1
|
Kindl GK, Reinhold AK, Escolano-Lozano F, Degenbeck J, Birklein F, Rittner HL, Teichmüller K. Monitoring Everyday Upper Extremity Function in Patients with Complex Regional Pain Syndrome: A Secondary, Retrospective Analysis from ncRNAPain. Pain Res Manag 2024; 2024:9993438. [PMID: 39220370 PMCID: PMC11366060 DOI: 10.1155/2024/9993438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 07/16/2024] [Accepted: 07/25/2024] [Indexed: 09/04/2024]
Abstract
Objective Complex regional pain syndrome (CRPS) represents a rare complication following injury to a limb. The DASH questionnaire (disability of arm, shoulder, and hand) evaluates everyday arm function. We assessed the DASH and its subitems in comparison to patients with brachial plexus lesions or fracture controls, analysed it over time, and in relation to active range of motion (ROM), to determine patients' impairment and trajectory. Methods The dataset included 193 patients with upper extremity CRPS from the noncoding RNA (ncRNA) Pain cohort, 36 fracture controls, and 12 patients with traumatic brachial plexus lesions. For the clinical and psychological characterisation, questionnaires and a goniometer for the measurement of ROM were utilized. Thirty-three patients were followed up after approximately 2.5 years of guideline treatment. Results CRPS patients had a similar mean DASH of 54.7 (standard deviation (S.D.) ±21) as brachial plexus lesion patients (M = 51.4, S.D. ± 16.1) but different significantly from fracture controls (M = 21.2, S.D. ± 21.1). Pain and older age were predictors of the DASH. Activities requiring force or impact on the arm, shoulder, or hand were mostly affected in patients with CRPS. After 2.5 years of standard treatment, the mean DASH score fell to 41.3 (S.D. ± 25.2), weakness in leisure activities was recuperated, pain feelings were lessened, and ROM, e.g., wrist flexion, recovered by 36°. Two-thirds of patients improved in both the DASH and the ROM. Conclusions CRPS is as disabling as a complete loss of arm function in brachial plexus lesions and exhibits only partial recovery. Developing QuickDASH versions for CRPS patients could reduce the load of questions in clinical studies. It would be prudent to consider the unexpected age dependency of the DASH in future studies. This trial is registered with DRKS00008964.
Collapse
Affiliation(s)
- Gudrun-Karin Kindl
- University Hospital WürzburgDepartment of AnaesthesiologyIntensive Care, Emergency and Pain MedicineCentre for Interdisciplinary Pain Medicine, Würzburg, Germany
| | - Ann-Kristin Reinhold
- University Hospital WürzburgDepartment of AnaesthesiologyIntensive Care, Emergency and Pain MedicineCentre for Interdisciplinary Pain Medicine, Würzburg, Germany
| | | | - Johannes Degenbeck
- University Hospital WürzburgDepartment of AnaesthesiologyIntensive Care, Emergency and Pain MedicineCentre for Interdisciplinary Pain Medicine, Würzburg, Germany
| | - Frank Birklein
- University Hospital of MainzDepartment of Neurology, Mainz, Germany
| | - Heike L. Rittner
- University Hospital WürzburgDepartment of AnaesthesiologyIntensive Care, Emergency and Pain MedicineCentre for Interdisciplinary Pain Medicine, Würzburg, Germany
| | - Karolin Teichmüller
- University Hospital WürzburgDepartment of AnaesthesiologyIntensive Care, Emergency and Pain MedicineCentre for Interdisciplinary Pain Medicine, Würzburg, Germany
| |
Collapse
|
2
|
Wiemann M, Blendow SL, Zimowski N, Enax-Krumova E, Fleischmann R, Penner IK, Grothe M, Strauss S. The role of fatigue in patients with complex regional pain syndrome. J Neurol 2024; 271:5246-5255. [PMID: 38849698 PMCID: PMC11319517 DOI: 10.1007/s00415-024-12473-3] [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: 04/02/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND AND PURPOSE Fatigue affects patients across a variety of neurological diseases, including chronic pain syndromes such as complex regional pain syndrome (CRPS). In CRPS, fatigue is often underestimated, as the focus lies in the assessment and managing of pain and sensorimotor deficits. This study aimed to investigate the prevalence, characteristics, and influence of fatigue on CRPS severity and quality of life in these patients. Such insights could enhance the clinical management of this challenging condition. METHODS In this prospective study, 181 CRPS patients and 141 age and gender-matched individuals with injury but without chronic pain were interviewed using the Fatigue Scale for Motor and Cognitive Function to assess fatigue. Depressive symptoms and quality of life (QoL) were also evaluated as additional outcome measures. Statistical analysis was performed to examine differences in fatigue prevalence between the groups, as well as associations with CRPS severity, pain levels, and clinical phenotype. In addition, best subsets regression was used to identify the primary factors influencing QoL. Fatigue was tested in a mediation analysis as a mediator between pain and depression. RESULTS CRPS patients showed significantly higher fatigue levels compared to controls (CRPS: 75 [IQR: 57-85] vs. controls: 39 [IQR: 25-57]). Based on the FSMC, 44.2% in the control group experienced fatigue, while 85% of patients with CRPS experienced fatigue (p < 0.001), of which 6% were mild, 15% moderate, and 67% severe. In CRPS severe fatigue was associated with higher pain intensities compared to no fatigue (pain at rest: p = 0.003; pain during movement: p = 0.007) or moderate fatigue (pain during movement: p = 0.03). QoL in our cohort was mainly influenced by pain (pain during movement: adj.R2 = 0.38; p < 0.001, pain at rest: Δadj.R2 = 0.02, p = 0.007) and depressive symptoms (Δadj.R2 = 0.12, p < 0.001). Subsequent analyses indicated that pain and depressive symptoms primarily impact QoL in CPRS whereas fatigue may exert an indirect influence by mediating the connection between pain and depression (p < 0.001). CONCLUSIONS This pioneering study investigates the prevalence of fatigue in CRPS patients and its relation to disease characteristics. Our results indicate a high prevalence of severe fatigue, strongly correlated with pain intensity, and its importance in the interaction between pain and depression in CRPS. These findings underscore the significant role of fatigue as a disease factor in CRPS. Therefore, the evaluation of CRPS-related disability should include a standardized assessment of fatigue for comprehensive clinical management.
Collapse
Affiliation(s)
- Matthias Wiemann
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str. 1, 17475, Greifswald, Germany
| | - Sarah-Luis Blendow
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str. 1, 17475, Greifswald, Germany
| | - Nikolas Zimowski
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str. 1, 17475, Greifswald, Germany
| | - Elena Enax-Krumova
- Department of Neurology, BG University Hospital Bergmannsheil gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Robert Fleischmann
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str. 1, 17475, Greifswald, Germany
| | - Iris-Katharina Penner
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Grothe
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str. 1, 17475, Greifswald, Germany
| | - Sebastian Strauss
- Department of Neurology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str. 1, 17475, Greifswald, Germany.
| |
Collapse
|
3
|
Shin M, Senol S, Gershon SL. Postoperative Medial Plantar and Sural Neuropathy With Complex Regional Pain Syndrome. Cureus 2024; 16:e62017. [PMID: 38984011 PMCID: PMC11233178 DOI: 10.7759/cureus.62017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2024] [Indexed: 07/11/2024] Open
Abstract
This case illustrates a distinct presentation of coexistent medial plantar and sural neuropathy leading to the development of complex regional pain syndrome (CRPS) in a 49-year-old male patient. CRPS is a broad medical diagnosis describing prolonged and excessive pain that is out of proportion to exam and has historically been diagnosed according to the Budapest criteria. To our knowledge, this is a rare report of a case of medial plantar and sural neuropathy further complicated with CRPS, status-post calcaneal fracture, surgery, and post-surgical boot placement. The case highlights the complexity of diagnosing and managing multiple concurrent neuropathies and underscores the need for interdisciplinary approaches in treating CRPS to improve patient outcomes.
