS Participants from 5 enrolling academic centers with an upper or lower limb amputation and established phantom pain received a single-injection ropivacaine peripheral nerve block(s) and perineural catheter insertion(s). They were subsequently randomized to receive a 6-day ambulatory perineural infusion of either ropivacaine 0.5% or normal saline in a double-masked fashion. Participants were contacted by telephone 1, 7, 14, 21, and 28 days after the infusion started, with pain measured using the Numeric Rating Scale. Treatment effects were assessed using the Wilcoxon rank-sum test at each time point. Adjusting for 4 time points (days 1, 7, 14, and 21), P < .0125 was deemed statistically significant. Significance at 28 days was reported using methods from the original, previously published article. RESULTS Pretreatment average phantom and residual pain scores were balanced between the groups. The day after infusion initiation (day 1), average phantom, and residual limb pain intensity was lower in patients receiving local anesthetic (n = 71) versus placebo (n = 73): median [quartiles] of 0 [0-2.5] vs 3.3 [0-5.0], median difference (98.75% confidence interval [CI]) of -1.0 (-3.0 to 0) for phantom pain (P = .001) and 0 [0-0] vs 0 [0-4.3], and median difference 0.0 (-2.0 to 0.0) for residual limb pain (P < .001). Pain's interference with physical and emotional functioning as measured with the interference domain of the Brief Pain Inventory improved during the infusion on day 1 for patients receiving local anesthetic versus placebo: 0 [0-10] vs 10 [0-40], median difference (98.75% CI) of 0.0 (-16.0 to 0.0), P = .002. Following infusion discontinuation (day 6), a few differences were found between the active and placebo treatment groups between days 7 and 21. In general, sample medians for average phantom and residual limb pain scores gradually increased after catheter removal for both treatments, but to a greater degree in the control group until day 28, at which time the differences between the groups returned to statistical significance. CONCLUSIONS This secondary analysis suggests that a continuous peripheral nerve block decreases phantom and residual limb pain during the infusion, although few improvements were again detected until day 28, 3 weeks following catheter removal.
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Affiliation(s)
- Brian M Ilfeld
- From the Department of Anesthesiology, University of California San Diego, San Diego, California.,Department of Anesthesiology, The Outcomes Research Consortium, Cleveland, Ohio
| | - Bahareh Khatibi
- From the Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Kamal Maheshwari
- Departments of General Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Departments of General Anesthesia and Outcomes Research, The Outcomes Research Consortium, Cleveland, Ohio
| | - Sarah J Madison
- From the Department of Anesthesiology, University of California San Diego, San Diego, California
| | - Wael Ali Sakr Esa
- Departments of General Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Departments of General Anesthesia and Outcomes Research, The Outcomes Research Consortium, Cleveland, Ohio
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Palo Alto Veterans Affairs, Palo Alto, California
| | - Michael L Kent
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Steven Hanling
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, California
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Department of Outcomes Research, The Outcomes Research Consortium, Cleveland, Ohio
| | - James C Eisenach
- Department of Anesthesiology, The Outcomes Research Consortium, Cleveland, Ohio.,Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Steven P Cohen
- Department of Anesthesiology, Johns Hopkins, Baltimore, Maryland
| | - Edward J Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Departments of Quantitative Health Sciences and Outcomes Research, The Outcomes Research Consortium, Cleveland, Ohio
| | - Dongsheng Yang
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Jennifer A Padwal
- Department of Radiology, University of California San Diego, San Diego, California.,Department of Radiology, Stanford University, Stanford, California
| | - Alparslan Turan
- Departments of General Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland, Ohio.,Departments of General Anesthesia and Outcomes Research, The Outcomes Research Consortium, Cleveland, Ohio
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Deer TR, Eldabe S, Falowski SM, Huntoon MA, Staats PS, Cassar IR, Crosby ND, Boggs JW. Peripherally Induced Reconditioning of the Central Nervous System: A Proposed Mechanistic Theory for Sustained Relief of Chronic Pain with Percutaneous Peripheral Nerve Stimulation. J Pain Res 2021; 14:721-736. [PMID: 33737830 PMCID: PMC7966353 DOI: 10.2147/jpr.s297091] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/26/2021] [Indexed: 12/23/2022] Open
Abstract
Peripheral nerve stimulation (PNS) is an effective tool for the treatment of chronic pain, although its efficacy and utilization have previously been significantly limited by technology. In recent years, purpose-built percutaneous PNS devices have been developed to overcome the limitations of conventional permanently implanted neurostimulation devices. Recent clinical evidence suggests clinically significant and sustained reductions in pain can persist well beyond the PNS treatment period, outcomes that have not previously been observed with conventional permanently implanted neurostimulation devices. This narrative review summarizes mechanistic processes that contribute to chronic pain, and the potential mechanisms by which selective large diameter afferent fiber activation may reverse these changes to induce a prolonged reduction in pain. The interplay of these mechanisms, supported by data in chronic pain states that have been effectively treated with percutaneous PNS, will also be discussed in support of a new theory of pain management in neuromodulation: Peripherally Induced Reconditioning of the Central Nervous System (CNS).
