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Abd-Elsayed A, Stark CW, Topoluk N, Isaamullah M, Uzodinma P, Viswanath O, Gyorfi MJ, Fattouh O, Schlidt KC, Dyara O. A brief review of complex regional pain syndrome and current management. Ann Med 2024; 56:2334398. [PMID: 38569195 PMCID: PMC10993759 DOI: 10.1080/07853890.2024.2334398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/28/2024] [Indexed: 04/05/2024] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating chronic pain condition that, although exceedingly rare, carries a significant burden for the affected patient population. The complex and ambiguous pathophysiology of this condition further complicates clinical management and therapeutic interventions. Furthermore, being a diagnosis of exclusion requires a diligent workup to ensure an accurate diagnosis and subsequent targeted management. The development of the Budapest diagnostic criteria helped to consolidate existing definitions of CRPS but extensive work remains in identifying the underlying pathways. Currently, two distinct types are identified by the presence (CRPS type 1) or absence (CRPS type 2) of neuronal injury. Current management directed at this disease is broad and growing, ranging from non-invasive modalities such as physical and psychological therapy to more invasive techniques such as dorsal root ganglion stimulation and potentially amputation. Ideal therapeutic interventions are multimodal in nature to address the likely multifactorial pathological development of CRPS. Regardless, a significant need remains for continued studies to elucidate the pathways involved in developing CRPS as well as more robust clinical trials for various treatment modalities.
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Affiliation(s)
- Alaa Abd-Elsayed
- Department of Anesthesiology, University of WI School of Medicine and Public Health, Madison, WI, USA
| | - Cain W. Stark
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Natasha Topoluk
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Mir Isaamullah
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Paul Uzodinma
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Omar Viswanath
- Anesthesiology, LSU Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Michael J. Gyorfi
- Department of Anesthesiology, University of WI School of Medicine and Public Health, Madison, WI, USA
| | - Osama Fattouh
- Department of Neurobiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Kevin C. Schlidt
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Omar Dyara
- Department of Anesthesiology, Medical College of Wisconsin, Wauwatosa, WI, USA
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Olomi J, Munthali V. Complex regional pain syndrome: diagnostic challenges and favorable response to prednisolone. BMC Musculoskelet Disord 2024; 25:278. [PMID: 38600551 PMCID: PMC11005296 DOI: 10.1186/s12891-024-07333-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/04/2024] [Indexed: 04/12/2024] Open
Abstract
Complex regional pain syndrome (CRPS), characterized by severe and disproportionate pain, is a rare and debilitating condition. Due to its rarity, evidence-based treatment guidelines remain limited, creating a challenge for clinicians. We present the case of a 20-year-old female with CRPS type 1 of the right hand. Her pain, initially triggered by a minor trauma, had persisted for three months. The patient demonstrated severe pain, swelling, hyperesthesia, and restricted range of motion. Despite multiple hospital visits, her symptoms did not improve until she was diagnosed with CRPS and treated with oral prednisolone. A dosage of 40 mg daily led to a dramatic response within 10 days. Our report emphasizes the importance of recognizing CRPS and highlights the potential of prednisolone as a treatment option, particularly in resource-limited settings, where more specialized interventions may be unavailable. Further research is essential to establish a stronger evidence base for the use of steroids in CRPS management.
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Affiliation(s)
- Jimmy Olomi
- University of Dar es salaam (UDSM), P.O. Box 608, Mbeya, Tanzania.
- Mbeya zonal referral hospital (MZRH), P.O. Box 419, Mbeya, Tanzania.
| | - Victoria Munthali
- Muhimbili Orthopedic Institute (MOI), P.O. Box 65474, Dar es salaam, Tanzania
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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: 0] [Impact Index Per Article: 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.
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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.
