Search

We present the acute worsening of clinical presentation in complex regional pain syndrome (CRPS), following mRNA-based COVID-19 vaccination. We report the case series of three patients diagnosed with CRPS type I who presented with acute worsening of symptoms after mRNA-based COVID-19 vaccination and their medical management. The acute clinical worsening after mRNA-based COVID-19 vaccination was transient and effectively managed with adjustment of individualized therapy in all three patients. The mortality and morbidity of COVID-19 infection are serious, and vaccination is recommended in the general population, including patients with a diagnosis of CRPS. However, clinicians should be aware of the possibility that there may be a clinical worsening CRPS after mRNA-based COVID-19 vaccination., Lay abstract This case series presents the worsening of symptoms in complex regional pain syndrome (CRPS), following mRNA-based COVID-19 vaccination. We report on three patients diagnosed with CRPS who presented with worsening of symptoms after mRNA-based COVID-19 vaccination and their medical management. The worsening of symptoms was temporary and managed with adjustment of individualized therapy in all three patients. The dangers of COVID-19 infection are serious, and vaccination is highly recommended in the general population, including patients with a diagnosis of CRPS. However, healthcare providers should be aware of the possibility of clinical worsening of CRPS after mRNA-based COVID-19 vaccination.

A 45‐year‐old woman presented with persistent bilateral breast and axillary pain lasting for more than 3 months. Lengthy work‐up failed to identify the etiology. Physical examination was entirely normal, including breast examination. A traditional Kampo medicine, Goshaku‐san, was tried, and the symptoms began to improve gradually. This case is characterized by persistent regional pain syndrome mainly on her breast yet not accompanied by other symptoms, and we would like to propose the current case as a novel unique disease entity. We also discuss the potential benefit of Kampo medicine for the symptoms., A case of bilateral persistent breast pain treated with Kampo medicine

Concern has been raised about whether HPV vaccines might cause serious neurological disorders including postural orthostatic tachycardia syndrome (POTS) and chronic regional pain syndrome (CRPS). The European Medicines Agency (EMA) investigated the issue and declared in 2015 that there is no link between HPV vaccines and serious neurological adverse events. However, the certainty conveyed in EMA’s official report is undermined by a leaked, confidential document that reveals important disagreements among the experts. Furthermore, in its assessments, EMA relied on the data the drug companies had provided to them even though it had been demonstrated that the companies had underreported possible neurological harms. Even though active comparators were used (aluminium adjuvants and other vaccines), our research group found significantly more serious neurological harms in the HPV vaccine groups than in the comparator groups in a systematic review based on clinical study reports in EMA’s possession. We outline areas where we believe the basis for EMA’s decision was flawed; highlight that the relationship between HPV vaccines and POTS remains uncertain; and suggest ways forward to resolve the uncertainty and debate.

In Japan, a significant number of adolescent females noted unusual symptoms after receiving the human papillomavirus (HPV) vaccination, of which the vast majority of them were initially diagnosed with psychiatric illnesses because of the absence of pathologic radiological images and specific abnormalities in laboratory test results. Later these symptoms were thought to be adverse effects of HPV vaccination. However, a causal link between HPV vaccination and the development of these symptoms has not been demonstrated. Between June 2013 and March 2021, we examined 200 patients who noted various symptoms after HPV vaccination. In total, 87 were diagnosed with HPV vaccination-related symptoms based on our proposed diagnostic criteria. The clinical histories of these 87 patients were analyzed. The age at initial vaccination ranged from 11 to 19 years old (mean ± SD: 13.5 ± 1.5 years old), and the age at the first appearance of symptoms ranged from 12 to 20 years old (mean ± SD: 14.3 ± 1.6 years old). The patients received an initial HPV vaccine injection between May 2010 and May 2013, but the first affected patient developed symptoms in October 2010, and the last affected developed symptoms in October 2015. A cluster of patients with a post-HPV vaccination disorder has not appeared in Japan during the last five years. Our study shows that, in Japan, the period of HPV vaccination considerably overlapped with that of a unique post-HPV vaccination disorder development. This disorder appears as a combination of orthostatic intolerance, chronic regional pain syndrome, and cognitive dysfunction, but its exact pathogenesis remains unclear.

Purpose of this study is to compare the American College of Rheumatology (ACR) 1990 and ACR 2010 classification criteria in fibromyalgia syndrome. Fifty-one patients with fibromyalgia syndrome (FMS) and 50 control patients were included in the study. Patients with FMS were diagnosed by a specialist, and ACR 1990 or ACR 2010 classification criteria were not considered as a necessity. Control group consisted of patients with non-inflammatory pain such as osteoarthritis, periarthritis, regional pain syndrome. Patients were evaluated for ACR 1990 and ACR 2010 criteria, and they were examined for algometry. While ACR 1990 classification criteria had a sensitivity of 0.74, a specificity of 0.88, accuracy of 0.81, ACR 2010 criteria had a sensitivity of 0.78, a specificity of 0.76, and an accuracy of 0.77. In our study, ACR 2010 classification criteria were found to be more sensitive than ACR 1990 classification criteria, but specificity was lower. Besides, the ACR 2010 classification criteria do not require a tender point examination and may be more advantageous in assessing physical and psychological symptoms. It is considered that the classification criteria of ACR 2010 may be more favorable for clinical diagnosis and monitoring of diagnosed disease. [Med-Science 2019; 8(4.000): 975-9]

