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Lewis JS, Wallace CS, White P, Mottram L, Ockenden G, Rehm K, Walker K. Early versus persistent Complex Regional Pain Syndrome: Is there a difference in patient reported outcomes following rehabilitation? Eur J Pain 2024; 28:464-475. [PMID: 37947050 DOI: 10.1002/ejp.2196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/18/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Expert consensus asserts that early treatment of Complex Regional Pain Syndrome (CRPS) leads to better outcomes. Yet no evidence supports this assumption regarding the recognized gold standard of multidisciplinary functional rehabilitation. To address this, we aimed to establish if there is a difference in outcomes between early CRPS (<1 year symptom duration) and persistent CRPS (= >1 year symptom duration) following rehabilitation and whether any gains are maintained at three months. METHOD Secondary analysis was conducted on previously collected clinical Patient Reported Outcome Measures (PROMS) data from 218 patients attending a residential multidisciplinary rehabilitation programme. Datasets were categorized into early CRPS (n = 40) or persistent CRPS (n = 178) dependent on symptom duration. Function, pain, self-efficacy, kinesiophobia and psychological health domains were compared using repeated measures analysis of covariance for a two group design for group difference post rehabilitation and at three month follow-up. RESULTS Post-rehabilitation, both groups improved in pain, function, kinesiophobia, psychological health and self-efficacy. At three months, the persistent CRPS group maintained improvements in pain and function. This was not achieved in early CRPS. CONCLUSION This exploratory study is the first to empirically test the assumption that those with early CRPS have better outcomes following rehabilitation. Our clinical data challenges this, as both early and persistent CRPS groups improved following rehabilitation. Findings indicate that rehabilitation benefits those with CRPS, regardless of symptom duration. However, unlike early CRPS, those with persistent CRPS sustain gains at follow-up. Further prospective exploration is warranted. SIGNIFICANCE Expert consensus recommends early treatment for Complex Regional Pain Syndrome, yet there is little empirical evidence to support this. Our findings are the first to challenge this assumption by revealing no difference in outcomes between early and persistent CRPS post-rehabilitation. However, those with persistent CRPS maintain gains after three months, unlike people with early CRPS (symptoms < one year). These findings are relevant to clinical practice as they challenge established assumptions, suggesting a focus on improving early CRPS follow-up outcomes.
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Affiliation(s)
- Jennifer S Lewis
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
- National Complex Regional Pain Syndrome Service, Royal United Hospitals NHS Trust, Bath, UK
| | - Chris S Wallace
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Paul White
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Laura Mottram
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Gareth Ockenden
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Kjetil Rehm
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - Kate Walker
- School for Health and Social Wellbeing, University of the West of England, Bristol, UK
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Hartmannsberger B, Scriba S, Guidolin C, Becker J, Mehling K, Doppler K, Sommer C, Rittner HL. Transient immune activation without loss of intraepidermal innervation and associated Schwann cells in patients with complex regional pain syndrome. J Neuroinflammation 2024; 21:23. [PMID: 38233858 PMCID: PMC10792943 DOI: 10.1186/s12974-023-02969-6] [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: 09/06/2023] [Accepted: 11/22/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) develops after injury and is characterized by disproportionate pain, oedema, and functional loss. CRPS has clinical signs of neuropathy as well as neurogenic inflammation. Here, we asked whether skin biopsies could be used to differentiate the contribution of these two systems to ultimately guide therapy. To this end, the cutaneous sensory system including nerve fibres and the recently described nociceptive Schwann cells as well as the cutaneous immune system were analysed. METHODS We systematically deep-phenotyped CRPS patients and immunolabelled glabrous skin biopsies from the affected ipsilateral and non-affected contralateral finger of 19 acute (< 12 months) and 6 chronic (> 12 months after trauma) CRPS patients as well as 25 sex- and age-matched healthy controls (HC). Murine foot pads harvested one week after sham or chronic constriction injury were immunolabelled to assess intraepidermal Schwann cells. RESULTS Intraepidermal Schwann cells were detected in human skin of the finger-but their density was much lower compared to mice. Acute and chronic CRPS patients suffered from moderate to severe CRPS symptoms and corresponding pain. Most patients had CRPS type I in the warm category. Their cutaneous neuroglial complex was completely unaffected despite sensory plus signs, e.g. allodynia and hyperalgesia. Cutaneous innate sentinel immune cells, e.g. mast cells and Langerhans cells, infiltrated or proliferated ipsilaterally independently of each other-but only in acute CRPS. No additional adaptive immune cells, e.g. T cells and plasma cells, infiltrated the skin. CONCLUSIONS Diagnostic skin punch biopsies could be used to diagnose individual pathophysiology in a very heterogenous disease like acute CRPS to guide tailored treatment in the future. Since numbers of inflammatory cells and pain did not necessarily correlate, more in-depth analysis of individual patients is necessary.
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Affiliation(s)
- Beate Hartmannsberger
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University of Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Sabrina Scriba
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University of Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Carolina Guidolin
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University of Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Juliane Becker
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University of Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Katharina Mehling
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University of Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany
| | - Kathrin Doppler
- Department of Neurology, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Claudia Sommer
- Department of Neurology, University Hospital Würzburg, 97080, Würzburg, Germany
| | - Heike L Rittner
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University of Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany.
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3
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Grieve S, Brunner F, Cabral DF, Connett R, Hirata H, Iwasaki N, Nakagawa Y, Sagir A, Sousa G, Vatine JJ, Vaughan-Spickers N, Xu J, Buckle L, McCabe C. An international study to explore the feasibility of collecting standardised outcome data for Complex Regional Pain Syndrome: recommendations for an international clinical research registry. Br J Pain 2023; 17:468-478. [PMID: 38107759 PMCID: PMC10722111 DOI: 10.1177/20494637231188333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
Introduction Complex Regional Pain Syndrome (CRPS) is a persistent pain condition with low prevalence. Multi-centre collaborative research is needed to attain sufficient sample sizes for meaningful studies. This international observational study: (1) tested the feasibility and acceptability of collecting outcome data using an agreed core measurement set (2) tested and refined an electronic data management system to collect and manage the data. Methods Adults with CRPS, meeting the Budapest diagnostic clinical criteria, were recruited to the study from 7 international research centres. After informed consent, a questionnaire comprising the core set outcome measures was completed: on paper at baseline (T1), and at 3 or 6 months (T2) using a paper or e-version. Participants and clinicians provided feedback on the data collection process. Clinicians completed the CRPS severity score at T1 and optionally, at T2. Ethical approval was obtained at each international centre. Results Ninety-eight adults were recruited (female n=66; mean age 46.6 years, range 19-89), of whom 32% chose to receive the T2 questionnaire in an electronic format. Fifty-five participants completed both T1 and T2. Eighteen participants and nine clinicians provided feedback on their data collection experience. Conclusion This study confirmed the questionnaire core outcome data are feasible and practicable to collect in clinical practice. The electronic data management system provided a robust means of collecting and managing the data across an international population. The findings have informed the final data collection tools and processes which will comprise the first international, clinical research registry and data bank for CRPS.
