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Macionis V. Chronic pain and local pain in usually painless conditions including neuroma may be due to compressive proximal neural lesion. FRONTIERS IN PAIN RESEARCH 2023; 4:1037376. [PMID: 36890855 PMCID: PMC9986610 DOI: 10.3389/fpain.2023.1037376] [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: 09/05/2022] [Accepted: 01/12/2023] [Indexed: 02/22/2023] Open
Abstract
It has been unexplained why chronic pain does not invariably accompany chronic pain-prone disorders. This question-driven, hypothesis-based article suggests that the reason may be varying occurrence of concomitant peripheral compressive proximal neural lesion (cPNL), e.g., radiculopathy and entrapment plexopathies. Transition of acute to chronic pain may involve development or aggravation of cPNL. Nociceptive hypersensitivity induced and/or maintained by cPNL may be responsible for all types of general chronic pain as well as for pain in isolated tissue conditions that are usually painless, e.g., neuroma, scar, and Dupuytren's fibromatosis. Compressive PNL induces focal neuroinflammation, which can maintain dorsal root ganglion neuron (DRGn) hyperexcitability (i.e., peripheral sensitization) and thus fuel central sensitization (i.e., hyperexcitability of central nociceptive pathways) and a vicious cycle of chronic pain. DRGn hyperexcitability and cPNL may reciprocally maintain each other, because cPNL can result from reflexive myospasm-induced myofascial tension, muscle weakness, and consequent muscle imbalance- and/or pain-provoked compensatory overuse. Because of pain and motor fiber damage, cPNL can worsen the causative musculoskeletal dysfunction, which further accounts for the reciprocity between the latter two factors. Sensitization increases nerve vulnerability and thus catalyzes this cycle. Because of these mechanisms and relatively greater number of neurons involved, cPNL is more likely to maintain DRGn hyperexcitability in comparison to distal neural and non-neural lesions. Compressive PNL is associated with restricted neural mobility. Intermittent (dynamic) nature of cPNL may be essential in chronic pain, because healed (i.e., fibrotic) lesions are physiologically silent and, consequently, cannot provide nociceptive input. Not all patients may be equally susceptible to develop cPNL, because occurrence of cPNL may vary as vary patients' predisposition to musculoskeletal impairment. Sensitization is accompanied by pressure pain threshold decrease and consequent mechanical allodynia and hyperalgesia, which can cause unusual local pain via natural pressure exerted by space occupying lesions or by their examination. Worsening of local pain is similarly explainable. Neuroma pain may be due to cPNL-induced axonal mechanical sensitivity and hypersensitivity of the nociceptive nervi nervorum of the nerve trunk and its stump. Intermittence and symptomatic complexity of cPNL may be the cause of frequent misdiagnosis of chronic pain.
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Kavka T. Harmful or safe? Exposure and pain provocation during physiotherapy of complex regional pain syndrome I: a narrative review. J Back Musculoskelet Rehabil 2022; 36:565-576. [PMID: 36530077 DOI: 10.3233/bmr-220081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a clinical diagnosis and an umbrella term for a heterogeneous group of states associated with pain disproportionate to any inciting event, together with a number of signs and symptoms that are manifested mainly in the limbs. There are often concerns among clinicians and patients about the potential harms caused by pain provocation during physiotherapy of CRPS, even though clinical guidelines de-emphasize pain-contingency. OBJECTIVE The objective of this narrative review is to summarize current evidence regarding potential harms due to pain provocation during so-called exposure-based therapies in individuals with CRPS. METHODS Six studies evaluating exposure-based approach were included (n= 6). RESULTS Although only one included study focused primarily on safety and in the rest of the included studies the reporting of harms was insufficient and therefore our certainty in evidence is very low, taken together with outcome measures, available data does not point to any long-term deterioration in symptoms or function, or any major harms associated with pain provocation during physiotherapy of CRPS. CONCLUSION There is a great need for higher-quality studies to determine which therapeutic approach is the most appropriate for whom and to evaluate the risks and benefits of different approaches in more detail.
