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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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Maria Frare J, Rodrigues P, Andrighetto Ruviaro N, Trevisan G. Chronic post-ischemic pain (CPIP) model of complex regional pain syndrome (CRPS-I): Role of oxidative stress and inflammation. Biochem Pharmacol 2024:116506. [PMID: 39182734 DOI: 10.1016/j.bcp.2024.116506] [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: 06/13/2024] [Revised: 08/17/2024] [Accepted: 08/22/2024] [Indexed: 08/27/2024]
Abstract
Complex regional pain syndrome (CRPS) presents as a persistent and distressing pain condition often stemming from limb trauma or ischemia, manifesting as either CRPS-I (without initial nerve injury) or CRPS-II (accompanied by nerve injury). Despite its prevalence and significant impact on functionality and emotional well-being, standard treatments for CRPS remain elusive. The multifaceted nature of CRPS complicates the identification of its underlying mechanisms. In efforts to elucidate these mechanisms, researchers have turned to animal models such as chronic post-ischemic pain (CPIP), which mirrors the symptoms of CRPS-I. Various mechanisms have been proposed to underlie the acute and chronic pain experienced in CRPS-I, including oxidative stress and inflammation. Traditional treatment approaches often involve antidepressants, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids. However, these methods frequently fall short of providing adequate relief. Accordingly, there is a growing interest in exploring alternative treatments, such as antioxidant supplementation, anti-inflammatory agents, and non-pharmacological interventions. Future research directions should focus on optimizing treatment strategies and addressing remaining gaps in knowledge to improve patient outcomes. This review aims to delve into the pathophysiological mechanisms implicated in the CPIP model, specifically focusing on oxidative stress and inflammation, with the ultimate goal of proposing innovative therapeutic strategies for alleviating the symptoms of CRPS-I.
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Affiliation(s)
- Julia Maria Frare
- Graduated Program in Biological Sciences: Toxicological Biochemistry, Federal University of Santa Maria (UFSM), 97105-900, Santa Maria, RS, Brazil
| | - Patrícia Rodrigues
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil
| | - Náthaly Andrighetto Ruviaro
- Graduated Program in Biological Sciences: Toxicological Biochemistry, Federal University of Santa Maria (UFSM), 97105-900, Santa Maria, RS, Brazil
| | - Gabriela Trevisan
- Graduated Program in Pharmacology, Federal University of Santa Maria (UFSM), 97105-900 Santa Maria, RS, Brazil; Graduated Program in Biological Sciences: Toxicological Biochemistry, Federal University of Santa Maria (UFSM), 97105-900, Santa Maria, RS, Brazil.
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3
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Rashaan R, Arkoumanis PT, Gakis C, Lyssiotis FA, Michalis J, Anagnostopoulos P, Stratakis K. Case Report on Botulinum Toxin Treatment for Complex Regional Pain Syndrome in a Digit Reconstruction. MAEDICA 2024; 19:182-185. [PMID: 38736925 PMCID: PMC11079730 DOI: 10.26574/maedica.2024.19.11.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
Objective:To evaluate subcutaneous Botulinum toxin type A (BTX-A) efficacy in alleviating severe allodynia in complex regional pain syndrome (CRPS) type II post-digit reconstruction. Methods: After surgical debridement and flap reconstruction for post-traumatic necrosis, a CRPS type II patient received subcutaneous BTX-A. Assessments tracked symptom changes and daily life improvements. Discussion:There are various CRPS management modalities, including rehabilitation and pharmacology. The limited efficacy of conventional non-steroidal antiinflammatory drugs contrasts with promising subcutaneous BTX-A, offering rapid pain relief. Conclusion:Our case underscores the efficacy of subcutaneous BTX-A in CRPS type II, prompting further research and safe outpatient protocol development.
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Affiliation(s)
- R Rashaan
- Dermatology Department, Guys and St. Thomas Hospital, London Bridge Road, London, United Kingdom
| | - P T Arkoumanis
- Plastic and Reconstructive Surgery Department, General Hospital of Attica "KAT", 2 Nikis 14561, Athens, Greece
| | - C Gakis
- Plastic and Reconstructive Surgery Department, General Hospital of Attica "KAT", 2 Nikis 14561, Athens, Greece
| | - F A Lyssiotis
- Plastic and Reconstructive Surgery Department, General Hospital of Attica "KAT", 2 Nikis 14561, Athens, Greece
| | - J Michalis
- Plastic and Reconstructive Surgery Department, General Hospital of Attica "KAT", 2 Nikis 14561, Athens, Greece
| | - P Anagnostopoulos
- Plastic and Reconstructive Surgery Department, General Hospital of Attica "KAT", 2 Nikis 14561, Athens, Greece
| | - K Stratakis
- Department of General Surgery, Valais Hospital, Sion, Switzerland
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Latour C, Prologo JD, Lin M, Amsbaugh A, Xhang Z, Levey AO. Safety and Effectiveness of Stellate Ganglion Cryoablation in Complex Regional Pain Syndrome. J Vasc Interv Radiol 2024; 35:69-73. [PMID: 37797740 DOI: 10.1016/j.jvir.2023.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 09/03/2023] [Accepted: 09/27/2023] [Indexed: 10/07/2023] Open
Abstract
This was a retrospective, observational, descriptive study to evaluate the safety and 6-month effectiveness of percutaneous cryoablation of the stellate ganglion for the treatment of complex regional pain syndrome (CRPS). Eight patients with CRPS diagnosed by Budapest criteria were treated with this procedure. CRPS symptom severity was assessed prior to the procedure and at 3-month intervals after the procedure using a novel CRPS scoring system-the Budapest score-created by the authors. The mean Budapest score prior to and 6 months (187 days, SD ± 43) after stellate ganglion cryoablation was 7.0 (SD ± 2.0) (n = 6) and 3.8 (SD ± 2.3) (n = 6), respectively, showing a decrease of 3.2 (SD ± 1.7) (n = 6; P = .006). There were no major adverse events due to the procedure, and there was only 1 minor adverse event. Stellate ganglion cryoablation is a feasible, safe, and minimally invasive procedure that may represent an efficacious adjunct treatment option for select patients with CRPS.
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Affiliation(s)
- Christopher Latour
- Department of Interventional Radiology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas; Department of Interventional Radiology, Washington University School of Medicine, St. Louis, Missouri.
| | - J David Prologo
- Interventional Radiology, Emory University School of Medicine, Atlanta, Georgia
| | - Matthew Lin
- Anesthesiology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - Ashley Amsbaugh
- Anesthesiology and Pain Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - Zu Xhang
- Clinical and Translational Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | - Alexa O Levey
- Department of Interventional Radiology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
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Park D, Choi JW, Chang MC. Experience from a single-center study on multimodal medication therapy for patients with complex regional pain syndrome. J Back Musculoskelet Rehabil 2024; 37:687-696. [PMID: 38160336 DOI: 10.3233/bmr-230179] [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: 01/03/2024]
Abstract
BACKGROUND Despite the application of various therapeutic methods, pain caused by complex regional pain syndrome (CRPS) is not sufficiently managed and often progresses to a chronic stage. For the systematic and effective treatment of CRPS, we developed an algorithm for multimodal medication therapy based on the established pathophysiology of CRPS to control CRPS-related pain. OBJECTIVE In this study, we present the outcomes of our novel algorithm for multimodal medication therapy for patients with CRPS, consisting of three major components: multimodal oral medication, intravenous ketamine, and intravenous lidocaine therapy. METHODS We retrospectively investigated patients with CRPS who received multimodal therapy. Pain severity scores were evaluated using a numerical rating scale at four time points (P1, pain at initial consultation; P2, pain after oral medication; P3, pain after ketamine treatment; and P4, pain after lidocaine treatment). The effect of the multimodal medication therapy algorithm on pain management was evaluated at each time point. RESULTS In patients with CRPS, multimodal oral medication, intravenous ketamine, and intravenous lidocaine therapies led to significantly improved pain control (p< 0.05). Additionally, the combination of these three therapies (through the multimodal medication therapy algorithm) resulted in significant pain relief in patients with CRPS (p< 0.05). CONCLUSIONS Our multimodal medication therapy algorithm effectively controlled pain in patients with CRPS. However, further prospective studies with large sample sizes and randomized controlled trials are needed for more accurate generalization.
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Affiliation(s)
- Donghwi Park
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Jin-Woo Choi
- Department of Physical Medicine and Rehabilitation, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Korea
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Fernández-Cuadros ME, Martín-Martín LM, Albaladejo-Florín MJ, Pérez-Moro OS, Goizueta-San-Martín G. [Sensitivity of the sympathetic skin response and scintigraphy in the diagnosis of complex regional pain syndrome]. Rehabilitacion (Madr) 2024; 58:100807. [PMID: 37862774 DOI: 10.1016/j.rh.2023.100807] [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: 05/22/2022] [Revised: 01/19/2023] [Accepted: 04/25/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE To evaluate the sensitivity of sympathetic skin response (SSR) and compare it with scintigraphy in patients with complex regional pain syndrome diagnosed according to the Budapest criteria. MATERIAL AND METHODS Twenty-two patients with complex regional pain syndrome who attended the Rehabilitation and Physical Medicine Department between January-2018 and May-2022 have been prospectively evaluated. The scintigraphy was considered positive if in the 1st-2nd phase slight asymmetric and diffuse uptake was observed, or when in the 3rd phase marked periarticular radioisotope uptake was observed. SSR was abnormal if: a) no response after 20 stimuli; b) lack of habituation with permanence of the stimuli greater than 67.2%. RESULTS Age 55.4±8.57 years. Complex regional pain syndrome was more frequent in women (90.9%), more common in upper limbs (68.2%) than lower limbs (31.8%). In SSR, we have observed normal response (<67.2%) in 2 patients (11.1%), lack of SSR in 2 patients (11.1%) and lack of habituation (>67.2%) in 14 patients (77.8%). In total, 16 patients presented abnormal or absent responses (88.8%). The diagnostic sensitivity of scintigraphy is similar to that of SSR (89.5% vs 88.8%), with no statistical difference (P=.6721). CONCLUSION Scintigraphy has shown similar sensitivity to SSR, although the simplicity, security, low cost, non-ionizing and non-invasiveness of the latter technique suggest that it could be more cost-effective. The lack of habituation and the absence of response could identify response patterns and localize the involvement in the afferent, central, efferent or post-ganglionic pathways.
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Affiliation(s)
- M E Fernández-Cuadros
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España.
| | - L M Martín-Martín
- Servicio de Neurofisiología Clínica, Hospital Universitario Santa Cristina, Madrid, España
| | - M J Albaladejo-Florín
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España
| | - O S Pérez-Moro
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España
| | - G Goizueta-San-Martín
- Servicio de Neurofisiología Clínica, Hospital Universitario Santa Cristina, Madrid, España
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Jia X, Li Z, Shen X, Zhang Y, Zhang L, Zhang L. High-intensity swimming alleviates nociception and neuroinflammation in a mouse model of chronic post-ischemia pain by activating the resolvin E1-chemerin receptor 23 axis in the spinal cord. Neural Regen Res 2023; 18:2535-2544. [PMID: 37282487 PMCID: PMC10360102 DOI: 10.4103/1673-5374.371373] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
Abstract
Physical exercise effectively alleviates chronic pain associated with complex regional pain syndrome type-I. However, the mechanism of exercise-induced analgesia has not been clarified. Recent studies have shown that the specialized pro-resolving lipid mediator resolvin E1 promotes relief of pathologic pain by binding to chemerin receptor 23 in the nervous system. However, whether the resolvin E1-chemerin receptor 23 axis is involved in exercise-induced analgesia in complex regional pain syndrome type-I has not been demonstrated. In the present study, a mouse model of chronic post-ischemia pain was established to mimic complex regional pain syndrome type-I and subjected to an intervention involving swimming at different intensities. Chronic pain was reduced only in mice that engaged in high-intensity swimming. The resolvin E1-chemerin receptor 23 axis was clearly downregulated in the spinal cord of mice with chronic pain, while high-intensity swimming restored expression of resolvin E1 and chemerin receptor 23. Finally, shRNA-mediated silencing of chemerin receptor 23 in the spinal cord reversed the analgesic effect of high-intensity swimming exercise on chronic post-ischemic pain and the anti-inflammatory polarization of microglia in the dorsal horn of the spinal cord. These findings suggest that high-intensity swimming can decrease chronic pain via the endogenous resolvin E1-chemerin receptor 23 axis in the spinal cord.
