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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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Huang JJ, Rodriguez DA, Slifer SH, Martin ER, Levitt RC, Galor A. Genome Wide Association Study of Neuropathic Ocular Pain. OPHTHALMOLOGY SCIENCE 2024; 4:100384. [PMID: 37868788 PMCID: PMC10587615 DOI: 10.1016/j.xops.2023.100384] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/02/2023] [Accepted: 08/07/2023] [Indexed: 10/24/2023]
Abstract
Purpose To conduct a genome-wide association study (GWAS) of individuals with neuropathic ocular pain (NOP) symptoms to identify genomic variants that may predispose to NOP development. Design Prospective study of individuals with NOP. Participants Three hundred twenty-nine patients recruited from the Miami Veterans Affairs eye clinic. Methods The Neuropathic Pain Symptom Inventory modified for the eye (NPSI-Eye) was completed to calculate a NPSI-Eye-Sub-Score (summed ratings of burning and wind sensitivity) as an indicator of NOP severity. A GWAS was performed for the NPSI-Eye-Sub-Score with a significance threshold of P < 5 × 10-8. A gene-based analysis was performed using the multimarker analysis of genomic annotation software (in the functional mapping and annotation of GWAS online platform). The 13 865 778 single nucleotide polymorphisms (SNPs) from our GWAS analysis were mapped to 10 834 protein coding genes, and significant genes were run through gene set enrichment analysis. Main Outcome Measures Identification of SNPs and protein products that may be associated with the development of NOP. Results One hundred seventy-one SNPs reached a threshold of P < 10-5, of which 10 SNPs reached the suggestive level of significance of P < 5 × 10-7 and 1 SNP met our genome-wide significance threshold of P < 5 × 10-8. This lead SNP, rs140293404 (P = 1.23 × 10-8), is an intronic variant found within gene ENSG00000287251 coding for transcript ENST00000662732.1. Rs140293404 is in linkage disequilibrium with exon variant rs7926353 (r2 > 0.8) within ENSG00000279046 coding for transcript ENST00000624288.1. The most significant genes from gene-based tests were matrix metalloproteinase-19 (MMP19) (P = 1.12 × 10-5), zinc finger RNA-binding motif and serine/arginine rich-1 (ZRSR1) (P = 1.48 × 10-4), CTC-487M23.8 (P = 1.79 × 10-4), receptor expression-enhancing protein-5 (REEP5) (P = 2.36 × 10-4), and signal recognition particle-19 (SRP19) (P = 2.56 × 10-4). From gene set enrichment analysis, the sensory perception (false discovery rate = 6.57 × 10-3) and olfactory signaling (false discovery rate = 1.63 × 10-2) pathways were enriched with the most significant genes. Conclusions Our GWAS revealed genes with protein products that may impact sensory perception, lending biological plausibility to a role for SNPs identified by our GWAS in the development of NOP. A better understanding of the biological relevance of these genes and pathways in the pathophysiology associated with NOP may facilitate future novel mechanism-based treatments. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Jaxon J. Huang
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
- Surgical and Research Services, Miami Veterans Administration Medical Center, Miami, Florida
| | | | - Susan H. Slifer
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida
| | - Eden R. Martin
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida
- John T. MacDonald Foundation Department of Human Genetics, University of Miami Miller School of Medicine, Miami, Florida
| | - Roy C. Levitt
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
- John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, Florida
- John T. MacDonald Foundation Department of Human Genetics, University of Miami Miller School of Medicine, Miami, Florida
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Anat Galor
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
- Surgical and Research Services, Miami Veterans Administration Medical Center, Miami, Florida
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Lorente A, Mariscal G, Lorente R. Incidence and risk factors for complex regional pain syndrome in radius fractures: meta-analysis. Arch Orthop Trauma Surg 2023; 143:5687-5699. [PMID: 37209231 DOI: 10.1007/s00402-023-04909-8] [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: 03/18/2023] [Accepted: 05/10/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE This meta-analysis aimed to evaluate the incidence and risk factors for complex regional pain syndrome (CRPS) in radius fractures. METHODS The meta-analysis was performed using the PubMed, Embase, Scopus, and Cochrane Collaboration Library databases. Studies focusing on patients with conservative or surgically treated radius fractures leading to CRPS were included. A control group consisting of patients with radius fractures and no CRPS (-) was included. The outcome measures were incidence and risk factors. Comparative studies were also included. Data were combined using Review Manager 5.4. RESULTS Out of 610 studies, nine studies were included. The incidence of CRPS after radius fractures ranged from 0.19 to 13.63% (95% CI: 11.12-16.15%). Open fractures, high-energy mechanisms in radial head fractures, and associations with ulnar fractures were risk factors for CRPS [(RR: 0.98; 95% CI: 0.97-1.00), (RR: 0.18; 95% CI: 0.07-0.47), and (RR: 1.25; 95% CI: 1.17-1.35), respectively]. Other risk factors were female sex and high body mass index [(RR: 1.20; 95% CI: 1.05-1.37) and (MD: 1.17; 95% CI: 0.45-1.88)]. Psychiatric factors also increased the incidence of CRPS (RR: 2.04; 95% CI: 1.83-2.28). On the other hand, the type of surgery (external fixation or open reduction and internal fixation) and manipulations; associated comorbidities (diabetes and hypertension) together with tobacco and alcohol abuse; marital status, educational level, employment status, and socioeconomic status were not risk factors (p > 0.05). CONCLUSION The incidence of CRPS in radius fractures was 13.63%. Fractures with greater complexity or greater associated tissue damage, female sex, high BMI, and psychiatric disorders were risk factors for the development of CRPS. LEVEL OF EVIDENCE Meta-analysis of cohort and case series studies; II.
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Affiliation(s)
- Alejandro Lorente
- Department of Traumatology and Orthopaedic Surgery, University Hospital Ramón y Cajal, Madrid, Spain
| | - Gonzalo Mariscal
- Institute for Research on Musculoskeletal Disorders, School of Medicine, Valencia Catholic University, Carrer de Quevedo, 2, 46001, València, Valencia, Spain.
- Mediterranean Observatory for Clinical and Health Research, Valencia, Spain.
| | - Rafael Lorente
- Department of Orthopedic Surgery and Traumatology, University Hospital of Badajoz, Badajoz, Spain
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Wyns A, Hendrix J, Lahousse A, De Bruyne E, Nijs J, Godderis L, Polli A. The Biology of Stress Intolerance in Patients with Chronic Pain—State of the Art and Future Directions. J Clin Med 2023; 12:jcm12062245. [PMID: 36983246 PMCID: PMC10057496 DOI: 10.3390/jcm12062245] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/07/2023] [Accepted: 03/10/2023] [Indexed: 03/16/2023] Open
Abstract
Stress has been consistently linked to negative impacts on physical and mental health. More specifically, patients with chronic pain experience stress intolerance, which is an exacerbation or occurrence of symptoms in response to any type of stress. The pathophysiological mechanisms underlying this phenomenon remain unsolved. In this state-of-the-art paper, we summarised the role of the autonomic nervous system (ANS) and hypothalamus-pituitary-adrenal (HPA) axis, the two major stress response systems in stress intolerance. We provided insights into such mechanisms based on evidence from clinical studies in both patients with chronic pain, showing dysregulated stress systems, and healthy controls supported by preclinical studies, highlighting the link between these systems and symptoms of stress intolerance. Furthermore, we explored the possible regulating role for (epi)genetic mechanisms influencing the ANS and HPA axis. The link between stress and chronic pain has become an important area of research as it has the potential to inform the development of interventions to improve the quality of life for individuals living with chronic pain. As stress has become a prevalent concern in modern society, understanding the connection between stress, HPA axis, ANS, and chronic health conditions such as chronic pain is crucial to improve public health and well-being.
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Affiliation(s)
- Arne Wyns
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (A.W.); (A.L.); (J.N.); (A.P.)
| | - Jolien Hendrix
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (A.W.); (A.L.); (J.N.); (A.P.)
- Department of Public Health and Primary Care, Centre for Environment & Health, KU Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium;
- Flanders Research Foundation-FWO, 1090 Brussels, Belgium
- Correspondence:
| | - Astrid Lahousse
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (A.W.); (A.L.); (J.N.); (A.P.)
- Flanders Research Foundation-FWO, 1090 Brussels, Belgium
- Chronic Pain Rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital, 1090 Brussels, Belgium
- Rehabilitation Research (RERE) Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy (KIMA), Vrije Universiteit Brussel, 1090 Brussels, Belgium
| | - Elke De Bruyne
- Department of Hematology and Immunology-Myeloma Center Brussels, Vrije Universiteit Brussel, 1090 Brussels, Belgium;
| | - Jo Nijs
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (A.W.); (A.L.); (J.N.); (A.P.)
- Chronic Pain Rehabilitation, Department of Physical Medicine and Physiotherapy, University Hospital, 1090 Brussels, Belgium
- Unit of Physiotherapy, Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Lode Godderis
- Department of Public Health and Primary Care, Centre for Environment & Health, KU Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium;
- External Service for Prevention and Protection at Work, IDEWE, 3001 Heverlee, Belgium
| | - Andrea Polli
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, 1090 Brussels, Belgium; (A.W.); (A.L.); (J.N.); (A.P.)
