1
|
Limerick G, Christo DK, Tram J, Moheimani R, Manor J, Chakravarthy K, Karri J, Christo PJ. Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments. Curr Pain Headache Rep 2023; 27:269-298. [PMID: 37421541 DOI: 10.1007/s11916-023-01130-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW This review presents the most current information about the epidemiology of complex regional pain syndrome (CRPS), classification and diagnostic criteria, childhood CRPS, subtypes, pathophysiology, conventional and less conventional treatments, and preventive strategies. RECENT FINDINGS CRPS is a painful disorder with multifactorial pathophysiology. The data describe sensitization of the central and peripheral nervous systems, inflammation, possible genetic factors, sympatho-afferent coupling, autoimmunity, and mental health factors as contributors to the syndrome. In addition to conventional subtypes (type I and type II), cluster analyses have uncovered other proposed subtypes. Prevalence of CRPS is approximately 1.2%, female gender is consistently associated with a higher risk of development, and substantial physical, emotional, and financial costs can result from the syndrome. Children with CRPS seem to benefit from multifaceted physical therapy leading to a high percentage of symptom-free patients. The best available evidence along with standard clinical practice supports pharmacological agents, physical and occupational therapy, sympathetic blocks for engaging physical restoration, steroids for acute CRPS, neuromodulation, ketamine, and intrathecal baclofen as therapeutic approaches. There are many emerging treatments that can be considered as a part of individualized, patient-centered care. Vitamin C may be preventive. CRPS can lead to progressively painful sensory and vascular changes, edema, limb weakness, and trophic disturbances, all of which substantially erode healthy living. Despite some progress in research, more comprehensive basic science investigation is needed to clarify the molecular mechanisms of the disease so that targeted treatments can be developed for better outcomes. Incorporating a variety of standard therapies with different modes of action may offer the most effective analgesia. Introducing less conventional approaches may also be helpful when traditional treatments fail to provide sufficient improvement.
Collapse
Affiliation(s)
- Gerard Limerick
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Dana K Christo
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jennifer Tram
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | | | - John Manor
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Jay Karri
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.
| |
Collapse
|
2
|
van den Berg C, de Bree PN, Huygen FJPM, Tiemensma J. Glucocorticoid treatment in patients with complex regional pain syndrome: A systematic review. Eur J Pain 2022; 26:2009-2035. [PMID: 35983980 PMCID: PMC9826269 DOI: 10.1002/ejp.2025] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVE The pathophysiology of complex regional pain syndrome (CRPS) is multifactorial, with an exaggerated inflammatory response being the most prominent. Treatment for CRPS is carried out according to the presenting pathophysiological mechanism. Anti-inflammatory treatment with glucocorticoids is therefore an option. The aim of this study was to systematically review the efficacy of glucocorticoids in CRPS. DATABASES AND DATA TREATMENT Embase, Medline, Web of Science and Google Scholar were systematically searched for articles focusing on glucocorticoid treatment and CRPS. Screening based on title and abstract was followed by full-text reading (including reference lists) to determine the final set of relevant articles. Bias was assessed using the revised Cochrane risk-of-bias-tool for randomized trials (Rob2). RESULTS Forty-one studies were included, which reported on 1208 CRPS patients. A wide variety of glucocorticoid administration strategies were applied, with oral being the most frequently chosen. Additionally, researchers found great heterogeneity in outcome parameters, including clinical symptoms, pain relief and range of motion. The use of glucocorticoids caused an improvement of parameters in all but two studies. In particular, improvement in pain relief and range of motion were reported. Using glucocorticoids in CRPS of longer duration (i.e. more than 3 months) appears to be less effective. CONCLUSION Based on the present review, there is evidence to support glucocorticoid treatment in CRPS. However, the ideal administration route and dose remain unclear. We therefore recommend future research via an intervention study, as well as studies on the aetiological mechanisms and corresponding optimal treatment because CRPS pathogenesis is only partially understood. SIGNIFICANCE Several studies point towards CRPS being an inflammatory response after tissue or nerve damage, with higher levels of pro-inflammatory cytokines in serum, plasma, cerebrospinal fluid and artificial skin blisters. Inflammation provides a possible role for glucocorticoids in treating CRPS. This systematic review provides a structured overview of glucocorticoid treatment in patients with CRPS. Improvement in pain and range of motion is shown. Systematic review registration number: PROSPERO-CRD42020144671.
