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Query: UMLS:C0030193 (pain)
 261,466 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Even when diagnosed early and treated appropriately, patients with complex regional pain syndrome (CRPS), a condition that can lead to severe painful dysfunction of the limb, may continue to have long-term pain. A retrospective study was conducted of 33 patients with a positive history of CRPS I, CRPS II, or sympathetically maintained pain (SMP) of the lower limb who were treated in either a clinical setting or a pain management center. The average age of individuals diagnosed with CRPS was 43.5 +/- 12.6 (mean +/-SD) years with 60% being female. The most common diagnosis was CRPS I (75.8%) followed by SMP (21.2%), and finally CRPS II (3.0%). The dominant etiology was confirmed as trauma (73%), with the remaining nine cases resulting from elective foot surgery. Fractures were the most common type of injury (45%) and excision of neuroma was the most frequent elective surgical procedure (30%). Time from injury to diagnosis in patients with foot and ankle trauma was 3.9 +/- 3.0 months and from elective surgery to diagnosis was 9.1 +/- 4.0 months (t test, p < .001). Thirteen patients were contacted for long-term follow-up with an average of 3.5 years after initial diagnosis. There was no difference when the pain rating at long-term follow-up was compared to the initial rating (6.2 +/- 1.2 vs. 7.3 +/- 0.6; p = .287), and 11 continue to have more than moderate pain. Thus, many patients with CRPS who seem to be successfully treated, and are discharged from care, still have severe pain years later.
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PMID:Complex regional pain syndrome of the lower extremity: a retrospective study of 33 patients. 1061 8

Sympathetic blockage and physiotherapy are among the most effective treatment approaches for the complex regional pain syndrome (CRPS). It is important to institute the treatment as early as possible in order to avoid major functional limitations of the affected limb. Unfortunately, there is a paucity of vigorously applied randomised or placebo-controlled trials for these therapeutic approaches. A prospective randomised study of 35 outpatient clinic patients with type I complex regional pain syndrome of the lower extremities lasting less than 6 months is described. One of two treatments, exercise alone or exercise in combination with manual lymph drainage, was applied for six weeks, three times a week, to the affected limb. Clinical and subjective parameters for pain, swelling, temperature, and range of motion were evaluated. Manual lymph drainage was chosen as adequate therapy for oedema reduction, whereas exercise was applied as standard therapy for contracture prophylaxis in reflex sympathetic dystrophy. Both groups were asked not to use analgesics but received extensive instructions for avoiding pain. Significant improvements in clinical parameters were observed in both groups, but no significant effect between treatment groups was found. Pain measurement alone with a verbal rating scale showed a tendency towards greater pain reduction in the group receiving lymph drainage. The results indicate that, during the first 6 months of complex regional pain syndrome type I, manual lymph drainage provides no additional benefit when applied in conjunction with an intensive exercise program.
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PMID:[Comparison of manual lymph drainage with physical therapy in complex regional pain syndrome, type I. A comparative randomized controlled therapy study]. 1072 65

In this prospective pilot study, nine patients suffering from complex regional pain syndrome of the arm were treated with morphine 0.16 mg h-1 (3.84 mg day-1) applied continuously through an axillary brachial plexus catheter. In all of them an oral analgesic medication including the less potent opioid tramadol had not provided sufficient pain relief. During regional treatment, patients were kept in hospital and physiotherapy was carried out frequently in order to improve strength and function of the affected arm. Pain at rest and during movement as well as grip strength were assessed at first visit, during morphine infusion and at a long-term follow-up visit. All assessments improved significantly during plexus analgesia. There were no major opioid related side-effects. The results from this pilot study indicate that continuous axillary brachial plexus analgesia with low dose morphine might be beneficial in patients suffering from complex regional pain syndrome of the arm.
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PMID:Continuous axillary brachial plexus analgesia with low dose morphine in patients with complex regional pain syndromes. 1075 69

