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

Background: Complex Regional Pain Syndrome (CRPS), previously known as reflex sympathetic dystrophy and causalgia, is a neuropathic pain condition that usually develops after an injury to an extremity. CRPS can be a debilitating condition with high levels of pain and reduced function. Aim: This case report aims to discuss the multimodal approach in the management of a patient who presented with ongoing poorly controlled pain secondary to CRPS from an injury that happened years prior. Case Presentation: A 45-year-old female was involved in a motor vehicle accident where her right leg was injured. She underwent several surgeries and developed CRPS that significantly reduced her mobility and quality of life. She presented to the pain clinic years after her initial injury and a multimodal regimen was started for her resulting in significantly improved function. Conclusion: CRPS can be a severely debilitating condition. While early diagnosis and management are important, ongoing management in the outpatient chronic pain setting is important in maintaining a good level of function.

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.

Pediatric Continuous Brachial Plexus Catheter for a Case of Complex Regional Pain Syndrome (CRPS)

Introduction: Complex regional pain syndrome (CRPS) is a disorder characterized by pain as well as a myriad of sensory, autonomic, and motor disturbances. We are reporting a case of child diagnosed with CRPS and successfully treated with supraclavicular brachial plexus catheter infusion of local anesthetic. Case Report: An eight-year-old male underwent a left thoracotomy, repair of esophageal vascular ring, and translocation of the left subclavian to the left carotid artery. Post-operative course was relevant for severe intractable left shoulder and left arm pain associated with allodynia and hyperalgesia. A supraclavicular catheter was inserted, and an infusion of ropivacaine 0.2% was started. The child was sent for physical therapy as he gradually regained all functions of his left arm and resumed his regular activities. Conclusion: Continuous supraclavicular brachial plexus catheter infusion of local anesthetic is a valuable method of reducing pain in severe cases of upper extremity pediatric CRPS and may be safer and more effective than other invasive measures such as sympathetic blocks and epidural catheterization. Further research surrounding the diagnosis and treatment of pediatric CRPS is needed to allow early diagnosis and treatment and to improve outcome.

Failure to fire after an electrical injury——A complex syndrome in a soldier: complex regional pain syndrome(CRPS)

Complex regional pain syndrome(CRPS) is a disorder characterized by an intractable, disabling pain of the affected limb. It is triggered by various injuries and is often resistant to standard therapy. We report a young soldier with CRPS of the right hand sustained from an electrical injury, who had improvement in resting pain with Zoledronic acid. In this report, we discuss the therapeutic options and the role of bisphosphonates in CRPS.

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.

Resolution of Crohn's disease and complex regional pain syndrome following treatment of paratuberculosis

A cohort of family members with various chronic diseases including Crohn's disease, asthma, complex regional pain syndrome, hypothyroidism, type 1 diabetes mellitus, and lymphangiomatosis and/or evidence of infection by Mycobacterium avium subsp. paratuberculosis(MAP) are described in this series of case reports. MAP was cultured from the blood of three members affected by the first five diseases and there was accompanying elevated anti-MAP Ig G in two members. The patient affected by the sixth disease has a markedly elevated anti-MAP titer. The two patients affected by the first four diseases have been treated with a combination of anti-MAP antibiotics and ultraviolet blood irradiation therapy with resolution of the disease symptomatology and inability to culture MAP in post treatment blood samples. These case reports of patients with MAP infections provide supportive evidence of a pathogenic role of MAP in humans.

Beliefs and Clinical Practice for Complex Regional Pain Syndrome (CRPS) Managed by Physiotherapists on the South Island of New Zealand

On the South Island of New Zealand, Anaesthetists and other Medical Professionals, frequently refer their patients with Complex Regional Pain Syndrome (CRPS) for physiotherapy management. Beliefs about what is important for the management of patients with CRPS are lacking across all medical and allied health disciplines. Difficulties are no gold standard for diagnosis and evidence for intervention methods is moderate or can be conflicting. This paper explores what Physiotherapists believe to be important in a clinical setting for their management of CRPS, as well as documenting and evaluating their interventional methods used in everyday clinical practice across the region of the South Island of New Zealand. This has not been recorded before. Eighty-one Physiotherapists replied to questions on their usual treatment interventions for the management of CRPS, their frequency of use of these treatment interventions, and what they believed to be important in the management of pain and improvement of function. The results demonstrated that CRPS is not a common condition seen regularly by Physiotherapists;that there is a high level of variation between the physiotherapy interventions used and that Physiotherapists’ beliefs regarding interventions used for pain management and functional restoration differ. Education was reported as the most frequently used intervention method. Those physiotherapists seeing CRPS patients more frequently are more likely to use evidence based intervention methods like graded motor imagery or sensory motor training.