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MacRae FA, Boissonnault E, Winston P. A retrospective review of the management and outcomes of patients diagnosed with complex regional pain syndrome type II using electrodiagnostic findings. Can J Pain 2023; 7:2242892. [PMID: 38229666 PMCID: PMC10791151 DOI: 10.1080/24740527.2023.2242892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/27/2023] [Indexed: 01/18/2024]
Abstract
Objectives The objective of this study was to assess the outcomes of the use of electrodiagnosis in the diagnosis and management of discrete nerve injuries in patients with complex regional pain syndrome (CRPS). Design This study is a secondary retrospective cohort analysis of patients diagnosed with CRPS from a single outpatient physical medicine and rehabilitation clinic and included all patients who had abnormal electrodiagnostic findings, in addition to CRPS. Results Sixty patients of 248 diagnosed with CRPS underwent electrodiagnosis, 41 of whom had abnormal electrodiagnostic findings indicating a discrete nerve injury. Only 51% of the 41 referrals had indicated the suspicion of a nerve injury. Nearly all patients had undergone physiotherapy. Forty-one percent responded to treatment with oral prednisone alone, 54% had a functional improvement after a combination of treatments including corticosteroids, and 5% improved with treatments that did not involve corticosteroids. Surgical interventions for nerve injuries were required for 34% of patients in the cohort. All surgeries involved the median or ulnar nerve, with the exception of one fibular nerve. After treatment, 39 of 41 patients had functional recoveries or better. Conclusions Electrodiagnosis can inform diagnosis of nerve injury and direct intervention including the need for surgical intervention. Electrodiagnosis should be considered for patients with initial signs of concomitant discrete nerve injury or with CRPS who are not responding to treatments because a nerve injury may be underlying. What is Known Complex Regional Pain Syndrome (CRPS) is a poorly understood pain condition. CRPS has been divided into two subtypes, the second subtype involves a discrete nerve injury with pain that extends beyond the territory of the nerve injury. What is New We observed that nerve injuries that may require surgical intervention are diagnosed just over half of the time upon initial assessment in patients with suspected CRPS. We observed that nerve injuries frequently required specifically directed interventions in place of or in conjunction with CRPS treatments. We suggest that electrodiagnosis is an important part of the triage protocol for CRPS II to reveal discrete nerve injuries that may be hidden. We recommend that electrodiagnosis be considered for patients with initial signs of concomitant discrete nerve injury or for CRPS patients who do not improve with medical therapies.
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Affiliation(s)
- Fraser Alexander MacRae
- Health Sciences, Western University, London, Canada
- Vancouver Island Health Authority, Victoria, Canada
| | - Eve Boissonnault
- Physical Medicine and Rehabilitation, University of Montreal, Montreal, Canada
| | - Paul Winston
- Faculty of Medicine, University of British Columbia, Victoria, Canada
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Kalita J, Pandey PC, Shukla R, Misra UK. Prednisolone 20 mg vs 40 mg in complex regional pain syndrome type I: A randomized controlled trial. J Clin Neurosci 2023; 113:108-113. [PMID: 37257216 DOI: 10.1016/j.jocn.2023.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND High dose of corticosteroid has been found beneficial in complex regional pain syndrome type I (CRPS-I). We report the efficacy and safety of prednisolone 20 mg versus 40 mg in CRPS-I in an open label randomized controlled trial. METHODS The patients with CRPS-I of the shoulder joint with a CRPS score of ≥8 were included. Their demographic details, comorbidities, and underlying etiology were noted. The severity of CRPS was assessed using a 0-14 CRPS scale, the pain using a 0-10 Visual Analogue Scale (VAS), and sleep quality using a 0-10. Daily Sleep Interference Scale (DSIS). Patients were randomized to prednisolone 40 mg/day (group I) or 20 mg/day (group II) for 14 days, then tapered to 10 mg in group I and to 5 mg in group II by 1 month. Thereafter both groups received prednisolone 5 mg/day for 2 months. The primary outcome was a >50% reduction in VAS score, and secondary outcomes were a reduction in CRPS score, DSIS score, and adverse events. RESULTS Fifty patients were included, and their baseline characteristics were comparable. At one month, all the patients had >50% reduction in the VAS score. The effect size was 0.38 (95% CI 0.93-0.20; p = 0.20). On the Kaplan-Mayer analysis, the improvement in the VAS score (Hazard ratio-1.43, 95 % CI-0.80-2.56, p = 0.22) and the CRPS score (HR-0.79,95 % CI-0.45-1.39; p = 0.41) was insignificant between the two groups. The DSIS score improved in group II (HR-1.85,95 % Cl-1.04-3.31,p = 0.04). Group I patients needed frequent adjustment of antidiabetic drugs (14 vs 6; p = 0.04). CONCLUSION The efficacy of prednisolone 20 mg is not inferior to 40 mg in CRPS-I, and is safe in diabetic patients. LIMITATIONS This is an open label randomized controlled trial with small sample size without a placebo arm.
