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Abstract
Background Evidence is overwhelming for sex differences in pain, with women representing the majority of the chronic pain patient population. There is a need to explore novel avenues to elucidate this sex bias in the development of chronic inflammatory pain conditions. Complex regional pain syndrome (CRPS) is a chronic neuropathic pain disorder, and the incidence of CRPS is greater in women than in men by ~4:1. Since neurogenic inflammation is a key feature of CRPS, dysregulation of inflammatory responses can be a factor in predisposing women to chronic pain. Methods Our studies investigating alterations in circulating microRNAs (miRNAs) in whole blood from female CRPS patients showed significant differential expression of miRNAs between responders and poor responders to ketamine treatment. Several of these miRNAs are predicted to target the long noncoding RNA, X-inactive-specific transcript (XIST). XIST mediates X-chromosome inactivation and is essential for equalizing the expression of X-linked genes between females and males. Based on the well-established role in inflammatory process, we focused on miR-34a, one of the miRNAs predicted to target XIST, and downregulated in CRPS patients responding poorly to ketamine. Results Our in vitro and in vivo models of acute inflammation and data from patients with CRPS showed that miR-34a can regulate XIST under inflammation directly, and through pro-inflammatory transcription factor Yin-Yang 1 (YY1). XIST was significantly upregulated in a subset of CRPS patients responding poorly to ketamine. Conclusion Since dysregulation of XIST can result in genes escaping inactivation or reactivation in female cells, further investigations on the role of XIST in the predominance of chronic inflammatory and pain disorders in women is warranted.
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Affiliation(s)
- Botros B Shenoda
- Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Yuzhen Tian
- Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Enrique Aradillas-Lopez
- Neurology, Drexel University College of Medicine, Philadelphia, PA, USA.,Vincera Institute, Philadelphia, PA, USA
| | | | - Seena K Ajit
- Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA, USA
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Becerra L, Schwartzman RJ, Kiefer RT, Rohr P, Moulton EA, Wallin D, Pendse G, Morris S, Borsook D. CNS Measures of Pain Responses Pre- and Post-Anesthetic Ketamine in a Patient with Complex Regional Pain Syndrome. ACTA ACUST UNITED AC 2016; 16:2368-85. [PMID: 26745152 DOI: 10.1111/pme.12939] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous reports have indicated that ketamine anesthesia may produce significant improvement if not complete recovery of patients with complex regional pain syndrome (CRPS). AIMS Here we report on a patient who had CRPS affecting mainly the right side of her body who underwent functional magnetic resonance imaging (fMRI) scans prior to and in the months following apparent successful treatment with anesthetic doses of ketamine. MATERIALS AND METHODS The patient underwent two imaging sessions: one during her pain state (CRPS+) and 1 month after her ketamine treatment in her pain-free state (CRPS-). Both spontaneous and evoked (brush, cold, and heat) pain scores decreased from 7–9/10 on a visual analog scale prior to the treatment to 0–1 immediately following and for months after the treatment. For each imaging session, the identical mechanical (brush) and thermal (cold and heat) stimuli were applied to the same location (the skin of the dorsum of the right hand). RESULTS Comparison of CRPS+ vs CRPS- for the three stimuli showed significant changes throughout the cerebral cortex (frontal, parietal, temporal, cingulate, and hippocampus), in subcortical regions such as caudate nucleus, and in the cerebellum. In addition, resting state network analysis showed a reversal of brain network state, and the recovered state paralleled specific default networks in healthy volunteers. DISCUSSION The observed changes in brain response to evoked stimuli provide a readout for the subjective response. CONCLUSION Future studies of brain function in these patients may provide novel insight into brain plasticity in response to this treatment for chronic pain.
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Affiliation(s)
- L Becerra
- Pain/Analgesia Imaging Neuroscience (PAIN) Group, Brain Imaging Center, McLean Hospital, Harvard Medical School, Belmont, Massachusetts
| | - R J Schwartzman
- Drexel University College of Medicine, Department of Neurology, Philadelphia, Pennsylvania, USA
| | - R T Kiefer
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tuebingen, Germany
| | - P Rohr
- Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tuebingen, Germany
| | - E A Moulton
- Pain/Analgesia Imaging Neuroscience (PAIN) Group, Brain Imaging Center, McLean Hospital, Harvard Medical School, Belmont, Massachusetts
| | - D Wallin
- Pain/Analgesia Imaging Neuroscience (PAIN) Group, Brain Imaging Center, McLean Hospital, Harvard Medical School, Belmont, Massachusetts
| | - G Pendse
- Pain/Analgesia Imaging Neuroscience (PAIN) Group, Brain Imaging Center, McLean Hospital, Harvard Medical School, Belmont, Massachusetts
| | - S Morris
- Pain/Analgesia Imaging Neuroscience (PAIN) Group, Brain Imaging Center, McLean Hospital, Harvard Medical School, Belmont, Massachusetts
| | - David Borsook
- Pain/Analgesia Imaging Neuroscience (PAIN) Group, Brain Imaging Center, McLean Hospital, Harvard Medical School, Belmont, Massachusetts
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Janicki PK, Alexander GM, Eckert J, Postula M, Schwartzman RJ. Analysis of Common Single Nucleotide Polymorphisms in Complex Regional Pain Syndrome: Genome Wide Association Study Approach and Pooled DNA Strategy. Pain Med 2016; 17:2344-2352. [PMID: 28025368 DOI: 10.1093/pm/pnw133] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The objective of this study was to use a genome-wide association (GWAS) approach and pooled DNA strategy to search for new genomic loci associated with complex regional pain syndrome (CRPS). DESIGN The study cohort consisted of 230 patients with established diagnosis of CRPS. The control group consisted of 230 age- and gender-matched subjects without chronic pain. We tested the association of common single nucleotide polymorphisms (SNPs), genotyped using a high-density microarray platform, with CRPS phenotype. This was followed by individual genotyping of the most significant SNPs identified in the microarray genomic scan, in both original discovery (N = 115) and independent verification (N = 115) groups of patients with CRPS, as well as in the appropriate matched control subjects. RESULTS The results of our study provide no support for the initial hypothesis of the existence of an association between any investigated genomic targets (including GWAS for all genomic loci available on the microarray, and focused scan of the HLA locus on chromosome 6) and CRPS phenotype. CONCLUSIONS Despite the fact that we interrogated about 83% of all of common SNPs in the human genome, we did not find evidence that any of the investigated common SNPs may be associated with CRPS phenotype.
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Affiliation(s)
- Piotr K Janicki
- *Department of Anesthesiology and Perioperative Medicine, Penn State Hershey College of Medicine, Hershey, Pennsylvania
| | | | - Jill Eckert
- *Department of Anesthesiology and Perioperative Medicine, Penn State Hershey College of Medicine, Hershey, Pennsylvania
| | - Marek Postula
- *Department of Anesthesiology and Perioperative Medicine, Penn State Hershey College of Medicine, Hershey, Pennsylvania
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Gzesh D, Flanders A, Schwartzman RJ. Acute Brown-Séquard Syndrome in a 25-Year-Old Female. J Neuroimaging 2016. [DOI: 10.1111/jon199114179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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5
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Douglas SR, Shenoda BB, Qureshi RA, Sacan A, Alexander GM, Perreault M, Barrett JE, Aradillas-Lopez E, Schwartzman RJ, Ajit SK. Analgesic Response to Intravenous Ketamine Is Linked to a Circulating microRNA Signature in Female Patients With Complex Regional Pain Syndrome. J Pain 2015; 16:814-24. [PMID: 26072390 DOI: 10.1016/j.jpain.2015.05.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/04/2015] [Accepted: 05/28/2015] [Indexed: 11/15/2022]
Abstract
Although ketamine is beneficial in treating complex regional pain syndrome (CRPS), a subset of patients respond poorly to therapy. We investigated treatment-induced microRNA (miRNA) changes and their predictive validity in determining treatment outcome by assessing miRNA changes in whole blood from patients with CRPS. Blood samples from female patients were collected before and after 5 days of intravenous ketamine administration. Seven patients were responders and 6 were poor responders. Differential miRNA expression was observed in whole blood before and after treatment. In addition, 33 miRNAs differed between responders and poor responders before therapy, suggesting the predictive utility of miRNAs as biomarkers. Investigation of the mechanistic significance of hsa-miR-548d-5p downregulation in poor responders showed that this miRNA can downregulate UDP-glucuronosyltransferase UGT1A1 mRNA. Poor responders had a higher conjugated/unconjugated bilirubin ratio, indicating increased UGT1A1 activity. We propose that lower pretreatment levels of miR-548d-5p may result in higher UDP-GT activity, leading to higher levels of inactive glucuronide conjugates, thereby minimizing the therapeutic efficacy of ketamine in poor responders. Differences in miRNA signatures can provide molecular insights distinguishing responders from poor responders. Extending this approach to other treatment and outcome assessments might permit stratification of patients for maximal therapeutic outcome. Perspective: This study suggests the usefulness of circulating miRNAs as potential biomarkers. Assessing miRNA signatures before and after treatment demonstrated miRNA alterations from therapy; differences in miRNA signature in responders and poor responders before therapy indicate prognostic value. Mechanistic studies on altered miRNAs can provide new insights into disease.
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Affiliation(s)
- Sabrina R Douglas
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Botros B Shenoda
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Rehman A Qureshi
- School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - Ahmet Sacan
- School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - Guillermo M Alexander
- Department of Neurology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Marielle Perreault
- Department of Neurology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - James E Barrett
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | | | - Robert J Schwartzman
- Department of Neurology, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Seena K Ajit
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, Pennsylvania.
