CRPS Bugle | April 2014 | All your research updates #CRPS

Welcome to the April update — click on ‘abstract’ for link to Pubmed

Dermatological Findings in Early Detection of Complex Regional Pain Syndrome.
Kabani R, Brassard A.

IMPORTANCE Complex regional pain syndrome (CRPS) is a chronic pain condition usually affecting the extremities. It mostly occurs in 3 distinct stages with intense pain being the hallmark feature in every stage. Skin abnormalities are common, and often necessary, in the clinical findings required to diagnose CRPS. OBSERVATIONS A man in his 30s presented to the dermatology clinic with complaints of recurrent redness, swelling, and burning pain in his left arm. Based on this clinical presentation with normal findings from a neurological examination and unremarkable findings on diagnostic imaging, the diagnosis of CRPS was made. CONCLUSIONS AND RELEVANCE It is important for dermatologists to understand and recognize CRPS as a neurological disorder with major dermatologic implications. The ability of dermatologists to identify and direct patients with this syndrome is a critical factor in determining the likelihood of favorable outcomes following diagnosis of CRPS. This report outlines and reviews a neurological condition presenting with clinically significant cutaneous changes. We illustrate the bias that dermatologists may have in exclusively associating patient complaints with dermatological implications. This stresses the necessity for dermatologists to perform comprehensive medical histories and physical examinations to minimize diagnostic error and improve patient care.


Complex regional pain syndrome in a 15-year-old girl successfully treated with continuous epidural anesthesia.
Saito Y1, Baba S2, Takahashi A3, Sone D4, Akashi N5, Koichihara R2, Ishiyama A2, Saito T2, Komaki H2, Nakagawa E2, Sugai K2, Sasaki M2, Otsuki T3.

A 15-year-old girl developed severe pain in her right upper limb within a few days after she experienced an astatic epileptic seizure accompanied by falling on her right side. She was treated with fluid infusion through a cannula into her right hand. Swelling, mild flaring, and muscle weakness of the right arm subsequently appeared. Pharmacotherapy and stellate ganglion block were ineffective, and continuous epidural anesthesia was commenced 14days after the falling event. The pain and accompanying symptoms completely disappeared within 5days. Early treatment with continuous epidural anesthesia may be a promising option for the management of complex regional pain syndrome during childhood.

RS: Interesting but remember this is a case study!


Case report: Long-standing complex regional pain syndrome relieved by a cephalosporin antibiotic.
Ware MA1, Bennett GJ2.

We describe a young woman who had had treatment-refractory complex regional pain syndrome (CRPS) for 6years before receiving antibiotic treatment with cefadroxil (a cephalosporin derivative) for a minor infection. Cefadroxil reduced the patient’s pain and motor dysfunction (dystonia and impaired voluntary movement) within days; the pain and motor disorder returned when cefadroxil was discontinued; and both again abated when cefadroxil was re-instituted. The patient has now had symptom relief for more than 3years on continuing cefadroxil therapy. We discuss this case in the context of previous reports of antibiotic treatment relieving neuropathic pain in experimental animals.

RS: Again interesting but a case study.


Complex Regional Pain Syndrome in a Young Athlete with Von Willebrand Disease.
Khadavi MJ1, Alm JC, Emerson JA.

A 17-year-old female with type 1 Von Willebrand Disease (vWD) developed left medial calf pain while running track. Over the next 6 months, orthopedic surgery, sports medicine, vascular surgery, and neurology treated her under various working diagnoses; however, the pain, allodynia, coldness, and pale skin color worsened. She was admitted to a tertiary pediatric hospital for intractable pain where PM&R diagnosed her with complex regional pain syndrome (CRPS) type 1, began gabapentin, and initiated an aggressive inpatient rehabilitation program. During her 3 weeks of inpatient rehabilitation, passive range of motion of knee extension improved from 40° from extension to full extension, and ankle dorsiflexion improved from 15° from neutral to a consistent range of motion beyond neutral. Additional outcome measures were distance of ambulation and assistive device usage; from admission to inpatient rehabilitation to 2 months postdischarge, her weight-bearing tolerance progressed from nonweight-bearing to partial weight-bearing, and ambulation improved from 20 feet with a three-point crutch gait to unlimited distances with a four-point crutch gait. This is the first known case of a bleeding disorder as the likely underlying microvascular pathology associated with CRPS, a theory exposed in 2010.