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Affiliation(s)
- Sharon Grieve
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- University of the West of England, Bristol, UK
| | | | - Danylo F Cabral
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | | | | | | | - Afrin Sagir
- Cleveland Clinic, Cleveland, Ohio, USA
- University of Pennsylvania, Philadelphia, USA
| | | | - Jean-Jacques Vatine
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Reuth Rehabilitation Hospital, Tel Aviv, Israel
| | | | - Jijun Xu
- Cleveland Clinic, Cleveland, Ohio, USA
| | - Lisa Buckle
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- University of the West of England, Bristol, UK
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Varenna M, Crotti C, Ughi N, Zucchi F, Caporali R. Determinants of Diagnostic Delay in Complex Regional Pain Syndrome Type 1: An Observational Study of 180 Consecutive New Cases. J Clin Rheumatol 2021; 27:e491-e495. [PMID: 32897995 DOI: 10.1097/rhu.0000000000001558] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Complex regional pain syndrome type 1 (CRPS-1) is a disabling painful disease, with variable outcomes in terms of chronic pain and disability. A long time between onset and diagnosis seems predictive for late recovery and progression toward a chronic disease. This study aims to investigate demographic and clinical variables associated with delayed CRPS-1 diagnosis. METHODS From March 2013 to January 2018, consecutive patients newly diagnosed according to International Association for the Study of Pain diagnostic criteria for CRPS-1 were recruited. Demographic and clinical variables were collected at diagnosis. Student t test and Mann-Whitney U test were used for comparisons; Cox proportional hazards model was applied to evaluate the variables associated with delayed CRPS-1 diagnosis. RESULTS One hundred eighty patients entered the study. At diagnosis, women were older, and foot was more often involved than hand. The triggering event was more commonly a trauma without fracture for foot disease and a fracture for hand localization. No differences between hand and foot disease were found by the International Association for the Study of Pain diagnostic categories (clinical vs research) or pain measures. Variables significantly associated with a longer time between disease onset and diagnosis were foot localization, general practitioner referral, higher number of visits before CRPS diagnosis, and prior physiotherapy prescribed for symptoms later diagnosed as CRPS. An overt clinical manifestation (research CRPS-1) predicted a shorter delay. CONCLUSIONS Foot localization, prior physiotherapy prescribed for symptoms later diagnosed as CRPS, and a disease without overt clinical manifestations were independent predictive factors for a delayed diagnosis. Clinicians should pay attention to these issues to ensure a timely diagnosis and possibly avoid progression toward a chronic disease.
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Affiliation(s)
| | - Chiara Crotti
- From the Department of Rheumatology, Gaetano Pini Institute
| | - Nicola Ughi
- From the Department of Rheumatology, Gaetano Pini Institute
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Bharwani KD, Kersten AB, Stone AL, Birklein F, Bruehl S, Dirckx M, Drummond PD, Gierthmühlen J, Goebel A, Knudsen L, Huygen FJPM. Denying the Truth Does Not Change the Facts: A Systematic Analysis of Pseudoscientific Denial of Complex Regional Pain Syndrome. J Pain Res 2021; 14:3359-3376. [PMID: 34737631 PMCID: PMC8558034 DOI: 10.2147/jpr.s326638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 09/03/2021] [Indexed: 12/31/2022] Open
Abstract
Purpose Several articles have claimed that complex regional pain syndrome (CRPS) does not exist. Although a minority view, it is important to understand the arguments presented in these articles. We conducted a systematic literature search to evaluate the methodological quality of articles that claim CRPS does not exist. We then examined and refuted the arguments supporting this claim using up-to-date scientific literature on CRPS. Methods A systematic search was conducted in MEDLINE, EMBASE and Cochrane CENTRAL databases. Inclusion criteria for articles were (a) a claim made that CRPS does not exist or that CRPS is not a distinct diagnostic entity and (b) support of these claims with subsequent argument(s). The methodological quality of articles was assessed if possible. Results Nine articles were included for analysis: 4 narrative reviews, 2 personal views, 1 letter, 1 editorial and 1 case report. Seven points of controversy were used in these articles to argue that CRPS does not exist: 1) disagreement with the label “CRPS”; 2) the “unclear” pathophysiology; 3) the validity of the diagnostic criteria; 4) CRPS as a normal consequence of immobilization; 5) the role of psychological factors; 6) other identifiable causes for CRPS symptoms; and 7) the methodological quality of CRPS research. Conclusion The level of evidence for the claim that CRPS does not exist is very weak. Published accounts concluding that CRPS does not exist, in the absence of primary evidence to underpin them, can harm patients by encouraging dismissal of patients’ signs and symptoms.
