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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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Tihista M, Robinson E, Polmear M, Scanaliato J, Ramirez M, Dunn J. Pharmacologic Treatments in Upper Extremity Complex Regional Pain Syndrome: A Review and Analysis of Quality of Evidence. Hand (N Y) 2024; 19:533-544. [PMID: 36424817 PMCID: PMC11141415 DOI: 10.1177/15589447221131847] [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] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study was to assess the quality of evidence informing on common pharmacologic modalities used in upper extremity complex regional pain syndrome (CRPS). METHODS A literature search was performed for primary prospective trials that reported on the pharmacologic treatment of CRPS type I and II specific to the upper extremity. Thirty-one trials were included and evaluated by 2 independent reviewers according to the Oxford Levels of Evidence (LOE), modified Coleman Methodology Score, and the revised Consolidated Standards of Reporting Trials (CONSORT) score. Cohen's kappa coefficient was calculated to measure interrater reliability. RESULTS Twenty-two Oxford LOE I and 9 level II trials met the inclusion criteria. Overall, there was high interrater reliability in the Oxford LOE (100% agreement), modified Coleman Methodology Score (87% agreement), and CONSORT score (94% agreement). The pharmacologic interventions with the highest quality of evidence supporting use in treatment of upper extremity CRPS were bisphosphonates and ketamine. Interventions that lack high-quality evidence are tricyclic antidepressants (TCAs) and topical dimethyl sulfoxide (DMSO). Pharmacologic agents that remain inconclusive are calcitonin, gabapentin, mycophenolate, probiotics, steroids, nonsteroidal anti-inflammatory drugs, vitamin C, and N-acetylcysteine. Agents with limited benefit are mannitol, isosorbide dinitrate, guanethidine, and morphine. CONCLUSIONS Based on the evidence evaluated in this study, bisphosphonates should be considered as a first-line medication in the treatment of CRPS. In patients presenting with chronic or refractory CRPS, strong consideration should be given for the use of ketamine. Adjunct treatment in the acute setting should include TCAs and/or topical DMSO.
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Affiliation(s)
- Mikel Tihista
- William Beaumont Army Medical Center, El Paso, TX, USA
| | | | | | | | | | - John Dunn
- William Beaumont Army Medical Center, El Paso, TX, USA
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Bonomo R, Bonomo G, Rubiu E, Iess G, Cammarata G, Innocenti N, Restelli F, Falco J, Porto E, Amato A, Zekaj E, Levi V. Integrative approaches in spinal cord stimulation: Neuropathic pain management and motor recovery in spinal cord injury. A narrative review. BRAIN & SPINE 2024; 4:102781. [PMID: 38601775 PMCID: PMC11004705 DOI: 10.1016/j.bas.2024.102781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/08/2024] [Accepted: 03/01/2024] [Indexed: 04/12/2024]
Abstract
Introduction Spinal cord stimulation is a widespread treatment of chronic neuropathic pain from different conditions. Several novel and improving technologies have been recently developed to increase the effect of neuromodulation in patients refractory to pharmacological therapy. Research question To explore spinal cord stimulation's mechanisms of action, indications, and management. Material and methods The paper initially explores the mechanism of action of this procedure based on the generation of an electric field between electrodes placed on the posterior dural surface of the spinal cord probably interfering with the transmission of pain stimuli to the brain. Subsequently, the most consolidated criteria for selecting patients for surgery, which constitute a major issue of debate, were defined. Thereafter, the fundamental patterns of stimulation were summarized by exploring the advantages and side effects. Lastly, the most common side effects and the related management were discussed. Results Proper selection of the patient is of paramount importance to achieve the best results from this specific neuromodulation treatment. Regarding the different types of stimulation patterns, no definite evidence-based guidelines exist on the most appropriate approach in relation to the specific type of neuropathic pain. Both burst stimulation and high-frequency stimulation are innovative techniques that reduce the risk of paresthesias compared with conventional stimulation. Discussion and conclusion Novel protocols of stimulation (burst stimulation and high frequency stimulation) may improve the trade-off between therapeutic benefits and potential side effects. Likewise, decreasing the rates of hardware-related complications will be also useful to increase the application of neuromodulation in clinical settings.
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Affiliation(s)
- Roberta Bonomo
- Department of Neurology, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- School of Medicine and Surgery, Kore University of Enna, Enna, Italy
| | - Giulio Bonomo
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- Department of Neurological Surgery, Policlinico “G. Rodolico-S. Marco” University Hospital, Catania, Italy
| | - Emanuele Rubiu
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Guglielmo Iess
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Giacomo Cammarata
- Department of Neurological Surgery, Policlinico “G. Rodolico-S. Marco” University Hospital, Catania, Italy
| | - Niccolò Innocenti
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Francesco Restelli
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Jacopo Falco
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Edoardo Porto
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Alessia Amato
- Department of Child Neuropsychiatry, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Edvin Zekaj
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Vincenzo Levi
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
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Iolascon G, Snichelotto F, Moretti A. An update on the pharmacotherapeutic options for complex regional pain syndrome. Expert Rev Neurother 2024; 24:177-190. [PMID: 38241139 DOI: 10.1080/14737175.2024.2307490] [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] [Received: 11/01/2023] [Accepted: 01/16/2024] [Indexed: 01/21/2024]
Abstract
INTRODUCTION Complex regional pain syndrome (CRPS) is a rare and painful condition that has a wide range of triggering factors, often traumatic, and can present various clinical manifestations. The lack of knowledge about the underlying mechanisms has led to numerous treatment approaches, both conservative and surgical, which work through different mechanisms of action. AREAS COVERED In this review, the authors explore the key aspects of CRPS, including definition, diagnostic criteria, pitfalls, pathogenic hypotheses, and treatment strategies with a focus on pharmacotherapy. The review was based on a comprehensive search of the literature using PubMed, while also considering international guidelines for managing CRPS. EXPERT OPINION Based on the available evidence, pharmacological interventions appear to be effective in treating CRPS, especially when they target peripheral mechanisms, specifically nociceptive inflammatory pain, and when administered early in the course of the disease. However, there is still a lack of reliable evidence regarding the effects of drugs on central mechanisms of chronic pain in CRPS. In our expert opinion, drug therapy should be initiated as soon as possible, particularly in warm CRPS patient clusters, to prevent significant functional limitations, psychological distress, and negative impacts on individuals' social and economic well-being.
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Affiliation(s)
- Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Snichelotto
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
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Mangnus TJP, Dirckx M, Huygen FJPM. Different Types of Pain in Complex Regional Pain Syndrome Require a Personalized Treatment Strategy. J Pain Res 2023; 16:4379-4391. [PMID: 38162406 PMCID: PMC10757771 DOI: 10.2147/jpr.s432209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating painful state of an extremity that can develop after trauma. CRPS is diagnosed by the new International Association for the Study of Pain (IASP) diagnostic criteria for CRPS. The syndrome is characterized by continuing regional pain with abnormal sensory, motor, sudomotor, vasomotor, edema, and/or trophic signs. The clinical presentation of CRPS can be very heterogeneous because CRPS is a multi-mechanism syndrome. Therefore, mechanism-based subgroups have been suggested to personalize treatment for CRPS. Additionally, the presentation of symptom pain may also be able to identify different subgroups of CRPS. In this review, the types of pain recognized by the IASP-nociceptive, neuropathic, and nociplastic pain-will be discussed as possible subgroups for CRPS. Each pain type should be identified in CRPS patients, with a thorough history taking, physical examination, and diagnostic tests or (novel) biomarkers to optimize treatment effectiveness. Over the course of the syndrome, patients with CRPS probably experience more than one distinct pain type. Therefore, pain specialists should be alert to not only adjust their treatment if underlying pathophysiologic mechanisms tend to change but also to personalize the treatment of the associated type of pain in the CRPS patient.
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Affiliation(s)
- Thomas J P Mangnus
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maaike Dirckx
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank J P M Huygen
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Alshehri FS. The complex regional pain syndrome: Diagnosis and management strategies. NEUROSCIENCES (RIYADH, SAUDI ARABIA) 2023; 28:211-219. [PMID: 37844940 PMCID: PMC10827038 DOI: 10.17712/nsj.2023.4.20230034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
Complex regional pain syndrome (CRPS) is a chronic disease that affects a limb following an injury or trauma. The CRPS associated with symptoms, including severe pain, swelling, as well as changes in skin color and temperature. Treatment of CRPS requires a multidisciplinary approach, with a focus on personalized treatment plans and addressing psychological factors. This review provides an overview of updates in the diagnosis and treatment of CRPS. There are clinical criteria for diagnosing CRPS, including persistent pain and swelling. The CRPS can also be diagnosed with imaging and laboratory tests. Novel insights into treatment approaches for CRPS have been gained from advances in understanding its pathophysiology. Treatment of CRPS includes both pharmacological and non-pharmacological interventions. The latest guidelines for CRPS treatment emphasize the importance of early diagnosis and intervention, personalized treatment plans, and addressing psychological factors in managing CRPS.
