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Shibasaki S, Kishino T, Sei Y, Harashima K, Sakata K, Ohnishi H, Watanabe T. Close relationships between neck and upper-back stiffness and transverse cervical artery flow velocity. Eur J Appl Physiol 2024; 124:1925-1931. [PMID: 38280013 DOI: 10.1007/s00421-024-05416-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 01/02/2024] [Indexed: 01/29/2024]
Abstract
PURPOSE Neck and upper-back stiffness is encountered in daily life, with symptoms appearing as dullness or aches predominantly in the trapezius muscle (TM). Our previous study demonstrated that TM hardness as measured with a muscle hardness meter correlates well with transverse cervical artery (TCA) flow supplying the TM. Muscle hardness meters, however, cannot measure hardness in the TM alone. Meanwhile, recent advances in ultrasound elastography have enabled the evaluation of localized hardness in targeted tissues. The present study, therefore, aimed to clarify the relationship between TM hardness as measured by elastography and TCA hemodynamics as measured on Doppler sonography, with reference to daily symptoms of upper-back stiffness. METHODS The study population comprised 66 healthy young adults (32 males, 34 females; mean age, 21 ± 1 years). Relationships were evaluated between TM hardness as a negative correlate of strain ratio from elastography and TCA hemodynamics on Doppler sonography. Hemodynamics in the TCA were evaluated according to the frequency of neck and upper-back stiffness. RESULTS TM strain ratio correlated with peak systolic velocity (PSV) in the TCA (r = 0.273, p = 0.036), particularly in symptomatic subjects (r = 0.417, p = 0.022). PSV in the TCA decreased with increasing frequency of daily symptoms (p = 0.045). CONCLUSION TCA hemodynamics correlated with muscle hardness when evaluating localized TM hardness. This relationship and low PSV in the TCA were evident in symptomatic subjects. These results suggest that PSV in the TCA is associated with neck and upper-back stiffness.
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Affiliation(s)
- Shohei Shibasaki
- Department of Medical Technology, Kyorin University Faculty of Health Sciences, Tokyo, Japan
| | - Tomonori Kishino
- Department of Clinical Engineering, Kyorin University Faculty of Health Sciences, 5-4-1 Shimorenjaku, Mitaka, Tokyo, 181-8612, Japan.
| | - Yoriko Sei
- Department of Medical Technology, Kyorin University Faculty of Health Sciences, Tokyo, Japan
| | - Keiichiro Harashima
- Department of Medical Technology, Kyorin University Faculty of Health Sciences, Tokyo, Japan
| | - Konomi Sakata
- Department of Clinical Engineering, Kyorin University Faculty of Health Sciences, 5-4-1 Shimorenjaku, Mitaka, Tokyo, 181-8612, Japan
| | - Hiroaki Ohnishi
- Department of Laboratory Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
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Wen B, Zhu H, Xu J, Xu L, Huang Y. NMDA Receptors Regulate Oxidative Damage in Keratinocytes during Complex Regional Pain Syndrome in HaCaT Cells and Male Rats. Antioxidants (Basel) 2024; 13:244. [PMID: 38397842 PMCID: PMC10886417 DOI: 10.3390/antiox13020244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/29/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024] Open
Abstract
Complex regional pain syndrome (CRPS), a type of primary chronic pain, occurs following trauma or systemic disease and typically affects the limbs. CRPS-induced pain responses result in vascular, cutaneous, and autonomic nerve alterations, seriously impacting the quality of life of affected individuals. We previously identified the involvement of keratinocyte N-methyl-d-asparagic acid (NMDA) receptor subunit 2 B (NR2B) in both peripheral and central sensitizations in CRPS, although the mechanisms whereby NR2B functions following activation remain unclear. Using an in vivo male rat model of chronic post-ischemia pain (CPIP) and an in vitro oxygen-glucose deprivation/reoxygenation (OGD/R) cell model, we discovered that oxidative injury occurs in rat keratinocytes and HaCaT cells, resulting in reduced cell viability, mitochondrial damage, oxidative damage of nucleotides, and increased apoptosis. In HaCaT cells, OGD/R induced increases in intracellular reactive oxygen species levels and disrupted the balance between oxidation and antioxidation by regulating a series of antioxidant genes. The activation of NMDA receptors via NMDA exacerbated these changes, whereas the inhibition of the NR2B subunit alleviated them. Co-administration of ifenprodil (an NR2B antagonist) and NMDA (an NMDA receptor agonist) during the reoxygenation stage did not result in any significant alterations. Furthermore, intraplantar injection of ifenprodil effectively reversed the altered gene expression that was observed in male CPIP rats, thereby revealing the potential mechanisms underlying the therapeutic effects of peripheral ifenprodil administration in CRPS. Collectively, our findings indicate that keratinocytes undergo oxidative injury in CRPS, with NMDA receptors playing regulatory roles.
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Affiliation(s)
- Bei Wen
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China; (B.W.); (H.Z.)
| | - He Zhu
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China; (B.W.); (H.Z.)
| | - Jijun Xu
- Department of Pain Management, Cleveland Clinic, Cleveland, OH 44195, USA;
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Li Xu
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China; (B.W.); (H.Z.)
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China; (B.W.); (H.Z.)
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Hong SW, Hwang MS, Kim JH, Kim M, Kim SH. Usefulness of the perfusion index for monitoring the response to intravenous ketamine infusion therapy in patients with complex regional pain syndrome. Pain Pract 2023. [PMID: 36840382 DOI: 10.1111/papr.13215] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/07/2022] [Accepted: 02/01/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND This study was performed to compare the perfusion index (PI) between affected and unaffected limbs in patients with complex regional pain syndrome (CRPS); it also evaluated the usefulness of the PI for monitoring the response to intravenous ketamine infusion therapy in such patients. METHODS In total, 46 patients with CRPS in one arm or leg were enrolled in this study. The PIs of the unaffected (PIControl ) and affected (PICRPS ) limbs were simultaneously evaluated before and after treatment. RESULTS PICRPS was significantly lower than PIControl at all time points. The change in PI from immediately before to 30 min after intravenous ketamine infusion therapy (TBefore and T30 min , respectively) in the affected limb was significantly correlated with the change in visual analog pain scale (VAS) between the two time points (r = 0.646, p < 0.001). The area under the curve for the changes in VAS and PICRPS between TBefore and T30 min was 0.928. The optimal threshold value for the change in PICRPS between TBefore and T30 min , to distinguish responders with a ≥ 50-point reduction in VAS score from nonresponders, was 22.60% with a sensitivity of 0.811 (95% CI: 0.774-0.848) and a specificity of 0.889 (95% CI: 0.848-0.930). Thirty-one patients showed a ≥ 50-point reduction in VAS score [67% (95% CI: 54%-80%)] and 15 patients showed a < 50-point reduction in VAS score [33% (95% CI: 20%-46%)]. Thirty patients showed an increased PI ≥ 22.60% [65% (95% CI: 50%-78%)] and 16 patients showed an increased PI < 22.60% [35% (95% CI: 22%-50%)]. Twenty-seven patients had a ≥ 50-point reduction in VAS score and an increased PI ≥ 22.60% [59% (95% CI: 44%-74%)]. Eleven patients had shown a < 50-point pain reduction in VAS score and increased PI < 22.60% [24% (95% CI: 13%-37%)]. CONCLUSION The PI significantly differed between affected and unaffected limbs in patients with CRPS. The PI may be useful for monitoring the response to intravenous ketamine therapy in patients with CRPS.