Visit our clinic site here for details on our specialist CRPS Clinics in London: Specialist Pain Physio Clinics, London or call us on 07932 689081


The Inner Voice — what is it saying? Do you respond?

We all know the little voice that chunters away at us whilst we are awake, often influencing our choices and behaviours. This inner dialogue structures our thoughts that emerge from our belief system, a system that has evolved since we started interacting with the world. That combination of our genetic blueprint and experience grooves the way we see ourselves and experience our lives. 



The Inner Voice – do you listen?

The inner voice impacts enormously; can’t live with it, can’t live without it. Both our brilliant thoughts and destructive thoughts come from this dialogue, the balance of the two driving our behaviours at any given moment. So are we passively subject to the words uttered in our head or can we choose whether we listen or ignore?

I would argue that we can choose how we respond to the inner voice. We are not always very good at it, but we can improve. The thoughts that I refer to are those known as automatic thoughts. They just pop in there, frequently come in waves and can if not checked, habitually trigger emotional and physical responses. These responses are both positive and negative, although it seems we err towards the latter. Perhaps this is a survival instinct to tend toward cautionary options. 

A negative thought that is ‘lived’, either dragging us back to an event in the past or one that exists in a future, is one we embody. We play it out via our physical existence. To the brain it is very real hence the feelings noted in the body. The brain does not differentiate between a thought and reality, the responses are similar. This leads to the question, how true are our thoughts? How close are they to reality? One could argue that if it is a thought about the past or the future, this cannot be reality because neither exist except in our heads. The past has gone. The future never comes.

To practice mindfulness means that we are paying attention to the present moment without judgement. For our thoughts that we cannot stop, we can be observant of the train that trundles through our head. But instead of letting it stop at every station and allowing a hullabaloo of passengers on an off, the train rolls on through with no or minimal impact. Thoughts come and thoughts go. It is only when we grab hold and play with them do the effects kick in. This sounds very simple and in practice, mindfulness is a simple concept. The truth is that it takes practice, although even after a few weeks of dedicated training, the effects are noticed.

The effects of mindful practice are far reaching in our body systems: for example, reduced muscle tension, clearer thinking, less pain, increased happiness, reduced inflammation, reduced rumination, increased energy, increased awareness, better relationships — sounds good doesn’t it? And the reason for these feel good factors? By and large we can say that it is due to reducing the threats in life that are consistently triggering protective responses in the body that include pain, tension, deteriorating performance at work and unhappiness. All the time that we are associating ourselves with our thoughts, defining ourselves with our thinking and letting the body systems protect in response to thoughts, we will be affecting our physical and mental health, and our ability to live — the essence of suffering.

I use mindfulness training as part of the comprehensive treatment and training programmes for chronic pain for the reasons outlined above. There is no mystery, no religious or spiritual connotation, but rather a simple way of training the mind to focus upon what you want to focus upon and not passively following the wandering mind. Remember that you cannot stop thinking and thoughts arising, that is the mind’s job. But you can become skilled at deciding whether to respond or just let it go, hence minimising the body’s responses and feelings of anxiety, stress and pain. It is important to point out that feelings of stress and anxiety are normal and actually desirable survival mechanisms that prepare us and motivate us for the right action, but in the short term and not in a prolonged manner that causes distress, suffering and an amplification of pain. So, take action, learn how to hear the voice but decide whether to respond or let it go.

Visit our clinic website here or call us to book an appointment: 07932 689081


CRPS Bugle | March 2014

bugle-450-pic-rexfeatures-271436732Welcome to the March CRPS Bugle, an update on the latest research into complex regional pain syndrome, also known as reflex sympathetic dystrophy (RSD).

Visit our clinic site here for information about our specialist CRPS Clinics.


J Foot Ankle Surg. 2014 Mar 5. pii: S1067-2516(14)00007-6. doi: 10.1053/j.jfas.2014.01.006.