Collapse
Affiliation(s)
- Corinne van den Berg
- Department of AnesthesiologyCentre for Pain MedicineErasmus MCRotterdamThe Netherlands
| | - Pim N. de Bree
- Department of AnesthesiologyCentre for Pain MedicineErasmus MCRotterdamThe Netherlands
| | - Frank J. P. M. Huygen
- Department of AnesthesiologyCentre for Pain MedicineErasmus MCRotterdamThe Netherlands
| | - Jitske Tiemensma
- Department of AnesthesiologyCentre for Pain MedicineErasmus MCRotterdamThe Netherlands
| |
Collapse
|
3
|
Kwak SG, Choo YJ, Chang MC. Effectiveness of prednisolone in complex regional pain syndrome treatment: A systematic narrative review. Pain Pract 2021; 22:381-390. [PMID: 34779145 DOI: 10.1111/papr.13090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/06/2021] [Accepted: 11/08/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Many patients with complex regional pain syndrome (CRPS) experience refractory pain with severe restrictions in the activities of daily living. Oral prednisolone is commonly used to treat these patients. PURPOSE To review previous studies assessing the effects of prednisolone in CRPS patients. METHODS AND MATERIALS Articles published from January 1, 1980 to July 23, 2021 in the PubMed database were searched using the following key phrases: (prednisolone OR corticosteroid OR steroid) AND (complex regional pain syndrome OR reflex sympathetic dystrophy OR shoulder-hand syndrome OR causalgia). Specifically, we included those articles in which oral prednisolone or corticosteroids were used to control the CRPS symptoms. RESULTS In total, 11 articles were included, comprising 3 randomized trials, 5 single-arm prospective observational studies, and 3 retrospective studies. Nearly all previous studies reported that oral prednisolone can effectively control the CRPS symptoms. Moreover, though 30-100 mg/day of oral prednisolone was initially administered in these studies, 30 mg/day was also found to be effective in controlling the symptoms. Although prednisolone was usually administered for 1-3 months, short-term treatment for 1-2 weeks was also reportedly effective. Furthermore, only 0%-30% of the patients in these studies had minor side effects after prednisolone treatment. CONCLUSIONS Our review showed that prednisolone may be effective in alleviating the CRPS symptoms. To determine higher levels of evidence, a full systematic review with more highly qualified studies, such as randomized controlled trials, should be conducted in the future.
Collapse
Affiliation(s)
- Sang Gyu Kwak
- Department of Medical Statistics, College of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Yoo Jin Choo
- Production R&D Division Advanced Interdisciplinary Team, Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation, Daegu, Korea
| | - Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| |
Collapse
|
4
|
Of mice, microglia, and (wo)men: a case series and mechanistic investigation of hydroxychloroquine for complex regional pain syndrome. Pain Rep 2021; 5:e841. [PMID: 33490839 PMCID: PMC7808678 DOI: 10.1097/pr9.0000000000000841] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/19/2020] [Accepted: 07/02/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction Complex regional pain syndrome (CRPS) is a condition that occurs after minor trauma characterized by sensory, trophic, and motor changes. Although preclinical studies have demonstrated that CRPS may be driven in part by autoinflammation, clinical use of immune-modulating drugs in CRPS is limited. Hydroxychloroquine (HCQ) is a disease-modifying antirheumatic drug used to treat malaria and autoimmune disorders that may provide benefit in CRPS. Objectives To describe the use of HCQ in patients with refractory CRPS and investigate possible mechanisms of benefit in a mouse model of CRPS. Methods We initiated HCQ therapy in 7 female patients with refractory CRPS undergoing treatment at the Stanford Pain Management Center. We subsequently undertook studies in the mouse tibial fracture-casting model of CRPS to identify mechanisms underlying symptom reduction. We evaluated behavior using mechanical allodynia and spinal cord autoinflammation by immunohistochemistry and enzyme-linked immunosorbent assay. Results We treated 7 female patients with chronic, refractory CRPS with HCQ 200 mg twice daily for 2 months, followed by 200 mg daily thereafter. Two patients stopped HCQ secondary to lack of response or side effects. Overall, HCQ significantly improved average numerical rating scale pain from 6.8 ± 1.1 before HCQ to 3.8 ± 1.9 after HCQ treatment. In the tibial fracture-casting mouse model of CRPS, we observed reductions in allodynia, paw edema, and warmth following daily HCQ treatment starting at 3 weeks after injury. Spinal cord dorsal horn microglial activation and cytokine levels were also reduced by HCQ treatment. Conclusion Together, these preclinical and clinical results suggest that HCQ may benefit patients with CRPS at least in part by modulating autoinflammation and support further investigation into the use of HCQ for CRPS.