Collapse
Affiliation(s)
- Michelle Shin
- Physical Medicine and Rehabilitation, Eastern Virginia Medical School, Norfolk, USA
| | - Selcen Senol
- Physical Medicine and Rehabilitation, Eastern Virginia Medical School, Norfolk, USA
| | | |
Collapse
|
4
|
Wiemann M, Zimowski N, Blendow SL, Enax-Krumova E, Naegel S, Fleischmann R, Strauss S. Evidence for converging pathophysiology in complex regional pain-syndrome and primary headache disorders: results from a case-control study. J Neurol 2024; 271:1850-1860. [PMID: 38070030 PMCID: PMC10972976 DOI: 10.1007/s00415-023-12119-w] [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: 08/29/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Neuroinflammation and maladaptive neuroplasticity play pivotal roles in migraine (MIG), trigeminal autonomic cephalalgias (TAC), and complex regional pain syndrome (CRPS). Notably, CRPS shares connections with calcitonin gene-related peptide (CGRP) in its pathophysiology. This study aims to assess if the documented links between CRPS and MIG/TAC in literature align with clinical phenotypes and disease progressions. This assessment may bolster the hypothesis of shared pathophysiological mechanisms. METHODS Patients with CRPS (n = 184) and an age-/gender-matched control group with trauma but without CRPS (n = 148) participated in this case-control study. Participant answered well-established questionnaires for the definition of CRPS symptoms, any headache complaints, headache entity, and clinical management. RESULTS Patients with CRPS were significantly more likely to suffer from migraine (OR: 3.23, 95% CI 1.82-5.85), TAC (OR: 8.07, 95% CI 1.33-154.79), or non-classified headaches (OR: 3.68, 95% CI 1.88-7.49) compared to the control group. Patients with MIG/TAC developed CRPS earlier in life (37.2 ± 11.1 vs 46.8 ± 13.5 years), had more often a central CRPS phenotype (60.6% vs. 37.0% overall) and were three times more likely to report allodynia compared to CRPS patients with other types of headaches. Additionally, these patients experienced higher pain levels and more severe CRPS, which intensified with an increasing number of headache days. Patients receiving monoclonal antibody treatment targeting the CGRP pathway for headaches reported positive effects on CRPS symptoms. CONCLUSION This study identified clinically relevant associations of MIG/TAC and CRPS not explained by chance. Further longitudinal investigations exploring potentially mutual pathomechanisms may improve the clinical management of both CRPS and primary headache disorders. TRIAL REGISTRATION German Clinical Trials Register (DRKS00022961).
Collapse
Affiliation(s)
- Matthias Wiemann
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Nikolas Zimowski
- Department of Trauma, Reconstructive Surgery and Rehabilitative Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Sarah-Luis Blendow
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Elena Enax-Krumova
- Department of Neurology, BG University Hospital Bergmannsheil gGmbH, Ruhr University Bochum, Bochum, Germany
| | - Steffen Naegel
- Department of Neurology, Martin Luther University Halle-Wittenberg and University Hospital Halle, Halle (Saale), Germany
- Department of Neurology, Alfried Krupp Hospital, Essen, Germany
| | - Robert Fleischmann
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Sebastian Strauss
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.
| |
Collapse
|
5
|
Sobeeh MG, Hassan KA, Silva AG, Bruehl S. Impact of different CRPS phenotypes and diagnostic criteria on quantitative sensory testing outcomes: systematic review and meta-analysis. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:211-225. [PMID: 37930043 DOI: 10.1093/pm/pnad144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVES This review and meta-analysis evaluated the impact of diagnostic criteria and clinical phenotypes on quantitative sensory testing (QST) outcomes in patients with complex regional pain syndrome (CRPS). METHODS Eight databases were searched based on a previously published protocol. Forty studies comparing QST outcomes between CRPS-I vs II, warm vs cold CRPS, upper vs lower limb CRPS, males vs females, or using Budapest vs older IASP criteria were included. RESULTS Studies investigating QST differences between CRPS-I vs II (n = 4), between males vs females (n = 2), and between upper and lower limb CRPS (n = 2) showed no significant differences. Four studies compared QST outcomes in warm vs cold CRPS, showing heat hyperalgesia in warm CRPS, with thermal and mechanical sensory loss in cold CRPS. Although CRPS diagnosed using the Budapest criteria (24 studies) vs 1994 IASP criteria (13 studies) showed similar sensory profiles, there was significant heterogeneity and low quality of evidence in the latter. CONCLUSIONS Based on the findings of this review, classifying CRPS according to presence or absence of nerve lesion into CRPS-I and II, location (upper or lower limb) or according to sex might not be clinically relevant as all appear to have comparable sensory profiles that might suggest similar underlying mechanisms. In contrast, warm vs cold phenotypes exhibited clear differences in their associated QST sensory profiles. To the extent that differences in underlying mechanisms might lead to differential treatment responsiveness, it appears unlikely that CRPS-I vs II, CRPS location, or patient sex would prove useful in guiding clinical management.
Collapse
Affiliation(s)
- Mohamed Gomaa Sobeeh
- Department of Physical Therapy for Musculoskeletal Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt
- Department of Physical Therapy for Orthopedic and orthopedic surgery, Faculty of Physical Therapy, Sinai University, Ismailia, Egypt
| | - Karima Abdelaty Hassan
- Department of Physical Therapy for Musculoskeletal Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Anabela G Silva
- CINTESIS.UA@RISE, School of Health Sciences, University of Aveiro, Aveiro, Portugal
| | - Stephen Bruehl
- Vanderbilt University Medical Center, Nashville, TN, United States
| |
Collapse
|
6
|
Zahn C, Puga C, Malik A, Khanna D. Painful Raynaud's mimics. Best Pract Res Clin Rheumatol 2024; 38:101948. [PMID: 38704280 DOI: 10.1016/j.berh.2024.101948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 04/04/2024] [Indexed: 05/06/2024]
Abstract
Raynaud's syndrome is a common finding in many autoimmune conditions. Accurately diagnosing Raynaud's, and differentiating it from mimicking conditions, is imperative in rheumatologic diseases. Raynaud's syndrome and Raynaud's mimickers, especially painful Raynaud's mimickers, can prove a diagnostic challenge for the practicing rheumatologist. Painful Raynaud's mimickers can lead to increased patient stress and unnecessary medical work up; Healthcare providers need to be aware of Raynaud's mimickers when evaluating patient concerns of skin color changes and pain. The present narrative review aims to highlight Raynaud's syndrome, important painful mimickers that may be seen, diagnosis, and updated management recommendations.
Collapse
Affiliation(s)
- Carleigh Zahn
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, 300 North Ingalls Building - Rm 7C27, Ann Arbor, MI, 48109, USA.
| | - Cindy Puga
- Cedars Sinai Internal Medicine Residency, 8700 Beverly Blvd, Becker Bldg. B105 A, Los Angeles, CA, 90048, USA.
| | - Aroosa Malik
- Department of Internal Medicine, Division of Vascular Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Dinesh Khanna
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, 300 North Ingalls Building - Rm 7C27, Ann Arbor, MI, 48109, USA.
| |
Collapse
|
7
|
Mangnus TJP, Dirckx M, Huygen FJPM. Different Types of Pain in Complex Regional Pain Syndrome Require a Personalized Treatment Strategy. J Pain Res 2023; 16:4379-4391. [PMID: 38162406 PMCID: PMC10757771 DOI: 10.2147/jpr.s432209] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024] Open
Abstract
Complex regional pain syndrome (CRPS) is a debilitating painful state of an extremity that can develop after trauma. CRPS is diagnosed by the new International Association for the Study of Pain (IASP) diagnostic criteria for CRPS. The syndrome is characterized by continuing regional pain with abnormal sensory, motor, sudomotor, vasomotor, edema, and/or trophic signs. The clinical presentation of CRPS can be very heterogeneous because CRPS is a multi-mechanism syndrome. Therefore, mechanism-based subgroups have been suggested to personalize treatment for CRPS. Additionally, the presentation of symptom pain may also be able to identify different subgroups of CRPS. In this review, the types of pain recognized by the IASP-nociceptive, neuropathic, and nociplastic pain-will be discussed as possible subgroups for CRPS. Each pain type should be identified in CRPS patients, with a thorough history taking, physical examination, and diagnostic tests or (novel) biomarkers to optimize treatment effectiveness. Over the course of the syndrome, patients with CRPS probably experience more than one distinct pain type. Therefore, pain specialists should be alert to not only adjust their treatment if underlying pathophysiologic mechanisms tend to change but also to personalize the treatment of the associated type of pain in the CRPS patient.