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6
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Schwartzman RJ. Objective Sensory Evaluation of the Spread of
Complex Regional Pain Syndrome. Pain Physician 2013. [DOI: 10.36076/ppj.2013/16/581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: The spread of complex regional pain syndrome (CRPS) has been well
documented. Many severe refractory long-standing patients have total body pain (TBP) that
evolved from a single extremity injury.
Objective: The purpose of this study was to document by objective sensory threshold
testing the extent of body area involvement in 20 long-standing patients with CRPS who
have TBP.
Study Design: A comparison of sensory threshold testing parameters between 20 longstanding refractory patients with CRPS who have TBP versus 10 healthy participants.
Methods: Twenty patients with CRPS who stated that they suffered from total body pain
were chosen from the Drexel University College of Medicine CRPS database. They were
compared to 10 healthy participants that were age and gender matched to the patients
with CRPS. The sensory parameters tested were: skin temperature; static and mechanical
allodynia; thermal allodynia; mechanical hyperalgesia; after sensations following all sensory
tests. The sites chosen for testing in the patients with CRPS were the most painful area in
each of 8 body regions that comprised the total body area.
Results: Five patients with CRPS had signs of CRPS over 100% of their body (20%). One
patient had pain over 87% and another had pain over 90% of their body area. The average
percentage of body involvement was 62% (range 37% – 100%). All patients with CRPS had
at least one sensory parameter abnormality in all body regions. All patients with CRPS had
lower pain thresholds for static allodynia in all body areas, while 50% demonstrated a lower
threshold for dynamic allodynia in all body regions compared to the healthy participants.
Cold allodynia had a higher median pain rating on the Likert pain scale in all body areas
versus healthy participants except for the chest, abdomen, and back. Eighty-five percent of
the patients with CRPS had a significantly lower pain threshold for mechanical hyperalgesia
in all body areas compared to the healthy participants. After sensations occurred after all
sensory parameters in the extremities in patients with CRPS.
Limitations:The primary limitations of this study would be the variability of self-reported
data (each subject’s assessment of pain/ discomfort to a tested parameter) and the challenge
to uniformly administer each parameter’s assessment since simple tools and not precision
instruments were used (with the exception of skin temperature).
Conclusions: TBP and objective sensory loss occur in 20% of patients with refractory longstanding CRPS.
Key words: CRPS, complex regional pain, static allodynia, dynamic allodynia, mechanoallodynia, thermal allodynia, allodynia, hyperalgesia, after sensation, total body pain, chronic
pain.
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7
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Edinger L, Schwartzman RJ, Ahmad A, Erwin K, Alexander GM. Objective sensory evaluation of the spread of complex regional pain syndrome. Pain Physician 2013; 16:581-591. [PMID: 24284843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The spread of complex regional pain syndrome (CRPS) has been well documented. Many severe refractory long-standing patients have total body pain (TBP) that evolved from a single extremity injury. OBJECTIVE The purpose of this study was to document by objective sensory threshold testing the extent of body area involvement in 20 long-standing patients with CRPS who have TBP. STUDY DESIGN A comparison of sensory threshold testing parameters between 20 long-standing refractory patients with CRPS who have TBP versus 10 healthy participants. METHODS Twenty patients with CRPS who stated that they suffered from total body pain were chosen from the Drexel University College of Medicine CRPS database. They were compared to 10 healthy participants that were age and gender matched to the patients with CRPS. The sensory parameters tested were: skin temperature; static and mechanical allodynia; thermal allodynia; mechanical hyperalgesia; after sensations following all sensory tests. The sites chosen for testing in the patients with CRPS were the most painful area in each of 8 body regions that comprised the total body area. RESULTS Five patients with CRPS had signs of CRPS over 100% of their body (20%). One patient had pain over 87% and another had pain over 90% of their body area. The average percentage of body involvement was 62% (range 37% - 100%). All patients with CRPS had at least one sensory parameter abnormality in all body regions. All patients with CRPS had lower pain thresholds for static allodynia in all body areas, while 50% demonstrated a lower threshold for dynamic allodynia in all body regions compared to the healthy participants. Cold allodynia had a higher median pain rating on the Likert pain scale in all body areas versus healthy participants except for the chest, abdomen, and back. Eighty-five percent of the patients with CRPS had a significantly lower pain threshold for mechanical hyperalgesia in all body areas compared to the healthy participants. After sensations occurred after all sensory parameters in the extremities in patients with CRPS. LIMITATIONS The primary limitations of this study would be the variability of self-reported data (each subject's assessment of pain/ discomfort to a tested parameter) and the challenge to uniformly administer each parameter's assessment since simple tools and not precision instruments were used (with the exception of skin temperature). CONCLUSIONS TBP and objective sensory loss occur in 20% of patients with refractory long-standing CRPS.
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Affiliation(s)
- Lara Edinger
- Drexel University College of Medicine; Department of Neurology, Philadelphia, PA
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8
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Edinger LK, Schwartzman RJ. Gardner-Diamond syndrome associated with complex regional pain syndrome. J Dermatol Case Rep 2013; 7:10-4. [PMID: 23580908 DOI: 10.3315/jdcr.2013.1128] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 08/06/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND Gardner-Diamond syndrome (GDS) is also known as psychogenic purpura, autoerythrocyte sensitization syndrome and painful bruising syndrome. MAIN OBSERVATION This is a case report of 27-year-old woman who presented with unexplained bruising and intramuscular hematomas after a seven year history of complex regional pain syndrome. Her evaluation consisted of hematological studies, skin and muscle biopsy; it failed to reveal an underlying coagulopathy, vasculitis or other demonstrable cause. In the absence of any other etiology, she was diagnosed as Gardner-Diamond syndrome. CONCLUSIONS This patient is unique because of intramuscular hematomas and the association of Complex regional pain syndrome with Gardner-Diamond syndrome.
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Affiliation(s)
- Lara K Edinger
- Drexel University College of Medicine, Department of Neurology, Philadelphia, PA, USA
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9
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Reichenberger ER, Alexander GM, Perreault MJ, Russell JA, Schwartzman RJ, Hershberg U, Rosen G. Establishing a relationship between bacteria in the human gut and complex regional pain syndrome. Brain Behav Immun 2013; 29:62-69. [PMID: 23261776 DOI: 10.1016/j.bbi.2012.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 11/22/2012] [Accepted: 12/07/2012] [Indexed: 12/20/2022] Open
Abstract
Complex Regional Pain Syndrome (CRPS) is a serious and painful condition involving the peripheral and central nervous systems. Full comprehension of the disorder's pathophysiology remains incomplete, but research implicates the immune system as a contributor to chronic pain. Because of the impact gastrointestinal bacteria have in the development and behavior of the immune system, this study compares the GI microbial communities of 16 participants with CRPS (5 of whom have intestinal discomforts) and 16 healthy controls using 454 sequencing technology. CRPS subjects were found to have significantly less diversity than their healthy counterparts. Statistical analysis of the phylogenetic classifications revealed significantly increased levels of Proteobacteria and decreased levels of Firmicutes in CRPS subjects. Clustering analysis showed significant separation between healthy controls and CRPS subjects. These results support the hypothesis that the GI microbial communities of CRPS participants differ from those of their healthy counterparts. These variations may hold the key to understanding how CRPS develops and provide information that could yield a potential treatment.
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Affiliation(s)
- Erin R Reichenberger
- School of Biomedical Engineering, Science and Health Systems, Drexel University, United States
| | | | | | | | | | - Uri Hershberg
- School of Biomedical Engineering, Science and Health Systems, Drexel University, United States
| | - Gail Rosen
- Department of Electrical and Computer Engineering, Drexel University, United States.
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10
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Abstract
Background: Accumulating experimental and clinical evidence supports the hypothesis
that complex regional pain syndrome type I (CRPS-I) may be a small fiber neuropathy.
Objectives: To evaluate the use of commercially available standard biopsy methods to
detect intradermal axon pathology in CRPS-I, and to ascertain if these structural changes
can explain quantitative sensory testing (QST) findings in CRPS-I.
Study Design: Retrospective review of charts and laboratory data.
Setting: Outpatient clinic
Methods: Skin biopsies from 43 patients with CRPS-I were stained with PGP 9.5,
and epidermal nerve fiber density, sweat gland nerve fiber density and morphological
abnormalities were evaluated. Thirty-five patients had quantitative sensory testing.
Results: Alterations in skin innervation were seen in approximately 20% of CRPS-I
patients with commercial processing. There were no patient characteristics, including
duration of disease, that predicted a decreased epidermal nerve fiber density (ENFD). There
was no consistent relationship between QST changes and ENFD measured by standard
commercial skin biopsy evaluation procedures.
Limitations: Commercial processing of tissue does not utilize stereologic quantitative
analysis of nerve fiber density. Biopsy material is utilized from a proximal and distal source
only, and differences in denervation of a partial nerve territory may be missed. The
functional attributes of small fibers cannot be assessed.
Conclusions: The negative results indicate that CRPS-I may be associated with changes
in the ultramicroscopic small fiber structure that cannot be visualized with commercially
available techniques. Alternatively, functional rather than structural alterations of small
fibers or pathological changes at a more proximal site such as the spinal cord or brain may
be responsible for the syndrome.