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Affiliation(s)
- Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India.
| | - Prakash C Pandey
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Ruchi Shukla
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Usha K Misra
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India
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DeDi C, Jones M, Oikonomou K, Jengo MD. Multidisciplinary Management of Complex Regional Pain Syndrome (CRPS) Type 1 in the Hand and Wrist: A Case Report. Cureus 2023; 15:e37227. [PMID: 37168206 PMCID: PMC10166377 DOI: 10.7759/cureus.37227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/13/2023] Open
Abstract
Complex regional pain syndrome (CRPS) is a rare disorder that presents as a highly variable combination of intense regional pain, autonomic and vasomotor disturbances that are uncharacteristic of the inciting trauma or event. We report a 36-year-old male construction worker who presented to the orthopedic department status post crush injury to his hand, with acutely increasing right-hand pain, swelling, skin/hair changes, and dysfunction. Presentation changed over a course of 2-8 weeks, with CRPS becoming the eventual working diagnosis. Initial diagnoses were not made by occupational med, nor the urgent care, and definitive diagnosis was achieved in the orthopedic hand office via a thorough history and physical exam as well as imaging modalities including X-ray, CT, and MRI. A multidisciplinary approach involving aggressive hand therapy, anti-inflammatory agents, high-dose prednisone, Gabapentin, and over-the-counter vitamins and supplements was used in the treatment of this patient. This patient had a unique progression of his condition with respect to his carpus, demonstrating acute reduction of bone density on plain film. Stiffness ensued. This patient's condition was almost "missed" by the masking of the ulnar ossicle variant (os triangulare), and anatomical snuffbox pain on exam, in the face of initially "normal" X-rays. It is important for providers to recognize the clinical signs of complex regional pain syndrome, especially in the acute phase of crush injury, swelling, skin and hair changes, and stiffness, and to treat patients' symptoms with a variety of treatment options due to the marked variability of this condition. The patient has made a favorable recovery with some residual functional deficits, however, the patient stated that his quality of life has been restored despite his current stiffness.
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Affiliation(s)
- Christian DeDi
- Orthopedic Surgery, Edward Via College of Osteopathic Medicine, Blacksburg, USA
| | - Micah Jones
- Orthopedics, Edward Via College of Osteopathic Medicine, Blacksburg, USA
- Orthopedic Surgery, LewisGale Medical Center, Salem, USA
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Arcidiacono UA, Armocida D, Pesce A, Maiotti M, Proietti L, D’Andrea G, Santoro A, Frati A. Complex Regional Pain Syndrome after Spine Surgery: A Rare Complication in Mini-Invasive Lumbar Spine Surgery: An Updated Comprehensive Review. J Clin Med 2022; 11:jcm11247409. [PMID: 36556025 PMCID: PMC9781971 DOI: 10.3390/jcm11247409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a postoperative, misdiagnosed condition highlighted only by pain therapists after numerous failed attempts at pain control by the treating surgeon in the case of prolonged pain after surgery. It only occurs rarely after spine surgery, causing the neurosurgeon's inappropriate decision to resort to a second surgical treatment. METHODS We performed a systematic review of the literature reporting and analyzing all recognized and reported cases of CRPS in patients undergoing spinal surgery to identify the best diagnostic and therapeutic strategies for this unusual condition. We compare our experience with the cases reported through a review of the literature. RESULTS We retrieve 20 articles. Most of the papers are clinical cases showing the disorder's rarity after spine surgery. Most of the time, the syndrome followed uncomplicated lumbar spine surgery involving one segment. The most proposed therapy was chemical sympathectomy and spinal cord stimulation. CONCLUSION CRPS is a rare pathology and is rarer after spine surgery. However, it is quite an invalidating disorder. Early therapy and resolution, however, require a rapid diagnosis of the syndrome. In our opinion, since CRPS occurs relatively rarely following spinal surgery, it should not have a substantial impact on the indications for and timing of these operations. Therefore, it is essential to diagnose this rare occurrence and treat it promptly and appropriately.
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Affiliation(s)
| | - Daniele Armocida
- Human Neurosciences Department, Neurosurgery Division, “Sapienza” University, 00185 Rome, Italy
- IRCCS “Neuromed”, 86077 Pozzilli, Italy
- Correspondence: ; Tel.: +39-393-287-4496
| | - Alessandro Pesce
- Neurosurgery Unit, Santa Maria Goretti Hospital, Via Guido Reni 1, 04100 Latina, Italy
| | - Marco Maiotti
- Villa Stuart Hospital, Orthopedic Clinic, 00135 Roma, Italy
| | - Luca Proietti
- Division of Spinal Surgery, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Institute of Orthopaedics, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | | | - Antonio Santoro
- Human Neurosciences Department, Neurosurgery Division, “Sapienza” University, 00185 Rome, Italy
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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.
