1
|
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.
Collapse
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
| |
Collapse
|
2
|
Weissmann R, Uziel Y. Pediatric complex regional pain syndrome: a review. Pediatr Rheumatol Online J 2016; 14:29. [PMID: 27130211 PMCID: PMC4850724 DOI: 10.1186/s12969-016-0090-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 04/25/2016] [Indexed: 11/15/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic, intensified localized pain condition that can affect children and adolescents as well as adults, but is more common among adolescent girls. Symptoms include limb pain; allodynia; hyperalgesia; swelling and/or changes in skin color of the affected limb; dry, mottled skin; hyperhidrosis and trophic changes of the nails and hair. The exact mechanism of CRPS is unknown, although several different mechanisms have been suggested. The diagnosis is clinical, with the aid of the adult criteria for CRPS. Standard care consists of a multidisciplinary approach with the implementation of intensive physical therapy in conjunction with psychological counseling. Pharmacological treatments may aid in reducing pain in order to allow the patient to participate fully in intensive physiotherapy. The prognosis in pediatric CRPS is favorable.
Collapse
Affiliation(s)
- Rotem Weissmann
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, 49 Tshernichovsky St., Kfar Saba, 44281 Israel ,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yosef Uziel
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, 49 Tshernichovsky St., Kfar Saba, 44281, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
3
|
Abstract
Neuropathic pain is relatively uncommon in children. Although some syndromes closely resemble those found in adults, the incidence and course of the condition can vary substantially in children, depending on developmental status and contextual factors. There are some neuropathic pain syndromes that are rare and relatively unique to the pediatric population. This article discusses the array of neuropathic pain conditions in children and available treatment strategies. Data are limited by small numbers and few randomized controlled trials. Research and clinical implications are discussed.
Collapse
Affiliation(s)
- Gary A Walco
- Department of Anesthesiology & Pain Medicine, Seattle Children's Hospital, WA 98105, USA.
| | | | | | | | | |
Collapse
|
4
|
Abstract
Reflex sympathetic dystrophy (RSD), an unusual diagnosis in general paediatrics, is well recognised by paediatric rheumatologists. This study reports the presentation and the clinical course of 46 patients (35 female, age range 8-15.2) with RSD. The patients saw professionals from an average of 2.3 specialties (range 1-5). Twenty five (54%) had a history of trauma. Median time to diagnosis was 12 weeks (range 1-130). Many children had multiple investigations and treatments. Once diagnosis was made, treatment followed with physiotherapy and analgesics. Median time to recovery was seven weeks (range 1-140), with 27.5% relapsing. Nine children required assessment by the child and adolescent psychiatry team. This disease, though rare, has significant morbidity and it is therefore important to raise clinicians' awareness of RSD in childhood. Children with the condition may then be recognised and referred for appropriate management earlier, and spared unnecessary investigations and treatments which may exacerbate the condition.
Collapse
Affiliation(s)
- C S Murray
- Department of Paediatric Rheumatology, Royal Liverpool Childrens Hospital, Eaton Road, Liverpool L12 2AP, UK
| | | | | | | | | |
Collapse
|
5
|
|
6
|
Stanton-Hicks M, Baron R, Boas R, Gordh T, Harden N, Hendler N, Koltzenburg M, Raj P, Wilder R. Complex Regional Pain Syndromes: guidelines for therapy. Clin J Pain 1998; 14:155-66. [PMID: 9647459 DOI: 10.1097/00002508-199806000-00012] [Citation(s) in RCA: 270] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This report aims to present an orderly approach to the treatment of Chronic Regional Pain Syndrome (CRPS) types I and II through an algorithm. The central theme is functional restoration: a coordinated but progressive approach that introduces each of the treatment modalities needed to achieve both remission and rehabilitation. Reaching objective and measurable rehabilitation goals is an essential element. Specific exercise therapy to reestablish function after musculoskeletal injury is central to this functional restoration. Its application to CRPS is more contingent on varying rates of progress that characterize the restoration of function in patients with CRPS. Also, the various modalities that may be used, including analgesia by pharmacologic means or regional anesthesia or the use of neuromodulation, behavioral management, and the qualitatively different approaches that are unique to the management of children with CRPS, are provided only to facilitate functional improvement in a stepwise but methodical manner. Patients with CRPS need an individual approach that requires extreme flexibility. This distinguishes the management of these conditions from other well-described medical conditions having a known pathophysiology. In particular, the special biopsychosocial factors that are critical to achieving a successful outcome are emphasized. This algorithm is a departure from the contemporary heterogeneous approach to treatment of patients with CRPS. The underlying principles are motivation, mobilization, and desensitization facilitated by the relief of pain and the use of pharmacologic and interventional procedures to treat specific signs and symptoms. Self-management techniques are emphasized, and functional rehabilitation is the key to the success of this algorithm.