Key words: Complex Regional Pain Syndrome, CRPS-1, CRPS, skin biopsy, epidermal
nerve fiber density, sweat gland nerve fiber density, quantitative sensory testing.
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11
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Kharkar S, Venkatesh YS, Grothusen JR, Rojas L, Schwartzman RJ. Skin biopsy in complex regional pain syndrome: case series and literature review. Pain Physician 2012; 15:255-266. [PMID: 22622910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Accumulating experimental and clinical evidence supports the hypothesis that complex regional pain syndrome type I (CRPS-I) may be a small fiber neuropathy. OBJECTIVES To evaluate the use of commercially available standard biopsy methods to detect intradermal axon pathology in CRPS-I, and to ascertain if these structural changes can explain quantitative sensory testing (QST) findings in CRPS-I. STUDY DESIGN Retrospective review of charts and laboratory data. SETTING Outpatient clinic METHODS Skin biopsies from 43 patients with CRPS-I were stained with PGP 9.5, and epidermal nerve fiber density, sweat gland nerve fiber density and morphological abnormalities were evaluated. Thirty-five patients had quantitative sensory testing. RESULTS Alterations in skin innervation were seen in approximately 20% of CRPS-I patients with commercial processing. There were no patient characteristics, including duration of disease, that predicted a decreased epidermal nerve fiber density (ENFD). There was no consistent relationship between QST changes and ENFD measured by standard commercial skin biopsy evaluation procedures. LIMITATIONS Commercial processing of tissue does not utilize stereologic quantitative analysis of nerve fiber density. Biopsy material is utilized from a proximal and distal source only, and differences in denervation of a partial nerve territory may be missed. The functional attributes of small fibers cannot be assessed. CONCLUSIONS The negative results indicate that CRPS-I may be associated with changes in the ultramicroscopic small fiber structure that cannot be visualized with commercially available techniques. Alternatively, functional rather than structural alterations of small fibers or pathological changes at a more proximal site such as the spinal cord or brain may be responsible for the syndrome.
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Affiliation(s)
- Siddharth Kharkar
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA, USA
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12
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Libon DJ, Alexander G, Schwartzman RJ. Neuropsychology and complex regional pain syndrome. Pain 2012; 153:1128. [DOI: 10.1016/j.pain.2012.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 11/02/2011] [Accepted: 01/31/2012] [Indexed: 11/26/2022]
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Alexander GM, Peterlin BL, Perreault MJ, Grothusen JR, Schwartzman RJ. Changes in plasma cytokines and their soluble receptors in complex regional pain syndrome. J Pain 2011; 13:10-20. [PMID: 22172450 DOI: 10.1016/j.jpain.2011.10.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 10/11/2011] [Accepted: 10/13/2011] [Indexed: 12/21/2022]
Abstract
UNLABELLED Complex Regional Pain Syndrome (CRPS) is a chronic and often disabling pain disorder. There is evidence demonstrating that neurogenic inflammation and activation of the immune system play a significant role in the pathophysiology of CRPS. This study evaluated the plasma levels of cytokines, chemokines, and their soluble receptors in 148 subjects afflicted with CRPS and in 60 gender- and age-matched healthy controls. Significant changes in plasma cytokines, chemokines, and their soluble receptors were found in subjects with CRPS as compared with healthy controls. For most analytes, these changes resulted from a distinct subset of the CRPS subjects. When the plasma data from the CRPS subjects was subjected to cluster analysis, it revealed 2 clusters within the CRPS population. The category identified as most important for cluster separation by the clustering algorithm was TNFα. Cluster 1 consisted of 64% of CRPS subjects and demonstrated analyte values similar to the healthy control individuals. Cluster 2 consisted of 36% of the CRPS subjects and demonstrated significantly elevated levels of most analytes and in addition, it showed that the increased plasma analyte levels in this cluster were correlated with disease duration and severity. PERSPECTIVE The identification of biomarkers that define disease subgroups can be of great value in the design of specific therapies and of great benefit to the design of clinical trials. It may also aid in advancing our understanding of the mechanisms involved in the pathophysiology of CRPS, which may lead to novel treatments for this very severe condition.
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Affiliation(s)
- Guillermo M Alexander
- Department of Neurology, Drexel University College of Medicine, Philadelphia, Pennsylvania 19102, USA.
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15
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Orlova IA, Alexander GM, Qureshi RA, Sacan A, Graziano A, Barrett JE, Schwartzman RJ, Ajit SK. MicroRNA modulation in complex regional pain syndrome. J Transl Med 2011; 9:195. [PMID: 22074333 PMCID: PMC3228853 DOI: 10.1186/1479-5876-9-195] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 11/10/2011] [Indexed: 01/11/2023] Open
Abstract
Background Aberrant expression of small noncoding RNAs called microRNAs (miRNAs) is a common feature of several human diseases. The objective of the study was to identify miRNA modulation in patients with complex regional pain syndrome (CRPS) a chronic pain condition resulting from dysfunction in the central and/or peripheral nervous systems. Due to a multitude of inciting pathologies, symptoms and treatment conditions, the CRPS patient population is very heterogeneous. Our goal was to identify differentially expressed miRNAs in blood and explore their utility in patient stratification. Methods We profiled miRNAs in whole blood from 41 patients with CRPS and 20 controls using TaqMan low density array cards. Since neurogenic inflammation is known to play a significant role in CRPS we measured inflammatory markers including chemokines, cytokines, and their soluble receptors in blood from the same individuals. Correlation analyses were performed for miRNAs, inflammatory markers and other parameters including disease symptoms, medication, and comorbid conditions. Results Three different groups emerged from miRNA profiling. One group was comprised of 60% of CRPS patients and contained no control subjects. miRNA profiles from the remaining patients were interspersed among control samples in the other two groups. We identified differential expression of 18 miRNAs in CRPS patients. Analysis of inflammatory markers showed that vascular endothelial growth factor (VEGF), interleukin1 receptor antagonist (IL1Ra) and monocyte chemotactic protein-1 (MCP1) were significantly elevated in CRPS patients. VEGF and IL1Ra showed significant correlation with the patients reported pain levels. Analysis of the patients who were clustered according to their miRNA profile revealed correlations that were not significant in the total patient population. Correlation analysis of miRNAs detected in blood with additional parameters identified miRNAs associated with comorbidities such as headache, thyroid disorder and use of narcotics and antiepileptic drugs. Conclusions miRNA profiles can be useful in patient stratification and have utility as potential biomarkers for pain. Differentially expressed miRNAs can provide molecular insights into gene regulation and could lead to new therapeutic intervention strategies for CRPS.
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Affiliation(s)
- Irina A Orlova
- Pharmacology & Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA
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16
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Irwin DJ, Schwartzman RJ. Complex regional pain syndrome with associated chest wall dystonia: a case report. J Brachial Plex Peripher Nerve Inj 2011; 6:6. [PMID: 21943053 PMCID: PMC3189858 DOI: 10.1186/1749-7221-6-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 09/26/2011] [Indexed: 01/06/2023] Open
Abstract
Patients with complex regional pain syndrome (CRPS) often suffer from an array of associated movement disorders, including dystonia of an affected limb. We present a case of a patient with long standing CRPS after a brachial plexus injury, who after displaying several features of the movement disorder previously, developed painful dystonia of chest wall musculature. Detailed neurologic examination found palpable sustained contractions of the pectoral and intercostal muscles in addition to surface allodynia. Needle electromyography of the intercostal and paraspinal muscles supported the diagnosis of dystonia. In addition, pulmonary function testing showed both restrictive and obstructive features in the absence of a clear cardiopulmonary etiology. Treatment was initiated with intrathecal baclofen and the patient had symptomatic relief and improvement of dystonia. This case illustrates a novel form of the movement disorder associated with CRPS with response to intrathecal baclofen treatment.
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Affiliation(s)
- David J Irwin
- Drexel University College of Medicine, Department of Neurology, Philadelphia, PA, USA.
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Aradillas E, Libon DJ, Schwartzman RJ. Acute loss of spatial navigational skills in a case of a right posterior hippocampus stroke. J Neurol Sci 2011; 308:144-6. [DOI: 10.1016/j.jns.2011.06.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 06/09/2011] [Accepted: 06/13/2011] [Indexed: 11/26/2022]
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Grothusen JR, Schwartzman RJ. Laser Doppler imaging: usefulness in chronic pain medicine. Pain Physician 2011; 14:491-498. [PMID: 21927054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Sympathetic nervous system dysfunction is thought to be a factor in neuropathic pain conditions such as Complex Regional Pain Syndrome and in vascular conditions such as Raynaud's phenomenon. Laser Doppler fluxmetry has been used as a fast non-invasive method to quantify changes in skin capillary blood flow which reflect activation of sympathetically mediated vasoconstriction of the arterioles that supply the capillaries. Studies of dynamic change of skin capillary blood flow with sympathetic activation such as cold or inspiratory gasp have generally used single point laser Doppler systems where the probe is in contact with the skin. The results are a single line tracing representing the capillary flow at a single point on the skin a few millimeters in diameter. Laser Doppler imaging (moorLDI laser Doppler imager, Moor Instruments Ltd.) allows for non-contact recording of skin blood flow of an area as large as 50 centimeters square with a resolution of 256 by 256 pixels and 4 milliseconds per pixel. Most work with laser Doppler imaging has studied changes that occur between successive scans. We have found it useful to look at changes that occur during a scan. In this way we obtain data that is comparable to the time resolution of single point laser Doppler methods, but with the larger spatial information that is available with laser Doppler imaging. We present a small series of case reports in which inspiratory gasp during laser Doppler imaging was able to provide quick, useful and unequivocal clinical information regarding the status of regional bilateral skin capillary response to sympathetic activation. This may be useful for distinguishing sympathetically mediated from sympathetically independent pain. We believe the methods described may provide the basis for future quantitative studies similar to those that use single point laser Doppler methods.
