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RESEARCH 2003
INTRODUCTION:
Some of these studies are abstracts and others are review articles
of research studies on RSD/CRPS. We have featured the prominent
researchers first and then listed more studies alphabetically according
to author. Important studies opening new ground or discoveries are
listed with *** at beginning.
Charles Berde MD PhD
Robert Schwartzman MD
Studies A-M
Studies N-Z
INTRODUCTION
Charles Berde MD PhD, presenter
at the Tampa conference, is a well known expert in the treatment
of CRPS in children and teens. The Pain Treatment Service has treated
over 600 children since 1986 and continues to do so.There is also
ongoing research at the Boston Hospital where he works.
PHYSICAL THERAPY AND COGNITIVE BEHAVIOURAL
TREATMENT FOR CRPS
Berde CB,Lee BH, Scharff L, Sethna NF, McCarthy
CF, Scott-Sutherland J, Shea AM, Sullivan P, Meier P, Zurakowski
D,Masek BJ. J Pediatr 2002 Jul;141(1):135-40
Pain Treatment Service and the Departments of Physical
Therapy, Orthopaedic Surgery, and Psychiatry,Children's Hospital,
Boston, Massachusetts.
Complex regional pain syndromes (CRPS; type 1, reflex sympathetic
dystrophy, and type 2, causalgia) involve persistent pain, allodynia,
and vasomotor signs. We conducted a prospective, randomized, single-blind
trial of physical therapy (PT) and cognitive-behavioral treatment
for children and adolescents with CRPS. Children 8 to 17 years of
age (n = 28) were randomly assigned to either group A (PT once per
week for 6 weeks) or group B (PT 3 times per week for 6 weeks).
Both groups received 6 sessions of cognitive-behavioral treatment.
Assessments of pain and function were repeated at two follow-up
time periods. Outcomes were compared at the three time points through
the use of parametric or nonparametric analysis of variance and
post hoc tests. All five measures of pain and function improved
significantly in both groups after treatment, with sustained benefit
evident in the majority of patients at long-term follow-up. Recurrent
episodes were reported in 50% of patients, and 10 patients eventually
received sympathetic blockade. Most children with CRPS showed reduced
pain and improved function with a noninvasive rehabilitative treatment
approach. Long-term functional outcomes were also very good.
PMID: 12091866
For a copy of this or any CRPS article,
visit McMaster Health Sciences Library. Search Pub Med using the
PMID number listed.
GENDER DIFFERENCES IN CRPS I/ RSD
IN CHILDREN AND ADOLESCENTS
Charles Berde, M.D., Ph.D., Harvard Medical School, Director, Pain
Treatment Service, Boston Children's Hospital, Boston, Massachusetts
Complex regional pain syndrome, type 1 (CRPS1) or reflex sympathetic
dystrophy (RSD) is being diagnosed more frequently in children and
adolescents. Over the last 12 years, our pain center has examined
the demographics, associated medical and lifestyle factors, and
responses to treatment in over 450 patients. Some demographic features
in children appear different from those described for adults:
(1) Children and adolescents have lower extremity involvement 6
times more often than upper extremity involvement.
(2) Girls are affected roughly 5 times as often as boys.
(3) RSD/CRPS1 is rare below age 8; the incidence increases markedly
just before puberty.
(4) Female dancers, gymnasts and competitive athletes comprise
a high percentage of the patients.
A high percentage of patients present either confined to crutches
or in a wheelchair. School absenteeism is more common in these patients
than in a matched population of rheumatology patients. Coexisting
psychiatric diagnoses commonly include depression, anxiety disorders,
post-traumatic stress disorders, distorted body image and eating
disorders, and stressful family dynamics.
Treatments advocated for RSD have varied largely according to subspecialty
and training of health providers. A program for prospective evaluation
of these patients was established recently with funding from NICHD.
Preliminary studies by Dr. Sethna and others on quantitative sensory
and autonomic evaluation will be summarized. Treatments under prospective
controlled evaluation include physical therapy, cognitive-behavioral
interventions, tricyclics and anticonvulsants, and continuous infusion
sympathetic blocks.
RSDS IN CHILDREN AND ADOLESCENTS
(summary of Dr. Berde’s presentation at RSDSA's Tampa
conference)
Treatment varies according to the individual child.
It is essential to maintain a close rapport with the patient and
family so that they can understand and cope with the treatment.