Collapse
Affiliation(s)
- Thomas J P Mangnus
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maaike Dirckx
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank J P M Huygen
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
8
|
De Schoenmacker I, Sirucek L, Scheuren PS, Lütolf R, Gorrell LM, Brunner F, Curt A, Rosner J, Schweinhardt P, Hubli M. Sensory phenotypes in complex regional pain syndrome and chronic low back pain-indication of common underlying pathomechanisms. Pain Rep 2023; 8:e1110. [PMID: 38027464 PMCID: PMC10653599 DOI: 10.1097/pr9.0000000000001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction First-line pain treatment is unsatisfactory in more than 50% of chronic pain patients, likely because of the heterogeneity of mechanisms underlying pain chronification. Objectives This cross-sectional study aimed to better understand pathomechanisms across different chronic pain cohorts, regardless of their diagnoses, by identifying distinct sensory phenotypes through a cluster analysis. Methods We recruited 81 chronic pain patients and 63 age-matched and sex-matched healthy controls (HC). Two distinct chronic pain cohorts were recruited, ie, complex regional pain syndrome (N = 20) and low back pain (N = 61). Quantitative sensory testing (QST) was performed in the most painful body area to investigate somatosensory changes related to clinical pain. Furthermore, QST was conducted in a pain-free area to identify remote sensory alterations, indicating more widespread changes in somatosensory processing. Results Two clusters were identified based on the QST measures in the painful area, which did not represent the 2 distinct pain diagnoses but contained patients from both cohorts. Cluster 1 showed increased pain sensitivities in the painful and control area, indicating central sensitization as a potential pathomechanism. Cluster 2 showed a similar sensory profile as HC in both tested areas. Hence, either QST was not sensitive enough and more objective measures are needed to detect sensitization within the nociceptive neuraxis or cluster 2 may not have pain primarily because of sensitization, but other factors such as psychosocial ones are involved. Conclusion These findings support the notion of shared pathomechanisms irrespective of the pain diagnosis. Conversely, different mechanisms might contribute to the pain of patients with the same diagnosis.
Collapse
Affiliation(s)
- Iara De Schoenmacker
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
| | - Laura Sirucek
- Neuroscience Center Zurich, University of Zurich, Zurich, Switzerland
- Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Paulina S. Scheuren
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Robin Lütolf
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Lindsay M. Gorrell
- Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Florian Brunner
- Physical Medicine and Rheumatology, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Petra Schweinhardt
- Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Alan Edward Center for Research on Pain, McGill University, Montreal, QC, Canada
| | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
9
|
Knudsen L, Santoro L, Bruehl S, Harden N, Brunner F. Subtypes of complex regional pain syndrome-a systematic review of the literature. Pain Rep 2023; 8:e1111. [PMID: 38027463 PMCID: PMC10653603 DOI: 10.1097/pr9.0000000000001111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 12/01/2023] Open
Abstract
To systematically identify and summarize possible subtypes of complex regional pain syndrome (CRPS), we searched MEDLINE, Embase, Cochrane, Scopus, and Web of Science for original studies reporting or investigating at least one subtype within a group of patients with CRPS. The search retrieved 4239 potentially relevant references. Twenty-five studies met our inclusion criteria and were included in the analysis. Complex regional pain syndrome phenotypes were investigated based on the following variables: clinical presentation/sensory disturbances, dystonia, skin temperature, disease duration, onset type, CRPS outcome, and neuropsychological test performance. Support was found for the following CRPS subtypes: CRPS type I, CRPS type II, acute CRPS, chronic CRPS, centralized CRPS, cold CRPS, warm CRPS, inflammatory CRPS, dystonic CRPS, nondystonic CRPS, familial CRPS, and nonfamilial CRPS. It is unclear whether these are distinct or overlapping subtypes. The results of this comprehensive review can facilitate the formulation of well-defined CRPS subtypes based on presumed underlying mechanisms. Our findings provide a foundation for establishing and defining clinically meaningful CRPS subtypes, with the ultimate goal of developing targeted and enhanced treatments for CRPS.
Collapse
Affiliation(s)
- Lone Knudsen
- National Rehabilitation Center for Neuromuscular Diseases, Aarhus, Denmark
| | - Lana Santoro
- Wheelock College of Education and Human Development, Boston University, Boston, MA, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Zurich, Switzerland
| |
Collapse
|
10
|
Mangnus TJP, Bharwani KD, Dik WA, Baart SJ, Dirckx M, Huygen FJPM. Is there an association between serum soluble interleukin-2 receptor levels and syndrome severity in persistent Complex Regional Pain Syndrome? PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1234-1243. [PMID: 37335874 PMCID: PMC10628980 DOI: 10.1093/pm/pnad081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/22/2023] [Accepted: 06/12/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE A potentially useful biomarker for Complex Regional Pain Syndrome (CRPS) is the serum soluble interleukin-2 receptor (sIL-2R) level, which is a marker for T-cell activation. Elevated serum sIL-2R levels have been described in CRPS patients compared to healthy controls. In T-cell mediated inflammatory diseases such as sarcoidosis and rheumatoid arthritis, the serum sIL-2R levels correlate with disease severity. In this study, we investigate whether an association exists between serum sIL-2R levels in CRPS patients and CRPS severity. METHODS A cross-sectional cohort study was conducted in a tertiary pain referral center in the Netherlands. Adult CRPS patients diagnosed by the IASP criteria were included between October 2018 until October 2022. The main study parameters were serum sIL-2R levels and the CRPS severity score. RESULTS Fifty-three CRPS patients were included with a mean syndrome duration of 84 months (Q3 - Q1:180 - 48). The majority had persistent CRPS with a syndrome duration >1 year (n = 52, 98%). The median pain Numerical Rating Score (NRS) was 7 (Q3 - Q1: 8 - 5) and the mean CRPS severity score was 11 (SD ± 2.3). The median serum sIL-2R level was 330 U/mL (Q3 - Q1:451 - 256). No statistically significant correlation was observed between serum sIL-2R levels and the CRPS severity score (rs = 0.15, P = .28). CONCLUSIONS Our findings suggest that serum sIL-2R levels cannot be used as a biomarker for syndrome severity in persistent CRPS (syndrome duration >1 year). Serial measurements of serum sIL-2R from early CRPS to persistent CRPS are needed to investigate whether serum sIL-2R levels can be used to monitor T-cell mediated inflammatory syndrome activity.
Collapse
Affiliation(s)
- Thomas J P Mangnus
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Krishna D Bharwani
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Willem A Dik
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sara J Baart
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Maaike Dirckx
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Frank J P M Huygen
- Department of Anesthesiology, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
11
|
Limerick G, Christo DK, Tram J, Moheimani R, Manor J, Chakravarthy K, Karri J, Christo PJ. Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments. Curr Pain Headache Rep 2023; 27:269-298. [PMID: 37421541 DOI: 10.1007/s11916-023-01130-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW This review presents the most current information about the epidemiology of complex regional pain syndrome (CRPS), classification and diagnostic criteria, childhood CRPS, subtypes, pathophysiology, conventional and less conventional treatments, and preventive strategies. RECENT FINDINGS CRPS is a painful disorder with multifactorial pathophysiology. The data describe sensitization of the central and peripheral nervous systems, inflammation, possible genetic factors, sympatho-afferent coupling, autoimmunity, and mental health factors as contributors to the syndrome. In addition to conventional subtypes (type I and type II), cluster analyses have uncovered other proposed subtypes. Prevalence of CRPS is approximately 1.2%, female gender is consistently associated with a higher risk of development, and substantial physical, emotional, and financial costs can result from the syndrome. Children with CRPS seem to benefit from multifaceted physical therapy leading to a high percentage of symptom-free patients. The best available evidence along with standard clinical practice supports pharmacological agents, physical and occupational therapy, sympathetic blocks for engaging physical restoration, steroids for acute CRPS, neuromodulation, ketamine, and intrathecal baclofen as therapeutic approaches. There are many emerging treatments that can be considered as a part of individualized, patient-centered care. Vitamin C may be preventive. CRPS can lead to progressively painful sensory and vascular changes, edema, limb weakness, and trophic disturbances, all of which substantially erode healthy living. Despite some progress in research, more comprehensive basic science investigation is needed to clarify the molecular mechanisms of the disease so that targeted treatments can be developed for better outcomes. Incorporating a variety of standard therapies with different modes of action may offer the most effective analgesia. Introducing less conventional approaches may also be helpful when traditional treatments fail to provide sufficient improvement.