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Affiliation(s)
- Seung-Wan Hong
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Min-Sik Hwang
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jae Hun Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Minjung Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Seong-Hyop Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.,Department of Medicine, Institute of Biomedical Science and Technology, Konkuk University School of Medicine, Seoul, Korea.,Department of Infection and Immunology, Konkuk University School of Medicine, Seoul, Korea
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Nrf2 Activation Mediates Antiallodynic Effect of Electroacupuncture on a Rat Model of Complex Regional Pain Syndrome Type-I through Reducing Local Oxidative Stress and Inflammation. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:8035109. [PMID: 35498128 PMCID: PMC9054487 DOI: 10.1155/2022/8035109] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/29/2021] [Indexed: 12/15/2022]
Abstract
Complex regional pain syndrome type-I (CRPS-I) represents a type of neurovascular condition featured by severe pain in affected extremities. Few treatments have proven effective for CRPS-I. Electroacupuncture (EA) is an effective therapy for pain relief. We explored the mechanism through which EA ameliorates pain in a rat CRPS-I model. The chronic postischemic pain (CPIP) model was established using Sprague-Dawley rats to mimic CRPS-I. We found that oxidative stress-related biological process was among the predominant biological processes in affected hindpaw of CPIP rats. Oxidative stress occurred primarily in local hindpaw but not in the spinal cord or serum of model rats. Antioxidant N-acetyl cysteine (NAC) attenuated mechanical allodynia and spinal glia overactivation in CPIP model rats, whereas locally increasing oxidative stress is sufficient to induce chronic pain and spinal glia overactivation in naive rats. EA exerted remarkable antiallodynia on CPIP rats by reducing local oxidative stress via enhancing nuclear factor erythroid 2-related factor 2 (Nrf2) expression. Pharmacological blocking Nrf2 abolished antioxidative and antiallodynic effects of EA. EA reduced spinal glia overactivation, attenuated the upregulation of inflammatory cytokines, reduced the enhanced TRPA1 channel activity in dorsal root ganglion neurons innervating the hindpaws, and improved blood flow dysfunction in hindpaws of CPIP rats, all of which were mimicked by NAC treatment. Thus, we identified local oxidative injury as an important contributor to pathogenesis of animal CRPS-I model. EA targets local oxidative injury by enhancing endogenous Nrf2-mediated antioxidative mechanism to relieve pain and inflammation. Our study indicates EA can be an alternative option for CRPS-I management.
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Fulas OA, Laferrière A, Coderre TJ. Novel Co-crystal of Pentoxifylline and Protocatechuic Acid Relieves Allodynia in Rat Models of Peripheral Neuropathic Pain and CRPS by Alleviating Local Tissue Hypoxia. ACS Chem Neurosci 2021; 12:3855-3863. [PMID: 34610235 DOI: 10.1021/acschemneuro.1c00312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Local tissue ischemic hypoxia is a peripheral process that can be targeted with topical treatment to alleviate pain under chronic pain conditions such as complex regional pain syndrome (CRPS) and peripheral neuropathic pain. We recently reported three novel salts and a co-crystal composed of vasoactive agents and antioxidant nutraceuticals, all of which produced potent topical anti-allodynic effects in the chronic postischemic pain (CPIP) rat model of CRPS. One of the products, pentx-pca, is a co-crystal synthesized from pentoxifylline (pentx) and protocatechuic acid (pca). Pentx-pca exhibited potent topical anti-allodynic effects in CPIP and rats with chronic constriction injury of the sciatic nerve exceeding effects produced individually by pentx and pca. We hypothesized that the anti-allodynic effects of pentx-pca in CPIP rats were due to its impact on local tissue oxygenation and subsequent oxygen-dependent mitochondrial respiration. Percutaneous tissue oxygen saturation (SaO2) measurements taken from the hind paw of the CPIP rats revealed that anti-allodynic doses of topical pentx-pca increased local tissue SaO2. Moreover, assessment of the oxygen-dependent mitochondrial function using a triphenyl tetrazolium chloride assay revealed that mitochondrial dysfunction significantly declined in the plantar muscle collected from CPIP rats topically treated with anti-allodynic doses of pentx-pca as compared to vehicle-treated CPIP rats. Furthermore, time-dependent resolution of plantar muscle mitochondrial dysfunction, that occurred in the CPIP rats at 6-week post procedure, paralleled the loss of the anti-allodynic response to topical treatment with pentx-pca. Our results indicated that pentx-pca produced potent anti-allodynic effects in the CPIP rat model of CRPS by alleviating peripheral tissue ischemia/hypoxia and downstream hypoxia-driven mitochondrial dysfunction.
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Affiliation(s)
- Oli Abate Fulas
- Department of Anesthesia, McGill University, 3655 Promenade Sir William Osler, Montreal, Québec H3G 1Y6, Canada
| | - André Laferrière
- Department of Anesthesia, McGill University, 3655 Promenade Sir William Osler, Montreal, Québec H3G 1Y6, Canada
| | - Terence J. Coderre
- Department of Anesthesia, McGill University, 3655 Promenade Sir William Osler, Montreal, Québec H3G 1Y6, Canada
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Efficacy and Effectiveness of Physical Agent Modalities in Complex Regional Pain Syndrome Type I: A Scoping Review. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11041857] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Complex regional pain syndrome type I (CRPS-I) is a rare condition with huge variability in triggering factors and clinical scenarios. The complexity of the pathophysiology of this condition fosters the proposal of several therapeutic options with different mechanisms of action in both research and clinical practice. An interdisciplinary and multimodal approach, including pharmacological and non-pharmacological interventions, particularly physical therapy, is recommended by international guidelines, but the benefits and harms of available interventions are poorly known. In this scoping review, the clinical rationale for use of physical agent modalities for patients with CRPS-I will be presented. We found 10 studies addressing the role of electromagnetic field therapy, electrotherapy, and laser therapy. Our findings suggest that physical therapy modalities, in particular transcutaneous electrical nerve stimulation (TENS) and pulsed electromagnetic field therapy (PEMF), may contribute to reduce pain and improve function in patients with CRPS-1.
