CRPS Bugle | March 2014

Welcome 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.

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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.

Abstract
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

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Rehabil Psychol. 2014 Mar 10.

Thought Intrusion Among Adults Living With Complex Regional Pain Syndrome.

Lohnberg JA, Altmaier EM.

Abstract

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.

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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.

Abstract
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.

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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.

Abstract
OBJECTIVE:
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.
MATERIALS AND METHODS:
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.
RESULTS:
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).
CONCLUSION:
Our findings suggest a possible role of oxidative stress in the pathogenesis of CRPS

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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.

Abstract
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.
PERSPECTIVE:
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

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

The neurobiology of skeletal pain.

Mantyh PW.

Abstract
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

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CRPS Bugle 10/10/13 | #CRPS

Welcome to The CRPS Bugle–a selection of recent papers to peruse:

Clin J Pain. 2013 Nov;29(11):e33-e34.

Favorable Outcome of an Acute Complex Regional Pain Syndrome With Immunoglobulin Infusions.

Medlin F, Zekeridou A, Renaud S, Kuntzer T.

Abstract

OBJECTIVE::

To emphasize that complex regional pain syndrome (CRPS), a disabling disorder with the implication of aberrant inflammation, vasomotor dysfunction, and maladaptive neuroplasticity, might be treated with a high dose of intravenous immunoglobulin infusions (IVIG).

METHODS::

We describe a patient who presented with CRPS in the acute phase of the disease.

RESULTS::

The CRPS developed secondary to sciatic compression in a young patient and was treated within 10 days by high-dose IVIG (2 g/kg). It resolved completely within days after infusions.

DISCUSSION::

This observational study emphasizes that high-dose IVIG may be a treatment option in the acute phase of CRPS

RS: Interesting but bear in mind that this is a case study with one patient

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Ann Intern Med. 2010 Feb 2;152(3):152-8. doi: 10.7326/0003-4819-152-3-201002020-00006.

Intravenous immunoglobulin treatment of the complex regional pain syndrome: a randomized trial.

Goebel A, Baranowski A, Maurer K, Ghiai A, McCabe C, Ambler G.

Source

University of Liverpool, Clinical Sciences Building, University Hospital Aintree, Liverpool L9 7AL, United Kingdom.

Abstract

BACKGROUND:

Treatment of long-standing complex regional pain syndrome (CRPS) is empirical and often of limited efficacy. Preliminary data suggest that the immune system is involved in sustaining this condition and that treatment with low-dose intravenous immunoglobulin (IVIG) may substantially reduce pain in some patients.

OBJECTIVE:

To evaluate the efficacy of IVIG in patients with longstanding CRPS under randomized, controlled conditions.

DESIGN:

A randomized, double-blind, placebo-controlled crossover trial. (National Research Registry number: N0263177713; International Standard Randomised Controlled Trial Number Registry: 63918259)

SETTING:

University College London Hospitals Pain Management Centre.

PATIENTS:

Persons who had pain intensity greater than 4 on an 11-point (0 to 10) numerical rating scale and had CRPS for 6 to 30 months that was refractory to standard treatment.

INTERVENTION:

IVIG, 0.5 g/kg, and normal saline in separate treatments, divided by a washout period of at least 28 days.

MEASUREMENTS:

The primary outcome was pain intensity 6 to 19 days after the initial treatment and the crossover treatment.

RESULTS:

13 eligible participants were randomly assigned between November 2005 and May 2008; 12 completed the trial. The average pain intensity was 1.55 units lower after IVIG treatment than after saline (95% CI, 1.29 to 1.82; P < 0.001). In 3 patients, pain intensity after IVIG was less than after saline by 50% or more. No serious adverse reactions were reported.

LIMITATION:

The trial was small, and recruitment bias and chance variation could have influenced results and their interpretation.

CONCLUSION:

IVIG, 0.5 g/kg, can reduce pain in refractory CRPS. Studies are required to determine the best immunoglobulin dose, the duration of effect, and when repeated treatments are needed.

RS: this study from 2010 demonstrated reduced pain but in a small group

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Arch Phys Med Rehabil. 2013 Sep 27

Complex regional pain syndrome type I. Incidence and risk factors in patients with fracture of the distal radius.

