Current Concepts in Adult CRPS

Rehabilitation Interventions for Adults With Complex Regional Pain Syndrome: A Scoping Review Protocol

OBJECTIVES

This scoping review will explore the literature related to rehabilitation interventions for the treatment of adults living with complex regional pain syndrome (CRPS), describe the domains and outcome measures used to assess their effectiveness, and examine the neurophysiological bases of these interventions.

INTRODUCTION

The unremitting symptoms of CRPS, a chronic pain condition, are associated with long-term disability, poor psychological health, decreased emotional and social well-being, and reduced quality of life. Effective treatment for persistent symptoms is notoriously difficult. Therapeutic approaches such as graded motor imagery or pain exposure therapy are recommended for CRPS but show mixed results, insufficient effectiveness, variability in outcome measures, and unclear neurophysiological bases.

INCLUSION CRITERIA

This review will consider studies that include any form of non-invasive rehabilitation intervention delivered by a healthcare professional in any setting for adults with a CRPS diagnosis. Quantitative, qualitative and observational studies, text and opinion papers will be considered.

METHODS

The Joanna Briggs Institute (JBI) methodology will be used to conduct this scoping review. MEDLINE, Embase, Scopus, APA PsycINFO, CINAHL, Cochrane, OpenGrey Google and ProQuest Dissertations and Theses Global (ProQuest) will be searched for studies in English published between 2007 and 2024. Two independent reviewers will screen the titles, abstracts, and full texts of the selected studies. Data collection will be performed using a tool developed by the researchers based on the standardised JBI tool. Data will be presented in a comprehensive narrative summary.

TRAIL REGISTRATION

https://doi.org/10.17605/OSF.IO/P967T.

Cognitive Multisensory Rehabilitation, a novel approach for Complex Regional Pain Syndrome: case series

INTRODUCTION

Effective treatment for Complex Regional Pain Syndrome (CRPS), a chronic pain condition, is challenging. Cognitive Multisensory Rehabilitation (CMR) is a cognitive and sensorimotor treatment approach aimed at restoring function that targets cognitive, somatosensory, and multisensory functions through sensory discrimination tasks.

PURPOSE

We aimed to apply CMR to treat CRPS within our clinical practice. Clinically, we have found promising results in reducing pain and other common features of CRPS, such as Body Perception Disturbances (BPD).

METHODS

In this clinical case series, four CRPS patients who participated in a two-week interdisciplinary CRPS rehabilitation program at the National Complex Regional Pain Syndrome Service in Bath, UK received CMR as part of their treatment. A combination of self-reported measures and clinical outcomes were collected pre and post-rehabilitation program.

RESULTS

Functional improvements and a reduction on BPD were observed in all clinical cases.

DISCUSSION

We demonstrate how CMR may improve several CRPS-related features that often hinder rehabilitation in people living with CRPS.

CONCLUSION

Research involving larger cohorts are necessary to provide empirical evidence of the application of CMR in treating CRPS.

Active Recharge Burst and Tonic Spinal Cord Stimulation Engage Different Supraspinal Mechanisms: A Functional Magnetic Resonance Imaging Study in Peripherally Injured Chronic Neuropathic Rats

OBJECTIVES

To assess the supraspinal working mechanisms of the burst spinal cord stimulation (SCS) mode, we used functional magnetic resonance imaging (fMRI) in chronic neuropathic rats. We hypothesized that active recharge burst SCS would induce a more profound blood oxygenation level-dependent (BOLD) signal increase in areas associated with cognitive-emotional aspects of pain, as compared to tonic SCS.

METHODS

Sprague Dawley rats (n = 17) underwent a unilateral partial sciatic nerve ligation, which resulted in chronic neuropathic pain. Quadripolar SCS electrodes were epidurally positioned on top of the dorsal columns at Th13. Isoflurane-anesthetized (1.5%) rats received either tonic SCS (n = 8) or burst SCS (n = 9) at 66% of motor threshold. BOLD fMRI was conducted before, during, and after SCS using a 9.4-T horizontal bore scanner.

RESULTS

Overall, both tonic and burst SCS induced a significant increase of BOLD signal levels in areas associated with the location and intensity of pain, and areas associated with cognitive-emotional aspects of pain. Additionally, burst SCS significantly increased BOLD signal levels in the raphe nuclei, nucleus accumbens, and caudate putamen. Tonic SCS did not induce a significant increase in BOLD signal levels in these areas.

CONCLUSIONS

In conclusion, active recharge burst and tonic SCS have different effects on the intensity and localization of SCS-induced activation responses in the brain. This work demonstrates that active recharge burst is another waveform that can engage brain areas associated with cognitive-emotional aspects of pain as well as areas associated with location and intensity of pain. Previous studies showing similar engagement used only passive recharge burst.

The Effectiveness of Transcranial Direct Current Stimulation as an Add-on Modality to Graded Motor Imagery for Treatment of Complex Regional Pain Syndrome: A Randomized Proof of Concept Study

BACKGROUND

The efficacy of Graded Motor Imagery (GMI) for the management of Complex Regional Pain Syndrome (CRPS) is supported by evidence, but its treatment effect remains generally modest. Transcranial Direct Current Stimulation (tDCS) has been advocated as an adjunct intervention to enhance the effect of motor imagery approaches in pain populations.