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Affiliation(s)
- Xin Jia
- Department of Neurology and Neurological Rehabilitation, Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, China
| | - Ziyang Li
- Department of Neurology and Neurological Rehabilitation, Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, China
| | - Xiafeng Shen
- Department of Rehabilitation, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
| | - Yu Zhang
- Key Laboratory of Cellular Physiology (Shanxi Medical University), Ministry of Education, and the Department of Physiology, Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Li Zhang
- Key Laboratory of Central CNS Regeneration (Ministry of Education), Guangdong-Hong Kong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, Guangdong Province, China
| | - Ling Zhang
- Department of Neurology and Neurological Rehabilitation, Shanghai Yangzhi Rehabilitation Hospital (Shanghai Sunshine Rehabilitation Center), School of Medicine, Tongji University, Shanghai, China
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Darole PA, Tayade KS, Uma S, Wadal AR, Patara PP. Recurrent Regional Autonomic Dysfunction as a Presentation of Relapsing Neuromyelitis Optica Spectrum Disorder, Responsive to Ketamine Infusion. Neurol India 2023; 71:1247-1249. [PMID: 38174468 DOI: 10.4103/0028-3886.391398] [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] [Indexed: 01/05/2024]
Abstract
Diagnostic criteria of neuromyelitis optica spectrum disorders (NMOSD) have expanded to include many new symptoms since the original description of Devic's disease in 1894, and the formulation of diagnostic criteria in 2006. Herein, we describe a patient with serum aquaporin positive NMOSD with the unusual presentation of recurrent regional autonomic dysfunction, with concordant MRI findings. The symptomatic treatment of the patient's causalgia required IV ketamine infusion. Besides, as the long segment myelitis occurred in the setting of extensively drug-resistant tuberculosis (XDR TB), there was the added challenge of ruling out TB myelitis and choosing an immunosuppressant that would have the least risk of reactivation of TB.
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Affiliation(s)
- Pramod A Darole
- Department of Medicine, LTMMC and LTMGH, Sion, Mumbai, Maharashtra, India
| | - Kamalesh S Tayade
- Department of Medicine, LTMMC and LTMGH, Sion, Mumbai, Maharashtra, India
| | - Sundar Uma
- Department of Medicine, LTMMC and LTMGH, Sion, Mumbai, Maharashtra, India
| | - Aniket R Wadal
- Department of Medicine, LTMMC and LTMGH, Sion, Mumbai, Maharashtra, India
| | - Pratik P Patara
- Department of Medicine, LTMMC and LTMGH, Sion, Mumbai, Maharashtra, India
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Vidal-Jiménez E, Carvajal-Parodi C, Guede-Rojas F. Complex regional pain syndrome type II localized to the index finger. A case report translating scientific evidence into clinical practice. Physiother Theory Pract 2023:1-14. [PMID: 37909770 DOI: 10.1080/09593985.2023.2276379] [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: 06/12/2023] [Accepted: 10/23/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Complex regional pain syndrome type II (CRPS-II) is a rare condition associated with peripheral nervous system lesions. Its localized distribution in the fingers is unique, and its treatment is unclear. CASE DESCRIPTION A 56-year-old male presented to the emergency department with a saw-cut index finger injury with associated tendon and nerve injuries. After surgery, he was admitted to physical therapy (PT) with persistent pain, joint stiffness, allodynia, and trophic changes compatible with CRPS-II localized in the index finger. The diagnosis was confirmed after applying the Budapest Criteria, and PT was progressive and individualized according to the patient's needs, including graded motor imagery, mobilizations, exercises, and education. OUTCOMES After 12 weeks of PT, a clinically significant decrease in pain intensity and improvements in mobility and index finger and upper limb functionality was observed, reducing CRPS symptomatology. DISCUSSION This report provides information about a unique case of a localized form of CRPS-II. After reviewing the literature on clinical cases of both CRPS-II and localized forms of CRPS, we highlight that the clinical features of this patient and his positive therapeutic response support the importance of translating the scientific evidence on CRPS into clinical practice.
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Affiliation(s)
- Esteban Vidal-Jiménez
- Servicio de Medicina Física y Rehabilitación, Hospital Clínico Herminda Martín, Chillán, Ñuble, Chile
| | - Claudio Carvajal-Parodi
- Escuela de Kinesiología, Facultad de Odontología y Ciencias de la Rehabilitación, Universidad San Sebastián Concepción, Bíobío, Chile
| | - Francisco Guede-Rojas
- Exercise and Rehabilitation Sciences Institute, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
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Istefan E, Belstock J, Dahlin LB, Nyman E. Surgery of Schwannoma in the upper limb - sensitivity and specificity of preoperative magnetic resonance imaging and relation between tumour size and symptoms. BMC Musculoskelet Disord 2023; 24:713. [PMID: 37679701 PMCID: PMC10483856 DOI: 10.1186/s12891-023-06838-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 08/27/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Benign peripheral nerve tumours consist of different types, most commonly Schwannomas. Preoperative Magnetic Resonance Imaging (MRI) is commonly performed before surgery and Pathoanatomical Diagnosis (PAD) confirms the diagnosis. Our aims were to study the utility of MRI and the relation between tumour size and symptoms. METHODS Retrospectively, patients, surgically treated for benign nerve tumours between 2008 and 2019, were identified and preoperative MRI, with measurement of tumour size, PAD, symptoms, peroperative details, and symptomatic outcomes of surgery, were analysed. RESULTS The sensitivity and specificity to correctly identify Schwannomas with preoperative MRI were 85% and 50%, respectively, based on 30 Schwannomas and nine neurofibromas that were identified. Tumour size did not affect the presence of preoperative symptoms, but patients with sensory dysfunction at last follow-up had larger Schwannomas (p < 0.05). Symptoms as a palpable tumour, paraesthesia and pain improved by surgical excision (p < 0.001, p < 0.001 and p < 0.012, respectively), but sensory and motor dysfunction were common postoperatively. No malignant peripheral nerve sheath tumours (MPNST) were found. Using a surgical microscope, instead of only loop magnification, lowered the risk of perioperative nerve injuries (p < 0.05), but did not further diminish postoperative symptoms. CONCLUSIONS Early and accurate diagnosis of Schwannomas is valuable for adequate presurgical preparation and prompt surgical intervention. Preoperative examination with MRI has a high sensitivity, but low specificity; although recent advancement in MRI technology indicates improvement in diagnostic precision. Surgical excision is preferably performed early in conjunction with symptomatic debut to improve outcome.
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Affiliation(s)
- Emanuel Istefan
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, 581 85, Sweden
| | - Johannes Belstock
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, 581 85, Sweden
| | - Lars B Dahlin
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, 581 85, Sweden
- Department of Translational Medicine - Hand Surgery, Lund University, Malmö, 205 02, Sweden
- Department of Hand Surgery, Skåne University Hospital, Malmö, 205 02, Sweden
| | - Erika Nyman
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, 581 85, Sweden.
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University Hospital, Linköping, 581 85, Sweden.
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Ghaly L, Bargnes V, Rahman S, Tawfik GA, Bergese S, Caldwell W. Interventional Treatment of Complex Regional Pain Syndrome. Biomedicines 2023; 11:2263. [PMID: 37626759 PMCID: PMC10452500 DOI: 10.3390/biomedicines11082263] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/21/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Complex regional pain syndrome (CRPS) is a rare but debilitating chronic pain disorder characterized by persistent pain disproportionate to any preceding injury. CRPS can have a significant impact on a person's quality of life, often leading to disability and psychological distress. Despite being recognized for over a century, finding the right treatment for CRPS can be challenging. In this article, we will explore the causes, symptoms, and interventional treatment options for CRPS, as well as the latest research on this complex and often misunderstood condition.
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Affiliation(s)
| | | | | | | | - Sergio Bergese
- Stony Brook University Hospital, Stony Brook, NY 11794, USA; (L.G.); (V.B.); (S.R.); (G.-A.T.); (W.C.)
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12
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MacRae FA, Boissonnault E, Winston P. A retrospective review of the management and outcomes of patients diagnosed with complex regional pain syndrome type II using electrodiagnostic findings. Can J Pain 2023; 7:2242892. [PMID: 38229666 PMCID: PMC10791151 DOI: 10.1080/24740527.2023.2242892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/27/2023] [Indexed: 01/18/2024]
Abstract
Objectives The objective of this study was to assess the outcomes of the use of electrodiagnosis in the diagnosis and management of discrete nerve injuries in patients with complex regional pain syndrome (CRPS). Design This study is a secondary retrospective cohort analysis of patients diagnosed with CRPS from a single outpatient physical medicine and rehabilitation clinic and included all patients who had abnormal electrodiagnostic findings, in addition to CRPS. Results Sixty patients of 248 diagnosed with CRPS underwent electrodiagnosis, 41 of whom had abnormal electrodiagnostic findings indicating a discrete nerve injury. Only 51% of the 41 referrals had indicated the suspicion of a nerve injury. Nearly all patients had undergone physiotherapy. Forty-one percent responded to treatment with oral prednisone alone, 54% had a functional improvement after a combination of treatments including corticosteroids, and 5% improved with treatments that did not involve corticosteroids. Surgical interventions for nerve injuries were required for 34% of patients in the cohort. All surgeries involved the median or ulnar nerve, with the exception of one fibular nerve. After treatment, 39 of 41 patients had functional recoveries or better. Conclusions Electrodiagnosis can inform diagnosis of nerve injury and direct intervention including the need for surgical intervention. Electrodiagnosis should be considered for patients with initial signs of concomitant discrete nerve injury or with CRPS who are not responding to treatments because a nerve injury may be underlying. What is Known Complex Regional Pain Syndrome (CRPS) is a poorly understood pain condition. CRPS has been divided into two subtypes, the second subtype involves a discrete nerve injury with pain that extends beyond the territory of the nerve injury. What is New We observed that nerve injuries that may require surgical intervention are diagnosed just over half of the time upon initial assessment in patients with suspected CRPS. We observed that nerve injuries frequently required specifically directed interventions in place of or in conjunction with CRPS treatments. We suggest that electrodiagnosis is an important part of the triage protocol for CRPS II to reveal discrete nerve injuries that may be hidden. We recommend that electrodiagnosis be considered for patients with initial signs of concomitant discrete nerve injury or for CRPS patients who do not improve with medical therapies.