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Kessler A, Yoo M, Calisoff R. Complex regional pain syndrome: An updated comprehensive review. NeuroRehabilitation 2020; 47:253-264. [PMID: 32986618 DOI: 10.3233/nre-208001] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Complex regional pain syndrome (CRPS) is a complex disorder that can have a significant impact on the quality of life of a person with this syndrome. The diagnosis and treatment of CRPS are often difficult as there is no one confirmatory test and no one definitive treatment. Currently, the most widely accepted clinical diagnostic criteria are the Budapest criteria, which were developed by expert consensus. Though no one single treatment has been found to be universally effective, early detection and an interdisciplinary approach to treatment appear to be key in treating CRPS. This review aims to present up-to-date clinical information regarding the diagnosis and management of CRPS and highlight the potential issues with diagnosis in the neurological population. Ultimately, more research is needed to identify the exact etiology of CRPS in order to help target appropriate therapies. In addition, more randomized controlled trials need to be performed in order to test new therapies or combinations of therapies, including pharmacological, interventional, and behavioral therapies, to determine the best treatment options for this potentially debilitating disorder.
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Affiliation(s)
- Allison Kessler
- Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, IL, USA.,Shirley Ryan Abilitylab, Chicago, IL, USA
| | - Min Yoo
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Randy Calisoff
- Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, IL, USA.,Shirley Ryan Abilitylab, Chicago, IL, USA
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Systematic Review and Synthesis of Mechanism-based Classification Systems for Pain Experienced in the Musculoskeletal System. Clin J Pain 2020; 36:793-812. [DOI: 10.1097/ajp.0000000000000860] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Ishida H, Saito SY, Horie A, Ishikawa T. Alleviation of mechanical stress-induced allodynia by improving blood flow in chronic constriction injury mice. Eur J Pharmacol 2019; 849:67-74. [PMID: 30716308 DOI: 10.1016/j.ejphar.2019.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/01/2019] [Accepted: 02/01/2019] [Indexed: 10/27/2022]
Abstract
Reduced blood flow in the skin is observed in patients with neuropathic pain and in animal models. The aim of the present study was to elucidate the relationship between reduced skin blood flow and neuropathic pain in mice with a chronic constriction injury (CCI). Noradrenaline-induced contraction was enhanced in isolated plantar arteries ipsilateral to the CCI surgery compared to the contralateral arteries. Ten μM hydralazine, a peripheral vasodilator, at improved the enhanced contractile response in the ipsilateral arteries. The plantar blood flow in vivo was lower on the ipsilateral side of the CCI mice than on the contralateral side, and a 50% paw withdrawal threshold, as measured using the von Frey filament test, was lower on the former than on the latter side. An intraperitoneal injection (i.p.) of hydralazine (1 mg/kg) or phentolamine (5 mg/kg) improved blood flow in the skin and hyperalgesia in the ipsilateral plantar. In adrenalectomized CCI mice, plantar blood flow in the skin on the ipsilateral side was increased compared to in sham-operated mice, which was accompanied by alleviation of hyperalgesia. Moreover, the enhanced contractile response to noradrenaline was also observed in the ipsilateral plantar arteries isolated from the adrenalectomized CCI mice. Either hydralazine (1 mg/kg, i.p.) or an adrenalectomy barely affected mean arterial pressure in the CCI mice, whereas phentolamine (5 mg/kg, i.p.) lowered it. These results suggest that reduced blood flow in the skin contributes to neuropathic pain and that improving that blood flow with peripheral vasodilators, such as hydralazine, can alleviate it.
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Affiliation(s)
- Hirotake Ishida
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Japan
| | - Shin-Ya Saito
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Japan
| | - Ayaka Horie
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Japan
| | - Tomohisa Ishikawa
- Department of Pharmacology, Graduate School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Japan.
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Garrido-Suárez BB, Garrido G, Castro-Labrada M, Pardo-Ruíz Z, Bellma Menéndez A, Spencer E, Godoy-Figueiredo J, Ferreira SH, Delgado-Hernández R. Anti-allodynic Effect of Mangiferin in Rats With Chronic Post-ischemia Pain: A Model of Complex Regional Pain Syndrome Type I. Front Pharmacol 2018; 9:1119. [PMID: 30333751 PMCID: PMC6176059 DOI: 10.3389/fphar.2018.01119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/13/2018] [Indexed: 12/29/2022] Open
Abstract
The present study reproduces chronic post-ischemia pain (CPIP), a model of complex regional pain syndrome type I (CRPS-I), in rats to examine the possible transient and long-term anti-allodynic effect of mangiferin (MG); as well as its potential beneficial interactions with some standard analgesic drugs and sympathetic-mediated vasoconstriction and vasodilator agents during the earlier stage of the pathology. A single dose of MG (50 and 100 mg/kg, p.o.) decreased mechanical allodynia 72 h post-ischemia-reperfusion (I/R). MG 100 mg/kg, i.p. (pre- vs. post-drug) increased von Frey thresholds in a yohimbine and naloxone-sensitive manner. Sub-effective doses of morphine, amitriptyline, prazosin, clonidine and a NO donor, SIN-1, in the presence of MG were found to be significantly anti-allodynic. A long-term anti-allodynic effect at 7 and 13 days post-I/R after repeated oral doses of MG (50 and 100 mg/kg) was also observed. Further, MG decreased spinal and muscle interleukin-1β concentration and restored muscle redox status. These results indicate that MG has a transient and long-term anti-allodynic effect in CPIP rats that appears to be at least partially attributable to the opioid and α2 adrenergic receptors. Additionally, its anti-inflammatory and antioxidant mechanisms could also be implicated in this effect. The association of MG with sub-effective doses of these drugs enhances the anti-allodynic effect; however, an isobolographic analysis should be performed to define a functional interaction between them. These findings suggest the possible clinical use of MG in the treatment of CRPS-I in both early sympathetically maintained pain and long-term sympathetically independent pain.
