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The evaluation of brain changes to a specific pain condition in pediatric and adult patients allows for insights into potential mechanisms of pain chronicity and possibly long-term brain changes. Here we focused on the primary somatosensory system (SS) involved in pain processing, namely the ventroposterolateral thalamus (VPL) and the primary somatosensory cortex (SI). We evaluated, using MRI, three specific processes: (a) somatotopy of changes in the SS for different pain origins (viz., foot vs. arm); (b) differences in acute (ankle sprain versus complex regional pain syndrome-CRPS); and (c) differences of the effects of CRPS on SS in pediatric versus adult patients. In all cases, age- and sex-matched individuals were used as controls. Our results suggest a shift in concurrent gray matter density (GMD) and resting functional connectivity strengths (rFC) across pediatric and adult CRPS with (a) differential patterns of GMD (VPL) and rFC (SI) on SS in pediatric vs. adult patterns that are consistent with upper and lower limb somatotopical organization; and (b) widespread GMD alterations in pediatric CRPS from sensory, emotional and descending modulatory processes to more confined sensory-emotional changes in adult CRPS and rFC patterns from sensory-sensory alterations in pediatric populations to a sensory-emotional change in adult populations. These results support the idea that pediatric and adult CRPS are differentially represented and may reflect underlying differences in pain chronification across age groups that may contribute to the well-known differences between child and adult pain vulnerability and resilience., (© 2019 Wiley Periodicals, Inc.)

Background: Hypersensitivity and altered sweating are often present in neuropathy patients. Nerve lesions are known to produce sudomotor dysfunctions but also patients suffering from complex regional pain syndrome, CRPS1-a condition without a nerve lesion-present with sweating disorders., Methods: Using proton nuclear magnetic resonance of sweat water, we quantified sweat output of mice suffering from a nerve lesion or a bone fracture without nerve lesion and correlated their sweating with behavioural paw hypersensitivity accessed in von Frey testings, water applications and weight-bearing measured with an incapacitance metre., Results: Lesioned animals sweat less and are hypersensitive compared to healthy controls, as expected. Fractured animals on the injured side sweat less acutely after the injury but more in the chronic phase. They are hypersensitive acutely as well as chronically after the fracture. These findings resemble human bone trauma patients in the acute phase and CRPS patients in the chronic phase., Conclusions: Sweating disorders are present both in neuropathic animals and in those with a bone fracture without nerve lesions, and autonomic dysfunctions might be considered as an important component in the aetiology of neuropathies., Significance: Sweat output changes in mice after bone trauma, potentially indicative of posttraumatic processes leading to CRPS in humans., (© 2018 European Pain Federation - EFIC®.)

Background: Complex regional pain syndrome (CRPS) is associated with deficits in limb recognition. The purpose of our study was to determine whether mental load during this task affected performance, sympathetic nervous system activity or pain in CRPS patients., Methods: We investigated twenty CRPS-I patients with pain in the upper extremity and twenty age- and sex-matched healthy controls. Each participant completed a limb recognition task. To experimentally manipulate mental load, the presentation time for each picture varied from 2 s (greatest mental load), 4, 6 to 10 s (least mental load). Before and after each run, pain intensity was assessed. Skin conductance was recorded continuously., Results: Patients with CRPS did not differ from controls in terms of limb recognition and skin conductance reactivity. However, patients with CRPS reported an increase in pain during the task, particularly during high mental load and during the latter stages of the task. Interestingly, state anxiety and depressive symptoms were also associated with increases in pain intensity during high mental load., Conclusions: These findings indicate that high mental load intensifies pain in CRPS. The increase of pain in association with anxiety and depression indicates a detrimental effect of negative affective states in situations of high stress and mental load in CRPS., Significance: The effects of mental load need to be considered when patients with CRPS-I are investigated for diagnostic or therapeutic reasons., (© 2018 European Pain Federation - EFIC®.)

