Complex Regional Pain Syndrome Research Articles

Complex Regional Pain Syndrome: Outpatient Pain Management in the Chronic Setting: A Case Report

Complex Regional Pain Syndrome: Outpatient Pain Management in the Chronic Setting: A Case Report

Outcomes of Ulnar Shortening Osteotomy with an Intramedullary Bone Graft for Idiopathic Ulnar Impaction Syndrome.

Although several techniques for the treatment of ulnar impaction syndrome (UIS) have been introduced, there have still been reports on various complications such as delayed union, nonunion, refracture, wrist pain, plate irritation, and chronic regional pain syndrome. This study aimed to compare the differences in radiological and clinical outcomes of patients in which intramedullary bone grafting was performed in addition to plate stabilization with those without additional bone grafting during ulnar shortening osteotomies (USOs). Between November 2014 and June 2021, 53 wrists of 50 patients with idiopathic UIS were retrospectively reviewed. Patients were divided into 2 groups according to whether intramedullary bone grafting was performed. Among the 53 wrists, USO with an intramedullary bone graft was performed in 21 wrists and USO without an intramedullary bone graft was performed in 32 wrists. Demographic data and factors potentially associated with bone union time were analyzed. There was no significant difference between the 2 groups when comparing postoperative radioulnar distance, postoperative ulnar variance, amount of ulnar shortening, and postoperative Disabilities of the Arm, Shoulder and Hand score. Compared to the without-intramedullary bone graft group, bone union time of the osteotomy site was significantly shortened, from 8.8 ± 3.0 weeks to 6.7 ± 1.3 weeks in the with-intramedullary bone graft group. Moreover, there were no cases of nonunion or plate-induced symptoms. Both in univariable and multivariable analyses, intramedullary bone grafting was associated with shorter bone union time. USO with an intramedullary bone graft for idiopathic UIS has favorable radiological and clinical outcomes. The advantage of this technique is the significant shortening of bone union time.

Effectiveness of Neural Therapy Application in Complex Regional Pain Syndrome Developing in a Fracture Case; Case presentation

Effectiveness of Neural Therapy Application in Complex Regional Pain Syndrome Developing in a Fracture Case; Case presentation

Utility of Ultrasound-Guided Continuous Lower Limb Perineural Catheters for Treatment of Pediatric Complex Regional Pain Syndrome Type I: A Primary Case Report from India

Abstract Complex regional pain syndrome (CRPS) is a chronic localized pain condition affecting all age groups with more propensity toward adolescent girls. This disease has a multifactorial pathophysiology involving the sympathetic and central nervous system, along with psychosocial, immune, and genetic factors. We reported a case of CRPS Type I in an adolescent boy who was successfully managed by continuous lower limb nerve blocks through perineural catheters along with the continuation of pharmacological management.

A Novel Surgical Approach to Treating Complex Regional Pain Syndrome: Three Case Reports

A Novel Surgical Approach to Treating Complex Regional Pain Syndrome: Three Case Reports

Ab. No. 122 Functional Restoration Approach in the Management of Complex Regional Pain Syndrome (Crps) Caused By Onychomycosis: A Case Report

Introduction: The objective of this case report is to highlight the importance of incorporating functional restoration approach in the physiotherapy management of CRPS. The significant pain and disability associated with CRPS is not only biomedically faceted but frequently encompasses psychosocial aspects too. Physiotherapy management should address both these aspects. The functional restoration approach emphasizes gradual progression, starting with pre-sensorimotor cortices activation, then advancing to functional tasks. Methods: This is a case review of a 61 year old man with history of Onychomycosis presenting with left shoulder, wrist and hand stiffness and pain 6 months post the infection. Patient also presented with fear of movement and was reported to have had not used the arm functionally for daily activities since the onset of the infection. Patient is a k/c/o intentional tremors since 25 years. The functional restoration approach included patient education, desensitization using kinetic sand, followed by movement with Mulligan’s technique and graded functional activity by perpetual training over subsequent sessions. Pre and post assessments after a 3-week intervention included Kinesiophobia, Function, Pain, ROM, and grip strength. Additionally, the Archimedes spiral test was used to gauge tremor severity as a secondary outcome. Results: Post-intervention, positive changes were observed in outcome measures: a 16% decrease in Tampa Scale of Kinesiophobia, 10% improvement in Michigan Hand Outcome, 7% in grip strength, and 7% and 8% in wrist and shoulder ROM, respectively. The Archimedes spiral test also showed a notable improvement. Conclusion: The approach demonstrated improvement in Function, pain, and Kinesiophobia, with notable changes in range of motion, grip strength, and tremors as well. Implication: Functional restoration approach is a comprehensive method of managing CRPS since it addresses the syndrome’s multifaceted nature. Simultaneous assessment of biopsychosocial components aids in tracking progress and predicting better outcomes.