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Affiliation(s)
- Fahad S. Alshehri
- From the Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
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Harnik MA, Kesselring P, Ott A, Urman RD, Luedi MM. Complex Regional Pain Syndrome (CRPS) and the Value of Early Detection. Curr Pain Headache Rep 2023; 27:417-427. [PMID: 37410335 PMCID: PMC10462545 DOI: 10.1007/s11916-023-01124-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE OF REVIEW The goal of this narrative review is to describe the current understanding of the pathology of Complex Regional Pain Syndrome (CRPS), as well as diagnostic standards and therapeutic options. We will then make the case for early recognition and management. RECENT FINDINGS CRPS remains an enigmatic pain syndrome, comprising several subtypes. Recent recommendations clarify diagnostic ambiguities and emphasize the importance of standardized assessment and therapy. Awareness of CRPS should be raised to promote prevention, early detection, and rapid escalation of therapy in refractory cases. Comorbidities and health costs (i.e., the socioeconomic impact) must also be addressed early to prevent negative consequences for patients.
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Affiliation(s)
- Michael Alexander Harnik
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pascal Kesselring
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Ott
- Department of Anaesthesiology and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Richard D. Urman
- Department of Anaesthesiology, College of Medicine, The Ohio State University, Columbus, OH 43210 USA
| | - Markus M. Luedi
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
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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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Shermon S, Fazio KM, Shim R, Abd-Elsayed A, Kim CH. Prescription Trends in Complex Regional Pain Syndrome: A Retrospective Case-Control Study. Brain Sci 2023; 13:1012. [PMID: 37508943 PMCID: PMC10377480 DOI: 10.3390/brainsci13071012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE The objective of this study was to evaluate discrepancies in prescription trends for analgesic medications in complex regional pain syndrome (CRPS) patients based on recommendations in the literature. DESIGN We conducted a retrospective case-control study. SUBJECTS A total of 2510 CRPS patients and 2510 demographic-matched controls participated in this study. METHODS The SlicerDicer feature in Epic was used to find patients diagnosed with CRPS I or II between January 2010 and November 2022. An equal number of age-, gender-, and race-matched controls without a CRPS diagnosis were retracted from Epic. General and CRPS-associated prescription frequencies for the following classes were retrieved for both cases and controls: benzodiazepines, bisphosphonates, calcitonin, capsaicin, neuropathic pain medications, NSAIDs, opioids, and steroids. RESULTS A total of 740 (29%) CRPS patients and 425 (17%) controls were prescribed benzodiazepines (95% CI 0.1-0.15), 154 (6.1%) CRPS patients and 52 (2.1%) controls were prescribed capsaicin (95% CI 0.03-0.05), 1837 (73%) CRPS patients and 927 (37%) controls were prescribed neuropathic pain medications (95% CI 0.05-0.34), 1769 (70%) CRPS patients and 1217 (48%) controls were prescribed opioids (95% CI 0.19-0.25), 1095 (44%) CRPS patients and 1217 (48%) controls were prescribed steroids (95% CI 0.08-0.14), and 1638 (65%) CRPS patients and 1765 (70%) controls were prescribed NSAIDs (95% CI -0.08-0.02), p < 0.001 for all classes. With CRPS-associated prescriptions, (95% CI 0.05-0.16, p < 0.001) more CRPS patients were prescribed opioids (N = 398, 59%) than controls (N = 327, 49%). CONCLUSIONS CRPS is difficult to treat with significant variance in suggested treatment modalities. Based on the results of our study, there is a divergence between some published recommendations and actual practice.
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Affiliation(s)
- Suzanna Shermon
- MetroHealth Medical Center, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA
| | - Kimberly M Fazio
- MetroHealth Medical Center, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA
| | - Richard Shim
- School of Medicine, Case Western Reserve University, Cleveland, OH 44109, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53706, USA
| | - Chong H Kim
- MetroHealth Medical Center, Case Western Reserve University, 4229 Pearl Road, Cleveland, OH 44109, USA
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Ferraro MC, Cashin AG, Wand BM, Smart KM, Berryman C, Marston L, Moseley GL, McAuley JH, O'Connell NE. Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD009416. [PMID: 37306570 PMCID: PMC10259367 DOI: 10.1002/14651858.cd009416.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a chronic pain condition that usually occurs in a limb following trauma or surgery. It is characterised by persisting pain that is disproportionate in magnitude or duration to the typical course of pain after similar injury. There is currently no consensus regarding the optimal management of CRPS, although a broad range of interventions have been described and are commonly used. This is the first update of the original Cochrane review published in Issue 4, 2013. OBJECTIVES To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the efficacy, effectiveness, and safety of any intervention used to reduce pain, disability, or both, in adults with CRPS. METHODS We identified Cochrane reviews and non-Cochrane reviews through a systematic search of Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, CINAHL, PEDro, LILACS and Epistemonikos from inception to October 2022, with no language restrictions. We included systematic reviews of randomised controlled trials that included adults (≥18 years) diagnosed with CRPS, using any diagnostic criteria. Two overview authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools respectively. We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes quality of life, emotional well-being, and participants' ratings of satisfaction or improvement with treatment. MAIN RESULTS: We included six Cochrane and 13 non-Cochrane systematic reviews in the previous version of this overview and five Cochrane and 12 non-Cochrane reviews in the current version. Using the AMSTAR 2 tool, we judged Cochrane reviews to have higher methodological quality than non-Cochrane reviews. The studies in the included reviews were typically small and mostly at high risk of bias or of low methodological quality. We found no high-certainty evidence for any comparison. There was low-certainty evidence that bisphosphonates may reduce pain intensity post-intervention (standardised mean difference (SMD) -2.6, 95% confidence interval (CI) -1.8 to -3.4, P = 0.001; I2 = 81%; 4 trials, n = 181) and moderate-certainty evidence that they are probably associated with increased adverse events of any nature (risk ratio (RR) 2.10, 95% CI 1.27 to 3.47; number needed to treat for an additional harmful outcome (NNTH) 4.6, 95% CI 2.4 to 168.0; 4 trials, n = 181). There was moderate-certainty evidence that lidocaine local anaesthetic sympathetic blockade probably does not reduce pain intensity compared with placebo, and low-certainty evidence that it may not reduce pain intensity compared with ultrasound of the stellate ganglion. No effect size was reported for either comparison. There was low-certainty evidence that topical dimethyl sulfoxide may not reduce pain intensity compared with oral N-acetylcysteine, but no effect size was reported. There was low-certainty evidence that continuous bupivacaine brachial plexus block may reduce pain intensity compared with continuous bupivacaine stellate ganglion block, but no effect size was reported. For a wide range of other commonly used interventions, the certainty in the evidence was very low and provides insufficient evidence to either support or refute their use. Comparisons with low- and very low-certainty evidence should be treated with substantial caution. We did not identify any RCT evidence for routinely used pharmacological interventions for CRPS such as tricyclic antidepressants or opioids. AUTHORS' CONCLUSIONS Despite a considerable increase in included evidence compared with the previous version of this overview, we identified no high-certainty evidence for the effectiveness of any therapy for CRPS. Until larger, high-quality trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult. Current non-Cochrane systematic reviews of interventions for CRPS are of low methodological quality and should not be relied upon to provide an accurate and comprehensive summary of the evidence.
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Affiliation(s)
- Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Benedict M Wand
- The School of Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Keith M Smart
- UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
- Physiotherapy Department, St Vincent's University Hospital, Dublin, Ireland
| | - Carolyn Berryman
- IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, South Australia, Australia
- School of Biomedicine, The University of Adelaide, Kaurna Country, Adelaide, Australia
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, UK
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, South Australia, Australia
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
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Norton KF, Furnish TJ. Perspectives on the pharmacological management of complex regional pain syndrome. Expert Opin Pharmacother 2023; 24:1295-1305. [PMID: 37224182 DOI: 10.1080/14656566.2023.2218032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/22/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Complex regional pain syndrome (CRPS) is a chronic pain condition that is notoriously difficult to treat. Therapies for CRPS include cognitive behavioral, physical, and occupational therapy, single or multidrug pharmacotherapy, and a variety of interventional techniques. Unfortunately, randomized clinical trials of these therapies are limited. The large number of potential pharmacologic options can be overwhelming for providers in their attempts to develop a treatment plan. AREAS COVERED This article will review the literature on the pharmacologic management of CRPS. It is based on a systematic search of PubMed using keywords, followed by evaluation of the bibliographies for relevant articles. EXPERT OPINION No single drug has amassed enough evidence to suggest clear efficacy, but a handful of agents with at least modest evidence are commonly used, including gabapentinoids, bisphosphonates, ketamine, and pulsed dose steroids. Meanwhile, other agents that lack significant evidence specifically in CRPS but have evidence in other neuropathic conditions are commonly prescribed, including tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SNRIs). In our opinion, careful selection and prompt initiation of appropriate pharmacotherapy may optimize pain relief and improve functionality in patients burdened with this debilitating condition.