Active PT and CBT (cogntive behaviour therapy) are at the top of
the list for treatment and a large percentage of kids improve with
these two methods. It is a stepwise return to weight bearing and
understanding the role of pain. Desensitization and aqua therapy
are also used. CBT includes relaxation training, biofeedback and
other coping pain skills. Many children recount that CBT helps with
daily stress and solving problems. If the pain and limb problem
becomes chronic, then treatment for depression or anxiety is considered.
Tricyclic antidepressants help with sleep and sometimes anticonvulsants
(Neurontin) are used. Finding the right dose of the right drug and
assessing side effects are all very important.Those who do not improve
with PT and CBT, can receive sympathetic blockade.
Various methods can be used from lumbar paravertebral, lumbar epidural
or IV regional with single shot or continuous methods. It depends
on the individual case. Invasive procedures are saved for those
who have tried all other therapies and did not respond well. These
treatments include spinal cord or peripheral stimulation, implantable
pumps and sympathectomy. No form of neurodestructive sympathectomy
is done due to possible long term complications.
Note: This review article appears in the Winter
Issue of the PARC PEARL.
FURTHER READING
Berde, C.B., & Sethna, N.F. (in press).
Sethna, N.F. (1999). Pharmacotherapy in long-term pain: Current
experience and future direction. In P. McGrath, & G.A. Finley
(Eds.), Chronic and recurrent pain in children and adolescents.
Progress in pain research and management (pp. 243-266). Seattle:
IASP Press.
Sherry DD et al Short and long term outcomes of children with CRPS
1 treated with exercise therapy. Clinical Journal of Pain 1999;
15:218-33
Stanton, R.P., Malcolm, J.R., Wesdock, K.A., & Singsen, B.H(1993).
Reflex sympathetic dystrophy in children: An orthopedic perspective.
Orthopedics, 16, 773-779.
Wilder, R.T., Berde, C.B., Wolohan, M., Vieyra, M.A., Masek, B.J.,
& Micheli, L.J. (1992). Reflex sympathetic dystrophy in children.
Clinical characteristics and follow-up of seventy patients. Journal
of Bone & Joint Surgery American Volume, 74, 910-919.
INTRODUCTION
Dr Robert Jay Schwartzman,
presenter at the Tampa conference, is a well known expert in the
treatment of CRPS in children and adults.He has been treating and
researching CRPS for many years and continues to break new ground.
He was the first to document the spread of CRPS (see Studies file)
and discover the movement disorder component of CRPS. What follows
are some of his most recent studies.
KETAMINE-MIDAZOLAM ANAESTHESIA FOR INTRACTABLE
CRPS-1
INTRODUCTION
CRPS-1 is a very hard to treat syndrome characterized by neuropathic
pain. CRPS can spread and become resistant to therapy. More treatments
are urgently needed. NMDA receptors are thought play an active role
in central pain and NMDA agonists as therapy for CRPS (and neuropathic
pain) are being studied.
METHODS
Ten patients with intractable CRPS-1 were given anesthesia which
consisted of ketamine and midazolam for 5 days. Some patients were
intubated and some had spontaneus breathing. On day 6 they were
slowly tapered from infusions.
OBSERVATIONS
INITIAL
All TEN responded by having no pain, no hyperalgesia, no allodynia
and an absence of CRPS-1 signs.
LONG TERM
Five out of ten had full pain relief for 2 months up to 3.5 years.
In 8/10 patients, after 6-8 weeks the original nociceptive pain
returned. In 7/8 the pain was at the original injury site. Hyperalgesia
and allodynia recurred in 4/10 who then received another ketamine
treatment. Success happened in 2/3. Patients were all able to use
less pain medication.
CONCLUSIONS
The authors are quick to say that this treatment shows potential
and could be an effective treatment option for severe CRPS-1. They
do raise the following issues: which patients would benefit most,
what selection criteria would be used to select patients, when to
treat the CRPS, and maintenance schedules for re-treatment.
This is the first attempt at using ketamine anesthesia for intractable
CRPS-1 and it does not come without its risks. Patients need to
be asleep and monitored carefully during the five day treatment.
Perhaps in future trials, a less risky form of treatment can be
found.