- Department of Public Health and Primary Care, Centre for Environment & Health, KU Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium;
- Flanders Research Foundation-FWO, 1090 Brussels, Belgium
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Bruehl S, Billings FT, Anderson S, Polkowski G, Shinar A, Schildcrout J, Shi Y, Milne G, Dematteo A, Mishra P, Harden RN. Preoperative Predictors of Complex Regional Pain Syndrome Outcomes in the 6 Months Following Total Knee Arthroplasty. THE JOURNAL OF PAIN 2022; 23:1712-1723. [PMID: 35470089 PMCID: PMC9560974 DOI: 10.1016/j.jpain.2022.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/30/2022] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Abstract
This prospective observational study evaluated preoperative predictors of complex regional pain syndrome (CRPS) outcomes in the 6 months following total knee arthroplasty (TKA). Participants were n = 110 osteoarthritis patients (64.5% female) undergoing unilateral TKA with no prior CRPS history. Domains of negative affect (depression, anxiety, catastrophizing), pain (intensity, widespread pain, temporal summation of pain [TSP]), pain interference, sleep disturbance, and pro-inflammatory status (tumor necrosis factor-alpha [TNF-a]) were assessed preoperatively. CRPS outcomes at 6-week and 6-month follow-up included the continuous CRPS Severity Score (CSS) and dichotomous CRPS diagnoses (2012 IASP criteria). At 6 months, 12.7% of participants met CRPS criteria, exhibiting a "warm CRPS" phenotype. Six-week CSS scores were predicted by greater preoperative depression, anxiety, catastrophizing, TSP, pain intensity, sleep disturbance, and TNF-a (P's < .05). Provisional CRPS diagnosis at 6 weeks was predicted by higher preoperative TSP, sleep disturbance, and TNF-a (P's < .05). CSS scores at 6 months were predicted by more widespread and intense preoperative pain, and higher preoperative TSP, pain interference, and TNF-a (P's < .01). CRPS diagnosis at 6 months was predicted only by more widespread and intense pain preoperatively (P's < .05). Risk for CRPS following TKA appears to involve preoperative central sensitization and inflammatory mechanisms. Preoperative negative affect is unlikely to directly influence long-term CRPS risk. PERSPECTIVE: This article identifies preoperative predictors of CRPS features at 6 months following total knee arthroplasty, including more widespread pain and higher pain intensity, temporal summation of pain, pain interference, and tumor necrosis factor-alpha levels. Findings suggest the importance of central sensitization and inflammatory mechanisms in CRPS risk following tissue trauma.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ginger Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony Dematteo
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - R Norman Harden
- Departments of Physical Medicine and Rehabilitation and Physical Therapy and Human Movement Science, Northwestern University, Chicago, Illinois
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Wang Y, Jiang M, Dai X, Zhang Q. Determinants of Complex Regional Pain Syndrome Type I among Radial Head Fracture Patients with Unilateral Arthroplasty. Orthop Surg 2022; 14:1395-1403. [PMID: 35673902 PMCID: PMC9251304 DOI: 10.1111/os.13320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 05/07/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aims to assess the proportions of complex regional pain syndrome type I (CRPS I) in radial head fracture patients undergoing unilateral arthroplasty and to explore associated factors. METHODS This is a prospective observational study. From March 2016 to May 2019, a total of 221 adult patients with radial head fracture patients were included in consecutive studies and completed the 1-year follow-up. All patients were treated by unilateral arthroplasty. At each follow-up visit, the visual analogue scale was used to measure patients' pain level. Occurrence of CRPS I, which was diagnosed by Budapest criteria, was the main outcome collected at baseline and the 1-, 3-, 6-, and 9-month follow-ups. The baseline data were collected before surgery and included demographic and clinical data. Independent t-tests and χ2 tests were used as univariate analyses to compare the baseline data of patients with and without CRPS I. Multivariate analysis (Backword-Wald) was used to identify factors independently associated with CRPS I. RESULTS The proportion of CRPS I cases among radial head fracture patients undergoing unilateral arthroplasty was 11% (n = 24). A total of 19 (79%) patients were diagnosed with CRPS I within 1 month after surgery. Multivariable logistic regression analysis revealed that female gender (odds ratios [OR]: 1.537; 95% confidence interval [CI]: 1.138-2.072), age younger than 60 years (OR: 1.682; 95% CI: 1.246-2.267), moderate and severe Mayo Elbow Performance Score (MEPS) pain (OR: 3.229; 95% CI: 2.392-4.351) and anxiety (OR: 83.346; 95% CI: 61.752-112.320) were independently associated with CRPS I. CONCLUSIONS This exploratory study reported that the incidence of CRPS I developing after radial head arthroplasty was 11%. Female sex, younger age, moderate and severe MEPS pain and anxiety patients seems more likely to develop CRPS I.
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Affiliation(s)
- Ye Wang
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Menglu Jiang
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China.,Soochow University, Soochow, China
| | - Xu Dai
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Qin Zhang
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China
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Harden RN, McCabe CS, Goebel A, Massey M, Suvar T, Grieve S, Bruehl S. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S1-S53. [PMID: 35687369 PMCID: PMC9186375 DOI: 10.1093/pm/pnac046] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/23/2022]
Abstract
There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for "better research." This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of "elder statesman" researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the "Budapest" criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient.
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Affiliation(s)
- R Norman Harden
- Departments of PM&R and Physical Therapy and Human Movement Sciences, Northwestern University
| | - Candida S McCabe
- University of the West of England, Stapleton, Bristol, UK
- Dorothy House Hospice, Bradford-on-Avon, Wilts, UK
| | - Andreas Goebel
- Pain Research Institute, Faculty of Health and Life Science, University of Liverpool, Liverpool, UK
| | - Michael Massey
- CentraCare Neurosciences Pain Center, CentraCare, St. Cloud, Minnesota, USA
| | - Tolga Suvar
- Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Sharon Grieve
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Centers, Nashville, Tennessee, USA
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Antunovich D, Tuck N, Reynolds LM, Bean D. "I Don't Identify with It": A Qualitative Analysis of People's Experiences of Living with Complex Regional Pain Styndrome. PAIN MEDICINE (MALDEN, MASS.) 2021; 22:3008-3020. [PMID: 33693870 DOI: 10.1093/pm/pnab094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 02/14/2021] [Accepted: 03/04/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Complex regional pain syndrome (CRPS) is a painful limb condition known to cause significant disability and distress. However, little previous research has explored CRPS from a patient perspective. The present qualitative study aimed to describe the experiences of people living with CRPS. SUBJECTS Forty-eight people with CRPS participated in this research. METHODS Participants completed a face-to-face or telephone interview about their perceptions and experiences of CRPS and completed three drawings to illustrate their experiences. Data were analyzed through reflexive thematic analysis, and images in drawings were grouped and coded by theme. RESULTS Three overarching themes encapsulated the data, including that 1) people experience CRPS as a source of severe symptoms and emotional difficulties, 2) CRPS undermines personal and social identity, and 3) this results in psychological responses that protect against the emotional and social impact of severe symptoms. Psychological responses include: a) searching for an explanation, b) "nothing is my fault," emphasizing a lack of personal responsibility and personal control, and c) detaching the limb from the self. CONCLUSIONS CRPS is experienced as highly threatening to physical ability, psychological state, and identity. In response to these threats, people may develop their own explanations for CRPS and may mentally detach themselves from responsibility, control, and the painful limb itself. Future research could explore the impact of these factors on psychological well-being and CRPS symptoms and outcomes.
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Affiliation(s)
- Dana Antunovich
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
- Pain Service, Northland District Health Board, Northland, New Zealand
| | - Natalie Tuck
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
- The Auckland Regional Pain Service, Auckland District Health Board, Auckland, New Zealand
- Chronic Pain Service, Department of Anaesthesia and Perioperative Medicine, Waitemata District Health Board, Auckland, New Zealand
| | - Lisa M Reynolds
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Debbie Bean
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
- Chronic Pain Service, Department of Anaesthesia and Perioperative Medicine, Waitemata District Health Board, Auckland, New Zealand
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Fallico N, Padmanabhan R, Rahman S, Somma F, Spagnoli AM. A randomised placebo-controlled clinical trial on the efficacy of local lidocaine injections and oral citalopram for the treatment of complex regional pain syndrome. J Plast Reconstr Aesthet Surg 2021; 75:970-979. [PMID: 34903493 DOI: 10.1016/j.bjps.2021.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 10/31/2021] [Accepted: 11/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a neuropathic pain condition with no universally recognised treatment. The study evaluates the efficacy of a therapeutic protocol consisting of oral citalopram and lidocaine injections in patients affected by CRPS. METHODS Between January 2010 and December 2014, 150 consecutive patients with CRPS were enrolled in the study and randomly assigned into three groups: group one - lidocaine injection and oral citalopram; group two - lidocaine injection and oral placebo; and group three - injective and oral placebo. The Impairment Sum Score (ISS) was used to assess the severity of CRPS before, as well as at regular intervals after treatment commenced. Statistical significance (p < 0.05) was determined by paired t-tests. RESULTS The combined treatment proved to be more effective (ISS 47.6 to 12.6) than local anaesthetic alone (ISS 47.5 to 21.5) and to placebo (ISS 47.2 to 29.9). CONCLUSION This study indicates that CRPS may be managed with well-tolerated association of oral citalopram and lidocaine injections.