Background and aims Complex Regional Pain Syndrome (CRPS) often recovers spontaneously within the first year, but when it becomes chronic, available rehabilitative therapies (pharmacological management, physiotherapy, and psychological intervention) have limited effectiveness. This study examined the effect of a 12-week intensive outpatient rehabilitation on pain relief and function in chronic CRPS patients. Rehabilitation program included memantine and morphine treatment (added to patient’s prior pain medication) and concurrent psychological and physiotherapeutic intervention. Primary outcome measure was a change in CRPS symptom count and secondary outcomes were motor performance, psychological factors, pain intensity, and quality of life. Methods Ten patients with chronic upper limb CRPS I (median 2.9 years, range 8 months to 12 years) were recruited to the study and were assessed before and after the intervention. Hand motor function of the patients was evaluated by an independent physiotherapist. There were standardized questionnaires for depression, pain anxiety, pain acceptance, quality of life, and CRPS symptom count. In addition, psychological factors were evaluated by a semi-structured interview. Severity of experienced pain was rated at movement and at rest. In addition, a video experiment of a hand action observation was conducted pre- and post-intervention to study possible change in neuronal maladaptation. Intervention consisted of pharmacological, psychological and physiotherapeutic treatment. First, 10 mg daily morphine was started and increased gradually to 30 mg daily, if tolerated. After 30 mg/day or tolerated dose of morphine was achieved, 5 mg daily memantine was started and increased gradually to 40 mg, if tolerated. Psychological intervention consisted of weekly group sessions, using cognitive and behavioral methods (relaxation, behavioral activation, and exposure) and acceptance and commitment therapy (ACT) and daily home practice. Physiotherapeutic intervention consisted of graded motor imagery and physiotherapy exercises with weekly group sessions and/or individual guidance by the physiotherapist, and individual exercise of the affected upper limb. Results Multimodal intensive intervention resulted in significant decrease in CRPS symptom count. The effect was strongest in motor and trophic symptoms (19% decrease after intervention) and in sensory symptoms (18% decrease). Additionally, improvement was seen in some, but not all, secondary outcomes (movement pain, motor symptoms, change in perceptions during video experiment of hand actions, and summary index with motor functioning, pain, and psychological factors). There were no dropouts. Conclusions Intensive 12-week multimodal intervention reduced some CRPS symptoms but was not sufficient to alter patients’ rest pain, distress, or quality of life. Implications These results support the efficacy of an interdisciplinary rehabilitation program for pain and function in chronic CRPS patients. After intervention, some CRPS symptoms reduced and function improved, but distress and quality of life were unchanged. This may be due to the relatively short duration of this program; to delayed effects; to particular cognitive problems of CPRS patients; and/or to low distress levels at baseline that make statistically significant reduction less likely.

Background Complex regional pain syndrome (CRPS) is a progressive and painful disease of the extremities that is characterized by continuous pain inconsistent with the initial trauma. CRPS is caused by a multi-mechanism process that involves both the peripheral and central nervous system, with a prominent role of inflammation in CRPS pathophysiology. This review examines what is currently known about the CRPS inflammatory and pain mechanisms, as well as the possible impact of neurostimulation therapies on the neuroimmune axis of CRPS. Study design A narrative review of preclinical and clinical studies provided an overview of the pain and inflammatory mechanisms in CRPS and addressed the effect of neurostimulation on immunomodulation. Methods A systematic literature search was conducted based on the PRISMA guidelines between September 2015 to September 2020. Data sources included relevant literature identified through searches of PubMed, Embase and the Cochrane Database of Systematic Reviews. Results Sixteen preclinical and eight clinical studies were reviewed. Preclinical studies identified different mechanisms of pain development in the acute and chronic CRPS phases. Several preclinical and clinical studies investigating inflammatory mechanisms, autoimmunity, and genetic profiles in CRPS, supported a role of neuroinflammation in the pathophysiology of CRPS. The immunomodulatory effects of neurostimulation therapy is still unclear, despite clinical improvement in the CRPS patients. Conclusions Increasing evidence supports a role for inflammation and neuroinflammation in CRPS pathophysiology. Preliminary neurostimulation findings, together with the role of (neuro)inflammation in CRPS, seems to provide a compelling rationale for its use in CRPS pain treatment. The possible immunomodulatory effects of neurostimulation opens new therapeutic possibilities, however further research is needed to gain a better understanding of the working mechanisms.

Background Trapeziometacarpal (TMC) osteoarthritis can be painful and cause disability for patients. Total joint replacement of the TMC joint provides a pseudo arthrosis with good restoration of the thumb motion and pain relief in most patients. But there is also a risk of no improvement following the operation. The purpose of this study was to identify patients at risk of no clinically important improvement following operative treatment of osteoarthritis of the TMC joint. Methods We included 287 consecutive patients (225 women, 62 men) treated with total joint replacement of the TMC joint due to osteoarthritis with a mean age of 58.9 years (range 41–80) in a prospective cohort study. We collected information preoperatively and 12 months postoperatively on disabilities of the arm, shoulder and hand score (DASH), grip strength and pain at rest and activity on a visual analogue scale (VAS).Results: We found a statistically significant improvement in DASH from 42.0 to 15.9 (p p p p Conclusion However, we were unable to detect one isolated preoperative predictor as indicator of successful result after operative treatment of TMC osteoarthritis, and as so it was not possible to establish a clinical valid tool for patient selection before surgery. Informed consent was obtained from all patients for being included in the study. The study needed no approval from The Regional Committee of Biomedical Research Ethics as the data was collected, as part of our normal pre- and postoperative clinical pathway, but the study is part of an outcome study of the results after total joint arthroplasty (TJA) of the TMC joint registered in Clinicaltrials.gov (NCT01554748). Trial registration Clinicaltrials.gov (NCT01554748). Registered 15 March 2012.