Incidence of Complex Regional Pain Syndrome after Foot and Ankle Surgery.

Rewhorn MJ1, Leung AH2, Gillespie A3, Moir JS3, Miller R4.

Complex regional pain syndrome (CRPS) is an uncommon complication of orthopedic surgery, and few investigators have considered the incidence in foot and ankle surgery. In the present retrospective cohort study of 390 patients who had undergone elective foot and/or ankle surgery in our department from January to December 2009, the incidence of postoperative CRPS was calculated and explanatory variables were analyzed. A total of 17 patients (4.36%) were identified as meeting the International Association for the Study of Pain criteria for the diagnosis of CRPS. Of the 17 patients with CRPS, the mean age was 47.2 ± 9.7 years, and 14 (82.35%) were female. All the operations were elective, and 9 (52.94%) involved the forefoot, 3 (17.65%) the hindfoot, 3 (17.65%) the ankle, and 2 (11.76%) the midfoot. Twelve patients (70.59%) had new-onset CRPS after a primary procedure, and 5 (29.41%) had developed CRPS after multiple surgeries. Three patients (17.65%) had documented nerve damage intraoperatively and thus developed new-onset CRPS type 2. Blood test results were available for 14 patients (82.35%) at a minimum of 3 months postoperatively, and none had elevated inflammatory markers. Five of the patients (29.41%) were smokers, and 8 (47.06%) had had a pre-existing diagnosis of anxiety and/or depression. From our findings, we recommend that middle-age females and those with a history of anxiety or depression, who will undergo elective foot surgery, should be counseled regarding the risk of developing CRPS during the consent process. We recommend similar studies be undertaken in other orthopedic units, and we currently are collecting data from other orthopedic departments within Scotland


Rehabil Psychol. 2014 Mar 10.

Thought Intrusion Among Adults Living With Complex Regional Pain Syndrome.

Lohnberg JA, Altmaier EM.


Purpose: This study investigated the presence and influence of intrusive thoughts among adults previously diagnosed with complex regional pain syndrome. Method: The present study used an Internet-based survey completed by a sample (N = 326) from two national organizations. Results: After controlling for age, gender, and pain level, intrusive thoughts were significantly related to disability and health-related quality of life. Conclusions/Implications: Intrusive thoughts about the inciting event that caused CRPS uniquely influenced pain and quality of life, suggesting a potential mechanism to target for intervention. Understanding factors that relate to maintenance of CRPS and its resulting disability will help in the development of treatments to improve quality of life.


Brain. 2013 Jul;136(Pt 7):2038-49. doi: 10.1093/brain/awt150. Epub 2013 Jun 13.

Secondary and primary dystonia: pathophysiological differences.

Kojovic M1, Pareés I, Kassavetis P, Palomar FJ, Mir P, Teo JT, Cordivari C, Rothwell JC, Bhatia KP, Edwards MJ.

Primary dystonia is thought to be a disorder of the basal ganglia because the symptoms resemble those of patients who have anatomical lesions in the same regions of the brain (secondary dystonia). However, these two groups of patients respond differently to therapy suggesting differences in pathophysiological mechanisms. Pathophysiological deficits in primary dystonia are well characterized and include reduced inhibition at many levels of the motor system and increased plasticity, while emerging evidence suggests additional cerebellar deficits. We compared electrophysiological features of primary and secondary dystonia, using transcranial magnetic stimulation of motor cortex and eye blink classical conditioning paradigm, to test whether dystonia symptoms share the same underlying mechanism. Eleven patients with hemidystonia caused by basal ganglia or thalamic lesions were tested over both hemispheres, corresponding to affected and non-affected side and compared with 10 patients with primary segmental dystonia with arm involvement and 10 healthy participants of similar age. We measured resting motor threshold, active motor threshold, input/output curve, short interval intracortical inhibition and cortical silent period. Plasticity was probed using an excitatory paired associative stimulation protocol. In secondary dystonia cerebellar-dependent conditioning was measured using delayed eye blink classical conditioning paradigm and results were compared with the data of patients with primary dystonia obtained previously. We found no difference in motor thresholds, input/output curves or cortical silent period between patients with secondary and primary dystonia or healthy controls. In secondary dystonia short interval intracortical inhibition was reduced on the affected side, whereas it was normal on the non-affected side. Patients with secondary dystonia had a normal response to the plasticity protocol on both the affected and non-affected side and normal eye blink classical conditioning that was not different from healthy participants. In contrast, patients with primary dystonia showed increased cortical plasticity and reduced eye blink classical conditioning. Normal motor cortex plasticity in secondary dystonia demonstrates that abnormally enhanced cortical plasticity is not required for clinical expression of dystonia, and normal eye blink conditioning suggests an absence of functional cerebellar involvement in this form of dystonia. Reduced short interval intracortical inhibition on the side of the lesion may result from abnormal basal ganglia output or may be a consequence of maintaining an abnormal dystonic posture. Dystonia appears to be a motor symptom that can reflect different pathophysiological states triggered by a variety of insults.