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Affiliation(s)
- Kyle F Norton
- Department of Anesthesiology, UC San Diego Medical Center, San Diego, CA, USA
| | - Timothy J Furnish
- Department of Anesthesiology, UC San Diego Medical Center, San Diego, CA, USA
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12
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Caradonna AJ, Lee D, Caparó M. Early Neuropathic Treatment May Prevent the Chronic Stage of Complex Regional Pain Syndrome Type II (CRPS II). Cureus 2023; 15:e36861. [PMID: 37123780 PMCID: PMC10147496 DOI: 10.7759/cureus.36861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 03/31/2023] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating condition characterized by autonomic and inflammatory features, often caused by fractures, surgeries, or other injuries. Multimodal treatment is utilized, which often includes neuropathic medications and physical therapy. We had a case of a 24-year-old man who was diagnosed with CRPS II following an open reduction and internal fixation of a trimalleolar fracture. Significant improvement of edema, pain, and function was achieved with early initiation of gabapentin, nortriptyline, and physical therapy. In this case report, we discuss the therapeutic challenges regarding his recovery and review the literature on the utility of medications and interventional methods in treating CRPS II. We note that early treatment response may be an important prognostic indicator for the progression of CRPS II and additional studies targeting interventions for the specific type and clinical stage of CRPS are needed.
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13
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We need to talk: The urgent conversation on chronic pain, mental health, prescribing patterns and the opioid crisis. J Psychopharmacol 2023; 37:437-448. [PMID: 37171242 DOI: 10.1177/02698811221144635] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
The opioid crisis’ pathways from first exposure onwards to eventual illnesses and fatalities are multiple, intertwined and difficult to dissect. Here, we offer a multidisciplinary appraisal of the relationships among mental health, chronic pain, prescribing patterns worldwide and the opioid crisis. Because the opioid crisis’ toll is especially harsh on young people, emphasis is given on data regarding the younger strata of the population. Because analgesic opioid prescription constitute a recognised entry point towards misuse, opioid use disorder, and ultimately overdose, prescribing patterns across different countries are examined as a modifiable hazard factor along these pathways of risk. Psychiatrists are called to play a more compelling role in this urgent conversation, as they are uniquely placed to provide synthesis and lead action among the different fields of knowledge and care that lie at the crossroads of the opioid crisis. Psychiatrists are also ideally positioned to gauge and disseminate the foundations for diagnosis and clinical management of mental conditions associated with chronic pain, including the identification of hazardous and protective factors. It is our hope to spark more interdisciplinary exchanges and encourage psychiatrists worldwide to become leaders in an urgent conversation with interlocutors from the clinical and basic sciences, policy makers and stakeholders including clients and their families.
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14
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Melf-Marzi A, Böhringer B, Wiehle M, Hausteiner-Wiehle C. Modern Principles of Diagnosis and Treatment in Complex Regional Pain Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:879-886. [PMID: 36482756 PMCID: PMC10011717 DOI: 10.3238/arztebl.m2022.0358] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 04/21/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Background: Complex regional pain syndrome (CRPS) is a relatively common complication, occurring in 5% of cases after injury or surgery, particularly in the limbs. The incidence of CPRS is around 5-26/100 000. The latest revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) now categorizes CRPS as a primary pain condition of multifactorial origin, rather than a disease of the skeletal system or the autonomic nervous system. METHODS Method: Based on a selective search of the literature, we summarize current principles for the diagnosis and treatment of CRPS. RESULTS Results: Regional findings in CRPS are accompanied by systemic symptoms, especially by neurocognitive disorders of body perception and of symptom processing. The therapeutic focus is shifting from predominantly passive peripheral measures to early active treatments acting both centrally and peripherally. The treatment is centered on physiotherapy and occupational therapy to improve sensory perception, strength, (fine) motor skills, and sensorimotor integration/ body perception. This is supported by stepped psychological interventions to reduce anxiety and avoidance behavior, medication to decrease inflammation and pain, passive physical measures for reduction of edema and of pain, and medical aids to improve functioning in daily life. Interventional procedures should be limited to exceptional cases and only be performed in specialized centers. Spinal cord and dorsal root ganglion stimulation, respectively, are the interventions with the best evidence. CONCLUSION Conclusion: The modern principles for the diagnosis and treatment of CRPS consider both, physiological and psychological mechanisms, with the primary goal of restoring function and participation. More research is needed to strengthen the evidence base in this field.
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Affiliation(s)
- Alexandra Melf-Marzi
- Department for BG Rehabilitation; Outpatient CRPS Clinic; BG Trauma Center Murnau; Department for Anesthesiology, Intensive Care Medicine and Pain Therapy; Multimodal Pain Therapy; BG Trauma Center Murnau; Department for Neurology, Clinical Neurophysiology and Stroke Unit; BG Trauma Center Murnau; Clinic and Polyclinic for Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich
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15
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Rebhorn C, Dimova V, Birklein F. [Complex regional pain syndrome-An update]. Schmerz 2022; 36:141-149. [PMID: 35316391 DOI: 10.1007/s00482-022-00641-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Complex regional pain syndrome (CRPS) is a pain disorder that develops in the hands or feet after injury. Currently, two types are differentiated, CRPS I without and CRPS II with nerve lesions as well as with either an initially warm or an initially cold subtype, depending on the clinical symptoms. After trauma a certain amount of inflammatory reaction is considered physiological. In acute CRPS this inflammation persists for months and is maintained by diverse inflammatory mediators in peripheral tissue and in blood. This persisting inflammation leads to a sensitization of the nociceptive system, causes somatic cells to proliferate and gives rise to a disrupted endothelial function. The treatment concept aims to antagonize the pathophysiologic components and includes anti-inflammatory and analgetic treatment, mobilization and restoration of the sensorimotor function of the affected limb.
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Affiliation(s)
- Cora Rebhorn
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - Violeta Dimova
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Frank Birklein
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
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16
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From a Symptom-Based to a Mechanism-Based Pharmacotherapeutic Treatment in Complex Regional Pain Syndrome. Drugs 2022; 82:511-531. [PMID: 35247200 PMCID: PMC9016036 DOI: 10.1007/s40265-022-01685-4] [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] [Accepted: 02/07/2022] [Indexed: 02/06/2023]
Abstract
Complex regional pain syndrome (CRPS) is a debilitating painful condition of a distal extremity that can develop after tissue damage. CRPS is thought to be a multimechanism syndrome and ideally the most prominent mechanism(s) should be targeted by drugs in an individually tailored manner. This review gives an overview of the action and evidence of current and future pharmacotherapeutic options for CRPS. The available options are grouped in four categories by their therapeutic actions on the CRPS mechanisms, i.e. inflammation, central sensitisation, vasomotor disturbances and motor disturbances. More knowledge about the underlying mechanisms of CRPS helps to specifically target important CRPS mechanisms. In the future, objective biomarkers could potentially aid in selecting appropriate mechanism-based drugs in order to increase the effectiveness of CRPS treatment. Using this approach, current and future pharmacotherapeutic options for CRPS should be studied in multicentre trials to prove their efficacy. The ultimate goal is to shift the symptom-based selection of therapy into a mechanism-based selection of therapy in CRPS.