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Affiliation(s)
- K D Bharwani
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - A B Kersten
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - A L Stone
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - F Birklein
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - S Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Dirckx
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - P D Drummond
- Discipline of Psychology, College of Science, Health, Engineering and Education, Murdoch University, Perth, WA, Australia
| | - J Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - A Goebel
- Director of the Pain Research Institute Reader in Pain Medicine, University of Liverpool Honorary Consultant in Pain Medicine, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - L Knudsen
- The National Rehabilitation Centre for Neuromuscular Diseases, Aarhus, Denmark
| | - F J P M Huygen
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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6
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Kotsougiani-Fischer D, Choi JS, Oh-Fischer JS, Diehm YF, Haug VF, Harhaus L, Gazyakan E, Hirche C, Kneser U, Fischer S. ICF-based multidisciplinary rehabilitation program for complex regional pain syndrome of the hand: efficacy, long-term outcomes, and impact of therapy duration. BMC Surg 2020; 20:306. [PMID: 33256710 PMCID: PMC7708143 DOI: 10.1186/s12893-020-00982-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background Complex regional pain syndrome (CRPS) is a rare but feared complication in hand surgery. Although multimodal therapy concepts are recommended, there is only low evidence on efficacy of such approaches. Furthermore, recommendations regarding therapy duration are lacking. Aim of this study was to validate the efficacy of an International Classification of Functioning, Disability and Health (ICF)-based multidisciplinary rehabilitation concept for treatment of CRPS of the hand and to find correlations between therapy duration and outcome measures. Methods Patients with CRPS of the hand after occupational trauma that underwent an ICF-based rehabilitation program between 2010 and 2014 were included in this retrospective study. Besides demographic data, outcomes included pain (VAS), range of motion assessed by fingertip-to-palm-distance (PTPD) and fingernail-to-table-distance (FTTD) as well as strength in grip, 3-point pinch and lateral pinch. All measures were gathered at admission to and discharge from inpatient rehabilitation therapy as well as at follow-up. Statistical analysis included paired t-test, ANOVA and Pearson's correlation analysis. Results Eighty-nine patients with a mean age of 45 years were included in this study. Duration of rehabilitation therapy was 53 days on average. All outcomes improved significantly during rehabilitation therapy. Pain decreased from 6.4 to 2.2. PTPD of digit 2 to 5 improved from 2.5, 2.8, 2.6, and 2.3 cm to 1.3, 1.4, 1.2, and 1.1 cm, respectively. FTTD of digit 2 to 5 decreased from 1.5, 1.7, 1.5, and 1.6 cm to 0.6, 0.8, 0.7, and 0.7 cm, respectively. Strength ameliorated from 9.5, 3.7, 2.7 kg to 17.9, 5.6, 5.0 kg in grip, lateral pinch, and 3-point pinch, respectively. Improvement in range of motion significantly correlated with therapy duration. 54% of patients participated at follow-up after a mean of 7.5 months. Outcome measures at follow-up remained stable compared to discharge values without significant differences. Conclusion The ICF-based rehabilitation concept is a reliable and durable treatment option for CRPS of the hand. Range of motion improved continuously with therapy duration and thus may serve as an indicator for optimum length of therapy.
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Affiliation(s)
- D Kotsougiani-Fischer
- BG Trauma Center Ludwigshafen, Department for Hand-, Plastic- and Reconstructive Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - J S Choi
- BG Trauma Center Ludwigshafen, Department for Hand-, Plastic- and Reconstructive Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - J S Oh-Fischer
- BG Trauma Center Ludwigshafen, Department for Hand-, Plastic- and Reconstructive Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Y F Diehm
- BG Trauma Center Ludwigshafen, Department for Hand-, Plastic- and Reconstructive Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - V F Haug
- BG Trauma Center Ludwigshafen, Department for Hand-, Plastic- and Reconstructive Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - L Harhaus
- BG Trauma Center Ludwigshafen, Department for Hand-, Plastic- and Reconstructive Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - E Gazyakan
- BG Trauma Center Ludwigshafen, Department for Hand-, Plastic- and Reconstructive Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - C Hirche
- BG Trauma Center Ludwigshafen, Department for Hand-, Plastic- and Reconstructive Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - U Kneser
- BG Trauma Center Ludwigshafen, Department for Hand-, Plastic- and Reconstructive Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - S Fischer
- BG Trauma Center Ludwigshafen, Department for Hand-, Plastic- and Reconstructive Surgery, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany.
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7
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Bisla J, Ambler G, Frank B, Gulati S, Hocken P, James M, Kelly J, Keshet-Price J, McCabe C, McGylnn D, Padfield N, Pang D, Pout G, Sanders M, Serpell M, Shenker N, Shoukrey K, Wesley S, Weston M, White-Alao B, Wyatt L, Murphy C, Goebel A. Successful and unsuccessful recruitment and retainment strategies in a UK multicentre drug trial for a rare chronic pain condition which performed above target. Br J Pain 2020; 14:171-179. [PMID: 32922778 DOI: 10.1177/2049463719893399] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Introduction Recruitment into trials in rare chronic pain conditions can be challenging, so such trials consequently are underpowered or fail. Methods Drawing from our experience in conducting, to date, the largest academic trial in a rare chronic pain condition, complex regional pain syndrome, we have identified recruitment and retention strategies for successful trial conduct. Results We present 13 strategies grouped across the categories of 'setting the recruitment rate', 'networking', 'patient information', 'trial management' and 'patient retention'. Moreover, six recruitment risks are also discussed. A conservative recruitment estimate, based on audits of newly referred patients to the trial centres without taking into account availability of 'old' patients or recruitment from outside centres, and assuming a 55% patient refusal rate yielded accurate numbers. Conclusion Appreciation of these identified recruitment challenges and opportunities may contribute to supporting prospective investigators when they design clinical trials for chronic pain patient population groups where it has been historically difficult to conduct high-quality and robust clinical trials.