Int J Rheum Dis. 2014 Feb;17(2):156-8. doi: 10.1111/1756-185X.12140. Epub 2013 Jun 24.

Antioxidant profile in patients with complex regional pain syndrome type I.

Baykal T1, Seferoglu B, Karsan O, Kiziltunc A, Senel K.

Complex regional pain syndrome (CRPS) type I is one of the most important problems with regard to physical medicine and rehabilitation. CRPS may cause not only higher therapeutic costs but also greater work time loss. The mechanism and pathogenesis of CRPS still remains unknown. Some findings indicating oxidative stress have been reported. This study was carried out to determine the role of oxidative stress in patients with CRPS.
Twenty patients (13 women and seven men) with CRPS and 20 age- and sex-matched healthy controls were enrolled in this study. Complex regional pain syndrome was diagnosed according to the modified International Association for the Study of Pain (IASP) criteria. We evaluated demographic, clinical and laboratory characteristics of the patients. Antioxidant enzymatic activities consisting of serum superoxide dismutase (SOD), glutathion peroxidase (GPX) and glutathione S-transferase (GST) activities were measured using appropriate methods and compared with healthy controls.
The mean age of the patients was 39.5 years and the mean duration of symptoms was 5.5 months. Complex regional pain syndrome devoleped after a traumatic event in 90% of patients. In 10% of patients there were no traumatic events. SOD, GPX and GST levels were significantly higher in patients with CRPS than healthy controls (P = 0.012, P = 0.036 and P = 0.016, respectively).
Our findings suggest a possible role of oxidative stress in the pathogenesis of CRPS


J Pain. 2014 Feb 11. pii: S1526-5900(14)00565-3. doi: 10.1016/j.jpain.2014.01.500.

The Outcome of Complex Regional Pain Syndrome Type 1: A Systematic Review

Bean DJ1, Johnson MH2, Kydd RR3.

The purpose of this systematic review was to examine the outcome of complex regional pain syndrome (CRPS) type-1. We searched Medline, Embase and Psychinfo for relevant studies, and included 18 studies, with 3991 participants, in this review. The following data were extracted: study details, measurement tools used, and rates or severity scores for the symptoms/signs of CRPS at baseline and follow-up, or in groups of patients with different disease durations. A quality assessment revealed significant limitations in the literature, with many studies utilising different diagnostic criteria. The 3 prospective studies demonstrated that for many patients, symptoms improve markedly within 6-13 months of onset. The 12 retrospective studies had highly heterogeneous findings, documenting lasting impairments in many patients. The 3 cross-sectional studies showed that rates of pain and sensory symptoms were highest amongst those with the longest duration of CRPS. Additionally, most studies showed that motor symptoms (stiffness and weakness) were the most likely to persist whilst sudomotor and vasomotor symptoms were the most likely to improve. Overall, this suggests that some CRPS patients make a good early recovery whilst others develop lasting pain and disability. As yet little is known about the prognostic factors that might differentiate between these groups.
We found evidence that many CRPS patients recover within 6-13 months, but a significant number experience some lasting symptoms, and some experience chronic pain and disability. The quality of the evidence was poor. Future research should examine the factors associated with recovery and identify those at risk of poor outcomes


Eur J Neurosci. 2014 Feb;39(3):508-19. doi: 10.1111/ejn.12462

The neurobiology of skeletal pain.