Jellad A, Salah S, Frih ZB.

Source

University of Monastir Tunisia, Faculty of Medicine, Department of Physical Medicine and Rehabilitation. Electronic address: anisjellad@gmail.com.

Abstract

OBJECTIVE:

To examine the incidence and predictors of complex regional pain syndrome type I (CRPS I) after fracture of the distal radius.

DESIGN:

Prospective study SETTING: University hospital PARTICIPANTS: A consecutive sample of patients (N=90) with fracture of the distal radius treated by closed reduction and casting.

INTERVENTIONS:

Not applicable MAIN OUTCOME MEASURES: Occurrence of CRPS I, pain, wrist and hand range of motion, radiographic measures, Patient-Rated Wrist Evaluation, Hospital Anxiety and Depression scale and The Short Form 36 at baseline and at 1, 3, 6 and 9 months follow-up.

RESULTS:

CRPS I occurred in 29 patients (32.2%) with a mean delay of 21.7±23.7 days from cast removal. Univariate analyses found significant differences between patients with CRPS I and patients without CRPS I at baseline for gender (p=0.021), socio economic level (p=0.023), type of trauma (p=0.05), pain at rest and at activity (p=0.006 and p<0.001), wrist dorsiflexion and pronation (p=0.002 and p=0.001), fingers flexion (p=0.047), thumb opposition (p=0.002), function of the hand (p<0.001), and physical quality of life (p=0.013). Logistic regression showed that risk for CRPS I was higher in cases of female gender (OR:5.774;95%CI:1.391 to 23.966), medium and low energy trauma (OR:7.718;95% CI:1.136 to 52.44), physical quality of life of the short form 36 < 40 (OR:4.931;95%CI:1.428 to 17.025) and patient-rated wrist evaluation pain subscale >16 (OR:12.192;95%CI:4.484 to 43.478).

CONCLUSIONS:

CRPS I occurs frequently during the third and fourth week after cast removal especially in women who report severe pain and impairment of their physical quality of life. Additional prospective studies are required to verify these findings in comminuted and operated fractures of the distal radius

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J Pain. 2013 Sep 21. pii: S1526-5900(13)01130-9. 

Motor Dysfunction of Complex Regional Pain Syndrome Is Related to Impaired Central Processing of Proprioceptive Information.

Bank PJ, Peper CL, Marinus J, Beek PJ, van Hilten JJ.

Source

Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Research Institute MOVE, Faculty of Human Movement Sciences, VU University Amsterdam, The Netherlands. Electronic address: p.j.m.bank@lumc.nl.

Abstract

Our understanding of proprioceptive deficits in complex regional pain syndrome (CRPS) and its potential contribution to impaired motor function is still limited. To gain more insight into these issues, we evaluated accuracy and precision of joint position sense over a range of flexion-extension angles of the wrist of the affected and unaffected sides in 25 chronic CRPS patients and in 50 healthy controls. The results revealed proprioceptive impairment at both the patients’ affected and unaffected sides, characterized predominantly by overestimation of wrist extension angles. Precision of the position estimates was more prominently reduced at the affected side. Importantly, group differences in proprioceptive performance were observed not only for tests at identical percentages of each individual’s range of wrist motion but also when controls were tested at wrist angles that corresponded to those of the patient’s affected side. More severe motor impairment of the affected side was associated with poorer proprioceptive performance. Based on additional sensory tests, variations in proprioceptive performance over the range of wrist angles, and comparisons between active and passive displacements, the disturbances of proprioceptive performance most likely resulted from altered processing of afferent (and not efferent) information and its subsequent interpretation in the context of a distorted “body schema.”

PERSPECTIVE:

The present results point at a significant role for impaired central processing of proprioceptive information in the motor dysfunction of CRPS and suggest that therapeutic strategies aimed at identification of proprioceptive impairments and their restoration may promote the recovery of motor function in CRPS patients.

RS: we know that in many persisting pain cases, especially those with a neuropathic pain mechanism, there is an altered body schema. This must be targeted within the treatment and training programme.

Visit our main clinic page here: Specialist Pain Physio Clinics for persisting pain and injury

 

Pain metaphors (1)

A recent comment that I thought summed up several dimensions of the pain experience: ‘my life is contracted’.