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Affiliation(s)
- Jatinder Bisla
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | | | - Sumit Gulati
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Poppy Hocken
- Royal National Hospital for Rheumatic Diseases, Bath, UK.,University of the West of England, Bristol, UK
| | - Mairi James
- Glasgow Clinical Research Facility, Queen Elizabeth University Hospital, Glasgow, UK
| | - Joanna Kelly
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - Candy McCabe
- Royal National Hospital for Rheumatic Diseases, Bath, UK.,University of the West of England, Bristol, UK.,Florence Nightingale Foundation, London, UK
| | - Deborah McGylnn
- Glasgow Clinical Research Facility, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nick Padfield
- Pain Management & Neuromodulation Centre, Guys & St Thomas' Hospital, London, UK
| | - David Pang
- Pain Management & Neuromodulation Centre, Guys & St Thomas' Hospital, London, UK
| | - Gill Pout
- Norfolk and Norwich University NHS Trust, Norwich, UK
| | - Mark Sanders
- Norfolk and Norwich University NHS Trust, Norwich, UK
| | - Mick Serpell
- Glasgow Clinical Research Facility, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nicholas Shenker
- Department of Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - Karim Shoukrey
- University Hospitals of Leicester NHS Trust, Leicester General Hospital, Leicester, UK
| | - Samuel Wesley
- Pain Management & Neuromodulation Centre, Guys & St Thomas' Hospital, London, UK
| | - Margaret Weston
- University Hospitals of Leicester NHS Trust, Leicester General Hospital, Leicester, UK
| | - Beverly White-Alao
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Lynne Wyatt
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Caroline Murphy
- King's Clinical Trials Unit, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Andreas Goebel
- University of Liverpool and The Walton Centre NHS Foundation Trust, Liverpool, UK
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8
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Kim IS, Hyun SE, Park J, Lim JY. Understanding the Rehabilitation Needs of Korean Patients With Complex Regional Pain Syndrome. Ann Rehabil Med 2020; 44:218-227. [PMID: 32475093 PMCID: PMC7349043 DOI: 10.5535/arm.19084] [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] [Received: 07/12/2019] [Revised: 09/04/2019] [Accepted: 09/11/2019] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To evaluate the current status of pain severity and quality of life (QoL) in patients with complex regional pain syndrome (CRPS), and to assess both their perceived needs and any unmet needs of current rehabilitation services. METHODS A single-center questionnaire-based survey was conducted on 47 patients with CRPS who were diagnosed based on Budapest's criteria. It collected demographic and clinical data, and the structured questionnaire included the Brief Pain Inventory (BPI), the Korean version of the World Health Organization Disability Assessment Schedule II (WHODAS-K II), as well as the 5-Level EuroQol-5D (EQ-5D-5L) for measuring the QoL. RESULTS The average value of BPI and WHODAS-K II were 7.69%±2.26% and 70.49%±19.22%, respectively. In the evaluation of their perceived needs and unmet needs for rehabilitation, patients had the highest rehabilitation needs in terms of pain (95.74%), followed by bodyaches (80.85%). Regarding their unmet needs, patients had the highest unmet needs in terms of memory impairment (83.33%), followed by weight management (72.00%). According to the regression analysis, only the overall BPI was significantly associated with QoL (p=0.01), and a higher BPI value led to poorer results for QoL. CONCLUSION In Korea, patients with CRPS do not receive adequate rehabilitation, and they are not satisfied with current received treatments. A more structured and individualized rehabilitation treatment plan is required to manage every aspect related to chronic pain, and provision should be made for improved care guidelines for future CRPS management.
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Affiliation(s)
- In Soo Kim
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Eun Hyun
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jihong Park
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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9
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Mancini F, Wang AP, Schira MM, Isherwood ZJ, McAuley JH, Iannetti GD, Sereno MI, Moseley GL, Rae CD. Fine-Grained Mapping of Cortical Somatotopies in Chronic Complex Regional Pain Syndrome. J Neurosci 2019; 39:9185-9196. [PMID: 31570533 PMCID: PMC6855684 DOI: 10.1523/jneurosci.2005-18.2019] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/13/2019] [Accepted: 08/19/2019] [Indexed: 01/21/2023] Open
Abstract
It has long been thought that severe chronic pain conditions, such as complex regional pain syndrome (CRPS), are not only associated with, but even maintained by a reorganization of the somatotopic representation of the affected limb in primary somatosensory cortex (S1). This notion has driven treatments that aim to restore S1 representations in CRPS patients, such as sensory discrimination training and mirror therapy. However, this notion is based on both indirect and incomplete evidence obtained with imaging methods with low spatial resolution. Here, we used fMRI to characterize the S1 representation of the affected and unaffected hand in humans (of either sex) with unilateral CRPS. The cortical area, location, and geometry of the S1 representation of the CRPS hand were largely comparable with those of both the unaffected hand and healthy controls. We found no differential relation between affected versus unaffected hand map measures and clinical measures (pain severity, upper limb disability, disease duration). Thus, if any map reorganization occurs, it does not appear to be directly related to pain and disease severity. These findings compel us to reconsider the cortical mechanisms underlying CRPS and the rationale for interventions that aim to "restore" somatotopic representations to treat pain.SIGNIFICANCE STATEMENT This study shows that the spatial map of the fingers in somatosensory cortex is largely preserved in chronic complex regional pain syndrome (CRPS). These findings challenge the treatment rationale for restoring somatotopic representations in complex regional pain syndrome patients.
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Affiliation(s)
- Flavia Mancini
- Computational and Biological Learning, Department of Engineering, University of Cambridge, Cambridge CB2 1PZ, United Kingdom,
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, United Kingdom
| | - Audrey P Wang
- Neuroscience Research Australia, Sydney, New South Wales 2031, Australia
- Faculty of Medicine and Health and Faculty of Health Sciences, University of Sydney, Sydney, New South Wales 2145, Australia
| | - Mark M Schira
- Neuroscience Research Australia, Sydney, New South Wales 2031, Australia
- School of Psychology, University of Wollongong, Wollongong, New South Wales 2522, Australia
| | - Zoey J Isherwood
- School of Psychology, University of Wollongong, Wollongong, New South Wales 2522, Australia
| | - James H McAuley
- Neuroscience Research Australia, Sydney, New South Wales 2031, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales 2052, Australia
| | - Giandomenico D Iannetti
- Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1E 6BT, United Kingdom
- Neuroscience and Behaviour Laboratory, Istituto Italiano di Tecnologia, Rome 00161, Italy
| | - Martin I Sereno
- Department of Psychology, University College London, London WC1E 6BT, United Kingdom
- Department of Psychology, San Diego State University, San Diego, California 92182, and
| | - G Lorimer Moseley
- Neuroscience Research Australia, Sydney, New South Wales 2031, Australia
- IMPACT in Health, University of South Australia, Adelaide, South Australia, Australia
| | - Caroline D Rae
- Neuroscience Research Australia, Sydney, New South Wales 2031, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales 2052, Australia
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10
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Herschkowitz D, Kubias J. A case report of wireless peripheral nerve stimulation for complex regional pain syndrome type-I of the upper extremity: 1 year follow up. Scand J Pain 2019; 19:829-835. [DOI: 10.1515/sjpain-2019-0071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 07/11/2019] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Complex regional pain syndrome (CRPS) is a chronic disabling painful disorder with limited options to achieve therapeutic relief. CRPS type I which follows trauma, may not show obvious damage to the nervous structures and remains dubious in its pathophysiology and also its response to conservative treatment or interventional pain management is elusive. Spinal cord and dorsal root ganglion stimulation (SCS, DRGS) provide good relief, mainly for causalgia or CRPS I of lower extremities but not very encouraging for upper extremity CRPS I. we reported earlier, a case of CRPS I of right arm treated successfully by wireless peripheral nerve stimulation (WPNS) with short term follow up. Here we present 1-year follow-up of this patient.