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17
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Okumo T, Takayama Y, Maruyama K, Kato M, Sunagawa M. Senso-Immunologic Prospects for Complex Regional Pain Syndrome Treatment. Front Immunol 2022; 12:786511. [PMID: 35069559 PMCID: PMC8767061 DOI: 10.3389/fimmu.2021.786511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/13/2021] [Indexed: 12/14/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain syndrome that occurs in tissue injuries as the result of surgery, trauma, or ischemia. The clinical features of this severely painful condition include redness and swelling of the affected skin. Intriguingly, it was recently suggested that transient receptor potential ankyrin 1 (TRPA1) is involved in chronic post-ischemia pain, a CRPS model. TRPA1 is a non-selective cation channel expressed in calcitonin gene-related peptide (CGRP)-positive primary nociceptors that becomes highly activated in ischemic conditions, leading to the generation of pain. In this review, we summarize the history of TRPA1 and its involvement in pain sensation, inflammation, and CRPS. Furthermore, bone atrophy is also thought to be a characteristic clinical sign of CRPS. The altered bone microstructure of CRPS patients is thought to be caused by aggravated bone resorption via enhanced osteoclast differentiation and activation. Although TRPA1 could be a target for pain treatment in CRPS patients, we also discuss the paradoxical situation in this review. Nociceptor activation decreases the risk of bone destruction via CGRP secretion from free nerve endings. Thus, TRPA1 inhibition could cause severe bone atrophy. However, the suitable therapeutic strategy is controversial because the pathologic mechanisms of bone atrophy in CRPS are unclear. Therefore, we propose focusing on the remission of abnormal bone turnover observed in CRPS using a recently developed concept: senso-immunology.
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Affiliation(s)
- Takayuki Okumo
- Department of Physiology, Showa University School of Medicine, Shinagawa, Japan
| | - Yasunori Takayama
- Department of Physiology, Showa University School of Medicine, Shinagawa, Japan
| | - Kenta Maruyama
- Department of Physiology, Showa University School of Medicine, Shinagawa, Japan.,Division of Cell Signaling, National Institute for Physiological Sciences, Natural Institutes for Natural Sciences, Okazaki, Japan
| | - Mami Kato
- Department of Physiology, Showa University School of Medicine, Shinagawa, Japan.,Department of Molecular and System Pharmacology, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Masataka Sunagawa
- Department of Physiology, Showa University School of Medicine, Shinagawa, Japan
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18
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OUP accepted manuscript. Rheumatology (Oxford) 2022; 61:3534-3546. [DOI: 10.1093/rheumatology/keac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 11/14/2022] Open
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19
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Rebhorn C, Dimova V, Birklein F. [Complex regional pain syndrome-An update]. DER NERVENARZT 2021; 92:1075-1083. [PMID: 34542658 DOI: 10.1007/s00115-021-01186-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 11/30/2022]
Abstract
Complex regional pain syndrome (CRPS) is a pain disorder that develops in the hands or feet after injury. Currently, two types are differentiated, CRPS I without and CRPS II with nerve lesions as well as with either an initially warm or an initially cold subtype, depending on the clinical symptoms. After trauma a certain amount of inflammatory reaction is considered physiological. In acute CRPS this inflammation persists for months and is maintained by diverse inflammatory mediators in peripheral tissue and in blood. This persisting inflammation leads to a sensitization of the nociceptive system, causes somatic cells to proliferate and gives rise to a disrupted endothelial function. The treatment concept aims to antagonize the pathophysiologic components and includes anti-inflammatory and analgetic treatment, mobilization and restoration of the sensorimotor function of the affected limb.
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Affiliation(s)
- Cora Rebhorn
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - Violeta Dimova
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Frank Birklein
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
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20
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Puri L, Nottage K, Hankins JS, Wang WC, McGregor O, Gossett JM, Kang G, Anghelescu DL. Gabapentin for acute pain in sickle cell disease: A randomized double-blinded placebo-controlled phase II clinical trial. EJHAEM 2021; 2:327-334. [PMID: 35844692 PMCID: PMC9175868 DOI: 10.1002/jha2.188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 06/15/2023]
Abstract
Pain in sickle cell disease (SCD) can have a neuropathic component. This randomized phase II double-blinded placebo-controlled study evaluated the efficacy of gabapentin in reducing pain and opioid consumption (morphine-equivalent dose [MED]) during acute vaso-occlusive crisis (VOC). Of 90 patients aged 1-18 years with VOC pain, 45 were randomized to a single gabapentin dose (15 mg/kg) and 45 to placebo, in addition to standard treatment; 42 and 44 patients were evaluable in the gabapentin and placebo arms, respectively. A decrease in pain of ≥33% was reported in 68% of patients in the gabapentin arm and 60% of those in the placebo arm (one-sided p = 0.23). The median MED (mg/kg) in the gabapentin (0.12) and placebo arms (0.13) was similar (p = 0.9). However, in the subset of patients with the HbSS genotype (n = 45), the mean (SD) absolute pain score decrease by the time of discharge was significantly greater in the gabapentin arm (5.9 [3.5]) than in the placebo arm (3.6 [3.3]) (p = 0.032). Pain scores in the overall study population were not significantly reduced when gabapentin was added to standard treatment; however, gabapentin benefited individuals with the more severe genotype, HbSS, during acute VOC. Larger, prospective studies are needed to confirm these findings.
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Affiliation(s)
- Latika Puri
- Department of HematologySt. Jude Children's Research HospitalMemphisTennesseeUSA
- Division of Pediatric Hematology/OncologyDepartment of PediatricsLoma Linda University Children's HospitalLoma LindaCaliforniaUSA
| | - Kerri Nottage
- Janssen Research and DevelopmentRaritanNew JerseyUSA
| | - Jane S. Hankins
- Department of HematologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Winfred C. Wang
- Department of HematologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Olivia McGregor
- Department of HematologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Jeffrey M. Gossett
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Guolian Kang
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Doralina L. Anghelescu
- Division of AnesthesiaDepartment of Pediatric MedicineSt. Jude Children's Research HospitalMemphisTennesseeUSA
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21
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Nirenberg M. Complex Regional Pain Syndrome: The Importance of Early Diagnosis. Orthop Nurs 2021; 40:204-208. [PMID: 34397974 DOI: 10.1097/nor.0000000000000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a potentially life-altering, neuropathic pain condition that often affects an extremity in response to surgery or even minor trauma. The pain is often disproportionate to the injury sustained or the surgical procedure performed-and it has been described as excruciating and unbearable. CRPS can result in irreversible, disabling changes in the affected limb. In some cases it has resulted in amputation or severe psychological issues. However, CRPS outcomes are generally more successful with early detection and treatment. This article presents an overview of CRPS and discusses the critical role nurses can play in recognizing the condition early, assisting with treatment, and providing psychological support.
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Affiliation(s)
- Michael Nirenberg
- Michael Nirenberg, DPM , Clinical and Forensic Podiatrist, Friendly Foot Care, PC, Crown Point, IN
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22
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Tileston KR, Griffin A, Wagner JFM, O'Day MN, Krane EJ. Team Approach: Complex Regional Pain Syndrome in Children and Adolescents. JBJS Rev 2021; 8:e0174. [PMID: 32304498 DOI: 10.2106/jbjs.rvw.19.00174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Children and adolescents with chronic pain are best managed by an interdisciplinary team. In cases of complex regional pain syndrome (CRPS), the interdisciplinary team consists of a pain management specialist, such as an anesthesiologist or physiatrist, a physical therapist, an occupational therapist, a pain psychologist, and an orthopaedist. It may also include other professions, such as a gastroenterologist, psychiatrist, nurse practitioner, nutritionist, endocrinologist, acupuncturist, or social worker. Key factors include rapid recognition of CRPS and the initiation of appropriate treatment, both for the pain syndrome as well as for the orthopaedic injury. Intensive therapies have been shown to be effective in treating CRPS in children. Children often are more responsive to noninvasive treatments than adults.
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Affiliation(s)
- Kali R Tileston
- Stanford University School of Medicine, Stanford, California
| | - Anya Griffin
- Stanford University School of Medicine, Stanford, California
| | | | | | - Elliot J Krane
- Stanford University School of Medicine, Stanford, California
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23
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Abstract
Pain is common but often underrecognized after stroke. Poststroke pain (PSP) hinders recovery, impairs quality of life, and is associated with the psychological state of patients with stroke. The most common subtypes of PSP include central PSP, complex regional pain syndrome, shoulder pain, spasticity-related pain, and headache. The pathophysiologies of these PSP subtypes are not yet clearly understood, and PSP is refractory to conventional treatment in many patients. However, recent studies have proposed potential pathophysiologies of PSP subtypes, which may help prioritize therapies that target specific mechanisms.