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Affiliation(s)
- Bárbara B. Garrido-Suárez
- Laboratorio de Farmacología y Toxicología, Centro de Investigación y Desarrollo de Medicamentos, Havana, Cuba
| | - Gabino Garrido
- Departamento de Ciencias Farmacéuticas, Facultad de Ciencias, Universidad Católica del Norte, Antofagasta, Chile
| | - Marian Castro-Labrada
- Laboratorio de Farmacología y Toxicología, Centro de Investigación y Desarrollo de Medicamentos, Havana, Cuba
| | - Zenia Pardo-Ruíz
- Laboratorio de Farmacología y Toxicología, Centro de Investigación y Desarrollo de Medicamentos, Havana, Cuba
| | - Addis Bellma Menéndez
- Laboratorio de Farmacología y Toxicología, Centro de Investigación y Desarrollo de Medicamentos, Havana, Cuba
| | - Evelyn Spencer
- Laboratorio de Farmacología y Toxicología, Centro de Investigación y Desarrollo de Medicamentos, Havana, Cuba
| | - Jozi Godoy-Figueiredo
- Department of Pharmacology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Sergio H. Ferreira
- Department of Pharmacology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - René Delgado-Hernández
- Centro de Estudio para las Investigaciones y Evaluaciones Biológicas, Instituto de Farmacia y Alimentos, Universidad de La Habana, Havana, Cuba
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11
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Queme LF, Ross JL, Jankowski MP. Peripheral Mechanisms of Ischemic Myalgia. Front Cell Neurosci 2017; 11:419. [PMID: 29311839 PMCID: PMC5743676 DOI: 10.3389/fncel.2017.00419] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/13/2017] [Indexed: 12/18/2022] Open
Abstract
Musculoskeletal pain due to ischemia is present in a variety of clinical conditions including peripheral vascular disease (PVD), sickle cell disease (SCD), complex regional pain syndrome (CRPS), and even fibromyalgia (FM). The clinical features associated with deep tissue ischemia are unique because although the subjective description of pain is common to other forms of myalgia, patients with ischemic muscle pain often respond poorly to conventional analgesic therapies. Moreover, these patients also display increased cardiovascular responses to muscle contraction, which often leads to exercise intolerance or exacerbation of underlying cardiovascular conditions. This suggests that the mechanisms of myalgia development and the role of altered cardiovascular function under conditions of ischemia may be distinct compared to other injuries/diseases of the muscles. It is widely accepted that group III and IV muscle afferents play an important role in the development of pain due to ischemia. These same muscle afferents also form the sensory component of the exercise pressor reflex (EPR), which is the increase in heart rate and blood pressure (BP) experienced after muscle contraction. Studies suggest that afferent sensitization after ischemia depends on interactions between purinergic (P2X and P2Y) receptors, transient receptor potential (TRP) channels, and acid sensing ion channels (ASICs) in individual populations of peripheral sensory neurons. Specific alterations in primary afferent function through these receptor mechanisms correlate with increased pain related behaviors and altered EPRs. Recent evidence suggests that factors within the muscles during ischemic conditions including upregulation of growth factors and cytokines, and microvascular changes may be linked to the overexpression of these different receptor molecules in the dorsal root ganglia (DRG) that in turn modulate pain and sympathetic reflexes. In this review article, we will discuss the peripheral mechanisms involved in the development of ischemic myalgia and the role that primary sensory neurons play in EPR modulation.
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Affiliation(s)
- Luis F Queme
- Department of Anesthesia, Division of Pain Management, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Jessica L Ross
- Department of Anesthesia, Division of Pain Management, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Michael P Jankowski
- Department of Anesthesia, Division of Pain Management, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Kriek N, Schreurs MW, Groeneweg JG, Dik WA, Tjiang GC, Gültuna I, Stronks DL, Huygen FJ. Spinal Cord Stimulation in Patients With Complex Regional Pain Syndrome: A Possible Target for Immunomodulation? Neuromodulation 2017; 21:77-86. [DOI: 10.1111/ner.12704] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 07/10/2017] [Accepted: 07/25/2017] [Indexed: 01/13/2023]
Affiliation(s)
- Nadia Kriek
- Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Marco W.J. Schreurs
- Department of Immunology; Erasmus University Medical Center; Rotterdam The Netherlands
| | - J. George Groeneweg
- Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Wim A. Dik
- Department of Immunology; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Gilbert C.H. Tjiang
- Department of Anaesthesiology, Pain Management and Intensive Care; Amphia Hospital; Oosterhout The Netherlands
| | - Ismail Gültuna
- Pain Treatment Center; Albert Schweitzer Hospital; Sliedrecht The Netherlands
| | - Dirk L. Stronks
- Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Frank J.P.M. Huygen
- Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
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13
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Hegelmaier T, Kumowski N, Mainka T, Vollert J, Goertz O, Lehnhardt M, Zahn P, Maier C, Kolbenschlag J. Remote ischaemic conditioning decreases blood flow and improves oxygen extraction in patients with early complex regional pain syndrome. Eur J Pain 2017; 21:1346-1354. [DOI: 10.1002/ejp.1033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2017] [Indexed: 12/17/2022]
Affiliation(s)
- T. Hegelmaier
- Department of Pain Medicine; BG University Hospital Bergmannsheil; Ruhr University; Bochum Germany
| | - N. Kumowski
- Department of Pain Medicine; BG University Hospital Bergmannsheil; Ruhr University; Bochum Germany
| | - T. Mainka
- Department of Pain Medicine; BG University Hospital Bergmannsheil; Ruhr University; Bochum Germany
- Department of Neurology; University Medical Center Hamburg Eppendorf; Germany
| | - J. Vollert
- Department of Pain Medicine; BG University Hospital Bergmannsheil; Ruhr University; Bochum Germany
- Center of Biomedicine and Medical Technology Mannheim (CBTM), Medical Faculty Mannheim; Heidelberg University; Germany
| | - O. Goertz
- Department of Plastic and Hand Surgery, Burn Center; BG University Hospital Bergmannsheil, Ruhr University; Bochum Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery; Martin-Luther-Hospital; Berlin Germany
| | - M. Lehnhardt
- Department of Plastic and Hand Surgery, Burn Center; BG University Hospital Bergmannsheil, Ruhr University; Bochum Germany
| | - P.K. Zahn
- Department of Anesthesiology, Intensive and Palliative Care; BG University Hospital Bergmannsheil; Ruhr University; Bochum Germany
| | - C. Maier
- Department of Pain Medicine; BG University Hospital Bergmannsheil; Ruhr University; Bochum Germany