Objective
To present the first case of WPNS for CRPS I with a year follow up. The patient had minimally invasive peripheral nerve stimulation (PNS), without implantable pulse generator (IPG) or its accessories.
Case report
This was a case of refractory CRPS I after blunt trauma to the right forearm of a young female. She underwent placement of two Stimwave electrodes (Leads: FR4A-RCV-A0 with tines, Generation 1 and FR4A-RCV-B0 with tines, Generation 1) in her forearm under intraoperative electrophysiological and ultrasound guidance along radial and median nerves. This WPNS required no IPG. At high frequency (HF) stimulation (HF 10 kHz/32 μs, 2.0 mA), patient had shown remarkable relief in pain, allodynia and temperature impairment. At 5 months she started driving without opioid consumption, while allodynia disappeared. At 1 year follow up she was relieved of pain [visual analogue scale (VAS) score of 4 from 7] and Kapanji Index (Score) improved to 7–8. Both hands look similar in color and temperature. She never made unscheduled visits to the clinic or visited emergency room for any complications related to the WPNS.
Conclusions
CRPS I involving upper extremity remain difficult to manage with conventional SCS or DRGS because of equipment related adverse events. Minimally invasive WPNS in this case had shown consistent relief without any complications or side effects related to the wireless technology or the technique at the end of 1 year.
Implications
This is the first case illustration of WPNS for CRPS I, successfully treated and followed up for 1 year.
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Affiliation(s)
| | - Jana Kubias
- Mgr, Parimed GmbH , Unter Sagi 6 , Stansstad 6362 , Switzerland
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11
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Grieve S, Llewellyn A, Jones L, Manns S, Glanville V, McCabe CS. Complex regional pain syndrome: An international survey of clinical practice. Eur J Pain 2019; 23:1890-1903. [PMID: 31376299 DOI: 10.1002/ejp.1463] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/21/2019] [Accepted: 07/28/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Sharon Grieve
- CRPS Service Royal United Hospitals Bath NHS Foundation Trust Bath UK
- Faculty of Health and Applied Sciences University of the West of England Bristol UK
| | - Alison Llewellyn
- CRPS Service Royal United Hospitals Bath NHS Foundation Trust Bath UK
- Faculty of Health and Applied Sciences University of the West of England Bristol UK
| | - Louise Jones
- Faculty of Health and Applied Sciences University of the West of England Bristol UK
| | - Sarah Manns
- Faculty of Health and Applied Sciences University of the West of England Bristol UK
| | - Victoria Glanville
- Therapies service Gloucestershire Hospitals NHS Foundation Trust Gloucestershire UK
| | - Candida S. McCabe
- CRPS Service Royal United Hospitals Bath NHS Foundation Trust Bath UK
- Faculty of Health and Applied Sciences University of the West of England Bristol UK
- The Florence Nightingale Foundation London UK
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Myalgia and chronic fatigue syndrome following immunization: macrophagic myofasciitis and animal studies support linkage to aluminum adjuvant persistency and diffusion in the immune system. Autoimmun Rev 2019; 18:691-705. [PMID: 31059838 DOI: 10.1016/j.autrev.2019.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 01/31/2019] [Indexed: 01/04/2023]
Abstract
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a multifactorial and poorly undersood disabling disease. We present epidemiological, clinical and experimental evidence that ME/CFS constitutes a major type of adverse effect of vaccines, especially those containing poorly degradable particulate aluminum adjuvants. Evidence has emerged very slowly due to the multiplicity, lack of specificity, delayed onset, and frequent medical underestimation of ME/CFS symptoms. It was supported by an epidemiological study comparing vaccinated vs unvaccinated militaries that remained undeployed during Gulf War II. Affected patients suffer from cognitive dysfunction affecting attention, memory and inter-hemispheric connexions, well correlated to brain perfusion defects and associated with a stereotyped and distinctive pattern of cerebral glucose hypometabolism. Deltoid muscle biopsy performed to investigate myalgia typically yields macrophagic myofasciitis (MMF), a histological biomarker assessing longstanding persistency of aluminum agglomerates within innate immune cells at site of previous immunization. MMF is seemingly linked to altered mineral particle detoxification by the xeno/autophagy machinery. Comparing toxicology of different forms of aluminum and different types of exposure is misleading and inadequate and small animal experiments have turned old dogma upside down. Instead of being rapidly solubilized in the extracellular space, injected aluminum particles are quickly captured by immune cells and transported to distant organs and the brain where they elicit an inflammatory response and exert selective low dose long-term neurotoxicity. Clinical observations and experiments in sheep, a large animal like humans, confirmed both systemic diffusion and neurotoxic effects of aluminum adjuvants. Post-immunization ME/CFS represents the core manifestation of "autoimmune/inflammatory syndrome induced by adjuvants" (ASIA).
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13
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Wireless peripheral nerve stimulation for complex regional pain syndrome type I of the upper extremity: a case illustration introducing a novel technology. Scand J Pain 2018; 18:555-560. [DOI: 10.1515/sjpain-2018-0014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 03/18/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Complex regional pain syndrome (CRPS) is a debilitating painful disorder, cryptic in its pathophysiology and refractory condition with limited therapeutic options. Type I CRPS with its variable relationship to trauma has often no discernible fractures or nerve injuries and remains enigmatic in its response to conservative treatment as well as the other limited interventional therapies. Neuromodulation in the form of spinal cord and dorsal root ganglion stimulation (SCS, DRGS) has shown encouraging results, especially of causalgia or CRPS I of lower extremities. Upper extremity CRPS I is far more difficult.