Source: Schwartzman, RJ et al "Ketamine-Midazolam Anesthesia
for Intractable CRPS-1" 2002 presented to IASP 2002 Conference
SKIN BLOOD FLOW CHANGES DURING KETAMINE/MIDAZOLAM ANESTHESIA FOR
INTRACTABLE CRPS-1
REVIEW
Skin temperature and color changes are an integral part of CRPS.
The skin can turn blue, reddish, mottled, or purple. Temperatures
vary from hot to warm or cold. Monitoring skin blood flow changes
help clinicians decide on the effectiveness of CRPS treatments e.g.
when using sympathetic blocks. One such new promising treatment
is ketamine/midazolam anesthesia for chronic CRPS-1. This study
is the first of its kind to investigate this treatment.
AIMS
Data on skin blood flow (SBF) at rest and during vasomotoric challenge
(with heating probe) was collected. Patient's status and responses
before, during and after ketamine anesthesia were observed. Could
this method be used to asses the ability of the blood vessels to
regulate themselves or determine vasomotor impairment in CRPS? Could
this be used as a tool to assess treatment success ?
PATIENTS
Eight patients with intractable CRPS-1 were analyzed for blood flow
with laser doppler flowmetry (PF 4001) and a heating probe was used
to raise skin temperature. Patients were measured at rest and during
the vasomotor challenge.
RESULTS
Under ketamine anesthesia, a significant increase in SBF was observed
in the first 72 hours. Interestingly, the areas of the most pain
showed the strongest increase, up to 10 fold. Then SBF normailzed
and vasomotor reagibility occured e.g. decreased, edema, hyperemia
and temperature changes. When the limb was locally heated, the highest
increase of SBF was found on day 2 and 3 of therapy.
CONCLUSIONS
The authors are the first to admit that more studies must be done
before LDF can be recommended as a diagnostic tool or for therapy.
Suggestions include monitoring SBF changes in CRPS, possibly predicting
therapeutic success, to quantify vasomotor reactive capacity (rest/vasomotor
challenge), to help assess sympathetic activity and to contribute
to a piece of the diagnostic puzzle of CRPS. Using LDF as a diagnostic
tool would be another first since there is none available at this
time.
Source: Schwartzman, RJ et al "Skin Blood Flow Changes During
Ketamine/Midazolam Anesthesia for Intractable CRPS-1 2002
Note: Low dose ketamine treatments are now being developed
in Canada. Contact us for the name of Canadian doctors offering
ketamine treatments. These review articles can be found in the PARC
PEARL March issue.
STUDIES A-M
***Argoff CE. A focused review on the use of botulinum
toxins for neuropathic pain. Clin J Pain. 2002 Nov-Dec;18(6
Suppl):S177-81.
Cohn Pain Management Center, North Shore University Hospital, New
York University School of Medicine, Bethpage, New York 11714, USA.
pargoff@optonline.net
Understanding the pathophysiology of a pain syndrome is helpful
in selecting appropriate treatment strategies. Nociceptive pain
is related to damage to tissues due to thermal, chemical, mechanical,
or other types of irritants. Neuropathic pain results from injury
to the peripheral or central nervous system. Common examples of
neuropathic pain include postherpetic neuralgia, diabetic neuropathy,
complex regional pain syndrome, and pain associated with spinal
cord injuries. Nociceptive pain may have similar clinical characteristics
to neuropathic pain. It is also possible for acute nociceptive pain
to become neuropathic in nature, as with myofascial pain syndrome.
A clear benefit of botulinum toxin therapy for treatment of neuropathic
pain disorders is that it often relieves pain symptoms. Although
the precise mechanism of pain relief is not completely understood,
the injection of botulinum toxin may reduce various substances that
sensitize nociceptors. As a result, botulinum toxin types A and
B are now being actively studied in nociceptive and neuropathic
pain disorders to better define their roles as analgesics.
PMID: 12569966
---------------
Basford JR, Sandroni P, Low PA, Hines SM, Gehrking JA, Gehrking
TL.Effects of linearly polarized 0.6-1.6 &mgr;M irradiation
on stellate ganglion function in normal subjects and people with
complex regional pain (CRPS I). Lasers Surg Med. 2003 Jun;32(5):417-423.
Department of Physical Medicine and Rehabilitation, Autonomic Disorder
Center, Mayo Clinic and Foundation, 200 Southwest Second Street,
Rochester, Minnesota 55905.