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Affiliation(s)
- Fraser Alexander MacRae
- Health Sciences, Western University, London, Canada
- Vancouver Island Health Authority, Victoria, Canada
| | - Eve Boissonnault
- Physical Medicine and Rehabilitation, University of Montreal, Montreal, Canada
| | - Paul Winston
- Faculty of Medicine, University of British Columbia, Victoria, Canada
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Georgiyeva K, Kumar H, Fernandez VE. A Decade of Complex Regional Pain Syndrome Following Orthopedic Wrist Surgery: A Case Report and a Literature Review. Cureus 2023; 15:e42540. [PMID: 37637569 PMCID: PMC10460122 DOI: 10.7759/cureus.42540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Every day, people of all ages in the United States break bones, with traumatic injury being the most common way, and wrist injury being in the top five most common areas in which bones break. Traumatic fractures are managed with either surgical or nonsurgical approaches. The surgical approach utilizes ortho procedures such as internal fixation and reduction, while the nonsurgical approach consists of procedures like RICE, ace bandage, and so on. However, in rare cases, patients are left with a peculiar constellation of symptoms, which cause edema, pain, skin changes, and loss of function at the trauma site. This occurrence is termed complex regional pain syndrome. Here, we present the case of a 55-year-old female patient who suffered a traumatic wrist injury. The trauma was fixed by pinning ORIF orthopedic surgery, and the patient developed manifestations of complex regional pain syndrome around 10 days postoperatively. In this case report, we describe the variation and complexity of symptoms in the patient over the course of a decade after the original injury. The case report explains the pain management therapies that reduced the patient's symptoms and highlights the ones that were ineffective. We have included some less frequently used yet effective treatments and shed light on how this disease affected the patient's overall well-being.
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Affiliation(s)
| | - Harendra Kumar
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
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14
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Papenhoff MC, Habig K, Schmitz C, Lundin S, Schreier D, Tineghe J, Dudda M. [Complex Regional Pain Syndrome (CRPS) - State of the Art in Diagnostics and Therapy]. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023; 161:337-352. [PMID: 37307853 DOI: 10.1055/a-1898-2454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The complex regional pain syndrome (CRPS) usually occurs within a few weeks in 2-5% of all patients after trauma or surgery or subsequent measures of the distal extremities. There are certain risk factors for its occurrence but no "CRPS personality", instead there are factors that negatively influence the course. The prognosis is generally good ("rule of thirds"), but remaining limitations are common. The diagnosis is clinically possible according to the "Budapest criteria". Additional examinations are possible in case of doubt but are neither conclusive nor exclusive. Corticoids and bisphosphonates are used alongside drugs that have an effect on neuropathic pain. Invasive therapies do not have good evidence and have therefore lost their importance. The rehabilitative therapy is carried out actively and with a lot of self-exercises at an early stage. Invasive anesthetic, passive therapies are obsolete. Special forms of treatment are "graded exposure" (GEXP) in the case of dominant anxiety and, e.g., "graded motor imagery" (GMI) in case of neglect-like symptoms. In addition to educational and behavioral therapy elements, psychotherapy for CRPS also includes participation as part of graded exposure.
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15
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Castillo-Vásquez KC, Condorhuamán Alvarado PY, Zúñiga Bartolomé C, Reinoso-Párraga PP. [Complex regional syndrome in the right tarsus of spontaneous onset. A disabling pathology]. Rev Esp Geriatr Gerontol 2023; 58:173-174. [PMID: 36631337 DOI: 10.1016/j.regg.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 01/11/2023]
Affiliation(s)
| | - Patricia Ysabel Condorhuamán Alvarado
- Servicio de Geriatría, Hospital Universitario La Paz, Madrid, España; Instituto de Investigación Biomédica, Hospital Universitario La Paz (IdiPaz), Madrid, España
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16
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Herson AB, Thompson CW, Barbari CA, Fischer ST, Rehm GM, Miller BT, Herson DM. Managing Chronic Regional Pain Syndrome: The Potential Impact of the Food and Drug Omnibus Reform Act. Cureus 2023; 15:e38336. [PMID: 37261183 PMCID: PMC10228706 DOI: 10.7759/cureus.38336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 06/02/2023] Open
Abstract
Complex regional pain syndrome (CRPS) is a neurological disorder characterized by persistent limb symptoms. With there being no definitive tests, diagnosis can be challenging. The Budapest criteria are the standard for diagnosis. The underlying mechanisms of CRPS involve changes in skin innervation, sensitization of the nervous system, inflammatory cytokines, and genetic and psychological factors. Treatment typically involves a multidisciplinary approach. We present a case of a 71-year-old male with CRPS involving the right upper extremity and a complex history of management including physical therapy, oxycodone, muscle relaxers, non-steroidal anti-inflammatory drugs, and multiple stellate ganglion blocks. The patient manages his pain with off-label medications, including methadone, duloxetine, and pregabalin. In the United States, the management of chronic pain may be affected by potential usage restrictions imposed by the Food and Drug Omnibus Reform Act (FDORA). Under this new act, physicians may face limitations in prescribing off-label medications for specific diagnoses. We aim to highlight the need for prioritizing patient care and individualized treatment in healthcare policy decision-making.
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Affiliation(s)
- Andrew B Herson
- Pain Management, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Chase W Thompson
- Pain Management, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Cody A Barbari
- Physical Medicine and Rehabilitation, Memorial Hospital, Hollywood, USA
| | - Steven T Fischer
- Pain Management, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Gina M Rehm
- Pain Management, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Brooke T Miller
- Pain Management, Lake Erie College of Osteopathic Medicine, Bradenton, USA
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17
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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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18
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Kim D, Kim MJ, Kim JH, Oh J, Choi K. A Pilot Study of Autonomic Function Screening Tests for Differentiating Complex Regional Pain Syndrome Type II and Traumatic Neuropathic Pain. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040646. [PMID: 37109606 PMCID: PMC10143614 DOI: 10.3390/medicina59040646] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: One of the most challenging tasks in a clinical setting is to differentiate between complex regional pain syndrome (CRPS) type II and traumatic neuropathic pain (NeP). CRPS is characterized by several dysautonomic manifestations, such as edema, hyper/hypohidrosis, skin color change, and tachycardia. This study compared the outcomes of autonomic function screening tests in patients with CRPS type II and traumatic NeP for diagnostic differentiation. Materials and Methods: CRPS type II was diagnosed according to the Budapest research criteria, while NeP was diagnosed according to the updated grading system suggested by the International Association for the Study of Pain Special Interest Group on Neuropathic Pain in 2016. Twenty patients with CRPS type II and twenty-five with traumatic NeP were investigated. Results: Twelve patients with CRPS type II presented abnormal results for the quantitative sudomotor axon reflex test (QSART). Abnormal QSART results were more common in the CRPS type II group. Conclusions: Analysis of QSART combined with other ancillary tests can help in the differential diagnosis of CRPS type II and traumatic NeP if factors influencing abnormal QSART are sufficiently controlled.
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Affiliation(s)
- Dayoung Kim
- Department of Neurology, Konkuk University College of Medicine, Konkuk University Medical Center, Seoul 05030, Republic of Korea
| | - Min Jung Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University College of Medicine, Konkuk University Medical Center, Seoul 05030, Republic of Korea
| | - Jae Hun Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University College of Medicine, Konkuk University Medical Center, Seoul 05030, Republic of Korea
| | - Jeeyoung Oh
- Department of Neurology, Konkuk University College of Medicine, Konkuk University Medical Center, Seoul 05030, Republic of Korea
| | - Kyomin Choi
- Department of Neurology, Konkuk University College of Medicine, Konkuk University Medical Center, Seoul 05030, Republic of Korea
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19
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Lu F, Kato J, Toramaru T, Zhang M, Morisaki H. Pharmacological Ischemic Conditioning with Roxadustat Does Not Affect Pain-Like Behaviors but Mitigates Sudomotor Impairment in a Murine Model of Deep Hind Paw Incision. J Pain Res 2023; 16:573-587. [PMID: 36852095 PMCID: PMC9960722 DOI: 10.2147/jpr.s397054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 01/26/2023] [Indexed: 02/22/2023] Open
Abstract
Purpose The involvement of hypoxic response mechanisms in local functional impairments in surgical wounds is unclear. In the present study, we characterized tissue hypoxia in surgical wounds and investigated the role of pharmacological ischemic conditioning (PIC) using roxadustat, an oral prolyl hydroxylase domain enzyme inhibitor, in postoperative local functional impairments in a murine model of deep hind paw incision. Methods Male BALB/cAJcl mice aged 9-13 weeks were used in all experiments. Plantar skins of mice that underwent surgical incision were subjected to immunohistochemistry to localise tissue hypoxia. Pain-like behaviours and sudomotor function were compared between mice treated with 6-week perioperative PIC and control mice. The effects of PIC were examined in vitro by immunocytochemistry using sympathetically differentiated PC12 cells and in vivo by immunohistochemistry using plantar skins collected on postoperative day 21. Results Prominent tissue hypoxia was detected within axons in the nerve bundles underneath surgical wounds. Six-week perioperative PIC using roxadustat failed to ease spontaneous pain-like behaviors; however, it mitigated local sudomotor impairment postoperatively. Upregulation of sympathetic innervation to the eccrine glands was observed in the PIC-treated skins collected on postoperative day 21, in accordance with the in vitro study wherein roxadustat promoted neurite growth of sympathetically differentiated PC12 cells. Conclusion This study suggests that tissue hypoxia is involved in the pathogenesis of local sudomotor dysfunction associated with surgical trauma. Targeting the hypoxic response mechanisms with PIC may be of therapeutic potential in postsurgical local sympathetic impairments that can be present in complex regional pain syndrome.
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Affiliation(s)
- Fanglin Lu
- Keio University Graduate School of Medicine Doctoral Programs, Tokyo, Japan.,Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Jungo Kato
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Tomoko Toramaru
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Mengting Zhang
- Keio University Graduate School of Medicine Doctoral Programs, Tokyo, Japan.,Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Morisaki
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
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20
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Sobeeh MG, Hassan KA, da Silva AG, Youssef EF, Fayaz NA, Mohammed MM. Pain mechanisms in complex regional pain syndrome: a systematic review and meta-analysis of quantitative sensory testing outcomes. J Orthop Surg Res 2023; 18:2. [PMID: 36593515 PMCID: PMC9806919 DOI: 10.1186/s13018-022-03461-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a chronic condition following inciting events such as fractures or surgeries with sensorimotor and autonomic manifestations and poor prognosis. This review aimed to provide conclusive evidence about the sensory phenotype of CRPS based on quantitative sensory testing (QST) to understand the underlying pain mechanisms and guide treatment strategies. DATABASES Eight databases were searched based on a previously published protocol. Forty studies comparing QST outcomes (thermal, mechanical, vibration, and electric detection thresholds, thermal, mechanical, pressure, and electric pain thresholds, wind-up ratio, mechanical pain sensitivity, allodynia, flare area, area after pinprick hyperalgesia, pleasantness after C-tactile stimulation, and pain ratings) in chronic CRPS (adults and children) versus healthy controls were included. RESULTS From 37 studies (14 of low quality, 22 of fair quality, and 1 of good quality), adults with CRPS showed: (i) significant loss of thermal, mechanical, and vibration sensations, significant gain of thermal and mechanical pain thresholds, significant elevation of pain ratings, and no difference in wind-up ratio; (ii) significant reduction of pleasantness levels and increased area of pinprick hyperalgesia, in the affected limb. From three fair-quality studies, adolescents and children with CRPS showed loss of cold detection with cold hyperalgesia in the affected limb. There was moderate to substantial overall heterogeneity. CONCLUSION Diffuse thermal and mechanical hypoesthesia with primary and secondary hyperalgesia, enhanced pain facilitation evidenced by increased area of pinprick hyperalgesia, and elevated pain ratings are dominant in adults with CRPS. Adolescents and children with CRPS showed less severe sensory abnormalities.