Frequency and Risk Factors of Complex Regional Pain Syndrome in Cotonou (Benin)

Aim: To determine the frequency and the risk factors of Complex Regional Pain syndrome (CRPS) in Cotonou (Benin). Patients and Méthod: This has been a transversal study carried out over 22 years on files of CRPS infected patients and submitted to rheumatologic consultation in the National Hospital University of Cotonou. Results: 73 out of 17,342 patients examined (0.42%) were suffering from CRPS. Those 73 patients (40 women, 54.8% and 33 men, 45.2%) were in average 54.66 years old and enjoyed an average duration of evolution of 5.79 months. The trauma (41 cases, 56.1%), the stroke (19 cases, 25%), the diabetes (8 cases, 11.3), were the main risk factors that were observed. CRPS was preferably located at the shoulder-hand (34.2%), shoulder (28.8%), wrist-hand (16.4%) and knee (11%). Inflammatory pain was observed in 55 cases. The treatment was dominated by griseofulvina (41 cases, 56.1%), antiinflammatory drugs (38 cases, 52%), analgesic (20 cases, 27, 3%), joint injection by betamethasone (17 cases, 27%). Conclusion: CRPS is not rare in our country. The first risk factor remains the trauma in rheumatologic consultation in Cotonou.

Septic Arthritis of the Hand during Treatment of Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) complicated with septic arthritis of the hand has not previously been described. We treated a patient in whom swelling of the wrist recurred during treatment of CRPS and septic arthritis of the hand was induced by group G hemolytic streptococcus. There are case reports of tuberculous arthritis of the hand during treatment of CRPS;however, the causal relationship of wrist joint inflammation with CRPS is unclear. Careful follow-up is necessary for wrist joint inflammation if a patient with CRPS relapses with swelling of the wrist.

Complex regional pain syndrome: From diagnosis to rehabilitation

Complex regional pain syndrome(CRPS) is a debilitating pathology characterised by intense chronic pain associated with vasomotor, sensory and motor dysfunction of the affected limb. Although the pathophysiology of CRPS is not fully understood, it is recognised that inflammatory processes and autonomic dysfunction are involved. These processes are associated with peripheral and central sensitisation as well as changes in brain structure and function, and are reflected in the clinical presentation of CRPS. CRPS management requires an interdisciplinary team and requires the therapeutic approach to be individualised. With regard to pharmacological treatment, bisphosphonates, corticosteroids, ketamine and anticonvulsants have been demonstrated to be effective for CRPS management. Psychotherapy, including cognitive-behavioural therapy, has produced promising results but more studies are needed to confirm its efficacy. Among rehabilitation interventions, there is evidence of the efficacy of physiotherapy and occupational therapy in diminishing CRPS symptoms and achieving a higher level of functioning. In this regard, the rehabilitation modality that seems the most promising according to the actual literature is graded motor imagery, which can help to reverse the maladaptive neuroplasticity occurring in CRPS.

Loss of Surround Inhibition and After Sensation as Diagnostic Parameters of Complex Regional Pain Syndrome

Complex Regional Pain Syndrome (CRPS) is a severe chronic pain condition. Patients with CRPS experience allodynia, hyperalgesia, autonomic dysfunction, movement difficulties and dystrophic changes. However other characteristics that may be unique to the pain in CRPS require further study. This study evaluated pain parameters in ninety five subjects composed of three groups: healthy pain free controls, patients with radiculopathy and CRPS patients. Healthy subjects were tested in all four extremities, whereas radiculopathy and CRPS patients were tested only on the most affected extremity. All subjects were tested for the following pain parameters: thermal allodynia, mechanical static and dynamic allodynia, windup, and a hyperalgesic mechanical stimulus. All subjects were also evaluated for autonomic dysfunction, movement disorder and dystrophic skin changes. Statistically significant differences were found between both pain groups and the healthy control subjects as well as between the two pain groups. The finding that statistically differentiated CRPS from radiculopathy and normal controls was pain spread following an algesic mechanical and cold stimulus as well as after sensations to these stimuli. The study demonstrated a simple bedside test that discriminated between CRPS, radiculopathy and healthy control subjects.

Two Cases of Double Crush Syndrome Progressing to Complex Regional Pain Syndrome

The double crush syndrome is described as an increased risk of distal nerve injury after a more proximal injury. This was a case series of two patients who developed Complex Regional Pain Syndrome under circumstances when a double crush phenomenon could have occurred. Both initially had spinal stenosis and subsequent spinal surgery. Both later had crush injuries to a unilateral lower extremity, which progressed to CRPS. There is no documented correlation between double crush syndrome and CRPS;however, these cases raise awareness about a heightened propensity for CRPS in such patients, which will lead to earlier, accurate diagnosis and treatment.

Systemic Complications of Complex Regional Pain Syndrome

Complex Regional Pain Syndrome (CRPS) is a neuropathic pain disorder that is characterized by: 1) Severe pain beyond the area of injury;2) Autonomic dysregulation;3) Neuropathic edema;4) A movement disorder, atrophy and dystrophy. It is most often caused by a fracture, soft-tissue injury or surgical procedure and is divided into Type I, in which no nerve lesion is identified (classic reflex sympathetic dystrophy), and Type II where a specific nerve has been damaged (causalgia). In addition to the peripheral manifestations, there are many internal medical complications whose etiology is often not appreciated. This article will examine how CRPS affects the systems of: cognition;constitutional, cardiac, and respiratory complications;systemic autonomic dysregulation;neurogenic edema;musculoskeletal, endocrine and dermatological manifestations;as well as urological and gastrointestinal function.

