Traditional Chinese medicine for foot pain in a patient with complex regional pain syndrome: A case report

BACKGROUND Complex regional pain syndrome(CRPS)is characterized by pain as well as sensory,motor,and sudomotor disorders.Generally,it is classified into two types CRPS-I and CRPS-II.There is no single diagnostic test or treatment approach for CRPS,and a multidisciplinary approach is gaining attention to improve patients’symptoms and their quality of life.CASE SUMMARY A 35-year-old woman with an unremarkable medical history sought treatment for CRPS at a hospital of Korean medicine.During her first visit,she was wheelchairbound due to severe pain in her left lower extremity.She had edema and discoloration of the left foot.She was treated with a combination of traditional Chinese medicine(TCM)approaches,including acupuncture,moxibustion,pharmacopuncture,and herbal decoction,for approximately 20 sessions.The foot and ankle outcome score(FAOS)and visual analog scale(VAS)score for pain were evaluated,along with general signs and functions.Her symptoms,signs,FAOS,and VAS scores improved after treatment,with a significant 7-degree decrease in the VAS score and a 62-point increase in the FAOS score.Additionally,the foot swelling and discoloration gradually resolved.During the phone follow-up,5 mo after the last visit,additional improvements in outcomes were observed.CONCLUSION Combined TCM treatment may be a reasonable and safe option for alleviating symptoms and improving function in patients with CRPS.

Impact of adolescent complex regional pain syndrome on the psychopathology of young men ahead of military service: A retrospective cohort analysis of Korean conscription data

Background: The relationship between physical and psychopathological features in complex regional pain syndrome(CRPS) has been a subject of constant interest, but no data are available in adolescents. Therefore, we aimed to identify the factors associated with psychopathology in adolescents with CRPS ahead of military service.Methods: We retrospectively reviewed all conscription examinees who had completed a Military Personality Inventory(MPI) during a period between February 2013 and December 2016. A total of 63 persons with a history of CRPS(19-years of age for all) were enrolled. Basic demographic and pain-related data were analyzed to examine their association with MPI results. The mean FGR score as well as the 8 subdomain scores were compared between those with pain duration at <15 months(n=30) vs. ≥15 months(n=33). Binary MPI results(normal-abnormal) were also compared between the two groups.Results: In multivariate analysis, abnormal MPI was associated with pain duration, with an odds ratio(OR) at 1.05 for every 1-month increase [95% confidence interval(CI) 1.02–1.08;P=0.002]. Subjects with pain duration at ≥15 months have lower faking good response score(P<0.001 vs. those with pain duration at <15 months), and higher abnormal MPI result rate, faking bad response, inconsistency, anxiety, depression, somatization, paranoid, personality disorder cluster A, and personality disorder cluster B scores(P<0.05). Pain duration was significantly associated with the MPI variables.Conclusions: Pain duration is associated with psychopathology in adolescents with CRPS. Psychopathologic features increased as the disease duration increased. A comprehensive understanding of time-dependent psychopathological factors could support the planning of multimodal approaches for managing adolescent CRPS.

High-intensity swimming alleviates nociception and neuroinflammation in a mouse model of chronic postischemia pain by activating the resolvin E1-chemerin receptor 23 axis in the spinal cord

Physical exe rcise effectively alleviates chronic pain associated with complex regional pain syndrome type-Ⅰ.However,the mechanism of exe rcise-induced analgesia has not been clarified.Recent studies have shown that the specialized pro-resolving lipid mediator resolvin E1 promotes relief of pathologic pain by binding to chemerin receptor 23 in the nervous system.However,whether the resolvin E1-chemerin receptor 23 axis is involved in exercise-induced analgesia in complex regional pain syndrome type-Ⅰ has not been demonstrated.In the present study,a mouse model of chronic post-ischemia pain was established to mimic complex regional pain syndrome type-Ⅰ and subjected to an intervention involving swimming at different intensities.Chronic pain was reduced only in mice that engaged in high-intensity swimming.The resolvin E1-chemerin receptor 23 axis was clearly downregulated in the spinal cord of mice with chronic pain,while high-intensity swimming restored expression of resolvin E1 and chemerin receptor 23.Finally,shRNA-mediated silencing of chemerin receptor 23in the spinal cord reve rsed the analgesic effect of high-intensity swimming exercise on chronic post-ischemic pain and the anti-inflammato ry pola rization of microglia in the dorsal horn of the spinal cord.These findings suggest that high-intensity swimming can decrease chronic pain via the endogenous resolvin E1-chemerin receptor 23 axis in the spinal cord.