Sander De Groote,1 Mats De Jaeger,1 Peter Van Schuerbeek,2 Stefan Sunaert,3 Ronald Peeters,3 Dirk Loeckx,4 Lisa Goudman,1,5 Patrice Forget,6 Ann De Smedt,7 Maarten Moens1,2,8 1Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium; 2Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium; 3Department of Radiology, Universitair Ziekenhuis Leuven, Leuven, Belgium; 4COMETRIX, Leuven, Belgium; 5Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussel, Belgium; 6Department Anesthesiology, Universitair Ziekenhuis Brussel, Brussels, Belgium; 7Department of Neurology, Universitair Ziekenhuis Brussel, Brussels, Belgium; 8Center for Neurosciences (C4N), Vrije Universiteit Brussel (VUB), Brussels, Belgium Background and purpose: Failed back surgery syndrome (FBSS) is a common and devastating chronic neuropathic pain disorder. Conventional spinal cord stimulation (SCS) applies electrical suprathreshold pulses to the spinal cord at a frequency of 40–60 Hz and relieves pain in FBSS patients. During the last decade, two major changes have emerged in the techniques of stimulating the spinal cord: paresthesia-free or subthreshold stimulation and administration of higher frequency or higher amounts of energy to the spinal cord. Despite the positive clinical results, the mechanism of action remains unclear. A functional MRI (fMRI) study was conducted to investigate the brain alterations during subthreshold and suprathreshold stimulation at different frequencies. Methods: Ten subjects with FBSS, treated with externalized SCS, received randomly four different stimulation frequencies (4 Hz, 60 Hz, 500 Hz, and 1 kHz) during four consecutive days. At every frequency, the patient underwent sub- and suprathreshold stimulation. Cerebral activity was monitored and assessed using fMRI. Results: Suprathreshold stimulation is generally accompanied with more activity than subthreshold SCS. Suprathreshold SCS resulted in increased bilateral activation of the frontal cortex, thalamus, pre- and postcentral gyri, basal ganglia, cingulate gyrus, insula, thalamus, and claustrum. We observed deactivation of the bilateral parahippocampus, amygdala, precuneus, posterior cingulate gyrus, postcentral gyrus, and unilateral superior temporal gyrus. Conclusion: Suprathreshold stimulation resulted in greater activity (both activation and deactivation) of the frontal brain regions; the sensory, limbic, and motor cortices; and the diencephalon in comparison with subthreshold stimulation. Each type of frequency at suprathreshold stimulation was characterized by an individual activation pattern. Keywords: spinal cord stimulation, fMRI, subthreshold, suprathreshold, frequency

Aim: This study aims to gain more knowledge of the sensorimotor incongruence in patients with chronic nonspecific complaints of arm, neck and shoulder. Method: Seven patients and seven healthy controls performed a left/right judgment task, and tactile acuity was assessed by the two-point discrimination threshold at fingers and shoulders. Results & conclusion: The results suggest a decreased tactile acuity in patients with chronic nonspecific complaints of arm, neck and shoulder and a faster reaction time at the painful arm, which might imply disturbed information processing of sensory and motor feedback. Due to the small sample size and low scores on the pain and disability questionnaires, these conclusions should be interpreted with care. Further research is recommended.

The authors would like to thank Liesbeth Jutten and Margareth Winants from the Trial Bureau of the Department of Orthopedics for their efforts during this study. This study was funded by the Weijerhorst Foundation (grant no. WH2).

Most of the abiotic environmental factors are electromagnetic in nature. Electromagnetic radiation from various artificial sources exerts a significant inf luence on living systems. It poses a problem of targeted application of electromagnetic waves in health care, ever yday life, and industr y. Recently, a fundamentally new direction in medicine has emerged: the use of low-power terahertz electromagnetic waves at the frequency of oscillation of active cellular metabolites (nitrogen oxide, molecular oxygen, etc.) for disease treatment and prevention. It has been demonstrated that if there is a match in frequency bet ween the emitted electromagnetic wave and the natural oscillation of the molecule, absorption occurs and this alters the amplitude of the molecular oscillation and modifies involvement of the molecule in the metabolic process. This fact is of great interest for biomedical technologies because cellular metabolites may significantly affect regional circulation, microcirculation, and blood rheology; prevent intravascular coagulation; provide anti-inf lammator y and analgesic effects; limit excessive lipid peroxidation and potentiate the antioxidant mechanism; activate cellular anti-stress mechanisms. Today, terahertz electromagnetic radiation at the frequency of oscillation of nitric oxide, a universal cellular regulator y molecule, has been shown to be beneficial in the treatment of cardiovascular diseases, burns, polyneuropathy, regional pain syndrome, etc. This review summarizes clinical and experimental data on implementation of terahertz electromagnetic waves in medicine and presents our current understanding of the mechanisms of action of terahertz electromagnetic waves at the frequency of oscillation of active cellular metabolites on a living system at the molecular, cellular, tissue, and organ levels of organization.