Does anyone relate to this?

There can be a physical sense to ‘contraction’ whereby limited movement causes stiffness alongside the tension and guarding that limit mobility and reduce tolerance for activities. Pertinent is the fact that often these activities are the normal day to day pass-times and tasks that one can take for granted, until they become difficult or deemed impossible.

One’s thinking and sensory experience of the World can be ‘contracted’ as the pain becomes all consuming, occupying thoughts and movements to the point that there is little else.

Metaphors that spill from the individual’s thinking and experiences are such valuable insight. Expression of narrative and metaphor should be encouraged and then crafted into different language underpinned by a reconceptualised perspective as the mechanisms of pain and the influences upon pain are discovered and understood.

If you are so inclined, share your thoughts.

RS – Specialist Pain Physio Clinics, London

CRPS Bugle 17th Sept 2013 | #CRPS

Here are some of the Cochrane Reviews relating to CRPS and chronic pain:

Local anaesthetic sympathetic blockade for complex regional pain syndrome.

Stanton TR, Wand BM, Carr DB, Birklein F, Wasner GL, O’Connell NE.

Cochrane Database Syst Rev. 2013 Aug 19;8:CD004598. doi: 10.1002/14651858.CD004598.pub3.

Source
Neuroscience Research Australia, Randwick, Australia.

Abstract
BACKGROUND:
This is an update of the original Cochrane review published in The Cochrane Library, 2005, Issue 4, on local anaesthetic blockade (LASB) of the sympathetic chain used to treat complex regional pain syndrome (CRPS).

OBJECTIVES:
To assess the efficacy of LASB for the treatment of pain in CRPS and to evaluate the incidence of adverse effects of the procedure.

SEARCH METHODS:
We updated searches of the Cochrane Pain, Palliative and Supportive Care Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library (Issue 11 of 12, 2012), MEDLINE (1966 to 22/11/12), EMBASE (1974 to 22/11/12), LILACS (1982 to 22/11/12), conference abstracts of the World Congresses of the International Association for the Study of Pain (1995 to 2010), and various clinical trial registers (inception to 2012). We also searched bibliographies from retrieved articles for additional studies.

SELECTION CRITERIA:
We considered for inclusion randomised controlled trials (RCTs) that evaluated the effect of sympathetic blockade with local anaesthetics in children or adults with CRPS.

DATA COLLECTION AND ANALYSIS:
The outcomes of interest were reduction in pain intensity levels, the proportion who achieved moderate or substantial pain relief, the duration of pain relief, and the presence of adverse effects in each treatment arm.

MAIN RESULTS:
We included an additional 10 studies (combined n = 363) in this update. Overall we include 12 studies (combined n = 386). All included studies were assessed to be at high or unclear risk of bias.Three small studies compared LASB to placebo/sham. We were able to pool the results from two of these trials (intervention n = 23). Pooling did not demonstrate significant short-term benefit for LASB (in terms of the risk of a 50% reduction of pain scores).Of two studies that investigated LASB as an addition to rehabilitation treatment, the only study that reported pain outcomes demonstrated no additional benefit from LASB.Eight small randomised studies compared sympathetic blockade to another active intervention. Most studies found no difference in pain outcomes between sympathetic block and other active treatments.Only five studies reported adverse effects, all with minor effects reported.

AUTHORS’ CONCLUSIONS:
This update has found similar results to the original systematic review. There remains a scarcity of published evidence to support the use of local anaesthetic sympathetic blockade for CRPS. From the existing evidence it is not possible to draw firm conclusions regarding the efficacy or safety of this intervention but the limited data available do not suggest that LASB is effective for reducing pain in CRPS

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Cochrane Database Syst Rev. 2013 Sep 2;9:CD002918. [Epub ahead of print]
Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome.
Straube S, Derry S, Moore RA, Cole P.

Source
Institute of Occupational, Social and Environmental Medicine, University Medical Center Göttingen, Waldweg 37 B, Göttingen, Germany, D-37073.