Pain management of hemiplegic shoulder pain post stroke in patients from Nanjing,China

We selected 106 hemiplegic patients with shoulder pain hospitalized after stroke from three hospi- tals in Nanjing, China between February 2007 and January 2012. All patients had complete clinical data sets and accounted for 45.5% of the inpatients because of stroke. Results showed that the number of patients with hemiplegic shoulder pain post stroke increased yearly, attacking mainly males 50-69 years of age. Of 106 patients, there were 60 cases （56.6%） of adhesive capsulitis, 19 （17.9%） of shoulder subluxation, 14 （13.2%） of complex regional pain syndrome, and 13 （12.6%） of central pain. The main symptoms were shoulder pain （100%）, limit of shoulder mobility （98.1%）, and adhesion of the scapula （56.6%）. MRI of the shoulder showed tendon and ligament lesions （57.1%） and rotator cuff tear （38.1%）. 53.8% of central pain was related to the thalamus, in addition to the basal ganglia, brain stem, and cerebellopontine angle. Shoulder pain, upper limb motor function, and function independence were significantly improved after comprehensive rehabilitation. In par- ticular, electroacupuncture based on basic physical therapy exhibited efficacy on shoulder subluxa- tion and complex regional pain syndrome. Multiple linear regression results showed a negative re- lationship of efficacy of pain management with the attack period of shoulder pain, involvement of the posterior limb of the internal capsule, and duration between onset and rehabilitation treatment, but a positive correlation with pain-related education, pain regression period, and pain diagnosis.

Persistent Post-Operative Low Back Pain, True Radiculopathy and Pseudoradiculopathy: Retrospective Observational Study and Point of View of a Practicing Clinician

Purpose: Persistent Postoperative Low Back Pain (PLBP) is inordinately common, and has been attributed to various pre-operative and post-operative anatomical and mechanical factors in the spine. It may or may not be associated with sensory symptoms in the lower extremities—frequently termed “radiculopathy”—with or without Electromyographic (EMG) or imaging abnormalities. The present study aimed to look at these various symptoms in the lower extremities from a different angle and perspective and to clarify the distinction between true radiculopathy and pseudoradiculopathy;and determine their possible relationship with the outcome of surgery. Methods: Medical records of twenty-four patients with PLBP who were referred to the author for clinical and electrodiagnostic examinations several months after surgery were reviewed. Clinical symptomatology, with special reference to the presence or absence of sensory and motor deficits together with EMG findings, were reviewed and categorized into 4 groups: non radicular, true radiculopathy, pseudoradiculopathy, and peripheral neuropathy. Results: Lower Back Pain (LBP) in all patients persisted following successful and uncomplicated surgery. LBP in patients with true radiculopathy persisted but was less disabling when the neurologic deficits resolved partially or significantly. As expected, the neurologic deficits related to peripheral neuropathy, together with LBP, remained persistent. Conclusion: LBP and various sensory and motor symptoms in the lower extremities are 2 distinct entities, both clinically and pathophysiologically. These sensory and motor symptoms, together with the heightened activity of various pro-inflammatory cytokines and neurotrophins—setting aside the various anatomical and mechanical factors in the spine—can influence the outcome of surgery, favorably or unfavorably.

Neuronal changes resulting in up-regulation of alpha-1 adrenoceptors after peripheral nerve injury

Under normal conditions, the sympathetic neurotransmitter noradrenaline inhibits the production and release of pro-inflammatory cytokines. However, after peripheral nerve and tissue injury, pro-inflammatory cytokines appear to induce the expression of the alphalA-adreno- ceptor subtype on immune cells and perhaps also on other cells in the injured tissue. In turn, noradrenaline may act on up-regulated alphal-adrenoceptors to increase the production of the pro-inflammatory cytokine interleukin-6. In addition, the release of inflammatory mediators and nerve growth factor from keratinocytes and other cells may augment the expression of alphal-adrenoceptors on peripheral nerve fibers. Consequently, nociceptive afferents acquire an abnormal excitability to adrenergic agents, and inflammatory processes build. These mechanisms could contribute to the development of sympathetically maintained pain in conditions such as post-herpetic neuralgia, cutaneous neuromas, amputation stump pain and complex regional pain syndrome.

Painful scar neuropathy:principles of diagnosis and treatment

Nerve-tissue interactions are critical.Peripheral nerve injuries may involve intraneural and extraneural scar formation and affect nerve gliding planes,sometimes leading to complex clinical presentations.All of these pathological entities involve pain as the main clinical symptom and can be subsumed under the term“painful scar neuropathy”.The authors review the literature on treatment approaches to peripheral nerve scar neuropathy and the outcomes of neurolysis-associated procedures and propose a simple classification and a therapeutic approach to scar neuropathy.The search retrieved twenty-one papers,twenty of which reported pain reduction or resolution with various techniques.There is no consensus on the best therapeutic approach to neuropathic pain due to scar tethering.Most authors report good or excellent results with different techniques,from nerve wrapping with anti-adhesion devices to nerve coverage or wrapping with vascularized tissue.The authors’classification of and therapeutic approach to peripheral nerve scar lesions aims at promoting a logical approach based on the analysis of lesion type(perineural,or endoneural and perineural),pain type(due to traction or external trauma,pain at rest),and number of previous operations.Patients need to be informed that multiple procedures may be required,that outcomes may be partial,and that surgery can potentially worsen preoperative conditions.The review found no evidence for the best therapeutic approach to scar neuropathy,but there is consensus on a multidisciplinary approach.