Background: An unusual case involving a middle-aged male with a 9-year history of presumptive chronic regional pain syndrome (CRPS) and ulnar neuropathy was referred for failure in treatment. Methods: On presentation, the patient was requesting an amputation of his arm. However, work-up uncovered a periosteal extra-digital glomus tumor on the base of the small finger metacarpal. Results: Surgical excision of the lesion resulted in rapid resolution of his pain and normal hand function was ultimately restored. Conclusions: Glomus tumors account for up to 5% of all soft tissue tumors of the upper extremity, occurring most frequently within or adjacent to the nail bed. Time from onset of symptoms to correct diagnosis may not be established for many years, especially with atypical tumor locations. Although glomus tumors have been widely reported, atypical locations of these tumors should be included in the differential diagnosis for patients with unusual chronic pain or neuropathy. Furthermore, when evaluating a chronic pain patient, our findings support the opinion that assignment of the diagnosis of CRPS should only be a diagnosis of exclusion.

Introduction The pediatric chronic regional pain syndrome (CRPS) type I is a recognized syndrome that follows a preliminary event (e.g., trauma, fracture) with amplified spontaneous or stimuli-induced extremity pain that differs from its adult form with rather favorable outcomes. Conservative treatment is usually indicated for CRPS treatment. Case Description We present a unique case of an adolescent girl who revealed severe wrist joint sequelae following a blunt trauma, complicated by a challenging CRPS resistant to treatment. Diagnostic wrist arthroscopy eventually revealed a massive cartilage degeneration and scapholunate tear as underlying causes for the pain and CRPS. It was decided to proceed with radioscapholunate wrist fusion, which promptly led to pain relief and disappearance of the CRPS. Conclusion The relevance of this report is therefore to emphasize the possibility, against earlier thoughts, that well-indicated surgeries in pediatric CRPS patients may lead to prompt symptom improvement and may not be uniformly predicted to fail. With the clinical probability of a presence of an uncontrolled, symptomatic causative factor such as cartilage degeneration and chondrolysis, further early diagnostic and therapeutic interventions may be indicated to control the disease.

Complex regional pain syndrome (CRPS) is a chronic, debilitating, neuropathic pain condition which is often misdiagnosed, difficult to manage, and lacks proven methods for remission. Most available methods provide some relief to a small percentage of patients. Recent FDA approval and superiority of the Nevro Senza 10-kHz high frequency (HF10) spinal cord stimulation (SCS) therapy over traditional low-frequency spinal cord stimulation for treatment of chronic back and leg pain may provide a new interventional therapeutic option for patients suffering from CRPS. We provide a case report of a 53-year-old Caucasian woman who suffered with CRPS in the right knee and thigh for over 7 years. Implantation of the HF10 device provided over 75% relief of pain, erythema, heat, swelling, and tissue necrosis to the entire region within 1 month of treatment. Because the HP10 therapy provides pain relief without paresthesia typical of traditional low-frequency, this system may provide relief for patients suffering from chronic pain. Key words: Complex regional pain syndrome, spinal cord stimulation, Nevro Senza HF10, erythema, knee, thigh

Complex regional pain syndrome (CRPS) presents a therapeutic challenge due to its many presentations and multifaceted pathophysiology. There is no approved treatment algorithm and clinical interventions are often applied empirically. In cases of CRPS where symptoms are localized to an extremity, a targeted treatment is indicated. We describe the use of intrathecal bupivacaine monotherapy, delivered through a retrograde catheter, in the treatment of CRPS affecting the lower extremity. The patient, a 57-yearold woman with a history of failed foot surgery, was seen in our office after 2 years of ineffective treatments with local blocks and neurolytic procedures. We advanced therapy to moderately invasive procedures with an emphasis on neuromodulation. A combined central and peripheral stimulation technique that initially provided 75% pain relief, failed to provide lasting analgesia. We proceeded with an intrathecal pump implant. Based on the results of dorsal root ganglion (DRG) mapping, L5-S1 was identified as the optimal target for therapy and a retrograde catheter was placed at this level. Various intrathecal medications were tested individually. An intrathecal morphine trial was ineffective (visual analog scale [VAS] 7), while intrathecal clonidine provided excellent pain relief (VAS 0) that was limited by severe side effects. Bupivacaine provided 100% analgesia with tolerable side effects (lower extremity weakness and minor bladder incontinence) and was selected for intrathecal infusion. After 14 months, bupivacaine treatment continued to control pain exacerbations. We conclude that CRPS patients benefit from early identification of the predominant underlying symptoms and a targeted treatment with moderately invasive techniques when less invasive techniques fail. Key words: Intrathecal bupivacaine, bupivacaine monotherapy, retrograde catheter, complex regional pain syndrome (CRPS), dual stimulation, dosal root ganglion (DRG) testing