Mantyh PW.

Disorders of the skeleton are one of the most common causes of chronic pain and long-term physical disability in the world. Chronic skeletal pain is caused by a remarkably diverse group of conditions including trauma-induced fracture, osteoarthritis, osteoporosis, low back pain, orthopedic procedures, celiac disease, sickle cell disease and bone cancer. While these disorders are diverse, what they share in common is that when chronic skeletal pain occurs in these disorders, there are currently few therapies that can fully control the pain without significant unwanted side effects. In this review we focus on recent advances in our knowledge concerning the unique population of primary afferent sensory nerve fibers that innervate the skeleton, the nociceptive and neuropathic mechanisms that are involved in driving skeletal pain, and the neurochemical and structural changes that can occur in sensory and sympathetic nerve fibers and the CNS in chronic skeletal pain. We also discuss therapies targeting nerve growth factor or sclerostin for treating skeletal pain. These therapies have provided unique insight into the factors that drive skeletal pain and the structural decline that occurs in the aging skeleton. We conclude by discussing how these advances have changed our understanding and potentially the therapeutic options for treating and/or preventing chronic pain in the injured, diseased and aged skeleton



Richmond interveiwed by Rachael Lowe from Physiopedia about pain

Richmond interveiwed by Rachael Lowe from Physiopedia about pain

Richmond specialises in the treatment of chronic pain, persisting pain and injuries in his clinics in London and Surrey. Interviewed by Rachael Lowe from Physiopedia, he talks about some of the modern concepts in pain and the importance of the psychosocial aspects within a comprehensive model of care that incorporates the physical, cognitive and emotional dimensions of pain.

Visit the main clinic website that outlines the treatment and training programmes for persisting pain and the Specialist Pain Physio Blog with many articles that explore modern pain concepts.

Change pain and change your life

What needs to be addressed to tackle CRPS?

Complex Regional Pain Syndrome (CRPS) is as the name suggests: complex, regional, painful and it is a syndrome that is a collection of signs and symptoms. The complexity stems from the different biological mechanisms at play, some of which we now understand, and the range of individual influences upon this biology. The latter is vital to consider when planning a treatment and training programme, yet often omitted. 

The mechanisms at play include inflammatory pain (neurogenic inflammation — that of nerves), mechanical pain, chemical pain and neuropathic pain. This involves activity in the peripheral nervous system and the central nervous system. The adaptations that occur create a physiological circumstance that means the brain continues to receive information that suggests there is a problem that requires protection. This biology is hugely influenced by many other factors that equally need addressing. Here are a few to think about:

  • Fatigue
  • Poor concentration and decision making ability
  • Stress and emotional state
  • What the individual is thinking about?
  • Where the individual is situated?
  • What have they been doing?
  • What are they thinking about doing?
  • What might they do, but they don’t know they are going to do?
  • Have they done it before?
  • Who are they with?

There are many influences! However, careful and compassionate communication reveals answers to many of these questions. Gathering clues by allowing the individual to tell their story helps decide what is affecting pain and sensitivity and subsequently which need targeting, firstly by raising awareness and secondly by changing the habits that have formed as part of a protective response.

A treatment and training programme must be comprehensive in tackling the physical, cognitive and emotional dimensions of CRPS and pain. Otherwise, you could be missing the key influence at any given moment, and this can change according to where the individual is situated, who they are with, what they are doing….it is complex, but just requires some thought.

Visit our clinic website here for details of our comprehensive treatment & training programmes for CRPS or call now to book your initial assessment: 07932 689081. Education sessions are available by request.


CRPS Bugle Feb 2014

Dear All,

Here is a selection of the latest CRPS research to be published:

J Pain. 2014 Jan 22. pii: S1526-5900(14)00518-5. doi: 10.1016/j.jpain.2014.01.490. 
Activation of cutaneous immune responses in complex regional pain syndrome.