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Affiliation(s)
- Nefer Fallico
- "Sapienza" University of Rome, Department of Plastic and Reconstructive Surgery, Rome, Italy; Guy's and St Thomas' Hospital, Department of Plastic Surgery, London, UK
| | | | - Shakeel Rahman
- Guy's and St Thomas' Hospital, Department of Plastic Surgery, London, UK
| | - Francesco Somma
- "Sapienza" University of Rome, Department of Plastic and Reconstructive Surgery, Rome, Italy
| | - Anna Maria Spagnoli
- "Sapienza" University of Rome, Department of Plastic and Reconstructive Surgery, Rome, Italy
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Lee HJ, Lee KH, Moon JY, Kim YC. Prevalence of autonomic nervous system dysfunction in complex regional pain syndrome. Reg Anesth Pain Med 2021; 46:196-202. [PMID: 33419877 DOI: 10.1136/rapm-2020-101644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/05/2020] [Accepted: 10/19/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND We aimed to investigate the prevalence of dysautonomia in complex regional pain syndrome (CRPS) via the combined autonomic nervous system (ANS) function tests, including the deep breathing test (DBT), orthostatic test (OST) and sympathetic skin response (SSR). METHOD We retrospectively examined 263 patients who underwent the combined ANS tests to evaluate CRPS between August 2013 and December 2016. Based on the Budapest clinical criteria, patients were stratified into confirmed-CRPS or suspected-CRPS groups. We performed binary logistic regression analysis using the inverse probability of treatment weighting to investigate the association between the tests and CRPS. Sensitivity and specificity were calculated to assess the diagnostic performance of the ANS tests for CRPS. We compared the results of these tests between the outcomes of sympathetic nerve blocks (SNBs). RESULTS Among 247 patients, finally included in this study, 199 patients (80.6%) were diagnosed with CRPS. Abnormal results of overall or each ANS function test showed significant associations with CRPS, excluding OST (overall abnormality: OR 2.44, 95% CI 1.51 to 3.95; p<0.001; DBT: OR 2.57, 95% CI 1.23 to 5.38, p=0.013; OST: OR 1.88, 95% CI 0.92 to 3.84, p=0.085; SSR: OR 2.71, 95% CI 1.38 to 5.32, p=0.004). However, their prevalence in CRPS and their sensitivities for CRPS were low (overall abnormality: 26.1%; each test: <15%). No significant association existed between dysautonomia and SNB outcomes. CONCLUSION Dysautonomia, as evaluated using the combined ANS tests, were observed in a small portion of patients with CRPS. The diagnostic performances of these tests for CRPS were inadequate for clinical purposes.
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Affiliation(s)
- Ho-Jin Lee
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongno-gu, Seoul, Korea (the Republic of)
| | - Kang Hee Lee
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongno-gu, Seoul, Korea (the Republic of)
| | - Jee Youn Moon
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongno-gu, Seoul, Korea (the Republic of) .,Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Yong-Chul Kim
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongno-gu, Seoul, Korea (the Republic of).,Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
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Complex regional pain syndrome: a focus on the autonomic nervous system. Clin Auton Res 2019; 29:457-467. [PMID: 31104164 DOI: 10.1007/s10286-019-00612-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/07/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Although autonomic features are part of the diagnostic criteria for complex regional pain syndrome (CRPS), the role of the autonomic nervous system in CRPS pathophysiology has been downplayed in recent years. The purpose of this review is to redress this imbalance. METHODS We focus in this review on the contribution of the autonomic nervous system to CRPS pathophysiology. In particular, we discuss regional sympathetic and systemic autonomic disturbances in CRPS and the mechanisms which may underlie them, and consider links between these mechanisms, immune disturbances and pain. RESULTS The focused literature research revealed that immune reactions, alterations in receptor populations (e.g., upregulation of adrenoceptors and reduced cutaneous nerve fiber density) and central changes in autonomic drive seem to contribute to regional and systemic disturbances in sympathetic activity and to sympathetically maintained pain in CRPS. CONCLUSIONS We conclude that alterations in the sympathetic nervous system contribute to CRPS pathology. Understanding these alterations may be an important step towards providing appropriate treatments for CRPS.
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Farzad M, Layeghi F, Hosseini A, Dianat A, Ahrari N, Rassafiani M, Mirzaei H. Investigate the Effect of Psychological Factors in Development of Complex Regional Pain Syndrome Type I in Patients with Fracture of the Distal Radius: A Prospective Study. J Hand Surg Asian Pac Vol 2018; 23:554-561. [DOI: 10.1142/s2424835518500571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: To investigate the role of psychological factors (anxiety and depression) and pain measured on a visual analogue scale (VAS) in the development of complex regional pain syndrome type I (CRPS I) following the distal radius fracture (DRF). Methods: A consecutive sample of patients (N=60) with a distal radius fracture was measured for signs of CRPS by Budapest criteria weekly till 8 weeks and then another follow-up one year after injury to determine the incidence and predictors of developing CRPS I in a prospective cohort study and also to discover whether there is difference between pain, depression, and anxiety level in the patients with and without CRPS I. The most of the patients were treated by Pin stabilization. The Beck depression inventoryshort form (BDI), State-Trait Anxiety Inventory, and Numerical pain rating scale were used to determine the patients’ psychological features and pain intensity at the base line and 8 weeks after the fracture. Results: CRPS I developed in 15 (25%) patients after eight weeks and just last in 10 (16.67%) patients after one year. No difference was found between the two groups (CRPS and non-CRPS group) in terms of state (STAI-I) and trait (STAI-II) anxiety, and BDI score. Pain at the base line was the most important risk factor in developing CRPS (odds ratio [OR] =1.52; 95% CI). Conclusions: After fracturing the distal radius, patients who have high pain intensity have a higher risk of developing CRPS I. To following these patients closely for the development of CRPS I may be advantageous for early preventative and therapeutic interventions.
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Affiliation(s)
- Maryam Farzad
- Department of Occupational Therapy, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Fereydoun Layeghi
- Department of Clinical Science, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Ali Hosseini
- Department of Occupational Therapy, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Al Dianat
- Medicine Department, Iran University of Medical Sciences, Tehran, Iran
| | - Nadiyeh Ahrari
- Department of Occupational Therapy, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Mehdi Rassafiani
- Department of Occupational Therapy, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Hooshang Mirzaei
- Department of Occupational Therapy, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Troncoso RJ, Herzberg DE, Meneses CS, Müller HY, Werner MP, Bustamante H. Mechanical/thermal sensitivity and superficial temperature in the stump of long-term tail-docked dairy cows. PeerJ 2018; 6:e5213. [PMID: 30042886 PMCID: PMC6054783 DOI: 10.7717/peerj.5213] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 06/21/2018] [Indexed: 01/06/2023] Open
Abstract
Background Tail docking of dairy cows is a painful procedure that affects animal welfare level. The aims of this study were first to evaluate the response to mechanical and thermal stimulation, and second to determine the superficial temperature of the stump of tail-docked dairy cows. Methods One hundred and sixty-four dairy cows were enrolled. From these, 133 cows were assigned to the tail-docked (TD) group and 31 cows were selected as control animals. The following sensory assessments to evaluate pain in tail-docked cows were performed. Sensitivity of the tail region in both groups of animals was evaluated using a portable algometer. Cold and heat sensitivity assessment was performed using a frozen pack (0 °C) and warm water (45 °C), respectively. Pinprick sensitivity was evaluated using a Wartenberg neurological pinwheel. Superficial temperature was evaluated using a thermographic camera. All sensory assessments and superficial temperature were evaluated in the ventral surface of the tail stump (TD) and tail (C). Results Pressure pain threshold was lower in TD cows (5.97 ± 0.19 kg) compared to control cows (11.75 ± 0.43 kg). Heat and cold sensitivity was higher in the TD cows compared to control cows with 29% and 23% of TD cows responding positively, respectively. Similarly, after pinprick sensitivity test was performed, 93% of TD cows elicited a positive response to stimulation. Tail-docked cows had lower superficial temperature (26.4 ± 0.27 °C) compared to control cows (29.9 ± 0.62 °C). Discussion Pressure pain threshold values in both groups of animals were higher than those previously reported for TD pigs, sows and cows. In contrast, pinprick stimulation evaluates the presence of punctate mechanical hyperalgesia/allodynia, usually related to traumatic nerve injury, and this association may reveal that it is possible that these animals developed a disorder associated to the development of a tail stump neuroma and concurrent neuropathic pain, previously reported in TD lambs, pigs and dogs. Thermal sensitivity showed that TD cows responded positively to heat and cold stimulation. These findings suggest that long-term TD cows could be suffering hyperalgesia/allodynia, which may be indicative of chronic pain. Lower superficial temperature in the stump may be associated to sympathetic fiber sprouting in the distal stump, which can lead to vasoconstriction and lower surface temperatures. Further studies are needed in order to confirm neuroma development and adrenergic sprouting.