Collapse
Affiliation(s)
- Gerard Limerick
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Dana K Christo
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Jennifer Tram
- Department of Anesthesiology, University of California, San Diego, CA, USA
| | | | - John Manor
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, USA
| | | | - Jay Karri
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.
| |
Collapse
|
12
|
Reinhold AK, Kindl GK, Dietz C, Scheu N, Mehling K, Brack A, Birklein F, Rittner HL. Molecular and clinical markers of pain relief in complex regional pain syndrome: An observational study. Eur J Pain 2023; 27:278-288. [PMID: 36440973 DOI: 10.1002/ejp.2058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is marked by disproportionate pain after trauma. Whilst the long-term outcome is crucial to patients, predictors or biomarkers of the course of pain or CRPS symptoms are still lacking. In particular, microRNAs, such as miR-223, decreased in CRPS, have been described only in cross-sectional studies. METHODS In this study, we characterised CRPS patients over a course of 2.5 years of standard treatment. The patient underwent clinical examination including pain measurement, symptom questionnaires, quantitative sensory testing (QST) and blood sampling. Exosomal microRNA levels were measured via qPCR. After follow-up, patients were stratified into 'pain relief' (mean pain reduced by ≥2 numeric rating scale) or 'persistence' (mean pain unchanged or worsened). The primary outcome was miR-223 and miR-939 expression, secondary outcomes were differences in clinical parameters between groups and time points. RESULTS Thirty-nine patients were included, 33 of whom qualified for stratification. Overall, patients reported lower pain and improved clinical characteristics after 2.5 years, but no significant changes in QST or miR-223 and miR-939 expression levels. 16 patients met the criteria for pain relief. This was associated with stable exosomal miR-223 expression, whilst levels further decreased in pain persistence. Clinically, pain relief was marked by shorter disease duration and correlated positively with high initial pain. CONCLUSION We identified progressively reduced miR-223 as a putative biomarker of chronic CRPS pain. Clinically, this study underlines the importance of early diagnosis and treatment showing that high initial pain does not predict an unfavourable outcome. Finally, pain relief and recovery of sensory disturbances seem independent processes.
Collapse
Affiliation(s)
- Ann Kristin Reinhold
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Gudrun-Karin Kindl
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Christopher Dietz
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Nathalie Scheu
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Katharina Mehling
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Alexander Brack
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Frank Birklein
- Department of Neurology, Mainz University Hospitals, Mainz, Germany
| | - Heike L Rittner
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Center for Interdisciplinary Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| |
Collapse
|
13
|
Sobeeh MG, Hassan KA, da Silva AG, Youssef EF, Fayaz NA, Mohammed MM. Pain mechanisms in complex regional pain syndrome: a systematic review and meta-analysis of quantitative sensory testing outcomes. J Orthop Surg Res 2023; 18:2. [PMID: 36593515 PMCID: PMC9806919 DOI: 10.1186/s13018-022-03461-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a chronic condition following inciting events such as fractures or surgeries with sensorimotor and autonomic manifestations and poor prognosis. This review aimed to provide conclusive evidence about the sensory phenotype of CRPS based on quantitative sensory testing (QST) to understand the underlying pain mechanisms and guide treatment strategies. DATABASES Eight databases were searched based on a previously published protocol. Forty studies comparing QST outcomes (thermal, mechanical, vibration, and electric detection thresholds, thermal, mechanical, pressure, and electric pain thresholds, wind-up ratio, mechanical pain sensitivity, allodynia, flare area, area after pinprick hyperalgesia, pleasantness after C-tactile stimulation, and pain ratings) in chronic CRPS (adults and children) versus healthy controls were included. RESULTS From 37 studies (14 of low quality, 22 of fair quality, and 1 of good quality), adults with CRPS showed: (i) significant loss of thermal, mechanical, and vibration sensations, significant gain of thermal and mechanical pain thresholds, significant elevation of pain ratings, and no difference in wind-up ratio; (ii) significant reduction of pleasantness levels and increased area of pinprick hyperalgesia, in the affected limb. From three fair-quality studies, adolescents and children with CRPS showed loss of cold detection with cold hyperalgesia in the affected limb. There was moderate to substantial overall heterogeneity. CONCLUSION Diffuse thermal and mechanical hypoesthesia with primary and secondary hyperalgesia, enhanced pain facilitation evidenced by increased area of pinprick hyperalgesia, and elevated pain ratings are dominant in adults with CRPS. Adolescents and children with CRPS showed less severe sensory abnormalities.
Collapse
Affiliation(s)
- Mohamed Gomaa Sobeeh
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt ,grid.442728.f0000 0004 5897 8474Faculty of Physical Therapy, Sinai University, Ismailia, Egypt
| | - Karima Abdelaty Hassan
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Anabela Gonçalves da Silva
- grid.7311.40000000123236065CINTESIS.UA@RISE, School of Health Sciences, University of Aveiro, Aveiro, Portugal
| | - Enas Fawzy Youssef
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Nadia Abdelazim Fayaz
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| | - Maha Mostafa Mohammed
- grid.7776.10000 0004 0639 9286Department of Physical Therapy for Musculoskeletal Disorders and its Surgeries, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| |
Collapse
|
14
|
Kriek N, de Vos CC, Groeneweg JG, Baart SJ, Huygen FJPM. Allodynia, Hyperalgesia, (Quantitative) Sensory Testing and Conditioned Pain Modulation in Patients With Complex Regional Pain Syndrome Before and After Spinal Cord Stimulation Therapy. Neuromodulation 2023; 26:78-86. [PMID: 36050204 DOI: 10.1016/j.neurom.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 05/14/2022] [Accepted: 06/07/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Complex regional pain syndrome (CRPS) is a chronic debilitating disease characterized by sensory abnormalities. Spinal cord stimulation (SCS) is an effective therapy for CRPS, but few studies have investigated the effects of SCS therapy on sensory characteristics. Therefore, this study investigated the effect of SCS on allodynia, hyperalgesia, electrical quantitative sensory testing (QST) parameters, and conditioned pain modulation (CPM) effect. MATERIALS AND METHODS This study is part of a multicenter randomized controlled trial (ISRCTN 36655259). Patients with CRPS in one extremity and eligible for SCS were included. The outcome parameters allodynia (symptom and sign), hyperalgesia (symptom), sensory thresholds with QST, CPM effect, and pain scores were tested before and after three months of SCS (40-Hz tonic SCS). Both the CRPS-affected extremity and the contralateral, clinically unaffected extremity were used to test three sensory thresholds with electrical QST: current perception threshold (CPT), pain perception threshold (PPT), and pain tolerance threshold (PTT). The PTT also was used as a test stimulus for the CPM paradigm both before and after the conditioning ice-water test. Nonparametric testing was used for all statistical analyses. RESULTS In total, 31 patients were included for analysis. Pain, allodynia (sign and symptom), and hyperalgesia (symptom) were all significantly reduced after SCS therapy. On the unaffected side, none of the QST thresholds (CPT, PPT, and PTT) was significantly altered after SCS therapy. However, the CPT on the CRPS-affected side was significantly increased after SCS therapy. A CPM effect was present both before and after SCS. CONCLUSIONS Standard 40-Hz tonic SCS significantly reduces pain, hyperalgesia, and allodynia in patients with CRPS. These findings suggest that SCS therapy should not be withheld from patients who suffer from allodynia and hyperalgesia, which contradicts previous findings derived from retrospective analysis and animal research. ISRCTN Registry: The ISRCTN registration number for the study is ISRCTN 36655259.
Collapse
Affiliation(s)
- Nadia Kriek
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Cecile C de Vos
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Johannes G Groeneweg
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sara J Baart
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Frank J P M Huygen
- Center for Pain Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
15
|
Karpin H, Vatine JJ, Bachar Kirshenboim Y, Markezana A, Weissman-Fogel I. Central Sensitization and Psychological State Distinguishing Complex Regional Pain Syndrome from Other Chronic Limb Pain Conditions: A Cluster Analysis Model. Biomedicines 2022; 11:89. [PMID: 36672597 PMCID: PMC9856064 DOI: 10.3390/biomedicines11010089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/23/2022] [Accepted: 12/23/2022] [Indexed: 01/01/2023] Open
Abstract
Complex regional pain syndrome (CRPS) taxonomy has been updated with reported subtypes and is defined as primary pain alongside other chronic limb pain (CLP) conditions. We aimed at identifying CRPS clinical phenotypes that distinguish CRPS from other CLP conditions. Cluster analysis was carried out to classify 61 chronic CRPS and 31 CLP patients based on evoked pain (intensity of hyperalgesia and dynamic allodynia, allodynia area, and after-sensation) and psychological (depression, kinesiophobia, mental distress, and depersonalization) measures. Pro-inflammatory cytokine IL-6 and TNF-α serum levels were measured. Three cluster groups were created: ‘CRPS’ (78.7% CRPS; 6.5% CLP); ‘CLP’ (64.5% CLP; 4.9% CRPS), and ‘Mixed’ (16.4% CRPS; 29% CLP). The groups differed in all measures, predominantly in allodynia and hyperalgesia (p < 0.001, η² > 0.58). ‘CRPS’ demonstrated higher psychological and evoked pain measures vs. ‘CLP’. ‘Mixed’ exhibited similarities to ‘CRPS’ in psychological profile and to ‘CLP’ in evoked pain measures. The serum level of TNF-αwas higher in the ‘CRPS’ vs. ‘CLP’ (p < 0.001) groups. In conclusion, pain hypersensitivity reflecting nociplastic pain mechanisms and psychological state measures created different clinical phenotypes of CRPS and possible CRPS subtypes, which distinguishes them from other CLP conditions, with the pro-inflammatory TNF-α cytokine as an additional potential biomarker.
