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Paschali M, Thompson GS, Mehta S, Howard PM, Yamin JB, Edwards RR, Donnino MW. Psychophysiologic symptom relief therapy for chronic back pain: hypothesis and trial rationale. FRONTIERS IN PAIN RESEARCH 2024; 5:1328495. [PMID: 39091382 PMCID: PMC11291320 DOI: 10.3389/fpain.2024.1328495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 05/24/2024] [Indexed: 08/04/2024] Open
Abstract
Chronic pain syndromes affect over one-third of the US adult population and often lead to significant disability and a reduced quality of life. Despite their high prevalence, causal links between chronic pain syndromes and anatomic abnormalities are often not apparent. Most current chronic pain treatments provide modest, if any, relief. Thus, there is a pressing need to understand the causal mechanisms implicated in chronic pain as a means to develop more targeted interventions for improvement in clinical outcomes and reduction in morbidity and financial burden. In the present manuscript, we summarize the current literature on treatment for chronic pain, and hypothesize that non-specific chronic back pain (without a clear organic etiology, such as tumors, infections or fractures) is of psychophysiologic origin. Based on this hypothesis, we developed Psychophysiologic Symptom Relief Therapy (PSRT), a novel pain reduction intervention for understanding and treating chronic pain. In this manuscript, we provide the rationale for PSRT, which we have tested in a pilot trial with a subsequent larger randomized trial underway. In the proposed trial, we will evaluate whether non-specific chronic back pain can be treated by addressing the underlying stressors and psychological underpinnings without specific physical interventions.
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Affiliation(s)
- Myrella Paschali
- Department of Anesthesiology, Harvard Medical School, Brigham & Women’s Hospital, Chestnut Hill, MA, United States
| | - Garrett S. Thompson
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Shivani Mehta
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Patricia M. Howard
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Jolin B. Yamin
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Robert R. Edwards
- Department of Anesthesiology, Harvard Medical School, Brigham & Women’s Hospital, Chestnut Hill, MA, United States
| | - Michael W. Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
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Harnik MA, Kesselring P, Ott A, Urman RD, Luedi MM. Complex Regional Pain Syndrome (CRPS) and the Value of Early Detection. Curr Pain Headache Rep 2023; 27:417-427. [PMID: 37410335 PMCID: PMC10462545 DOI: 10.1007/s11916-023-01124-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE OF REVIEW The goal of this narrative review is to describe the current understanding of the pathology of Complex Regional Pain Syndrome (CRPS), as well as diagnostic standards and therapeutic options. We will then make the case for early recognition and management. RECENT FINDINGS CRPS remains an enigmatic pain syndrome, comprising several subtypes. Recent recommendations clarify diagnostic ambiguities and emphasize the importance of standardized assessment and therapy. Awareness of CRPS should be raised to promote prevention, early detection, and rapid escalation of therapy in refractory cases. Comorbidities and health costs (i.e., the socioeconomic impact) must also be addressed early to prevent negative consequences for patients.
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Affiliation(s)
- Michael Alexander Harnik
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pascal Kesselring
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Ott
- Department of Anaesthesiology and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Richard D. Urman
- Department of Anaesthesiology, College of Medicine, The Ohio State University, Columbus, OH 43210 USA
| | - Markus M. Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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Sherry DD, Mondal A, McGill M, Gmuca S. Pediatric Complex Regional Pain Syndrome With and Without a History of Prior Physical Trauma at Onset. Clin J Pain 2023; 39:437-441. [PMID: 37335219 PMCID: PMC10399929 DOI: 10.1097/ajp.0000000000001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 05/16/2023] [Accepted: 06/09/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE To determine whether differences exist between children with complex regional pain syndrome (CRPS) who identify an inciting physical traumatic event (group T) versus those without such history (group NT). METHODS We performed a single-center, retrospective study of children diagnosed with CRPS, 18 years old or younger, presenting between April 2008 and March 2021 and enrolled in a patient registry. Abstracted data included clinical characteristics, pain symptoms, Functional Disability Inventory, psychological history, and Pain Catastrophizing scale for children. Charts were reviewed for outcome data. RESULTS We identified 301 children with CRPS, 95 (64%) reported prior physical trauma. There was no difference between the groups regarding age, sex, duration, pain level, function, psychological symptoms, and scores on the Pain Catastrophizing Scale for Children. However, those in group T were more likely to have had a cast (43% vs 23%, P < 0.001). Those in group T were less likely to experience complete resolution of symptoms (64% vs 76%, P = 0.036). There were no other outcome differences between the groups. DISCUSSION We found minimal differences in children with CRPS who report a prior history of physical trauma to those who do not. Physical trauma may not play as significant a role as immobility, such as casting. The groups mostly had similar psychological backgrounds and outcomes.