Factors associated with chronic pelvic pain in women with endometriosis: A national study on clinical and sociodemographic characteristics, lifestyles, quality of life, and perceptions of quality of care, during the COVID-19 pandemic.

Endometriosis is a persistent inflammatory condition that affects women of reproductive age and causes pelvic pain. Chronic pelvic pain is a chronic regional pain syndrome involving the pelvic area. This survey aimed to characterize the clinical and sociodemographic characteristics, lifestyles, quality of life, and perceptions of quality of care in women with endometriosis who reported chronic pelvic pain during the Covid pandemic. We conducted a cross-sectional survey among the Italian population from July to September 2021. Snowball sampling was used to interview a large sample of adult women who reported a diagnosis of endometriosis, through a self-reported questionnaire. Univariate and multivariable logistic regression analyses were performed to identify the factors associated with chronic pelvic pain. The primary outcome was describing women who reported chronic pelvic pain. A total of 661 out of 1045 (63%) women who responded to the survey reported chronic pelvic pain. The multivariable analysis evidenced that chronic pelvic pain was related to physical and mental quality perception, pelvic floor disorders (adjusted odds ratio = 1.58; 95% CI = 1.10-2.27; p = 0.012), dyspareunia (adjusted odds ratio = 1.87; 95% CI = 1.31-2.65; p < 0.001), adhesions syndrome (adjusted odds ratio = 1.49; 95% CI = 1.05-2.11; p = 0.026), and the delay in diagnosing endometriosis (adjusted odds ratio = 1.04; 95% CI = 1.00-1.09; p = 0.034). The only social factor associated with chronic pelvic pain was marital status (adjusted odds ratio = 0.66; 95% CI = 0.46-0.93; p = 0.019). In the pandemic period, there was a very high prevalence of chronic pelvic pain in women with endometriosis in Italy. The pandemic highlighted the need for careful attention to diagnose endometriosis and the need for psychological and partner support, which would allow better pain management and prevent chronicity.

Peripheral Nerve Stimulation With High-Frequency Electromagnetic Coupling at the Sural and Posterior Tibial Nerves for the Treatment of Complex Regional Pain Syndrome in Lower Extremities: Case Report

BACKGROUND: Complex regional pain syndrome (CRPS) type 1 is a debilitating condition that is notoriously difficult to treat due to its various manifestations. Peripheral nerve stimulation (PNS) is generally recommended when a patient’s symptoms are refractory to conservative measures, as CRPS often is. We present one case of CRPS with intractable lower extremity pain managed effectively with PNS. CASE REPORT: A 32-year-old man developed CRPS after a work-related accident that resulted in multiple injuries, including a crushed pelvis, injured left lower extremity, and a fractured face and skull. After pelvic and hip reconstruction, the patient was left with numbness, tingling, and pain in the left foot affecting functional activities and sleep. Previous therapies, including nerve blocks, physical therapy, narcotics, opioids, anticonvulsants, antidepressants, and nonsteroidal anti-inflammatory drugs, did not alleviate symptoms. The placement of a PNS device, however, led to significant improvement. RESULTS: Pain scores at baseline compared to 12-month follow-up decreased from 6/10 to 2/10 at rest and from 8/10 to 4/10 with activity. Average hours of sleep per night increased from 4 to 8 hours (an improvement of 100%). Antidepressants have been discontinued and opioids reduced to an as-needed basis (once every few days). The patient reports decreased sensitivity to cold, reduced swelling, and improved color changes in the foot. In addition, the patient has been able to increase activity, such as walking, standing, and wearing closed-toed shoes, from 20 minutes to now 4 hours at a time with pain levels maintained at a 4/10. CONCLUSIONS: Subthreshold PNS utilizing high-frequency electromagnetic coupling at the posterior tibial and sural nerves successfully relieved the patient’s chronic, debilitating pain in the lower extremity as a result of CRPS. KEY WORDS: Peripheral nerve stimulation, chronic pain, posterior tibial, sural, CRPS, lower extremity, foot