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Affiliation(s)
- John R Grothusen
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19102-1192, USA.
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Kharkar S, Ambady P, Venkatesh Y, Schwartzman RJ. Intramuscular botulinum toxin in complex regional pain syndrome: case series and literature review. Pain Physician 2011; 14:419-424. [PMID: 21927045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Pain associated with Complex Regional Pain Syndrome (CRPS) is frequently excruciating and intractable. The use of botulinum toxin for relief of CRPS-associated pain has not been well described. OBJECTIVES To assess whether intramuscular botulinum toxin injections cause relief of pain caused by CRPS, and to assess the risks of this treatment. STUDY DESIGN Retrospective chart review. SETTING Outpatient clinic. METHODS 37 patients with spasm/dystonia in the neck and/or upper limb girdle muscles. INTERVENTION EMG-guided injection of Botulinum Toxin - A (BtxA), 10-20 units per muscle. Total dose used was 100 units in each patient. Local pain score was measured on an 11-point Likert scale, 4 weeks after BtxA injections. RESULTS Mean pain score decreased by 43% (8.2 ± 0.8 to 4.5 ± 1.1, P < 0.001). 97% patients had significant pain relief. One patient had transient neck drop after the injections. LIMITATIONS This is a retrospective study, it lacks a control group and hence the placebo effect cannot be eliminated. This study does not provide information on the efficacy of this treatment after 4 weeks. CONCLUSIONS Intramuscular injection of botulinum toxin in the upper limb girdle muscles was beneficial for short term relief of pain caused by CRPS. The incidence of complications was low (2.7%).
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Affiliation(s)
- Siddharth Kharkar
- Hahnemann University Hospital, Philadelphia, PA and Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19107, USA
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Abstract
OBJECTIVES Problem residents are found across most medical specialties at a prevalence of about 10%. This study was designed to explore the prevalence and causes of problem neurology residents and to compare neurology programs' responses and outcomes. METHODS Directors of 126 US neurology residency programs were sent an electronic survey. We collected data on demographics, first and all "identifiers" of problem residents, and year of training in which the problem was found. We asked about observable signs, etiology, and who performed remediation. We asked what resources were used and what outcomes occurred. RESULTS Ninety-five program directors completed surveys (75% response rate). Almost all neurology programs have problem residents (81%). Age, sex, marital status, being a US native, or attending a US medical school had no effect on problem status. Being a parent carried a lower likelihood of problems (32%). Most commonly the problem is acted on during the first year of training. Faculty members without defined educational roles were the most frequent first identifiers. Program directors were the most common remediators. The most common remediation techniques were increasing supervision and assigning a faculty mentor. Graduate medical education office and psychiatric or psychological counseling services were most often used. Eleven percent of problem residents required a program for impaired physicians and 14% required a leave of absence. Sixteen percent were dismissed from their programs. CONCLUSIONS The prevalence of problem residents in neurology is similar to other disciplines, and various resources are available to remediate them.
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Affiliation(s)
- David S Tabby
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19107, USA.
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21
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Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a debilitating pain syndrome characterized clinically by severe pain along with signs and symptoms of autonomic dysfunction. Presyncope and syncope are common in these patients. The purpose of this study was to investigate the cause of these symptoms in these patients. HYPOTHESIS Patients with CRPS are more prone to presyncope and syncope as evidenced by head-up tilt table testing (HUTT). METHODS Patients with CRPS underwent a complete cardiac evaluation that included a 12-lead electrocardiogram, 2-dimensional echocardiography, 24-hour Holter monitoring, and HUTT. RESULTS Seventy-four patients with CRPS were evaluated. Eight CRPS patients (10%) could not complete a HUTT due to pain. Of the 66 CRPS patients who completed a HUTT, 15 (37.9%) reported pretest symptoms of presyncope or syncope. Twenty-eight CRPS patients (42.4%) had a positive HUTT. CRPS patients with lower limb involvement were more likely to have vasovagal syncope or orthostasis on HUTT than those with upper extremity or total body involvement (12 of 18 [67%] vs 16 of 48 [33%]; P = 0.015). CONCLUSIONS Syncope is common in patients with CRPS, especially with lower limb involvement. Autonomic dysregulation of the lower extremities leads to impaired sympathetic vasoconstriction and venous pooling, which can predispose these patients to syncope. Physician awareness of this syndrome will lead to improved recognition and treatment of their symptoms of presyncope or syncope.
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Affiliation(s)
- Jason A Smith
- Department of Cardiology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.
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Schwartzman RJ, Alexander GM, Grothusen JR. The use of ketamine in complex regional pain syndrome: possible mechanisms. Expert Rev Neurother 2011; 11:719-734. [DOI: 10.1586/ern.11.31] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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23
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Kharkar S, Ambady P, Yedatore V, Schwartzman RJ. Intramuscular botulinum toxin A (BtxA) in complex regional pain syndrome. Pain Physician 2011; 14:311-316. [PMID: 21587336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Pain associated with complex regional pain syndrome (CRPS) is frequently excruciating and intractable. The use of botulinum toxin for relief of CRPS-associated pain has not been well described. OBJECTIVES To assess whether intramuscular botulinum toxin injections cause relief of pain caused by CRPS, and to assess the risks of this treatment. STUDY DESIGN Retrospective chart review. SETTING Outpatient clinic. PATIENTS 37 patients with spasm/dystonia in the neck and/or upper limb girdle muscles. INTERVENTION Electromyography-guided injection of botulinum toxin A (BtxA), 10-20 U per muscle. Total dose used was 100 U in each patient. MEASUREMENT Local pain score on an 11 point Likert scale, 4 weeks after BtxA injections. RESULTS Mean pain score decreased by 43% (8.2 ± 0.8 to 4.5 ± 1.1, P < 0.001). Ninety-seven percent of the patients had significant pain relief. One patient had transient neck drop after the injections. LIMITATIONS This is a retrospective study; it lacks a control group and therefore the placebo effect cannot be eliminated. This study does not provide information on the efficacy of this treatment after 4 weeks. CONCLUSION(S) Intramuscular injection of botulinum toxin A in the upper limb girdle muscles was beneficial for short term relief of pain caused by CRPS in this retrospective case series. The incidence of complications was low (2.7%).
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Ritz BW, Alexander GM, Nogusa S, Perreault MJ, Peterlin BL, Grothusen JR, Schwartzman RJ. Elevated blood levels of inflammatory monocytes (CD14+ CD16+ ) in patients with complex regional pain syndrome. Clin Exp Immunol 2011; 164:108-17. [PMID: 21303362 DOI: 10.1111/j.1365-2249.2010.04308.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain disorder. Although its pathophysiology is not completely understood, neurogenic inflammation is thought to play a significant role. Microglia and astrocytes are activated following tissue injury or inflammation and have been reported to be both necessary and sufficient for enhanced nociception. Blood-borne monocytes/macrophages can infiltrate the central nervous system (CNS) and differentiate into microglia resulting in hypersensitivity and chronic pain. The primary aim of this study was to evaluate the proportion of the proinflammatory CD14(+) CD16(+) monocytes as well as plasma cytokine levels in blood from CRPS patients compared to age- and gender-matched healthy control individuals. Forty-six subjects (25 CRPS, 21 controls) were recruited for this study. The percentage of monocytes, T, B or natural killer (NK) cells did not differ between CRPS and controls. However, the percentage of the CD14(+) CD16(+) monocyte/macrophage subgroup was elevated significantly (P<0·01) in CRPS compared to controls. Individuals with high percentage of CD14(+) CD16(+) demonstrated significantly lower (P<0·05) plasma levels on the anti-inflammatory cytokine interleukin (IL)-10. Our data cannot determine whether CD14(+) CD16(+) monocytes became elevated prior to or after developing CRPS. In either case, the elevation of blood proinflammatoty monocytes prior to the initiating event may predispose individuals for developing the syndrome whereas the elevation of blood proinflammatory monocytes following the development of CRPS may be relevant for its maintenance. Further evaluation of the role the immune system plays in the pathogenesis of CRPS may aid in elucidating disease mechanisms as well as the development of novel therapies for its treatment.