Abstract

BACKGROUND:
This review is an update of a review first published in Issue 2, 2003, which was substantially updated in Issue 7, 2010. The concept that many neuropathic pain syndromes (traditionally this definition would include complex regional pain syndromes (CRPS)) are “sympathetically maintained pains” has historically led to treatments that interrupt the sympathetic nervous system. Chemical sympathectomies use alcohol or phenol injections to destroy ganglia of the sympathetic chain, while surgical ablation is performed by open removal or electrocoagulation of the sympathetic chain or by minimally invasive procedures using thermal or laser interruption.

OBJECTIVES:
To review the evidence from randomised, double blind, controlled trials on the efficacy and safety of chemical and surgical sympathectomy for neuropathic pain, including complex regional pain syndrome. Sympathectomy may be compared with placebo (sham) or other active treatment, provided both participants and outcome assessors are blind to treatment group allocation.

SEARCH METHODS:
On 2 July 2013, we searched CENTRAL, MEDLINE, EMBASE, and the Oxford Pain Relief Database. We reviewed the bibliographies of all randomised trials identified and of review articles and also searched two clinical trial databases, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform, to identify additional published or unpublished data. We screened references in the retrieved articles and literature reviews and contacted experts in the field of neuropathic pain.

SELECTION CRITERIA:

Randomised, double blind, placebo or active controlled studies assessing the effects of sympathectomy for neuropathic pain and CRPS.

DATA COLLECTION AND ANALYSIS:
Two review authors independently assessed trial quality and validity, and extracted data. No pooled analysis of data was possible.

MAIN RESULTS:
Only one study satisfied our inclusion criteria, comparing percutaneous radiofrequency thermal lumbar sympathectomy with lumbar sympathetic neurolysis using phenol in 20 participants with CRPS. There was no comparison of sympathectomy versus sham or placebo. No dichotomous pain outcomes were reported. Average baseline scores of 8-9/10 on several pain scales fell to about 4/10 initially (1 day) and remained at 3-5/10 over four months. There were no significant differences between groups, except for “unpleasant sensation”, which was higher with radiofrequency ablation. One participant in the phenol group experienced post sympathectomy neuralgia, while two in the radiofrequency group and one in the phenol group complained of paraesthesia during needle positioning. All participants had soreness at the injection site.

AUTHORS’ CONCLUSIONS:
The practice of surgical and chemical sympathectomy for neuropathic pain and CRPS is based on very little high quality evidence. Sympathectomy should be used cautiously in clinical practice, in carefully selected patients, and probably only after failure of other treatment options. In these circumstances, establishing a clinical register of sympathectomy may help to inform treatment options on an individual patient basis.

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Psychological therapies for the management of chronic and recurrent pain in children and adolescents

Eccleston C, Palermo TM, Williams AC de C, Lewandowski A, Morley S, Fisher E, Law E
Published Online: August 23, 2013
– See more at: http://summaries.cochrane.org/CD003968/psychological-therapies-for-the-management-of-chronic-and-recurrent-pain-in-children-and-adolescents#sthash.eWN3HPP5.dpuf

Background:
Chronic pain affects many children, who report severe pain, distressed mood, and disability. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This update adds recently published randomised controlled trials (RCTs) to the review published in 2009.

Objectives:
To assess the effectiveness of psychological therapies, principally cognitive behavioural therapy and behavioural therapy, for reducing pain, disability, and improving mood in children and adolescents with recurrent, episodic, or persistent pain. We also assessed the risk of bias and methodological quality of the included studies.

Search strategy:
Searches were undertaken of MEDLINE, EMBASE, and PsycLIT. We searched for RCTs in references of all identified studies, meta-analyses and reviews. Date of most recent search: March 2012.

Selection criteria:
RCTs with at least 10 participants in each arm post-treatment comparing psychological therapies with active treatment were eligible for inclusion (waiting list or standard medical care) for children or adolescents with episodic, recurrent or persistent pain.

Data collection and analysis:
All included studies were analysed and the quality of the studies recorded. All treatments were combined into one class: psychological treatments; headache and non-headache outcomes were separately analysed on three outcomes: pain, disability, and mood. Data were extracted at two time points; post-treatment (immediately or the earliest data available following end of treatment) and at follow-up (at least three months after the post-treatment assessment point, but not more than 12 months).