Background: The timing of diagnosis of complex regional pain syndrome (CRPS) 1 remains a challenge due to the large heterogeneity of clinical presentations. We describe the distribution and differences in outcomes and clinical manifestations between time points and patient groups with and without CRPS 1 following an initiating event., Methods: Prospective cohort study with a consecutive registration of patients presenting with painful swelling of the affected extremity after an initiating event and follow-up visits after 3, 6 and 12 months., Results: Forty-two patients were enrolled (37 females, mean age 55.1 years). At baseline, 35 participants (83%, females n = 30) fulfilled the diagnostic criteria for CRPS 1. At 3 months, 19 out of the initial 35 CRPS 1 patients (54%) did not meet the diagnostic criteria anymore. Besides our inclusion criteria of a painful swelling, early manifestations indicating a CRPS 1 primarily include an impaired quality of life (SF-35, EQ5-D), more pain (NRS, MPQ) and restricted range of motion., Conclusions: CRPS 1 develops within 8 weeks following a noxious event. Although many CRPS 1 patients reach partial remission within the first 3 months, signs and symptoms do not improve significantly at 1 year. In order to identify prognostic risk factors large prospective cohort studies are needed., Significance: This prospective cohort study follows patients with complaints most suspected for complex regional pain syndrome (CRPS) 1. CRPS 1 develops within 8 weeks following a noxious event. Although many CRPS 1 patients reach partial remission within the 3 months, symptoms do not improve significantly at 1 year., (© 2017 European Pain Federation - EFIC®.)

Background: The question of hormonal dysregulation in patients with CRPS I in whole was investigated very scantily. There are only a few studies concerning catecholamines, oestrogens and endorphins independently. Other hormones were studied in patients with different other chronic pain conditions. Considering the accumulation of sufficient knowledge about the role of disadaptation processes in CRPS I pathogenesis and the role of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-ovarian systems in the process of adaptation it was logical and consistent to define the role of hormonal dysregulation of these systems in patients with CRPS I., Objectives: Our objective was to determine the role of hypothalamic-pituitary-adrenal and hypothalamic-pituitary-ovarian systems in pathogenesis of complex regional pain syndrome type I (CRPS I) in women., Methods: We investigated the pituitary gonadotropic function and the function of sex glands in women with CRPS I and healthy volunteers by measuring the plasma levels of estradiol (E 2 ), follicle-stimulating hormone, luteinizing hormone, prolactin, adrenocorticotropic hormone, and cortisol, and urinary excretion of 17-ketosteroids, 17-oxycocorticosteroids, epinephrine and norepinephrine., Results: Women with CRPS I were characterized by the decreased content of oestrogens in the blood plasma and increased pituitary gonadotrophic function. The disturbed ratio of anabolic and catabolic steroids in women with CRPS I was detected due to lower adrenal cortex function., Conclusions: In patients with CRPS I endocrine status is characterized by hormonal imbalances of the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal systems. The changes in reproductive and adaptation homeostasis characterize CRPS I as a form of the disease of disadaptation., Significance: This study determined the role of hypothalamic-pituitary-adrenal and hypothalamic-pituitary-ovarian systems in pathogenesis of CRPS I., (© 2016 European Pain Federation - EFIC®.)

Background: Unusual symptoms such as digit misidentification and neglect-like phenomena have been reported in complex regional pain syndrome (CRPS), which we hypothesized could be explained by parietal lobe dysfunction., Methods: Twenty-two patients with chronic CRPS attending an in-patient rehabilitation programme underwent standard neurological examination followed by clinical assessment of parietal lobe function and detailed sensory testing., Results: Fifteen (68%) patients had evidence of parietal lobe dysfunction. Six (27%) subjects failed six or more test categories and demonstrated new clinical signs consistent with their parietal testing impairments, which were impacting significantly on activities of daily living. A higher incidence was noted in subjects with >1 limb involvement, CRPS affecting the dominant side and in left-handed subjects. Eighteen patients (82%) had mechanical allodynia covering 3-57.5% of the body surface area. Allochiria (unilateral tactile stimulation perceived only in the analogous location on the opposite limb), sensory extinction (concurrent bilateral tactile stimulation perceived only in one limb), referred sensations (unilateral tactile stimulation perceived concurrently in another discrete body area) and dysynchiria (unilateral non-noxious tactile stimulation perceived bilaterally as noxious) were present in some patients. Greater extent of body surface allodynia was correlated with worse parietal function (Spearman's rho = -0.674, p = 0.001)., Conclusion: In patients with chronic CRPS, detailed clinical examination may reveal parietal dysfunction, with severity relating to the extent of allodynia., (© 2012 European Federation of International Association for the Study of Pain Chapters.)