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Steven M Falowski
- Department of Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Marc A Huntoon
- Anesthesiology, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Ilfeld BM, Khatibi B, Maheshwari K, Madison SJ, Esa WAS, Mariano ER, Kent ML, Hanling S, Sessler DI, Eisenach JC, Cohen SP, Mascha EJ, Ma C, Padwal JA, Turan A. Ambulatory continuous peripheral nerve blocks to treat postamputation phantom limb pain: a multicenter, randomized, quadruple-masked, placebo-controlled clinical trial. Pain 2021; 162:938-955. [PMID: 33021563 PMCID: PMC7920494 DOI: 10.1097/j.pain.0000000000002087] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 01/13/2023]
Abstract
Phantom limb pain is thought to be sustained by reentrant neural pathways, which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0 to 12 weeks. Pretreatment pain scores were similar in both groups, with a median (interquartile range) of 5.0 (4.0, 7.0) for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic vs 4.5 (2.6) in those given placebo (difference [95% confidence interval] 1.3 [0.4, 2.2], P = 0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 (0, 5.0) vs 1.5 (0, 5.0) for the placebo group; there seemed to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.
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Affiliation(s)
- Brian M. Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
- Outcomes Research Consortium, Cleveland, OH, United States
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Kamal Maheshwari
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Sarah J. Madison
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Wael Ali Sakr Esa
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Edward R. Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Palo Alto Veterans Affairs, Palo Alto, CA, United States
| | - Michael L. Kent
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Steven Hanling
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA, United States
| | - Daniel I. Sessler
- Outcomes Research Consortium, Cleveland, OH, United States
- Department of Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - James C. Eisenach
- Outcomes Research Consortium, Cleveland, OH, United States
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Steven P. Cohen
- Department of Anesthesiology, Johns Hopkins, Baltimore, MD, United States
| | - Edward J. Mascha
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of Quantitative Health Sciences and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Chao Ma
- Departments of Quantitative Health Sciences and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Jennifer A. Padwal
- Department of Radiology, University of California San Diego, San Diego, CA, United States
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Alparslan Turan
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
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6
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Gilmore CA, Kapural L, McGee MJ, Boggs JW. Percutaneous Peripheral Nerve Stimulation for Chronic Low Back Pain: Prospective Case Series With 1 Year of Sustained Relief Following Short-Term Implant. Pain Pract 2020; 20:310-320. [PMID: 31693791 PMCID: PMC7079182 DOI: 10.1111/papr.12856] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Percutaneous peripheral nerve stimulation (PNS) provides an opportunity to relieve chronic low back pain and reduce opioid analgesic consumption as an alternative to radiofrequency ablation and permanently implanted neurostimulation systems. Traditionally, the use of neurostimulation earlier in the treatment continuum has been limited by its associated risk, invasiveness, and cost. METHODS Percutaneous PNS leads (SPRINT MicroLead) were placed bilaterally to target the medial branches of the dorsal rami nerves under image guidance. The percutaneous leads were connected to miniature wearable stimulators (SPRINT PNS System) for the 1-month therapy period, after which the leads were removed. Pain and disability were assessed long-term up to 12 months after lead removal. RESULTS Substantial, clinically significant reductions in average pain intensity (≥50% reduction as measured by the Brief Pain Inventory Short Form) were experienced by a majority of subjects (67%) at end of treatment compared to baseline (average 80% reduction among responders; P < 0.05, analysis of variance; n = 9). Twelve months after the end of PNS treatment, a majority of subjects who completed the long-term follow-up visits experienced sustained, clinically significant reductions in pain and/or disability (67%, n = 6; average 63% reduction in pain intensity and 32-point reduction in disability among responders). No serious or unanticipated adverse events were reported. CONCLUSIONS This study challenges the long-held notion that a positive trial of PNS should be followed by a permanent implant in responders. Percutaneous PNS may serve as an effective neurostimulation therapy for patients with chronic low back pain and should be considered earlier in the treatment continuum as a motor-sparing means of avoiding opioids, denervation, and permanently implanted neurostimulation systems.