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Affiliation(s)
- Renata J Troncoso
- Veterinary Clinical Sciences Department, Universidad Austral de Chile, Valdivia, Chile
| | - Daniel E Herzberg
- Graduate School, School of Veterinary Sciences, Universidad Austral de Chile, Valdivia, Chile
| | - Constanza S Meneses
- Graduate School, School of Veterinary Sciences, Universidad Austral de Chile, Valdivia, Chile
| | - Heine Y Müller
- Graduate School, School of Veterinary Sciences, Universidad Austral de Chile, Valdivia, Chile
| | - Marianne P Werner
- Animal Science Department/School of Veterinary Sciences, Universidad Austral de Chile, Valdivia, Chile
| | - Hedie Bustamante
- Veterinary Clinical Sciences Department, Universidad Austral de Chile, Valdivia, Chile
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Is there an association between psychological factors and developing complex regional pain syndrome after an ankle fracture? CURRENT ORTHOPAEDIC PRACTICE 2018. [DOI: 10.1097/bco.0000000000000622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lee YH, Lee KM, Kim HG, Kang SK, Auh QS, Hong JP, Chun YH. Orofacial complex regional pain syndrome: pathophysiologic mechanisms and functional MRI. Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 124:e164-e170. [PMID: 28522185 DOI: 10.1016/j.oooo.2017.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 02/27/2017] [Accepted: 03/03/2017] [Indexed: 01/29/2023]
Abstract
Complex regional pain syndrome (CRPS) is one of the most challenging chronic pain conditions and is characterized by burning pain, allodynia, hyperalgesia, autonomic changes, trophic changes, edema, and functional loss involving mainly the extremities. Until recently, very few reports have been published concerning CRPS involving the orofacial area. We report on a 50-year-old female patient who presented with unbearable pain in all of her teeth and hypersensitivity of the facial skin. She also reported intractable pain in both extremities accompanied by temperature changes and orofacial pain that increased when the other pains were aggravated. In the case of CRPS with trigeminal neuropathic pain, protocols for proper diagnosis and prompt treatment have yet to be established in academia or in the clinical field. We performed functional magnetic resonance imaging for a thorough analysis of the cortical representation of the affected orofacial area immediately before and immediately after isolated light stimulus of the affected hand and foot and concluded that CRPS can be correlated with trigeminal neuropathy in the orofacial area. Furthermore, the patient was treated with carbamazepine administration and stellate ganglion block, which can result in a rapid improvement of pain in the trigeminal region.
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Affiliation(s)
- Yeon-Hee Lee
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
| | - Kyung Mi Lee
- Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, Korea.
| | - Hyug-Gi Kim
- Department of Radiology, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Soo-Kyung Kang
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
| | - Q-Schick Auh
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
| | - Jyung-Pyo Hong
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
| | - Yang-Hyun Chun
- Department of Orofacial Pain and Oral Medicine, Kyung Hee University Dental Hospital, Seoul, Korea
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Buryanov A, Kostrub A, Kotiuk V. Endocrine disorders in women with complex regional pain syndrome type I. Eur J Pain 2016; 21:302-308. [PMID: 27506801 DOI: 10.1002/ejp.924] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND The question of hormonal dysregulation in patients with CRPS I in whole was investigated very scantily. There are only a few studies concerning catecholamines, oestrogens and endorphins independently. Other hormones were studied in patients with different other chronic pain conditions. Considering the accumulation of sufficient knowledge about the role of disadaptation processes in CRPS I pathogenesis and the role of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-ovarian systems in the process of adaptation it was logical and consistent to define the role of hormonal dysregulation of these systems in patients with CRPS I. OBJECTIVES Our objective was to determine the role of hypothalamic-pituitary-adrenal and hypothalamic-pituitary-ovarian systems in pathogenesis of complex regional pain syndrome type I (CRPS I) in women. METHODS We investigated the pituitary gonadotropic function and the function of sex glands in women with CRPS I and healthy volunteers by measuring the plasma levels of estradiol (E2 ), follicle-stimulating hormone, luteinizing hormone, prolactin, adrenocorticotropic hormone, and cortisol, and urinary excretion of 17-ketosteroids, 17-oxycocorticosteroids, epinephrine and norepinephrine. RESULTS Women with CRPS I were characterized by the decreased content of oestrogens in the blood plasma and increased pituitary gonadotrophic function. The disturbed ratio of anabolic and catabolic steroids in women with CRPS I was detected due to lower adrenal cortex function. CONCLUSIONS In patients with CRPS I endocrine status is characterized by hormonal imbalances of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal systems. The changes in reproductive and adaptation homeostasis characterize CRPS I as a form of the disease of disadaptation. SIGNIFICANCE This study determined the role of hypothalamic-pituitary-adrenal and hypothalamic-pituitary-ovarian systems in pathogenesis of CRPS I.
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Affiliation(s)
- A Buryanov
- Department of Orthopedics and Traumatology, National Medical University n.a. Bohomoletz A.A., Kiev, Ukraine
| | - A Kostrub
- Department of sports and ballet trauma, State Institution "Institute of Traumatology and Orthopedics of National Academy of Medical Sciences of Ukraine", Kiev, Ukraine
| | - V Kotiuk
- Department of sports and ballet trauma, State Institution "Institute of Traumatology and Orthopedics of National Academy of Medical Sciences of Ukraine", Kiev, Ukraine
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Barrett JE, Haas DA. Perspectives and Trends in Pharmacological Approaches to the Modulation of Pain. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2016; 75:1-33. [PMID: 26920007 DOI: 10.1016/bs.apha.2015.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pharmacological approaches to our understanding and treatment of pain have had a long history and have traditionally relied on very few drugs that either have significant side effects and abuse liability, such as the nonsteroidal anti-inflammatory drugs or the opioids, respectively, or those that have been developed for other conditions such as the tricyclic antidepressants. The pathophysiology of pain is undoubtedly complex, complicated in part by the fact that it is not a singular condition, and has a variety of etiologies and a number of associated comorbidities that make treatment interventions challenging. Moreover, there are changes in the central nervous system during the course of the development of chronic pain that, in a manner parallel to neurodegenerative disorders, likely require different pharmacological approaches in the early stages of acute pain compared to those that would be effective when pain has become chronic. This chapter reviews the current status of the field of pain research focusing on some relatively underdeveloped areas, such as pain and its associated comorbidities, and the use of transgenic animals and drug self-administration procedures in the context of analgesic assessment. This chapter also incorporates more recent developments and emerging trends in the area of epigenetics, biomarkers, and the use of induced pluripotent stem cells for pharmacological evaluation, target identification, and validation. Recent progress in the study of "organs-on-a-chip" will also be included in this overview, setting expectations for future progress that integrates these advances for deeper insights into mechanisms, novel treatments, and facilitated efforts in drug discovery.
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Affiliation(s)
- James E Barrett
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.
| | - Derick A Haas
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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Nascimento FP, Magnussen C, Yousefpour N, Ribeiro-da-Silva A. Sympathetic fibre sprouting in the skin contributes to pain-related behaviour in spared nerve injury and cuff models of neuropathic pain. Mol Pain 2015; 11:59. [PMID: 26376854 PMCID: PMC4574171 DOI: 10.1186/s12990-015-0062-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/08/2015] [Indexed: 02/06/2023] Open
Abstract
Background Cuff and spared nerve injury (SNI) in the sciatic territory are widely used to model neuropathic pain. Because nociceptive information is first detected in skin, it is important to understand how alterations in peripheral innervation contribute to pain in each model. Over 16 weeks in male rats, changes in sensory and autonomic innervation of the skin were described after cuff and SNI using immunohistochemistry to label myelinated (neurofilament 200 positive—NF200+) and peptidergic (calcitonin gene-related peptide positive—CGRP+) primary afferents and sympathetic fibres (dopamine β-hydroxylase positive—DBH+) Results Cuff and SNI caused an early loss and later reinnervation of NF200 and CGRP fibres in the plantar hind paw skin. In both models, DBH+ fibres sprouted into the upper dermis of the plantar skin 4 and 6 weeks after injury. Despite these similarities, behavioural pain measures were significantly different in each model. Sympathectomy using guanethidine significantly alleviated mechanical allodynia 6 weeks after cuff, when peak sympathetic sprouting was observed, having no effect at 2 weeks, when fibres were absent. In SNI animals, mechanical allodynia in the lateral paw was significantly improved by guanethidine at 2 and 6 weeks, and the development of cold hyperalgesia, which roughly paralleled the appearance of ectopic sympathetic fibres, was alleviated by guanethidine at 6 weeks. Sympathetic fibres did not sprout into the dorsal root ganglia at 2 or 6 weeks, indicating their unimportance to pain behaviour in these two models. Conclusions Alterations in sympathetic innervation in the skin represents an important mechanism that contributes to pain in cuff and SNI models of neuropathic pain.