Cortical reorganisation of sensory, motor and autonomic systems can lead to dysfunctional central integrative control. This may contribute to signs and symptoms of Complex Regional Pain Syndrome (CRPS), including pain. It has been hypothesised that central neuroplastic changes may cause afferent sensory feedback conflicts and produce pain. We investigated autonomic responses produced by ambiguous visual stimuli (AVS) in CRPS, and their relationship to pain. Thirty CRPS patients with upper limb involvement and 30 age and sex matched healthy controls had sympathetic autonomic function assessed using laser Doppler flowmetry of the finger pulp at baseline and while viewing a control figure or AVS. Compared to controls, there were diminished vasoconstrictor responses and a significant difference in the ratio of response between affected and unaffected limbs (symmetry ratio) to a deep breath and viewing AVS. While viewing visual stimuli, 33.5% of patients had asymmetric vasomotor responses and all healthy controls had a homologous symmetric pattern of response. Nineteen (61%) CRPS patients had enhanced pain within seconds of viewing the AVS. All the asymmetric vasomotor responses were in this group, and were not predictable from baseline autonomic function. Ten patients had accompanying dystonic reactions in their affected limb: 50% were in the asymmetric sub-group. In conclusion, there is a group of CRPS patients that demonstrate abnormal pain networks interacting with central somatomotor and autonomic integrational pathways., (© 2011 European Federation of International Association for the Study of Pain Chapters.)

Reactive oxygen species (ROS) are known to be involved in the pathophysiology of complex regional pain syndrome type I (CRPS I). Since the mitochondrial respiratory chain is a major source of ROS, we hypothesized that mitochondria play a role in the pathophysiology of CRPS I. The hypothesis was tested by studying mitochondrial energy metabolism in muscle tissue from amputated limbs of CRPS I patients. We observed that mitochondria obtained from CRPS I muscle tissue displayed reduced mitochondrial ATP production and substrate oxidation rates in comparison to control muscle tissue. Moreover, we observed reactive oxygen species evoked damage to mitochondrial proteins and reduced MnSOD levels. It remains to be established if the mitochondrial dysfunction that is apparent at the end-stage of CRPS I is also present in earlier stages of the disease, or are secondary to CRPS I. The observation of a reduced mitochondrial energy production combined with reactive oxygen species induced damage in muscle tissue from CRPS I patients warrants further studies into the involvement of mitochondrial dysfunctioning in the pathophysiology of CRPS I., (Copyright © 2010 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.)

Objective: To source and critically evaluate the evidence on the effectiveness of Physiotherapy to manage adult CRPS-1., Design: Systematic literature review., Methods: Electronic databases, conference proceedings, clinical guidelines and text books were searched for quantitative studies on CRPS-1 in adults where Physiotherapy was a sole or significant component of the intervention. Data were extracted according to predefined criteria by two independent reviewers. Methodological quality was assessed using the Critical Review Form., Results: The search strategy identified 1320 potential articles. Of these, 14 articles, representing 11 studies, met inclusion criteria. There were five randomised controlled trials, one comparative study and five case series. Methodological quality was dependent on study type, with randomised controlled trials being higher in quality. Physiotherapy treatments varied between studies and were often provided in combination with medical management. This did not allow for the 'stand-alone' value of Physiotherapy to be determined. Heterogeneity across the studies, with respect to participants, interventions evaluated and outcome measures used, prevented meta-analysis. Narrative synthesis of the results, based on effect size, found there was good to very good quality level II evidence that graded motor imagery is effective in reducing pain in adults with CRPS-1, irrespective of the outcome measure used. No evidence was found to support treatments frequently recommended in clinical guidelines, such as stress loading., Conclusions: Graded motor imagery should be used to reduce pain in adult CRPS-1 patients. Further, the results of this review should be used to update CRPS-1 clinical guidelines.