Collapse
|
5
|
Ji J, Wu M, Zhong L, Liu Z, Wang C, Shao Z, Xie Q, Liu Z. Early, low-dose, short-term methylprednisolone decreased the mortality in critical COVID-19 patients: A multicenter retrospective cohort study. J Infect 2020; 82:84-123. [PMID: 33176176 PMCID: PMC7649028 DOI: 10.1016/j.jinf.2020.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/05/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Jingjing Ji
- Department of Critical Care Medicine, General Hospital of Southern Theater Command of PLA, Guangzhou, 510010, China
| | - Ming Wu
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, The Second People's Hospital of Shenzhen & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, 518035, China
| | - Li Zhong
- Department of Critical Care Medicine, The First Affiliated Hospital, Guizhou University of Chinese Medicine, Guiyang, 550001, China
| | - Zheying Liu
- Department of Critical Care Medicine, General Hospital of Southern Theater Command of PLA, Guangzhou, 510010, China
| | - Conglin Wang
- Department of Critical Care Medicine, General Hospital of Southern Theater Command of PLA, Guangzhou, 510010, China
| | - Ziyun Shao
- Department of Nephrology, General Hospital of Central Theater Command of PLA, Wuhan, 430070, China
| | - Qifeng Xie
- Department of Critical Care Medicine, General Hospital of Southern Theater Command of PLA, Guangzhou, 510010, China
| | - Zhifeng Liu
- Department of Critical Care Medicine, General Hospital of Southern Theater Command of PLA, Guangzhou, 510010, China; Key Laboratory of Hot Zone Trauma Care and Tissue Repair of PLA, General Hospital of Southern Theater Command of PLA, Guangzhou, 510010, China; The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510010, China.
| |
Collapse
|
6
|
Binkley K, Katznelson R. Successful Treatment of Long Standing Complex Regional Pain Syndrome with Hyperbaric Oxygen Therapy. J Neuroimmune Pharmacol 2019; 15:1-6. [PMID: 31838618 DOI: 10.1007/s11481-019-09901-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 12/09/2019] [Indexed: 01/07/2023]
Abstract
Complex regional pain syndrome (CRPS) is a devastating posttraumatic neuroinflammatory condition with both autoinflammatory and autoimmune features, characterized by unrelenting severe pain and disability, with the majority of affected patients being unable to function socially or vocationally. Remission is more likely in children than adults, and if treatment is started early. Once established, there are no universally effective treatments, and these are desperately needed. A single limb is often involved, but there can be multi-limb spread, and systemic autonomic manifestations. We describe a case of long-standing CRPS with multi-limb spread and systemic autonomic features, controlled only with very high dose oral corticosteroids, which led to several complications. Multiple other treatment modalities failed or were insufficient to control the CRPS and allow tapering of the corticosteroids, but the patient had a dramatic response to hyperbaric oxygen therapy (HBOT), allowing a reduction in prednisone dose to just over the physiologic range. When symptoms started to increase several months later, a second course of HBOT treatments allowed reduction in prednisone dose into the physiologic range while still controlling CRPS symptoms. This case is unique in that it shows that HBOT can be effective in long-standing CRPS, both initially, and for subsequent flares, and adds to the evidence supporting HBOT as a potential treatment for this condition. Graphical Abstract HBOT effect on prednisone dose for symptom control.
Collapse
Affiliation(s)
- Karen Binkley
- Division of Clinical Immunology and Allergy, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Rita Katznelson
- Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|