Objective
To report a case of upper extremity CRPS I treated by wireless peripheral nerve stimulation (WPNS) for its unique features and minimally invasive technique. The system does not involve implantation of battery or its connections.
Case report
A 47 year old female patient presented with refractory CRPS I following a blunt trauma to her right forearm. As interventional treatment in the form of local anesthetics (Anesthesia of peripheral branches of radial nerve) and combined infusions of ketamine/lidocaine failed to provide any significant relief she opted for WPNS treatment. Based on the topographic distribution, two electrodes (Stimwave Leads: FR4A-RCV-A0 with tines, Generation 1 and FR4A-RCV-B0 with tines, Generation 1), were placed along the course of radial and median nerves under ultrasonography monitoring and guided by intraoperative stimulation. This procedure did not involve implantation of extension cables or the power source. At a frequency of 60 Hz and 300 μs the stimulation induced paresthesia along the distribution of the nerves. Therapeutic relief was observed with high frequency (HF) stimulation (HF 10 kHz/32 μs, 2.0 mA) reducing her pain from a visual analogue scale (VAS) score of 7–4 postoperatively. Three HF stimulations programs were provided at the time of discharge, as she improved in her sensory impairment to touch, pressure and temperature at her first follow up visit. At 5-months she was able to drive, did not require opioids and allodynia disappeared.
Conclusions
In a case with difficult CRPS I involving upper extremity, a minimally invasive WPNS of radial and median nerves provided good symptomatic relief. The procedure was tolerated well and both electrodes remained in place without any adverse events.
Implications
In view of the very limited options currently available to manage CRPS, WPNS can be a promising therapeutic modality.
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Abstract
OBJECTIVES The efficacy of ketamine in relieving complex regional pain syndrome (CRPS) lacks predictive factors. The value of three-phase bone scintigraphy (TPBS) was assessed for this purpose. MATERIALS AND METHODS TPBS was performed in 105 patients with unilateral, focal CRPS of type 1 before 5 days of ketamine infusions. Tracer uptake was measured in the region of interest concerned by CRPS and the contralateral homologous region. For the 3 scintigraphic phases (vascular, tissular, and bone phases), an asymmetry ratio of fixation was calculated between the affected and the unaffected sides (vascular phase [VPr], tissular phase [TPr], and bone phase [BPr]). Ketamine efficacy was assessed on pain intensity scores. RESULTS Ketamine-induced pain relief did not correlate with VPr, TPr, and BPr, but with the ratios of these ratios: BPr/TPr (r=0.32, P=0.009), BPr/VPr (r=0.34, P=0.005), and TPr/VPr (r=0.23, P=0.02). The optimum cut-off value for predicting the response to ketamine therapy was >1.125 for BPr/TPr, >1.075 for BPr/VPr, and >0.935 for TPr/VPr. The combination of increased values of BPr/TPr, BPr/VPr, and TPr/VPr was highly significantly associated with ketamine therapy outcome. CONCLUSIONS The relative hyperfixation of the radioactive tracer in the limb region concerned by CRPS in phases 2 and 3 versus phase 1 of TPBS correlated positively to the analgesic efficacy of ketamine. This study shows for the first time the potential predictive value of TPBS regarding ketamine therapy outcome. In addition, these results suggest that the analgesic action of ketamine is not restricted to "central" mechanisms, but may also involve "peripheral" mechanisms related to tissue inflammation and bone remodeling.
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15
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Miller C, Williams M, Heine P, Williamson E, O'connell N. Current practice in the rehabilitation of complex regional pain syndrome: a survey of practitioners. Disabil Rehabil 2017; 41:847-853. [PMID: 29228823 DOI: 10.1080/09638288.2017.1407968] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION International clinical guidelines for Complex Regional Pain Syndrome recommend a wide range and variation of rehabilitation therapies as the core treatment. It is likely that most therapists employ a range of approaches when managing people with Complex Regional Pain Syndrome but a recent Cochrane review identified little evidence relating to the effectiveness of multi-modal rehabilitation. There is need for up to date trials of rehabilitation for Complex Regional Pain Syndrome, but in order to develop a clear model of best practice that can be rigorously evaluated we need to understand current practice. METHOD An electronic survey was disseminated internationally to clinicians involved in the rehabilitation of individuals with Complex Regional Pain Syndrome. The survey aimed to establish which criteria are used for diagnosis and which modalities clinicians use to treat Complex Regional Pain Syndrome and which they consider ineffective or harmful. RESULTS 132 valid responses were received. A third of participants did not use any established criteria to diagnose Complex Regional Pain Syndrome. Current practice commonly included patient education, encouragement of self-management, and physical exercises. Cortically directed treatments such as graded motor imagery and psychological approaches were often incorporated into treatment whereas pain provocative therapies, splinting, contrast bathing, and cold and heat therapy were rarely used in the acute or chronic phase of Complex Regional Pain Syndrome. CONCLUSION A broad range of modalities are currently used in Complex Regional Pain Syndrome rehabilitation. Practice appears to be characterized by educational and exercise based interventions delivered in a pain-contingent manner which largely echoes recommendations in international clinical guidelines. Implications for Rehabilitation: Patients with Complex Regional Pain Syndrome suffer from a painful and disabling condition for which we still do not know the best treatment options. From our survey sample most clinicians use treatments recommended in the international guidelines. A large proportion of clinicians from our survey sample are not using internationally recognized diagnostic criteria and we therefore recommend that clinicians become familiar with these criteria and use them for all suspected Complex Regional Pain Syndrome cases.