Complex regional pain syndrome type I (CRPS-I) is not uncommon in children, particularly in adolescent girls. Most often, the condition involves a foot and is characterized by spontaneous pain, tactile allodynia and dysautonomic signs. There is usually a history of a minor, local trauma but sometimes no reasonable cause can be identified, and there are no signs of persistent tissue injury giving rise to ongoing nociception. Common analgesics are generally of no benefit, and the standard treatment includes sociopsychological support, physiotherapy, tricyclic antidepressants and antiepileptic drugs, sympathetic blocks (SB), and cognitive-behavioural therapy. For a minority of patients who prove to be resistant to such therapies, spinal cord stimulation (SCS) may be tried. The present study comprises seven girls, 11-14 years of age, presenting with severe, incapacitating and therapy-resistant CRPS-I, who were subjected to SCS. In two of them, percutaneous electrode implantation had to be performed in general anaesthesia. Trial stimulation was performed in all, but one. In two cases, it was not possible to produce paraesthesias that entirely covered the pain area. A pain relieving effect of SCS was usually not reported until after 1-2 weeks of trial stimulation. After another 2-6 weeks, pain alleviation was complete in five of the seven patients, one to eight years after the intervention. In one case, a local infection necessitated the removal of the electrode; nevertheless a few days of trial stimulation produced substantial pain relief that still persists. In four patients, the SCS use was gradually diminished and eventually the device could be removed. The favourable outcome in all seven cases with no or minor remaining symptoms and without severe recurrences illustrates that SCS may also be an efficient treatment in paediatric cases with exceptionally therapy resistant forms of CRPS I.

Background: Although the current clinical guideline of diagnostic criteria for the complex regional pain syndrome I (CRPS I) is a landmark endeavour to define this complex condition it does not prioritise its most important clinical manifestations., Aim: We set out to obtain an expert agreed priority list of diagnostic and follow-up parameters in the diagnosis and management of CRPS I., Methods: A two round Delphi survey: We asked international experts to list (first round) and weight (second round) parameters (scale 1-10) they believed to be relevant in diagnosis and follow-up. Median ratings and interquartile ranges (IQR) were calculated. Rates 7 and IQR 3 depicted important and expert agreed parameters., Results: Thirty-two diagnostic and 23 follow-up listings and ratings of 13 experts were available for analysis. In three domains (clinical presentation, further examinations and follow-up) experts agreed on the following parameters, pain (10; 9-10) with its subcategories hyperesthesia (7; 5-8) hyperalgesia (8; 8-8) and allodynia (8; 7-10), signs with oedema (9; 8-10) and colour change (8; 5-8) and mobility with its categories motor change (7; 5-8) and decreased range of motion (8; 8-8). The experts agreed that no further examinations were necessary for diagnosis (10; 8-10). The agreed important follow-up parameter was clinical course (10; 8-10) with its categories decrease in pain (8; 8-9) and hyperalgesia (8; 6-8), decreased oedema (8; 7-10) and improvements in motor function (10; 8-10) and strength (8; 6-9)., Conclusion: This expert survey conveys an agreed set of relevant diagnostic parameters of CRPS I and proposes that in follow-up examinations treatment success should be based on restoration of those manifestations.

Recently, several functional imaging studies have shown that sensorimotor cortical representations may be changed in complex regional pain syndromes (CRPS). Therefore, we investigated tactile performance and tactile learning as indirect markers of cortical changes in patients with CRPS type I and controls. Patients had significant higher spatial discrimination thresholds at CRPS-affected extremities compared to both unaffected sides and control subjects. Furthermore, in order to improve tactile spatial acuity we used a Hebbian stimulation protocol of tactile coactivation. This consistently improved tactile acuity, both in controls and patients. However, the gain of performance was significantly lower on the CRPS-affected side implying an impaired perceptual learning ability. Therefore, we provide further support for an involvement of the CNS in CRPS, which may have implications to future neurorehabilitation strategies for this disease.