BACKGROUND AND OBJECTIVES: Stellate ganglion blocks are an effective
but invasive treatment of upper extremity pain. Linearly polarized
red and near-infrared (IR) light is promoted as a safe alternative
to this procedure, but its effects are poorly established. This
study was designed to assess the physiological effects of this latter
approach and to quantitate its benefits in people with upper extremity
pain due to Complex Regional Pain Syndrome I (CRPS I, RSD). STUDY
DESIGN/MATERIALS AND METHODS: This was a two-part study. In the
first phase, six adults (ages 18-60) with normal neurological examinations
underwent transcutaneous irradiation of their right stellate ganglion
with linearly polarized 0.6-1.6 &mgr;m light (0.92 W, 88.3 J).
Phase two consisted of a double-blinded evaluation of active and
placebo radiation in 12 subjects (ages 18-72) of which 6 had upper
extremity CRPS I and 6 served as "normal" controls. Skin
temperature, heart rate (HR), sudomotor function, and vasomotor
tone were monitored before, during, and for 30 minutes following
irradiation. Analgesic and sensory effects were assessed over the
same period as well as 1 and 2 weeks later. RESULTS: Three of six
subjects with CRPS I and no control subjects experienced a sensation
of warmth following active irradiation (P = 0.025). Two of the CRPS
I subjects reported a >50% pain reduction. However, four noted
minimal or no change and improvement did not reach statistical significance
for the group as a whole. No statistically significant changes in
autonomic function were noted. There were no adverse consequences.
CONCLUSIONS: Irradiation is well tolerated. There is a suggestion
in this small study that treatment is beneficial and that its benefits
are not dependent on changes in sympathetic tone. Further evaluation
is warranted. Lasers Surg. Med. 32:417-423, 2003. Copyright 2003
Wiley-Liss, Inc.
PMID: 12766967
-------------------
Bennett GJ. Are the complex regional pain syndromes due
to neurogenic inflammation?
Neurology. 2001 Dec 26;57(12):2161-2.
Comment on:
Neurology. 2001 Dec 26;57(12):2179-84.
Letter
PMID: 11756591
----------------------
***Cordivari, MD 1 2, V. Peter Misra, MD, FRCP 1, Santiago Catania,
MRCP 1, Andrew J. Lees, MD, FRCP 2 *
Treatment of dystonic clenched fist with botulinum toxin.
Mov Disord. 2001 Sep;16(5):907-13.
Department of Clinical Neurophysiology, The National Hospital for
Neurology and Neurosurgery, Queen Square, London, United Kingdom
2Reta Lila Weston Institute of Neurological Studies, University
College of London, United Kingdom
email: Andrew J. Lees (alees@ion.ucl.ac.uk)
* Correspondence to Andrew J. Lees, Reta Lila Weston Institute
of Neurological Studies, Windeyer Building, 46 Cleveland Street,
University College of London W1T 4JF, UK
A videotape accompanies this article.
Abstract
Fourteen patients with dystonic clenched fist (three with Corticobasal
Ganglionic Degeneration, seven with Parkinson's disease, and four
with Dystonic-Complex Regional Pain Syndrome) were treated with
botulinum toxin A (BTXA, Dysport®). The muscles involved were
identified by the hand posture and EMG activity recorded at rest
and during active and passive flexion/extension movements of the
finger and wrist. EMG was useful in distinguishing between muscle
contraction and underlying contractures and to determine the dosage
of BTX. All patients had some degree of flexion at the proximal
metacarpophalangeal joints and required injections into the lumbricals.
The response in patients depended on the severity of the deformity
and the degree of contracture. All patients had significant benefit
to pain, with accompanying muscle relaxation, and palmar infection,
when present, was eradicated. Four patients with Parkinson's disease
and one patient with Dystonia-Complex Regional Pain Syndrome obtained
functional benefit. © 2001 Movement Disorder Society.
Received: 18 December 2000; Revised: 4 April 2001; Accepted: 19
April 2001
__________
***Kobana,M. S. Leisa, S. Schultze-Mosgaub and F. Birklein
Tissue hypoxia in complex regional pain syndrome
c/a Neurologische Klinik, Friedrich-Alexander-Universität Erlangen-Nürnberg,
Universitätsstraße 17, D-91054, Erlangen, Germany
b Klinik für Mund-, Kiefer- und Gesichtschirurgie Friedrich-Alexander-Universität
Erlangen-Nürnberg, Universitätsstraße 17, D-91054,
Erlangen, Germany c Neurologische Klinik, Johannes Gutenberg-Universität
Mainz, Langenbeckstraße 1, D-51101, Mainz, Germany
Received 26 February 2002; accepted 6 December 2002. ; Available
online 14 May 2003.