Digital Clubbing in a Patient with the Complex Regional Pain Syndrome

Digital Clubbing in a Patient with the Complex Regional Pain Syndrome

Difficult Single-Lead Spinal Cord Stimulator Trial for Failed Back Surgery Syndrome Salvages Treatment

BACKGROUND: Spinal cord stimulation (SCS) is a minimally invasive neuromodulation treatment modality primarily used for failed back surgery syndrome (FBSS), complex regional pain syndrome, and diabetic neuropathy. Specifically, when utilized for the treatment of FBSS, placement can be complicated by the excessive scarring, adhesions, and altered anatomy limiting the access to the epidural space and advancement of the leads. CASE REPORT: Our patient is a 58-year-old woman with a history of scoliosis and severe lumbar spinal stenosis who presented for trial of an SCS for FBSS. Given the refractory nature to medical and minimally invasive management, an SCS trial was performed. Unfortunately, due to the extensive fibrosis and adhesions in her epidural space, only a single lead could be placed but experienced pain relief. During the permanent SCS, 2 leads were successfully placed with the patient ultimately receiving &gt; 50% pain relief. CONCLUSIONS: Here, we present a case of FBSS refractory to medical and minimally invasive management where a single SCS lead was placed during the trial, due to scarring and adhesions, and 2 leads during the permanent SCS procedure. Our case report suggests considering even the trial of a single-lead placement during an SCS trial in patients with an otherwise difficult anatomy, as the placement of the permanent lead offers greater access to the epidural space potentially allowing for the placement of a second lead and potentially salvaging the entire therapy. KEY WORDS: Spinal cord stimulator, spinal stenosis, single lead, failed back surgery syndrome

Failure Rate and Early Complications of Thumb Carpometacarpal Joint Replacement-A Multicenter Retrospective Study of Two Modern Implant Designs.

Joint replacement arthroplasty for the treatment of thumb osteoarthritis is gaining popularity as recent studies have demonstrated better pinch and grip strength and faster rehabilitation. Our aim was to identify early complications in modern implant designs using a multicenter study. A total of 381 patients who underwent thumb carpometacarpal replacement surgery in six participating hospitals were enrolled. The complications included were fractures, dislocations, infections, tendon and nerve injuries, and complex regional pain syndrome. Major complications were defined as a failure to implant the prosthesis, revision surgery to remove the implant, and any other need for further surgical intervention. The secondary outcomes were any other complications treated non-surgically and the timing of the complications. Eleven procedures failed, and these patients were treated with trapeziectomies. Twelve other patients required repeat surgical interventions. Minor adverse events occurred in 25.4% of the cases, and transient irritation of the superficial radial nerve and De Quervain tendinopathy were the most prevalent complications. Although this cohort depicted the learning curves of multiple surgeons, our study demonstrated low short-term failure rates. An inability to achieve primary stability of the cup in the trapezium was the leading cause of failure. Dislocations and other major complications with modern implants were very few.

Patients With Preexisting Anxiety and Mood Disorders Are More Likely to Develop Complex Regional Pain Syndrome After Fractures.

Complex regional pain syndrome (CRPS) is a multifactorial condition that may affect patients who sustain a fracture in the upper and lower extremities. Prior investigations have formed a foundation for exploring a possible association between psychiatric disorders and the development of CRPS; however, current studies are conflicted regarding the existence and temporality of a relationship between psychiatric disorders and the potential development of CRPS. (1) Are patients with preexisting anxiety and mood disorders (AMDs) at increased risk of receiving a diagnosis of CRPS after upper or lower extremity fractures? (2) Are patients with preexisting AMDs at increased risk of being diagnosed with CRPS after surgical fixation of their fracture? A large, retrospective cohort study was conducted using the TriNetX electronic medical record platform, which contains data from more than 100 million patients. This platform gathers data from healthcare organizations in the United States and Europe and collects comprehensive data over time that includes temporality rather than simply the binary presence or absence of conditions. The cohort included 760,595 patients older than 18 years with upper or lower extremity fractures between 2003 and 2022. Included patients had a minimum 1-year follow-up. We defined AMDs as any diagnosis of anxiety, depressive episode or disorder, a manic episode, or bipolar disorder. Patients with polytrauma or concurrent upper and lower extremity fractures were excluded to reduce confounders. CRPS I diagnosis was identified via International Classification of Diseases, Tenth Edition codes. Propensity score matching was performed to balance cohorts based on age, gender, and race. Hazard ratios and Aalen-Johansen cumulative incidence curves for the diagnosis of CRPS were calculated for patients with and without AMD diagnoses before sustaining a fracture. A subanalysis was performed in which we examined individuals in the upper and lower extremity fracture cohorts who underwent surgical treatment. Patients with preexisting AMDs were at a higher risk of experiencing CRPS I than patients without AMDs were (upper extremity: HR 1.8 [95% CI 1.7 to 1.9]; p < 0.01, lower extremity: HR 2.2 [95% CI 2.0 to 2.3]; p < 0.01). Similarly, patients with preexisting AMDs were at higher risk of experiencing CRPS I after fracture fixation than patients without AMDs were (upper extremity: HR 1.3 [95% CI 1.2 to 1.5]; p < 0.01, lower extremity: HR 2.3 [95% CI 2.1 to 2.5]; p < 0.01). Awareness of the relationship between AMDs and CRPS I will direct future research about the development of this condition and associated neurologic changes. Additionally, surgeons can address AMDs perioperatively and arrange for the treatment of these AMDs with psychiatrists, neurologists, or social work, as appropriate. Accordingly, patients with AMDs should also be made aware of the inherent risk of CRPS I after an upper or lower extremity fracture to comprehensively educate and care for this at-risk patient population. Level III, therapeutic study.