Regional Block Anesthesia in Breast Surgery: What Do We Know So Far?

Breast cancer is the most prevalent cancer in women worldwide, and pain following mastectomy is a major post-surgical complication. This paper highlights the risk factors for chronic pain in breast surgery and evaluates various regional block techniques used to reduce post-operative pain, and minimize hospital stays in high-risk patients. Further research is needed to evaluate the effectiveness of novel regional anaesthesia techniques in an enhanced recovery context, and to assess their role in preventing or reducing chronic pain.

Regional anesthesia for acute pain management in elderly patients

Normal aging is a process that involves loss of functional reserve of most organ systems of the human body, most significantly: cardiovascular, pulmonary, renal and nervous systems. Advancements in both surgery and anesthesia have made it possible to operate more safely on the elderly population and those older patients with multiple severe co-morbidities that were not routinely possible in the recent past. Regional anesthesiologist have proven to be instrumental in this regard as regional anesthetic/analgesic techniques may now permit surgeons to operate on the elderly who were not ideal surgical candidates or unable to tolerate general anesthesia. In addition, regional techniques provide alternatives that may optimize acute pain control and reduce the incidence of devastating side effects during the perioperative period such as: myocardial infarction, pulmonary embolism, pneumonia, and also increases the opportunity to allow for early ambulation and shorter hospital stays. These anesthetic options now provide the elderly patient with better medical care alternatives, but also can show a significant financial impact on health care system resources. Further understanding on aging molecular biology, physiology and pathophysiology, together with technical improvements of regional anesthetic techniques will continue to make it safer and more efficacious to operate on the elderly population with evidence of reduced morbidity and mortality. Although there is only anecdotal evidence that regional anesthesia(RA) improves survival, there is little doubt that RA plays an important role in perioperative optimization of pain control and decreases pain management complications as well as a reduction in healthcare costs. Beyond traditional operating rooms, elderly patients may increasingly benefit from RA and acute pain management in Emergency Rooms, medical clinics and even within a patient's home. Therefore, the focus of this review is directed toward geriatric patients and beneficial effects of RA on outcomes in the elderly.

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.

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.

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.

Comparison of flow rate accuracy and consistency between the on-Q, baxter, and ambu pain infusion devices

AIM: Providing analgesia via peripheral nerve catheters attached to an infusion pump is an effective pain management option in children.METHODS: Portable infusion pumps are being used with increased frequency in pediatric patients. Because these pumps are infusing potentially toxic doses of medications, the accuracy and consistency of these devices becomes very important in this patient population. This study is a comparison of the actual delivery volume of local anesthetic of three elastomeric infusion devices approved for patient use in the ambulatory setting. Three brands of disposable elastomeric infusion devices were used(Five On-Q, Five Baxter, and Five Ambu pumps). Each was filled with 200 m L of Ropivicaine 0.1% and connected to a single, end hole infusion catheter and set to infuse at 12 m L/h. The devices were run simultaneously. The fluid delivered was measured every hour with a graduated column over a tenhour period. The ambient temperature was also recorded.RESULTS: There were statistically significant differences in the output from each elastomeric device over the 10 h infusion period when compared to the nominal rate of 12 m L/h. The output from the Ambu and Baxter pumps was less than that set on the regulator, while the output from the On-Q pump was greater than that set on the regulator. The results remained statistically significant after adjusting the nominal rate to correct for differences in temperature. The Ambu infusion device was the most consistent, while the Baxter infusion device was the most accurate. This emphasizes the importance of health care providers understanding the infusion profile of the pump being used for continuous peripheral nerve block, as these alterations in flow could result in inadequate analgesia, early reservoir exhaustion, excessive muscle weakness or potential toxicity, especially when used in pediatric patients.CONCLUSION: This investigation demonstrates that three modern elastomeric infusion pumps have significantly different output than the nominal rate set on the regulator.

Complex Inpatient Pain Management in a Critically Ill Lung Transplant Recipient: A Case Report

Thoracic surgery is known to cause severe pain that may not subside during the course of hospitalization. Early pain control is important in these patients because it improves ventilation and promotes mobility. Lung transplant recipients can experience post-operative complications that lead to extended hospital stays. This increases the time a patient is sedentary, which further deconditions patients;therefore, rehabilitation should be initiated early post-operatively. We present a unique case of a critically ill double lung transplant recipient whose rehabilitation post-operatively was hindered by severe vasopressor-induced ischemic pain. Due to debilitating pain, he was unable to regain mobility. His pain management course was challenging due to sensitivity to opioids, renal failure, and anticoagulation.