Untreated complex regional pain syndrome (CRPS) may progress from
acute stages with increased hair and nail growth in the affected
limb to chronic stages with atrophy of the skin, muscles and bones.
The aim of this study was to investigate whether tissue hypoxia
could be one mechanism responsible for this late CRPS symptoms.
Nineteen patients with CRPS and two control groups (healthy control
subjects, surgery patients with edema) participated in this study.
Skin capillary hemoglobin oxygenation (HbO2 ) was measured non-invasively
employing micro-lightguide spectrophotometry (EMPHO). The EMPHO
probe was mounted force-controlled onto the skin of the affected
and unaffected hand. HbO2 was measured at rest and during postischemic
reactive hyperemia.
HbO2 did not differ between the right (58.20%±1.12) and
left (57.79%±1.31, ns) hand in control subjects. However,
in patients, HbO2 of the affected side (36.63%±2.16) was
significantly decreased as compared to the clinically unaffected
side (46.35%±2.97, P<0.01). As compared to controls, HbO2
in CRPS was reduced on both sides (P <0.001). Postischemic hyperoxygenation
was impaired on the affected side in CRPS (60.81%±2.90) –
as compared to the unaffected side (67.73%±1.50, P<0.04)
and to controls (68.63%±0.87, P<0.005). The unaffected
limb in CRPS did not differ from controls. Despite skin edema, pre-
(49.06%±2.02) and postsurgery HbO2 (53.15%±4.44, ns)
were not different in the second control group.
Our results indicate skin hypoxia in CRPS. Impairment of nutritive
blood flow in the affected limb may be one factor contributing to
atrophy and ulceration in chronic CRPS. The investigation of patients
after surgery revealed that edema could not be the only reason for
hypoxia.
[Corresponding Author Contact Information] Corresponding author.
Tel.: +49-6131-173270; fax: +49-6131-175625
--------------
Kuczkowski, KM. Bretylium in the treatment of complex
regional pain syndrome: uncommon side-effect of a common drug. Anaesthesia
2003 Feb;58(2):201-2 Letter.
PMID: 12562438
---------------------------------------------
STUDIES N-Z
McCabe CS, Haigh RC, Ring EF, Halligan PW, Wall PD, Blake DR. A
controlled pilot study of the utility of mirror visual feedback
in the treatment of complex regional pain syndrome (type 1).
Rheumatology (Oxford) 2003 Jan;42(1):97-101
The Royal National Hospital for Rheumatic Diseases, Upper Borough
Walls, Bath BA1 1RL, UK. candy.mccabe@rnhrd-tr.swest.nhs.uk
BACKGROUND: We assessed mirror visual feedback (MVF) to test the
hypothesis that incongruence between motor output and sensory input
produces complex regional pain syndrome (CRPS) (type 1) pain. METHODS:
Eight subjects (disease duration > or =3 weeks to < or =3
yr) were studied over 6 weeks with assessments including two controls
(no device and viewing a non-reflective surface) and the intervention
(MVF). Pain severity and vasomotor changes were recorded. RESULTS:
The control stages had no analgesic effect. MVF in early CRPS (<
or =8 weeks) had an immediate analgesic effect and in intermediate
disease (< or =1 yr) led to a reduction in stiffness. At 6 weeks,
normalization of function and thermal differences had occurred (early
and intermediate disease). No change was found in chronic CRPS.
CONCLUSIONS: In early CRPS (type 1), visual input from a moving,
unaffected limb re-establishes the pain-free relationship between
sensory feedback and motor execution. Trophic changes and a less
plastic neural pathway preclude this in chronic disease.
PMID: 12509620
--------------------------------
Parisod E, Murray RF, Cousins MJ.
Conversion disorder after implant of a spinal cord stimulator
in a patient with a complex regional pain syndrome. Anesth
Analg 2003 Jan;96(1):201-6, University of Sydney, Pain Management
& Research Centre, Royal North Shore Hospital, St. Leonards,
Australia.