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Affiliation(s)
- B W Ritz
- Department of Biology, Drexel University Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19102-1192, USA
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25
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Abstract
The aim was to assess the relative frequency of migraine and the headache characteristics of complex regional pain syndrome (CRPS) sufferers. CRPS and migraine are chronic, often disabling pain syndromes. Recent studies suggest that headache is associated with the development of CRPS. Consecutive adults fulfilling International Association for the Study of Pain criteria for CRPS at a pain clinic were included. Demographics, medical history, and pain characteristics were obtained. Headache diagnoses were made using International Classification of Headache Disorders, 2nd edn criteria. Migraine and pain characteristics were compared in those with migraine with those without. anova with Tukey post hoc tests was used to determine the significance of continuous variables and Fisher's exact or χ(2) tests for categorical variables. The expected prevalence of migraine and chronic daily headache (CDH) was calculated based on age- and gender-stratified general population estimates. Standardized morbidity ratios (SMR) were calculated by dividing the observed prevalence of migraine by the expected prevalence from the general population. The sample consisted of 124 CRPS participants. The mean age was 45.5 ± 12.0 years. Age- and gender-adjusted SMRs showed that those with CRPS were 3.6 times more likely to have migraine and nearly twice as likely to have CDH as the general population. Aura was reported in 59.7% (74/124) of participants. Of those CRPS sufferers with migraine, 61.2% (41/67) reported the onset of severe headaches before the onset of CRPS symptoms Mean age of onset of CRPS was earlier in those with migraine (34.9 ± 11.1 years) and CDH (32.5 ± 13.4 years) compared with those with no headaches (46.8 ± 14.9 years) and those with tension-type headache (TTH) (39.9 ± 9.9 years), P < 0.05. More extremities were affected by CRPS in participants with migraine (median of four extremities) compared with the combined group of those CRPS sufferers with no headaches or TTH (median 2.0 extremities), P < 0.05. The presence of static, dynamic and deep joint mechano-allodynia together was reported by more CRPS participants with migraine (72.2%) than those with no headaches or TTH (46.2%), P ≤ 0.05. Migraine may be a risk factor for CRPS and the presence of migraine may be associated with a more severe form of CRPS. Specifically: (i) migraine occurs in a greater percentage of CRPS sufferers than expected in the general population; (ii) the onset of CRPS is reported earlier in those with migraine than in those without; and (iii) CRPS symptoms are present in more extremities in those CRPS sufferers with migraine compared with those without. In addition, as we also found that the presence of aura is reported in a higher percentage of those CRPS sufferers with migraine than reported in migraineurs in the general population, further evaluation of the cardiovascular risk profile of CRPS sufferers is warranted.
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Affiliation(s)
- B L Peterlin
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
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26
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Aradillas E, Schwartzman RJ. Kinesigenic dyskinesia in a case of voltage-gated potassium channel-complex protein antibody encephalitis. ACTA ACUST UNITED AC 2010; 68:529-32. [PMID: 21149804 DOI: 10.1001/archneurol.2010.317] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To describe the first case (to our knowledge) of voltage-gated potassium channel-complex protein antibody encephalitis with kinesigenic dyskinesia and cramp-fasciculation syndrome. DESIGN Case report. SETTING Hospitalized care. PATIENT A 38-year-old man with a history of bronchial asthma, eczema, vitiligo, and immune complex mesangiopathic glomerulonephritis presented with abnormal movements. MAIN OUTCOME MEASURES Clinical examination, magnetic resonance imaging, single-photon emission computed tomography, electromyography and nerve conduction studies, video-electroencephalographic monitoring, plasmapheresis exchange therapy, and intravenous immunoglobulin administration. RESULTS Clinical examination revealed paroxysmal kinesigenic dyskinesia and fasciculations. Magnetic resonance imaging of the brain revealed a left caudate and left putamen increased signal lesion on T2-weighted and fluid-attenuated inversion recovery sequences as well as increased flow in the same region on single-photon emission computed tomographic scans. Electromyography and nerve conduction studies revealed significant afterdischarges, cramp potentials, and continuous motor activity. The video-electroencephalographic monitoring revealed no epileptiform discharges. The patient dramatically improved after 5 plasmapheresis exchange treatments and a course of intravenous immunoglobulin at 2 gm/kg over 5 divided doses. CONCLUSION To our knowledge, this is the first report of paroxysmal kinesigenic dyskinesia with voltage-gated potassium channel-complex protein antibody encephalitis associated with the cramp fasciculation syndrome.
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Affiliation(s)
- Enrique Aradillas
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19102-1192, USA
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27
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Goldberg ME, Schwartzman RJ, Torjman MC, Wainer IW. Ketamine infusion successful in some patients. Pain Physician 2010; 13:E371-E373. [PMID: 21102974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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28
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Goldberg ME, Torjman MC, Schwartzman RJ, Mager DE, Wainer IW. Enantioselective pharmacokinetics of (R)- and (S)-ketamine after a 5-day infusion in patients with complex regional pain syndrome. Chirality 2010; 23:138-43. [PMID: 20803495 DOI: 10.1002/chir.20890] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 06/11/2010] [Indexed: 11/12/2022]
Abstract
INTRODUCTION This study determined the pharmacokinetics and pharmacodynamics of (R)- and (S)-ketamine and (R)- and (S)-norketamine following a 5-day moderate dose, as a continuous (R,S)-ketamine infusion in complex regional pain syndrome (CRPS) patients. MATERIALS AND METHODS Ketamine was titrated to 10-40 mg/h and maintained for 5 days. (R)- and (S)-Ketamine and (R)- and (S)-norketamine pharmacokinetic and pharmacodynamic studies were performed. Blood samples were obtained on Day 1 preinfusion, and at 60-90, 120-150, 180-210, and 240-300 min after the start of the infusion, on Days 2, 3, 4, 5, and on Day 5 at 60 min after the end of infusion. The plasma concentrations of (R)- and (S)-ketamine and (R)- and (S)-norketamine were determined using enantioselective liquid chromatography-mass spectrometry. RESULTS Ketamine and norketamine levels stabilized 5 h after the start of the infusion. (R)-Ketamine clearance was significantly lower resulting in higher steady-state plasma concentrations than (S)-ketamine. The first-order elimination for (S)-norketamine was significantly greater than that of (R)-enantiomer. When comparing the pharmacokinetic parameters of the patients who responded to ketamine treatment with those who did not, no differences were observed in ketamine clearance and the first-order elimination of norketamine. CONCLUSION The results indicate that (R)- and (S)-ketamine and (R)- and (S)-norketamine plasma concentrations do not explain the antinociceptive activity of the drug in patients suffering from CRPS.
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Affiliation(s)
- Michael E Goldberg
- Cooper University Hospital, Department of Anesthesiology, UMDNJ-Robert Wood Johnson Medical School, Camden, New Jersey, USA.
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29
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Goldberg ME, Torjman MC, Schwartzman RJ, Mager DE, Wainer IW. Pharmacodynamic profiles of ketamine (R)- and (S)- with 5-day inpatient infusion for the treatment of complex regional pain syndrome. Pain Physician 2010; 13:379-387. [PMID: 20648207 PMCID: PMC2950807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Ketamine might be effective in blocking central sensitization of pain transmission neurons through its effect on NMDA receptors in refractory Complex Regional Pain Syndrome (CRPS) patients. At higher doses, ketamine infusions can be associated with significant risks; outpatient therapy requires return visits for a 10-day period with variable efficacy and duration. OBJECTIVE This study determined the efficacy of a 5-day moderate dose, continuous racemic ketamine infusion. The pharmacodynamic responses to racemic ketamine and norketamine were examined. DESIGN Observational study METHODS In this study, ketamine was titrated from 10-40 mg/hour in 16 CRPS patients, and maintained for 5 days. Pain was assessed daily. Ketamine and norketamine concentrations were obtained on Day 1 before starting the infusion; at 60 to 90 minutes, 120 to 150 minutes, 180 to 210 minutes, and 240 to 300 minutes after the initiation of the infusion on Days 2, 3, 4, and 5; and on Day 5 at 60 minutes after the conclusion of the infusion. The plasma concentrations of (R)-ketamine, (S)-ketamine, (R)-norketamine and (S)-norketamine were determined using an enantioselective liquid chromatography - mass spectrometry method. RESULTS Ketamine and norketamine infusion rates stabilized 5 hours after the start of the infusion. The subjects showed no evidence of significant tachycardia, arterial oxygen desaturation, or hallucinatory responses. Subjects generally experienced minimal pain relief on day one followed by significant relief by day 3. Mean pain scores decreased from the 8-9 to 3-5 ranges; however, the analgesic response to ketamine infusion was not uniform. On Day 5, there was little or no change in the pain measure assessed as the worst pain experienced over the last 24 hours in 37% of the subjects. (R)- and (S)-ketamine concentrations peaked at 240-300 min. (R)- and (S)-norketamine concentrations were lower and peaked on Day 2 of the infusion, as opposed to Day 1 for (R)- and (S)-ketamine. Significant pain relief was achieved by the second day of infusion and correlated with the maximum plasma levels of ketamine and norketamine. Pain relief continued to significantly improve over the 5-day infusion at concentrations of 200-225 ng/mL for (R)- and (S)-ketamine, and 90-120 ng/mL for (R)- and (S)-norketamine. CONCLUSIONS A 5-day ketamine infusion for the treatment of severe CRPS provided significant (p <0.05) pain relief by Day 3 compared to baseline. The pain relief experienced on Day 2 of the infusion continued to improve over the 5-day infusion period and correlated with the maximum plasma levels of ketamine and norketamine. We speculate that downstream metabolites of ketamine and norketamine might be playing a role in its therapeutic efficacy.
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Affiliation(s)
- Michael E Goldberg
- Cooper University Hospital, UMDNJ-Robert Wood Johnson Medical School, Camden, NJ, USA.