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Affiliation(s)
- Francisney P Nascimento
- Department of Pharmacology and Therapeutics, McGill University, McIntyre Medical Building, 3655 Promenade Sir William Osler, Room 1215, Montreal, QC, H3G 1Y6, Canada. .,Alan Edwards Centre for Research on Pain, McGill University, Montreal, QC, H3A 0G1, Canada.
| | - Claire Magnussen
- Department of Pharmacology and Therapeutics, McGill University, McIntyre Medical Building, 3655 Promenade Sir William Osler, Room 1215, Montreal, QC, H3G 1Y6, Canada. .,Alan Edwards Centre for Research on Pain, McGill University, Montreal, QC, H3A 0G1, Canada.
| | - Noosha Yousefpour
- Department of Pharmacology and Therapeutics, McGill University, McIntyre Medical Building, 3655 Promenade Sir William Osler, Room 1215, Montreal, QC, H3G 1Y6, Canada. .,Alan Edwards Centre for Research on Pain, McGill University, Montreal, QC, H3A 0G1, Canada.
| | - Alfredo Ribeiro-da-Silva
- Department of Pharmacology and Therapeutics, McGill University, McIntyre Medical Building, 3655 Promenade Sir William Osler, Room 1215, Montreal, QC, H3G 1Y6, Canada. .,Alan Edwards Centre for Research on Pain, McGill University, Montreal, QC, H3A 0G1, Canada. .,Department of Anatomy and Cell Biology, McGill University, Montreal, QC, H3A 0C7, Canada.
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Smith SB, Reenilä I, Männistö PT, Slade GD, Maixner W, Diatchenko L, Nackley AG. Epistasis between polymorphisms in COMT, ESR1, and GCH1 influences COMT enzyme activity and pain. Pain 2014; 155:2390-9. [PMID: 25218601 DOI: 10.1016/j.pain.2014.09.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 07/29/2014] [Accepted: 09/04/2014] [Indexed: 01/19/2023]
Abstract
Abnormalities in the enzymatic activity of catechol-O-methyltransferase (COMT) contribute to chronic pain conditions, such as temporomandibular disorders (TMD). Thus, we sought to determine the effects of polymorphisms in COMT and functionally related pain genes in the COMT pathway (estrogen receptor 1 [ESR1], guanosine-5-triphosphate cyclohydrolase 1 [GCH1], methylenetetrahydrofolate reductase [MTHFR]) on COMT enzymatic activity, musculoskeletal pain, and pain-related intermediate phenotypes among TMD cases and healthy control subjects. Results show that the COMT rs4680 (val(158)met) polymorphism is most strongly associated with outcome measures, such that individuals with the minor A allele (met) exhibit reduced COMT activity, increased TMD risk, and increased musculoskeletal pain. Epistatic interactions were observed between the COMT rs4680 polymorphism and polymorphisms in GCH1 and ESR1. Among individuals with the COMT met allele, those with 2 copies of the GCH1 rs10483639 minor G allele exhibit normalized COMT activity and increased mechanical pain thresholds. Among individuals with the COMT val allele, those with 2 copies of the ESR1 rs3020377 minor A allele exhibit reduced COMT activity, increased bodily pain, and poorer self-reported health. These data reveal that the GCH1 minor G allele confers a protective advantage among met carriers, whereas the ESR1 minor A allele is disadvantageous among val carriers. Furthermore, these data suggest that the ability to predict the downstream effects of genetic variation on COMT activity is critically important to understanding the molecular basis of chronic pain conditions.
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Affiliation(s)
- Shad B Smith
- Center for Pain Research and Innovation, School of Dentistry, University of North Carolina, Chapel Hill, NC, USA
| | - Ilkka Reenilä
- Division of Pharmacology and Toxicology, University of Helsinki, Helsinki, Finland
| | - Pekka T Männistö
- Division of Pharmacology and Toxicology, University of Helsinki, Helsinki, Finland
| | - Gary D Slade
- Center for Pain Research and Innovation, School of Dentistry, University of North Carolina, Chapel Hill, NC, USA
| | - William Maixner
- Center for Pain Research and Innovation, School of Dentistry, University of North Carolina, Chapel Hill, NC, USA
| | - Luda Diatchenko
- Center for Pain Research and Innovation, School of Dentistry, University of North Carolina, Chapel Hill, NC, USA; Alan Edwards Pain Centre For Research on Pain, McGill University, Montreal, Canada
| | - Andrea G Nackley
- Center for Pain Research and Innovation, School of Dentistry, University of North Carolina, Chapel Hill, NC, USA.
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Lecours A, Piché M. Complex regional pain syndrome: From diagnosis to rehabilitation. World J Anesthesiol 2014; 3:46-60. [DOI: 10.5313/wja.v3.i1.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 09/25/2013] [Accepted: 12/16/2013] [Indexed: 02/07/2023] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating pathology characterised by intense chronic pain associated with vasomotor, sensory and motor dysfunction of the affected limb. Although the pathophysiology of CRPS is not fully understood, it is recognised that inflammatory processes and autonomic dysfunction are involved. These processes are associated with peripheral and central sensitisation as well as changes in brain structure and function, and are reflected in the clinical presentation of CRPS. CRPS management requires an interdisciplinary team and requires the therapeutic approach to be individualised. With regard to pharmacological treatment, bisphosphonates, corticosteroids, ketamine and anticonvulsants have been demonstrated to be effective for CRPS management. Psychotherapy, including cognitive-behavioural therapy, has produced promising results but more studies are needed to confirm its efficacy. Among rehabilitation interventions, there is evidence of the efficacy of physiotherapy and occupational therapy in diminishing CRPS symptoms and achieving a higher level of functioning. In this regard, the rehabilitation modality that seems the most promising according to the actual literature is graded motor imagery, which can help to reverse the maladaptive neuroplasticity occurring in CRPS.
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Borchers A, Gershwin M. Complex regional pain syndrome: A comprehensive and critical review. Autoimmun Rev 2014; 13:242-65. [DOI: 10.1016/j.autrev.2013.10.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2013] [Indexed: 12/19/2022]
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Schlereth T, Drummond PD, Birklein F. Inflammation in CRPS: role of the sympathetic supply. Auton Neurosci 2013; 182:102-7. [PMID: 24411269 DOI: 10.1016/j.autneu.2013.12.011] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 12/11/2013] [Indexed: 12/21/2022]
Abstract
Acute Complex Regional Pain Syndrome (CRPS) is associated with signs of inflammation such as increased skin temperature, oedema, skin colour changes and pain. Pro-inflammatory cytokines (tumour necrosis factor-α (TNF-α), interleukin-2 (IL-2), IL-1beta, IL-6) are up-regulated, whereas anti-inflammatory cytokines (IL-4, IL-10) are diminished. Adaptive immunity seems to be involved in CRPS pathophysiology as many patients have autoantibodies directed against β2 adrenergic and muscarinic-2 receptors. In an animal tibial fracture model changes in the innate immune response such as up-regulation of keratinocytes are also found. Additionally, CRPS is accompanied by increased neurogenic inflammation which depends mainly on neuropeptides such as CGRP and Substance P. Besides inflammatory signs, sympathetic nervous system involvement in CRPS results in cool skin, increased sweating and sympathetically-maintained pain. The norepinephrine level is lower in the CRPS-affected than contralateral limb, but sympathetic sprouting and up-regulation of alpha-adrenoceptors may result in an adrenergic supersensitivity. The sympathetic nervous system and inflammation interact: norepinephrine influences the immune system and the production of cytokines. There is substantial evidence that this interaction contributes to the pathophysiology and clinical presentation of CRPS, but this interaction is not straightforward. How inflammation in CRPS might be exaggerated by sympathetic transmitters requires further elucidation.
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Affiliation(s)
- Tanja Schlereth
- Department of Neurology, Langenbeckstr, 1, D-55131 Mainz, Germany.
| | - Peter D Drummond
- School of Psychology and Exercise Science, Murdoch University, 6150 Western Australia, Australia
| | - Frank Birklein
- Department of Neurology, Langenbeckstr, 1, D-55131 Mainz, Germany
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Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a painful disorder without a known unifying mechanism. There are little data on which to base evaluation and treatment decisions, and what data are available come from studies involving adults; however, even that literature is relatively sparse. Developing robust research for CRPS in children is essential for the progress toward optimal treatment. OBJECTIVES To determine potential avenues of research in pediatric CRPS based on a review of the literature. Areas of concern include diagnostic criteria, peripheral mechanisms, central nervous system mechanisms, the role of the autonomic nervous system, possible risk factors, options for prevention and potential avenues of treatment. METHODS A literature review was performed and the results applied to form the hypotheses posited in the form of research questions. RESULTS AND CONCLUSIONS CRPS is a complicated entity that is more than a painful sensory condition. There is evidence for peripheral inflammatory and neurological changes, and reorganization in both sensory and motor cortexes. In addition, a significant motor component is frequently observed and there appear to be tangible risk factors. Many of these pieces of evidence suggest options for prevention, treatment and monitoring progress and outcome. Most of the data are derived from adult studies and need to be replicated in children. Furthermore, there may be factors unique to pediatrics due to developmental changes in neuroplasticity as well as somatic, endocrinological and emotional growth. Some of these developmental factors may shed light on the adult condition.