| | - J. Kolbenschlag
- Department of Plastic and Hand Surgery, Burn Center; BG University Hospital Bergmannsheil, Ruhr University; Bochum Germany
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery; Martin-Luther-Hospital; Berlin Germany
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Complex regional pain syndrome: evidence for warm and cold subtypes in a large prospective clinical sample. Pain 2017; 157:1674-81. [PMID: 27023422 DOI: 10.1097/j.pain.0000000000000569] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Limited research suggests that there may be Warm complex regional pain syndrome (CRPS) and Cold CRPS subtypes, with inflammatory mechanisms contributing most strongly to the former. This study for the first time used an unbiased statistical pattern recognition technique to evaluate whether distinct Warm vs Cold CRPS subtypes can be discerned in the clinical population. An international, multisite study was conducted using standardized procedures to evaluate signs and symptoms in 152 patients with clinical CRPS at baseline, with 3-month follow-up evaluations in 112 of these patients. Two-step cluster analysis using automated cluster selection identified a 2-cluster solution as optimal. Results revealed a Warm CRPS patient cluster characterized by a warm, red, edematous, and sweaty extremity and a Cold CRPS patient cluster characterized by a cold, blue, and less edematous extremity. Median pain duration was significantly (P < 0.001) shorter in the Warm CRPS (4.7 months) than in the Cold CRPS subtype (20 months), with pain intensity comparable. A derived total inflammatory score was significantly (P < 0.001) elevated in the Warm CRPS group (compared with Cold CRPS) at baseline but diminished significantly (P < 0.001) over the follow-up period, whereas this score did not diminish in the Cold CRPS group (time × subtype interaction: P < 0.001). Results support the existence of a Warm CRPS subtype common in patients with acute (<6 months) CRPS and a relatively distinct Cold CRPS subtype most common in chronic CRPS. The pattern of clinical features suggests that inflammatory mechanisms contribute most prominently to the Warm CRPS subtype but that these mechanisms diminish substantially during the first year postinjury.
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Charrua A, Pinto R, Birder LA, Cruz F. Sympathetic nervous system and chronic bladder pain: a new tune for an old song. Transl Androl Urol 2016; 4:534-42. [PMID: 26816852 PMCID: PMC4708549 DOI: 10.3978/j.issn.2223-4683.2015.09.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Chronic bladder pain (CBP) patients present with pelvic pain or discomfort during bladder filling, for at least a period of 6 months, which may be accompanied by lower urinary tract symptoms such as frequency, nocturia, and urgency. However, both the etiology of CBP and pathophysiological mechanisms are not well described. A number of clinical and basic animal model findings support involvement of sympathetic nervous system in chronic pain syndromes such as CBP. Examples include sympathetic overactivity and high plasma or urinary catecholamine levels that have a high correlation with nociceptive symptoms. In this review, we explored the current evidence in support of the involvement of sympathetic overactivity in CBP. As bladder inflammation often occurs among subgroups of CBP patients, we discuss the possible role of sympathetic nervous system in mastocytosis as well examples examples of animal models that further support the involvement of sympathetic dysfunction in CBP. As there is substantive evidence for cross-organ sensitization in the pelvis can lead to co-morbidity of genitourinary and gastrointestinal dysfunctions, we also include how sympathetic dysfunction may play a role in a number of co-morbid chronic pain syndromes.
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Affiliation(s)
- Ana Charrua
- 1 I3S, Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal ; 2 IBMC-Instituto de Biologia Molecular e Celular, University of Porto, Porto, Portugal ; 3 Department of Renal, Urologic and Infectious diseases, Faculty of Medicine of University of Porto, Porto, Portugal ; 4 Department of Urology, Hospital S. João, Porto, Portugal ; 5 Departments of Medicine and Pharmacology-Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rui Pinto
- 1 I3S, Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal ; 2 IBMC-Instituto de Biologia Molecular e Celular, University of Porto, Porto, Portugal ; 3 Department of Renal, Urologic and Infectious diseases, Faculty of Medicine of University of Porto, Porto, Portugal ; 4 Department of Urology, Hospital S. João, Porto, Portugal ; 5 Departments of Medicine and Pharmacology-Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lori Ann Birder
- 1 I3S, Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal ; 2 IBMC-Instituto de Biologia Molecular e Celular, University of Porto, Porto, Portugal ; 3 Department of Renal, Urologic and Infectious diseases, Faculty of Medicine of University of Porto, Porto, Portugal ; 4 Department of Urology, Hospital S. João, Porto, Portugal ; 5 Departments of Medicine and Pharmacology-Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Francisco Cruz
- 1 I3S, Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal ; 2 IBMC-Instituto de Biologia Molecular e Celular, University of Porto, Porto, Portugal ; 3 Department of Renal, Urologic and Infectious diseases, Faculty of Medicine of University of Porto, Porto, Portugal ; 4 Department of Urology, Hospital S. João, Porto, Portugal ; 5 Departments of Medicine and Pharmacology-Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Radu BM, Banciu A, Banciu DD, Radu M. Acid-Sensing Ion Channels as Potential Pharmacological Targets in Peripheral and Central Nervous System Diseases. ADVANCES IN PROTEIN CHEMISTRY AND STRUCTURAL BIOLOGY 2015; 103:137-67. [PMID: 26920689 DOI: 10.1016/bs.apcsb.2015.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Acid-sensing ion channels (ASICs) are widely expressed in the body and represent good sensors for detecting protons. The pH drop in the nervous system is equivalent to ischemia and acidosis, and ASICs are very good detectors in discriminating slight changes in acidity. ASICs are important pharmacological targets being involved in a variety of pathophysiological processes affecting both the peripheral nervous system (e.g., peripheral pain, diabetic neuropathy) and the central nervous system (e.g., stroke, epilepsy, migraine, anxiety, fear, depression, neurodegenerative diseases, etc.). This review discusses the role played by ASICs in different pathologies and the pharmacological agents acting on ASICs that might represent promising drugs. As the majority of above-mentioned pathologies involve not only neuronal dysfunctions but also microvascular alterations, in the next future, ASICs may be also considered as potential pharmacological targets at the vasculature level. Perspectives and limitations in the use of ASICs antagonists and modulators as pharmaceutical agents are also discussed.