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Affiliation(s)
- Mohamed Gomaa Sobeeh
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt ,grid.442728.f0000 0004 5897 8474Faculty of Physical Therapy, Sinai University, Ismailia, Egypt
| | - Karima Abdelaty Hassan
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Anabela Gonçalves da Silva
- grid.7311.40000000123236065CINTESIS.UA@RISE, School of Health Sciences, University of Aveiro, Aveiro, Portugal
| | - Enas Fawzy Youssef
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Nadia Abdelazim Fayaz
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Maha Mostafa Mohammed
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
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21
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Bao QY, Chang PC, Centeno MV, Farmer MA, Baliki M, Procissi D, Zhang W, Apkarian AV. Reversal of neuropathic pain is associated with corticostriatal functional reorganization after nerve repair in the spared nerve injury model. Pain 2022; 163:1929-1938. [PMID: 35082247 PMCID: PMC9309182 DOI: 10.1097/j.pain.0000000000002590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 12/13/2021] [Indexed: 02/04/2023]
Abstract
ABSTRACT Following surgical repair after peripheral nerve injury, neuropathic pain diminishes in most patients but can persist in a small proportion of cases, the mechanism of which remains poorly understood. Based on the spared nerve injury (SNI), we developed a rat nerve repair (NR) model, where a delayed reconstruction of the SNI-injured nerves resulted in alleviating chronic pain-like behavior only in a subpopulation of rats. Multiple behavioral measures were assayed over 11-week presurgery and postsurgery periods (tactile allodynia, pain prick responses, sucrose preference, motor coordination, and cold allodynia) in SNI (n = 10), sham (n = 8), and NR (n = 12) rats. All rats also underwent resting-state functional magnetic resonance imaging under anesthesia at multiple time points postsurgery, and at 10 weeks, histology and retrograde labeling were used to calculate peripheral reinnervation. Behavioral measures indicated that at approximately 5 weeks postsurgery, the NR group separated to pain persisting (NR persisting, n = 5) and recovering (NR recovering, n = 7) groups. Counts of afferent nerves and dorsal root ganglion cells were not different between NR groups. Therefore, NR group differences could not be explained by peripheral reorganization. By contrast, large brain functional connectivity differences were observed between NR groups, where corticolimbic reorganization paralleled with pain recovery (repeated-measures analysis of variance, false discovery rate, P < 0.05), and functional connectivity between accumbens and medial frontal cortex was related both to tactile allodynia (nociception) and to sucrose preference (anhedonia) in the NR group. Our study highlights the importance of brain circuitry in the reversal of neuropathic pain as a natural pain-relieving mechanism. Further studies regarding the therapeutic potentials of these processes are warranted.
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Affiliation(s)
- Qi-Yuan Bao
- Department of Orthopaedics, Ruijin Hospital, Jiaotong University School of Medicine, Shanghai, China
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Pei-Ching Chang
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Maria Virginia Centeno
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Melissa A Farmer
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Marwan Baliki
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
- Pain Management Center, Chicago, IL, United States
| | - Daniel Procissi
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Weibin Zhang
- Department of Orthopaedics, Ruijin Hospital, Jiaotong University School of Medicine, Shanghai, China
| | - A Vania Apkarian
- Department of Physiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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22
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Glomus Tumor of the Lower Extremity Previously Misdiagnosed as Complex Regional Pain Syndrome in Close Proximity to a Myxofibrosarcoma: A Case Report. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202207000-00002. [PMID: 35797605 PMCID: PMC9263485 DOI: 10.5435/jaaosglobal-d-21-00311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/09/2022] [Indexed: 11/18/2022]
Abstract
Complex regional pain syndrome (CRPS) is a potentially devastating condition that can result in severe psychological and social morbidity. It is a diagnosis of exclusion, and other pathologic entities must be ruled out first. Glomus tumors are exquisitely painful benign vascular tumors that are most common in the hand and are rarely found in the lower extremity. Here, we present a case of a patient who developed a focus of severe anterior knee pain and tenderness a few months after a car accident that had been misdiagnosed as CRPS for 15 years. She coincidentally developed a sarcoma of her ipsilateral leg distal to this site. Magnetic resonance imaging of the sarcoma included the area of knee pain where, interestingly, it identified a separate small soft-tissue mass. A glomus tumor was diagnosed histologically in a needle biopsy specimen from this mass, which was resected along with the sarcoma. For the first time in 15 years, despite the additional sarcoma surgery, she reported relief of her pain and complete resolution of her “CRPS.”
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Loy E, Scheidler A, Packham T, Dow H, Winston P. Patient satisfaction with virtual evaluation, diagnosis, and treatment of CRPS. Can J Pain 2022; 6:77-84. [PMID: 35694140 PMCID: PMC9176228 DOI: 10.1080/24740527.2022.2063113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The COVID-19 pandemic has led to an increased reliance on virtual care in the rehabilitation setting for patients with conditions such as complex regional pain syndrome (CRPS). Aims The aim of this study was to perform a quality improvement initiative to assess patient satisfaction and ensure that outcomes following virtual assessment, diagnosis, and treatment of CRPS with prednisone are safe and effective. Methods An online survey was distributed to 18 patients with CRPS who had been seen virtually between March and December 2020 through a rehabilitation clinic and treated with oral prednisone. Thirteen participants completed the survey, which was designed de novo by our team to evaluate participant perceptions and satisfaction regarding the virtual care experience. Also included in the survey was a CRPS-specific validated patient-report questionnaire (Hamilton Inventory for CRPS: PR-HI-CRPS), which allowed participants to describe their specific symptoms and associated functional and psychosocial impacts, both previously (pretreatment baseline) and at the time of survey (posttreatment). Results CRPS symptoms and related impacts were scored as significantly improved from baseline following treatment with prednisone. Likert scale results from survey responses related to patients' experiences and satisfaction with the virtual care process were analyzed; the majority of patients reported satisfaction with a virtual appointment for evaluation of CRPS, as well as with subsequent treatment decisions based on virtual assessment. Conclusions This quality improvement study suggests that virtual care is a potential option for a patient-accepted approach to overcoming challenges with in-person care imposed by the COVID-19 pandemic and could help inform future considerations in addressing geographic and patient-specific disparities in access to specialist care for CRPS.
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Affiliation(s)
- Emma Loy
- Faculty of Medicine, University of British Columbia, Vancouver, BritishColumbia, Canada
| | - Anna Scheidler
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tara Packham
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Heather Dow
- Canadian Association of Physical Medicine and Rehabilitation, Kingston, Ontario, Canada
| | - Paul Winston
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BritishColumbia, Canada,CONTACT Dr. Paul Winston Division of Physical Medicine and Rehabilitation, University of British Columbia, 1 Hospital Way, Victoria General Hospital, Victoria, BCV8Z 6R5, Canada
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24
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Zhang Y, Chen R, Hu Q, Wang J, Nie H, Yin C, Li Y, Wei H, Liu B, Tai Y, Fang J, Shao X, Jin X, Fang J, Liu B. Electroacupuncture Ameliorates Mechanical Allodynia of a Rat Model of CRPS-I via Suppressing NLRP3 Inflammasome Activation in Spinal Cord Dorsal Horn Neurons. Front Cell Neurosci 2022; 16:826777. [PMID: 35693886 PMCID: PMC9174662 DOI: 10.3389/fncel.2022.826777] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
Complex regional pain syndrome type-I (CRPS-I) is a chronic neurological disorder that results in severe pain and affects patients' life quality. Conventional therapies usually lack effectiveness. Electroacupuncture (EA) is an effective physical therapy for relieving CRPS-I pain. However, the mechanism underlying EA-induced analgesia on CRPS-I still remain unknown. Spinal NLRP3 inflammasome was recently identified to contribute to pain and neuroinflammation in a rat model of CRPS-I by our group. Here, we aimed to study whether EA could inhibit spinal NLRP3 inflammasome activation, thus resulting in pain relief and attenuation of spinal neuroinflammation in the rat model of CRPS-I. We established the rat chronic post-ischemic pain (CPIP) model to mimic CRPS-I. CPIP rats developed remarkable mechanical allodynia that could be relieved by daily EA intervention. NLRP3 inflammasome was activated in spinal cord dorsal horn (SCDH) of CPIP rats, accompanied with over-production of pro-inflammatory cytokine IL-1β. Immunostaining revealed that the cellular distribution of NLRP3 was predominantly located in SCDH neurons. Pharmacological activation of NLRP3 inflammasome per se is sufficient to produce persistent mechanical allodynia in naïve animals, whereas blocking NLRP3 inflammasome attenuates mechanical allodynia of CPIP rats. EA exclusively reduced NLRP3 overexpression in SCDH neurons and attenuated spinal glial cell over-activation in CPIP rats. EA-induced anti-allodynia with attenuation of spinal glial cell over-activation were all mimicked by intrathecal blocking NLRP3 inflammasome and reversed by activating NLRP3 inflammasome, respectively, through pharmacological methods. Finally, spinal blocking IL-1β attenuated mechanical allodynia and spinal glial cell over-activation in CPIP rats, resembling the effects of EA. In all, these results demonstrate that spinal NLRP3 inflammasome activation contributes to mechanical allodynia of the rat model of CRPS-I and EA ameliorates mechanical allodynia through inhibiting NLRP3 inflammasome activation in SCDH neurons. Our study further supports EA can be used as an effective treatment for CRPS-I.
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Affiliation(s)
- Yunwen Zhang
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ruixiang Chen
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
- Centre for Neurodevelopmental and Neurodegenerative Diseases, The Brain Cognition and Brain Disease Institute of Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Qimiao Hu
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jie Wang
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Huimin Nie
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Chengyu Yin
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuanyuan Li
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Huina Wei
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Boyu Liu
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yan Tai
- Academy of Chinese Medical Sciences, Zhejiang Chinese Medical University, Hangzhou, China
| | - Junfan Fang
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaomei Shao
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaoqing Jin
- Department of Acupuncture, Zhejiang Hospital, Hangzhou, China
- *Correspondence: Xiaoqing Jin
| | - Jianqiao Fang
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
- Jianqiao Fang
| | - Boyi Liu
- Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Department of Neurobiology and Acupuncture Research, The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
- Boyi Liu
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Moore E, Braithwaite FA, Stanton TR, Bellan V, Moseley GL, Berryman C. What do I need to know? Essential educational concepts for complex regional pain syndrome. Eur J Pain 2022; 26:1481-1498. [PMID: 35598314 PMCID: PMC9542775 DOI: 10.1002/ejp.1976] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/01/2022] [Accepted: 05/07/2022] [Indexed: 11/12/2022]
Abstract
Background Methods Results Conclusion Significance
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Affiliation(s)
- E. Moore
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - F. A. Braithwaite
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - T. R. Stanton
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - V. Bellan
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
| | - G. L. Moseley
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
- Neuroscience Research Australia, Randwick Sydney Australia
| | - C. Berryman
- IIMPACT in Health The University of South Australia Kaurna Country Adelaide Australia
- Brain Stimulation, Imaging and Cognition Group School of Medicine The University of Adelaide, Kaurna Country Adelaide Australia
- Corresponding author. Carolyn Berryman, Level 7 Centenary Building University of South Australia Kaurna Country, Adelaide, Australia, 5005
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Johnson EM, Yoon D, Biswal S, Curtin C, Fox P, Wilson TJ, Carroll I, Lutz A, Tawfik VL. Characteristics of Patients With Complex Limb Pain Evaluated Through an Interdisciplinary Approach Utilizing Magnetic Resonance Neurography. FRONTIERS IN PAIN RESEARCH (LAUSANNE, SWITZERLAND) 2022; 2:689402. [PMID: 35295513 PMCID: PMC8915577 DOI: 10.3389/fpain.2021.689402] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/06/2021] [Indexed: 12/24/2022]
Abstract
Patients with persistent complex limb pain represent a substantial diagnostic challenge. Physical exam, and tests such as nerve conduction, are often normal even though the patient suffers from severe pain. In 2015, we initiated a team-based approach to evaluate such patients. The approach included physicians from several specialties (Anesthesiology/Pain Medicine, Radiology, Plastic Surgery, Neurosurgery) combined with the use of advanced imaging with Magnetic Resonance Neurography (MRN). This preliminary case series discusses MRN findings identified in patients with previously difficult-to-diagnose peripheral limb pain and describes how this combination of approaches influenced our diagnosis and treatment plans. We extracted demographics, patient characteristics, presenting features, diagnostic tests performed, treatments provided, referral diagnosis and the diagnosis after interdisciplinary team evaluation from patient charts. We evaluated MRN and electrodiagnostic studies (EDX) ability to identify injured nerves. We compared abnormal findings from these diagnostics to patient reported outcome after ultrasound-guided nerve block. A total of 58 patients, 17 males and 41 females, were identified. The majority of patients presented with lower extremity pain (75%) and had prior surgery (43%). The most commonly identified abnormality on MRN was nerve signal alteration on fluid sensitive sequences, followed by caliber change and impingement. Comparing the outcome of diagnostic nerve blocks with abnormal nerve findings on MRN or EDX, we found that MRN had a sensitivity of 67% and specificity of 100% while for EDX it was 45 and 0%, respectively. After interdisciplinary discussion and imaging review, a more specific diagnosis was produced in 78% of evaluated cases opening up additional treatment pathways such as nerve-targeted surgery, which was performed in 36% cases. This descriptive case series demonstrates that a majority of patients evaluated by our team for complex limb pain were women with lower extremity pain resulting from surgery. In addition, an interdisciplinary team evaluation and the use of the moderately sensitive but highly specific MRN imaging modality resulted in a change in diagnosis for a majority of patients with complex limb pain. Future studies investigating patient outcomes after diagnosis change are currently underway based on the findings of this preliminary study.