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Malessy MJA, de Boer R, Muñoz Romero I, Eekhof JLA, van Zwet EW, Kliot M, Dahan A, Pondaag W. Predictive value of a diagnostic block in focal nerve injury with neuropathic pain when surgery is considered. PLoS One 2018; 13:e0203345. [PMID: 30208078 PMCID: PMC6135496 DOI: 10.1371/journal.pone.0203345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/20/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECT In patients with focal nerve injury and neuropathic pain cutting the nerve to obtain permanent pain reduction can be considered. Surgery is indicated only if a diagnostic nerve block provides temporary pain relief. We evaluated the predictive value of a block on the outcome of surgery. METHODS In total, three blocks were performed at two week intervals. Patients were blinded to injections containing lidocaine 1% and a placebo was included. Surgery was offered regardless of the effect of the blocks. Twenty-four patients received 72 blocks. Sixteen patients opted for surgery, 5 patients refrained from surgery, and in 3 the blocks provided permanent pain relief. The predictive ability of the block on the outcome of surgery was assessed by calculating the area under a Receiver Operating Characteristic curve (AUC). RESULTS The AUC of the first lidocaine block was 0.35 with a 95% confidence interval from 0.077 to 0.62. At 95% confidence (two-sided), the AUC is less than 0.62, and hence the predictive ability of the block was poor. The outcome of the second lidocaine block and saline block did not change the conclusion of the first block. CONCLUSIONS We conclude that the use of blocks to select patients for surgery should be critically appraised. PERSPECTIVE A pain relieving response to one open block is currently considered mandatory before patients with focal nerve injury and neuropathic pain are offered surgery. Blinded blocks including a placebo show that responses for selection should be carefully interpreted because they may not be as predictive as generally presumed.
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Affiliation(s)
- Martijn J. A. Malessy
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Ralph de Boer
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Ildefonso Muñoz Romero
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
- Neurological Center at the American British Cowdray Medical Center, Mexico City, Mexico
| | - Job L. A. Eekhof
- Department of Neurology, Alrijne Hospital, Leiden, The Netherlands
| | - Erik. W. van Zwet
- Department of Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Michel Kliot
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States of America
| | - Albert Dahan
- Department of Anaesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Pondaag
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
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Seo DK, Lee HS, Hong JP, Seo JH, Shin JW. Treatment of complex regional pain syndrome using free-flap surgery: a case report. J Pain Res 2017; 10:2699-2702. [PMID: 29200885 PMCID: PMC5703149 DOI: 10.2147/jpr.s149379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Complex regional pain syndrome is a chronic progressive illness with sensory, autonomic, trophic, and motor abnormalities. Treatment is difficult and controversial. We report the results of free-flap and vein wrapping of the superficial peroneal nerve surgery to treat complex regional pain syndrome.
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Affiliation(s)
- Dong-Kyo Seo
- Department of Orthopedic Surgery, GangNeung Asan Hospital, College of Medicine, University of Ulsan, GangNeung-si, South Korea
| | | | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Jeong-Ho Seo
- Department of Orthopedic Surgery, Cheil Orthopedic Hospital, Gangnam-gu, Seoul, South Korea
| | - Jin Woo Shin
- Department of Anesthesia, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
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Corradini C, Bosizio C, Moretti A. Algodystrophy (CRPS) in minor orthopedic surgery. CLINICAL CASES IN MINERAL AND BONE METABOLISM : THE OFFICIAL JOURNAL OF THE ITALIAN SOCIETY OF OSTEOPOROSIS, MINERAL METABOLISM, AND SKELETAL DISEASES 2015; 12:21-5. [PMID: 27134628 PMCID: PMC4832412 DOI: 10.11138/ccmbm/2015.12.3s.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Algodystrophy or Chronic Regional Pain Syndrome (CRPS) is a painful disorder that develops especially at upper or lower extremities of the limbs after a fracture. This syndrome is probably due to bone microvascular changes with subsequent sympathetic nervous system involvement. The pain that characterizes CRPS is spontaneous, disproportionate to the traumatic event and is associated with hyperalgesia, and a variety of autonomic and trophic disorders. This condition has a variable incidence up to 37% of the cases, increasing along with the severity of the fracture. CRPS has a higher chance of developing in women, in older individuals, in smokers, and in patients with reduced bone strength. Early diagnosis is associated with remission in 80-90% of cases. Since the typical onset of the disease is insidious over 2 weeks after surgery, a diagnostic and therapeutic delay may occur. These are the major causes of a high percentage of chronic and disabling complications leading to impaired functional outcomes. In the acute or subacute phase, infusion of bisphosphonates has proven to be the first-choice of treatment with a high percentage of remissions. Moreover, it has been suggested the utility of vitamin C in prevention of CRPS. Furthermore, in the chronic phase electroanalgesia seems to provide promising results.