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Affiliation(s)
- David D. Sherry
- Division of Rheumatology, Department of Pediatrics, Children’s Hospital of Philadelphia
- University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia
| | - Antara Mondal
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, the Children’s Hospital of Philadelphia
| | - Mackenzie McGill
- Division of Rheumatology, Department of Pediatrics, Children’s Hospital of Philadelphia
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia
- Policy Lab, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, Philadelphia, PA
| | - Sabrina Gmuca
- Division of Rheumatology, Department of Pediatrics, Children’s Hospital of Philadelphia
- University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia
- Policy Lab, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, Philadelphia, PA
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Mesaroli G, McLennan L, Friedrich Y, Stinson J, Sethna N, Logan D. Signs and symptoms of pediatric complex regional pain syndrome -type 1: A retrospective cohort study. Can J Pain 2023; 7:2179917. [PMID: 37091835 PMCID: PMC10116922 DOI: 10.1080/24740527.2023.2179917] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Background Complex regional pain syndrome (CRPS) presents with an array of symptoms that can vary from child to child, making it difficult to diagnose and differentiate from other pain conditions such as chronic musculoskeletal (MSK) pain. Thirteen symptoms and signs are outlined in the Budapest criteria for CRPS (developed and validated for adults) but have not been well described in pediatrics. Aims The aim of this study was to describe the signs and symptoms of pediatric CRPS type 1 (CRPS 1) and determine whether a cluster of symptoms can differentiate CRPS 1 from chronic MSK pain. Methods A retrospective cohort study of pediatric patients with CRPS 1 and MSK pain in a pediatric pain program was conducted. Descriptive statistics were used to report demographics and pain characteristics. The chi-square test was used to evaluate differences in signs and symptoms between patients with CRPS and MSK pain. A logistic regression model was used to evaluate whether a cluster of symptoms could predict a diagnosis of CRPS 1. Results The sample included 187 patients (99 with CRPS 1 and 88 with MSK pain); 81% were female with a mean age 14.1 years. The most prevalent CRPS symptoms were hyperalgesia (54%) and allodynia (52%). A cluster of symptoms (hyperalgesia, color changes, and range of motion) predicted the probability of a diagnosis of CRPS 1. Conclusions A cluster of symptoms may be critical in differentiating pediatric CRPS 1 and MSK pain. Future research is needed to determine if this model is valid in external populations and to explore whether a similar model can differentiate CRPS 1 from other pain conditions (e.g., neuropathic pain).