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Affiliation(s)
- Emily M Johnson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Daehyun Yoon
- Department of Radiology/Musculoskeletal Imaging, Stanford University School of Medicine, Stanford, CA, United States
| | - Sandip Biswal
- Department of Radiology/Musculoskeletal Imaging, Stanford University School of Medicine, Stanford, CA, United States
| | - Catherine Curtin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Paige Fox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Thomas J Wilson
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Ian Carroll
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
| | - Amelie Lutz
- Department of Radiology/Musculoskeletal Imaging, Stanford University School of Medicine, Stanford, CA, United States
| | - Vivianne L Tawfik
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, United States
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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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Simonyan AS, Tyurnikov VM, Simonyan AD, Gushcha AO. Epidural unilateral stimulation with "adaptive stim" option in treatment of type II CRPS. Clin Case Rep 2022; 10:e05305. [PMID: 35079397 PMCID: PMC8777047 DOI: 10.1002/ccr3.5305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/14/2021] [Accepted: 11/18/2021] [Indexed: 11/12/2022] Open
Abstract
CRPS is a type of severe pain syndrome and can be triggered by previous surgery or trauma. CRPS involves vasomotor changes such as changes in color and temperature of the skin, edema, increased sensitivity to touch, and a limited range of movement. Depending on the presence of nerve damage, CRPS is divided into two types. CRPS type II is associated with a confirmed peripheral nerve injury, while CRPS type I is not associated with an apparent peripheral nerve injury. Despite the ongoing therapy, sometimes, patients still have persistent, burning pain. Intractable CRPS that fail more conservative treatments may undergo neuromodulation. We want to present to your attention a case report of the successful treatment of a patient with CRPS type II using epidural unilateral stimulation. The 44-year-old woman came to us with complaints of burning pain and numbness of 1-3 fingers of the right hand, the lateral surface of the right wrist, and lower quarter of the forearm, and shooting pain in the projection of the right median nerve from the shoulder to the wrist. A clinical diagnosis was made-CRPS type II. During the stimulation trial, the most effective pain relief was obtained when the electrode was located in the right side of epidural space at the C4-Th1 level. The implantation of a pulse generator was performed, and the final selection of the stimulation parameters was carried out (Pulse width: 60 ms, Rate: 210 Hz, and Amplitude: 0.9-1.6 V). The severity of pain syndrome was measured using validated scales in the preoperative period (VAS: 8-9, Pain Detect: 22, NTSS-9: 4.62, and DN4: 8), in the early postoperative period (VAS: 0-1, Pain Detect: 6, NTSS -9: 0.66, and DN4: 1), and after 12 months (VAS: 0-2, Pain Detect: 6, NTSS-9: 0.99, and DN4: 1). Observation during 12 months showed that a stable analgesic effect of neurostimulation was achieved using standard neuromodulation regimens and the adaptive stim option. Unilateral stimulation is an effective type of SCS in the treatment of pain syndromes. adaptive stim is usually not applicable for lead implantation at the cervical level. Nevertheless, the rational use of stimulation at threshold values allowed our patient to use adaptive stim in a non-standard situation.
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Kindl G, Teichmüller K, Escolano-Lozano F, Birklein F, Rittner HL. Pain, disability, and lifestyle: Patients with complex regional pain syndrome compared to chronic musculoskeletal pain - a retrospective analysis. Eur J Pain 2021; 26:719-728. [PMID: 34958709 DOI: 10.1002/ejp.1900] [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: 07/13/2021] [Revised: 10/11/2021] [Accepted: 12/19/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is an orphan disease occurring as a complication after trauma. Due to its acute onset and the typical clinical presentation of the inflammatory and autonomous signs, it is an eye-catching chronic pain disease affecting also young and working people. In social media and the internet, high pain severity and unfavorable prognosis is often empathized. METHODS Here, we compared epidemiological, pain and lifestyle factors of 223 CPRS patients from the "ncRNAPain" cohort with 255 patients with chronic musculoskeletal pain (MSK). MSK patients were recruited at the beginning of a multimodal pain therapy program. We searched for factors predicting pain intensity. RESULTS Both chronic pain diseases affected women in middle age. Patients with MSK were more obese, drank more alcohol and were less educated (Pearson Chi-square Test or Mann-Whitney/U-Test). Both groups smoked more than healthy people in the OECD (Organization for Economic Cooperation and Development). Mann-Whitney/U-Test confirmed that CRPS patients did not have more severe pain and did not suffer more from pain-related disability than patients with MSK. CRPS patients also had less psychiatric comorbidities. Multiple linear regression analysis revealed that group assignment, depressive characteristics, body mass index, average alcohol consumption and smoking predicted higher pain ratings, while disease duration, anxiety symptoms or gender had no influence on pain intensity. CONCLUSION In summary our study supports a more optimistic view on pain in CRPS patients in comparison to MSK and identifies lifestyle factors which might contribute to the pathophysiology like smoking and drinking. Important next steps are the identification of CRPS patients at risk for chronification or - vice versa - with protective factors for pain resolution.
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Affiliation(s)
- Gudrun Kindl
- Center for Interdisciplinary Pain Medicine, Department of Anesthesiology, University Hospital of Würzburg, Würzburg, Germany
| | - Karolin Teichmüller
- Center for Interdisciplinary Pain Medicine, Department of Anesthesiology, University Hospital of Würzburg, Würzburg, Germany
| | | | - Frank Birklein
- Department of Neurology, University Hospital of Mainz, Mainz, Germany
| | - Heike L Rittner
- Center for Interdisciplinary Pain Medicine, Department of Anesthesiology, University Hospital of Würzburg, Würzburg, Germany
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Taylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, Carlson T, Myrcik D, Varrassi G, Viswanath O. Complex Regional Pain Syndrome: A Comprehensive Review. Pain Ther 2021; 10:875-892. [PMID: 34165690 PMCID: PMC8586273 DOI: 10.1007/s40122-021-00279-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 06/03/2021] [Indexed: 12/22/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain condition often involving hyperalgesia and allodynia of the extremities. CRPS is divided into CRPS-I and CRPS-II. Type I occurs when there is no confirmed nerve injury. Type II is when there is known associated nerve injury. Female gender is a risk factor for developing CRPS. Other risk factors include fibromyalgia and rheumatoid arthritis. Unfortunately, the pathogenesis of CRPS is not yet clarified. Some studies have demonstrated different potential pathways. Neuropathic inflammation, specifically activation of peripheral nociceptors of C-fibers, has been shown to play a critical role in developing CRPS. The autonomic nervous system (ANS) is involved. Depending on whether it is acute or chronic CRPS, norepinephrine levels are either decreased or increased, respectively. Some studies have suggested the importance of genetics in developing CRPS. More consideration is being given to the role of psychological factors. Some association between a history of depression and/or post-traumatic stress disorder (PTSD) and the diagnosis of CRPS has been demonstrated. Treatment modalities available range from physical therapy, pharmacotherapy, and interventional techniques. Physical and occupational therapies include mirror therapy and graded motor imagery. Medical management with non-steroidal anti-inflammatory drugs (NSAIDs) has not shown significant improvement. There have been supporting findings in the use of short-course steroids, bisphosphonates, gabapentin, and ketamine. Antioxidant treatment has also shown some promise. Other pharmacotherapies include low-dose naltrexone and Botulinum toxin A (BTX-A). Sympathetic blocks are routinely used, even if their short- and long-term effects are not clear. Finally, spinal cord stimulation (SCS) has been used for decades. In conclusion, CRPS is a multifactorial condition that still requires further studying to better understand its pathogenesis, epidemiology, genetic involvement, psychological implications, and treatment options. Future studies are warranted to better understand this syndrome. This will provide an opportunity for better prevention, diagnosis, and treatment of CRPS.
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Affiliation(s)
- Samantha-Su Taylor
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Nazir Noor
- Department of Anesthesiology, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33130, USA.
| | - Ivan Urits
- grid.492905.3Southcoast Physician Group Pain Medicine, Southcoast Health, North Dartmouth, MA USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA
| | - Antonella Paladini
- grid.158820.60000 0004 1757 2611Department of MESVA, University of L’Aquila, 67100 L’Aquila, Italy
| | - Monica Sri Sadhu
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Clay Gibb
- grid.260024.2Midwestern University Chicago College of Osteopathic Medicine, Chicago, IL USA
| | - Tyler Carlson
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA
| | - Dariusz Myrcik
- grid.411728.90000 0001 2198 0923Department of Internal Medicine, Medical University of Silesia, 42-600 Katowice, Bytom Poland
| | | | - Omar Viswanath
- grid.134563.60000 0001 2168 186XUniversity of Arizona College of Medicine-Phoenix, Phoenix, AZ USA ,grid.64337.350000 0001 0662 7451Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA USA ,Valley Pain Consultants-Envision Physician Services, Phoenix, AZ USA ,grid.254748.80000 0004 1936 8876Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE USA
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Kwak SG, Choo YJ, Chang MC. Effectiveness of prednisolone in complex regional pain syndrome treatment: A systematic narrative review. Pain Pract 2021; 22:381-390. [PMID: 34779145 DOI: 10.1111/papr.13090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/06/2021] [Accepted: 11/08/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Many patients with complex regional pain syndrome (CRPS) experience refractory pain with severe restrictions in the activities of daily living. Oral prednisolone is commonly used to treat these patients. PURPOSE To review previous studies assessing the effects of prednisolone in CRPS patients. METHODS AND MATERIALS Articles published from January 1, 1980 to July 23, 2021 in the PubMed database were searched using the following key phrases: (prednisolone OR corticosteroid OR steroid) AND (complex regional pain syndrome OR reflex sympathetic dystrophy OR shoulder-hand syndrome OR causalgia). Specifically, we included those articles in which oral prednisolone or corticosteroids were used to control the CRPS symptoms. RESULTS In total, 11 articles were included, comprising 3 randomized trials, 5 single-arm prospective observational studies, and 3 retrospective studies. Nearly all previous studies reported that oral prednisolone can effectively control the CRPS symptoms. Moreover, though 30-100 mg/day of oral prednisolone was initially administered in these studies, 30 mg/day was also found to be effective in controlling the symptoms. Although prednisolone was usually administered for 1-3 months, short-term treatment for 1-2 weeks was also reportedly effective. Furthermore, only 0%-30% of the patients in these studies had minor side effects after prednisolone treatment. CONCLUSIONS Our review showed that prednisolone may be effective in alleviating the CRPS symptoms. To determine higher levels of evidence, a full systematic review with more highly qualified studies, such as randomized controlled trials, should be conducted in the future.