Main results:
Eight studies were added in this update of the review, giving a total of 37 studies. The total number of participants completing treatments was 1938. Twenty-one studies addressed treatments for headache (including migraine); seven for abdominal pain; four included mixed pain conditions including headache pain, two for fibromyalgia, two for pain associated with sickle cell disease, and one for juvenile idiopathic arthritis. Analyses revealed five significant effects. Pain was found to improve for headache and non-headache groups at post-treatment, and for the headache group at follow-up. Mood significantly improved for the headache group at follow-up, although, this should be interpreted with caution as there were only two small studies entered into the analysis. Finally, disability significantly improved in the non-headache group at post-treatment. There were no other significant effects.

Authors’ conclusions:
Psychological treatments are effective in reducing pain intensity for children and adolescents (<18 years) with headache and benefits from therapy appear to be maintained. Psychological treatments also improve pain and disability for children with non-headache pain. There is limited evidence available to estimate the effects of psychological therapies on mood for children and adolescents with headache and non-headache pain. There is also limited evidence to estimate the effects on disability in children with headache. These conclusions replicate and add to those of the previous review which found psychological therapies were effective in reducing pain intensity for children with headache and non-headache pain conditions, and these effects were maintained at follow-up.

Visit our clinic site here: Specialist Pain Physio Clinics

Pain is a construct | #pain #neuroscience

Pain is a construct that is unique to our own brain hence the individual nature of the experience. By definition, according to the International Association for the Study of Pain (IASP), pain is a sensory and emotional experience. Both sensations and emotions are also brain constructs, in other words our brains create the experience to be played out via the body. In essence this is why pain is so influenced by our mental state and attentional processes: most patients I talk to will describe an increase in pain at times of stress (stress can also reduce pain; stress induced analgesia–this being the case when something else is more salient at the time) and when they are unable to distract themselves.

Our language, pain descriptions, our inner voice are all brain constructs that emerge as are the movements we make–more on this soon

Pain emerges from the body tissues, or in the case of phantom limb pain (PLP) in the space that was once occupied. A great deal has been learned from PLP (see video below with VS Ramachandran talking about ‘The Tell-Tale Brain’) including the fact that pain cannot be created by the tissues as they are clearly not in existence, however the cortical representation (the somatosensory maps, motor maps etc) remain in the brain, igniting under certain circumstances to construct a pain experience via the salient network. The salient network exists to detect differences in physiological activity and respond accordingly, perhaps with protection in mind that would include pain in the area of the body deemed under threat. For pain is about ‘threat’. When the brain receives contextual information suggestive of threat, it must scrutinise this data and compare to what it knows before responding. On there being a perception of threat, regardless of the reality (eg/ light brushing, a simple movement, watching someone else move, thinking about movement–some readers will know only too well how the latter cues can trigger pain), the brain will protect, drive attention and motivate action via the experience of pain in the body.

Our individual belief system, our resilience at the time, our mood at the time and the context will all impact upon the pain perception and what happens next. The construct of pain, the common denominator being that it hurts in the body, is varied in its volume, location and pattern in many cases when the sensitivity has persisted for some time. In other cases, the pain can have a mechanical pattern (not implying that a structure is out of place and can be put back by manual therapy) meaning that certain movements or touch can hurt and be more predictable. However, the bottom line remains that the brain must perceive a threat.

On the positive side, although complex and modulated at many levels, pain is changeable. There are many access routes into changing the experience and a person’s belief that they can gain increasing control over their pain to be able to reduce the feeling and train to decrease sensitivity. The newer brain focused therapies all aim to do this by targeting changes and adaptations in the central nervous system, although I would argue that we are seeking to change the processing of the danger signals with any of the techniques used in the clinic. Light manual techniques that result in pain relief do not ‘put discs back’ but they can alter the threat value and hence change guarding, reflexive protection and the perception of touch leading to relief and ease of movement. We just have to think carefully about which techniques and strategies are most appropriate at the time, how we set the environment and context so that the brain is acceptant of the treatment and responds by reducing activity in the pain matrix or representation.

Undoubtedly treating chronic pain is complex but if we think about the pain mechanisms and the influences upon pain (stress, anxiety, mood, exercise, movement, sleep etc), we can build a comprehensive programme to address the different dimensions: physical, cognitive and emotional. Let us treat the tissues with care to nourish and promote healthy movement, but to do this effectively we have to think about the brain and how it is constructing the reality of the patient and get it onside.