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Affiliation(s)
- Beatrice Mihaela Radu
- Department of Neurological and Movement Sciences, Section of Anatomy and Histology, University of Verona, Verona, Italy; Department of Anatomy, Animal Physiology and Biophysics, Faculty of Biology, University of Bucharest, Bucharest, Romania
| | - Adela Banciu
- Department of Anatomy, Animal Physiology and Biophysics, Faculty of Biology, University of Bucharest, Bucharest, Romania
| | - Daniel Dumitru Banciu
- Department of Anatomy, Animal Physiology and Biophysics, Faculty of Biology, University of Bucharest, Bucharest, Romania
| | - Mihai Radu
- Department of Neurological and Movement Sciences, Section of Anatomy and Histology, University of Verona, Verona, Italy; Department of Life and Environmental Physics, 'Horia Hulubei' National Institute for Physics and Nuclear Engineering, Magurele, Romania.
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Kortekaas MC, Niehof SP, Stolker RJ, Huygen FJ. Pathophysiological Mechanisms Involved in Vasomotor Disturbances in Complex Regional Pain Syndrome and Implications for Therapy: A Review. Pain Pract 2015; 16:905-14. [DOI: 10.1111/papr.12403] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 07/05/2015] [Accepted: 08/10/2015] [Indexed: 12/28/2022]
Affiliation(s)
- Minke C. Kortekaas
- Department of Anesthesiology; Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Sjoerd P. Niehof
- Department of Anesthesiology; Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Robert J. Stolker
- Department of Anesthesiology; Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Frank J.P.M. Huygen
- Department of Anesthesiology; Center for Pain Medicine; Erasmus University Medical Center; Rotterdam The Netherlands
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DIRCKX M, STRONKS DL, VAN BODEGRAVEN-HOF EAM, WESSELDIJK F, GROENEWEG JG, HUYGEN FJPM. Inflammation in cold complex regional pain syndrome. Acta Anaesthesiol Scand 2015; 59:733-9. [PMID: 25598133 DOI: 10.1111/aas.12465] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 12/01/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients with complex regional pain syndrome (CRPS), the temperature of the affected side often differs from that of the contralateral side. In the acute phase, the affected side is usually warmer than the contralateral side, the so-called 'warm' CRPS. This thermal asymmetry can develop into a colder affected side, the so-called 'cold' CRPS. In contrast to cold CRPS, in warm CRPS, inflammation is generally assumed to be present. However, there are reports of cold CRPS patients, successfully treated with vasodilatation therapy, who subsequently displayed warm CRPS. It seems that inflammation could be 'hidden' behind vasomotor disturbance. This study was designed to test this hypothesis. METHODS A retrospective analysis was made of patients in our CRPS database. We defined three types of CRPS: cold CRPS, neither cold nor warm (intermediate) CRPS, and warm CRPS. Of these patients, the difference between the level of the pro-inflammatory cytokines interleukin (IL)-6 (Δ IL-6) and tumor necrosis factor (TNF)-α (Δ TNF-α) in the affected extremity and that in the contralateral extremity was determined. RESULTS The bilateral difference of the level of these cytokines did not differ among patients with cold CRPS, intermediate CRPS, or those with warm CRPS. CONCLUSION Inflammation may be involved in cold CRPS.
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Affiliation(s)
- M. DIRCKX
- Center for Pain Medicine; Erasmus MC; Rotterdam The Netherlands
| | - D. L. STRONKS
- Center for Pain Medicine; Erasmus MC; Rotterdam The Netherlands
| | | | - F. WESSELDIJK
- Center for Pain Medicine; Erasmus MC; Rotterdam The Netherlands
| | - J. G. GROENEWEG
- Center for Pain Medicine; Erasmus MC; Rotterdam The Netherlands
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Castillo-Guzmán S, Nava-Obregón T, Palacios-Ríos D, Estrada-Cortinas J, González-García M, Mendez-Guerra J, González-Santiago O. Complex regional pain syndrome (CRPS), a review. MEDICINA UNIVERSITARIA 2015. [DOI: 10.1016/j.rmu.2015.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Schilder JC, Niehof SP, Marinus J, van Hilten JJ. Diurnal and Nocturnal Skin Temperature Regulation in Chronic Complex Regional Pain Syndrome. THE JOURNAL OF PAIN 2015; 16:207-13. [DOI: 10.1016/j.jpain.2014.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 10/29/2014] [Accepted: 11/22/2014] [Indexed: 10/24/2022]
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Stergaard L, Terkelsen AJ, Finnerup NB, Knudsen L, Drasbek KR, Jespersen SN, Svensson P, Srensen JCH, Jensen TS. Capillary dysfunction and impaired tissue oxygenation in complex regional pain syndrome: a hypothesis. Pain 2014; 155:1922-1926. [PMID: 24946228 DOI: 10.1016/j.pain.2014.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 05/19/2014] [Accepted: 06/10/2014] [Indexed: 01/30/2023]
Affiliation(s)
- Leif Stergaard
- Center of Functionally Integrative Neuroscience and MINDLab, Aarhus University, Aarhus, Denmark Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark Danish Pain Research Center, Aarhus University, Aarhus, Denmark Department of Neurology, Aarhus University Hospital, Aarhus, Denmark Department of Physics and Astronomy, Aarhus University, Aarhus, Denmark Section of Clinical Oral Physiology, School of Dentistry, Aarhus University, Aarhus, Denmark Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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Schilder JCM, van Dijk JG, Dressler D, Koelman JHTM, Marinus J, van Hilten JJ. Responsiveness to botulinum toxin type A in muscles of complex regional pain patients with tonic dystonia. J Neural Transm (Vienna) 2014; 121:761-7. [PMID: 24532257 DOI: 10.1007/s00702-014-1172-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 02/02/2014] [Indexed: 11/27/2022]
Abstract
Tonic dystonia of the limbs in complex regional pain syndrome (CRPS) is associated with considerable disability. Treatment options are scarce. Botulinum toxin (BoNT) is sometimes used, but the effect is often said to be disappointing. However, this notion stems from case reports and clinicians' opinions but has never been formally studied. We therefore investigated responsiveness to BoNT in CRPS patients with tonic dystonia. We injected the extensor digitorum brevis (EDB) muscle with BoNT-A in 17 patients with CRPS and tonic dystonia to compare the response between affected and unaffected legs. We also investigated the right legs of 17 healthy controls. Responsiveness was defined as a decrease of the amplitude of the compound muscle action potential (CMAP) of >20% from baseline 2 weeks after BoNT-A injection. We controlled for a temperature effect on BoNT efficacy by measuring skin temperature hourly directly above the EDB muscle in the first 2 weeks. CMAP amplitude decreased >20% after injection on the affected side in 16 of 17 CRPS patients, similar to the response in unaffected legs (12/13) or legs of controls (17/17). The degree of CMAP reduction was significantly smaller in patients than in controls (56.0 ± 22.3 vs. 70.6 ± 14.6%; p = 0.031). This may be due to a lower physical activity level and a greater difficulty to localize the EDB muscle properly in affected legs. The decrease in CMAP amplitude was not related to skin temperature. Contrary to the prevailing opinion, BoNT-A has a normal, although perhaps slightly lower efficacy in CRPS patients with dystonia.