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Affiliation(s)
- Sang Gyu Kwak
- Department of Medical Statistics, College of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Yoo Jin Choo
- Production R&D Division Advanced Interdisciplinary Team, Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation, Daegu, Korea
| | - Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Korea
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Algoneurodystrophy in a Patient with Major Depressive Disorder. Case Rep Psychiatry 2021; 2021:9981521. [PMID: 34664021 PMCID: PMC8520495 DOI: 10.1155/2021/9981521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 09/13/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction. Not infrequently, in patients with a psychiatric illness who have concomitant physical symptoms, these symptoms are often wrongly attributed to a psychiatric illness. Consequently, there is a delay in establishing the correct diagnosis, which may have an impact on the prognosis of the disease. The authors aim to present a case report of a patient with a diagnosis of major depressive disorder and conversion disorder that was later correctly diagnosed with algoneurodystrophy. The authors intend to draw attention to the importance of a careful medical history and this entity. Case Presentation. A patient went to the emergency department multiple times with complaints of decreased strength and pain in the right upper limb, concomitantly with depressive symptoms. The patient was first diagnosed with conversion disorder and major depressive disorder. After the worsening of the clinical condition with the appearance of neuropathic pain and the exclusion of other organic pathologies, the probable diagnosis of algoneurodystrophy was made. At that time, the patient started treatment and a favorable clinical evolution was observed. Discussion. The clinical case highlights the importance of conducting a careful medical history in a patient with a psychiatric illness, so as not to mistakenly exclude the presence of an organic disease. The absence or delay in making a correct diagnosis can have adverse consequences in terms of the prognosis of the disease.
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Allen Demers F, Zangrandi A, Schneider C. Theta-Burst Stimulation of Forearm Muscles in Patients With Complex Regional Pain Syndrome: Influence on Brain and Clinical Outcomes. FRONTIERS IN PAIN RESEARCH 2021; 2:736806. [PMID: 35295471 PMCID: PMC8915654 DOI: 10.3389/fpain.2021.736806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 08/16/2021] [Indexed: 11/30/2022] Open
Abstract
Objective: Complex regional pain syndrome (CRPS) is a common pain condition characterized by the changes in the brain that are not yet addressed by conventional treatment regimens. Repetitive peripheral magnetic stimulation (rPMS) of muscles is painless and non-invasive and can influence these changes (the induction of brain plasticity) to reduce pain and improve motricity. In patients with CRPS, this open-label pilot study tested rPMS after-effects on the pain intensity and sensorimotor control of the upper limb along with the excitability changes of the primary motor cortex (M1). Methods: Eight patients with CRPS were enrolled in a single-session program. Patients were tested at pre- and post-rPMS over the flexor digitorum superficialis (FDS) muscle. The clinical outcomes were pain intensity, proprioception, active range of motion (ROM), and grip strength. M1 excitability was tested using the single- and paired-pulse transcranial magnetic stimulation (TMS) of M1. Results: In our small sample study, rPMS reduced instant and week pain, improved proprioception and ROM, and reduced the hemispheric imbalance of several TMS outcomes. The more M1 contralateral to the CRPS side was hyperactivated at baseline, the more pain was reduced. Discussion: This open-label pilot study provided promising findings for the use of rPMS in CRPS with a focus on M1 plastic changes. Future randomized, placebo-controlled clinical trials should confirm the existence of a causal relationship between the TMS outcomes and post-rPMS decrease of pain. This will favor the development of personalized treatments of peripheral non-invasive neurostimulation in CRPS.
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Affiliation(s)
- Fannie Allen Demers
- Noninvasive Stimulation Laboratory (NovaStim), Quebec City, QC, Canada
- Neuroscience Division of Centre de Recherche du CHU of Québec – Université Laval, Quebec City, QC, Canada
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Andrea Zangrandi
- Noninvasive Stimulation Laboratory (NovaStim), Quebec City, QC, Canada
- Neuroscience Division of Centre de Recherche du CHU of Québec – Université Laval, Quebec City, QC, Canada
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Cyril Schneider
- Noninvasive Stimulation Laboratory (NovaStim), Quebec City, QC, Canada
- Neuroscience Division of Centre de Recherche du CHU of Québec – Université Laval, Quebec City, QC, Canada
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
- Department of Rehabilitation, Université Laval, Quebec City, QC, Canada
- *Correspondence: Cyril Schneider
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Zangrandi A, Allen Demers F, Schneider C. Complex Regional Pain Syndrome. A Comprehensive Review on Neuroplastic Changes Supporting the Use of Non-invasive Neurostimulation in Clinical Settings. FRONTIERS IN PAIN RESEARCH 2021; 2:732343. [PMID: 35295500 PMCID: PMC8915550 DOI: 10.3389/fpain.2021.732343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Complex regional pain syndrome (CRPS) is a rare debilitating disorder characterized by severe pain affecting one or more limbs. CRPS presents a complex multifactorial physiopathology. The peripheral and sensorimotor abnormalities reflect maladaptive changes of the central nervous system. These changes of volume, connectivity, activation, metabolism, etc., could be the keys to understand chronicization, refractoriness to conventional treatment, and developing more efficient treatments. Objective: This review discusses the use of non-pharmacological, non-invasive neurostimulation techniques in CRPS, with regard to the CRPS physiopathology, brain changes underlying chronicization, conventional approaches to treat CRPS, current evidence, and mechanisms of action of peripheral and brain stimulation. Conclusion: Future work is warranted to foster the evidence of the efficacy of non-invasive neurostimulation in CRPS. It seems that the approach has to be individualized owing to the integrity of the brain and corticospinal function. Non-invasive neurostimulation of the brain or of nerve/muscles/spinal roots, alone or in combination with conventional therapy, represents a fertile ground to develop more efficient approaches for pain management in CRPS.
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Affiliation(s)
- Andrea Zangrandi
- Noninvasive Neurostimulation Laboratory (NovaStim), Quebec City, QC, Canada
- Neuroscience Division of Centre de Recherche du CHU of Québec, Université Laval, Quebec City, QC, Canada
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Fannie Allen Demers
- Noninvasive Neurostimulation Laboratory (NovaStim), Quebec City, QC, Canada
- Neuroscience Division of Centre de Recherche du CHU of Québec, Université Laval, Quebec City, QC, Canada
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Cyril Schneider
- Noninvasive Neurostimulation Laboratory (NovaStim), Quebec City, QC, Canada
- Neuroscience Division of Centre de Recherche du CHU of Québec, Université Laval, Quebec City, QC, Canada
- Faculty of Medicine, Université Laval, Quebec City, QC, Canada
- Department Rehabilitation, Université Laval, Quebec City, QC, Canada
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Groenveld TD, Boersma EZ, Blokhuis TJ, Bloemers FW, Frölke JPM. Decreasing incidence of complex regional pain syndrome in the Netherlands: a retrospective multicenter study. Br J Pain 2021; 16:214-222. [PMID: 35419200 PMCID: PMC8998521 DOI: 10.1177/20494637211041935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Complex regional pain syndrome type I (CRPS) is a symptom-based diagnosis of which the reported incidence varies widely. In daily practice, there appears to be a decrease in incidence of CRPS after a distal radius fracture and in general. Questions/purposes: The aim of this study was to assess the trend in the incidence of CRPS after a distal radius fracture and in general in the Netherlands from 2014 to 2018. Methods: The incidence of CRPS after a distal radius fracture was calculated by dividing the number of confirmed cases of CRPS after distal radius fracture by the total number of patients diagnosed with a distal radius fracture. Medical records of these patients were reviewed. Hospital-based data were used to establish a trend in incidence of CRPS in general. A Dutch national database was used to measure the trend in the incidence of CRPS in the Netherlands by calculating annual incidence rates: the number of new CRPS cases, collected from the national database, divided by the Dutch mid-year population. Results: The incidence of CRPS after distal radius fracture over the whole study period was 0.36%. Hospital data showed an absolute decrease in CRPS cases from 520 in 2014 to 223 in 2018. National data confirmed this with a decrease in annual incidence from 23.2 (95% CI: 22.5–23.9) per 100,000 person years in 2014 to 16.1 (95% CI: 15.5–16.7) per 100,000 person years in 2018. Conclusion: A decreasing trend of CRPS is shown in this study. We hypothesize this to be the result of the changing approach towards CRPS and fracture management, with more focus on prevention and the psychological aspects of disproportionate posttraumatic pain. Level of Evidence: level 3 (retrospective cohort study).
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Affiliation(s)
- Tjitske D Groenveld
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Emily Z Boersma
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Taco J Blokhuis
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Jan Paul M Frölke
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Nicolaides M, Pafitanis G, Vris A. Open tibial fractures: An overview. J Clin Orthop Trauma 2021; 20:101483. [PMID: 34262849 PMCID: PMC8254044 DOI: 10.1016/j.jcot.2021.101483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/06/2021] [Accepted: 06/19/2021] [Indexed: 12/31/2022] Open
Abstract
Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.
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Affiliation(s)
- Marios Nicolaides
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Georgios Pafitanis
- Group for Academic Plastic Surgery, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Plastic and Reconstructive Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexandros Vris
- Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Trauma and Orthopaedic Surgery, The Royal London Hospital, Barts Health NHS Trust, London, UK
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Truffyn EE, Moayedi M, Brown SC, Ruskin D, Duerden EG. Sensory Function and Psychological Factors in Children With Complex Regional Pain Syndrome Type 1. J Child Neurol 2021; 36:823-830. [PMID: 33882728 PMCID: PMC8438776 DOI: 10.1177/08830738211007685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess thermal-sensory thresholds and psychosocial factors in children with Complex Regional Pain Syndrome Type 1 (CRPS-I) compared to healthy children. METHODS We conducted quantitative sensory testing on 34 children with CRPS-I and 56 pain-free children. Warm, cool, heat, and cold stimuli were applied to the forearm. Children with CRPS-I had the protocol administered to the pain site and the contralateral-pain site. Participants completed the self-report Behavior Assessment System for Children. RESULTS Longer pain durations (>5.1 months) were associated with decreased sensitivity to cold pain on the pain site (P = .04). Higher pain-intensity ratings were associated with elevated anxiety scores (P = .03). Anxiety and social stress were associated with warmth sensitivity (both P < .05) on the contralateral-pain site. CONCLUSIONS Pain duration is an important factor in assessing pediatric CRPS-I. Hyposensitivity in the affected limb may emerge due to degeneration of nociceptive nerves. Anxiety may contribute to thermal-sensory perception in childhood CRPS-I.
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Affiliation(s)
- Emma E. Truffyn
- Applied Psychology, Western University, London, Ontario, Canada
| | - Massieh Moayedi
- Centre for Multimodal Sensorimotor and Pain Research, University of Toronto, Toronto, Ontario, Canada
| | - Stephen C. Brown
- Department of Anaesthesia and Pain Medicine, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada
| | - Danielle Ruskin
- Centre for Multimodal Sensorimotor and Pain Research, University of Toronto, Toronto, Ontario, Canada
| | - Emma G. Duerden
- Applied Psychology, Western University, London, Ontario, Canada
- Children’s Health Research Institute, London, Ontario, Canada
- Emma G. Duerden, PhD, Applied Psychology, Faculty of Education, 1137 Western Rd, London, Ontario, Canada N6G 1G7.