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Affiliation(s)
- Costantino Corradini
- Department of Biomedical Surgical and Dental Sciences, Sports Trauma Researches Center, State University of Milan c/o 1st Division of Orthopedics and Traumatology, Orthopedic Center Pini CTO - ASST Gaetano Pini, Milan, Italy
- Address for correspondence: Costantino Corradini, MD, Department of Biomedical Surgical and Dental Sciences, Sports Trauma Researches Center, State University of Milan c/o 1st Division of Orthopedics and Traumatology, Orthopedic Center Pini CTO - ASST Gaetano Pini Milan, Italy, E-mail:
| | - Claudia Bosizio
- Department of Biomedical Surgical and Dental Sciences, Sports Trauma Researches Center, State University of Milan c/o 1st Division of Orthopedics and Traumatology, Orthopedic Center Pini CTO - ASST Gaetano Pini, Milan, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, Second University of Naples, Naples, Italy
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Gallic acid and exercise training improve motor function, nerve conduction velocity but not pain sense reflex after experimental sciatic nerve crush in male rats. AVICENNA JOURNAL OF PHYTOMEDICINE 2015; 5:288-97. [PMID: 26445710 PMCID: PMC4587608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of present study was to evaluate the effects of oral administration of gallic acid (GA) for 21 days alone and in combination with exercise on nerve conduction velocity and sensory and motor functions in rats with sciatic nerve crush. MATERIALS AND METHODS Seventy adult male Wistar rats (250-300 g) were divided randomly into 7 groups with 10 in each: 1) Control (Cont), 2) Crushed + Vehicle (Cr +Veh), 3-5) Crushed + gallic acid (Cr+GA) (50, 100, and 200 mg/kg/2 mL, orally), 6) Crushed + exercise (Cr+Exe), and 7) Crushed + exercise + effective dose of gallic acid (Cr+Exe +GA200) for 21 days. In order to establish an animal model of sciatic nerve crush, equivalent to 7 kg of force pressed on 2-3 mm of sciatic nerve for 30 s, three times with 30 s intervals. Pain sense reflex in hot plate, motor coordination in rotarod, and sciatic nerve conduction velocity (SNCV) in all groups were tested. Data were analyzed using one-way ANOVA followed by Tukey's post hoc test and p<0.05 has assigned as the significant difference. RESULTS Pain threshold was increased significantly in untreated crushed rats while motor function and SNCV were decreased in all groups with nerve crush (p<0.05, p<0.01, p<0.001 vs. control). Pain reflex latency was not changed in treated groups. Motor coordination and SNCV were improved in groups Cr+GA200 and Cr+Exe + GA200 (p<0.05, p<0.01 vs. Cr+Veh). CONCLUSION GA, dose-dependently, may have therapeutic potential to improve the peripheral nerve degeneration, which is most likely related, at least in part, to its antioxidant and therapeutic properties.
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Borchers A, Gershwin M. Complex regional pain syndrome: A comprehensive and critical review. Autoimmun Rev 2014; 13:242-65. [DOI: 10.1016/j.autrev.2013.10.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2013] [Indexed: 12/19/2022]
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Matsuda K, Kikuchi M, Murase T, Hosokawa K, Shibata M. Free flap transfer for complex regional pain syndrome type II. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2014; 1:1-4. [PMID: 27252946 PMCID: PMC4627105 DOI: 10.3109/23320885.2014.966106] [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: 07/16/2014] [Revised: 08/20/2014] [Accepted: 09/12/2014] [Indexed: 11/30/2022]
Abstract
A patient with complex regional pain syndrome type II was successfully treated using free anterolateral thigh flap transfer with digital nerve coaptation to the cutaneous nerve of the flap. Release of the scarred tissue and soft tissue coverage with targeted sensory nerve coaptation were useful in relieving severe pain.