Birklein et al. 

The pathogenesis of complex regional pain syndrome (CRPS) is unresolved, but TNF-α and IL-6 are elevated in experimental skin blister fluid fromCRPS affected limbs, as is tryptase, a marker for mast cells. In the rat fracture model of CRPS exaggerated sensory and sympathetic neural signaling stimulate keratinocyte and mast cell proliferation, causing the local production of high levels of inflammatory cytokines leading to pain behavior. The current investigation used CRPS patient skin biopsies to determine whether keratinocyte and mast cell proliferation occur in CRPSskin and to identify the cellular source of the up-regulated TNF-α, IL-6, and tryptase observed in CRPS experimental skin blister fluid. Skin biopsies were collected from the affected skin and the contralateral mirror site in 55 CRPS patients and the biopsy sections were immunostained for keratinocyte, cell proliferation, mast cell markers, TNF-α, and IL-6. In early CRPS keratinocytes were activated in the affected skin, resulting in proliferation, epidermal thickening, and up-regulated TNF-α and IL-6 expression. In chronic CRPS there was reduced keratinocyte proliferation with epidermal thinning in the affected skin. Acute CRPS patients also had increased mast cell accumulation in the affected skin, but there was no increase in mast cell numbers in chronic CRPS.


The results of this study support the hypotheses that CRPS involves activation of the innate immune system, with keratinocyte and mast cell activation and proliferation, inflammatory mediator release, and pain.


Auton Neurosci. 2013 Dec 22. pii: S1566-0702(13)00781-9. doi: 10.1016/j.autneu.2013.12.011.

Inflammation in CRPS: Role of the sympathetic supply.


Acute Complex Regional Pain Syndrome (CRPS) is associated with signs of inflammation such as increased skin temperature, oedema, skin colour changes and pain. Pro-inflammatory cytokines (tumour necrosis factor-α (TNF-α), interleukin-2 (IL-2), IL-1beta, IL-6) are up-regulated, whereas anti-inflammatory cytokines (IL-4, IL-10) are diminished. Adaptive immunity seems to be involved in CRPS pathophysiology as many patients have autoantibodies directed against β2 adrenergic and muscarinic-2 receptors. In an animal tibial fracture model changes in the innate immune response such as up-regulation of keratinocytes are also found. Additionally, CRPS is accompanied by increased neurogenic inflammation which depends mainly on neuropeptides such as CGRP and Substance P. Besides inflammatory signs, sympathetic nervous system involvement in CRPS results in cool skin, increased sweating and sympathetically-maintained pain. The norepinephrine level is lower in the CRPS-affected than contralateral limb, but sympathetic sprouting and up-regulation of alpha-adrenoceptors may result in an adrenergic supersensitivity. The sympathetic nervous system and inflammation interact: norepinephrine influences the immune system and the production of cytokines. There is substantial evidence that this interaction contributes to the pathophysiology and clinical presentation of CRPS, but this interaction is not straightforward. How inflammation inCRPS might be exaggerated by sympathetic transmitters requires further elucidation


Pain. 2014 Jan 18. pii: S0304-3959(14)00022-0. doi: 10.1016/j.pain.2014.01.014.
Osteoprotegerin: A new biomarker for impaired bone metabolism in complex regional pain syndrome?