Background: Complex Regional Pain Syndrome type 1 (CRPS 1) is a potentially incapacitating complication in which pain seems to be the most disabling factor. We performed a late follow up study of a well-defined CRPS 1 population more than eight years after diagnosis. The relationships between early and late impairments were studied with a view to outcome prediction and to investigate possible differences in long-term impairments according to initial CRPS 1 subdiagnosis (i.e. "warm" or "cold", diagnosed according to skin temperature measured via infrared thermometer)., Methods: We again measured patients using the Impairment Level SumScore (ISS) (T8). These data were compared with earlier ISS measurements at CRPS diagnosis (T0) and after one year's treatment (T1). Correlations were determined between these measures., Results: Forty-five patients participated in the present study. Total median ISS improved by 55% (statistically/clinically significant) after one year's treatment (T1), and worsened (non-significantly) by 14% from T1 to T8 - without differences according to original subdiagnosis. ISS correlations were stronger for T1 vs. T8 than for T0 vs. T1 or T0 vs. T8, being strongest for the ISS factors related to pain., Conclusions: Considerable impairments, as measured by ISS, are still present over eight years after first CRPS 1 diagnosis. These do not greatly change between one and eight years post-diagnosis. ISS outcomes are similar for "cold" and "warm" CRPS 1 diagnostic subgroups. Component ISS scores associated with pain appear to possess greatest predictive power.

Background: An upper limb-activity monitor (ULAM) has been developed to determine activity limitations in complex regional pain syndrome type 1 (CRPS1). The ULAM is based on 24h ambulatory monitoring of body segment accelerations and enables valid and objective quantification of mobility and upper limb activity in transversal studies., Aims: To explore upper limb activity over time in acute upper limb CRPS1 as measured with the ULAM in a longitudinal study, and to compare this to time courses of other outcome measures for activity limitations and impairments., Methods: Four subjects were measured four times during a treatment protocol. Several ULAM outcome measures related to upper limb usage and mobility, three questionnaires (RASQ, DASH, RAND36), and six impairment outcome indicators (VAS-momentary pain, VAS-pain resulting from effort, volume, temperature, active range of motion, strength) were used., Results: Objectively measured upper limb activity frequently improved; improvements of >5% were found for 63% of the ULAM outcome measures at final assessment. The ULAM outcome measures had a time course more similar to the body-part and CRPS1 specific questionnaire RASQ than the other questionnaires. The time course of impaired temperature was most often in accordance with the ULAM, and both VAS scores showed least accordance., Conclusions: Clear changes in upper limb activity over time were frequently found as objectively measured with the ULAM, and relationships among the time courses of the ULAM and other outcome measures were largely explainable. The ULAM can validly assess upper limb activity over time in CRPS1, but between-measurement variability needs careful consideration.

Complex regional pain syndrome type I (CRPS-I) is a complex disorder characterised by pain, autonomic dysfunction, and decreased range of motion. The syndrome was believed as a well-recognized disorder in adults but, less commonly recognized in children. CRPS-I after vaccination has been rarely reported. We reported an 11-year-old young girl with CRPS-I due to rubella vaccine.

Background and Purpose: In this prospective trial we assessed the long-term effect of spinal cord stimulation (SCS) on the improvement of functional status in complex regional pain syndrome type I (CRPS I)., Methods: A prerequisite for eligibility to SCS treatment was the responsiveness of patients to sympathetic nerve block. In 29 patients with chronic sympathetically maintained CRPS I, the efficacy of SCS on deep pain, allodynia and functional disability was determined. Pain intensity was estimated during SCS free intervals of 45 min (inactivation test) every 3 months and compared with that under SCS treatment., Results: On SCS treatment, both deep pain and allodynia could be permanently reduced from 10 to 0-2 on a 10 cm visual analogue scale (VAS) (p<0.01). During the inactivation tests, reoccurrence of pain up to 8 VAS (quartiles 6-8) was measured. Considerable impairments in daily living activities, objectified by the pain disability index, were also restored (p<0.01). After a follow-up period of 35.6+/-21 months, 12 of 16 patients with affected upper limb showed significant increase of the fist grip strength from 0 to 0.35 (quartiles 0.1-0.5) kg compared with 0.9 (quartiles 0.7-1.1) kg on the unaffected side (p<0.01). Eight of ten patients with lower limb disability resumed walking without crutches. Previous pain medication could be significantly reduced (p<0.01)., Conclusions: As a result of permanent pain relief under long-term SCS combined with physiotherapy, the functional status and the quality of life could be significantly improved in sympathetically maintained CRPS I.