OBJECTIVE

The purpose of this study was to investigate the effectiveness of GMI+active tDCS compared with the GMI+sham tDCS in the treatment of CRPS type I.

METHODS

A total of 22 patients (n=11/group) were randomly assigned to the experimental (GMI+tDCS) or placebo (GMI+sham tDCS) group. GMI treatments lasted 6 weeks; anodal tDCS was applied over the motor cortex for 5 consecutive days during the first 2 weeks and once a week thereafter. Changes in pain perception, quality of life, kinesiophobia, pain catastrophizing, anxiety and mood were monitored after 6 weeks of treatment (T1) and 1-month posttreatment (T2).

RESULTS

GMI+tDCS induced no statistically significant reduction in pain compared with GMI+sham tDCS. Although we observed significant group differences in kinesiophobia (P=0.012), pain catastrophizing (P=0.049), and anxiety (P=0.046) at T1, these improvements were not maintained at T2 and did not reached a clinically significant difference.

DISCUSSION

We found no added value of tDCS combined with GMI treatments for reducing pain in patients with chronic CRPS. However, given that GMI+sham tDCS induced no significant change, further studies comparing GMI+tDCS and tDCS alone are needed to further document tDCS's effect in CRPS.

Prevalence and Cost Analysis of Complex Regional Pain Syndrome (CRPS): A Role for Neuromodulation

OBJECTIVE

The diagnosis and treatment of complex regional pain syndrome (CRPS) is challenging and there is a paucity of data describing its overall cost burden and quantifying its impact on the US healthcare system. The aim of this study was to assess the prevalence and healthcare utilization costs associated with CRPS.

MATERIALS AND METHODS

A retrospective longitudinal study was performed using the Truven MarketScan® database to identify patients with a new indexed diagnosis of CRPS (Type I, II, or both) from 2001 to 2012. We collected total, outpatient, and pain prescription costs three years prior to CRPS diagnosis (baseline), at year of CRPS diagnosis, and eight-year post-CRPS diagnosis. A longitudinal multivariate analysis was used to model the estimated total and pain prescription cost ratios comparing patients diagnosed before and after CRPS.

RESULTS

We included 35,316 patients with a newly indexed diagnosis of CRPS (Type I: n = 18,703, Type II: n = 14,599, Unspecified: n = 2014). Baseline characteristics were similar between the CRPS cohorts. Compared to two- and three-year baseline costs, one-year prior to diagnosis for all CRPS patients yielded the highest interquartile median [IQR] costs: total costs $7904[$3469, $16,084]; outpatient costs $6706[$3119, $12,715]; and pain prescription costs $1862[$147, $7649]. At the year of CRPS diagnosis, the median [IQR] costs were significantly higher than baseline costs: total costs $8508[$3943, $16,666]; outpatient costs $7251[$3527, $13,568]; and pain prescription costs $2077[$140, $8856]. Over the eight-year period after CRPS diagnosis, costs between all the years were similar, ranging from the highest (one-year) to lowest (seven-years), $4845 to $3888. The median total cumulative cost 8-years after CRPS diagnosis was $43,026 and $12,037 for pain prescription costs. [Correction added on 06 November 2017 after first online publication: the preceding sentence has been updated to demonstrate the median cumulative cost in replacement of the additive cumulative mean costs.]. During the CRPS diagnosis period, patients are expected to have a total cost 2.17-fold and prescription cost 2.56-fold of their baseline cost annually.

CONCLUSIONS

Our study demonstrates that there is a significant increase in cost and healthcare resource utilization one-year prior to and around the time of CRPS diagnosis. Furthermore, there is an increased annual cost post-diagnosis compared to baseline costs prior to CRPS diagnosis.

The impact of spinal cord stimulation for upper extremity complex regional pain syndrome on level of function

Background/aims

Spinal cord stimulation (SCS) is able to provide significant pain relief in individuals with complex regional pain syndrome (CRPS). Less is known about how this treatment impacts on function, particularly from the patients' perspective. This qualitative exploratory study was part of a larger service evaluation into current and future management of this patient group. This evaluation aimed to gain insight into the influence of SCS on daily activity and work and to explore the patients' journey from symptoms to diagnosis, SCS implant and afterwards.

Methods

A purposive sample of three patients took part in semi-structured interviews. Thematic content analysis of the data was then used to extract themes and subthemes.

Results

Thematic content analysis identified two emerging concepts: freedom and conflict. Within these two concepts, seven subthemes were apparent. Although participants described feelings of independence due to the effect of SCS on activity levels, other less encouraging issues were identified. These include a dependence on the stimulator, a lack of control over the future, and a perceived lack of understanding of their condition by others.

Conclusion

How these concepts relate to patients' ability to return to work is explored and areas for further research are identified.

Development of complex regional pain syndrome after a snake bite: a case report

The occurrence of CRPS after a snake bite was very rare, only two cases were reported worldwide. Here we report a case that the 44-year-old female patient bitten by snakes CRPS type 1 was treated consecutive intravenous regional block, lumbar sympathectomy and antiepileptic drug therapy, also discuss the possible pathophysiology.