Real-time functional magnetic resonance imaging (fMRI) is a promising non-invasive method for brain computer interfaces (BCIs). BCIs translate brain activity into signals that allow communication with the outside world. Visual and motor imagery are often used as information-encoding strategies, but can be challenging if not grounded in recent experience in these modalities, e.g. in patients with locked-in-syndrome (LIS). In contrast, somatosensory imagery might constitute a more suitable information-encoding strategy as somatosensory function is often very robust. Somatosensory imagery has been shown to activate somatotopic cortex, but it has been unclear so far whether it can be reliably detected on a single-trial level and successfully classified according to specific somatosensory imagery content.Using ultra-high field 7-T fMRI, we show reliable and high-accuracy single-trial decoding of left-foot vs. right-hand somatosensory imagery. Correspondingly, higher decoding accuracies were associated with greater spatial separation of hand and foot decoding-weight patterns in primary somatosensory cortex (S1). Exploiting these novel neuroscientific insights, we developed – and provide a proof of concept for – basic BCI communication by showing that binary (yes/no) answers encoded by somatosensory imagery can be decoded with high accuracy not only offline but also in real-time.This study demonstrates that body part-specific somatosensory imagery differentially activates somatosensory cortex in a topographically specific manner; evidence which was surprisingly still lacking in the literature. It is also offers a promising novel somatosensory imagery based fMRI-BCI control strategy, with particularly high potential for visually and motor-impaired patients. The strategy could also be transferred to lower MRI field strengths and to mobile functional near-infrared spectroscopy. Finally, given that communication BCIs provide the BCI user with a form of feedback based on their brain signals and can thus be considered as a specific form of neurofeedback, and that repeated use of a BCI has been shown to enhance underlying representations, we expect that the current BCI could also offer an interesting new approach for somatosensory rehabilitation training in the context of stroke and phantom limb pain.

Complex regional pain syndrome has long been recognized as a severe and high impact chronic pain disorder. However, the condition has historically been difficult to define and classify and little attention has been given to where complex regional pain syndrome sits within other apparently similar chronic pain disorders, such as fibromyalgia and regional pain syndrome. In this review challenges in regard to nomenclature, definitions, and classification of complex regional pain syndrome are reviewed and suggestions are provided about future directions.

A number of controlled trials have previously found that in some contexts, vitamin C can have beneficial effects on blood pressure, infections, bronchoconstriction, atrial fibrillation, and acute kidney injury. However, the practical significance of these effects is not clear. The purpose of this meta-analysis was to evaluate whether vitamin C has an effect on the practical outcomes: length of stay in the intensive care unit (ICU) and duration of mechanical ventilation. We identified 18 relevant controlled trials with a total of 2004 patients, 13 of which investigated patients undergoing elective cardiac surgery. We carried out the meta-analysis using the inverse variance, fixed effect options, using the ratio of means scale. In 12 trials with 1766 patients, vitamin C reduced the length of ICU stay on average by 7.8% (95% CI: 4.2% to 11.2%, p = 0.00003). In six trials, orally administered vitamin C in doses of 1&ndash, 3 g/day (weighted mean 2.0 g/day) reduced the length of ICU stay by 8.6% (p = 0.003). In three trials in which patients needed mechanical ventilation for over 24 hours, vitamin C shortened the duration of mechanical ventilation by 18.2% (95% CI 7.7% to 27%, p = 0.001). Given the insignificant cost of vitamin C, even an 8% reduction in ICU stay is worth exploring. The effects of vitamin C on ICU patients should be investigated in more detail.

SUMMARY Complex regional pain syndrome (CRPS), a relatively rare condition, is commonly diagnosed late and has no known cause or cure. There is a limited evidence base for therapeutic interventions and the majority of patients make a spontaneous recovery. The florid signs and symptoms of early CRPS are diminished and altered in the more persistent treatment-resistant form. New signs and symptoms, not listed in diagnostic criteria, begin to emerge that can confuse both the patient and clinician, and lead to questioning of the diagnosis. Trying to implement timely and evidence-based rehabilitation techniques within the above scenario is a significant challenge. This article will discuss those challenges and consider recent clinical and research advances that have sought to address some of these problems in CRPS type I.

Chronic regional pain syndrome (CRPS) can be intractable to treat and patients sometimes suffer for many years. Therefore, new treatment strategies are needed to alleviate symptoms in CRPS patients. This case report describes a patient suffering from intractable CRPS type 1 for 13 years. Due to her swollen painful feet and left knee she is wheelchair-bound. The combination of palmitoylethanolamide and ketamine 10% cream reduced her pain by more than 50% after 1 month of treatment, and a marked reduction in swelling and skin discoloration was noticed. Furthermore, she could walk independently again and she experienced no side effects. Thus, palmitoylethanolamide and topical ketamine could be a combination therapy option for treating CRPS patients.

The localization of harmful stimuli approaching our body is essential for survival. Here we investigated whether the mapping of nociceptive stimuli is based on a spatial representation that is anchored to the stimulated limb. In three experiments, we measured the effect of unilateral visual stimuli on the perceived temporal order of nociceptive stimuli, applied to each hand. Crucially, the position of the hands and the visual stimuli was manipulated, so that visual and nociceptive stimuli occurred in an adjacent or non-adjacent spatial position. Temporal order judgments of nociceptive stimuli were biased in favor of the stimulus applied to the hand most adjacent to the visual stimulus, irrespective to their positions in space. This suggests that the ability to determine the position of a nociceptive stimulus on a specific body area is based on a peripersonal representation of the stimulated limb following it during limb displacement.