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Harden RN, Oaklander AL, Burton AW, Perez RSGM, Richardson K, Swan M, Barthel J, Costa B, Graciosa JR, Bruehl S. Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. PAIN MEDICINE 2013; 14:180-229. [PMID: 23331950 DOI: 10.1111/pme.12033] [Citation(s) in RCA: 292] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This is the fourth edition of diagnostic and treatment guidelines for complex regional pain syndrome (CRPS; aka reflex sympathetic dystrophy). METHODS Expert practitioners in each discipline traditionally utilized in the treatment of CRPS systematically reviewed the available and relevant literature; due to the paucity of levels 1 and 2 studies, less rigorous, preliminary research reports were included. The literature review was supplemented with knowledge gained from extensive empirical clinical experience, particularly in areas where high-quality evidence to guide therapy is lacking. RESULTS The research quality, clinical relevance, and "state of the art" of diagnostic criteria or treatment modalities are discussed, sometimes in considerable detail with an eye to the expert practitioner in each therapeutic area. Levels of evidence are mentioned when available, so that the practitioner can better assess and analyze the modality under discussion, and if desired, to personally consider the citations. Tables provide details on characteristics of studies in different subject domains described in the literature. CONCLUSIONS In the humanitarian spirit of making the most of all current thinking in the area, balanced by a careful case-by-case analysis of the risk/cost vs benefit analysis, the authors offer these "practical" guidelines.
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Affiliation(s)
- R Norman Harden
- Center for Pain Studies, Rehabilitation Institute of Chicago, Illinois 60611, USA.
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Complex [corrected] regional pain syndrome: what specialized rehabilitation services do patients require? Curr Pain Headache Rep 2012; 16:139-46. [PMID: 22415615 DOI: 10.1007/s11916-012-0253-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Complex [corrected] regional pain syndrome (CRPS) is a complex disorder, the optimal treatment of which requires an interdisciplinary approach encompassing medical, interventional, psychological, and rehabilitation services that emphasize the role of physical and occupational therapies. The central focus of treatment is the restoration of function, utilizing a systematic, coordinated, and progressive set of therapeutic strategies. The poorly delineated pathophysiology and variable course of CRPS suggest that individualized strategies are required for optimal management, but also mean that carefully controlled trials of physiotherapy are difficult to conduct. This article presents a brief review of the nature and pathophysiology of CRPS, the medical and psychological approaches that have been found to be effective, and a review of the current trends in rehabilitation.
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Guo W, Wang H, Zou S, Gu M, Watanabe M, Wei F, Dubner R, Huang GTJ, Ren K. Bone marrow stromal cells produce long-term pain relief in rat models of persistent pain. Stem Cells 2011; 29:1294-303. [PMID: 21630378 DOI: 10.1002/stem.667] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Chronic pain conditions are difficult to treat and are major health problems. Bone marrow stromal cells (BMSCs) have generated considerable interest as a candidate for cell-based therapy. BMSCs are readily accessible and are easy to isolate and expand ex vivo. Clinical studies show that direct injection of BMSCs does not produce unwanted side effects and is well tolerated and safe. Here, we show that a single systemic (intravenous) or local injection (into the lesion site) of rat primary BMSCs reversed pain hypersensitivity in rats after injury and that the effect lasted until the conclusion of the study at 22 weeks. The pain hypersensitivity was rekindled by naloxone hydrochloride, an opioid receptor antagonist that acts peripherally and centrally, when tested at 1-5 weeks after BMSC infusion. In contrast, naloxone methiodide, a peripherally acting opioid receptor antagonist, only rekindled hyperalgesia in the first 3 weeks of BMSC treatment. Focal downregulation of brainstem mu opioid receptors by RNA interference (RNAi) reversed the effect of BMSCs, when RNAi was introduced at 5- but not 1-week after BMSC transplantation. Thus, BMSCs produced long-term relief of pain and this effect involved activation of peripheral and central opioid receptors in distinct time domains. The findings prompt studies to elucidate the cellular mechanisms of the BMSC-induced pain relieving effect and translate these observations into clinical settings.
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Affiliation(s)
- Wei Guo
- Department of Neural and Pain Sciences, Dental School, University of Maryland, Baltimore, Maryland 21201-1586, USA
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Azari P, Lu Y, Clarke CFM, Collins T, Briones D, Huh B. Pathophysiology of the spreading of complex regional pain syndrome revisited: a case report. Neuromodulation 2011; 14:428-31; discussion 431. [PMID: 21854496 DOI: 10.1111/j.1525-1403.2011.00385.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine if there is a relationship in our patient developing complex regional pain syndrome from a jellyfish and its subsequent spread to the contralateral side. METHODS Data bases were searched using PubMed and Ovid. Keywords searched include "complex regional pain syndrome,""jelly fish," and "pathophysiology." RESULTS This patient was successfully treated with a spinal cord stimulator implantation with bilateral lead placement at thoracic spine (T9) stimulating her lower extremities in addition to the leads that had already been placed in her cervical spine for her upper extremities. CONCLUSION Definite knowledge of the pathophysiology of complex regional pain syndrome would allow better identification of risk factors for the development of this condition after trauma. This patient is at higher risk of developing complex regional pain syndrome and should avoid surgeries (such as knee and wrist surgeries) and high risk physical activities.
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Affiliation(s)
- Pari Azari
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA.
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Henson P, Bruehl S. Complex regional pain syndrome: state of the art update. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 12:156-67. [PMID: 20842553 DOI: 10.1007/s11936-010-0063-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OPINION STATEMENT Although the pathophysiology of complex regional pain syndrome (CRPS) is not fully understood, it appears to reflect multiple interacting mechanisms. In addition to altered autonomic function, a role for inflammatory mechanisms and altered somatosensory and motor function in the brain is increasingly suggested. Several possible risk factors for development of CRPS, including genetic factors, have been identified. Few treatments have been proven effective for CRPS in well-designed clinical trials. However, recent work suggests that bisphosphonates may be useful in CRPS management and that the N-methyl-D: -aspartate receptor antagonist ketamine significantly reduces CRPS pain when administered topically or intravenously at subanesthetic dosages. Extended use of ketamine at anesthetic dosages ("ketamine coma") remains a controversial and unproven treatment for CRPS. Spinal cord stimulation may be effective for reducing pain in approximately two thirds of CRPS patients not responding to other treatments, but its efficacy appears to diminish over time.
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Affiliation(s)
- Patrick Henson
- Vanderbilt University Medical Center, 701 Medical Arts Building, 1211 Twenty-First Avenue South, Nashville, TN, 37212, USA
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van de Meent H, Oerlemans M, Bruggeman A, Klomp F, van Dongen R, Oostendorp R, Frölke JP. Safety of "pain exposure" physical therapy in patients with complex regional pain syndrome type 1. Pain 2011; 152:1431-1438. [PMID: 21474244 DOI: 10.1016/j.pain.2011.02.032] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 02/14/2011] [Accepted: 02/14/2011] [Indexed: 02/07/2023]
Abstract
"Pain exposure" physical therapy (PEPT) is a new treatment for patients with complex regional pain syndrome type 1 (CRPS-1) that consists of a progressive-loading exercise program and management of pain-avoidance behavior without the use of specific CRPS-1 medication or analgesics. The aim of this study was to investigate primarily whether PEPT could be applied safely in patients with CRPS-1. Twenty patients with CRPS-1 were consecutively enrolled in the study after giving informed consent. The diagnosis of CRPS-1 was defined using the Bruehl and Harden/IASP diagnostic criteria. CRPS-1 was diagnosed between 3 and 18 months after the inciting event (trauma). According to a multiple single-case design (baseline [A1], treatment [B], follow-up [A2]), multiple baseline and follow-up measurements were performed to evaluate changes in CRPS signs and symptoms and to assess functional parameters. When comparing the baseline with the follow-up phase, patients improved significantly with respect to pain on the visual analogue scale (57%), pain intensity (48%), muscle strength (52%), arm/shoulder/hand disability (36%), 10-meter walking speed (29%), pain disability index (60%), kinesiophobia (18%), and the domains of perceived health change in the SF-36 survey (269%). Three patients initially showed increased vegetative signs but improved in all other CRPS parameters and showed good functional recovery at follow-up. We conclude that PEPT is a safe and effective treatment for patients with CRPS-1. A progressive-loading exercise program and management of pain-avoidance behavior without the use of specific medication ("pain exposure" physical therapy) is safe and effective for patients with complex regional pain syndrome.
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Affiliation(s)
- Hendrik van de Meent
- Department of Rehabilitation, Nijmegen Centre of Evidence Based Practice, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Department of Orthopedic Surgery, Nijmegen Centre of Evidence Based Practice, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Scientific Institute for Quality of Healthcare, Nijmegen Centre of Evidence Based Practice, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Department of Surgery, Nijmegen Centre of Evidence Based Practice, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Department of Anesthesiology, Pain and Palliative Medicine, Nijmegen Centre of Evidence Based Practice, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Beerthuizen A, Stronks DL, Huygen FJPM, Passchier J, Klein J, Spijker AV. The association between psychological factors and the development of complex regional pain syndrome type 1 (CRPS1)--a prospective multicenter study. Eur J Pain 2011; 15:971-5. [PMID: 21459637 DOI: 10.1016/j.ejpain.2011.02.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Revised: 01/16/2011] [Accepted: 02/24/2011] [Indexed: 02/08/2023]
Abstract
The objective of this study was to investigate the association between psychological factors and complex regional pain syndrome type 1 (CRPS1). A prospective multicenter cohort study was performed involving the emergency room of three hospitals, and patients age 18years or older, with a single fracture, were included in the study. At baseline (T0), participants completed a questionnaire covering demographic, psychological (Symptom Checklist-90), and medical variables. At plaster removal (T1) and at T2, the participants completed a questionnaire addressing symptoms of CRPS1. Psychological factors that were analysed were agoraphobia, depression, somatization, insufficiency, (interpersonal) sensitivity, insomnia, and life events. In total, 596 consecutive patients were included in the study, and 7.0% were diagnosed with CRPS1. None of the psychological factors predicted the development of CRPS1. The scores on the Symptom Checklist-90 subscales fell into the range of the general population and were, in most cases, average or below average when compared with those of pain patients or psychiatric patients. No empirical evidence supports a diagnosis of CRPS1 patients as psychologically different, and the current results indicate that there is no association between psychological factors and CRPS1.