Early diagnosis is a prerequisite for a successful treatment of complex regional pain syndrome (CRPS). In order to describe neurological symptoms which characterize CRPS, we evaluated 145 patients prospectively. Two-thirds of these were women, the mean age at time of investigation was 50.4 years. CRPS followed limb trauma, surgery and nerve lesion. Employing the current IASP criteria 122 patients were classified as CRPS I and 23 as CRPS II. All patients were assessed clinically pain was quantified using the McGill pain questionnaire, skin temperature was measured by an infrared thermometer and a subgroup of 57 patients was retested in order to determine thermal thresholds (QST). Of our patients 42% reported stressful life events in a close relationship to the onset of CRPS and 41% had a history of chronic pain before CRPS. The latter group of patients gave a higher rating of CRPS pain (P<0.05). The major symptoms were pain at rest in 77% and hyperalgesia in 94%. Typical pain was deep in the limb having a tearing character. Patients getting physical therapy had significantly less pain than those without (P<0.04). Autonomic signs were frequent (98%) and often changed with the duration of CRPS. Skin temperature was warmer in acute and colder in chronic stages (P<0.001). Likewise edema had a higher incidence in acute stages (P<0.001). We found no correlation between pain and autonomic dysfunction. Motor dysfunction (present in 97%) included weakness, tremor, exaggerated tendon reflexes, dystonia or myoclonic jerks. QST revealed increased warm perception thresholds (P<0.02) and decreased cold pain thresholds (P<0.03) of the affected limb. The detailed knowledge of clinical features of CRPS could help physicians early to recognize the disease and thus to improve therapy outcome.
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PMID:Neurological findings in complex regional pain syndromes--analysis of 145 cases. 1077 May 24

We present a case of complex regional pain syndrome (CRPS) Type 1 in a 12-year-old girl. The patient did not respond to the usual therapeutic modalities used to treat CRPS, including physical therapy, lumbar sympathetic block, epidural local anesthetic block, intravenous lidocaine infusion, or other oral medications. Of note is the fact that, during epidural block, the patient demonstrated a resistance to local anesthetic neural blockade in the area of the body involved with the pain problem. The mechanism of this resistance could be related to the changes in the dorsal horn cells of the spinal cord, secondary to activation of N-methyl-D-aspartate receptors, which may play a role in the pathophysiology of this pain syndrome.
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PMID:Complex regional pain syndrome (CRPS) with resistance to local anesthetic block: a case report. 1077 13

The clinical approach to complex regional pain syndrome (CRPS) is complicated by a lack of precision diagnostically, and a lack of evidence-based information for treatment. The vagaries of diagnosis were somewhat improved by the Orlando Conference (1993), where a consensus panel of experts developed a new taxonomy and criteria. Unfortunately the criteria can be based entirely on subjective grounds (patient history), and as such provides a very sensitive but not very specific device. There is some effort in the research community to amend these criteria to make them more specific. We encourage the practicing physician to include as much objective data along with the quasi-objective and subjective information currently used in formulating the diagnosis. This imprecision in diagnostic issues has significantly hampered treatment because it has not led to solid, generalizable, randomized controlled trials. To date there are no substantial scientific trials of any particular therapy or medication in the specific diagnosis of CRPS. Much can be inferred from the work with peripheral neuropathy and central pain. However, it is unlikely that this will be a perfect concordance with best therapy for CRPS. It remains our responsibility to diagnose each patient as best we can, supported by the best possible objective signs and testing. Once the diagnosis is made it is necessary to proceed in a pragmatic empirical way, following the best guidelines available. The guidelines should be considered a "rough sketch" and the key to clinical success will be flexibility, a vast fund of the available knowledge, patience, and compassion. To allow the deficiencies in the science to paralyze the clinical process is therapeutic nihilism, and not acceptable.
Clin J Pain 2000 Jun
PMID:A clinical approach to complex regional pain syndrome. 1087 Jul 37

Our knowledge about the pathogenesis of neuropathic pain has grown significantly during last two decades. Basic research with animal models of neuropathic pain and human clinical trials with neuropathic pain have accumulated solid evidence that a number of pathophysiologic and biochemical changes take place in the nervous system at a peripheral or central level as a result of the insult or disease. Many similarities between the pathophysiologic phenomena observed in some epilepsy models and neuropathic pain models justify the rationale for the use of anticonvulsant drugs in the symptomatic management of neuropathic pain disorders. Carbamazepine (CBZ) was the first representative from this class of drugs to be studied in clinical trials. It has been used for the treatment of neuropathic pain syndromes, in particular, trigeminal neuralgia (TN), for the longest time of any of the drugs in this class. Results from clinical trials support the use of CBZ in the treatment of TN, painful diabetic neuropathy, and postherpetic neuralgia. The use of CBZ was not studied for complex regional pain syndrome, phantom limb pain, and other neuropathic conditions, however. Phenytoin was the first anticonvulsant to be used as an antinociceptive agent, but based on clinical trials, there is no evidence for its efficacy in relieving neuropathic pain. Newer anticonvulsants have marked a new era in the treatment of neuropathic pain, with clinical trials of higher quality standards. Gabapentin (GBP) has most clearly demonstrated an analgesic effect for the treatment of neuropathic pain, specifically for the treatment of painful diabetic neuropathy and postherpetic neuralgia. Gabapentin has a favorable side effects profile, and based on the results of these studies, it should be considered a first-line treatment for neuropathic pain. Gabapentin mechanisms of action are still not thoroughly defined, but GBP is effective in relieving indexes of allodynia and hyperalgesia in animal models. It still remains to be seen whether GBP is as effective in other painful disorders. One small clinical trial with lamotrigine demonstrated improved pain control in TN. Evidence in support of the efficacy of anticonvulsant drugs in the treatment of neuropathic pain continues to evolve, and benefits have been clearly demonstrated in the case of GBP and CBZ. More advances in our understanding of the mechanisms underlying neuropathic pain syndromes should further our opportunities to establish the role of anticonvulsants in the treatment of neuropathic pain.
Clin J Pain 2000 Jun
PMID:Anticonvulsants (antineuropathics) for neuropathic pain syndromes. 1087 Jul 43