IMPLICATIONS: This case history describes the treatment of a patient
suffering with persistent pain. He was treated surgically with implantation
of a spinal cord stimulator. After surgery, a partial paralysis
that could not be explained medically and that was probably related
to emotional factors occurred, and cognitive behavioral treatment
was begun. This paper discusses the importance of considering social
and psychological factors when medical treatment options are considered.
PMID: 12505953
------------------
***Sandroni,P., Lisa M. Benrud-Larson, Robyn L. McClelland and
Phillip A. Low Complex regional pain syndrome type I: incidence
and prevalence in Olmsted county, a population-based study
Mayo Clinic, 200 First Stret SW, Rochester, MN 55905, USA
Received 5 September 2002; accepted 9 December 2002. ; Available
online 8 May 2003.
Abstract
The objective of this study is to undertake a population based
study on the incidence, prevalence, natural history, and response
to treatment of complex regional pain syndrome (CRPS). All Mayo
Clinic and Olmsted Medical Group medical records with codes for
reflexsympathetic dystrophy (RSD), CRPS, and compatible diagnoses
in the period 1989–1999 were reviewed as part of the Rochester
Epidemiology Project. We used IASP criteria for CRPS. The study
population was in the Olmsted County, Minnesota (1990 population,
106,470). The main outcome measures were CRPS I incidence, prevalence,
and outcome. Seventy-four cases of CRPS I were identified, resulting
in an incidence rate of 5.46 per 100,000 person years at risk, and
a period prevalence of 20.57 per 100,000. Female:male ratio was
4:1, with a median age of 46 years at onset. Upper limb was affected
twice as commonly as lower limb. All cases reported an antecedent
event and fracture was the most common trigger (46%). Excellent
concordance was found between symptoms and signs and vasomotor symptoms
were the most commonly present. Three phase bone scan and autonomic
testing diagnosed the condition in >80% of cases. Seventy-four
percent of patients underwent resolution, often spontaneously. CRPS
I is of low prevalence, more commonly affects women than men, the
upper more than the lower extremity, and three out of four cases
undergo resolution. These results suggest that invasive treatment
of CRPS may not be warranted in the majority of cases.
[Corresponding Author Contact Information] Corresponding author.
Tel.: +1-507-284-2090; fax: +1-507-266-6754
--------------------
Schasfoort FC, Bussmann JB, Zandbergen AM, Stam HJ.
Impact of upper limb complex regional pain syndrome type
1 on everyday life measured with a novel upper limb-activity monitor.
Pain 2003 Jan;101(1-2):79-88
Department of Rehabilitation Medicine, Erasmus MC, University Medical
Center Rotterdam, PO Box 1738, 300 DR Rotterdam, Rotterdam, The
Netherlands. schasfoort@rev.fgg.eur.nl
Complex regional pain syndrome type 1 (CRPS1) often leads to serious
activity limitations in everyday life. To date, however, limitations
in patients with CRPS1 of an upper limb have not been objectively
measured.Therefore, the aim of this study was to determine the long-term
impact of upper limb CRPS1 on general mobility and upper limb usage
during everyday life, as measured with a novel upper limb-activity
monitor (ULAM). In ten female chronic CRPS1 patients and ten healthy
control subjects, 24-h activity patterns were measured with the
ULAM. This ULAM consists of body-fixed acceleration sensors, connected
to a recorder worn around the waist. The ULAM automatically detects
upper limb activity during mobility-related activities. Several
outcome measures related to general mobility and upper limb usage
were compared between patients and controls. The results showed
that CRPSI in the dominant upper limb had modest impact on general
mobility; i.e. on the percentages spent in body positions and body
motions and on mean intensity of body activity. For upper limb usage
outcome measures during sitting, there was a marked difference between
CRPS1 patients and controls. Especially patients with dominant side
involvement clearly showed less activity of their involved limb
during sitting, indicated by significant differences for the mean
intensity (P=0.014), percentage (P=0.004), and proportion (P=0.032)
of upper limb activity. It is concluded that these ten chronic CRPS1
patients still had limitations in upper limb usage during everyday
life, 3.7 years (average) after the causative event.
PMID: 12507702
-----------------------
Schouten AC, Van De Beek WJ, Van Hilten JJ, Van Der Helm FC.
Proprioceptive reflexes in patients with reflex sympathetic
dystrophy.