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30
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Schwartzman RJ, Alexander GM, Grothusen JR, Paylor T, Reichenberger E, Perreault M. Outpatient intravenous ketamine for the treatment of complex regional pain syndrome: a double-blind placebo controlled study. Pain 2009; 147:107-15. [PMID: 19783371 DOI: 10.1016/j.pain.2009.08.015] [Citation(s) in RCA: 200] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Revised: 07/16/2009] [Accepted: 08/18/2009] [Indexed: 12/31/2022]
Abstract
Complex regional pain syndrome (CRPS) is a severe chronic pain condition that most often develops following trauma. The pathophysiology of CRPS is not known but both clinical and experimental evidence demonstrate the important of the NMDA receptor and glial activation in its induction and maintenance. Ketamine is the most potent clinically available safe NMDA antagonist that has a well established role in the treatment of acute and chronic pain. This randomized double-blind placebo controlled trial was designed to evaluate the effectiveness of intravenous ketamine in the treatment of CRPS. Before treatment, after informed consent was obtained, each subject was randomized into a ketamine or a placebo infusion group. Study subjects were evaluated for at least 2 weeks prior to treatment and for 3 months following treatment. All subjects were infused intravenously with normal saline with or without ketamine for 4h (25ml/h) daily for 10 days. The maximum ketamine infusion rate was 0.35mg/kg/h, not to exceed 25mg/h over a 4h period. Subjects in both the ketamine and placebo groups were administered clonidine and versed. This study showed that intravenous ketamine administered in an outpatient setting resulted in statistically significant (p<0.05) reductions in many pain parameters. It also showed that subjects in our placebo group demonstrated no treatment effect in any parameter. The results of this study warrant a larger randomized placebo controlled trial using higher doses of ketamine and a longer follow-up period.
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Affiliation(s)
- Robert J Schwartzman
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
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31
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Rasmussen JW, Grothusen JR, Rosso AL, Schwartzman RJ. Atypical chest pain: evidence of intercostobrachial nerve sensitization in Complex Regional Pain Syndrome. Pain Physician 2009; 12:E329-E334. [PMID: 19787018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Atypical chest pain is a common complaint among Complex Regional Pain Syndrome (CRPS) patients with brachial plexus involvement. Anatomically, the intercostobrachial nerve (ICBN) is connected to the brachial plexus and innervates the axilla, medial arm and anterior chest wall. By connecting to the brachial plexus, the ICBN could become sensitized by CRPS spread and become a source of atypical chest pain. OBJECTIVE To evaluate the sensitivity of chest areas in CRPS patients and normal controls. DESIGN Prospective investigation of pressure algometry in chest areas to determine chest wall sensitivity. METHODS CRPS patients and normal controls volunteered to participate in our study. Each individual was examined to meet inclusion criteria. Patients' report of chest pain history was collected from every participant. Pressure algometry was used to measure pressure sensitivity in the axilla, anterior axillary line second intercostal space, mid-clavicular third rib, mid-clavicular tenth rib, and midsternal. Each of these measurements were compared to an intra-participant abdominal measure to control for an individuals generalized sensitivity. The ratios of chest wall sensitivities were compared between CRPS patients and normal controls. RESULTS A history of chest pain was reported by a majority (94%) of CRPS patients and a minority (19%) of normal controls. CRPS patients reported lifting their arm as a major initiating factor for chest pain. To pressure algometry, the ratios of CRPS patients were significantly greater than control subjects (p< 0.02 throughout), indicating increased chest wall sensitivity. LIMITATIONS This study is limited by the relatively small number of patients (n=35) and controls (n=21) used. CONCLUSION The results of this study support the idea that chest pain is greater in CRPS patients than normal controls. The ICBN could be the source of this sensitization by CRPS spread from the brachial plexus.
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Schwartzman RJ, Patel M, Grothusen JR, Alexander GM. Efficacy of 5-Day Continuous Lidocaine Infusion for the Treatment of Refractory Complex Regional Pain Syndrome. Pain Med 2009; 10:401-412. [DOI: 10.1111/j.1526-4637.2009.00573.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Del Valle L, Schwartzman RJ, Alexander G. Spinal cord histopathological alterations in a patient with longstanding complex regional pain syndrome. Brain Behav Immun 2009; 23:85-91. [PMID: 18786633 DOI: 10.1016/j.bbi.2008.08.004] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 08/05/2008] [Accepted: 08/12/2008] [Indexed: 12/18/2022] Open
Abstract
Complex regional pain syndrome (CRPS) is a chronic pain condition that usually arises from an injury or as a complication from a surgical procedure. CRPS can result from multiple mechanisms including active processes involving both the peripheral and the central nervous system and sickness like responses involving interactions between the immune and nervous systems. In animal models both peripheral and central sensitization as well as loss of inhibition has been implicated in neuropathic pain states. Glial cells, in particular microglia and astrocytes, are the immunocompetent cells in the central nervous system and are activated following tissue injury or inflammation. In animal studies, activated glia have been shown to be both necessary and sufficient for enhanced nociception. Using immunohistochemical techniques, this study evaluated the degree of astrocytic and microglial activation as well as neuronal loss in autopsy tissue from the cervical, thoracic and lumbar spinal cord of a patient afflicted with CRPS as compared to four control individuals. The major findings of this study are that in long standing CRPS there was significant posterior horn cell loss and activation of both microglia and astrocytes most prominently at the level of the original injury but extending throughout the entire length of the spinal cord. Our hope is that the data obtained from this and other studies of autopsy material may aid in elucidating the mechanisms involved in the pathophysiology of CRPS, which may lead to the refinement of current therapies as well as novel treatments.
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Affiliation(s)
- Luis Del Valle
- Department of Neuroscience, Neuropathology Core and Center for Neurovirology, Temple University School of Medicine, 1900 North 12th Street, Philadelphia, PA 19122, USA
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Goldberg ME, Schwartzman RJ, Domsky R, Sabia M, Torjman MC. Deep cervical plexus block for the treatment of cervicogenic headache. Pain Physician 2008; 11:849-854. [PMID: 19057630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Cervicogenic headache descriptors include its unilateral nature, "signs and symptoms linking it to the neck," and trauma of the neck. Since the pain often occurs over the C2 or C3 nerve root, we used a modification of the deep cervical block technique for treatment of this refractory type headache. OBJECTIVE To determine the efficacy of a modified deep cervical block for treatment of cervicogenic headache. DESIGN Prospective case study. METHODS Thirty-nine patients referred to our pain clinic participated in this study. All patients had undergone extensive screening/diagnostic testing. The blocks were performed unilaterally, without inducing a risk of invading the neural foramen, and repeat injection of the contra-lateral side occurred at >1 week after initial injection. Patients were followed for a 6-month period using a pain diary and questionnaire. Pain was assessed pre- and post-injection and 3 and 6 months post treatments. RESULTS The mean treatment period was 59 +/- 61 days. The mean values for pre- and post-injection series pain scores (0-10 pain scale) were 9.54 +/- 1.53 and 6.75 +/- 3.23 respectively (p <0.001). Thirty-three percent (33%) of the patients reported pain scores of < or = 4 on the 0-10 pain scale after their last treatment. Effectiveness of the therapy following the injection procedure was rated to be 42% effective for all first injections and 40% effective for last injections (p =NS). Six months evaluations showed that return of moderate to severe pain took 6.62 +/- 8.1 weeks. At the 3 and 6 months follow up evaluations, mean pain scores had returned to 8.41 +/- 2.96 and 8.83 +/- 2.78, respectively. Ten patients (24%) had pain scores < or = 4 at the 3-month evaluation while 7 of the patients (18%) had pain scores < or = 4 at the 6-month evaluation. CONCLUSIONS These results showed that for some patients this series of blocks provided effective pain relief for 3 months post treatment but by 6 months the pain had returned to pre-treatment levels. This block technique significantly diminished pain after the initial as well as the last treatment. These clinically significant changes in pain relief suggest that more aggressive selective therapy targeting these nerve routes might provide longer lasting relief.
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Affiliation(s)
- Michael E Goldberg
- Department of Anesthesiology, Division of Pain Management, Cooper University Hospital, The Robert Wood Johnson Medical School - UMDNJ, Camden, NJ 08103, USA.
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Kiefer RT, Rohr P, Ploppa A, Dieterich HJ, Grothusen J, Koffler S, Altemeyer KH, Unertl K, Schwartzman RJ. Efficacy of Ketamine in Anesthetic Dosage for the Treatment of Refractory Complex Regional Pain Syndrome: An Open-Label Phase II Study. Pain Med 2008; 9:1173-201. [DOI: 10.1111/j.1526-4637.2007.00402.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kiefer RT, Rohr P, Ploppa A, Nohé B, Dieterich HJ, Grothusen J, Altemeyer KH, Unertl K, Schwartzman RJ. A pilot open-label study of the efficacy of subanesthetic isomeric S(+)-ketamine in refractory CRPS patients. Pain Med 2008; 9:44-54. [PMID: 18254766 DOI: 10.1111/j.1526-4637.2006.00223.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Complex regional pain syndrome (CRPS) is a severe neuropathic pain state that is often disproportionate to the initial trauma. Associated features are autonomic dysregulation, swelling, motor dysfunction, and trophic changes to varying degrees. Despite a multitude of treatment modalities, a subgroup of CRPS patients remain refractory to all standard therapies. In these patients, the disease may spread extraterritorially, which results in severe disability. A critical involvement of N-methyl-D-aspartate receptors (NMDARs) has been demonstrated both clinically and by animal experimentation. NMDA antagonists may be effective in many neuropathic pain states. In long-standing, generalized CRPS, we investigated the effects of S(+)-ketamine on pain relief and somatosensory features, assessed by quantitative sensory testing (QST). METHODS Four refractory CRPS patients received continous S(+)-ketamine-infusions, gradually titrated (50 mg/day-500 mg/day) over a 10-day period. Pain intensities (average, peak, and least pain) and side effects were rated on visual analogue scales, during a 4-day baseline, over 10 treatment days, and 2 days following treatment. QST (thermo-, mechanical detection, and pain thresholds) was analyzed at baseline and following treatment. RESULTS Subanesthetic S(+)-ketamine showed no reduction of pain and effected no change in thermo- and mechanical detection or pain thresholds. This procedure caused no relevant side effects. The lack of therapeutic response in the first four patients led to termination of this pilot study. CONCLUSION S(+)-ketamine can be gradually titrated to large doses (500 mg/day) without clinically relevant side effects. There was no pain relief or change in QST measurements in this series of long-standing severe CRPS patients.