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Affiliation(s)
- Seoyon Yang
- Department of Rehabilitation Medicine, Ewha Woman's University Seoul Hospital, Ewha Woman's University School of Medicine, Seoul, Korea
| | - Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Republic of Korea
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24
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Javed S, Abdi S. Use of anticonvulsants and antidepressants for treatment of complex regional pain syndrome: a literature review. Pain Manag 2020; 11:189-199. [PMID: 33183126 DOI: 10.2217/pmt-2020-0060] [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: 11/21/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is characterized by pain accompanied by symptoms including skin changes, sensory, motor, trophic changes and autonomic dysfunction. Anticonvulsants and antidepressants are commonly prescribed for neuropathic pain conditions; however, evidence is sparse whether these drugs are effective in reducing CRPS-related pain. As such, Pubmed was searched for studies published from January 1990 through March 2020; 13 studies were included in this review. Overall, evidence is considered insufficient for use of gabapentinoids for CRPS-related pain. However, three randomized controlled trials (RCTs) did find gabapentin to result in significant improvement in pain whereas one RCT reported use of amitriptyline to be equally as effective as gabapentin. Multiple case reports discussing the efficacy of pregabalin in pediatric CRPS patients, with relatively short duration of disease and underlying psychiatric illness, have been reported, but these findings need to be validated with RCTs.
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Affiliation(s)
- Saba Javed
- University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Salahadin Abdi
- University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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25
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Cutts S, Gangoo S, Srinivasan SH, Modi N, Pasapula C, Power D. Complex regional pain syndrome: an evolving perspective. Postgrad Med J 2020; 97:250-255. [PMID: 33184132 DOI: 10.1136/postgradmedj-2020-137808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/12/2020] [Accepted: 06/18/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a heterogenous and poorly understood condition that can be provoked by quite minor injuries. The symptoms and signs of CRPS persist, long after the patient has recovered from the inciting event. In some cases, there is a clear association with a peripheral nerve injury. The degree of disability produced by CRPS is often out of proportion to the scale of the original insult and the condition is associated with protracted recovery times and frequent litigation. METHODS We have performed a PubMed literature search, referenced landmark papers in the field and included a national expert in peripheral nerve injury and repair in our team of authors. RESULTS AND CONCLUSIONS The diagnostic criteria for CRPS have changed repeatedly over the last two centuries and much of the historical literature is difficult to compare with more recent research. In this review article, we consider how our understanding of the condition has evolved and discuss its pathogenesis, its apparent heterogenicity and the various investigations and treatments available to the clinician.
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Affiliation(s)
- Steven Cutts
- Orthopaedics, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
| | - Shafat Gangoo
- Orthopaedics, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
| | | | - Nitin Modi
- Orthopaedics, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, UK
| | - Chandra Pasapula
- Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK
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26
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Kessler A, Yoo M, Calisoff R. Complex regional pain syndrome: An updated comprehensive review. NeuroRehabilitation 2020; 47:253-264. [PMID: 32986618 DOI: 10.3233/nre-208001] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Complex regional pain syndrome (CRPS) is a complex disorder that can have a significant impact on the quality of life of a person with this syndrome. The diagnosis and treatment of CRPS are often difficult as there is no one confirmatory test and no one definitive treatment. Currently, the most widely accepted clinical diagnostic criteria are the Budapest criteria, which were developed by expert consensus. Though no one single treatment has been found to be universally effective, early detection and an interdisciplinary approach to treatment appear to be key in treating CRPS. This review aims to present up-to-date clinical information regarding the diagnosis and management of CRPS and highlight the potential issues with diagnosis in the neurological population. Ultimately, more research is needed to identify the exact etiology of CRPS in order to help target appropriate therapies. In addition, more randomized controlled trials need to be performed in order to test new therapies or combinations of therapies, including pharmacological, interventional, and behavioral therapies, to determine the best treatment options for this potentially debilitating disorder.
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Affiliation(s)
- Allison Kessler
- Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, IL, USA.,Shirley Ryan Abilitylab, Chicago, IL, USA
| | - Min Yoo
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Randy Calisoff
- Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, IL, USA.,Shirley Ryan Abilitylab, Chicago, IL, USA
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27
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Orsolini L, Pompili S, Volpe U. The ‘collateral side’ of mood stabilizers: safety and evidence-based strategies for managing side effects. Expert Opin Drug Saf 2020; 19:1461-1495. [DOI: 10.1080/14740338.2020.1820984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Laura Orsolini
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Simone Pompili
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
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28
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Ikram M, Rehman S, Akhtar MN, Subhan F, Aslam S. Selective Urease Inhibitory and Antimicrobial Activities of Transition Metal Complexes of Amino Acid Bearing Schiff Base Ligand: Thermal Degradation Behavior of Complexes. Pharm Chem J 2020. [DOI: 10.1007/s11094-020-02224-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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29
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Cruz Salcedo EM, Blanco A, Reed J. Complex Regional Pain Syndrome Developing After a Coral Snake Bite: A Case Report. Cureus 2020; 12:e9787. [PMID: 32953303 PMCID: PMC7491678 DOI: 10.7759/cureus.9787] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Complex regional pain syndrome (CRPS) usually occurs after an inciting injury. Poor understanding of pathophysiology, management, and disease awareness has led to misdiagnosis of this condition. We report a rare case of a 69-year-old male who developed CRPS following a Florida Coral snake bite on his right foot. Initially, it was misdiagnosed as recurrent cellulitis; however, he developed chronic right lower extremity (RLE) pain with worsening flares associated with right leg swelling and erythema. Examination was remarkable for nonpitting edema, erythema, and severe tenderness to light touch of the RLE, all symptoms that highly supported the diagnosis of CRPS. Treatment was initiated and consisted of physical therapy in addition to gabapentin which resulted in marked improvement. CRPS remains a challenging diagnosis due to lack of gold standard test and can be easily misdiagnosed. Clinical evaluation applying Budapest criteria can aid with diagnosis and should be routinely used for all patients with suspected CRPS.
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Affiliation(s)
- Elis M Cruz Salcedo
- Internal Medicine, Ocala Regional Medical Center/University of Central Florida College of Medicine, Ocala, USA
| | - Anamarys Blanco
- Internal Medicine, Ocala Regional Medical Center/University of Central Florida College of Medicine, Ocala, USA
| | - Justin Reed
- Internal Medicine, Ocala Regional Medical Center/University of Central Florida College of Medicine, Ocala, USA
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30
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Altas EU, Onat ŞŞ, Konak HE, Polat CS. Post-stroke complex regional pain syndrome and related factors: Experiences from a tertiary rehabilitation center. J Stroke Cerebrovasc Dis 2020; 29:104995. [PMID: 32807418 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104995] [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] [Received: 03/27/2020] [Accepted: 05/23/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE In this study, it is aimed to determine the risk factors associated with CRPS after stroke and the clinical parameters of the patients and the treatment agents used for CPRS METHOD: 213 hemiplegic patients with CRPS diagnosed in Group 1 and 213 hemiplegic patients without CRPS in group 2 (control group) were included in the study designed retrospectively. Demographic data of the patients, Brunnstrom stage, Modified Ashworth scale, Barthel index were recorded from patients files. Associated risk faktors with CRPS such as Shoulder subluxation, adhesive capsulitis, fracture, deep vein thrombosis, spasticity, neglect, visual field defect, heterotopic ossification, entrapment neuropathies, brachial plexus damage, pressure wound, lower respiratory tract infection (LRTI), urinary tract infection, epilepsy, and depression were questioned. In addition, clinical findings, medical treatments, and physical therapy agents used were recorded. RESULTS The average age of the participants was 67.9 ± 10.3 in group 1 and 66.1 ± 9.9 in group 2. According to the multivariate logistic regression analysis, the presence of the duration of hemiplegi, the duration of hospitalization, shoulder subluxation, soft tissue lesion, adhesive capsulitis, spasticity, entrapment neuropathy, brachial plexus ınjury, protein energy malnutrition, LRTI, urinary infection, depression, coronary artery disease were significantly increased the development of CRPS (p<0.05). As a clinical parameter, edema was present in 95.3% of the patients, while trophic change was the lowest in 1.9%. While sensory reeducation was used in all patients in physical therapy, ganglion blockade was the lowest with 0.9% of patients. In medical treatment, the use of oral paracetamol was 28.2%, while the use of gabapentin was the last with 8.9%. CONCLUSIONS In our study, the risk factors of CRPS after hemiplegia, which are as important as its treatment, as well as its diagnosis and prevention, are shown.