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Magone KM, Ben-Ari E, Hacquebord JH, Virk MS. Complex Region Pain Syndrome Following Shoulder Surgery. Arthrosc Sports Med Rehabil 2021; 3:e1037-e1045. [PMID: 34430883 PMCID: PMC8365219 DOI: 10.1016/j.asmr.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/14/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To describe the clinical features, treatment, and outcomes in patients with complex region pain syndrome (CRPS) following shoulder surgeries. Methods Three patients were diagnosed with CRPS according to the Budapest criteria. Patients were followed up prospectively at regular intervals for a minimum of 2 years. Demographic data, clinical symptoms, physical examination findings, treatment received, and outcomes were collected and reported. Results The minimum time interval between surgery and diagnosis was 3 weeks (average, 8 weeks). The index procedures included 2 arthroscopic rotator cuff repairs and 1 open Latarjet. Neurologic pain, muscle spasms, hand and wrist swelling, and joint stiffness were seen in the shoulder, wrist, and hand, but the elbow was spared in all patients. Despite the use of multimodal treatment modalities, the symptoms were refractory to treatment for prolonged periods (range, 6-12 months). Hand and wrist symptoms took an average of 4 months longer than shoulder symptoms to improve. At the latest follow-up (range, 24-26 months), varying degrees of residual hand dysfunction, pain, and inability to make a fist or fully extend the fingers were noted in all 3 patients. Conclusions CPRS type 1 following shoulder surgery is a disabling condition with a long-protracted clinical course. CRPS can present as early as few weeks after shoulder surgery, with symptoms of neuropathic pain, spasm, and stiffness affecting the entire upper-extremity joints except the elbow. CRPS symptoms resolve earlier in the shoulder compared with the wrist and hand, with pain improving first, followed by recovery of motion and function. Residual stiffness affecting grip function is last to recover and can present up to 2 years after onset of symptoms. Although prompt recognition and multimodal approach are considered the mainstay of treatment, there is no gold standard treatment modality that can reproducibly alter the natural history of CRPS. Level of Evidence IV, therapeutic case series.
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Affiliation(s)
- Kevin M. Magone
- Divisions of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, U.S.A
| | - Erel Ben-Ari
- Divisions of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, U.S.A
| | - Jacques H. Hacquebord
- Hand Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, U.S.A
| | - Mandeep S. Virk
- Divisions of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, U.S.A
- Address correspondence to Mandeep S. Virk, M.D., Assistant Professor, Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, NYU Grossman School of Medicine, NYU Langone Orthopedic Hospital, NYU Langone Health, 246 E 20th St., New York, NY 10003.
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Raja SN, Buvanendran A, Marcondes L. Complex Regional Pain Syndrome: A Comprehensive Qualitative Research Study on Unmet Needs in the "Patient Journey". J Pain Res 2021; 14:2391-2401. [PMID: 34408484 DOI: 10.2147/jpr.s317648] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/15/2021] [Indexed: 12/26/2022] Open
Abstract
Purpose This qualitative research study aimed to characterize the "patient journey" for patients with complex regional pain syndrome (CRPS) and identify the unmet needs related to the management and treatment of the condition for healthcare providers (HCPs), patients, and their caregivers. Materials and Methods Multifaceted, dynamic methodology, iteratively gathering cognitive, emotional and social insights, was used to support and conduct in-depth, immersion interviews across the USA with 59 HCPs in-office and in roundtable discussions, and 20 patient-support partner dyads in-home. Results Patients were aged >18 years, primarily female, and all were diagnosed with CRPS (limited to type 1 in this patient cohort). Results show that the current state of CRPS treatment may fall short in multiple key areas. In some cases, poor awareness of CRPS causes delayed diagnoses impacting the opportunity for early treatment, resulting in long-term poor health outcomes. Consequently, the CRPS "patient journey" may be characterized by clinical frustration of physicians and disappointment for some patients. The poor treatment experiences and outcomes for some patients and HCPs may build the perception of a non-collaborative relationship. HCPs and patients agree that an effective treatment would be one that addresses CRPS rather than its symptoms, and the availability of such an option would transform the treatment experience. Conclusion CRPS leads to cognitive, social and emotional burdens for patients and their caregivers. There is an unmet need for improved CRPS disease awareness and successful therapeutic options to aid in earlier diagnoses, effective treatment and better outcomes for HCPs, patients, and their caregivers.
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Affiliation(s)
- Srinivasa N Raja
- Anesthesiology & Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Asokumar Buvanendran
- William Gottschalk, Endowed Chair of Anesthesiology, Rush University Medical Center, Chicago, IL, USA
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Sabourin S, Tram J, Sheldon BL, Pilitsis JG. Defining minimal clinically important differences in pain and disability outcomes of patients with chronic pain treated with spinal cord stimulation. J Neurosurg Spine 2021; 35:243-250. [PMID: 34087802 DOI: 10.3171/2020.11.spine201431] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 11/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Minimal clinically important difference (MCID) thresholds for a limited number of outcome metrics were previously defined for patients with failed back surgery syndrome (FBSS) at 6 months after spinal cord stimulation (SCS). This study aimed to further define MCID values for pain and disability outcomes. Additionally, the authors established 1-year MCID values for outcome measures with previously defined metrics commonly used to assess SCS efficacy. METHODS Preoperative and 1-year postoperative outcomes were collected from 114 patients who received SCS therapy for FBSS, complex regional pain syndrome, and neuropathic pain. MCID values were established for the numerical rating scale (NRS), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), McGill Pain Questionnaire (MPQ), and Pain Catastrophizing Scale (PCS). Four established anchor-based methods were utilized to compute MCID values with two anchored questions: "Are you satisfied with SCS therapy?" and "Would you have SCS surgery again?" For each question, patients were categorized as responders if they answered "yes" or as nonresponders if they responded "no." The methodologies utilized to compute MCID scores included the average change method, minimum detectable change approach, change difference calculation, and receiver operating characteristic (ROC) analysis. Area under the ROC curve (AUC) analysis has been shown to inform the accuracy at which the MCID value can distinguish responders from nonresponders and was analyzed for each instrument. RESULTS For the first time, ranges of MCID values after SCS were established for MPQ (1-2.3) and PCS (1.9-13.6). One-year MCID values were defined for all indications: NRS (range 0.9-2.7), ODI (3.5-6.9), and BDI (2-5.9). AUC values were significant for NRS (0.78, p < 0.001), ODI (0.71, p = 0.003), MPQ (0.74, p < 0.001), and PCS (0.77, p < 0.001), indicating notable accuracy for distinguishing satisfied patients. CONCLUSIONS This was the first study to successfully determine MCID values for two prominent instruments, MPQ and PCS, used to assess pain after SCS surgery. Additionally, previously established MCID values for ODI, BDI, and the visual analog scale for patients with FBSS at 6 months after treatment were explored at 12 months for the most common indications for SCS. These data may better inform physicians of patient response to and success with SCS therapy.
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Affiliation(s)
- Shelby Sabourin
- Departments of1Neuroscience and Experimental Therapeutics, and
| | - Justin Tram
- Departments of1Neuroscience and Experimental Therapeutics, and
| | | | - Julie G Pilitsis
- Departments of1Neuroscience and Experimental Therapeutics, and
- 2Neurosurgery, Albany Medical Center, Albany, New York
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Emami SA, Majedi H, Espahbodi E, Sanatkar M. Bier block as a successful management of a patient with intractable complex regional pain syndrome (CRPS) type 1: A case report. Clin Case Rep 2021; 9:e04554. [PMID: 34306705 PMCID: PMC8294144 DOI: 10.1002/ccr3.4554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/03/2021] [Accepted: 06/16/2021] [Indexed: 11/10/2022] Open
Abstract
Bier block was successful in the pain management of complex regional pain syndrome (CRPS) type 1.
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Affiliation(s)
- Seyed Ali Emami
- Anesthesiology and Pain DepartmentImam Khomeini Medical CenterTehran University of Medical SciencesTehranIran
- Neuroscience Research CentreNeuroscience InstituteTehran University of Medical SciencesTehranIran
| | - Hossein Majedi
- Anesthesiology and Pain DepartmentImam Khomeini Medical CenterTehran University of Medical SciencesTehranIran
- Neuroscience Research CentreNeuroscience InstituteTehran University of Medical SciencesTehranIran
| | - Ebrahim Espahbodi
- Anesthesiology and Pain DepartmentImam Khomeini Medical CenterTehran University of Medical SciencesTehranIran
- Neuroscience Research CentreNeuroscience InstituteTehran University of Medical SciencesTehranIran
| | - Mehdi Sanatkar
- Anesthesiology and Pain DepartmentImam Khomeini Medical CenterTehran University of Medical SciencesTehranIran
- Neuroscience Research CentreNeuroscience InstituteTehran University of Medical SciencesTehranIran
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42
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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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43
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Canever JB, Barbosa RI, Hendler KG, Neves LMSD, Kuriki HU, Júnior ASA, Fonseca MDCR, Marcolino AM. Effects of photobiomodulation on different application points and different phases of complex regional pain syndrome type I in the experimental model. Korean J Pain 2021; 34:250-261. [PMID: 34193632 PMCID: PMC8255157 DOI: 10.3344/kjp.2021.34.3.250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/17/2021] [Accepted: 04/17/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Complex regional pain syndrome type I (CRPS-I) consists of disorders caused by spontaneous pain or induced by some stimulus. The objective was to verify the effects of photobiomodulation (PBM) using 830 nm wavelength light at the affected paw and involved spinal cord segments during the warm or acute phase. METHODS Fifty-six mice were randomized into seven groups. Group (G) 1 was the placebo group; G2 and G3 were treated with PBM on the paw in the warm and acute phase, respectively; G4 and G5 treated with PBM on involved spinal cord segments in the warm and acute phase, respectively; G6 and G7 treated with PBM on paw and involved spinal cord segments in the warm and acute phase, respectively. Edema degree, thermal and mechanical hyperalgesia, skin temperature, and functional quality of gait (Sciatic Static Index [SSI] and Sciatic Functional Index [SFI]) were evaluated. RESULTS Edema was lower in G3 and G7, and these were the only groups to return to baseline values at the end of treatment. For thermal hyperalgesia only G3 and G5 returned to baseline values. Regarding mechanical hyperalgesia, the groups did not show significant differences. Thermography showed increased temperature in all groups on the seventh day. In SSI and SFI assessment, G3 and G7 showed lower values when compared to G1, respectively. CONCLUSIONS PBM irradiation in the acute phase and in the affected paw showed better results in reducing edema, thermal and mechanical hyperalgesia, and in improving gait quality, demonstrating efficacy in treatment of CRPS-I symptoms.