Specialist Pain Physio Clinics, London

CRPS Bugle | #CRPS | Body perception

Welcome to the latest Bugle that focuses upon body perception, so often affected in CRPS. Body perception should form part of the assessment in my view, as the construction of this sense by the brain is a feature of the condition and must be addressed.

Evaluation of a prototype tool for communicating body perception disturbances in complex regional pain syndrome

Ailie J. Turton, Mark Palmer, Sharon Grieve, Timothy P. Moss, Jenny Lewis and Candida S. McCabe

Patients with Complex Regional Pain Syndrome (CRPS) experience distressing changes in body perception. However representing body perception is a challenge. A digital media tool for communicating body perception disturbances was developed. A proof of concept study evaluating the acceptability of the application for patients to communicate their body perception is reported in this methods paper. Thirteen CRPS participants admitted to a 2-week inpatient rehabilitation program used the application in a consultation with a research nurse. Audio recordings were made of the process and a structured questionnaire was administered to capture experiences of using the tool. Participants produced powerful images of disturbances in their body perception. All reported the tool acceptable for communicating their body perception. Participants described the positive impact of now seeing an image they had previously only imagined and could now convey to others. The application has provided a novel way for communicating perceptions that are otherwise difficult to convey.

* Full article available on the Frontiers in Human Neuroscience website – click here

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Eur J Pain. 2012 Oct;16(9):1320-30

Perceptions of the painful body: the relationship between body perception disturbance, pain and tactile discrimination in complex regional pain syndrome.

Lewis JS, Schweinhardt P.

Abstract
BACKGROUND:
Disturbances in body perception are increasingly acknowledged as a feature of complex regional pain syndrome (CRPS). Conventional treatments have limited success particularly among those with long-standing disease. Understanding the relationship between body perception disturbance, pain and tactile acuity might provide insight into alternative avenues for treatment. The aim of this study was to test the hypotheses that (1) body perception disturbance is positively related to pain and (2) decreased tactile acuity is related to increased body perception disturbance.
METHODS:
A controlled observational design was used to measure these features among those with CRPS of one arm. The extent of body perception disturbance was assessed using the Bath CRPS body perception disturbance scale and pain was measured using the neuropathic pain symptom inventory. Two-point discrimination threshold testing was performed as a measure of tactile acuity.
RESULTS:
Findings confirmed both hypotheses. Body perception disturbance was found to positively correlate with pain such that those in greater pain had more extensive body perception disturbance (r = 0.57, p < 0.01). Furthermore, a positive correlation was revealed between body perception disturbance and two-point discrimination thresholds (r = 0.5, p < 0.025) so those with greater body perception disturbance had worse tactile acuity. Interestingly, those with longer disease duration had significantly greater body perception disturbance (r = 0.66, p < 0.001).
CONCLUSION:
Aberrant central processing is suggested as the neural correlate of body perception disturbance and tactile impairment. The exact relationship between body perception disturbance, pain and tactile acuity and how they may be modulated for pain relief requires further exploration.

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Pain. 2012 Nov;153(11):2174-81

Impaired spatial body representation in complex regional pain syndrome type 1 (CRPS I).

Reinersmann A, Landwehrt J, Krumova EK, Ocklenburg S, Güntürkün O, Maier C.

Abstract
Recently, a shift of the visual subjective body midline (vSM), a correlate of the egocentric reference frame, towards the affected side was reported in patients with complex regional pain syndrome (CRPS). However, the specificity of this finding is as yet unclear. This study compares 24 CRPS patients to 21 patients with upper limb pain of other origin (pain control) and to 24 healthy subjects using a comprehensive test battery, including assessment of the vSM in light and dark, line bisection, hand laterality recognition, neglect-like severity symptoms, and motor impairment (disability of the arm, shoulder, and hand). Statistics: 1-way analysis of variance, t-tests, significance level: 0.05. In the dark, CRPS patients displayed a significantly larger leftward spatial bias when estimating their vSM, compared to pain controls and healthy subjects, and also reported lower motor function than pain controls. For right-affected CRPS patients only, the deviation of the vSM correlated significantly with the severity of distorted body perception. Results confirm previous findings of impaired visuospatial perception in CRPS patients, which might be the result of the involvement of supraspinal mechanisms in this pain syndrome. These mechanisms might accentuate the leftward bias that results from a right-hemispheric dominance in visuospatial processing and is known as pseudoneglect. Pseudoneglect reveals itself in the tendency to perceive the midpoint of horizontal lines or the subjective body midline left of the centre. It was observable in all 3 groups, but most pronounced in CRPS patients, which might be due to the cortical reorganisation processes associated with this syndrome.