The ability to localize nociceptive stimuli on the body surface is essential for an organism to respond appropriately to potential physical threats. This ability not only requires a representation of the space of the observer׳s body, but also of the external space with respect to their body. Therefore, localizing nociceptive stimuli requires coordinating multiple senses into an integrated frame of reference. The peripersonal frame of reference allows for the coding of the position of somatosensory stimuli on the body surface and the position of stimuli occurring close to the body (e.g., visual stimuli). Intensively studied for touch, this topic has been largely ignored when it comes to nociception. Here, we investigated, using a temporal order judgment task, whether the spatial perception of nociceptive stimuli is coordinated with that of proximal visual stimuli into an integrated representation of peripersonal space. Participants judged which of two nociceptive stimuli, one presented to either hand, had been presented first. Each pair of nociceptive stimuli was preceded by lateralized visual cues presented either unilaterally or bilaterally, and either close to, or far from, the participant׳s body. The perception of nociceptive stimuli was biased in favor of the stimulus delivered on the hand adjacent to the unilateral visual cue, especially when the cue was presented near the participant׳s hand. These results therefore suggest that a peripersonal frame of reference is used to map the position of nociceptive stimuli in multisensory space. We propose that peripersonal space constitutes a kind of margin of safety around the body to alert an organism to possible threats.

Myofascial pain syndrome (MPS) has been defined as a regional pain syndrome characterized by muscle pain caused by myofascial trigger points (MTrPs) clinically. MTrP is defined as the hyperirritable spot in a palpable taut band of skeletal muscle fibers. Appropriate treatment to MTrPs can effectively relieve the clinical pain of MPS. Needling therapies, such as MTrP injection, dry needling, or acupuncture (AcP) can effectively eliminate pain immediately. AcP is probably the first reported technique in treating MPS patients with dry needling based on the Traditional Chinese Medicine (TCM) theory. The possible mechanism of AcP analgesia were studied and published in recent decades. The analgesic effect of AcP is hypothesized to be related to immune, hormonal, and nervous systems. Compared to slow-acting hormonal system, nervous system acts in a faster manner. Given these complexities, AcP analgesia cannot be explained by any single mechanism. There are several principles for selection of acupoints based on the TCM principles: “Ah-Shi” point, proximal or remote acupoints on the meridian, and extra-meridian acupoints. Correlations between acupoints and MTrPs are discussed. Some clinical and animal studies of remote AcP for MTrPs and the possible mechanisms of remote effectiveness are reviewed and discussed.

Treatment results for 9 patients with distal forearm fractures complicated by sympathetically dependant type of complex regional pain syndrome were analyzed. After clinical, radiologic examination, laser Doppler flowmetry, computer thermography one-step open reposition of bone fragments with osteosynthesis and perivascular sympathectomy was performed in all patients. Follow-up period made up from 4 to 7 months. Excellent results was achieved in 1 (11%) patient, good - in 7 (78%), satisfactory - in 1 (11%) patient.

Objective To describe our experience performing cryoablative procedures for patients with painful peripheral nerve lesions, excluding patients with chronic regional pain syndrome. Summary The real-time nature of ultrasound makes it ideally suited to provide guidance for a variety of musculoskeletal interventional procedures involving peripheral nerves. Continuous observation of the needle ensures proper placement and allows continuous monitoring when performing localized ablative therapy and therefore, more accurate positioning of a cryoprobe, use of smaller needles, as well as access to small structures. In the current talk, we describe our experience performing cryoablative procedures for a variety of painful peripheral nerve lesions. In our experience, patients undergoing cryoneurolysis have reported varying degrees of long-term pain relief and improvement in function; no serious complications have yet been identified. Ultrasound guided cryoneurolysis can provide a useful, safe alternative to other ablative techniques to achieve long-term analgesia. In as much as there is only limited patient outcome data available to date, we present descriptive information as to our current technique with limited patient follow-up. For purposes of the current discussion, we will not include examples of patients with chronic regional pain syndrome as they form a complex group of patients not easily addressed through simple targeted ablative techniques.

Subtalar arthrodesis was performed on a 48-year-old, non-insulin-dependent diabetic with a history of chronic ankle instability and lateral ankle pain. In the early post-operative period he presented as an emergency with an infection at the operative site. This was treated with 2 returns to the operating theatre for washout and debridement. His wounds were left open and at 3 weeks after emergency admission he was referred for adjunctive hyperbaric oxygen (HBO) therapy to aid healing by secondary intention. He received a total of 19 hyperbaric sessions, at a pressure of 2.2 ATA, one treatment per day for 5 days a week. Shortly after commencing HBO therapy his ankle became increasingly painful, despite the introduction of analgesia. By 7 weeks after emergency admission his wounds had virtually healed but hyperesthesia persisted over the dorsum of the foot. A computerized tomography scan at 5½ months post-operatively showed satisfactory joint fusion and revealed no evidence of infection. Symptoms and signs at this time were compatible with a diagnosis of chronic regional pain syndrome (CRPS). There is published evidence to suggest that HBO therapy may be a useful modality in the treatment of established CRPS. Here, we seek to publicize a case in which early treatment with HBO for another indication did not prevent the simultaneous development of CRPS Type 1. Key words: Subtalar arthrodesis, hyperbaric oxygenation, chronic regional pain syndrome