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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
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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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Loy E, Scheidler A, Packham T, Dow H, Winston P. Patient satisfaction with virtual evaluation, diagnosis, and treatment of CRPS. Can J Pain 2022; 6:77-84. [PMID: 35694140 PMCID: PMC9176228 DOI: 10.1080/24740527.2022.2063113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The COVID-19 pandemic has led to an increased reliance on virtual care in the rehabilitation setting for patients with conditions such as complex regional pain syndrome (CRPS). Aims The aim of this study was to perform a quality improvement initiative to assess patient satisfaction and ensure that outcomes following virtual assessment, diagnosis, and treatment of CRPS with prednisone are safe and effective. Methods An online survey was distributed to 18 patients with CRPS who had been seen virtually between March and December 2020 through a rehabilitation clinic and treated with oral prednisone. Thirteen participants completed the survey, which was designed de novo by our team to evaluate participant perceptions and satisfaction regarding the virtual care experience. Also included in the survey was a CRPS-specific validated patient-report questionnaire (Hamilton Inventory for CRPS: PR-HI-CRPS), which allowed participants to describe their specific symptoms and associated functional and psychosocial impacts, both previously (pretreatment baseline) and at the time of survey (posttreatment). Results CRPS symptoms and related impacts were scored as significantly improved from baseline following treatment with prednisone. Likert scale results from survey responses related to patients' experiences and satisfaction with the virtual care process were analyzed; the majority of patients reported satisfaction with a virtual appointment for evaluation of CRPS, as well as with subsequent treatment decisions based on virtual assessment. Conclusions This quality improvement study suggests that virtual care is a potential option for a patient-accepted approach to overcoming challenges with in-person care imposed by the COVID-19 pandemic and could help inform future considerations in addressing geographic and patient-specific disparities in access to specialist care for CRPS.
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Affiliation(s)
- Emma Loy
- Faculty of Medicine, University of British Columbia, Vancouver, BritishColumbia, Canada
| | - Anna Scheidler
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tara Packham
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Heather Dow
- Canadian Association of Physical Medicine and Rehabilitation, Kingston, Ontario, Canada
| | - Paul Winston
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BritishColumbia, Canada,CONTACT Dr. Paul Winston Division of Physical Medicine and Rehabilitation, University of British Columbia, 1 Hospital Way, Victoria General Hospital, Victoria, BCV8Z 6R5, Canada
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Taylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, Carlson T, Myrcik D, Varrassi G, Viswanath O. Complex Regional Pain Syndrome: A Comprehensive Review. Pain Ther 2021; 10:875-892. [PMID: 34165690 PMCID: PMC8586273 DOI: 10.1007/s40122-021-00279-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/03/2021] [Indexed: 12/22/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain condition often involving hyperalgesia and allodynia of the extremities. CRPS is divided into CRPS-I and CRPS-II. Type I occurs when there is no confirmed nerve injury. Type II is when there is known associated nerve injury. Female gender is a risk factor for developing CRPS. Other risk factors include fibromyalgia and rheumatoid arthritis. Unfortunately, the pathogenesis of CRPS is not yet clarified. Some studies have demonstrated different potential pathways. Neuropathic inflammation, specifically activation of peripheral nociceptors of C-fibers, has been shown to play a critical role in developing CRPS. The autonomic nervous system (ANS) is involved. Depending on whether it is acute or chronic CRPS, norepinephrine levels are either decreased or increased, respectively. Some studies have suggested the importance of genetics in developing CRPS. More consideration is being given to the role of psychological factors. Some association between a history of depression and/or post-traumatic stress disorder (PTSD) and the diagnosis of CRPS has been demonstrated. Treatment modalities available range from physical therapy, pharmacotherapy, and interventional techniques. Physical and occupational therapies include mirror therapy and graded motor imagery. Medical management with non-steroidal anti-inflammatory drugs (NSAIDs) has not shown significant improvement. There have been supporting findings in the use of short-course steroids, bisphosphonates, gabapentin, and ketamine. Antioxidant treatment has also shown some promise. Other pharmacotherapies include low-dose naltrexone and Botulinum toxin A (BTX-A). Sympathetic blocks are routinely used, even if their short- and long-term effects are not clear. Finally, spinal cord stimulation (SCS) has been used for decades. In conclusion, CRPS is a multifactorial condition that still requires further studying to better understand its pathogenesis, epidemiology, genetic involvement, psychological implications, and treatment options. Future studies are warranted to better understand this syndrome. This will provide an opportunity for better prevention, diagnosis, and treatment of CRPS.