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Affiliation(s)
- Jaquelini Betta Canever
- Laboratory of Assesment and Rehabilitation of the Locomotor Apparatus, Department of Health Sciences, Center Araranguá, Federal University of Santa Catarina, Araranguá, Brazil
| | - Rafael Inácio Barbosa
- Laboratory of Assesment and Rehabilitation of the Locomotor Apparatus, Department of Health Sciences, Center Araranguá, Federal University of Santa Catarina, Araranguá, Brazil
- Postgraduate Program in Rehabilitation Sciences, Federal University of Santa Catarina, Araranguá, Brazil
| | - Ketlyn Germann Hendler
- Laboratory of Assesment and Rehabilitation of the Locomotor Apparatus, Department of Health Sciences, Center Araranguá, Federal University of Santa Catarina, Araranguá, Brazil
- Postgraduate Program in Rehabilitation Sciences, Federal University of Santa Catarina, Araranguá, Brazil
| | - Lais Mara Siqueira das Neves
- Laboratory of Assesment and Rehabilitation of the Locomotor Apparatus, Department of Health Sciences, Center Araranguá, Federal University of Santa Catarina, Araranguá, Brazil
- Postgraduate Program in Rehabilitation and Functional Performance of the Departament of Health Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Heloyse Uliam Kuriki
- Laboratory of Assesment and Rehabilitation of the Locomotor Apparatus, Department of Health Sciences, Center Araranguá, Federal University of Santa Catarina, Araranguá, Brazil
- Postgraduate Program in Rehabilitation Sciences, Federal University of Santa Catarina, Araranguá, Brazil
| | | | - Marisa de Cassia Registro Fonseca
- Postgraduate Program in Rehabilitation and Functional Performance of the Departament of Health Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, Brazil
| | - Alexandre Márcio Marcolino
- Laboratory of Assesment and Rehabilitation of the Locomotor Apparatus, Department of Health Sciences, Center Araranguá, Federal University of Santa Catarina, Araranguá, Brazil
- Postgraduate Program in Rehabilitation Sciences, Federal University of Santa Catarina, Araranguá, Brazil
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Cox D, McParland JL, Jordan A. Parenting an adolescent with complex regional pain syndrome: A dyadic qualitative investigation of resilience. Br J Health Psychol 2021; 27:194-214. [PMID: 34085746 DOI: 10.1111/bjhp.12541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 05/05/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Adolescent chronic pain exists within a social context, affecting the lives of adolescents, parents, peers, and wider family members. Typically, parental research has focussed on the negative impact on parents associated with parenting an adolescent with chronic pain. However, a small number of studies have identified positive parental outcomes and functioning, with a focus on parental resilience. This study sought to extend existing knowledge by providing a detailed and contextualized understanding of how parental dyads experience and demonstrate resilience in response to parenting an adolescent with Complex Regional Pain Syndrome (CRPS) and the meaning that parents ascribe to these shared experiences. DESIGN An Interpretative Phenomenological Analysis (IPA) was used to conduct an in-depth qualitative interview study of parents of an adolescent with CRPS. METHODS Semi-structured interviews were conducted via Skype with eight mother-father parental dyads of an adolescent aged 11-25 years with CRPS. RESULTS A single prominent theme 'masking reality in the face of pain' dominated the parental discourse and experience of resilience. Resilience was experienced as an incongruence between private distress and the perceived obligation to display socially desirable resilience behaviours to protect their child from their own distress. CONCLUSIONS Study findings highlight the benefits of strength-based interventions to enhance parental resilience. This is particularly important since parental behaviours have been shown to influence child pain outcomes. Future research should seek to explore resilience in different populations such as lone parents, siblings, and those parenting an adolescent with pain conditions other than CRPS.
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Affiliation(s)
- Danielle Cox
- Department of Psychology, Claverton Down, University of Bath, Bath, UK
| | - Joanna L McParland
- Department of Psychology, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Abbie Jordan
- Department of Psychology and Centre for Pain Research, Claverton Down, University of Bath, Bath, UK
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Marton N, Ramos-Oliver I, Cajal AG, de Albert M, Dominguez Oronoz R. Transarticular epithelioid hemangioma of the ankle-a case of a rare vascular neoplasm. Skeletal Radiol 2021; 50:1263-1270. [PMID: 33420574 DOI: 10.1007/s00256-020-03687-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 02/02/2023]
Abstract
Epithelioid hemangioma of the bone is a rare kind of vascular neoplasm posing a diagnostic challenge because of its ability to mimic malignant tumors. We report a case of a fast-growing, talofibular joint-involving epithelioid hemangioma, which was suspectedly initiated by vascular damage due to trauma and arthroscopy. The ankle mass appeared as a lytic lesion on the CT images and as a T1 hypo-, T2 mildly hyperintense, lobulated structure on the MRI scans. The contrast enhancement pattern was typical to vascular neoplasms. Histologically the lesion consisted of well-formed vessels lined with epithelioid cells with a slightly atypical nuclear morphology, inflammation with a significant number of eosinophils, and low mitotic rate. Immunohistochemistry analysis showed the presence of vascular markers but no rearrangements characteristic of soft tissue sarcomas were registered by the next-generation sequencing. The surgical treatment was curative. The report presents current imaging methods and summarizes the imaging findings of transarticular spreading tumors. The paper also highlights that for the differential diagnosis of vascular tumors showing signs of aggressivity, the pathological analysis is inevitable. Correct diagnosis of the epithelioid hemangioma is essential, as the treatment of more malignant entities is substantially different. An added value of the report is that to the best of our knowledge, a transarticular spreading epithelioid hemangioma of the ankle has never been described before.
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Affiliation(s)
- Nikolett Marton
- Department of Radiology, Jahn Ferenc Hospital, 1 Koves ut, Budapest, H-1204, Hungary. .,Experimental Rheumatology Research Group, Semmelweis University, Budapest, Hungary.
| | | | | | - Matías de Albert
- Department of Radiology, Vall d'Hebron Hospital, Barcelona, Spain
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Jokonya L, Mungazi S, Mduluza-Jokonya TL, Kalangu KKN. Truncal complex regional pain syndrome, myth or reality: Case report. Int J Surg Case Rep 2021; 83:105959. [PMID: 33965752 PMCID: PMC8121956 DOI: 10.1016/j.ijscr.2021.105959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/28/2021] [Accepted: 04/28/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Complex regional pain syndrome (CRPS) is an under diagonised, chronic pain condition commonly described occurring in the extremities. Its occurrence in the trunk is rarely reported and is thought by some to be non existent. Case presentation We report an unusual case of trunkul CRPS post appendectomy which presented with debilitating pain and review relevant literature. Discussion and conclusion We recommend that subsequent descriptions and diagnostic criteria should include the trunk as a site of occurrence of CRPS and not just the extremities. This will help reduce under diagnosis of this important condition. CRPS can also occur in the trunk and not only limbs as previously thought. CRPS can also occur after appendicectomy and surgeons must be wary. Early diagnosis and treatment are essential for better outcome.
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Affiliation(s)
- Luxwell Jokonya
- Department of Surgery, College of Health Sciences, University of Zimbabwe, Zimbabwe; Optics & Imaging, Doris Duke Medical Research Institute, College of Health Sciences, University of KwaZulu-Natal; KwaZulu-Natal, Durban, South Africa.
| | - Simbarashe Mungazi
- Department of Surgery and Anaesthetics, National University of Science and Technology, Zimbabwe
| | - Tariro L Mduluza-Jokonya
- Optics & Imaging, Doris Duke Medical Research Institute, College of Health Sciences, University of KwaZulu-Natal; KwaZulu-Natal, Durban, South Africa
| | - Kazadi K N Kalangu
- Department of Surgery, College of Health Sciences, University of Zimbabwe, Zimbabwe
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Salmon DA, Lambert PH, Nohynek HM, Gee J, Parashar UD, Tate JE, Wilder-Smith A, Hartigan-Go KY, Smith PG, Zuber PLF. Novel vaccine safety issues and areas that would benefit from further research. BMJ Glob Health 2021; 6:e003814. [PMID: 34011502 PMCID: PMC8137224 DOI: 10.1136/bmjgh-2020-003814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 12/01/2020] [Accepted: 01/06/2021] [Indexed: 12/20/2022] Open
Abstract
Vaccine licensure requires a very high safety standard and vaccines routinely used are very safe. Vaccine safety monitoring prelicensure and postlicensure enables continual assessment to ensure the benefits outweigh the risks and, when safety problems arise, they are quickly identified, characterised and further problems prevented when possible. We review five vaccine safety case studies: (1) dengue vaccine and enhanced dengue disease, (2) pandemic influenza vaccine and narcolepsy, (3) rotavirus vaccine and intussusception, (4) human papillomavirus vaccine and postural orthostatic tachycardia syndrome and complex regional pain syndrome, and (5) RTS,S/adjuvant system 01 malaria vaccine and meningitis, cerebral malaria, female mortality and rebound severe malaria. These case studies were selected because they are recent and varied in the vaccine safety challenges they elucidate. Bringing these case studies together, we develop lessons learned that can be useful for addressing some of the potential safety issues that will inevitably arise with new vaccines.
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Affiliation(s)
- Daniel A Salmon
- Global Disease Epidemiology and Control, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Hanna M Nohynek
- Infectious Disease Control and Vaccinations Unit, Department of Health Security, Finnish Institute for Health and Welfare, Helsinki, Uusimaa, Finland
| | - Julianne Gee
- Division of Healthcare Quality Promotion, National Center of Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, Georgia, USA
| | - Umesh D Parashar
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia, USA
| | - Jacqueline E Tate
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia, USA
| | | | | | - Peter G Smith
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, London, UK
| | - Patrick Louis F Zuber
- Essential Medicines and Health Products, Organisation Mondiale de la Sante, Geneve, Switzerland
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Abstract
Given the high prevalence and associated cost of chronic pain, it has a significant impact on individuals and society. Improvements in the treatment and management of chronic pain may increase patients’ quality of life and reduce societal costs. In this paper, we evaluate state-of-the-art machine learning approaches in chronic pain research. A literature search was conducted using the PubMed, IEEE Xplore, and the Association of Computing Machinery (ACM) Digital Library databases. Relevant studies were identified by screening titles and abstracts for keywords related to chronic pain and machine learning, followed by analysing full texts. Two hundred and eighty-seven publications were identified in the literature search. In total, fifty-three papers on chronic pain research and machine learning were reviewed. The review showed that while many studies have emphasised machine learning-based classification for the diagnosis of chronic pain, far less attention has been paid to the treatment and management of chronic pain. More research is needed on machine learning approaches to the treatment, rehabilitation, and self-management of chronic pain. As with other chronic conditions, patient involvement and self-management are crucial. In order to achieve this, patients with chronic pain need digital tools that can help them make decisions about their own treatment and care.
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Interventional Modalities to Treat Complex Regional Pain Syndrome. Curr Pain Headache Rep 2021; 25:10. [PMID: 33537907 DOI: 10.1007/s11916-020-00904-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW Complex regional pain syndrome (CRPS) is a debilitating pain condition that often requires a multidisciplinary approach including medication, physical therapy, occupational therapy, psychological therapy, and interventional procedures to restore the patient's quality of life. This article reviews the interventional treatments for pain resulting from CRPS. RECENT FINDINGS Sympathetic nerve blocks (stellate ganglion and lumbar sympathetic) are the first-line interventional treatment options for patients with CRPS of the upper and lower extremities, respectively. Fluoroscopic techniques for lumbar sympathetic blocks have not significantly changed throughout the years. However, both novel fluoroscopic and ultrasound approaches to stellate ganglion blockade have arisen. In addition, novel neuromodulation therapies to treat CRPS have been developed to include new waveforms with dorsal column stimulation and entirely new nerve targets such as dorsal root ganglion stimulation. This paper will review the latest interventional treatment options available for the treatment of CRPS.
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Mundluru T, Saraghi M. Anesthetic Management of a Complex Regional Pain Syndrome (CRPS) Patient With Ketamine. Anesth Prog 2021; 67:219-225. [PMID: 33393601 DOI: 10.2344/anpr-67-02-07] [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: 05/29/2019] [Accepted: 04/13/2020] [Indexed: 11/11/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a potentially debilitating form of neuropathic pain that may manifest following a traumatic injury or surgery. CRPS is also known as algodystrophy, causalgia, or reflex sympathetic dystrophy (RSD). Patients describe unbearable burning pain from nonnociceptive stimuli, such as when taking a shower or brushing against another object. Regular tactile stimuli encountered during routine dental procedures may not be well-tolerated by a patient with CRPS. Ketamine infusions have been reported to help alleviate acute exacerbations or "flare-ups" of CRPS symptoms. This case report provides a brief overview of CRPS pathophysiology and treatment including data supporting the use of ketamine infusions and a discussion regarding the anesthetic management of a patient with CRPS presenting for dental care under deep sedation utilizing high-dose intravenous ketamine.
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Affiliation(s)
- Tarun Mundluru
- Resident in Orofacial Pain and Oral Medicine, The Herman Ostrow School of Dentistry at the University of Southern California, Los Angeles, California
| | - Mana Saraghi
- Director, Dental Anesthesiology Residency Program, Jacobi Medical Center Bronx, New York
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