Collapse
Affiliation(s)
- M Stanton-Hicks
- Pain Management Center, The Cleveland Clinic Foundation, OH 44195, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Affiliation(s)
- R Hood-White
- Santa Barbara Medical Foundation Clinic, Santa Barbara, Calif, USA
| | | |
Collapse
|
8
|
Stanton RP, Malcolm JR, Wesdock KA, Singsen BH. Reflex sympathetic dystrophy in children: an orthopedic perspective. Orthopedics 1993; 16:773-9; discussion 779-80. [PMID: 8361916 DOI: 10.3928/0147-7447-19930701-06] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To design diagnostic criteria for reflex sympathetic dystrophy (RSD) and to initiate a prospective treatment protocol, we reviewed our experience with 49 episodes of RSD in 36 children. There were 24 females and 12 males; mean age at diagnosis was 13.4 years (range: 8 to 19); mean time from pain onset to correct diagnosis was 9.2 months (range: 1 to 53). Lower extremity involvement predominated. Pain was "severe" in 61%, and skin color changes, swelling, hyperesthesia, abnormal skin temperatures, muscle weakness, and decreased range of motion were all present in at least 75% of cases. Osteopenia was observed in 15 of 38 radiographs; of 24 bone scans, 7 were normal, 11 showed increased uptake, and 6 demonstrated decreased uptake. Of the 23 children who had psychological evaluations, 83% revealed some type of significant emotional dysfunction. Analgesic and antiinflammatory medications were not helpful, nor were local injections or regional blockades effective. An inpatient diagnostic and rehabilitation program for treating chronic pain, including orthopedics, rheumatology, psychology, and twice-daily physical therapy was most likely to lead to resumption of age-appropriate activities. Despite extensive physiological testing, physician, parent, and/or patient reluctance to accept absence of a primary organic disease was common. We present diagnostic criteria for pediatric RSD.
Collapse
Affiliation(s)
- R P Stanton
- Department of Orthopaedic Surgery, Alfred I. duPont Institute, Wilmington, Del 19899
| | | | | | | |
Collapse
|
9
|
Koman LA, Barden A, Smith BP, Pollock FE, Sinal S, Poehling GG. Reflex sympathetic dystrophy in an adolescent. FOOT & ANKLE 1993; 14:273-7. [PMID: 8349213 DOI: 10.1177/107110079301400507] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The clinical course of an adolescent with reflex sympathetic dystrophy of the foot is presented. The potential problems of establishing objective diagnostic criteria for reflex sympathetic dystrophy are related to the dynamic nature of the disorder. Serial radiographic studies, radionuclide scans, and quantitative densitometric measurements may be useful in combination; isolated cold stress testing and laser Doppler fluxmetry are useful in assessing thermoregulation and vasomotor instability. A regimen of amitriptyline and phenytoin plus physical therapy with stress loading was useful in this patient, but in many patients the course is progressive, leading to chronic pain and debilitation.
Collapse
Affiliation(s)
- L A Koman
- Department of Orthopaedic Surgery, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina 27157-1070
| | | | | | | | | | | |
Collapse
|
10
|
Wesdock KA, Stanton RP, Singsen BH. Reflex sympathetic dystrophy in children. A physical therapy approach. ARTHRITIS CARE AND RESEARCH : THE OFFICIAL JOURNAL OF THE ARTHRITIS HEALTH PROFESSIONS ASSOCIATION 1991; 4:32-8. [PMID: 11188585 DOI: 10.1002/art.1790040107] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Children with reflex sympathetic dystrophy (RSD) almost always receive physical therapy as part of a multidisciplinary approach, but there is controversy about the efficacy of many alternative modalities. In a retrospective chart review of 24 females and 12 males with 49 episodes of RSD (mean age at onset, 13.4 years), the average time to correct diagnosis was 9.4 months (median, 4.2 months; range, 1-53 months). Sixteen ankles, 12 knees, eight wrists, two hips, and two shoulders were involved. Psychological assessments revealed significant abnormalities in 25 (83%) of 30 children evaluated. Thirty-four (94%) of 36 children received physical therapy including a wide variety of nonstandardized approaches. Children with one to two episodes of RSD averaged 4.0 physical therapy modalities; unresolved cases had 8.9 modalities attempted. Time from the first RSD episode to resolution averaged 9.0 months in 69% of children. Incorrect diagnoses prolonged many initial episodes; following correct diagnosis, symptom resolution occurred in 3.1 months. Recurrences are common, and 25% of children still exhibited RSD symptoms at last follow-up.