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Affiliation(s)
- Annemerle Beerthuizen
- Department of Medical Psychology and Psychotherapy, Erasmus MC, Rotterdam, The Netherlands.
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Dilek B, Yemez B, Kizil R, Kartal E, Gulbahar S, Sari O, Akalin E. Anxious personality is a risk factor for developing complex regional pain syndrome type I. Rheumatol Int 2011; 32:915-20. [DOI: 10.1007/s00296-010-1714-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Accepted: 12/18/2010] [Indexed: 11/24/2022]
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Harden NR, Bruehl S, Perez RS, Birklein F, Marinus J, Maihofner C, Lubenow T, Buvanendran A, Mackey S, Graciosa J, Mogilevski M, Ramsden C, Schlereth T, Chont M, Vatine JJ. Development of a severity score for CRPS. Pain 2010; 151:870-876. [DOI: 10.1016/j.pain.2010.09.031] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 09/17/2010] [Accepted: 09/24/2010] [Indexed: 10/18/2022]
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Psychologic factors in the development of complex regional pain syndrome: history, myth, and evidence. Clin J Pain 2010; 26:258-63. [PMID: 20173441 DOI: 10.1097/ajp.0b013e3181bff815] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The present paper examines the literature that addresses psychologic aspects involved in complex regional pain syndrome from a historic perspective to provide a rationale for the emergence of psychologic theories to explain its pathogenesis. The support of such perspective is then analyzed through the review of evidence-based studies. METHODS A review of the literature from a historic perspective was presented since its first description to the present time, including the clinical presentation and associated symptoms. An evidence-based approach was used to review the literature on complex regional pain syndrome and psychologic factors associated with the etiology or as predictors in the development of the disorder. RESULTS After reviewing the literature on the history and the myths associated with complex regional pain syndrome, a hypothesis is provided based on an analysis of the Zeitgeist in the development of the psychologic theory associated with the disorder. We also concluded there is no evidence to support a linear relationship that establishes a psychologic predisposition to develop the disorder. DISCUSSION An analysis of the Zeitgeist when complex regional pain syndrome was first described helps to understand the long-standing theories associated with a psychological theory of its etiology. This understanding should help to undermine the perpetuation of such claims which may contribute to undertreatment and misdiagnosis. To be consistent with todays Zeitgeist we must incorporate psychologic aspects, which while not causal in nature or exclusive of complex regional pain syndrome, are strongly associated with a wide spectrum of chronic pain disorders.
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Edwards RR, Wasan AD, Bingham CO, Bathon J, Haythornthwaite JA, Smith MT, Page GG. Enhanced reactivity to pain in patients with rheumatoid arthritis. Arthritis Res Ther 2009; 11:R61. [PMID: 19413909 PMCID: PMC2714104 DOI: 10.1186/ar2684] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Revised: 04/17/2009] [Accepted: 05/04/2009] [Indexed: 12/31/2022] Open
Abstract
Introduction Maladaptive physiological responses to stress appear to play a role in chronic inflammatory diseases such as rheumatoid arthritis (RA). However, relatively little stress research in RA patients has involved the study of pain, the most commonly reported and most impairing stressor in RA. In the present study, we compared psychophysical and physiological responses to standardized noxious stimulation in 19 RA patients and 21 healthy controls. Methods Participants underwent a single psychophysical testing session in which responses to a variety of painful stimuli were recorded, and blood samples were taken at multiple time points to evaluate the reactivity of cortisol, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) to the experience of acute pain. Results The findings suggest that RA patients display a fairly general hyperalgesia to mechanical and thermal stimuli across several body sites. In addition, while serum cortisol levels did not differ at baseline or following pain testing in patients relative to controls, the RA patients tended to show elevations in serum IL-6 and demonstrated enhanced pain-reactivity of serum levels of TNF-α compared with the healthy controls (P < 0.05). Conclusions These findings highlight the importance of pain as a stressor in RA patients and add to a small body of literature documenting amplified responses to pain in RA. Future studies of the pathophysiology of RA would benefit from the consideration of acute pain levels when comparing RA patients with other groups, and future trials of analgesic interventions in RA patients may benefit from evaluating the effects of such interventions on inflammatory activity.
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Affiliation(s)
- Robert R Edwards
- Department of Anesthesiology, Harvard Medical School, Brigham & Women's Hospital, Chestnut Hill, MA 02467, USA.
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Low enzymatic activity haplotypes of the human catechol-O-methyltransferase gene: enrichment for marker SNPs. PLoS One 2009; 4:e5237. [PMID: 19365560 PMCID: PMC2664927 DOI: 10.1371/journal.pone.0005237] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Accepted: 03/17/2009] [Indexed: 12/18/2022] Open
Abstract
Catechol-O-methyltransferase (COMT) is an enzyme that plays a key role in the modulation of catechol-dependent functions such as cognition, cardiovascular function, and pain processing. Three common haplotypes of the human COMT gene, divergent in two synonymous and one nonsynonymous (val(158)met) position, designated as low (LPS), average (APS), and high pain sensitive (HPS), are associated with experimental pain sensitivity and risk of developing chronic musculoskeletal pain conditions. APS and HPS haplotypes produce significant functional effects, coding for 3- and 20-fold reductions in COMT enzymatic activity, respectively. In the present study, we investigated whether additional minor single nucleotide polymorphisms (SNPs), accruing in 1 to 5% of the population, situated in the COMT transcript region contribute to haplotype-dependent enzymatic activity. Computer analysis of COMT ESTs showed that one synonymous minor SNP (rs769224) is linked to the APS haplotype and three minor SNPs (two synonymous: rs6267, rs740602 and one nonsynonymous: rs8192488) are linked to the HPS haplotype. Results from in silico and in vitro experiments revealed that inclusion of allelic variants of these minor SNPs in APS or HPS haplotypes did not modify COMT function at the level of mRNA folding, RNA transcription, protein translation, or enzymatic activity. These data suggest that neutral variants are carried with APS and HPS haplotypes, while the high activity LPS haplotype displays less linked variation. Thus, both minor synonymous and nonsynonymous SNPs in the coding region are markers of functional APS and HPS haplotypes rather than independent contributors to COMT activity.
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37
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Affiliation(s)
- Marissa de Mos
- Erasmus University Medical Center, Pharmaco-epidemiology Unit, Departments of Medical Informatics and Epidemiology & Biostatistics, Rotterdam, The Netherlands.
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Harden RN, Gagnon CM, Gallizzi M, Khan AS, Newman D. Residual Limbs of Amputees Are Significantly Cooler than Contralateral Intact Limbs. Pain Pract 2008; 8:342-7. [DOI: 10.1111/j.1533-2500.2008.00216.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wesseldijk F, Fekkes D, Huygen FJ, Bogaerts-Taal E, Zijlstra FJ. Increased plasma serotonin in complex regional pain syndrome type 1. Anesth Analg 2008; 106:1862-7. [PMID: 18499624 DOI: 10.1213/ane.0b013e318172c2f4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In patients with complex regional pain syndrome type 1 (CRPS1), some improvement can be achieved by the administration of ketanserin, a 5-HT(2A) receptor antagonist. We measured plasma levels of serotonin (5-HT) during CRPS1 and correlated these levels with disease characteristics. METHODS Plasma 5-HT was measured in 35 patients who had CRPS1 for 3 yr and compared with 35 age-matched healthy controls. RESULTS The plasma 5-HT levels were 411 +/- 263 nmol/L and 29 +/- 18 nmol/L, respectively (P < 0.001). No correlations with disease characteristics were observed. CONCLUSIONS The markedly elevated levels of plasma 5-HT in CRPS1 patients suggest a role for 5-HT during the course of this disease. However, because of the lack of correlations with distinct disease characteristics, 5-HT is probably one of a number of mediators in CRPS1.
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Affiliation(s)
- Feikje Wesseldijk
- Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
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Kaufmann I, Eisner C, Richter P, Huge V, Beyer A, Chouker A, Schelling G, Thiel M. Psychoneuroendocrine stress response may impair neutrophil function in complex regional pain syndrome. Clin Immunol 2007; 125:103-11. [PMID: 17702656 DOI: 10.1016/j.clim.2007.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Revised: 07/08/2007] [Accepted: 07/09/2007] [Indexed: 11/18/2022]
Abstract
In order to elucidate the interaction between pain, stress and innate immunity in complex regional pain syndrome (CRPS), we assessed pain and stress levels in CRPS patients and compared ex vivo functions of neutrophils between patients with CRPS and healthy volunteers. As compared with healthy volunteers, the following major alterations in CRPS patients were found: (I) elevated stress score (PTSS-10) and stress hormone concentrations, (II) decreased expression of the CD62L and CD11b/CD18 on neutrophils, (III) impaired ability of autologous plasma to enhance the capability of neutrophils to phagocytose zymosan particles, and (IV) a negative correlation between PTSS-10 values and autologous plasma enhanced phagocytosis. In vitro incubation of neutrophils with catecholamines decreased phagocytosis of zymosan. In conclusion, CRPS patients exhibit signs of impaired innate immunity which might reflect the immunological consequence of an immunosuppressive neuroendocrine stress response.