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Affiliation(s)
- Caroline Miller
- a Physiotherapy Department , University hospitals Birmingham Foundation Trust , Birmingham , United Kingdom
| | - Mark Williams
- b Department of Sport, Health Sciences and Social work , Oxford Brookes University , Oxford , United Kingdom
| | - Peter Heine
- c Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , United Kingdom
| | - Esther Williamson
- c Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences , University of Oxford , Oxford , United Kingdom
| | - Neil O'connell
- d Department of Clinical Sciences , Brunel University , London , United Kingdom
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16
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Migraine and Complex Regional Pain Syndrome: A Case-Referent Clinical Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5714673. [PMID: 29214172 PMCID: PMC5682894 DOI: 10.1155/2017/5714673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/25/2017] [Accepted: 10/01/2017] [Indexed: 01/03/2023]
Abstract
We studied clinical phenotype differences between migraineurs with CRPS (Mig + CRPS) and those without (Mig − CRPS). Mig + CRPS cases and Mig − CRPS referents aged ≥18 years were enrolled. Diagnosis was made in accordance with International Classification of Headache Disorders-3 beta (ICHD-3 beta) for migraine and Budapest Criteria for CRPS. Migraines both with and without aura were included. A total of 70 Mig + CRPS cases (13% males, mean age 48 years) and 80 Mig − CRPS referents (17% males, mean age 51 years) were included. 33% of Mig + CRPS and 38% of Mig − CRPS exhibited episodic migraine (EM) while 66% of Mig + CRPS and 62% of Mig − CRPS had chronic migraine (CM) (OR = 0.98, CI 0.36, 2.67). Median duration of CRPS was 3 years among EM + CRPS and 6 years among CM + CRPS cohort (p < 0.02). Mig + CRPS (57%) carried higher psychological and medical comorbidities compared to Mig − CRPS (6%) (OR 16.7, CI 10.2, 23.6). Higher migraine frequency was associated with longer CRPS duration. Migraineurs who developed CRPS had higher prevalence of psychological and medical disorders. Alleviating migraineurs' psychological and medical comorbidities may help lower CRPS occurrence.
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17
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Novel Signs and Their Clinical Utility in Diagnosing Complex Regional Pain Syndrome (CRPS). Clin J Pain 2017; 33:496-502. [DOI: 10.1097/ajp.0000000000000434] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cho CW, Nahm FS, Choi E, Lee PB, Jang IK, Lee CJ, Kim YC, Lee SC. Multicenter study on the asymmetry of skin temperature in complex regional pain syndrome: An examination of temperature distribution and symptom duration. Medicine (Baltimore) 2016; 95:e5548. [PMID: 28033251 PMCID: PMC5207547 DOI: 10.1097/md.0000000000005548] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
According to the International Association for the Study of Pain (IASP) and American Medical Association (AMA), the diagnostic criteria for complex regional pain syndrome (CRPS) require the presence of skin temperature asymmetry. In CRPS, it is generally accepted that the temperature of skin of affected limbs changes from warm to cold; however, in our clinical practice, we have experienced many cases with different thermographic characteristics. Therefore, we conducted a retrospective multicenter study that examined the distribution of skin temperature in patients with CRPS and skin temperature asymmetry versus symptom duration.Patients diagnosed with type 1 or 2 CRPS were recruited. After confirming CRPS according to the IASP diagnostic criteria, infrared thermographic images were evaluated for skin temperature differences (ΔT) between the affected and unaffected limbs.A total of 296 patients with CRPS were included in this study. The median duration of symptoms was 6 months and the mean ± standard deviation of ΔT was -0.72 ± 1.65°C. A skin temperature difference between bilateral limbs (|ΔT|) of 1°C or less was seen in 131 patients (44.3%); thus, these 131 patients did not meet the IASP criteria for CRPS. Further, cool skin temperature was not observed in 88 patients (29.7%), meaning that these patients did not meet the AMA criteria for CRPS. There was no correlation between the symptom duration and ΔT (Spearman's rho = -0.075, P = 0.196) and there was no significant difference in the average ΔT among the 4 symptom duration groups (0-3 months, 4-6 months, 7-12 months, >12 months, P = 0.08).In conclusion, a considerable proportion of the patients that participated in this study did not meet the thermal criteria set forth by the IASP and AMA. Further, there was no correlation between symptom duration and skin temperature difference.
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Affiliation(s)
- Chan Woo Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Francis Sahngun Nahm
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Eunjoo Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - Pyung-Bok Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | - In-Ki Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam
| | | | - Yong Chul Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
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19
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Ryan CG, King R, Robinson V, Punt TD, Dinse HR, Grunenberg C, Johnson MI, Martin DJ. Transcutaneous electrical nerve stimulation using an LTP-like repetitive stimulation protocol for patients with upper limb complex regional pain syndrome: A feasibility study. HAND THERAPY 2016. [DOI: 10.1177/1758998316678588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction This feasibility study aimed to (i) develop a clinical protocol using a long-term potentiation-like repetitive stimulation protocol for transcutaneous electrical nerve stimulation in patients with upper limb complex regional pain syndrome and (ii) develop a research protocol for a single-blind randomised controlled trial investigating the efficacy of transcutaneous electrical nerve stimulation for complex regional pain syndrome. Methods This small-scale single-blind feasibility randomised-controlled trial planned to randomise 30 patients with upper limb complex regional pain syndrome to either a variant of transcutaneous electrical nerve stimulation or placebo transcutaneous electrical nerve stimulation for three weeks. Stimulation comprised 20 pulses over 1 s with a non-stimulation interval of 5 s, a so-called repetitive electrical stimulation protocol following the timing of long-term potentiation. Pain, function and body image were measured at baseline, post-treatment and at three months follow-up. At three months, participants were invited to one-to-one interviews, which were analysed thematically. Results A transcutaneous electrical nerve stimulation protocol with electrodes applied proximal to the area of allodynia in the region of the upper arm was developed. Participant concordance with the protocol was high. Recruitment was below target (transcutaneous electrical nerve stimulation (n = 6), placebo (n = 2)). Mean (SD) pain intensity for the transcutaneous electrical nerve stimulation group on a 0 to 10 scale was 7.2 (2.4), 6.6 (2.8) and 7.8 (1.9), at baseline, post-treatment and at three-month follow-up, respectively. Qualitative data suggested that some patients found transcutaneous electrical nerve stimulation beneficial, easy to use and were still using it at three months. Conclusion Patients tolerated transcutaneous electrical nerve stimulation well, and important methodological information to facilitate the design of a large-scale trial was obtained (ISRCTN48768534).