Krämer et al

Osteoprotegerin (OPG) is important for bone remodeling and may contribute to complex regional pain syndrome (CRPS) pathophysiology. We aimed to assess the value of OPG as a biomarker for CRPS and a possible correlation with radiotracer uptake in 3-phase bone scintigraphy (TPBS). OPG levels were analyzed in 23 CRPS patients (17 women; mean age 50±9.0years; disease duration: 12weeks [IQR 8-24]), 10 controls (6 women; mean age 58±9.6years) and 21 patients after uncomplicated fractures (12 women; mean age: 43±15years; time after fracture: 15weeks [IQR: 6-22]). The CRPS and control patients also underwent TPBS. OPG in CRPS patients was significantly increased by comparison with both control groups (P=0.001; Kruskal-Wallis test; CRPS patients: 74.1pg/mL [IQR: 47.1-100.7]; controls: 46.7pg/mL [IQR: 35.5-55.0]; P=0.004; fracture patients: 45.9pg/mL [IQR: 37.5-56.7]; P=0.001). As a diagnostic test for CRPS, OPG had a sensitivity of 0.74, specificity of 0.80, positive predictive value of 68% and negative predictive value of 84%. Receiver operating characteristic curve analysis showed an area under the curve of 0.80 (CI: 0.68-0.91). For the CRPS-affected hand, a significant correlation between OPG and TPBS region of interest analysis in phase III was detected (carpal bones; r=0.391; P=0.03). The persistent OPG increase in CRPS indicates enhanced osteoblastic activity shown by increased radiotracer uptake in TPBS phase III. A contribution of bone turnover to CRPS pathophysiology is likely. OPG might be useful as a biomarker for CRPS


PLoS One. 2014 Jan 9;9(1):e85372. doi: 10.1371/journal.pone.0085372. FULL ARTICLE HERE
Complex regional pain syndrome type I affects brain structure in prefrontal and motor cortex.
Pleger et al.

The complex regional pain syndrome (CRPS) is a rare but debilitating pain disorder that mostly occurs after injuries to the upper limb. A number of studies indicated altered brain function in CRPS, whereas possible influences on brain structure remain poorly investigated. We acquired structural magnetic resonance imaging data from CRPS type I patients and applied voxel-by-voxel statistics to compare white and gray matter brain segments of CRPS patients with matched controls. Patients and controls were statistically compared in two different ways: First, we applied a 2-sample ttest to compare whole brain white and gray matter structure between patients and controls. Second, we aimed to assess structural alterations specifically of the primary somatosensory (S1) and motor cortex (M1) contralateral to the CRPS affected side. To this end, MRI scans of patients with left-sided CRPS (and matched controls) were horizontally flipped before preprocessing and region-of-interest-based group comparison. The unpaired ttest of the “non-flipped” data revealed that CRPS patients presented increased gray matter density in the dorsomedial prefrontal cortex. The same test applied to the “flipped” data showed further increases in gray matter density, not in the S1, but in the M1 contralateral to the CRPS-affected limb which were inversely related to decreased white matter density of the internal capsule within the ipsilateral brain hemisphere. The gray-white matter interaction between motor cortex and internal capsule suggests compensatory mechanisms within the central motor system possibly due to motor dysfunction. Altered gray matter structure in dorsomedial prefrontal cortex may occur in response to emotional processes such as pain-related suffering or elevated analgesic top-down control.


Eur J Pain. 2014 Jan 2. doi: 10.1002/j.1532-2149.2013.00446.x. 
Force modulation deficits in complex regional pain syndrome: A potential role for impaired sense of force production.
Bank PJ, van Rooijen DE, Marinus J, Reilmann R, van Hilten JJ.
Compelling evidence points at both impaired proprioception and disturbed force control in patients with chronic complex regional pain syndrome (CRPS). Because force modulation at least partly relies on proprioception, we evaluated if impaired sense of force production contributes to disturbances of force control in patients with CRPS.
Characteristics of voluntary force modulation were examined in the affected upper extremity in 28 CRPS patients with abnormal postures, in 12 CRPS patients without abnormal postures, and in 32 healthy controls. Isometric grip-force matching was compared between conditions with and without visual feedback to identify potential deficits in the sense of force production in terms of force reproduction errors.
Voluntary force modulation was impaired in CRPS patients, but more so in patients with abnormal postures. In particular, CRPS patients with abnormal postures were characterized by reduced maximum force, reduced ability to increase force output according to task instructions, higher variability of force output and less adequate correction of deviations from the target force. Although effects of visual feedback removal appeared largely similar for the two patient groups and controls, our findings with respect to force reproduction errors suggested that an impaired sense of force production may contribute to the motor dysfunction in CRPS.
CRPS patients, in particular those with abnormal postures, showed impaired voluntary force control and an impaired sense of force production. This suggests that therapeutic strategies aimed at restoration of proprioceptive impairments, possibly using online visual feedback, may promote the recovery of motor function in CRPS.