Background: Atypical chest pain is a common complaint among Complex Regional Pain Syndrome (CRPS) patients with brachial plexus involvement. Anatomically, the intercostobrachial nerve (ICBN) is connected to the brachial plexus and innervates the axilla, medial arm and anterior chest wall. By connecting to the brachial plexus, the ICBN could become sensitized by CRPS spread and become a source of atypical chest pain. Objective: To evaluate the sensitivity of chest areas in CRPS patients and normal controls. Design: Prospective investigation of pressure algometry in chest areas to determine chest wall sensitivity. Methods: CRPS patients and normal controls volunteered to participate in our study. Each individual was examined to meet inclusion criteria. Patients’ report of chest pain history was collected from every participant. Pressure algometry was used to measure pressure sensitivity in the axilla, anterior axillary line second intercostal space, mid-clavicular third rib, mid-clavicular tenth rib, and midsternal. Each of these measurements were compared to an intra-participant abdominal measure to control for an individuals generalized sensitivity. The ratios of chest wall sensitivities were compared between CRPS patients and normal controls. Results: A history of chest pain was reported by a majority (94%) of CRPS patients and a minority (19%) of normal controls. CRPS patients reported lifting their arm as a major initiating factor for chest pain. To pressure algometry, the ratios of CRPS patients were significantly greater than control subjects (p< 0.02 throughout), indicating increased chest wall sensitivity. Limitations: This study is limited by the relatively small number of patients (n=35) and controls (n=21) used. Conclusion: The results of this study support the idea that chest pain is greater in CRPS patients than normal controls. The ICBN could be the source of this sensitization by CRPS spread from the brachial plexus. Key words: Intercostobrachial nerve (ICBN), complex regional pain syndrome (CRPS), atypical chest pain, algometry, reflex sympathetic dystrophy (RSD), brachial plexus

Neural representations, or neurotags, refer to the idea that networks of brain cells, distributed across multiple brain areas, work in synergy to produce outputs. The brain can be considered then, a complex array of neurotags, each influencing and being influenced by each other. The output of some neurotags act on other systems, for example, movement, or on consciousness, for example, pain. This concept of neurotags has sparked a new body of research into pain and rehabilitation. We draw on this research and the concept of a cortical body matrix - a network of representations that subserves the regulation and protection of the body and the space around it - to suggest important implications for rehabilitation of sports injury and for sports performance. Protective behaviours associated with pain have been reinterpreted in light of these conceptual models. With a particular focus on rehabilitation of the injured athlete, this review presents the theoretical underpinnings of the cortical body matrix and its application within the sporting context. Therapeutic approaches based on these ideas are discussed and the efficacy of the most tested approaches is addressed. By integrating current thought in pain and cognitive neuroscience related to sports rehabilitation, recommendations for clinical practice and future research are suggested. Refereed/Peer-reviewed

To react efficiently to potentially threatening stimuli, we have to be able to localize these stimuli in space. In daily life we are constantly moving so that our limbs can be positioned at the opposite side of space. Therefore, a somatotopic frame of reference is insufficient to localize nociceptive stimuli. Here we investigated whether nociceptive stimuli are mapped into a spatiotopic frame of reference, and more specifically a peripersonal frame of reference, which takes into account the position of the body limbs in external space, as well as the occurrence of external objects presented near the body. Two temporal order judgment (TOJ) experiments were conducted, during which participants had to decide which of two nociceptive stimuli, one applied to either hand, had been presented first while their hands were either uncrossed or crossed over the body midline. The occurrence of the nociceptive stimuli was cued by uninformative visual cues. We found that the visual cues prioritized the perception of nociceptive stimuli applied to the hand laying in the cued side of space, irrespective of posture. Moreover, the influence of the cues was smaller when they were presented far in front of participants' hands as compared to when they were presented in close proximity. Finally, participants' temporal sensitivity was reduced by changing posture. These findings are compatible with the existence of a peripersonal frame of reference for the localization of nociceptive stimuli. This allows for the construction of a stable representation of our body and the space closely surrounding our body, enabling a quick and efficient reaction to potential physical threats.

Complex regional pain syndrome (CRPS) is an incompletely understood disorder characterized by progressive regional pain and sensory changes, with fluctuating cutaneous edema and erythema. We describe a patient with a rarely reported severe bullous CRPS variant on the left lower extremity, which resolved immediately upon developing spinal paralysis.

Purpose. To report outcome of Scarf osteotomy with or without proximal phalangeal osteotomy for correction of severe hallux valgus deformity. Methods. Records of 48 women and 4 men aged 28 to 68 (mean, 52) years who underwent 57 Scarf osteotomies with or without proximal phalangeal osteotomy for severe hallux valgus by a single surgeon were reviewed. The patients had a hallux valgus angle (HVA) of up to 55°. An additional proximal phalangeal osteotomy was performed in 11 of the patients whose hallux valgus persisted (HVA >10°). The American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, the HVA and intermetatarsal angle (IMA) on radiographs, and the complication rate were assessed. Results. The mean follow-up period was 26 (range, 24–36) months. The mean AOFAS hallux score improved from 57.4 (range, 49–64) to 91.6 (range, 75–100). The mean HVA improved from 38.1° (range, 28°–52°) to 12.8° (range, 5°–20°). The mean IMA improved from 17.0° (range, 13°–24°) to 6.8° (range, 3°–10°). One patient developed chronic regional pain syndrome. There were no instances of non-union, delayed union, or malunion of the osteotomy site. Conclusion. Scarf osteotomy with or without proximal phalangeal osteotomy is an effective treatment for correcting severe hallux valgus deformity.

Stellate ganglion block (SGB) is very effective in management of chronic regional pain syndrome (CRPS-1). However, serious complication may occur due to accidental intravascular (intra-arterial) injection of local anaesthetic agents. Abdi and others, has suggested a modified technique in which fluoroscopy-guided block is given at the junction of uncinate process and body of vertebra at C7 level. In this approach vascular structures remain away from the trajectory of needle and thus avoid accidental vascular injection. We have used this technique of SGB in nine patients who were treated for CRPS-I. The blocks were effective in all the patients all the time without any vascular or other serious complication.