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Affiliation(s)
- Ines Kaufmann
- Department of Anesthesiology, Klinikum Grosshadern, Ludwig-Maximilians-University, 81377, Munich, Germany
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Kaufmann I, Eisner C, Richter P, Huge V, Beyer A, Chouker A, Schelling G, Thiel M. Lymphocyte subsets and the role of TH1/TH2 balance in stressed chronic pain patients. Neuroimmunomodulation 2007; 14:272-80. [PMID: 18239379 DOI: 10.1159/000115041] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 11/14/2007] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The complex regional pain syndrome (CRPS) and fibromyalgia (FM) are chronic pain syndromes occurring in highly stressed individuals. Despite the known connection between the nervous system and immune cells, information on distribution of lymphocyte subsets under stress and pain conditions is limited. METHODS We performed a comparative study in 15 patients with CRPS type I, 22 patients with FM and 37 age- and sex-matched healthy controls and investigated the influence of pain and stress on lymphocyte number, subpopulations and the Th1/Th2 cytokine ratio in T lymphocytes. RESULTS Lymphocyte numbers did not differ between groups. Quantitative analyses of lymphocyte subpopulations showed a significant reduction of cytotoxic CD8+ lymphocytes in both CRPS (p < 0.01) and FM (p < 0.05) patients as compared with healthy controls. Additionally, CRPS patients were characterized by a lower percentage of IL-2-producing T cell subpopulations reflecting a diminished Th1 response in contrast to no changes in the Th2 cytokine profile. CONCLUSIONS Future studies are warranted to answer whether such immunological changes play a pathogenetic role in CRPS and FM or merely reflect the consequences of a pain-induced neurohumoral stress response, and whether they contribute to immunosuppression in stressed chronic pain patients.
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Affiliation(s)
- Ines Kaufmann
- Department of Anesthesiology, Klinikum Grosshadern, Ludwig Maximilians University, Munich, Germany
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Berthelot JM. Current management of reflex sympathetic dystrophy syndrome (complex regional pain syndrome type I). Joint Bone Spine 2006; 73:495-9. [PMID: 16837228 DOI: 10.1016/j.jbspin.2005.11.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2005] [Accepted: 11/30/2005] [Indexed: 11/15/2022]
Abstract
Although no major advances have occurred in the curative treatment of reflex sympathetic dystrophy syndrome (RSDS), new pathogenic insights may soon lead to innovative approaches, which may also prove effective in alleviating some forms of neuropathic pain. Preventing nerve compression and ischemia-reperfusion injury constitute valuable measures for preventing RSDS. Vitamin C administration can also prevent RSDS, together with clonidine in high-risk patients. Short-term glucocorticoid therapy has been found effective in preventing RSDS after stroke but has not been evaluated in other situations. Beneficial effects of bisphosphonates have been documented in several placebo-controlled trials. Placebo-controlled trials of ketamine and spinal cord stimulation are in order to confirm or refute the promising results obtained in open-label studies. Mirror visual feedback was introduced recently for the rehabilitation of patients with RSDS but needs to be evaluated in randomized controlled trials.
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Affiliation(s)
- Jean-Marie Berthelot
- Service de rhumatologie, Hôtel-Dieu, CHU de Nantes, 1, place Alexis, Nantes cedex 01, France.
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Abstract
Psychological and behavioral factors can exacerbate the pain and dysfunction associated with complex regional pain syndrome (CRPS) and could help maintain the condition in some patients. Effective management of CRPS requires that these psychosocial and behavioral aspects be addressed as part of an integrated multidisciplinary treatment approach. Well-controlled studies to guide the development of a psychological approach to CRPS management are not currently available. A sequenced protocol for psychological care in CRPS is therefore proposed based on available data and clinical experience. Regardless of the duration of the condition, all CRPS patients and their families should receive education about the negative effects of disuse, the pathophysiology of the syndrome, and possible interactions with psychological/behavioral factors. Patients with acute CRPS (<6-8 weeks) may not need additional psychological care. All patients with chronic CRPS should receive a thorough psychological evaluation, followed by cognitive-behavioral pain management treatment, including relaxation training with biofeedback. Patients making insufficient overall treatment progress or in whom comorbid psychiatric disorders/major ongoing life stressors are identified should additionally receive general cognitive-behavioral therapy to address these issues. The psychological component of treatment can work synergistically with medical and physical/occupational therapies to improve function and increase patients' ability to manage the condition successfully.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN 37212, USA.
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Burton AW, Bruehl S, Harden RN. Current diagnosis and therapy of complex regional pain syndrome: refining diagnostic criteria and therapeutic options. Expert Rev Neurother 2006; 5:643-51. [PMID: 16162088 DOI: 10.1586/14737175.5.5.643] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Complex regional pain syndrome is a clinically challenging entity both in terms of accurate diagnosis and effective treatment. Complex regional pain syndrome is a post-traumatic painful neurologic syndrome involving the somatosensory, sympathetic and often the somatomotor systems. This complex condition consists of local neurogenic inflammation out of proportion to injury; severe pain in the skin, subcutaneous tissues and joints; and a central hyperexcitability that is often compounded with a sympathetic component. The syndrome is multifaceted manifesting both central and peripheral neurologic pathophysiology, frequently including a prominent psychosocial component. The wide array of possible patient presentations and antecedent pathologies also complicate successful treatment. To further add to the clinical challenges of complex regional pain syndrome, the epidemiology and natural history of complex regional pain syndrome are only partially known; evidence concerning complex regional pain syndrome treatment has grown slowly, due in large part to the vagaries of diagnosis; and research data--when they are available--are difficult to interpret. Thus, in spite of our evolving understanding of this neurologic disorder, in many cases complex regional pain syndrome remains difficult to diagnose and treat successfully.
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Affiliation(s)
- Allen W Burton
- University of Texas MD Anderson Cancer Center, Department of Anestiology and Pain Medicine, 1400 Holcombe Boulavard-409, Houston, TX 77030, USA.
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Villemure C, Wassimi S, Bennett GJ, Shir Y, Bushnell CM. Unpleasant odors increase pain processing in a patient with neuropathic pain: psychophysical and fMRI investigation. Pain 2005; 120:213-220. [PMID: 16361059 DOI: 10.1016/j.pain.2005.10.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Revised: 10/03/2005] [Accepted: 10/31/2005] [Indexed: 11/30/2022]
Abstract
A 49-year old man with neuropathic pain in his right elbow, wrist and digits III-V of his hand reported that certain odors increased his pain by superimposing an electric shock-like pain to his already existing pain. Psychophysical testing revealed that the best predictor of pain exacerbation was odor unpleasantness. Functional magnetic resonance imaging (fMRI) showed increased activation following an unpleasant odor in pain related areas, including the thalamus, amygdala, insular and anterior cingulate cortices, with similar trends in primary somatosensory cortex hand/arm area. The increased pain and associated neural activations in response to unpleasant odors may be related to the phenomenon of synesthesia, to a rewiring of olfactory pathways onto pain pathways mimicking synesthesia or, to activation of the sympathetic nervous system.
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Affiliation(s)
- Chantal Villemure
- McGill Centre for Research on Pain, McGill University, Montreal, Québec, Canada Department of Anesthesia, McGill University, Montreal, Québec, Canada Faculty of Dentistry, McGill University, Montreal, Québec, Canada
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Harden RN, Houle TT, Green S, Remble TA, Weinland SR, Colio S, Lauzon J, Kuiken T. Biofeedback in the treatment of phantom limb pain: a time-series analysis. Appl Psychophysiol Biofeedback 2005; 30:83-93. [PMID: 15889588 DOI: 10.1007/s10484-005-2177-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Phantom limb pain (PLP) is a noxious, painful sensation that is perceived to occur in an amputated limb. It has been reported to occur in up to 85% of amputees. This pilot study examined the effectiveness of biofeedback in the treatment of nine individuals with PLP who received up to seven thermal/autogenic biofeedback sessions over the course of 4-6 weeks. Pain was assessed daily using the visual analog scale (VAS), the sum of the sensory descriptors, and the sum of the affective descriptors of the McGill short form. Interrupted time-series analytical models were created for each of the participants, allowing biofeedback sessions to be modeled as discrete interventions. Analyses of the VAS revealed that a 20% pain reduction was seen in five of the nine patients in the weeks after session 4, and that at least a 30% pain reduction (range: 25-66%) was seen in six of the seven patients in the weeks following session 6. Sensory descriptors of pain decreased more than the affective pain descriptors. These preliminary results provide some support for the use of biofeedback in the treatment of PLP and indicate the need for further, definitive study.
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Affiliation(s)
- R Norman Harden
- Center for Pain Studies, Rehabilitation Institute of Chicago/Northwestern University Medical School, Chicago, 446 Ontario Street, Suite 1011, Chicago, Illinois 60611, USA.
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