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Affiliation(s)
- Giulia Mesaroli
- Department of Physical Therapy, University of Toronto; Department of Rehabilitation and Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Logan McLennan
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Yvonne Friedrich
- Department of Clinical Psychology, Friedrich-Schiller University Jena, Germany
| | - Jennifer Stinson
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto and Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Navil Sethna
- Department of Anesthesia, Perioperative and Pain Medicine, Mayo Family Pediatric Pain Rehabilitation Center, Boston Children’s Hospital, Boston, MA, USA
| | - Deirdre Logan
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School
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Melf-Marzi A, Böhringer B, Wiehle M, Hausteiner-Wiehle C. Modern Principles of Diagnosis and Treatment in Complex Regional Pain Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:879-886. [PMID: 36482756 PMCID: PMC10011717 DOI: 10.3238/arztebl.m2022.0358] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 04/21/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Background: Complex regional pain syndrome (CRPS) is a relatively common complication, occurring in 5% of cases after injury or surgery, particularly in the limbs. The incidence of CPRS is around 5-26/100 000. The latest revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) now categorizes CRPS as a primary pain condition of multifactorial origin, rather than a disease of the skeletal system or the autonomic nervous system. METHODS Method: Based on a selective search of the literature, we summarize current principles for the diagnosis and treatment of CRPS. RESULTS Results: Regional findings in CRPS are accompanied by systemic symptoms, especially by neurocognitive disorders of body perception and of symptom processing. The therapeutic focus is shifting from predominantly passive peripheral measures to early active treatments acting both centrally and peripherally. The treatment is centered on physiotherapy and occupational therapy to improve sensory perception, strength, (fine) motor skills, and sensorimotor integration/ body perception. This is supported by stepped psychological interventions to reduce anxiety and avoidance behavior, medication to decrease inflammation and pain, passive physical measures for reduction of edema and of pain, and medical aids to improve functioning in daily life. Interventional procedures should be limited to exceptional cases and only be performed in specialized centers. Spinal cord and dorsal root ganglion stimulation, respectively, are the interventions with the best evidence. CONCLUSION Conclusion: The modern principles for the diagnosis and treatment of CRPS consider both, physiological and psychological mechanisms, with the primary goal of restoring function and participation. More research is needed to strengthen the evidence base in this field.
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Affiliation(s)
- Alexandra Melf-Marzi
- Department for BG Rehabilitation; Outpatient CRPS Clinic; BG Trauma Center Murnau; Department for Anesthesiology, Intensive Care Medicine and Pain Therapy; Multimodal Pain Therapy; BG Trauma Center Murnau; Department for Neurology, Clinical Neurophysiology and Stroke Unit; BG Trauma Center Murnau; Clinic and Polyclinic for Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich
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Martínez-Lavín M, Vargas A, Silveira LH, Amezcua-Guerra LM, Martínez-Martínez LA, Pineda C. Complex Regional Pain Syndrome Evolving to Full-Blown Fibromyalgia: A Proposal of Common Mechanisms. J Clin Rheumatol 2021; 27:S274-S277. [PMID: 32028304 DOI: 10.1097/rhu.0000000000001304] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Spread of complex regional pain syndrome (CRPS) outside the affected limb is a well-recognized phenomenon; nevertheless, the actual evolution from CRPS to fibromyalgia is poorly documented. Similar mechanisms have been recently put forward to explain the development of CRPS and fibromyalgia including dorsal root ganglia (DRG) hyperexcitability and small fiber neuropathy. OBJECTIVES The aims of this study were to describe 3 cases with typical CRPS evolving to full-blown fibromyalgia and to discuss the potential pathogenetic mechanisms linking these debilitating illnesses. METHODS This was a review of medical records and PubMed search on the relationship between CRPS-fibromyalgia with DRG and small nerve fiber neuropathy. RESULTS Our 3 cases displayed over time orderly evolution from CRPS to fibromyalgia. Dorsal root ganglion hyperexcitability and small fiber neuropathy have been recently demonstrated in CRPS and in fibromyalgia. Dorsal root ganglia contain the small nerve fiber cell bodies surrounded by glial cells. After trauma, DRG perineuronal glial cells produce diverse proinflammatory mediators. Macrophages, lymphocytes, and satellite glial cells may drive the immune response to more rostrally and caudally located DRG and other spinal cord sites. Dorsal root ganglion metabolic changes may lead to small nerve fiber degeneration. This mechanism may explain the development of widespread pain and autonomic dysfunction. CONCLUSIONS Clinicians should be aware that CRPS can evolve to full-blown fibromyalgia. Spreading of neuroinflammation through DRG glial cell activation could theoretically explain the transformation from regional to generalized complex pain syndrome.