Prevalence and predisposing factors of post-stroke complex regional pain syndrome: Retrospective case-control study

Poststroke complex regional pain syndrome (CRPS) is an important complication in stroke survivors. The identification of factors associated with post-stroke CRPS is important for preventive measures and early diagnosis. A total of 141 first-ever stroke survivors in the subacute stage were retrospectively analyzed. Demographic data, diagnosis time, duration of hospitalization, location of brain lesion, etiology, comorbidities, and blood test findings were investigated. Clinical data included Medical Research Council (MRC) grade, Fugl-Meyer assessment (FMA), National Institute for Health Stroke Scale (NIHSS), Berg Balance Scale (BBS). Among 141 patients with subacute stroke, 22 were diagnosed with CRPS, with a prevalence of 15.6%. The mean time to diagnosis was 38.6 (±16.5) days. The prevalence according to the degree of paralysis was 33.3% in MRC grades 0 and 1, 8.6% in grade 2, and 0% in grade 3 or higher. The incidence rates within 1 month after stroke were 1.42% and 22.47% between 1 and 3 months after stroke, respectively. The independent risk factors for CRPS were hospitalization duration and FMA, NIHSS, and BBS scores. The sensitivity and specificity of the NIHSS score for predicting post-stroke CRPS were 86.4% and 59.7%, respectively, with an optimal cutoff value of 7.5. CRPS of the affected upper limb in stroke patients is associated with stroke severity, including paralysis, and the incidence increases over time during the subacute phase. Additionally, having sufficient strength to move through a full range of motion against gravity had a protective effect against CRPS.

Ketamine for Chronic Non-Cancer Pain: A 2023 Update

What Is the Issue?&#x0D; &#x0D; Doctors use ketamine to induce loss of consciousness as general anesthesia during surgery. At low doses that do not produce dissociation, practitioners use ketamine to relieve acute or chronic pain.&#x0D; The previous CADTH report published in 2020 found that IV ketamine, compared to placebo, could only provide short-term pain relief in patients with chronic non-cancer pain, with increased risks of nausea, vomiting, and psychomimetic effects. The included guidelines did not provide definitive recommendations due to insufficient evidence.&#x0D; Decision-makers want to know if there is any new evidence to support the use of ketamine for treating of chronic non-cancer pain in adults.&#x0D; &#x0D; What Did We Do?&#x0D; &#x0D; To inform decisions about the use of ketamine for treating of chronic non-cancer pain, CADTH sought to update the previous report by identifying and summarizing literature comparing the clinical effectiveness and cost-effectiveness of ketamine with placebo or other pharmacological therapies for chronic non-cancer pain. We also attempted to identify evidence-based recommendations from most recent guidelines for the use of ketamine for chronic non-cancer pain.&#x0D; A research information specialist conducted a literature search of the peer-reviewed and grey literature with a search strategy focused on ketamine, chronic non-cancer pain, and adults. The search was limited to English-language documents published since 2020 up to November 06, 2023. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included studies, and narratively summarized the findings.&#x0D; &#x0D; What Did We Find?&#x0D; &#x0D; We found 3 SRs and 1 randomized controlled trial on the use of ketamine for the treatment of patients with neuropathic pain, complex regional pain syndrome, fibromyalgia, and other chronic pain conditions. Collective evidence from the included studies suggests that ketamine treatment was associated with short-term pain reduction in patients with chronic non-cancer pain. However, the long-term efficacy of ketamine in pain relief remains unclear.&#x0D; Adverse events (AEs) associated with ketamine treatment were with psychedelic effects, discomfort, dizziness, fatigue, headache, and nausea; all of those events appeared to be short-lasting.&#x0D; There were mixed results regarding the effect of ketamine on quality of life and functional improvement.&#x0D; We did not find any studies on the cost-effectiveness of ketamine or new evidence-based guidelines on the use of ketamine for treating chronic non-cancer pain.&#x0D; &#x0D; What Does It Mean?&#x0D; &#x0D; The findings in this review are consistent with the previous CADTH report published in 2020.&#x0D; Well-controlled studies with larger populations and longer follow-ups are needed to determine the optimal treatment protocol of ketamine for each specific type of chronic pain.&#x0D; Given that ketamine is a dissociative drug that could be associated with the development of a substance use disorder, decision-makers may wish to consider the use of ketamine for long-term treatment of chronic non-cancer pain. The long-term effects and dangers of ketamine remain to be determined.&#x0D;