Eur J Pain. 2013 Dec 17. doi: 10.1002/j.1532-2149.2013.00434.x. 
Complex regional pain syndrome type I of the knee: A systematic literature review.
van Bussel CM, Stronks DL, Huygen FJ.
In our Center for Pain Medicine, a group of patients reported to have symptoms possibly attributable to complex regional pain syndrome (CRPS) of only the knee(s). Therefore, this study aimed to investigate whether the literature reports on patients with CRPS type I in the knee(s) alone and, if so, to summarize the reported diagnostics, aetiology and treatment strategies of CRPS of the knee(s). Medline, Embase, Cochrane Library, PubMed and Web of Science were searched for articles focusing on a painful disorder of the knee, most likely CRPS type I. Screening on title and abstract was followed by full-text reading and searching of reference lists to determine the final set of relevant articles. Of the 513 articles identified, 31 met the inclusion criteria. These articles reported on a total of 368 patients diagnosed with CRPS of the knee(s) based on the diagnostic criteria used at the time of publication. Knee surgery, especially arthroscopic surgery, was the most common inciting event in developing CRPS of the knee(s). Various treatment strategies were applied with variable outcomes. In conclusion, the scientific literature does report cases of CRPS type I of only the knee(s). This applies when using the diagnostic criteria prevailing at the time of publication and, obviously for a smaller number of cases, also when using the current Budapest criteria set. Arthroscopic knee surgery is described multiple times as the inciting event. We recommend to include CRPS of the knee in future research on the aetiological mechanisms of and optimal treatment for CRPS.


Visit our clinic site here for information about specialist clinics for CRPS and chronic pain: Specialist Pain Physio Clinics, London

Love, lefties, golf and the cortical force field


We enjoy the clinical anecdotes that pour into NOI, especially when they are repeated and can be related to modern thoughts about brain science.

The wife of a dear friend, (let’s call him Seamus) wrote in about his ongoing arm pain following an accident where he was hit by a car.

“In the first year after the accident we were watching the British Open on TV… you know the usual suspects McIlroy, Woods etc…..every time Phil Michelson stepped up to the tee and took out the big driver, Seamus’s shoulder would go into the involuntary spasm with little /no warning. It just lasted a few seconds and then it would take a while for the pain to subside. After that I wondered if when Tiger came to take the big driver out of the bag would it happen again?….but nothing happened. Over the day while watching the golf it happened…

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Announcing TED-Ed Clubs, for any student interested in learning to give a TED talk

TED Blog

TED-ED-Clubs-mainThe effect of laughter on someone who’s sad. The danger and excitement of dirt biking. The reason human beings need so much sleep. The thought of infinity.

These are just a few of the topics that students are exploring through TED-Ed Clubs. This new program, announced today by our educational initiative TED-Ed, is a way to celebrate the ideas of students around the globe. Through TED-Ed Clubs, students — with the help of an adult facilitator — identify and research the ideas that matter to them most. And while TED-Ed Clubs offer students the opportunity to connect with others who, like them, are unabashedly curious about the world, TED-Ed Clubs are also about presentation literacy. TED-Ed Clubs offer students a hands-on opportunity to work on the storytelling and communication skills that will be vital, no matter what career path they end up strolling down.

TED-Ed Clubs are for…

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Become a Cognitive Behavioural Therapist for £39? Pfffftttt….


Time Out London is currently offering this absolutely bloody ridiculous offer on their site: “93% off a Cognitive Behavioural Therapy Diploma”. Actually worth a “whopping £599” it’s currently available for the low, low price of £39!

Pretty amazing. Especially when it turns out that the course is being run by the NLP Centre of Excellence, and NLP as we all know, is a pile of incoherent and festering ordure. Also, a closer reading of the text reveals that the course is just a few e-books.

Cognitive Behavioural Therapy (CBT) is a serious set of therapeutic technologies, with a substantial evidence base, useful for treating several classes of mental health issues. It usually takes several years to become a CBT therapist – the most common route is to complete a clinical doctorate training program, and then do additional specialist training afterwards. In the UK, CBT therapists are registered with…

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