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Affiliation(s)
| | - Leonardo Kapural
- Center for Clinical ResearchCarolinas Pain InstituteWinston SalemNorth CarolinaU.S.A.
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Referred cramping phantom hand pain elicited in the face and eliminated by peripheral nerve block. Exp Brain Res 2018; 236:1815-1824. [PMID: 29666885 DOI: 10.1007/s00221-018-5262-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/10/2018] [Indexed: 01/05/2023]
Abstract
Phantom limb pain is a restricting condition for a substantial number of amputees with quite different characteristics of pain. Here, we report on a forearm amputee with constant phantom pain in the hand, in whom we could regularly elicit the rare phenomenon of referred cramping phantom pain by touching the face. To clarify the underlying mechanisms, we followed the cramp during the course of an axillary blockade of the brachial plexus. During the blockade, both phantom pain and the referred cramp were abolished, while a referred sensation of "being touched at the phantom" persisted. Furthermore, to identify the cortical substrate, we elicited the cramp during functional magnetic imaging. Imaging revealed that referred cramping phantom limb pain was associated with brain activation of the hand representation in the primary sensorimotor cortex. The results support the hypothesis that referred cramping phantom limb pain in this case is associated with a substantial brain activation in the hand area of the deafferented sensorimotor cortex. However, this alone is not sufficient to elicit referred cramping phantom limb pain. Peripheral inputs, both, from the arm nerves affected by the amputation and from the skin in the face at which the referred cramp is evoked, are a precondition for referred cramping phantom limb pain to occur, at least in this case.
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Weiss T. Plasticity and Cortical Reorganization Associated With Pain. ZEITSCHRIFT FUR PSYCHOLOGIE-JOURNAL OF PSYCHOLOGY 2016. [DOI: 10.1027/2151-2604/a000241] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Abstract. This review focuses on plasticity and reorganization associated with pain. It is well established that noxious stimulation activates a large network of neural structures in the human brain, which is often denominated as the neuromatrix of pain. Repeated stimulation is able to induce plasticity in nearly all structures of this neuromatrix. While the plasticity to short-term stimulation is usually transient, long-term stimulation might induce persistent changes within the neuromatrix network and reorganize its functions and structures. Interestingly, a large longitudinal study on patients with subacute back pain found predictors for the persistence of pain versus remission in mesolimbic structures not usually included in the neuromatrix of pain. From these results, new concepts of nociception, pain, and transition from acute to chronic pain emerged. Overall, this review outlines a number of plastic changes in response to pain. However, the role of plasticity for chronic pain has still to be established.
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Affiliation(s)
- Thomas Weiss
- Department of Biological and Clinical Psychology, Friedrich Schiller University Jena, Germany
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10
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Rork JF, Berde CB, Goldstein RD. Regional anesthesia approaches to pain management in pediatric palliative care: a review of current knowledge. J Pain Symptom Manage 2013; 46:859-73. [PMID: 23541741 DOI: 10.1016/j.jpainsymman.2013.01.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 12/31/2012] [Accepted: 01/02/2013] [Indexed: 12/14/2022]
Abstract
CONTEXT Although systemic analgesic therapies are the mainstay of pain treatment in pediatric palliative care, there are cases where they fail to adequately relieve symptoms or produce side effects that undermine effectiveness. Regional anesthesia may be considered as a potential therapy for these patients. OBJECTIVES To review the literature on regional techniques in pediatric patients with life-limiting and chronic conditions, including pain from tumor infiltration, chest pain in advanced pulmonary disease, chronic abdominal pain, phantom limb pain, and spasticity and dystonia. Where relevant, the authors' clinical experiences are included. METHODS References were identified by searches of PubMed from 1980 until June 2012 with related terms. RESULTS Case reports and case series were identified for each condition. Regional anesthesia techniques performed included central neuraxial infusions, peripheral nerve and plexus blocks or infusions, neurolytic blocks, and implanted intrathecal ports and pumps for baclofen, opioids, local anesthetics, and other adjuvants. The reports described positive contributions to the management of moderate-to-severe pain. Clinical context for these techniques frequently included the failure of systemic treatments and/or intolerable medication side effects. Complications varied according to the procedure and the underlying patient pathology; however, these risks were often acceptable when the potential benefits were consistent with the overall goals of care. CONCLUSION The present medical literature on regional anesthesia techniques in children receiving palliative care is limited to case reports and case series. Based on this evidence, recommendations must be provisional. Careful thought and discussion with pain management specialists are encouraged when pain symptoms are inadequately managed or the treatments produce deleterious side effects.