Physical Medicine and Rehabilitation for Complex Regional Pain Syndromes

A common clinical constellation of pain, sensory, autonomic, motor, or trophic symptoms that can no longer be attributed to the initial trauma characterizes Complex Regional Pain Syndrome (CRPS). These signs and symptoms are not localized to the areas of innervation. Most of the diagnosis is clinical. Following that, mobility difficulties, fluctuating skin temperature, sensory loss and changes in body perception are the prominent symptoms. In acute phases, pharmaceutical treatment may be very beneficial. Empirically, common anti-neuropathic pain medications can be suggested. Physical and occupational therapy, as well as behavioral therapy, are crucial parts of the treatment.

Pain relief and dermatological changes in complex regional pain syndrome with peripheral nerve stimulation.

Pain relief and dermatological changes in complex regional pain syndrome with peripheral nerve stimulation.

A Case of Intractable Complex Regional Pain Syndrome Successfully Treated with a Combination of Regional Anesthesia and Physical Therapy

A Case of Intractable Complex Regional Pain Syndrome Successfully Treated with a Combination of Regional Anesthesia and Physical Therapy

Finger Manipulation Under Peripheral Nerves Blocks for the Treatment of Stiffness in Refractory Symptoms of Complex Regional Pain Syndrome.

Finger Manipulation Under Peripheral Nerves Blocks for the Treatment of Stiffness in Refractory Symptoms of Complex Regional Pain Syndrome.

Remission of hypersensitivity by simple weight load stimuli in a complex regional pain syndrome mouse model.

Painful sensitivity of the hand or foot are the most common and debilitating symptoms of complex regional pain syndrome (CRPS). Physical therapy is standard treatment for CRPS, but evidence supporting its efficacy is minimal and it can be essentially impossible for CRPS patients to actively exercise the painful limb. Using the well-characterized distal tibial fracture CRPS mouse model, we compared the therapeutic effects of several weeks of daily hindlimb loading versus rotarod walking exercise. The effects of loading and exercise were evaluated by weekly testing of hind-paw withdrawal thresholds to von Frey fibers and radiant heat, as well as measurements of paw and ankle edema. At 6 weeks after fracture, the mice were killed and the ipsilateral femur, spinal cord and L4/5 dorsal root ganglia, and hind-paw skin collected for PCR assays and paw skin Immunohistochemistry evaluation. Hindlimb loading reduced hind-paw von Frey allodynia and heat hyperalgesia and edema within a week and these effects persisted for at least a week after discontinuing treatment. These therapeutic effects of loading exceeded the beneficial effects observed with rotarod walking exercise in fracture mice. Levels of nerve growth factor and transient receptor potential vanilloid 1 (TRPV1) immunostaining in the hind-paw skin were increased at 6 weeks after fracture, and both loading and exercise treatment reduced increases. Collectively, these results suggest that loading may be an effective and possibly curative treatment in CRPS patients with sensitivity in the affected limb.

Evidence for converging pathophysiology in complex regional pain-syndrome and primary headache disorders: results from a case–control study

BackgroundNeuroinflammation 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.MethodsPatients 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.ResultsPatients 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.ConclusionThis 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 registrationGerman Clinical Trials Register (DRKS00022961).