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Affiliation(s)
- Elif Umay Altas
- Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Türkocağı street No:3, Sıhhiye, Ankara, Turkey.
| | - Şule Şahin Onat
- Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Türkocağı street No:3, Sıhhiye, Ankara, Turkey
| | - Hatice Ecem Konak
- Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Türkocağı street No:3, Sıhhiye, Ankara, Turkey
| | - Cemile Sevgi Polat
- Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Türkocağı street No:3, Sıhhiye, Ankara, Turkey
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Zhang Y, Wang X, Dong G. The analgesic efficiency of pregabalin for the treatment of postoperative pain in total hip arthroplasty: A randomized controlled study protocol. Medicine (Baltimore) 2020; 99:e21071. [PMID: 32629738 PMCID: PMC7337400 DOI: 10.1097/md.0000000000021071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Only few studies have yet investigated whether perioperative administration of pregabalin can reduce the incidence of postoperative chronic neuropathic pain after total hip arthroplasty (THA). This prospective, randomized study compared placebo with pregabalin in the hope that a lower pregabalin dose would improve analgesia without increasing side-effects after THA. METHODS This study was a prospective randomized blinded study, with a parallel design and an allocation ratio of 1:1 for the treatment groups. The study was approved by the Institutional Review Board in Weifang People's Hospital and written informed consent was obtained from all subjects before enrolment. A total of 120 patients who meet inclusion criteria are randomized to either pregabalin or placebo group. The primary objective of the study was visual analog scale score. As secondary outcomes, opioid consumption measurement, Harris Hip Score, hip range of motion, patient satisfaction, and complications were made at different time points throughout the study for comparison. RESULTS The null hypothesis of this study was that pregabalin would reduce pain after THA. TRIAL REGISTRATION This study protocol was registered in Research Registry (researchregistry5669).
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Eldufani J, Elahmer N, Blaise G. A medical mystery of complex regional pain syndrome. Heliyon 2020; 6:e03329. [PMID: 32149194 PMCID: PMC7033333 DOI: 10.1016/j.heliyon.2020.e03329] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/31/2019] [Accepted: 01/27/2020] [Indexed: 12/12/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a condition of neuropathic pain, which is characterized by significant autonomic and inflammatory features. CRPS occurs in patients who have limb surgery, limb fractures, or trauma. Many patients may have pain resolve within twelve months of the inciting incident; however, a small subset progresses to the chronic form. This transitional process often happens by changing from warm CRPS with dominant inflammatory phase to cold CRPS, in which autonomic characteristics or manifestations dominate. Several peripheral and central mechanisms are involved, which might vary among individuals over a period of time. Other contributors include peripheral and central sensitization, autonomic alterations, inflammatory and immune changes, neurochemical changes, and psychological and genetic factors. Although effective management of the chronic CRPS form is often challenging, there are a few high quality randomized controlled trials that support the efficacy of the most commonly used therapeutic approaches.
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Affiliation(s)
- Jabril Eldufani
- Department of Medicine, Faculty of Medicine, Elmergib University, El-khums, Libya
- Department of Medicine and Anesthesia, Faculty of Medicine, University of Montréal, Montreal, Quebec, Canada
| | - Nyruz Elahmer
- Department of Pharmacology and Physiology, Faculty of Medicine, University of Montréal, Montreal, Quebec, Canada
| | - Gilbert Blaise
- Department of Medicine and Anesthesia, Faculty of Medicine, University of Montréal, Montreal, Quebec, Canada
- Department of Anesthesiology and Pain Management, Centre hospitalier de l’Université de Montréal (CHUM), Montreal, Quebec, Canada
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Belbachir A, Fuzier R, Biau D. Unexplained pain after scheduled limb surgery. Orthop Traumatol Surg Res 2020; 106:S13-S18. [PMID: 31843513 DOI: 10.1016/j.otsr.2019.05.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/02/2019] [Accepted: 05/14/2019] [Indexed: 02/02/2023]
Abstract
Orthopedic surgery can lead to pain that is poorly if at all explicable, both in the immediate postoperative period and at longer term, impairing the surgical result and necessitating a multidisciplinary approach of multimodal analgesia throughout the patient's care pathway. Preoperatively, patients at high risk of postoperative pain need to be identified and referred to a pain specialist to optimize pain management. Surgical and anesthesiological measures then need to be taken intraoperatively to limit the risk of pain. Finally, and most importantly, when pain does occur postoperatively, the surgeon needs to be able to treat any obvious cause and then rapidly to call in a pain specialist to identify the underlying causes and treat them effectively.
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Affiliation(s)
- Anissa Belbachir
- Service d'anesthésie réanimation, UF Douleur, université Paris-Descartes, hôpital Cochin, Assistance publique-Hôpitaux de Paris, Paris, France.
| | - Régis Fuzier
- Département d'anesthésie, institut Claudius-Regaud, institut universitaire du cancer Toulouse-Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France
| | - David Biau
- Inserm U1153, service de chirurgie Orthopédique, université Paris-Descartes, hôpital Cochin, Assistance publique-Hôpitaux de Paris, Paris, France
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Torres-Salguero I, Rubiano AM. Complex regional pain syndrome secondary to sacrococcygeal dislocation following trauma to the lumbosacral region. Case report. CASE REPORTS 2020. [DOI: 10.15446/cr.v6n1.80451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: The complex regional pain síndrome (CRPS) is a rare condition characterized by inflammatory, vasomotor and central nervous system (CNS) involvement. Its clinical presentation can be subacute, acute or chronic, and may have severe effects on the patient’s quality of life.Case description: 21-year-old female patient with trauma in the lumbosacral region associated with pain and functional limitation. Diagnostic imaging showed sacrococcygeal dislocation with subsequent inflammatory and acute and chronic autonomic symptoms that were treated medically and surgically. The patient responded to treatment with long-term improvement of the symptoms.Discussion: In this case, CRPS occurred after trauma and caused subacute symptoms that became even more acute until reaching a chronic presentation. Inflammation, vasomotor dysfunction and CNS involvement made this case a multidisciplinary diagnostic and therapeutic challenge.Conclusion: CRPS is a rare disease that is difficult to diagnose. However, diagnosis should be timely in order to initiate personalized treatment, since this disease considerably affects the patient’s quality of life.
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Rand SE, Basu S, Khalid S. Complex Regional Pain Syndrome: Current Diagnostic and Treatment Considerations. Curr Sports Med Rep 2019; 18:325-329. [PMID: 31503044 DOI: 10.1249/jsr.0000000000000633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Complex Regional Pain Syndrome is a severe complication of extremity fracture or other injury. Patients who develop this show marked hyperalgesia and allodynia, altered vasomotor, sudomotor and trophic changes. The condition affects women more than men and is most common in those between the ages of 50 and 70 years but can be seen in younger athletes. The diagnosis is made clinically, and treatment is directed at functional recovery using medications, occupational and physical therapy, and psychological interventions. Prognosis for complete recovery is variable and unpredictable.
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Affiliation(s)
- Scott E Rand
- Houston Methodist Willowbrook Hospital.,Houston Methodist Orthopedics and Sports Medicine, Houston, TX
| | - Sumana Basu
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX
| | - Shoaib Khalid
- Houston Methodist Orthopedics and Sports Medicine, Houston, TX
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Abstract
The acute phase of complex regional pain syndrome (CRPS) is pathophysiologically characterized by an activation of the immune system and its associated inflammatory response. During the course of CRPS, central nervous symptoms like mechanical hyperalgesia, loss of sensation, and body perception disorders develop. Psychological factors such as pain-related anxiety and traumatic events might have a negative effect on the treatment outcome. While the visible inflammatory symptoms improve, the pain often persists. A stage adapted, targeted treatment could improve the prognosis. Effective multidisciplinary treatment includes the following: pharmacotherapy with steroids, bisphosphonates, or dimethylsulfoxide cream (acute phase), and antineuropathic analgesics (all phases); physiotherapy and behavioral therapy for pain-related anxiety and avoidance of movement; and interventional treatment like spinal cord or dorsal root ganglion stimulation if noninvasive options failed.
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Affiliation(s)
- V Dimova
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55101, Mainz, Deutschland.
| | - F Birklein
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55101, Mainz, Deutschland
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Abstract
INTRODUCTION Complex regional pain syndromes (CRPS) are rare painful conditions characterized by considerable variability in possible triggering factors, usually traumatic, and in the clinical scenario. The limited knowledge of the pathophysiological mechanisms has led to countless treatment attempts with multiple conservative and surgical options that act by different mechanisms of action. AREAS COVERED In this narrative review, the authors discuss key points about CRPS definitions, diagnostic criteria and pitfalls, pathophysiological hypotheses, and treatment strategies with particular reference to pharmacotherapy. The article was based on a literature search using PubMed while the available guidelines for the management of CRPS were also examined. EXPERT OPINION According to the quality of evidence, pharmacological interventions for CRPS seem to be more effective all the more so when they act on peripheral mechanisms, particularly on nociceptive pain, and when applied early in the disease, while reliable evidence about central mechanisms of chronic pain in CRPS is lacking. In our opinion, drug therapy should be preferred as early as possible, particularly in warm forms of CRPS to prevent significant functional limitation, psychological distress, and social and economic fallout.