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Affiliation(s)
- Johanna C M Schilder
- Department of Neurology and Clinical Neurophysiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands,
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Dirckx M, Groeneweg G, Wesseldijk F, Stronks DL, Huygen FJPM. Report of a preliminary discontinued double-blind, randomized, placebo-controlled trial of the anti-TNF-α chimeric monoclonal antibody infliximab in complex regional pain syndrome. Pain Pract 2013; 13:633-40. [PMID: 23692303 DOI: 10.1111/papr.12078] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 04/13/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Inflammation appears to play a role in CRPS as, for example, cytokines (like TNF-α) are involved in the affected limb. The ongoing inflammation is probably responsible for the central sensitization that sometimes occurs in CRPS. Thus, early start of a TNF-α antagonist may counteract inflammation, thereby preventing rest damage and leading to recovery of the disease. DESIGN Patients (n = 13) were randomly assigned to infliximab 5 mg/kg or placebo, both administered at week 0, 2, and 6. OUTCOME MEASURES The aim was to confirm a reduction in clinical signs of regional inflammation (based on total impairment level sumscore: ISS) after systemic administration of infliximab. Also, levels of mediators in the fluid of induced blisters were examined in relation to normalization and improvement in quality of life. RESULTS Six patients received infliximab and 7, placebo. There was no significant change in total ISS score between the two groups. Similarly, no significant difference in change in cytokine levels was found between infliximab compared with placebo. However, there was a trend toward a greater reduction of TNF-α in the intervention group compared with the placebo group. A subscale of the EuroQol (ie EuroQol VAS) revealed significant decrease in health status in the intervention group compared with the placebo group. CONCLUSIONS This study was terminated before the required number of participants had been reached for sufficient statistical power. Nevertheless, a trend was found toward an effect of infliximab on the initially high TNF-α concentration.
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Affiliation(s)
- Maaike Dirckx
- Erasmus MC, Center for Pain Medicine, Rotterdam, The Netherlands
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Hafner F, Froehlich H, Gary T, Brodmann M. Intra-arterial injection, a rare but serious complication of sclerotherapy. Phlebology 2013; 28:64-73. [PMID: 22422795 DOI: 10.1258/phleb.2011.011155] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Intra-arterial injections represent the most feared complication of sclerotherapy for varicose veins. We present a case of an inadvertent intra-arterial injection of polidocanol at the left medial calf in a 59-year-old woman with subsequent arterial occlusions of the posterior tibial artery and foot arteries. Despite several therapeutic interventions, lower-limb amputation could not be prevented. We conducted a PubMed search for articles reporting arterial complications related to sclerotherapy, in order to evaluate aetiology, clinical presentation, therapeutic management and outcome of sclerotherapy-associated intra-arterial injections during the past 50 years. Intra-arterial injection of a sclerosing solution was reported in 63 cases, mostly after injection near the ankle region or the distal medial calf. Clinical presentation was frequently characterized by immediate pain during injection and distal ischaemia with subsequent tissue loss. Despite several treatment approaches, amputation could not be prevented in 31 cases (52.5%). The pathophysiology of arterial complications related to intra-arterial injection and advisable therapeutic interventions are discussed. Inadvertent intra-arterial injection represents a limb-threatening complication of sclerotherapy. Target-oriented and prompt therapy seems inevitable in order to reduce the risk of permanent tissue loss and amputation.
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Affiliation(s)
- F Hafner
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Ri HS, Lee DH, Kim KH. Searching for Hidden, Painful Osteochondral Lesions of the Ankle in Patients with Chronic Lower Limb Pain - Two Case Reports -. Korean J Pain 2013; 26:164-8. [PMID: 23614079 PMCID: PMC3629344 DOI: 10.3344/kjp.2013.26.2.164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/27/2012] [Accepted: 01/16/2013] [Indexed: 11/16/2022] Open
Abstract
It is easy to overlook osteochondral lesions (OCLs) of the ankle in patients with chronic lower limb pain, such as complex regional pain syndrome (CRPS) or thromboangiitis obliterans (TAO, Buerger's disease). A 57-year-old woman diagnosed with type 1 CRPS, and a 58-year-old man, diagnosed with TAO, complained of tactile and cold allodynia in their lower legs. After neurolytic lumbar sympathethic ganglion block and titration of medications for neuropathic pain, each subject could walk without the aid of crutches. However, they both complained of constant pain on the left ankle during walking. Focal tenderness was noted; subsequent imaging studies revealed OCLs of her talus and his distal tibia, respectively. Immediately after percutaneous osteoplasties, the patients could walk without ankle pain. It is important to consider the presence of a hidden OCL in chronic pain patients that develop weight-bearing pain and complain of localized tenderness on the ankle.