The validity with respect to presence or absence of CRPS I according to Veldman's criteria was assessed for measured pain, temperature, volume differences and limitations in range of motion. Evaluated were 155 assessments of 66 outpatients, initially diagnosed with CRPS I, but many of them not so on follow up visits. Pain was measured with VAS and McGill, temperature by infrared thermometry, volume differences by water displacement volumeters and limitations in range of motion by universal goniometers. Sensitivity, specificity, positive and negative predictive value of the measurement instruments at different cut-off points was calculated. Combined symptom scores were evaluated in a similar fashion. High sensitivity was found for the VAS, McGill, and range of motion. The specificity was overall lower, but highest values were obtained for volume differences. The positive predictive value was good for all measurement instruments. Negative predictive value was lower, especially for measurement of temperature and volume asymmetries. If sensitivity and specificity are equally important, VAS>3 cm, McGill>6 words, temperature difference>or=0.4 degrees C, volume difference>6.5% and ROM limitation>15% provide the best results. Using these cut off values, the highest value of sensitivity and of sensitivity and specificity combined, was found for a combination of VAS, McGill and ROM. The highest value of specificity was found for different combinations of 3, 4 and 5 instruments, all containing the VAS. We conclude that the measured pain, temperature, volume and range of motion can be used as diagnostic indicators for establishing presence or absence of CRPS I.

Complex regional pain syndromes (CRPS, reflex sympathetic dystrophy, causalgia) are painful disorders that develop after trauma affecting a limb with (I) or without (II) nerve injury. Clinical features are pain, impairment of motor function, swelling and autonomic abnormalities (changes in sweating and blood flow). Autonomic abnormalities. The maximal skin temperature difference between the affected and unaffected extremity that occurs during a controlled thermoregulation can be used as a diagnostic tool. SMP. Sympathetic outflow to the painful extremity was experimentally activated. The intensity as well as area of spontaneous pain and mechanical hyperalgesia increased considerably in patients that had been classified as having SMP by positive sympathetic blocks. A pathological interaction between sympathetic vasoconstrictor and afferent neurons within the affected skin is the likely explanation for SMP in CRPS patients. Motor abnormalities. Kinematic analysis of target reaching as well as grip force analysis showed a pathological sensorimotor integration located in the parietal cortex. Furthermore, MEG studies demonstrated a continuous inhibition of the primary motor cortex. Neurogenic inflammation. Some features of acute CRPS (vasodilatation, swelling, pain) indicate a localized inflammatory process. Transcutaneous electrical stimulation of nociceptive C-fibre provoked protein extravasation into the interstitial fluid (microdialysis) only in CRPS patients and not in controls.

Chronic regional pain syndrome refers to a class of disorders thought to involve common neuropathic and clinical features. These disorders usually are caused by injury, and they manifest in pain and sensory changes that are disproportionate in intensity, distribution, and duration to the underlying pathology. The result of these injuries is significant impairment of motor function over time. This article is divided into two parts. Part I discusses background information such as pain, pathophysiology, diagnosis, clinical stages, and the most common treatment modality, sympathetic nerve blocks. Part II, discusses alternate treatment modalities, such as sympathectomy, physical therapy, stimulators, trigger point injections, acupuncture, tourniquet effects, placebo effects, and amputation.

Skin blood flow in reflex sympathetic dystrophy (RSD) patients has been reported to develop from an increase at an early stage to a decrease at later stages. So far, it remains unclear whether these abnormalities are solely of microcirculatory origin, and result from functional vasospasm or structural vessel wall changes. Eighty-seven RSD patients were categorized as follows: stage I in case of a stationary warmth sensation; stage II in case of an intermittent warmth and cold sensation; and stage III in case of a stationary cold sensation. Laser Doppler flowmetry (LDF) was used as a measure of total skin blood flow and transcutaneous oximetry (TCPO2) as a measure of vascular reactivity in the more superficial skin layers. Local skin heating and reactive hyperaemia were used to study the relative reserve capacity of skin microvessels. Finapres was used to assess digital arterial pressures. As compared to healthy volunteers (n = 16), LDF under control conditions demonstrated an increase in skin blood flow at stage I (P < 0.01). A decrease in skin blood flow under control conditions was seen at stages II (P < 0.05) and III (P < 0.05), but the relative flow reserve capacity, as measured with LDF, was not impaired at these stages. Regression analysis did not show a relation between LDF parameters and duration of the syndrome. TCPO2 revealed no differences between patient groups and controls. Regression analysis did not demonstrate a relation between TCPO2 parameters and duration of the syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)