Current IASP diagnostic criteria for CRPS have low specificity, potentially leading to overdiagnosis. This validation study compared current IASP diagnostic criteria for CRPS to proposed new diagnostic criteria (the "Budapest Criteria") regarding diagnostic accuracy. Structured evaluations of CRPS-related signs and symptoms were conducted in 113 CRPS-I and 47 non-CRPS neuropathic pain patients. Discriminating between diagnostic groups based on presence of signs or symptoms meeting IASP criteria showed high diagnostic sensitivity (1.00), but poor specificity (0.41), replicating prior work. In comparison, the Budapest clinical criteria retained the exceptional sensitivity of the IASP criteria (0.99), but greatly improved upon the specificity (0.68). As designed, the Budapest research criteria resulted in the highest specificity (0.79), again replicating prior work. Analyses indicated that inclusion of four distinct CRPS components in the Budapest Criteria contributed to enhanced specificity. Overall, results corroborate the validity of the Budapest Criteria and suggest they improve upon existing IASP diagnostic criteria for CRPS. (C) 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

OBJECTIVE: The aim of this study was to investigate patients' knowledge of the most salient features of complex regional pain syndrome and to identify patient characteristics associated with the patients' level of knowledge. METHODS: Questionnaire interview of 101 patients with complex regional pain syndrome in Switzerland (mean age 54 years, 77% female). A questionnaire about patients' disease-related knowledge was developed and piloted. The level of knowledge was defined by a consensus process among clinical experts and a patient. The questions were based on expert consensus about the minimum knowledge a person affected with complex regional pain syndrome should have. RESULTS: Only 6 patients (6%) reached the minimum medical knowledge. The mean score for all participants was 7.6 points out of a total score of 11 points (range 3-11, SD 2.1). The scores were slightly higher among patients with higher education (apprenticeship, vocational school +0.38 (95% confidence interval (CI); -0.59 to 1.34: p=0.44), university entrance diploma +1.12 (95% CI-0.16 to 2.49: p=0.08), university diploma, advanced technical college +2.36 (95% CI 1.11-3.61: p

The authors explore how doctors in primary care can identify, approach, and refer patients with regional pain syndrome

Limb amputation is characterized by complex and intermingled brain reorganization processes combining sensorimotor deprivation induced by the loss of the limb per se, and compensatory behaviors, such as the over-use of the intact or remaining limb. While a large body of evidence documents sensorimotor representation plasticity following arm amputation, less investigations have been performed to fully understand the use-dependent plasticity phenomenon and the role of behavioral compensation in brain reorganization. In this article, I will review the findings on sensorimotor plasticity after limb amputation, focusing on these two aspects: sensorimotor deprivation and adaptive patterns of limb usage, and describe the models that attempt to link these reorganizational processes with phantom limb pain. Two main models have been proposed: the maladaptive plasticity model which states that the reorganization of the adjacent cortical territories into the representation of the missing limb is proportional to phantom pain intensity, and the persistent representation model, which rather suggests that the intensity of residual brain activity associated with phantom hand movements scales with phantom limb pain intensity. I will finally illustrate how this fundamental research helps designing new therapeutic strategies for phantom plain relief. (C) 2021 The Author. Published by Elsevier Masson SAS.

The continuous stream of multisensory information between the brain and the body during body-environment interactions is crucial to maintain the updated representation of the perceived dimensions of body parts (metric body representation) and the space around the body (the peripersonal space). Such flow of multisensory signals is often limited by upper limb sensorimotor deficits after stroke. This would suggest the presence of systematic distortions of metric body representation and peripersonal space in chronic patients with persistent sensorimotor deficits. We assessed metric body representation and peripersonal space representation in 60 chronic stroke patients with unilateral upper limb motor deficits, in comparison with age-matched healthy controls. We also administered a questionnaire capturing explicit feelings towards the affected limb. These novel measures were analysed with respect to patients' clinical profiles and brain lesions to investigate the neural and functional origin of putative deficits. Stroke patients showed distortions in metric body representation of the affected limb, characterized by an underestimation of the arm length and an alteration of the arm global shape. A descriptive lesion analysis (subtraction analysis) suggests that these distortions may be more frequently associated with lesions involving the superior corona radiata and the superior frontal gyrus. Peripersonal space representation was also altered, with reduced multisensory facilitation for stimuli presented around the affected limb. These deficits were more common in patients reporting pain during motion. Explorative lesion analyses (subtraction analysis, disconnection maps) suggest that the peripersonal space distortions would be more frequently associated with lesions involving the parietal operculum and white matter frontoparietal connections. Moreover, patients reported altered feelings towards the affected limb, which were associated with right brain damage, proprioceptive deficits and a lower cognitive profile. These results reveal implicit and explicit distortions involving metric body representation, peripersonal space representation and the perception of the affected limb in chronic stroke patients. These findings might have important clinical implications for the longitudinal monitoring and the treatments of often-neglected deficits in body perception and representation., Bassolino et al. studied body perception in post-stroke chronic patients with upper limb sensorimotor deficits. Results reveal distortions in the perceived dimensions, representation of peripersonal space and explicit feelings towards the affected limb. This motivates quantitative assessments of body perception even in later phases after stroke.