Collapse
Affiliation(s)
- K A Wesdock
- Department of Physical Therapy, Alfred I. duPont Institute, Wilmington, Delaware, USA
| | | | | |
Collapse
|
11
|
Patt RB, Balter K. Posttraumatic reflex sympathetic dystrophy: Mechanisms and medical management. JOURNAL OF OCCUPATIONAL REHABILITATION 1991; 1:57-70. [PMID: 24242326 DOI: 10.1007/bf01073280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Reflex sympathetic dystrophy (RSD) refers to a symptom complex of posttraumatic pain associated with a wide and varying spectrum of vasomotor and neurologic changes. The diagnosis of reflex sympathetic dystrophy is made almost entirely on clinical grounds, and is often confirmed by observation of the results of diagnostic local anesthetic nerve blocks. Laboratory and radiographic investigations are useful adjuncts to diagnosis. The key to successful management is early recognition, as delays in treatment are associated with worse outcome. A multimodal approach to treatment is recommended that may include nerve blocks, rehabilitation, and pharmacologic and behavioral pain management. The role of other modalities including surgery and electrical stimulation remains controversial.
Collapse
Affiliation(s)
- R B Patt
- University of Rochester School of Medicine and Dentistry, Departments of Anesthesiology, Psychiatry, and Oncology, Pain Treatment Center, Strong Memorial Hospital, Rochester, New York
| | | |
Collapse
|
12
|
|
13
|
Goldsmith DP, Vivino FB, Eichenfield AH, Athreya BH, Heyman S. Nuclear imaging and clinical features of childhood reflex neurovascular dystrophy: comparison with adults. ARTHRITIS AND RHEUMATISM 1989; 32:480-5. [PMID: 2706031 DOI: 10.1002/anr.1780320419] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Reflex neurovascular dystrophy (RND) is less common in children than in adults, and differences in onset, clinical course, response to treatment, and degree of disability suggest a different pathogenesis. We have assessed the usefulness of nuclear imaging in 15 children with RND who were evaluated from March 1983 to September 1985. Abnormal findings on 3-phase bone scans were observed in 14 children, with diffusely decreased bone uptake at the symptomatic site being the most common observation. This contrasts sharply with previous reports of diffusely increased uptake in most adults with RND.
Collapse
Affiliation(s)
- D P Goldsmith
- Pediatric Rheumatology Center, Children's Hospital of Philadelphia, PA 19104
| | | | | | | | | |
Collapse
|
14
|
Rush PJ, Wilmot D, Saunders N, Gladman D, Shore A. Severe reflex neurovascular dystrophy in childhood. ARTHRITIS AND RHEUMATISM 1985; 28:952-6. [PMID: 4026892 DOI: 10.1002/art.1780280818] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
15
|
Laxer RM, Allen RC, Malleson PN, Morrison RT, Petty RE. Technetium 99m-methylene diphosphonate bone scans in children with reflex neurovascular dystrophy. J Pediatr 1985; 106:437-40. [PMID: 3156227 DOI: 10.1016/s0022-3476(85)80671-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Eleven children with reflex neurovascular dystrophy were investigated by technetium-labeled methylene diphosphonate bone scanning. Eight of 12 scans demonstrated abnormal findings, four showing diffusely decreased uptake and four diffusely increased uptake of the radionuclide in the affected site. Three scans showed normal findings initially, as did one previously abnormal scan when repeated in the asymptomatic patient 6 months later. Diffusely abnormal findings can be helpful in the diagnosis of childhood reflex neurovascular dystrophy, but a normal scan does not exclude the diagnosis.
Collapse
|