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Specialist Pain Physio Clinics, London

Painstaking research – tackling chronic pain

From the Wellcome Trust, here’s an interesting blog looking at some of the research for chronic pain by Mun-Keat Looi.

‘Pain is an important warning system in our bodies, but what if it never stops? It is estimated that one in five Europeans suffer from chronic pain, yet there are few effective treatments that offer adequate relief. Mun-Keat Looi talks to researchers from the London Pain Consortium, whose discoveries are prompting a surge in promising drug targets.’

Painstaking research – tackling chronic pain.

More on neuroplasticity | Let’s learn, change and grow #neuroplasticity #learning

Professor Micheal Merzenich talks about how we can use our knowledge of neuroplasticity to thrive and grow. This is certainly a neuro-characteristic that is potent and valuable in rehabilitation from an injury or a painful condition such as complex regional pain syndrome.

CRPS Bugle 13 Aug #CRPS

Welcome to the latest CRPS Bugle

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Acute and chronic phases of complex regional pain syndrome in mice are accompanied by distinct transcriptional changes in the spinal cord.

Mol Pain. 2013 Aug 8;9(1):40.

Gallagher JJ, Tajerian M, Guo T, Shi X, Li W, Zheng M, Peltz G, Kingery W, Clark JD.

Abstract

BACKGROUND:

CRPS is a painful, debilitating, and often-chronic condition characterized by various sensory, motor, and vascular disturbances. Despite many years of study, current treatments are limited by our understanding of the underlying mechanisms. Little is known on the molecular level concerning changes in gene expression supporting the nociceptive sensitization commonly observed in CRPS limbs, or how those changes might evolve over time.

RESULTS:

We used a well-characterized mouse tibial fracture/cast immobilization model of CRPS to study molecular, vascular and nociceptive changes. We observed that the acute (3 weeks after fracture) and chronic (7 weeks after fracture) phases of CRPS-like changes in our model were accompanied by unique alterations in spinal gene expression corresponding to distinct canonical pathways. For the acute phase, top regulated pathways were: chemokine signaling, glycogen degradation, and cAMP-mediated signaling; while for the chronic phase, the associated pathways were: coagulation system, granzyme A signaling, and aryl hydrocarbon receptor signaling. We then focused on the role of CcL2, a chemokine that we showed to be upregulated at the mRNA and protein levels in spinal cord tissue in our model. We confirmed its association with the nociceptive sensitization displayed in this model by demonstrating that the spinal but not peripheral administration of a CCR2 antagonist (RS504393) in CRPS animals could decrease mechanical allodynia. The spinal administration of CcL2 itself resulted in mechanical allodynia in control mice.

CONCLUSIONS:

Our data provide a global look at the transcriptional changes in the spinal cord that accompany the acute and chronic phases of CRPS as modeled in mice. Furthermore, it follows up on one of the top-regulated genes coding for CcL2 and validates its role in regulating nociception in the fracture/cast model of CRPS.

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An older paper identifying the effects of immobilisation that are similar to CRPS and the role of substance P in the vascular changes.

Substance P signalling contributes to the vascular and nociceptive abnormalities observed in a tibial fracture rat model of complex regional pain syndrome type I.

Pain. 2004 Mar;108(1-2):95-107.

Guo TZ, Offley SC, Boyd EA, Jacobs CR, Kingery WS.

Source

Physical Medicine and Rehabilitation Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA.