Delft University of Technology, Department of Mechanical Engineering,
Man Machine Systems and Control, Mekelweg 2, 2628 CD Delft, Leiden,
The Netherlands.
Reflex sympathetic dystrophy (RSD) is a syndrome that frequently
follows an injury and is characterized by sensory, autonomic and
motor features of the affected extremities. One of the more common
motor features of RSD is tonic dystonia, which is caused by impairment
of inhibitory interneuronal spinal circuits. In this study the circuits
that modulate the gain of proprioceptive reflexes of the shoulder
musculature are quantitatively assessed in 19 RSD patients, 9 of
whom presented with dystonia. The proprioceptive reflexes are quantified
by applying two types of force disturbances: (1) disturbances with
a fixed low frequency and a variable bandwidth and (2) disturbances
with a small bandwidth around a prescribed centre frequency. Compared
to controls, patients have lower reflex gains for velocity feedback
in response to the disturbances around a prescribed centre frequency.
Additionally, patients with dystonia lack the ability to generate
negative reflex gains for position feedback, for these same disturbances.
Proprioceptive reflexes to the disturbances with a fixed low frequency
and variable bandwidth present no difference between patients and
controls. Although dystonia in the RSD patients was limited to the
distal musculature, the results suggest involvement of interneuronal
circuits that mediate postsynaptic inhibition of the motoneurons
of the proximal musculature.
PMID: 12743675
------------------------
Singh B, Moodley J, Shaik AS, Robbs JV.
Sympathectomy for complex regional pain syndrome.
J Vasc Surg 2003 Mar;37(3):508-11
Department of Surgery, Nelson R. Mandela School of Medicine, Faculty
of Health Sciences, University of Natal, 4013 Congella, South Africa.
BACKGROUND: With the easier and earlier recognition of complex
regional pain syndrome (CRPS), a reappraisal of its therapy, particularly
the role and timing of sympathectomy, is warranted. PATIENTS AND
METHODS: Over a 9-year period, 42 patients with CRPS type II of
the upper extremity were referred for sympathectomy. Patients were
categorized according to the duration of the symptoms (group I,
<3 months; group II, >3 months). All patients underwent initial
medical treatment; stellate ganglion blocks were performed when
symptoms persisted beyond 6 weeks. Patients were referred for thoracoscopic
sympathectomy on persistence of the pain syndrome. A visual linear
analogue scale was used to evaluate outcome of sympathectomy. RESULTS:
Thoracoscopic dorsal sympathectomy was successfully undertaken in
32 patients. In the remaining 10 patients, thoracoscopy was not
technically feasible and open sympathectomy was performed. There
was an overall improvement in all 42 patients undergoing sympathectomy
(P <.001, Wilcoxon signed rank test). The outcome in group I
was significantly better than in group II (P <.003, Mann-Whitney
U test). The diagnosis of sympathetically mediated pain with stellate
blockade did not correlate with clinical outcome. Patients undergoing
thoracoscopic sympathectomy had a better outcome than those undergoing
open sympathectomy. There were no complications, and the hospital
stay was shorter in the thoracoscopic group. CONCLUSION: Early recognition
of CRPS and prompt recourse to surgical sympathectomy is a useful
option in the management of CRPS.
PMID: 12618683
-------------------------------------
Son UC, Kim MC, Moon DE, Kang JK.
Motor cortex stimulation in a patient with intractable complex
regional pain syndrome type II with hemibody involvement. Case report.
J Neurosurg 2003 Jan;98(1):175-9
Department of Neurosurgery, Kangnam St. Mary's Hospital, College
of Medicine, The Catholic University of Korea, Seoul, Korea. sbc@cmc.cuk.ac.kr
The authors describe the effectiveness of motor cortex stimulation
(MCS) in a patient with complex regional pain syndrome (CRPS) Type
II, formerly known as causalgia, with hemibody allodynia. During
MCS, a subjective sensation of warm paresthesia developed in the
painful hand and forearm and spread toward the trunk. Pain and allodynia
in the areas associated with this sensation were alleviated significantly.
The analgesic effect of stimulation proved to be long lasting and
was still present at the 12-month follow up. The authors speculate
that MCS might exert its effect through the modulation of thalamic
activity in this particular case of CRPS with hemisensory deficit.
A central mechanism associated with functional disturbance in noxious-event
processing in the thalamus might have an important role in the pathogenesis
of the condition.