Collapse
Affiliation(s)
- Hana Karpin
- Physical Therapy Department, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa 3498838, Israel
- Reuth Rehabilitation Hospital, Tel Aviv 6772829, Israel
| | - Jean-Jacques Vatine
- Reuth Rehabilitation Hospital, Tel Aviv 6772829, Israel
- Physical Medicine and Rehabilitation Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Yishai Bachar Kirshenboim
- Reuth Rehabilitation Hospital, Tel Aviv 6772829, Israel
- Department of Occupational Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Aurelia Markezana
- Goldyne Savad Institute of Gene Therapy, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel
| | - Irit Weissman-Fogel
- Physical Therapy Department, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa 3498838, Israel
| |
Collapse
|
16
|
Melf-Marzi A, Böhringer B, Wiehle M, Hausteiner-Wiehle C. Modern Principles of Diagnosis and Treatment in Complex Regional Pain Syndrome. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:879-886. [PMID: 36482756 PMCID: PMC10011717 DOI: 10.3238/arztebl.m2022.0358] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 04/21/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Background: Complex regional pain syndrome (CRPS) is a relatively common complication, occurring in 5% of cases after injury or surgery, particularly in the limbs. The incidence of CPRS is around 5-26/100 000. The latest revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) now categorizes CRPS as a primary pain condition of multifactorial origin, rather than a disease of the skeletal system or the autonomic nervous system. METHODS Method: Based on a selective search of the literature, we summarize current principles for the diagnosis and treatment of CRPS. RESULTS Results: Regional findings in CRPS are accompanied by systemic symptoms, especially by neurocognitive disorders of body perception and of symptom processing. The therapeutic focus is shifting from predominantly passive peripheral measures to early active treatments acting both centrally and peripherally. The treatment is centered on physiotherapy and occupational therapy to improve sensory perception, strength, (fine) motor skills, and sensorimotor integration/ body perception. This is supported by stepped psychological interventions to reduce anxiety and avoidance behavior, medication to decrease inflammation and pain, passive physical measures for reduction of edema and of pain, and medical aids to improve functioning in daily life. Interventional procedures should be limited to exceptional cases and only be performed in specialized centers. Spinal cord and dorsal root ganglion stimulation, respectively, are the interventions with the best evidence. CONCLUSION Conclusion: The modern principles for the diagnosis and treatment of CRPS consider both, physiological and psychological mechanisms, with the primary goal of restoring function and participation. More research is needed to strengthen the evidence base in this field.
Collapse
Affiliation(s)
- Alexandra Melf-Marzi
- Department for BG Rehabilitation; Outpatient CRPS Clinic; BG Trauma Center Murnau; Department for Anesthesiology, Intensive Care Medicine and Pain Therapy; Multimodal Pain Therapy; BG Trauma Center Murnau; Department for Neurology, Clinical Neurophysiology and Stroke Unit; BG Trauma Center Murnau; Clinic and Polyclinic for Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich
| | | | | | | |
Collapse
|
17
|
Bruehl S, Billings FT, Anderson S, Polkowski G, Shinar A, Schildcrout J, Shi Y, Milne G, Dematteo A, Mishra P, Harden RN. Preoperative Predictors of Complex Regional Pain Syndrome Outcomes in the 6 Months Following Total Knee Arthroplasty. THE JOURNAL OF PAIN 2022; 23:1712-1723. [PMID: 35470089 PMCID: PMC9560974 DOI: 10.1016/j.jpain.2022.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/30/2022] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Abstract
This prospective observational study evaluated preoperative predictors of complex regional pain syndrome (CRPS) outcomes in the 6 months following total knee arthroplasty (TKA). Participants were n = 110 osteoarthritis patients (64.5% female) undergoing unilateral TKA with no prior CRPS history. Domains of negative affect (depression, anxiety, catastrophizing), pain (intensity, widespread pain, temporal summation of pain [TSP]), pain interference, sleep disturbance, and pro-inflammatory status (tumor necrosis factor-alpha [TNF-a]) were assessed preoperatively. CRPS outcomes at 6-week and 6-month follow-up included the continuous CRPS Severity Score (CSS) and dichotomous CRPS diagnoses (2012 IASP criteria). At 6 months, 12.7% of participants met CRPS criteria, exhibiting a "warm CRPS" phenotype. Six-week CSS scores were predicted by greater preoperative depression, anxiety, catastrophizing, TSP, pain intensity, sleep disturbance, and TNF-a (P's < .05). Provisional CRPS diagnosis at 6 weeks was predicted by higher preoperative TSP, sleep disturbance, and TNF-a (P's < .05). CSS scores at 6 months were predicted by more widespread and intense preoperative pain, and higher preoperative TSP, pain interference, and TNF-a (P's < .01). CRPS diagnosis at 6 months was predicted only by more widespread and intense pain preoperatively (P's < .05). Risk for CRPS following TKA appears to involve preoperative central sensitization and inflammatory mechanisms. Preoperative negative affect is unlikely to directly influence long-term CRPS risk. PERSPECTIVE: This article identifies preoperative predictors of CRPS features at 6 months following total knee arthroplasty, including more widespread pain and higher pain intensity, temporal summation of pain, pain interference, and tumor necrosis factor-alpha levels. Findings suggest the importance of central sensitization and inflammatory mechanisms in CRPS risk following tissue trauma.
Collapse
Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ginger Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony Dematteo
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - R Norman Harden
- Departments of Physical Medicine and Rehabilitation and Physical Therapy and Human Movement Science, Northwestern University, Chicago, Illinois
| |
Collapse
|
18
|
Hu C, Li Y, Wang F, Peng Z. Application of Machine Learning for Clinical Subphenotype Identification in Sepsis. Infect Dis Ther 2022; 11:1949-1964. [PMID: 36006560 DOI: 10.1007/s40121-022-00684-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Sepsis is a heterogeneous clinical syndrome. Identification of sepsis subphenotypes could lead to allowing more precise therapy. However, there is a lack of models to identify the subphenotypes in such patients. Thus, we aimed to identify possible subphenotypes and compare the clinical outcomes for subphenotypes in a large sepsis cohort. METHODS This machine learning-based, cluster analysis was performed using the Medical Information Mart in Intensive Care (MIMIC)-IV database. We enrolled all adult (> 18 years old) patients diagnosed with sepsis in the first 24 h after intensive care unit (ICU) admission. K-means cluster analysis was performed to identify the number of classes. Multivariable logistic regression models were used to estimate the association between sepsis subphenotypes and in-hospital mortality. RESULTS A total of 8817 participants with sepsis were enrolled. The median age was 66.8 (IQR, 55.9-77.1) years, and 38.1% (3361/8817) were female. Two subphenotypes resulted in optimal separation including 11 routinely available clinical variables obtained during the first 24 h after ICU admission. Participants in subphenotype B showed higher levels of lactate, glucose and creatinine, white blood cell count, sodium and heart rate and lower body temperature, platelet count, systolic blood pressure, hemoglobin and PaO2/FiO2 ratio. In addition, the in-hospital mortality in patients with subphenotype B was significantly higher than that in subphenotype A (29.4% vs. 8.5%, P < 0.001). The difference was still significant after adjustment for potential covariates (adjusted OR 2.214; 95% CI 1.780-2.754, P < 0.001). CONCLUSIONS Two sepsis subphenotypes with different clinical outcomes could be rapidly identified using the K-means clustering analysis based on routinely available clinical data. This finding may help clinicians to identify the subphenotype rapidly at the bedside.