Abstract

Wrist and ankle fractures are the most frequent causes of complex regional pain syndrome (CRPS type I). The current study examined the temporal development of vascular, nociceptive and bony changes after distal tibial fracture in rats and compared these changes to those observed after cast immobilization in intact normal rats. After baseline testing the right distal tibial was fractured and the hindlimb casted. A control group was simply casted without fracturing the tibia. After 4 weeks the casts were removed and the rats retested. Subsequent testing was performed at 6, 8, 10, 16, and 20 weeks after onset of treatment. Distal tibial fracture or cast immobilization alone generated chronic hindlimb warmth, edema, spontaneous protein extravasation, allodynia, and periarticular osteoporosis, changes resembling those observed in CRPS. Hindlimb warmth and allodynia resolved much more quickly after cast immobilization than after fracture. Previously we observed that the substance P receptor (NK(1)) antagonist LY303870 reversed vascular and nociceptive changes in a sciatic section rat model of CRPS type II. Postulating that facilitated substance P signaling may also contribute to the vascular and nociceptive abnormalities observed after tibial fracture or cast immobilization, we attempted to reverse these changes with LY303870. Hindpaw warmth, spontaneous extravasation, edema, and allodynia were inhibited by LY303870. Collectively, these data support the hypotheses that the distal tibial fracture model simulates CRPS, immobilization alone can generate a syndrome resembling CRPS, and substance P signaling contributes to the vascular and nociceptive changes observed in these models.

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Pain-related fear, perceived harmfulness of activities, and functional limitations in complex regional pain syndrome type I.

J Pain. 2011 Dec;12(12):1209-18. doi: 10.1016/j.jpain.2011.06.010.

de Jong JR, Vlaeyen JW, de Gelder JM, Patijn J.

Source

Department of Rehabilitation, University Hospital Maastricht, Maastricht, The Netherlands. jeroen.dejong@mumc.nl

Abstract

Numerous studies have shown that pain-related fear is one of the strongest predictors of pain disability in patients with chronic musculoskeletal pain, and there is evidence that the reduction of pain-related fear through an exposure treatment can be associated with restoration of functional abilities in patients with complex regional pain syndrome type I (CRPS-I). These findings suggest that pain-related fear may be associated with functional limitations in neuropathic pain as well. The aim of the current study was to test whether the debilitating role of pain-related fear generalizes to patients with CRPS-I. The results of 2 studies are presented. Study I includes a sample of patients with early CRPS-I referred to an outpatient pain clinic. In Study II, patients with chronic CRPS who are members of a patients’ association were invited to participate. The results show that in early CRPS-I, pain severity but not fear of movement/(re)injury as measured with the Tampa Scale for Kinesiophobia was related to functional limitations. In patients with chronic CRPS-I, however, perceived harmfulness of activities as measured with the pictorial assessment method significantly predicted functional limitations beyond and above the contribution of pain severity. Not fear of movement/(re)injury in general, but the perceived harmfulness of activities appears a key factor that might be addressed more systematically in the clinical assessment of patients with CRPS-I. These results support the idea that pain-related fear might be a promising concept in the understanding of pain disability in patients with neuropathic pain.

PERSPECTIVE:

This is the first study showing that perceived harmfulness of activities contribute to the functional limitations in CRPS-I. The current findings may help clinicians customizing cognitive-behavioral treatments for patients with chronic neuropathic pain.

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Please visit our clinic site for further information on treatment, training & coaching for CRPS (RSD): Specialist Pain Physio Clinics, London or call us on 07932 689081

‘The mystery of chronic pain’ TED Talk #pain

Elliot Krane talks about his 20 years experience of working with individuals who suffer complex pain. He describes a common scenario that I see in my clinic, whereby the pain has persisted beyond the expected timeline, sometimes by many years, and is accompanied by a range of other signs and symptoms that are all manifestations of the sensitivity that has evolved and become entrenched. This includes a variety of protective behaviours and beliefs about pain and what it means, the latter usually informing the former. The belief system is molded by experiences throughout life and messages given by those responsible for their healthcare. These messages and metaphors can often evoke potent imagery and fear that leads to avoidance and strategies that appear to be useful but are actually preventing the move forwards.

Moving forwards is a challenge. But, we are designed to change, grow and develop. Hence by creating the right conditions, this is what we can achieve with the understanding of pain biology, a range of effective movement based strategies, a toolbox of motivational techniques, a progressive plan, courage, belief in oneself (self-efficacy), support, perseverance and some brain focused therapies.

Please visit our clinic site here to learn more about our treatment, training and coaching programmes or call us: 07932 689081