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Affiliation(s)
| | - Angelica Vargas
- From the Rheumatology Department, National Institute of Cardiology
| | - Luis H Silveira
- From the Rheumatology Department, National Institute of Cardiology
| | | | | | - Carlos Pineda
- Division of Musculoskeletal and Rheumatic Disorders, National Institute of Rehabilitation, Mexico City, Mexico
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Bass C, Yates G. Complex regional pain syndrome type 1 in the medico-legal setting: High rates of somatoform disorders, opiate use and diagnostic uncertainty. MEDICINE, SCIENCE, AND THE LAW 2018; 58:147-155. [PMID: 29865933 DOI: 10.1177/0025802418779934] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Objective The aim of this study was to review demographic and clinical characteristics of patients with complex regional pain syndrome type 1 (CRPS) seen in a UK medico-legal setting - particularly the relationship between CRPS and somatoform disorders. Methods Fifty consecutive cases of CRPS (interviewed 2005-2016) undergoing psychiatric assessment were reviewed. A systematic assessment of mental states was conducted via interview and examination of medical/psychiatric records. Thirty patients also completed the Brief Illness Perception Questionnaire (BIPQ). Results Sixty per cent of patients ( n = 30) were female, and the mean age was 43 years. Twenty-two per cent ( n = 11) were employed, and 60% ( n = 30) received disability benefits. Symptoms were reported in the upper limb (62%; n = 31), lower limb (30%; n = 15), both (6%; n = 3) or elsewhere (2%; n = 1). Eighty-four per cent ( n = 42) satisfied DSM-5 criteria for current somatoform disorder. A history of more than two pain-related functional somatic syndromes (e.g. non-cardiac chest pain) was found in 42% ( n = 21) and functional neurological symptoms (e.g. 'claw-hand') in 42% ( n = 21). BIPQ scores resembled those associated with somatoform disorders and disorders mediated by psychological factors (e.g. irritable bowel syndrome). In 38% ( n = 19), the CRPS diagnosis was disputed among experts. A history of depression was noted in 60% ( n = 30), panic attacks in 20% ( n = 10) and alcohol/substance misuse in 18% ( n = 9). Opiates were prescribed to 64% ( n = 32). Conclusions Patients diagnosed with CRPS involved in litigation have high rates of prior psychopathology (mainly somatoform disorders) and pain-related disability for which opiate use is common. They risk an adverse reaction to limb pain 'shaped' by maladaptive illness beliefs. The CRPS diagnosis lacks reliability in medico-legal settings and may cause iatrogenic harm.
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Affiliation(s)
- Christopher Bass
- 1 Department of Psychological Medicine, John Radcliffe Hospital, UK
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Grieve S, Perez RSGM, Birklein F, Brunner F, Bruehl S, Harden R N, Packham T, Gobeil F, Haigh R, Holly J, Terkelsen A, Davies L, Lewis J, Thomassen I, Connett R, Worth T, Vatine JJ, McCabe CS. Recommendations for a first Core Outcome Measurement set for complex regional PAin syndrome Clinical sTudies (COMPACT). Pain 2017; 158:1083-1090. [PMID: 28178071 PMCID: PMC5438049 DOI: 10.1097/j.pain.0000000000000866] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Complex regional pain syndrome (CRPS) is a persistent pain condition that remains incompletely understood and challenging to treat. Historically, a wide range of different outcome measures have been used to capture the multidimensional nature of CRPS. This has been a significant limiting factor in the advancement of our understanding of the mechanisms and management of CRPS. In 2013, an international consortium of patients, clinicians, researchers, and industry representatives was established, to develop and agree on a minimum core set of standardised outcome measures for use in future CRPS clinical research, including but not limited to clinical trials within adult populations. The development of a core measurement set was informed through workshops and supplementary work, using an iterative consensus process. "What is the clinical presentation and course of CRPS, and what factors influence it?" was agreed as the most pertinent research question that our standardised set of patient-reported outcome measures should be selected to answer. The domains encompassing the key concepts necessary to answer the research question were agreed as follows: pain, disease severity, participation and physical function, emotional and psychological function, self-efficacy, catastrophizing, and patient's global impression of change. The final core measurement set included the optimum generic or condition-specific patient-reported questionnaire outcome measures, which captured the essence of each domain, and 1 clinician-reported outcome measure to capture the degree of severity of CRPS. The next step is to test the feasibility and acceptability of collecting outcome measure data using the core measurement set in the CRPS population internationally.