PMID: 12546368
---------------
van de Beek WJ, Schwartzman RJ, van Nes SI, Delhaas EM, van Hilten
JJ. Diagnostic criteria used in studies of reflex sympathetic
dystrophy.
Neurology. 2002 Feb 26;58(4):522-6.
Department of Neurology, Leiden University Medical Center, the Netherlands.
OBJECTIVE: Assessment of the diagnostic criteria of reflex sympathetic
dystrophy (RSD) and evaluation of the impact of the introduction
of the diagnostic criteria of complex regional pain syndrome (CRPS)
on the international application of diagnostic criteria of RSD.
METHODS: Randomized controlled trials and clinical investigations,
published between January 1980 and June 2000, were evaluated with
regard to the applied diagnostic criteria of RSD. RESULTS: One hundred
seven studies were identified. Thirty-four of these studies were
excluded because of inadequate reporting of diagnostic criteria.
The 73 included studies were not homogeneous with regard to the
diagnostic criteria because they applied many different aspects
of sensory and autonomic features. Only 12% of the studies considered
the presence of motor features, mostly vaguely described, as mandatory
for the diagnosis RSD. Although 10 of the 23 studies published since
the introduction of CRPS have applied this term, only 3 used the
exact criteria without additions or other modifications. CONCLUSION:
Diagnostic criteria sets of RSD focus on many different aspects
of sensory and autonomic features that generally are described vaguely.
This has not changed since the introduction of the CPRS criteria.
These findings question whether the current criteria adequately
define RSD.
PMID: 11865127
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***van de Beek WJ, Vein A, Hilgevoord AA, van Dijk JG, van Hilten
BJ.
Neurophysiologic aspects of patients with generalized or
multifocal tonic dystonia of reflex sympathetic dystrophy.
J Clin Neurophysiol. 2002 Jan;19(1):77-83.
Department of Neurology, Leiden University Medical Center, 2300
RC Leiden, The Netherlands.
Reflex sympathetic dystrophy (RSD) is a syndrome dominated by sensory,
autonomic, and motor features of the extremities. In this study,
10 severely affected RSD patients who progressed to multifocal or
generalized tonic dystonia underwent H-reflex evaluation, needle
electromyography (EMG), polysomnography, somatosensory evoked potentials,
and transcranial magnetic stimulation. H-reflex evaluation revealed
an impaired vibratory inhibition of the H-reflex and a higher facilitation
peak in the recovery curve between 200 to 350 msec. Needle EMG revealed
an impaired reciprocal inhibition, and many patients were unable
to alter the amount of muscle activity voluntarily. Evaluations
of the stretch reflex showed a markedly decreased threshold and
abnormal responses to tonic and phasic changes. Polysomnography
performed in five patients revealed no abnormal EMG activity during
nonrapid eye movement and rapid eye movement sleep, but EEG arousal
phenomena provoked abnormally high and brief bursts of surface EMG
activity in all registered muscle groups. Somatosensory evoked potentials
and transcranial magnetic stimulation were normal. Taken together,
the findings in these patients with tonic dystonia of RSD are in
accordance with an impairment of inhibitory interneuronal circuits
at the level of the brainstem or spinal cord.
PMID: 11896357
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***van de Beeka, Willem-Johan T., Bart O. Roepb, Arno R. van der
Slikb, Marius J. Giphartb and Bob J. van Hilten,
Susceptibility loci for complex regional pain syndrome
a) Department of Neurology, Leiden University Medical Center, P.O.
Box 9600, 2300 RC, Leiden, The Netherlands b) Department Immunohematology
and Blood Transfusion, Leiden University Medical Center, Leiden,
The Netherlands
Received 11 April 2002; accepted 22 October 2002. ; Available online
27 March 2003.
An association between HLA-DR13 and patients with complex regional
pain syndrome (CRPS) who progressed towards multifocal or generalized
tonic dystonia was recently reported. We now report on a new locus,
centromeric in HLA-class I, which was significantly associated with
a spontaneous development of CRPS, suggesting an interaction between
trauma severity and genetic factors conferring CRPS susceptibility.
Additionally, an association with the D6S1014 locus was found, supporting
the previous finding of an association with HLA-DR13.
[Corresponding Author Contact Information] Corresponding author.
Tel.: +31-71-526-2895; fax: +31-71-524-8253
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