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Affiliation(s)
- CG Ryan
- Institute of Health and Social Care, Teesside University, Middlesbrough, UK
| | - R King
- Pain Clinic, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - V Robinson
- Pain Clinic, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - TD Punt
- School of Sport, Exercise and Rehabilitation Sciences, Birmingham University, UK
| | - HR Dinse
- Neural Plasticity Lab, Institute Neuroinformatik, Ruhr-University Bochum, Bochum, Germany: Department of Neurology, BG University Hospital Bergmannsheil, Bochum, Germany
| | - C Grunenberg
- Hochschule für Gesundheit Bochum, Universitätsstrasse, Bochum, Germany
| | - MI Johnson
- Faculty of Health and Social Sciences, Leeds Beckett University, Leeds, UK
| | - DJ Martin
- Institute of Health and Social Care, Teesside University, Middlesbrough, UK
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20
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Borchers AT, Gershwin ME. The clinical relevance of complex regional pain syndrome type I: The Emperor's New Clothes. Autoimmun Rev 2016; 16:22-33. [PMID: 27666818 DOI: 10.1016/j.autrev.2016.09.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023]
Abstract
The management of patients with chronic pain is a nearly daily challenge to rheumatologists, neurologists, orthopedic surgeons, pain specialists and indeed a issue in nearly every clinical practice. Among the myriad of causes of pain are often included a unique syndrome, generally referred to as complex regional pain syndrome type I (CRPS). Unfortunately CRPS I has become a catch all phase and there are serious questions on whether it exists at all; this has led to an extraordinary number of poorly defined diagnostic criteria. It has also led to an etiologic quagmire that includes features as diverse as autoimmunity to simple trauma. These, in turn, have led to overdiagnosis and often overzealous use of pain medications, including narcotics. In a previous paper, we raised the issue of whether CRPS type I reflected a valid diagnosis. Indeed, the diagnostic criteria for CRPS I, and therefore the diagnosis itself, is unreliable for a number of reasons: 1) the underlying pathophysiology of the signs and symptoms of CPRS I are not biologically plausible; 2) there are no consistent laboratory or imaging testing available; 3) the signs and symptoms fluctuate over time without a medical explanation; 4) the definitions of most studies are derived from statistical analysis with little consideration to required sample size, i.e. power calculations; 5) interobserver reliability in the assessment of the signs and symptoms are often only fair to moderate, and agreement on the diagnosis of "CRPS I" is poor. Even physicians who still believe in the concept of "CRPS I" admit that it is vastly overdiagnosed and has become a diagnosis of last resort, often without a complete differential diagnosis and an alternative explanation. Finally, one of the most convincing arguments that there is no clinical entity as "CRPS I" comes from the enormous heterogeneity in sign and symptom profiles and the heterogeneity of pathophysiological mechanisms postulated. This observation is underscored by the diversity of responses among "CRPS I" patients to essentially all treatment modalities. It has even led to the concept that the signs and symptoms of CRPS can spread throughout the body, as if it is an infectious disease, without any medical plausible explanation. If true progress is to be made in helping patients with pain, it will require entirely new and different concepts and abandoning CRPS I as a legitimate diagnosis.
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Affiliation(s)
- Andrea T Borchers
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States
| | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States.
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Kuttikat A, Noreika V, Shenker N, Chennu S, Bekinschtein T, Brown CA. Neurocognitive and Neuroplastic Mechanisms of Novel Clinical Signs in CRPS. Front Hum Neurosci 2016; 10:16. [PMID: 26858626 PMCID: PMC4728301 DOI: 10.3389/fnhum.2016.00016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 01/12/2016] [Indexed: 12/16/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic, debilitating pain condition that usually arises after trauma to a limb, but its precise etiology remains elusive. Novel clinical signs based on body perceptual disturbances have been reported, but their pathophysiological mechanisms remain poorly understood. Investigators have used functional neuroimaging techniques (including MEG, EEG, fMRI, and PET) to study changes mainly within the somatosensory and motor cortices. Here, we provide a focused review of the neuroimaging research findings that have generated insights into the potential neurocognitive and neuroplastic mechanisms underlying perceptual disturbances in CRPS. Neuroimaging findings, particularly with regard to somatosensory processing, have been promising but limited by a number of technique-specific factors (such as the complexity of neuroimaging investigations, poor spatial resolution of EEG/MEG, and use of modeling procedures that do not draw causal inferences) and more general factors including small samples sizes and poorly characterized patients. These factors have led to an underappreciation of the potential heterogeneity of pathophysiology that may underlie variable clinical presentation in CRPS. Also, until now, neurological deficits have been predominantly investigated separately from perceptual and cognitive disturbances. Here, we highlight the need to identify neurocognitive phenotypes of patients with CRPS that are underpinned by causal explanations for perceptual disturbances. We suggest that a combination of larger cohorts, patient phenotyping, the use of both high temporal, and spatial resolution neuroimaging methods, and the identification of simplified biomarkers is likely to be the most fruitful approach to identifying neurocognitive phenotypes in CRPS. Based on our review, we explain how such phenotypes could be characterized in terms of hierarchical models of perception and corresponding disturbances in recurrent processing involving the somatosensory, salience and executive brain networks. We also draw attention to complementary neurological factors that may explain some CRPS symptoms, including the possibility of central neuroinflammation and neuronal atrophy, and how these phenomena may overlap but be partially separable from neurocognitive deficits.
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Affiliation(s)
- Anoop Kuttikat
- Department of Rheumatology, Addenbrooke's Hospital , Cambridge , UK
| | - Valdas Noreika
- Cognition and Brain Sciences Unit, Medical Research Council , Cambridge , UK
| | - Nicholas Shenker
- Department of Rheumatology, Addenbrooke's Hospital , Cambridge , UK
| | - Srivas Chennu
- Cognition and Brain Sciences Unit, Medical Research Council, Cambridge, UK; Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Tristan Bekinschtein
- Cognition and Brain Sciences Unit, Medical Research Council, Cambridge, UK; Department of Psychology, University of Cambridge, Cambridge, UK
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22
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Grieve S, Adams J, McCabe C. ‘What I Really Needed Was the Truth’. Exploring the Information Needs of People with Complex Regional Pain Syndrome. Musculoskeletal Care 2015; 14:15-25. [PMID: 26076593 DOI: 10.1002/msc.1107] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Sharon Grieve
- Royal United Hospitals; Bath UK
- University of Southampton; Southampton UK
- University of the West of England; Bristol UK
| | - Jo Adams
- University of Southampton; Southampton UK
| | - Candida McCabe
- Royal United Hospitals; Bath UK
- University of the West of England; Bristol UK
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