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Affiliation(s)
- Sharon Grieve
- Royal United Hospitals NHS Foundation Trust, Bath, UK
- University of the West of England, Bristol, UK
| | | | | | | | - Stephen Bruehl
- Vanderbilt University School of Medicine, Nashville, USA
| | | | | | | | | | - Janet Holly
- The Ottawa Hospital Rehabilitation Centre, Ottawa, Canada
| | | | | | - Jennifer Lewis
- Royal United Hospitals NHS Foundation Trust, Bath, UK
- University of the West of England, Bristol, UK
| | | | | | | | - Jean-Jacques Vatine
- Sackler Faculty of Medicine, Tel Aviv University, Israel
- Reuth Rehabilitation Hospital, Tel Aviv, Israel
| | - Candida S McCabe
- Royal United Hospitals NHS Foundation Trust, Bath, UK
- University of the West of England, Bristol, UK
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Weinstock LB, Myers TL, Walters AS, Schwartz OA, Younger JW, Chopra PJ, Guarino AH. Identification and Treatment of New Inflammatory Triggers for Complex Regional Pain Syndrome: Small Intestinal Bacterial Overgrowth and Obstructive Sleep Apnea. ACTA ACUST UNITED AC 2017; 6:272-6. [PMID: 26867023 DOI: 10.1213/xaa.0000000000000292] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Complex regional pain syndrome (CRPS) is evoked by conditions that may be associated with local and/or systemic inflammation. We present a case of long-standing CRPS in a patient with Ehlers-Danlos syndrome in which prolonged remission was attained by directing therapy toward concomitant small intestinal bacterial overgrowth, obstructive sleep apnea, and potential increased microglia activity. We theorize that cytokine production produced by small intestinal bacterial overgrowth and obstructive sleep apnea may act as stimuli for ongoing CRPS symptoms. CRPS may also benefit from the properties of low-dose naltrexone that blocks microglia Toll-like receptors and induces production of endorphins that regulate and reduce inflammation.
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Affiliation(s)
- Leonard B Weinstock
- From the Departments of *Anesthesia and †Internal Medicine, Washington University School of Medicine, St. Louis, Missouri; ‡Specialists in Gastroenterology, LLC, St. Louis, Missouri; §Department of Neurology, Vanderbilt University, Nashville, Tennessee; ‖Sleep and EEG Laboratory, Barnes Jewish West County, BJC Medical Group Center for Sleep Medicine, St. Louis, Missouri; Departments of ¶Psychology, #Anesthesiology, and **Rheumatology, Neuroinflammation, Pain and Fatigue Lab, University of Alabama, Birmingham, Alabama; ††Pain Management Center, Department of Anesthesia, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and ‡‡Department of Anesthesia, Washington University School of Medicine, St. Louis, Missouri
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Time Since Inciting Event Is Associated With Higher Centralized Pain Symptoms in Patients Diagnosed With Complex Regional Pain Syndrome. Reg Anesth Pain Med 2016; 41:731-736. [DOI: 10.1097/aap.0000000000000483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Osborne S, Farrell J, Dearman RJ, MacIver K, Naisbitt DJ, Moots RJ, Edwards SW, Goebel A. Cutaneous immunopathology of long-standing complex regional pain syndrome. Eur J Pain 2015; 19:1516-26. [PMID: 25728589 DOI: 10.1002/ejp.685] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Both increased mast cells numbers and raised immune mediator concentrations indicate immune activation in the affected skin of patients with early complex regional pain syndrome (CRPS), but little is known about regional immune cell involvement in late-stage CRPS. The aim of the current study was to determine skin immune cell populations in long-standing CRPS. METHODS Using 6-mm skin punch biopsies from CRPS-affected and non-affected tissues, and a combination of chemical and immunofluorescence staining, we examined the density and function of key cell populations including mast cells, epidermal Langerhans