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Moesker AA, Karl HW, Trescot AM. Treatment of Phantom Limb Pain by Cryoneurolysis of the Amputated Nerve. Pain Pract 2012; 14:52-6. [DOI: 10.1111/papr.12020] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 10/29/2012] [Indexed: 01/01/2023]
Affiliation(s)
| | - Helen W. Karl
- University of Washington School of Medicine; Seattle Washington U.S.A
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12
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Effects of temporary functional deafferentation on the brain, sensation, and behavior of stroke patients. J Neurosci 2012; 32:11773-9. [PMID: 22915119 DOI: 10.1523/jneurosci.5912-11.2012] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Following stroke, many patients suffer from chronic motor impairment and reduced somatosensation in the stroke-affected body parts. Recent experimental studies suggest that temporary functional deafferentation (TFD) of parts of the stroke-affected upper limb or of the less-affected contralateral limb might improve the sensorimotor capacity of the stroke-affected hand. The present study sought evidence of cortical reorganization and related sensory and motor improvements following pharmacologically induced TFD of the stroke-affected forearm. Examination was performed during 2 d of Constraint-Induced Movement Therapy. Thirty-six human patients were deafferented on the stroke-affected forearm by an anesthetic cream (containing lidocaine and prilocaine) on one of the 2 d, and a placebo cream was applied on the other. The order of TFD and placebo treatment was counterbalanced across patients. Somatosensory and motor performance were assessed using a Grating orienting task and a Shape-sorter-drum task, and with somatosensory-evoked magnetic fields. Evoked magnetic fields showed significant pre- to postevaluation magnitude increases in response to tactile stimulation of the thumb of the stroke-affected hand during TFD but not following placebo treatment. We also observed a rapid extension of the distance between cortical representations of the stroke-affected thumb and little finger following TFD but not following placebo treatment. Moreover, somatosensory and motor performance of the stroke-affected hand was significantly enhanced during TFD but not during placebo treatment. Thus, pharmacologically induced TFD of a stroke-affected forearm might improve the somatosensory and motor functions of the stroke-affected upper limb, accompanied by cortical plasticity.
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13
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Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract 2012; 2012:560879. [PMID: 22761615 PMCID: PMC3385590 DOI: 10.1155/2012/560879] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 04/10/2012] [Accepted: 04/17/2012] [Indexed: 12/29/2022] Open
Abstract
A continuous peripheral nerve block (cPNB) is provided in the hospital and ambulatory setting. The most common use of CPNBs is in the peri- and postoperative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain. The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of postoperative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of postsurgical chronic pain and reduction of costs. Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate postoperative effects. Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life measures is still lacking. This review will give an overview of the advantages and adverse effects of cPNBs.
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Affiliation(s)
- José Aguirre
- Division of Anesthesiology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Alicia Del Moral
- Department of Anesthesiology, General University Hospital of Valencia, 46014 Valencia, Spain
| | - Irina Cobo
- Department of Anesthesiology, General University Hospital of Valencia, 46014 Valencia, Spain
| | - Alain Borgeat
- Division of Anesthesiology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Stephan Blumenthal
- Department of Anesthesiology, Triemli Hospital, 8063 Zurich, Switzerland
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Preißler S, Meissner W, Weiss T. Brachial Plexus Block in Phantom Limb Pain: Not Only Interesting, But (Sometimes) with Clinical Benefit. PAIN MEDICINE 2012; 13:850-1. [DOI: 10.1111/j.1526-4637.2012.01399.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Preißler S, Feiler J, Dietrich C, Hofmann GO, Miltner WHR, Weiss T. Gray Matter Changes Following Limb Amputation with High and Low Intensities of Phantom Limb Pain. Cereb Cortex 2012; 23:1038-48. [DOI: 10.1093/cercor/bhs063] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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