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Affiliation(s)
- Giovanni Iolascon
- a Department of Medical and Surgical Specialties and Dentistry , University of Campania "Luigi Vanvitelli" , Naples , Italy
| | - Antimo Moretti
- a Department of Medical and Surgical Specialties and Dentistry , University of Campania "Luigi Vanvitelli" , Naples , Italy
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Shim H, Rose J, Halle S, Shekane P. Complex regional pain syndrome: a narrative review for the practising clinician. Br J Anaesth 2019; 123:e424-e433. [PMID: 31056241 DOI: 10.1016/j.bja.2019.03.030] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 02/25/2019] [Accepted: 03/22/2019] [Indexed: 12/15/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a life-altering condition that usually affects the extremities after a trauma or nerve injury. The physiologic changes that occur as a result of the inciting injury are complex, as the name of the syndrome implies. The pain and disability associated with CRPS often lead to psychological co-morbidities that create a vicious cycle of pain, isolation, and depression. We review recent developments in the understanding of CRPS and advancements in management of this syndrome. Further research in targeting specific mechanisms involved in the pathophysiology of CRPS should lead to prevention of this condition.
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Affiliation(s)
- H Shim
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA
| | - J Rose
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA
| | - S Halle
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA
| | - P Shekane
- Icahn School of Medicine at Mount Sinai West and St. Luke's Hospitals, Department of Anesthesiology, Perioperative and Pain Medicine, New York, NY, USA.
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Abstract
BACKGROUND The gabapentinoid drugs gabapentin and pregabalin were originally developed as antiseizure drugs but now are prescribed mainly for treatment of pain. For gabapentin, the only pain-related indication approved by the US Food and Drug Administration (FDA) is postherpetic neuralgia. For pregabalin, FDA-approved indications related to pain are limited to postherpetic neuralgia, neuropathic pain associated with diabetic neuropathy or spinal cord injury, and fibromyalgia. Despite these limited indications, gabapentin and pregabalin are widely prescribed off-label for various other pain syndromes. Such use is growing, possibly because clinicians are searching increasingly for alternatives to opioids. OBSERVATIONS This report summarizes the limited published evidence to support off-label gabapentinoid uses, describes clinical cases in which off-label use is problematic, and notes how review articles and guidelines tend to overstate gabapentinoid effectiveness. CONCLUSIONS Clinicians who prescribe gabapentinoids off-label for pain should be aware of the limited evidence and should acknowledge to patients that potential benefits are uncertain for most off-label uses.
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Affiliation(s)
| | - Allan S Brett
- Department of Medicine, University of South Carolina School of Medicine, Columbia
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Misidou C, Papagoras C. Complex Regional Pain Syndrome: An update. Mediterr J Rheumatol 2019; 30:16-25. [PMID: 32185338 PMCID: PMC7045919 DOI: 10.31138/mjr.30.1.16] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/06/2019] [Accepted: 01/21/2019] [Indexed: 12/18/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a perplexing painful syndrome of the extremities usually following a harmful event. It is distinguished in two types, mainly depending on the presence of nerve injury. Although its prevalence may vary depending on social and ethnic factors, middle-aged women seem to suffer most often and the upper limb is the most commonly affected extremity. Apart from pain, which is the dominating feature, the clinical picture unfolds across several domains: sensory, motor, autonomic and trophic. This syndrome develops in two phases, the acute (warm) phase, with the classic symptoms of inflammation, and the chronic (cold) phase, often characterized by trophic changes of the soft tissues and even bones. Although the syndrome has been studied for over two decades, no imaging or laboratory test has been established for the diagnosis and recently proposed diagnostic criteria have not yet been validated and are only occasionally applied. Its pathophysiology is still quite obscure, although the most likely mechanisms involve the classic and neurogenic paths of inflammation mediated by cytokines and neuropeptides, intertwined with changes of the autonomic and central nervous system, psychological mechanisms and, perhaps, autoimmunity. Although plenty of treatment modalities have been tried, none has been proven unequivocally efficacious. Apart from information and education, which should be offered to all patients, the most effective pharmacological treatments seem to be bisphosphonates, glucocorticoids and vasoactive mediators, while physical therapy and rehabilitation therapy also make part of the treatment.
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Affiliation(s)
- Christina Misidou
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Charalampos Papagoras
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
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Ferland CE, Villemure C, Michon PE, Gandhi W, Ma ML, Chouchou F, Parent AJ, Bushnell MC, Lavigne G, Rainville P, Ware MA, Jackson PL, Schweinhardt P, Marchand S. Multicenter assessment of quantitative sensory testing (QST) for the detection of neuropathic-like pain responses using the topical capsaicin model. Can J Pain 2018; 2:266-279. [PMID: 35005384 PMCID: PMC8730652 DOI: 10.1080/24740527.2018.1525682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background The use of quantitative sensory testing (QST) in multicenter studies has been quite limited, due in part to lack of standardized procedures among centers. Aim The aim of this study was to assess the application of the capsaicin pain model as a surrogate experimental human model of neuropathic pain in different centers and verify the variation in reports of QST measures across centers. Methods A multicenter study conducted by the Quebec Pain Research Network in six laboratories allowed the evaluation of nine QST parameters in 60 healthy subjects treated with topical capsaicin to model unilateral pain and allodynia. The same measurements (without capsaicin) were taken in 20 patients with chronic neuropathic pain recruited from an independent pain clinic. Results Results revealed that six parameters detected a significant difference between the capsaicin-treated and the control skin areas: (1) cold detection threshold (CDT) and (2) cold pain threshold (CPT) are lower on the capsaicin-treated side, indicating a decreased in cold sensitivity; (3) heat pain threshold (HPT) was lower on the capsaicin-treated side in healthy subjects, suggesting an increased heat pain sensitivity; (4) dynamic mechanical allodynia (DMA); (5) mechanical pain after two stimulations (MPS2); and (6) mechanical pain summation after ten stimulations (MPS10), are increased on the capsaicin-treated side, suggesting an increased in mechanical pain (P < 0.002). CDT, CPT and HPT showed comparable effects across all six centers, with CPT and HPT demonstrating the best sensitivity. Data from the patients showed significant difference between affected and unaffected body side but only with CDT. Conclusion These results provide further support for the application of QST in multicenter studies examining normal and pathological pain responses.
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Affiliation(s)
- Catherine E Ferland
- Quebec Pain Research Network, Université de Sherbrooke, Sherbrooke, QC, Canada.,Research Centre, Shriners Hospitals for Children-Canada, Montreal, QC, Canada.,Department of Anesthesia, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Chantal Villemure
- Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, QC, Canada
| | - Pierre-Emmanuel Michon
- Division des Neurosciences cliniques et cognitives, centre de recherche CERVO, Université Laval, Quebec, QC, Canada
| | - Wiebke Gandhi
- Centre for Integrative Neuroscience and Neurodynamics, School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - My-Linh Ma
- Research Centre, Shriners Hospitals for Children-Canada, Montreal, QC, Canada
| | - Florian Chouchou
- Département santé buccale, Faculté de médecine dentaire, Université de Montréal, Montreal, QC, Canada
| | - Alexandre J Parent
- Quebec Pain Research Network, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - M Catherine Bushnell
- National Centre for Complementary and Integrative Health, NIH, Bethesda, MD, USA
| | - Gilles Lavigne
- Quebec Pain Research Network, Université de Sherbrooke, Sherbrooke, QC, Canada.,Département santé buccale, Faculté de médecine dentaire, Université de Montréal, Montreal, QC, Canada
| | - Pierre Rainville
- Quebec Pain Research Network, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de recherche de l'Institut universitaire de gériatrie de Montréal (CRIUGM), Montreal, QC, Canada.,Département de stomatologie, Faculté de médecine dentaire, Université de Montréal, Montreal, QC, Canada
| | - Mark A Ware
- Quebec Pain Research Network, Université de Sherbrooke, Sherbrooke, QC, Canada.,Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, QC, Canada
| | - Philip L Jackson
- Quebec Pain Research Network, Université de Sherbrooke, Sherbrooke, QC, Canada.,Division des Neurosciences cliniques et cognitives, centre de recherche CERVO, Université Laval, Quebec, QC, Canada.,School of Psychology, Université Laval, Quebec, QC, Canada
| | - Petra Schweinhardt
- Quebec Pain Research Network, Université de Sherbrooke, Sherbrooke, QC, Canada.,Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Serge Marchand
- Quebec Pain Research Network, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de recherche du CHUS, Sherbrooke, QC, Canada.,Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Québec, Canada
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Morgan B, Wooden S. Diagnosis and Treatment of Common Pain Syndromes and Disorders. Nurs Clin North Am 2018; 53:349-360. [DOI: 10.1016/j.cnur.2018.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Park GY, Rak Kwon D, Gil Kwon D. Complex regional pain syndrome type II after cervical transforaminal epidural injection: A case report. Medicine (Baltimore) 2018; 97:e10784. [PMID: 29768371 PMCID: PMC5976320 DOI: 10.1097/md.0000000000010784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE We report a case of a 61-year-old patient who developed complex regional pain syndrome (CRPS) type II after a cervical transforaminal epidural steroid injection (CTESI). PATIENT CONCERNS The patient developed sudden-onset severe pain and swelling of his upper right limb after a cervical transforaminal epidural injection. DIAGNOSES On physical examination, the patient's symptoms and signs corresponded to the Budapest criteria for CRPS. Cervical magnetic resonance imaging and laboratory tests were performed to rule out other causes. An electrodiagnostic study revealed right C6/7 radiculopathies. A three-phase bone scan showed increased uptake in the right wrist in all phases. Thus, he was diagnosed with CRPS type II due to a cervical nerve root injury caused by the transforaminal epidural injection. INTERVENTIONS He received oral methylprednisolone and gabapentin, and underwent physical therapy for 9 days. OUTCOMES The pain and swelling of his right upper limb disappeared and he returned to his previous functional activities. LESSONS CRPS type II due to cervical root injury is rare but can develop during CTESI. Early comprehensive physical therapy and oral medications might result in good outcomes.