Studies on the psychosocial impact of neuropathic pain conditions, including postherpetic neuralgia, diabetic neuropathy, complex regional pain syndrome, post spinal cord injury, postamputation, and AIDS-related neuropathy, are reviewed. Although limited, data are consistent with the larger literature on chronic pain and indicate that neuropathic pain reduces quality of life, including mood and physical and social functioning. Depression and pain coping strategies such as catastrophizing and social support predict pain severity, and a single diary study demonstrates a prospective relation between depressed mood and increased pain. Clinical trials of psychological interventions have not been reported, although some case series of successful treatment of neuropathic pain are reported, primarily in the area of biofeedback. Given the evidence indicating the broad impact of neuropathic pain on many areas of function, it is surprising that so few studies have investigated the impact of psychological interventions in these populations.
Clin J Pain 2000 Jun
PMID:Psychological aspects of neuropathic pain. 1087 Jul 48

The aim of this study was to investigate the role of local acidosis in the generation of pain in complex regional pain syndrome (CRPS). We investigated ten patients with CRPS of the upper extremity with a mean duration of the disease of 43 weeks (range 4-280 weeks) and ten control subjects for sensitivity to infusion of fluids with low pH (pH 6.1). Another group of five CRPS patients and three healthy controls was investigated using the same protocol but neutral infusion fluid (pH 7.4). A motorized syringe pump was installed for a constant infusion of synthetic interstitial fluid (SIF, either acidified (pH 6.1) or neutral) into the skin at the back of the hands and, thereafter, into the interosseus I muscle on both sides. A flow rate of 30 ml/h was chosen for intradermal and 7.5 ml/h for intramuscular infusion over a period of 10 min. The magnitude of pain was rated on an electronic visual analogue scale. Patients were requested to give their ratings every 10 s during the whole stimulation period. The ratings were normalized as fractions of individual grand mean values. We found significantly increased pain perception during infusion of acidified SIF on the affected side in CRPS patients. Low pH fluid into the skin was significantly more painful between 4 and 6 min (ipsi 1.27 normalized rating (NR) (0. 19-1.94), contra 0.31 NR (0.03-0.51), P<0.02) and between 8 and 10 min (ipsi 1.38 NR (0.19-1.94), contra 0.08 NR (0-0.27), P<0.03) on the affected side, while analysis over the whole stimulation period just failed to reach statistical significance (ipsi 281 area under the curve (AUC) (187-834), contra 87 AUC (28-293), P=0.059). Low pH infusion into the muscle was significantly more painful on the affected side during the whole infusion time (ipsi 861 AUC (308-1377), contra 190 AUC (96-528), P<0.01). The quality of the deep pain during infusion into the muscle was described by the patients as very similar to the CRPS-related pain. In controls we found no side differences of pain intensity during low pH stimulation. Neutral SIF evoked no pain at all, neither in CRPS patients (ipsi 0 AUC, contra 0 AUC) nor in healthy controls. Our results suggest that hyperalgesia to protons is present in patients with CRPS. Further, we could demonstrate that pain is not only restricted to the skin but is also generated in deep somatic tissue of the affected limb.
Pain 2000 Aug
PMID:Experimental tissue acidosis leads to increased pain in complex regional pain syndrome (CRPS). 1092 16

Because of the controversy concerning the manner in which the sympathetic nervous system is involved in reflex sympathetic dystrophy (RSD), its name was changed to one having no mechanistic connotations. This article reviews the relevant literature in support of not only the taxonomical changes to complex regional pain syndrome (CRPS) but also provides evidence of sympathetic dysfunction demonstrated in animal models of neuropathic pain.
Curr Rev Pain 2000
PMID:Reflex sympathetic dystrophy: a sympathetically mediated pain syndrome or not? 1095 74


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