Collapse
Affiliation(s)
- Chang Hu
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.,Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071, Hubei, China
| | - Yiming Li
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.,Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071, Hubei, China
| | - Fengyun Wang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China.,Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071, Hubei, China
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, 430071, Hubei, China. .,Clinical Research Center of Hubei Critical Care Medicine, Wuhan, 430071, Hubei, China.
| |
Collapse
|
19
|
Lunden LK, Kleggetveit IP, Schmelz M, Jorum E. Cold allodynia is correlated to paroxysmal and evoked mechanical pain in complex regional pain syndrome (CRPS). Scand J Pain 2022; 22:533-542. [PMID: 35429156 DOI: 10.1515/sjpain-2021-0208] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/09/2022] [Indexed: 02/28/2024]
Abstract
OBJECTIVES Mechanisms of complex regional pain syndrome (CRPS) are still debated. Identifying subgroups of patients have been attempted in the hope of linking clinical findings to possible mechanisms. The aim of the present study was to investigate whether subgroups of CRPS (based on quantitative sensory testing (QST)-results) differed with respect to different characteristics of pain like spontaneous ongoing or paroxysmal pain and mechanical dynamic allodynia. METHODS 61 CRPS-patients (type 1 and 2) were examined clinically and with QST, in affected and contralateral extremity, with assessment of thresholds for warmth, cold and heat-and cold pain. RESULTS 43 patients (20 men, 23 men) were diagnosed with CRPS 1 (70.5%) and 18 patients (8 women and 10 men) with CRPS 2 (29.5%). Three subgroups were defined based on thermal thresholds; A (thermal allodynia 22.9%), B (thermal hyposensitivity 37.3%), C (thermal allodynia and hyposensitivity 39.3%). Paroxysmal pain was more prevalent in patients with thermal allodynia (merging group A + C, 25/38-65.8%) compared to patients without thermal allodynia (group B, 5/23-21.7%) (p-value=0.00085). CONCLUSIONS We suggest that cold allodynia is based on hyper-excitability of very superficial skin nociceptors. The correlation between paroxysmal pain, allodynia to light touch and cold allodynia suggests that activity in those peripheral nociceptors can drive both, paroxysmal pain and spinal sensitization leading to stroke evoked allodynia. Mechanistically, the physical cold stimulus can unmask disease-related hyperexcitability by closure of temperature-sensitive potassium channels or induction of resurgent currents. Small fiber degeneration alone may not be the crucial mechanism in CRPS, nor explain pain.
Collapse
Affiliation(s)
- Lars Kristian Lunden
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Inge Petter Kleggetveit
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Martin Schmelz
- Department of Experimental Pain Research, MCTN, University of Heidelberg, Mannheim, Germany
| | - Ellen Jorum
- Section of Clinical Neurophysiology, Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
20
|
Harden RN, McCabe CS, Goebel A, Massey M, Suvar T, Grieve S, Bruehl S. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. PAIN MEDICINE (MALDEN, MASS.) 2022; 23:S1-S53. [PMID: 35687369 PMCID: PMC9186375 DOI: 10.1093/pm/pnac046] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/15/2022] [Indexed: 11/23/2022]
Abstract
There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for "better research." This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of "elder statesman" researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the "Budapest" criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient.
Collapse
Affiliation(s)
- R Norman Harden
- Departments of PM&R and Physical Therapy and Human Movement Sciences, Northwestern University
| | - Candida S McCabe
- University of the West of England, Stapleton, Bristol, UK
- Dorothy House Hospice, Bradford-on-Avon, Wilts, UK
| | - Andreas Goebel
- Pain Research Institute, Faculty of Health and Life Science, University of Liverpool, Liverpool, UK
| | - Michael Massey
- CentraCare Neurosciences Pain Center, CentraCare, St. Cloud, Minnesota, USA
| | - Tolga Suvar
- Department of Anesthesiology and Pain Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Sharon Grieve
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Centers, Nashville, Tennessee, USA
| |
Collapse
|
21
|
Reinhold AK, Salvador E, Förster CY, Birklein F, Rittner HL. Microvascular Barrier Protection by microRNA-183 via FoxO1 Repression: A Pathway Disturbed in Neuropathy and Complex Regional Pain Syndrome. THE JOURNAL OF PAIN 2022; 23:967-980. [PMID: 34974173 DOI: 10.1016/j.jpain.2021.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/14/2021] [Accepted: 12/17/2021] [Indexed: 06/14/2023]
Abstract
Blood nerve barrier disruption and edema are common in neuropathic pain as well as in complex regional pain syndrome (CRPS). MicroRNAs (miRNA) are epigenetic multitarget switches controlling neuronal and non-neuronal cells in pain. The miR-183 complex attenuates hyperexcitability in nociceptors, but additional non-neuronal effects via transcription factors could contribute as well. This study explored exosomal miR-183 in CRPS and murine neuropathy, its effect on the microvascular barrier via transcription factor FoxO1 and tight junction protein claudin-5, and its antihyperalgesic potential. Sciatic miR-183 decreased after CCI. Substitution with perineural miR-183 mimic attenuated mechanical hypersensitivity and restored blood nerve barrier function. In vitro, serum from CCI mice und CRPS patients weakened the microvascular barrier of murine cerebellar endothelial cells, increased active FoxO1 and reduced claudin-5, concomitant with a lack of exosomal miR-183 in CRPS patients. Cellular stress also compromised the microvascular barrier which was rescued either by miR-183 mimic via FoxO1 repression or by prior silencing of Foxo1. PERSPECTIVE: Low miR-183 leading to barrier impairment via FoxO1 and subsequent claudin-5 suppression is a new aspect in the pathophysiology of CRPS and neuropathic pain. This pathway might help untangle the wide symptomatic range of CRPS and nurture further research into miRNA mimics or FoxO1 inhibitors.
Collapse
Affiliation(s)
- Ann-Kristin Reinhold
- University Hospital Würzburg, Department of Anesthesiology, Intensive Care, Emergency Care and Pain Management, Center for Interdisciplinary Pain Medicine, Würzburg, Germany
| | - Ellaine Salvador
- University Hospital Würzburg, Department of Anesthesiology, Intensive Care, Emergency Care and Pain Management, Center for Interdisciplinary Pain Medicine, Würzburg, Germany; University Hospital Würzburg, Department of Neurosurgery, Tumorbiology Laboratory, Würzburg, Germany
| | - Carola Y Förster
- University Hospital Würzburg, Department of Anesthesiology, Intensive Care, Emergency Care and Pain Management, Center for Interdisciplinary Pain Medicine, Würzburg, Germany
| | - Frank Birklein
- Mainz University Hospitals, Department of Neurology, Mainz, Germany
| | - Heike L Rittner
- University Hospital Würzburg, Department of Anesthesiology, Intensive Care, Emergency Care and Pain Management, Center for Interdisciplinary Pain Medicine, Würzburg, Germany.
| |
Collapse
|
22
|
Smart KM, Ferraro MC, Wand BM, O'Connell NE. Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Database Syst Rev 2022; 5:CD010853. [PMID: 35579382 PMCID: PMC9112661 DOI: 10.1002/14651858.cd010853.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually manifests in response to trauma or surgery and is associated with significant pain and disability. CRPS can be classified into two types: type I (CRPS I) in which a specific nerve lesion has not been identified and type II (CRPS II) where there is an identifiable nerve lesion. Guidelines recommend the inclusion of a variety of physiotherapy interventions as part of the multimodal treatment of people with CRPS. This is the first update of the review originally published in Issue 2, 2016. OBJECTIVES To determine the effectiveness of physiotherapy interventions for treating pain and disability associated with CRPS types I and II in adults. SEARCH METHODS For this update we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL, PsycINFO, LILACS, PEDro, Web of Science, DARE and Health Technology Assessments from February 2015 to July 2021 without language restrictions, we searched the reference lists of included studies and we contacted an expert in the field. We also searched additional online sources for unpublished trials and trials in progress. SELECTION CRITERIA We included randomised controlled trials (RCTs) of physiotherapy interventions compared with placebo, no treatment, another intervention or usual care, or other physiotherapy interventions in adults with CRPS I and II. Primary outcomes were pain intensity and disability. Secondary outcomes were composite scores for CRPS symptoms, health-related quality of life (HRQoL), patient global impression of change (PGIC) scales and adverse effects. DATA COLLECTION AND ANALYSIS Two review authors independently screened database searches for eligibility, extracted data, evaluated risk of bias and assessed the certainty of evidence using the GRADE system. MAIN RESULTS We included 16 new trials (600 participants) along with the 18 trials from the original review totalling 34 RCTs (1339 participants). Thirty-three trials included participants with CRPS I and one trial included participants with CRPS II. Included trials compared a diverse range of interventions including physical rehabilitation, electrotherapy modalities, cortically directed rehabilitation, electroacupuncture and exposure-based approaches. Most interventions were tested in small, single trials. Most were at high risk of bias overall (27 trials) and the remainder were at 'unclear' risk of bias (seven trials). For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as very low, downgraded due to serious study limitations, imprecision and inconsistency. Included trials rarely reported adverse effects. Physiotherapy compared with minimal care for adults with CRPS I One trial (135 participants) of multimodal physiotherapy, for which pain data were unavailable, found no between-group differences in pain intensity at 12-month follow-up. Multimodal physiotherapy demonstrated a small between-group improvement in disability at 12 months follow-up compared to an attention control (Impairment Level Sum score, 5 to 50 scale; mean difference (MD) -3.7, 95% confidence interval (CI) -7.13 to -0.27) (very low-certainty evidence). Equivalent data for pain were not available. Details regarding adverse events were not reported. Physiotherapy compared with minimal care for adults with CRPS II We did not find any trials of physiotherapy compared with minimal care for adults with CRPS II. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of physiotherapy interventions on pain and disability in CRPS. This conclusion is similar to our 2016 review. Large-scale, high-quality RCTs with longer-term follow-up are required to test the effectiveness of physiotherapy-based interventions for treating pain and disability in adults with CRPS I and II.