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Affiliation(s)
- Ralph-Thomas Kiefer
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
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Schwartzman RJ, Gurusinghe C, Gracely E. Prevalence of complex regional pain syndrome in a cohort of multiple sclerosis patients. Pain Physician 2008; 11:133-136. [PMID: 18354707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND More than 50% of multiple sclerosis patients experience chronic pain syndrome. We set out to determine the specific type of chronic pain that was seen in our multiple sclerosis patients. METHODS Patients with multiple sclerosis were catalogued between January 2002 and April 2006 and identified by a search of the database. Only MS patients that met the 2005 revised McDonald criteria were included. RESULTS We determined the prevalence rate of complex regional pain syndrome in a cohort of multiple sclerosis patients. In our sample of 205 multiple sclerosis patients, the prevalence of complex regional pain syndrome was 4 cases per 205 compared to an expected age and sex-adjusted total prevalence of 0.078 cases per 205 (p < 0.0001). CONCLUSION This study suggests that multiple sclerosis patients are at a higher risk of developing complex regional pain syndrome than the general population.
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Affiliation(s)
- Robert J Schwartzman
- Drexel University College of Medicine, Department of Neurology, Philadelphia, PA, USA
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Assadi M, Leone P, Veloski JJ, Schwartzman RJ, Janson CG, Campellone JV. Validating an Ataxia Functional Composite Scale in spinocerebellar ataxia. J Neurol Sci 2008; 268:136-9. [PMID: 18191149 DOI: 10.1016/j.jns.2007.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Revised: 11/08/2007] [Accepted: 11/27/2007] [Indexed: 10/22/2022]
Abstract
The Ataxia Functional Composite Scale (AFCS) may provide a sensitive and reproducible assessment of treatment responses in studies of the spinocerebellar ataxias (SCA). We previously assessed the effects of buspirone in a cohort of patients with SCA via the International Cooperative Ataxia Rating Scale (ICARS). At each assessment period, AFCS scores were also obtained. A strong correlation of AFCS with ICARS scores was demonstrated at all assessment periods. This study supports the validity of the AFCS as a useful assessment of ataxia in this population.
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Affiliation(s)
- Mitra Assadi
- Department of Medicine, Division of Neurology, Cooper University Hospital/Robert Wood Johnson Medical School, Camden, New Jersey, USA.
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Assadi M, Campellone JV, Janson CG, Veloski JJ, Schwartzman RJ, Leone P. Treatment of spinocerebellar ataxia with buspirone. J Neurol Sci 2007; 260:143-6. [PMID: 17512011 DOI: 10.1016/j.jns.2007.04.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2007] [Revised: 04/13/2007] [Accepted: 04/16/2007] [Indexed: 10/23/2022]
Abstract
Preliminary data suggest potential benefit of 5-HT receptor agonists in the treatment of ataxias. We studied the effects of buspirone in a cohort of twenty patients with spinocerebellar ataxia (SCA). Twenty patients were treated in this double-blind, placebo controlled, cross-over trial with either buspirone HCl 30 mg twice daily or placebo for 3 months. Buspirone was not shown to be superior to placebo in the treatment of patients with SCA.
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Affiliation(s)
- Mitra Assadi
- Department of Medicine, Division of Neurology, Cooper University Hospital/Robert Wood Johnson Medical School, Camden, New Jersey, USA.
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Koffler SP, Hampstead BM, Irani F, Tinker J, Kiefer RT, Rohr P, Schwartzman RJ. The neurocognitive effects of 5 day anesthetic ketamine for the treatment of refractory complex regional pain syndrome. Arch Clin Neuropsychol 2007; 22:719-29. [PMID: 17611073 DOI: 10.1016/j.acn.2007.05.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Revised: 05/21/2007] [Accepted: 05/22/2007] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Complex regional pain syndrome I (CRPS) is characterized by severe neuropathic pain that exceeds the severity of an injury and is refractory to traditional treatments. Recent experimental interventions include ketamine infusion therapy. OBJECTIVE We sought to evaluate the physical, neurocognitive, and emotional effects of extended treatment with anesthetic doses of ketamine in refractory CRPS I patients. METHODS Nine patients (eight females) received a neuropsychological evaluation pre- and 6 weeks post-treatment that evaluated intellectual and academic abilities, executive functioning/processing speed, attention, learning and memory, and motor functioning. Mood/affect and personality were also evaluated and patients completed an extensive pain questionnaire. RESULTS There was a marked reduction in the report of both acute and overall pain after treatment. Brief attention and processing speed improved significantly post-treatment, whereas all other cognitive domains remained stable, with the exception of a mild decline in motor strength. CONCLUSIONS Findings suggest that, at least at a 6-week follow up: (1) deep ketamine therapy is effective for relief of pain CRPS I and (2) there were no adverse cognitive effects of extended treatment with deep ketamine infusion. No definitive conclusions could be drawn about the relationship between mood and personality factors and the presence of CRPS I.
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Affiliation(s)
- Sandra P Koffler
- Department of Psychiatry, College of Medicine, Drexel University, 245 North 15th Street, Philadelphia, PA 19102, USA.
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Abstract
Background: Electroconvulsive therapy (ECT) is a well-established treatment method
for medically refractory depression. ECT has also been used in the treatment of pain for
over 50 years. The mechanism of action of ECT is still unknown, although several observations have been made regarding the effect of ECT on pain processes. It has been reported that several patients with medically refractory depression and Complex Regional
Pain Syndrome who were treated with ECT for their depression were also cured of their
CRPS symptoms.
Objective: We report a case of CRPS in a patient who also suffered from medically refractory depression. She was treated with ECT for her depression and subsequently was
relieved of all her CRPS symptoms.
Case Report: A 42 year-old female patient underwent a series of 12 standard bitemporal electroconvulsive therapy treatments for medically refractory depression. Physical examination and Quantitative Sensory Testing was done before and after the patient’s treatment with ECT. This standard treatment procedure for refractory depression completely
resolved the patient’s depressive symptoms. In addition, the patient’s CRPS symptoms
were also reversed. Physical examination as well as Quantitative Sensory Testing done before and after the ECT treatment correlated with her CRPS symptom improvement.
Conclusion: ECT was effective in the treatment of severe refractory CRPS in this patient.
Key words: Iimpedance, posture change, spinal cord stimulation
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Wolanin MW, Gulevski V, Schwartzman RJ. Treatment of CRPS with ECT. Pain Physician 2007; 10:573-8. [PMID: 17660856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is a well-established treatment method for medically refractory depression. ECT has also been used in the treatment of pain for over 50 years. The mechanism of action of ECT is still unknown, although several observations have been made regarding the effect of ECT on pain processes. It has been reported that several patients with medically refractory depression and Complex Regional Pain Syndrome who were treated with ECT for their depression were also cured of their CRPS symptoms. OBJECTIVE We report a case of CRPS in a patient who also suffered from medically refractory depression. She was treated with ECT for her depression and subsequently was relieved of all her CRPS symptoms. CASE REPORT A 42 year-old female patient underwent a series of 12 standard bitemporal electroconvulsive therapy treatments for medically refractory depression. Physical examination and Quantitative Sensory Testing was done before and after the patient's treatment with ECT. This standard treatment procedure for refractory depression completely resolved the patient's depressive symptoms. In addition, the patient's CRPS symptoms were also reversed. Physical examination as well as Quantitative Sensory Testing done before and after the ECT treatment correlated with her CRPS symptom improvement. CONCLUSION ECT was effective in the treatment of severe refractory CRPS in this patient.
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Alexander GM, Perreault MJ, Reichenberger ER, Schwartzman RJ. Changes in immune and glial markers in the CSF of patients with Complex Regional Pain Syndrome. Brain Behav Immun 2007; 21:668-76. [PMID: 17129705 DOI: 10.1016/j.bbi.2006.10.009] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Revised: 10/17/2006] [Accepted: 10/19/2006] [Indexed: 12/21/2022] Open
Abstract
Complex Regional Pain Syndrome is a severe chronic pain condition characterized by sensory, autonomic, motor and dystrophic signs and symptoms. The pain in CRPS is continuous, it worsens over time, and it is usually disproportionate to the severity and duration of the inciting event. This study compares cerebrospinal fluid (CSF) levels of pro- and anti-inflammatory cytokines, chemokines and several biochemical factors (glial fibrillary acidic protein (GFAP), the nitric oxide metabolites (nitrate plus nitrite), the excitatory amino acid neurotransmitter glutamate, calcium, total protein and glucose) in patients afflicted with CRPS to levels found in patients suffering with other non-painful or painful conditions. The aim of the study is to determine the degree of involvement of glial cells and immune system mediators in the pathophysiology of CRPS. There was no elevation or reduction of a CSF marker that was specific for CRPS patients. However, there were several patterns of markers that could be helpful in both elucidating the mechanisms involved in the disease process and supporting the diagnosis of CRPS. The most common pattern was found in 50% (11 out of 22) of the CRPS patients and consisted of; elevated IL-6, low levels of IL-4 or IL-10, increased GFAP or MCP1 and increases in at least two of the following markers NO metabolites, calcium or glutamate. The results from this and other similar studies may aid in elucidating the mechanisms involved in the pathophysiology of CRPS. A better understanding of these mechanisms may lead to novel treatments for this very severe, life-altering illness.