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Żyluk A, Puchalski P. Effectiveness of complex regional pain syndrome treatment: A systematic review. Neurol Neurochir Pol 2018; 52:326-333. [PMID: 29559178 DOI: 10.1016/j.pjnns.2018.03.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/04/2018] [Indexed: 11/17/2022]
Abstract
Complex regional pain syndrome (CRPS) is a descriptive term for a complex of symptoms and signs typically occurring following trauma of the extremity. Typical symptomatology includes severe pain, swelling, vasomotor instability and functional impairment of the affected limb. At present there is no one, effective method of treatment of the condition. A large number of treatments have been investigated but major multicentre randomized controlled trials are lacking. This study presents the results of a systematic review of the evidence on effectiveness of treatment methods in CRPS. It is a follow-up to earlier reviews of randomized controlled trials on CRPS treatment published between 1966 and 2016. RESULTS The review of randomized controlled trials showed that only bisphosphonates were found to give uniformly positive effects, statistically significantly better than placebo. Improvement has been reported with topical dimethyl sulfoxide, systemic steroids, spinal cord stimulation and graded motor imagery/mirror therapy programmes. The available evidence does not support the use of other treatments in CRPS, however they are frequently used in clinical practice. CONCLUSION Available evidence, although numerous, does not necessarily reflect what is truly effective and what is sham in the management of CRPS.
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Affiliation(s)
- Andrzej Żyluk
- Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland.
| | - Piotr Puchalski
- Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland.
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Duong S, Bravo D, Todd KJ, Finlayson RJ, Tran DQ. Treatment of complex regional pain syndrome: an updated systematic review and narrative synthesis. Can J Anaesth 2018; 65:658-684. [PMID: 29492826 DOI: 10.1007/s12630-018-1091-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 10/17/2022] Open
Abstract
PURPOSE Although multiple treatments have been advocated for complex regional pain syndrome (CRPS), the levels of supportive evidence are variable and sometimes limited. The purpose of this updated review is to provide a critical analysis of the evidence pertaining to the treatment of CRPS derived from recent randomized-controlled trials (RCTs). SOURCE The MEDLINE, EMBASE, Psychinfo, and CINAHL databases were searched to identify relevant RCTs conducted on human subjects and published in English between 1 May 2009 and 24 August 2017. PRINCIPAL FINDINGS The search yielded 35 RCTs of variable quality pertaining to the treatment of CRPS. Published trials continue to support the use of bisphosphonates and short courses of oral steroids in the setting of CRPS. Although emerging evidence suggests a therapeutic role for ketamine, memantine, intravenous immunoglobulin, epidural clonidine, intrathecal clonidine/baclofen/adenosine, aerobic exercise, mirror therapy, virtual body swapping, and dorsal root ganglion stimulation, further confirmatory RCTs are warranted. Similarly, trials also suggest an expanding role for peripheral sympathetic blockade (i.e., lumbar/thoracic sympathetic, stellate ganglion, and brachial plexus blocks). CONCLUSIONS Since our prior systematic review article (published in 2010), 35 RCTs related to CRPS have been reported. Nevertheless, the quality of trials remains variable. Therefore, further research is required to continue investigating possible treatments for CRPS.
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Affiliation(s)
- Silvia Duong
- Jewish General Hospital, Herzl Family Medicine Center, Montreal, QC, Canada
| | - Daniela Bravo
- Department of Anesthesia, Hospital Clínico Universidad de Chile, University of Chile, Santiago, Chile
| | - Keith J Todd
- Jewish General Hospital, Herzl Family Medicine Center, Montreal, QC, Canada
| | - Roderick J Finlayson
- Department of Anesthesia, Montreal General Hospital, McGill University, 1650 Ave Cedar, D10-144, Montreal, QC, H3G 1A4, Canada
| | - De Q Tran
- Department of Anesthesia, Montreal General Hospital, McGill University, 1650 Ave Cedar, D10-144, Montreal, QC, H3G 1A4, Canada.
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Therapeutic effects of diclofenac, pregabalin, and duloxetine on disuse-induced chronic musculoskeletal pain in rats. Sci Rep 2018; 8:3311. [PMID: 29459641 PMCID: PMC5818528 DOI: 10.1038/s41598-018-21429-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 02/01/2018] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to clarify the mechanism of disuse-induced muscle hyperalgesia through the evaluation of the pharmacological behaviour of muscle hyperalgesia profiles in chronic post-cast pain (CPCP) rats with acute and chronic-phase mirror-image muscle hyperalgesia treated with diclofenac (NSAID), pregabalin (an inhibitor of Ca2+ channel α2δ), and duloxetine (SNRI). After 2 weeks of cast immobilization, the peak cross-sectional area and muscle wet weight of the ipsilateral soleus and gastrocnemius muscles decreased more significantly in CPCP rats than in untreated rats. Histological findings revealed disuse-induced muscle atrophy in CPCP rats. The blood biochemical parameters of CPCP rats in acute and chronic phases did not differ significantly from those of untreated rats. The diclofenac and pregabalin-treated groups exhibited no improvement in acute or chronic muscle hyperalgesia. In contrast, the duloxetine-treated group exhibited an improvement in acute muscle hyperalgesia, but showed no apparent effect on chronic muscle hyperalgesia on ipsilateral or contralateral sides. However, the chronic muscle hyperalgesia was reversed by intrathecal administration of DAMGO (a μ-opioid receptor agonist). The results suggest that chronic muscle hyperalgesia in CPCP rats did not result from an inflammatory mechanism, and there is only a low probability that it's caused by a neuropathic mechanism.
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Abstract
Acute vaso-occlusive crisis (VOC) is a hallmark of sickle cell disease (SCD). Multiple complex pathophysiological processes can result in pain during a VOC. Despite significant improvements in the understanding and management of SCD, little progress has been made in the management of pain in SCD, although new treatments are being explored. Opioids and non-steroidal anti-inflammatory drugs (NSAIDs) remain the mainstay of treatment of VOC pain, but new classes of drugs are being tested to prevent and treat acute pain. Advancements in the understanding of the pathophysiology of SCD and pain and the pharmacogenomics of opioids have yet to be effectively utilized in the management of VOC. Opioid tolerance and opioid-induced hyperalgesia are significant problems associated with the long-term use of opioids, and better strategies for chronic pain therapy are needed. This report reviews the mechanisms of pain associated with acute VOC, describes the current management of VOC, and describes some of the new therapies under evaluation for the management of acute VOC in SCD.
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Lo JCC, Cavazos J, Burnett C. Management of complex regional pain syndrome. Proc (Bayl Univ Med Cent) 2017; 30:286-288. [PMID: 28670058 DOI: 10.1080/08998280.2017.11929616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a relatively rare, chronic, and debilitating condition that significantly impacts the patient's quality of life. There is an overall paucity of literature addressing the management of CRPS in immunocompromised patients. We define features of CRPS, outline its treatment options, and describe a course of CRPS management for a 35-year-old patient who had heart transplantation requiring immunosuppressive medications.
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Affiliation(s)
| | - Joel Cavazos
- Department of Anesthesiology, Baylor Scott and White Health, Temple, Texas
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