cells (LCs) and tissue resident T-cells. RESULTS We found no significant differences in either overall immune cell infiltrates, or mast cell density between CRPS-affected and non-affected sub-epidermal tissue sections, contrasting recent findings in early CRPS by other groups. However, CD1a(+) LC densities in the epidermal layer were significantly decreased in affected compared to non-affected CRPS limbs (p < 0.01). T-cell clones isolated from CRPS-affected sub-epidermal tissues displayed a trend towards increased IL-13 production in ELISPOT assays when compared to T-cells isolated from non-affected areas, suggesting a Th2 bias. CONCLUSIONS Immune cell abnormalities are maintained in late-stage CRPS disease as manifest by changes in epidermal LC density and tissue resident T-cell phenotype.
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Affiliation(s)
- S Osborne
- Institute of Integrative Biology, University of Liverpool, UK
| | - J Farrell
- MRC Centre for Drug Safety Science and Institute of Translational Medicine, Department of Molecular and Clinical Pharmacology, University of Liverpool, UK
| | - R J Dearman
- Faculty of Life Sciences, University of Manchester, UK
| | - K MacIver
- Pain Research Institute, Department of Translational Medicine, Liverpool University, UK
| | - D J Naisbitt
- MRC Centre for Drug Safety Science and Institute of Translational Medicine, Department of Molecular and Clinical Pharmacology, University of Liverpool, UK
| | - R J Moots
- Rheumatology Research Group, Institute of Ageing and Chronic Disease, University of Liverpool, UK
| | - S W Edwards
- Institute of Integrative Biology, University of Liverpool, UK
| | - A Goebel
- Pain Research Institute, Department of Translational Medicine, Liverpool University, UK.,The Walton Centre NHS Foundation Trust, Liverpool, UK
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Abstract
Complex regional pain syndrome (CRPS) is the current consensus-derived name for a syndrome usually triggered by limb trauma. Required elements include prolonged, disproportionate distal-limb pain and microvascular dysregulation (e.g., edema or color changes) or altered sweating. CRPS-II (formerly "causalgia") describes patients with identified nerve injuries. CRPS-I (formerly "reflex sympathetic dystrophy") describes most patients who lack evidence of specific nerve injuries. Diagnosis is clinical and the pathophysiology involves combinations of small-fiber axonopathy, microvasculopathy, inflammation, and brain plasticity/sensitization. Females have much higher risk and workplace accidents are a well-recognized cause. Inflammation and dysimmunity, perhaps facilitated by injury to the blood-nerve barrier, may contribute. Most patients, particularly the young, recover gradually, but treatment can speed healing. Evidence of efficacy is strongest for rehabilitation therapies (e.g., graded-motor imagery), neuropathic pain medications, and electric stimulation of the spinal cord, injured nerve, or motor cortex. Investigational treatments include ketamine, botulinum toxin, immunoglobulins, and transcranial neuromodulation. Nonrecovering patients should be re-evaluated for neurosurgically treatable causal lesions (nerve entrapment, impingement, infections, or tumors) and treatable potentiating medical conditions, including polyneuropathy and circulatory insufficiency. Earlier impressions that CRPS represents malingering or psychosomatic illness have been replaced by evidence that CRPS is a rare complication of limb injury in biologically susceptible individuals.
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Affiliation(s)
- Anne Louise Oaklander
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Pathology (Neuropathology), Massachusetts General Hospital, Boston, MA, USA.
| | - Steven H Horowitz
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, School of Medicine, Tufts University, Boston, MA, USA
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