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Affiliation(s)
- Guillermo M Alexander
- Department of Neurology, Drexel University College of Medicine, Philadelphia, PA 19102, USA.
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Patel SA, Hum BA, Gonzalez CF, Schwartzman RJ, Faro SH, Mohamed FB. Application of voxelwise analysis in the detection of regions of reduced fractional anisotropy in multiple sclerosis patients. J Magn Reson Imaging 2007; 26:552-6. [PMID: 17729348 DOI: 10.1002/jmri.21076] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To investigate the utility of voxelwise analysis in the detection of lesions in the normal appearing white matter (NAWM) of individual multiple sclerosis (MS) patients. MATERIALS AND METHODS Diffusion tensor imaging (DTI) was performed on 10 normal controls and six patients with MS lesions. The fractional anisotropy (FA) maps derived from the diffusion-weighted images were then spatially normalized (via an affine transformation) into Montreal Neurological Institute (MNI) space, and the normalized FA map of each of the patients was compared voxelwise with the normalized FA maps of the group of normals in a one-sample t-test (P = 0.0001). Two independent board-certified neuroradiologists reviewed the data. RESULTS In the patient data for all six cases, the two reviewers determined detection sensitivities of 72% and 96% for the voxelwise technique based on known fluid-attenuated inversion-recovery (FLAIR) lesions. In addition, between the two reviewers, nine NAWM regions exhibiting FA reductions were identified in the six patients. However, numerous regions of abnormal FA were detected that were attributed to poor intersubject image registration. CONCLUSION Voxelwise analysis of spatially normalized FA maps has the potential to identify regions of FA reduction in lesions and in the NAWM of individual MS patients in a rapid and reproducible fashion. J. Magn. Reson. Imaging 2007;26:552-556. (c) 2007 Wiley-Liss, Inc.
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Affiliation(s)
- Sunil A Patel
- Department of Biomedical Engineering, Drexel University, Philadelphia, Pennsylvania, USA
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Abstract
Complex regional pain syndrome (CRPS) most often follows injury to peripheral nerves or their endings in soft tissue. A combination of prostanoids, kinins and cytokines cause peripheral nociceptive sensitization. In time, the Mg(2+) block of the N-methyl-D-aspartate receptor is removed, pain transmission neurons (PTN) are altered by an influx of Ca(2+) that activates kinases for excitation and phosphatases for depression, activity-dependent plasticity that alters the firing of PTN. In time, these neurons undergo central sensitization that lead to a major physiological change of the autonomic, pain and motor systems. The role of the immune system and the sickness response is becoming clearer as microglia are activated following injury and can induce central sensitization while astrocytes may maintain the process.
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Affiliation(s)
- Robert J Schwartzman
- Drexel University College of Medicine, Department of Neurology, 245 N. 15 Street, MS 423 Philadelphia, PA 19102, USA.
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Abstract
INTRODUCTION Propofol infusion syndrome is described in the pediatric literature as metabolic acidosis, rhabdomyolysis, and bradycardia that results in death. The pathogenesis of this syndrome is thought to be activation of the systemic inflammatory response, which culminates in acidosis and muscle necrosis. MATERIALS AND METHODS Retrospective chart review of three patients in the Neurological Critical Care Units at Hahnemann and Massachusetts General Hospitals between October 2001 and September 2004. RESULTS Patient 1: A 27-year-old woman had seizures secondary to hemorrhage from an arteriovenous malformation. Propofol coma was induced for sedation. After initiation of propofol, she developed a metabolic acidosis, hypotension, and bradycardia and expired. Patient 2: A 64-year-old man presented in status epilepticus. After prolonged propofol administration, he developed metabolic acidosis, hypotension, and rhabdomyolysis and expired. Patient 3: A 24-year-old woman presented in status epilepticus secondary to encephalitis. Propofol was added for seizure control. She developed hypotension, metabolic acidosis, and bradyarrhythmias. Despite transvenous pacing, she expired. CONCLUSION These data show an association between extended propofol use and metabolic acidosis, rhabdomyolysis, and death in adults, as well as children. Risk factors for propofol infusion syndrome in adults include lean body mass index, high dose, and administration of more than 24-hour duration. Creatine phosphokinase, lactic acid levels, electrolytes, and arterial blood gases should be monitored frequently. Both bacterial and fungal cultures should be obtained. If this syndrome is suspected, hemodialysis should be considered. In fatal cases, autopsy should include electron microscopy of cardiac and skeletal muscle to look for mitochondrial dysfunction. Further study is warranted.
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Affiliation(s)
- Monisha A Kumar
- Vascular and Critical Care Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Alexander GM, van Rijn MA, van Hilten JJ, Perreault MJ, Schwartzman RJ. Changes in cerebrospinal fluid levels of pro-inflammatory cytokines in CRPS. Pain 2005; 116:213-219. [PMID: 15964681 DOI: 10.1016/j.pain.2005.04.013] [Citation(s) in RCA: 201] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2004] [Revised: 03/23/2005] [Accepted: 04/07/2005] [Indexed: 11/17/2022]
Abstract
Complex Regional Pain Syndrome (CRPS) Types I and II are characterized by various combinations of sensory, autonomic and motor abnormalities. Pain disproportionate to the severity and duration of the inciting event is the most devastating symptom. In animal studies, conditions resulting in exaggerated pain states demonstrate elevated pro-inflammatory cytokines. In addition, pro-inflammatory cytokines have been shown to induce or increase neuropathic and inflammatory pain. Utilizing high sensitivity enzyme linked immunosorbent assay (ELISA), we compared the levels of the pro-inflammatory cytokines interleukin-1beta (IL-1beta), interleukin-6 (IL-6) and Tumor Necrosis Factor-alpha (TNF-alpha) in the cerebrospinal fluid (CSF) of patients afflicted with CRPS to CSF levels found in other patients with and without painful conditions. The results from this study demonstrated significant increases in IL-1beta and IL-6, but not TNF-alpha in the CSF of individuals afflicted with CRPS as compared to controls. CSF cytokine levels in controls with painful conditions did not differ from levels in controls without pain. These increases showed no correlation with the patient's gender or weight. These results are consistent with studies that suggest that the pathogenesis of CRPS is due in part to central neuroimmune activation.
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Affiliation(s)
- Guillermo M Alexander
- Department of Neurology, Drexel University College of Medicine, Mail Stop 423, 245 North 15th Street, Philadelphia, PA 19102, USA Department of Neurology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
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Goldberg ME, Domsky R, Scaringe D, Hirsh R, Dotson J, Sharaf I, Torjman MC, Schwartzman RJ. Multi-day low dose ketamine infusion for the treatment of complex regional pain syndrome. Pain Physician 2005; 8:175-9. [PMID: 16850072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is characterized by pain that is out of proportion to the injury and is regional in distribution. A large body of literature supports a dynamic change in the physiology and structure of central pain projecting neurons mediated through the N-methyl-D-aspartate (NMDA) receptor. A critical factor in central sensitization seems to be the release of the magnesium block on the NMDA receptor with influx of calcium and initiation of intracellular cascades. Current literature supports the effectiveness of ketamine in blocking central sensitization through its effects on the NMDA receptor. Recent treatment with anesthetic doses of ketamine in severely ill patients with generalized CRPS prompted our interest in a lower dose therapy. OBJECTIVE To report on the efficacy of low dose outpatient ketamine infusion for the treatment of CRPS diagnosed by International Association for the Study of Pain (IASP) criteria in patients who have failed conservative treatment. DESIGN Open label, prospective, pain journal evaluation of a 10-day infusion of intravenous ketamine in the CRPS patient. METHODS Patients diagnosed with CRPS by a single neurologist were assigned to receive a 10-day outpatient infusion of ketamine supervised by an Anesthesiologist/Pain Management Specialist. The infusion was administered in a short procedure unit after each patient had been instructed on how to complete a pain questionnaire. Monitoring consisted of continuous ECG, pulse oximetry, and non-invasive blood pressure every 15 minutes. Patients made journal entries each day prior to the infusion of 40-80 mg of ketamine. The subjects were also asked to rate their pain intensity using a verbal analog pain scale of 0-10 and the affective component using a verbal scale of 0-4. RESULTS There was a significant reduction in pain intensity from initiation of infusion (Day 1) to the 10th day, with a significant reduction in the percentage of patients experiencing pain by Day 10 as well as a reduction in the level of their "worst" pain. The nadirs of pain were lower by Day 10 with a significant reduction in the incidence of "punishing pain." Moreover, there was a significant improvement in the ability to initiate movement by the 10th day. CONCLUSION A four-hour ketamine infusion escalated from 40-80 mg over a 10-day period can result in a significant reduction of pain with increased mobility and a tendency to decreased autonomic dysregulation.
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Affiliation(s)
- Michael E Goldberg
- Department of Anesthesiology, Professor of Anesthesiology, UMDNJ Robert Wood Johnson Medical School at Camden, Cooper University Hospital, One Cooper Plaza, Camden, NJ 08103, USA.
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