Collapse
Affiliation(s)
- Keith M Smart
- UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
- Physiotherapy Department, St Vincent's University Hospital, Dublin, Ireland
| | - Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Benedict M Wand
- School of Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| |
Collapse
|
23
|
Rebhorn C, Dimova V, Birklein F. [Complex regional pain syndrome-An update]. Schmerz 2022; 36:141-149. [PMID: 35316391 DOI: 10.1007/s00482-022-00641-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Complex regional pain syndrome (CRPS) is a pain disorder that develops in the hands or feet after injury. Currently, two types are differentiated, CRPS I without and CRPS II with nerve lesions as well as with either an initially warm or an initially cold subtype, depending on the clinical symptoms. After trauma a certain amount of inflammatory reaction is considered physiological. In acute CRPS this inflammation persists for months and is maintained by diverse inflammatory mediators in peripheral tissue and in blood. This persisting inflammation leads to a sensitization of the nociceptive system, causes somatic cells to proliferate and gives rise to a disrupted endothelial function. The treatment concept aims to antagonize the pathophysiologic components and includes anti-inflammatory and analgetic treatment, mobilization and restoration of the sensorimotor function of the affected limb.
Collapse
Affiliation(s)
- Cora Rebhorn
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - Violeta Dimova
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Frank Birklein
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| |
Collapse
|
24
|
Kindl G, Teichmüller K, Escolano-Lozano F, Birklein F, Rittner HL. Pain, disability, and lifestyle: Patients with complex regional pain syndrome compared to chronic musculoskeletal pain - a retrospective analysis. Eur J Pain 2021; 26:719-728. [PMID: 34958709 DOI: 10.1002/ejp.1900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/11/2021] [Accepted: 12/19/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is an orphan disease occurring as a complication after trauma. Due to its acute onset and the typical clinical presentation of the inflammatory and autonomous signs, it is an eye-catching chronic pain disease affecting also young and working people. In social media and the internet, high pain severity and unfavorable prognosis is often empathized. METHODS Here, we compared epidemiological, pain and lifestyle factors of 223 CPRS patients from the "ncRNAPain" cohort with 255 patients with chronic musculoskeletal pain (MSK). MSK patients were recruited at the beginning of a multimodal pain therapy program. We searched for factors predicting pain intensity. RESULTS Both chronic pain diseases affected women in middle age. Patients with MSK were more obese, drank more alcohol and were less educated (Pearson Chi-square Test or Mann-Whitney/U-Test). Both groups smoked more than healthy people in the OECD (Organization for Economic Cooperation and Development). Mann-Whitney/U-Test confirmed that CRPS patients did not have more severe pain and did not suffer more from pain-related disability than patients with MSK. CRPS patients also had less psychiatric comorbidities. Multiple linear regression analysis revealed that group assignment, depressive characteristics, body mass index, average alcohol consumption and smoking predicted higher pain ratings, while disease duration, anxiety symptoms or gender had no influence on pain intensity. CONCLUSION In summary our study supports a more optimistic view on pain in CRPS patients in comparison to MSK and identifies lifestyle factors which might contribute to the pathophysiology like smoking and drinking. Important next steps are the identification of CRPS patients at risk for chronification or - vice versa - with protective factors for pain resolution.
Collapse
Affiliation(s)
- Gudrun Kindl
- Center for Interdisciplinary Pain Medicine, Department of Anesthesiology, University Hospital of Würzburg, Würzburg, Germany
| | - Karolin Teichmüller
- Center for Interdisciplinary Pain Medicine, Department of Anesthesiology, University Hospital of Würzburg, Würzburg, Germany
| | | | - Frank Birklein
- Department of Neurology, University Hospital of Mainz, Mainz, Germany
| | - Heike L Rittner
- Center for Interdisciplinary Pain Medicine, Department of Anesthesiology, University Hospital of Würzburg, Würzburg, Germany
| |
Collapse
|
25
|
Bharwani KD, Kersten AB, Stone AL, Birklein F, Bruehl S, Dirckx M, Drummond PD, Gierthmühlen J, Goebel A, Knudsen L, Huygen FJPM. Denying the Truth Does Not Change the Facts: A Systematic Analysis of Pseudoscientific Denial of Complex Regional Pain Syndrome. J Pain Res 2021; 14:3359-3376. [PMID: 34737631 PMCID: PMC8558034 DOI: 10.2147/jpr.s326638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 09/03/2021] [Indexed: 12/31/2022] Open
Abstract
Purpose Several articles have claimed that complex regional pain syndrome (CRPS) does not exist. Although a minority view, it is important to understand the arguments presented in these articles. We conducted a systematic literature search to evaluate the methodological quality of articles that claim CRPS does not exist. We then examined and refuted the arguments supporting this claim using up-to-date scientific literature on CRPS. Methods A systematic search was conducted in MEDLINE, EMBASE and Cochrane CENTRAL databases. Inclusion criteria for articles were (a) a claim made that CRPS does not exist or that CRPS is not a distinct diagnostic entity and (b) support of these claims with subsequent argument(s). The methodological quality of articles was assessed if possible. Results Nine articles were included for analysis: 4 narrative reviews, 2 personal views, 1 letter, 1 editorial and 1 case report. Seven points of controversy were used in these articles to argue that CRPS does not exist: 1) disagreement with the label “CRPS”; 2) the “unclear” pathophysiology; 3) the validity of the diagnostic criteria; 4) CRPS as a normal consequence of immobilization; 5) the role of psychological factors; 6) other identifiable causes for CRPS symptoms; and 7) the methodological quality of CRPS research. Conclusion The level of evidence for the claim that CRPS does not exist is very weak. Published accounts concluding that CRPS does not exist, in the absence of primary evidence to underpin them, can harm patients by encouraging dismissal of patients’ signs and symptoms.
Collapse
Affiliation(s)
- K D Bharwani
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - A B Kersten
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - A L Stone
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - F Birklein
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - S Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Dirckx
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - P D Drummond
- Discipline of Psychology, College of Science, Health, Engineering and Education, Murdoch University, Perth, WA, Australia
| | - J Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - A Goebel
- Director of the Pain Research Institute Reader in Pain Medicine, University of Liverpool Honorary Consultant in Pain Medicine, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - L Knudsen
- The National Rehabilitation Centre for Neuromuscular Diseases, Aarhus, Denmark
| | - F J P M Huygen
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
26
|
Rebhorn C, Dimova V, Birklein F. [Complex regional pain syndrome-An update]. DER NERVENARZT 2021; 92:1075-1083. [PMID: 34542658 DOI: 10.1007/s00115-021-01186-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 11/30/2022]
Abstract
Complex regional pain syndrome (CRPS) is a pain disorder that develops in the hands or feet after injury. Currently, two types are differentiated, CRPS I without and CRPS II with nerve lesions as well as with either an initially warm or an initially cold subtype, depending on the clinical symptoms. After trauma a certain amount of inflammatory reaction is considered physiological. In acute CRPS this inflammation persists for months and is maintained by diverse inflammatory mediators in peripheral tissue and in blood. This persisting inflammation leads to a sensitization of the nociceptive system, causes somatic cells to proliferate and gives rise to a disrupted endothelial function. The treatment concept aims to antagonize the pathophysiologic components and includes anti-inflammatory and analgetic treatment, mobilization and restoration of the sensorimotor function of the affected limb.