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Affiliation(s)
- Hyun Su Ri
- Department of Anesthesiology and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Dong Heon Lee
- Department of Anesthesiology and Pain Medicine, Chnagwon Samsung Medical Center, Changwon, Korea
| | - Kyung Hoon Kim
- Department of Anesthesiology and Pain Medicine, Chnagwon Samsung Medical Center, Changwon, Korea
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Derenthal N, Maecken T, Krumova E, Germing A, Maier C. Morphological macrovascular alterations in complex regional pain syndrome type I demonstrated by increased intima-media thickness. BMC Neurol 2013; 13:14. [PMID: 23383716 PMCID: PMC3570292 DOI: 10.1186/1471-2377-13-14] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 02/03/2013] [Indexed: 11/29/2022] Open
Abstract
Background Although intima-media thickness (IMT) was increased in several inflammatory diseases, studies investigating whether the inflammatory processes lead to macrovascular alteration with increased IMT in complex regional pain syndrome (CRPS) lack. Methods Using ultrasound (high-resolution B-mode), we compared bilaterally the IMT of the common carotid artery (CCA-IMT), the radial artery (RA-IMT), the brachial artery (BRA-IMT) and the quotient QRA/CCA, in CRPS type I (n=17), peripheral nerve injury (PNI, n=17) and pain-free controls (PFC, n=22, matched to CRPS by gender, age and traditional cardiovascular risk factors). Statistics: Spearman’s correlation, paired t-test, ANOVA (p<0.05). Results Compared to PFC, RA-IMT were significantly increased in both patient groups bilaterally (mean±standard deviation, CRPS affected side vs. PFC dominant side: 0.32±0.08 mm vs. 0.19±0.08 mm, p<0.001; PNI affected side vs. PFC dominant side: 0.27±0.09 mm vs. 0.19±0.08 mm, p< 0.05; CRPS non-affected side vs. PFC non-dominant side: 0.30±0.10 mm vs. 0.19±0.09 mm, p<0.001; PNI non-affected side vs. PFC non-dominant side: 0.25±0.10 mm vs. 0.19±0.09 mm, p<0.05) and QRA/CCA (CRPS affected-side vs. PFC dominant side: 0.49±0.12 vs. 0.30±0.11, p<0.001; PNI affected side vs. PFC dominant side: 0.41±0.10 vs. 0.30±0.11, p<0.05; CRPS non-affected side vs. PFC non-dominant side: 0.43±0.19 vs. 0.30±0.13, p<0.001; PNI non-affected side vs. PFC non-dominant side: 0.39±0.14 vs. 0.30±0.13, p<0.05), and BRA-IMT - only on the affected side in CRPS (CRPS: 0.42±0.06 mm vs. PFC: 0.35±0.08 mm; p<0.05). In CRPS, QRA/CCA was significantly higher on the affected side compared to PNI (p<0.05). However, only CRPS displayed within-group side-to-side differences with a significantly increased RA-IMT and QRA/CCA on the affected side (p<0.05). The CCA-IMT was comparable between all groups and sides. Conclusions The increased IMT of peripheral arteries in CRPS suggests ongoing inflammatory process. Until now, only endothelial dysfunction has been reported. The presented morphological macrovascular alterations might explain the treatment resistance of some CRPS patients.
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Affiliation(s)
- Nicola Derenthal
- Department of Pain Medicine, Ruhr University Bochum, Bochum, Germany
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Cohen HE, Hall J, Harris N, McCabe CS, Blake DR, Jänig W. Enhanced pain and autonomic responses to ambiguous visual stimuli in chronic Complex Regional Pain Syndrome (CRPS) type I. Eur J Pain 2012; 16:182-95. [PMID: 22323371 DOI: 10.1016/j.ejpain.2011.06.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Cortical reorganisation of sensory, motor and autonomic systems can lead to dysfunctional central integrative control. This may contribute to signs and symptoms of Complex Regional Pain Syndrome (CRPS), including pain. It has been hypothesised that central neuroplastic changes may cause afferent sensory feedback conflicts and produce pain. We investigated autonomic responses produced by ambiguous visual stimuli (AVS) in CRPS, and their relationship to pain. Thirty CRPS patients with upper limb involvement and 30 age and sex matched healthy controls had sympathetic autonomic function assessed using laser Doppler flowmetry of the finger pulp at baseline and while viewing a control figure or AVS. Compared to controls, there were diminished vasoconstrictor responses and a significant difference in the ratio of response between affected and unaffected limbs (symmetry ratio) to a deep breath and viewing AVS. While viewing visual stimuli, 33.5% of patients had asymmetric vasomotor responses and all healthy controls had a homologous symmetric pattern of response. Nineteen (61%) CRPS patients had enhanced pain within seconds of viewing the AVS. All the asymmetric vasomotor responses were in this group, and were not predictable from baseline autonomic function. Ten patients had accompanying dystonic reactions in their affected limb: 50% were in the asymmetric sub-group. In conclusion, there is a group of CRPS patients that demonstrate abnormal pain networks interacting with central somatomotor and autonomic integrational pathways.
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Affiliation(s)
- H E Cohen
- Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK.
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Taha R, Blaise GA. Update on the pathogenesis of complex regional pain syndrome: role of oxidative stress. Can J Anaesth 2012; 59:875-81. [PMID: 22798149 DOI: 10.1007/s12630-012-9748-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 06/14/2012] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Complex regional pain syndrome (CRPS) is a chronic inflammatory pain syndrome that affects one or more extremities of the body. It is characterized by burning pain and abnormalities in the sensory, motor, and autonomic nervous systems. This review illustrates how oxidative stress and nuclear factor erythroid 2-related factor (Nrf2) activation might contribute to understanding the etiopathogenesis of CRPS. PRINCIPAL FINDINGS The precise cause of CRPS remains unclear, and current treatments are not effective in many patients. The mechanism underlying CRPS may differ across patients and even within a single patient over time. Inflammatory and neuronal mechanisms have been suggested as key contributors to CRPS. Recent evidence demonstrates that oxidative stress is associated with clinical symptoms in patients with CRPS-I. Oxidative stress plays a key role in CRPS pathogenesis. The Nrf2 factor is a master regulator of the transcription of multiple antioxidants, which protects against oxidative stress and inflammation by inducing antioxidant and detoxifying genes through binding with an antioxidant response element. It has antinociceptive effects against inflammatory pain in an animal model. CONCLUSION This review summarises the effect of oxidative stress and mitochondrial dysfunction in the pathogenesis of CRPS. It also addresses the question of whether there is a potential role for Nrf2 (activated by pharmacological or nutritional activators) in alleviating the clinical features of CRPS or preventing its progression.
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Affiliation(s)
- Rame Taha
- Multinnova Medical Centre, Université de Montréal, Montreal, QC, Canada
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Walker S, Drummond PD. Implications of a Local Overproduction of Tumor Necrosis Factor-α in Complex Regional Pain Syndrome. PAIN MEDICINE 2011; 12:1784-807. [DOI: 10.1111/j.1526-4637.2011.01273.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Dwyer PL. Chronic pelvic pain in urogynecological practice: a personal view. Int Urogynecol J 2011; 22:383-4. [PMID: 21347732 DOI: 10.1007/s00192-011-1370-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Women with chronic pelvic pain are frequently referred to gynaecologists as over 50% also have genitourinary or irritable bowel symptoms or both. When no specific pathology is found and the pathophysiology is unclear, the aetiology is probably an interplay of neuropathic, inflammatory and functional factors. The principles of medical and surgical treatment are discussed and should be based on evidence-based medicine.
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Affiliation(s)
- Peter L Dwyer
- Department of Urogynecology, Mercy Hospital for Women, University of Melbourne, Melbourne, Australia.
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