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Affiliation(s)
- Samantha-Su Taylor
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Nazir Noor
- Department of Anesthesiology, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33130, USA.
| | - Ivan Urits
- grid.492905.3Southcoast Physician Group Pain Medicine, Southcoast Health, North Dartmouth, MA USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA
| | - Antonella Paladini
- grid.158820.60000 0004 1757 2611Department of MESVA, University of L’Aquila, 67100 L’Aquila, Italy
| | - Monica Sri Sadhu
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Clay Gibb
- grid.260024.2Midwestern University Chicago College of Osteopathic Medicine, Chicago, IL USA
| | - Tyler Carlson
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Dariusz Myrcik
- grid.411728.90000 0001 2198 0923Department of Internal Medicine, Medical University of Silesia, 42-600 Katowice, Bytom Poland
| | | | - Omar Viswanath
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA ,Valley Pain Consultants-Envision Physician Services, Phoenix, AZ USA ,grid.254748.80000 0004 1936 8876Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE USA
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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.
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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
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Fitterer JW, Picelli A, Winston P. A Novel Approach to New-Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm. Front Neurol 2021; 12:668370. [PMID: 34122312 PMCID: PMC8194087 DOI: 10.3389/fneur.2021.668370] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/14/2021] [Indexed: 01/19/2023] Open
Abstract
Introduction: Hemiplegic shoulder pain (HSP) is the most common pain disorder after stroke with incidence estimates of 30–70% and associated with reductions in function, interference with rehabilitation, and a reduced quality of life. Onset may occur as soon as a week after stroke in 17% of patients. Management of HSP represents a complex treatment pathway with a lack of evidence to support one treatment. The pain has heterogeneous causes. In the acute setting, decreased range of motion in the shoulder can be due to early-onset spasticity, capsular pattern stiffness, glenohumeral pathology, or complex regional pain syndrome (CRPS). As contracture can form in up to 50% of patients after stroke, effective management of the painful shoulder and upper limb with decreased range of motion requires assessment of each possible contributor for effective treatment. The anesthetic diagnostic nerve block (DNB) is known to differentiate spasticity from contracture and other disorders of immobility and can be useful in determining an appropriate treatment pathway. Objective: To create a diagnostic algorithm to differentiate between the causes of HSP in the stiff, painful shoulder in the subacute setting using diagnostic techniques including the Budapest Criteria for CRPS and DNB for spasticity and pain generators. Results: Examination of each joint in the upper extremity with HSP may differentiate each diagnosis with the use of an algorithm. Pain and stiffness isolated to the shoulder may be differentiated as primary shoulder pathology; sensory suprascapular DNB or intra-articular/subacromial injection can assist in differentiating adhesive capsulitis, arthritis, or rotator cuff injury. CRPS may affect the shoulder, elbow, wrist, and hand and can be evaluated with the Budapest Criteria. Spasticity can be differentiated with the use of motor DNB. A combination of these disorders may cause HSP, and the proposed treatment algorithm may offer assistance in selecting a systematic treatment pathway.
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Affiliation(s)
- John W Fitterer
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada
| | - Alessandro Picelli
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada.,Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, Neuromotor and Cognitive Rehabilitation Research Center, University of Verona, Verona, Italy
| | - Paul Winston
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada.,Division of Physical Medicine and Rehabilitation, University of British Columbia, Victoria, BC, Canada
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Abstract
Ischemic monomelic neuropathy (IMN) is a little-known, painful axonal neuropathy, secondary to vascular occlusion or steal phenomenon. It typically occurs after vascular bypass, hemodialysis fistulization, or diabetic microvascular disease in the absence of significant clinical features of ischemia. There is limited literature to assist in the characterization and diagnosis of this condition. We describe three patients with IMN with no surgical or peripheral vascular disease history who exhibited spontaneous, persistent foot pain, edema numbness, and weakness with denervation on needle electromyogram in a distal lower leg peripheral nerve distribution. Occlusive disease was found in all patients on angiogram, requiring vascular bypass surgery.
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