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Affiliation(s)
- Ken Matsuda
- Division of Plastic and Reconstructive Surgery, Niigata University Graduate School of Medicine , Niigata, Japan
| | - Mamoru Kikuchi
- Department of Plastic and Reconstructive Surgery, Saga University Hospital , Saga, Japan
| | - Tsuyoshi Murase
- Department of Orthopaedics, Osaka University Graduate School of Medicine , Suita, Osaka, Japan
| | - Ko Hosokawa
- Department of Plastic and Reconstructive Surgery, Osaka University Graduate School of Medicine , Suita, Osaka, Japan
| | - Minoru Shibata
- Division of Plastic and Reconstructive Surgery, Niigata University Graduate School of Medicine , Niigata, Japan
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Riant T, Rigaud J, Delavierre D, Sibert L, Labat JJ. [Predictive factors and prevention of chronic postoperative pelvic and perineal pain]. Prog Urol 2010; 20:1145-57. [PMID: 21056397 DOI: 10.1016/j.purol.2010.08.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Accepted: 08/16/2010] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Chronic postoperative pain has been defined as pain arising after a surgical operation, present for at least 2 months, with no organic (active cancer or chronic infection) or preexisting cause. The purpose of this article is to review the risk factors and prevention of chronic postoperative pelvic and perineal pain. MATERIAL AND METHODS A review of the literature was performed by searching PubMed for articles on risk factors and prevention of chronic postoperative pelvic and perineal pain. RESULTS Chronic postoperative pain is frequent, disabling and represent a high cost to the community. This pain is generated by variable and complex interactions between the surgical procedure (the operated zone, perioperative management, the disease requiring the operative procedure) and the patient (age, gender, genetics, concomitant diseases, personal history). The multifactorial nature of chronic postoperative pain suggests the need for multidisciplinary management with prevention and reduction of the main risk factors. Similarly, appropriate management of acute postoperative pain has a major impact on the risk of chronic pain. CONCLUSION A good knowledge of the risk factors and appropriate prevention can decrease the incidence and consequences of chronic postoperative pain.
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Affiliation(s)
- T Riant
- Unité d'évaluation et de traitement de la douleur, centre Catherine-de-Sienne, 44000 Nantes, France
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Dellon L, Andonian E, Rosson GD. Lower extremity complex regional pain syndrome: long-term outcome after surgical treatment of peripheral pain generators. J Foot Ankle Surg 2010; 49:33-6. [PMID: 20123284 DOI: 10.1053/j.jfas.2009.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Indexed: 02/03/2023]
Abstract
We undertook a retrospective study to evaluate the hypothesis that complex regional pain syndrome (CRPS) I, known as the "new" reflex sympathetic dystrophy, persists because of undiagnosed injured joint afferents, cutaneous neuromas, or nerve compressions, and is, therefore, a misdiagnosed form of CRPS II, which is known as the "new" causalgia. We used a research protocol, with institutional review board approval, to review medical records for the purpose of identifying 30 patients with lower extremity reflex sympathetic dystrophy, based on their history, physical examination, neurosensory testing, and response to peripheral nerve blocks, who were treated surgically at the level of the peripheral nerve. In this report, we describe long-term outcomes in 13 of these patients who were followed up for a minimum of 24 months (mean, 47.8 months; range, 25-90 months). Based primarily on the results of physical examination and the response to peripheral nerve blocks, surgery included a combination of joint denervation, neuroma resection plus muscle implantation, and neurolysis. Outcomes were measured in terms of decreased pain medication usage and recovery of function, and the results were excellent in 7 (55%), good in 4 (30%), and poor (failure) in 2 (15%) of the patients. Based on these results, we concluded that most patients referred with a diagnosis of CRPS I have continuing pain input from injured joint or cutaneous afferents, and chronic nerve compression, which is indistinguishable from CRPS II, and amenable to successful treatment by means of an appropriate peripheral nerve surgical strategy.
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Affiliation(s)
- Lee Dellon
- Johns Hopkins University, Baltimore, MD, USA.
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