Collapse
Affiliation(s)
- Cora Rebhorn
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland.
| | - Violeta Dimova
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| | - Frank Birklein
- Klinik und Poliklinik für Neurologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland
| |
Collapse
|
27
|
Tucker-Bartley A, Lemme J, Gomez-Morad A, Shah N, Veliu M, Birklein F, Storz C, Rutkove S, Kronn D, Boyce AM, Kraft E, Upadhyay J. Pain Phenotypes in Rare Musculoskeletal and Neuromuscular Diseases. Neurosci Biobehav Rev 2021; 124:267-290. [PMID: 33581222 PMCID: PMC9521731 DOI: 10.1016/j.neubiorev.2021.02.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/18/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
For patients diagnosed with a rare musculoskeletal or neuromuscular disease, pain may transition from acute to chronic; the latter yielding additional challenges for both patients and care providers. We assessed the present understanding of pain across a set of ten rare, noninfectious, noncancerous disorders; Osteogenesis Imperfecta, Ehlers-Danlos Syndrome, Achondroplasia, Fibrodysplasia Ossificans Progressiva, Fibrous Dysplasia/McCune-Albright Syndrome, Complex Regional Pain Syndrome, Duchenne Muscular Dystrophy, Infantile- and Late-Onset Pompe disease, Charcot-Marie-Tooth Disease, and Amyotrophic Lateral Sclerosis. Through the integration of natural history, cross-sectional, retrospective, clinical trials, & case studies we described pathologic and genetic factors, pain sources, phenotypes, and lastly, existing therapeutic approaches. We highlight that while rare diseases possess distinct core pathologic features, there are a number of shared pain phenotypes and mechanisms that may be prospectively examined and therapeutically targeted in a parallel manner. Finally, we describe clinical and research approaches that may facilitate more accurate diagnosis, monitoring, and treatment of pain as well as elucidation of the evolving nature of pain phenotypes in rare musculoskeletal or neuromuscular illnesses.
Collapse
Affiliation(s)
- Anthony Tucker-Bartley
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Jordan Lemme
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Andrea Gomez-Morad
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Nehal Shah
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Miranda Veliu
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Frank Birklein
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Rhineland-Palatinate, 55131, Germany
| | - Claudia Storz
- Department of Orthopedics, Physical Medicine and Rehabilitation, University Hospital LMU Munich, Munich, Bavaria, 80539, Germany
| | - Seward Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - David Kronn
- Department of Pathology and Pediatrics, New York Medical College, Valhalla, NY, 10595, USA; Medical Genetics, Inherited Metabolic & Lysosomal Storage Disorders Center, Boston Children's Health Physicians, Westchester, NY, 10532, USA
| | - Alison M Boyce
- Skeletal Disorders and Mineral Homeostasis Section, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Eduard Kraft
- Department of Orthopedics, Physical Medicine and Rehabilitation, University Hospital LMU Munich, Munich, Bavaria, 80539, Germany; Interdisciplinary Pain Unit, University Hospital LMU Munich, Munich, 80539, Germany
| | - Jaymin Upadhyay
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA; Department of Psychiatry, McLean Hospital, Harvard Medical School, Belmont, MA, 02478, USA.
| |
Collapse
|
28
|
Dietz C, Reinhold AK, Escolano-Lozano F, Mehling K, Forer L, Kress M, Üçeyler N, Sommer C, Dimova V, Birklein F, Rittner HL. Complex regional pain syndrome: role of contralateral sensitisation. Br J Anaesth 2021; 127:e1-e3. [PMID: 33941363 DOI: 10.1016/j.bja.2021.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/03/2021] [Accepted: 03/17/2021] [Indexed: 10/21/2022] Open
Affiliation(s)
- Christopher Dietz
- Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, University Hospital of Würzburg, Würzburg, Germany
| | - Ann-Kristin Reinhold
- Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, University Hospital of Würzburg, Würzburg, Germany
| | | | - Katharina Mehling
- Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, University Hospital of Würzburg, Würzburg, Germany
| | - Lukas Forer
- Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michaela Kress
- Division of Physiology, Department of Physiology and Medical Physics, University of Innsbruck, Innsbruck, Austria
| | - Nurcan Üçeyler
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Claudia Sommer
- Department of Neurology, University Hospital of Würzburg, Würzburg, Germany
| | - Violeta Dimova
- Department of Neurology, University Hospital of Mainz, Mainz, Germany
| | - Frank Birklein
- Department of Neurology, University Hospital of Mainz, Mainz, Germany
| | - Heike L Rittner
- Centre for Interdisciplinary Pain Medicine, Department of Anaesthesiology, University Hospital of Würzburg, Würzburg, Germany.
| |
Collapse
|
29
|
Popkirov S, Enax-Krumova EK, Mainka T, Hoheisel M, Hausteiner-Wiehle C. Functional pain disorders - more than nociplastic pain. NeuroRehabilitation 2021; 47:343-353. [PMID: 32986624 DOI: 10.3233/nre-208007] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nociplastic pain has been recently introduced as a third mechanistic descriptor of pain arising primarily from alterations of neural processing, in contrast to pain due to tissue damage leading to nociceptor activation (nociceptive) or due to lesion or disease of the somatosensory nervous system (neuropathic). It is characterized by hyperalgesia and allodynia, inconsistency and reversibility, as well as dynamic cross-system interactions with biological and psychobehavioral factors. Along with this renewed understanding, functional pain disorders, also classified as chronic primary pain, are being reframed as biopsychosocial conditions that benefit from multimodal treatment. OBJECTIVE To summarize the current understanding of nociplastic pain and functional pain disorders, with a focus on conditions that are common in neurology practice. METHODS This was a narrative literature review. RESULTS Chronic back pain, fibromyalgia syndrome and complex regional pain syndrome are best understood within a biopsychosocial framework of pain perception that considers structural factors (predispositions and sequelae) and psychobehavioral mechanisms. Although pain is often the primary complaint, it should not be the only focus of treatment, as accompanying symptoms such as sleep or mood problems can significantly impact quality of life and offer useful leverage points for multimodal treatment. Analgesic pharmacotherapy is rarely helpful on its own, and should always be imbedded in a multidisciplinary setting.
Collapse
Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Elena K Enax-Krumova
- Department of Neurology, BG University Hospital Bergmannsheil Bochum, Ruhr University Bochum, Bochum, Germany
| | - Tina Mainka
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | | | - Constanze Hausteiner-Wiehle
- Neurocenter, BG Trauma Center Murnau, Murnau, Germany.,Department of Psychosomatic Medicine and Psychotherapy, Technical University of Munich, Munich, Germany
| |
Collapse
|
30
|
Halicka M, Vittersø AD, McCullough H, Goebel A, Heelas L, Proulx MJ, Bultitude JH. Prism adaptation treatment for upper-limb complex regional pain syndrome: a double-blind randomized controlled trial. Pain 2021; 162:471-489. [PMID: 32833791 PMCID: PMC7808368 DOI: 10.1097/j.pain.0000000000002053] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 12/17/2022]
Abstract
ABSTRACT Initial evidence suggested that people with complex regional pain syndrome (CRPS) have reduced attention to the affected side of their body and the surrounding space, which might be related to pain and other clinical symptoms. Three previous unblinded, uncontrolled studies showed pain relief after treatment with prism adaptation, an intervention that has been used to counter lateralised attention bias in brain-lesioned patients. To provide a robust test of its effectiveness for CRPS, we conducted a double-blind randomized controlled trial of prism adaptation for unilateral upper-limb CRPS-I. Forty-nine eligible adults with CRPS were randomized to undergo 2 weeks of twice-daily home-based prism adaptation treatment (n = 23) or sham treatment (n = 26). Outcomes were assessed in person 4 weeks before and immediately before treatment, and immediately after and 4 weeks after treatment. Long-term postal follow-ups were conducted 3 and 6 months after treatment. We examined the effects of prism adaptation vs sham treatment on current pain intensity and the CRPS symptom severity score (primary outcomes), as well as sensory, motor, and autonomic functions, self-reported psychological functioning, and experimentally tested neuropsychological functions (secondary outcomes). We found no evidence that primary or secondary outcomes differed between the prism adaptation and sham treatment groups when tested at either time point after treatment. Overall, CRPS severity significantly decreased over time for both groups, but we found no benefits of prism adaptation beyond sham treatment. Our findings do not support the efficacy of prism adaptation treatment for relieving upper-limb CRPS-I. This trial was prospectively registered (ISRCTN46828292).
Collapse
Affiliation(s)
- Monika Halicka
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Department of Psychology, University of Bath, Bath, United Kingdom
| | - Axel D. Vittersø
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Department of Psychology, University of Bath, Bath, United Kingdom
- Department of Sport and Health Sciences, University of Exeter, Exeter, United Kingdom
| | - Hayley McCullough
- Department of Translational Medicine, Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
| | - Andreas Goebel
- Department of Translational Medicine, Pain Research Institute, University of Liverpool, Liverpool, United Kingdom
- Department of Pain Medicine, Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Leila Heelas
- Optimise Pain Rehabilitation Unit, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Michael J. Proulx
- Department of Psychology, University of Bath, Bath, United Kingdom
- Department of Computer Science, Centre for Real & Virtual Environments Augmentation Labs, University of Bath, Bath, United Kingdom
| | - Janet H. Bultitude
- Centre for Pain Research, University of Bath, Bath, United Kingdom
- Department of Psychology, University of Bath, Bath, United Kingdom
| |
Collapse
|
31
|
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]
|