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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.

Chronic pelvic pain syndrome (PPS) refers to pain of three to six months duration (or longer) that occurs below the umbilicus. PPS is considered a form of chronic regional pain syndrome or functional somatic pain syndrome. Multimodal ollaborative and patient-centered approach is critical component of treatment for women with CPPS. The current review encompasses the linical manifestations and therapeutic interventions for CPPS - a yet to be defined problem.

Objectives To assess the supraspinal working mechanisms of the burst spinal cord stimulation (SCS) mode, we used functional magnetic resonance imaging (fMRI) in chronic neuropathic rats. We hypothesized that active recharge burst SCS would induce a more profound blood oxygenation level-dependent (BOLD) signal increase in areas associated with cognitive-emotional aspects of pain, as compared to tonic SCS.Methods Sprague Dawley rats (n = 17) underwent a unilateral partial sciatic nerve ligation, which resulted in chronic neuropathic pain. Quadripolar SCS electrodes were epidurally positioned on top of the dorsal columns at Th13. Isoflurane-anesthetized (1.5%) rats received either tonic SCS (n = 8) or burst SCS (n = 9) at 66% of motor threshold. BOLD fMRI was conducted before, during, and after SCS using a 9.4-T horizontal bore scanner.Results Overall, both tonic and burst SCS induced a significant increase of BOLD signal levels in areas associated with the location and intensity of pain, and areas associated with cognitive-emotional aspects of pain. Additionally, burst SCS significantly increased BOLD signal levels in the raphe nuclei, nucleus accumbens, and caudate putamen. Tonic SCS did not induce a significant increase in BOLD signal levels in these areas.Conclusions In conclusion, active recharge burst and tonic SCS have different effects on the intensity and localization of SCS-induced activation responses in the brain. This work demonstrates that active recharge burst is another waveform that can engage brain areas associated with cognitive-emotional aspects of pain as well as areas associated with location and intensity of pain. Previous studies showing similar engagement used only passive recharge burst.

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.

Complex regional pain syndrome (CRPS) is a chronic pain condition that affects the extremities, believed to be caused by damage to, or malfunction of, the peripheral and central nervous systems. And while CRPS is its own unique disease entity, its potential pathophysiological mechanisms have frequently been compared to those of neuropathy and fibromyalgia (FM). Furthermore, treatment of CRPS has proven difficult given the fact that its unverified pathophysiology and variable presentation make accurate clinical diagnosis challenging. The geriatric population is considered those 65 years of age and older. And although CRPS can occur at any age it does occur in geriatric individuals, yet there are very limited published data specifically involving this population. Surprisingly, some reports suggest that CRPS is most prevalent among the elderly (65+), yet it is underreported. This may be due to the wide variety of terminology used to describe CRPS, overlap of CRPS with other pain conditions, and even comorbidities in geriatric patients. Currently, the literature lacks high-quality evidence to guide treatment of CRPS, especially in geriatric patients, and patients even with known diagnoses continue to suffer refractory pain. Therefore, since there are limited data involving CRPS and the elderly, this chapter will attempt to extrapolate relevant information from resources involving chronic pain in the elderly and CRPS in the elderly. Overall, there is a gap in the literature involving this patient population and more published studies are necessary to address this gap.

ObjectivesDorsal root ganglion (DRG) stimulation is a recent neuromodulation option that has delivered safe, effective pain relief for a number of etiologies. This prospective observational study was intended to establish the effectiveness of this treatment in a typical real-world clinical context.Materials and MethodsParticipants with chronic, intractable pain of the trunk or lower limbs were recruited from multiple pain clinics in the Netherlands. Subjects were trialed and implanted with DRG stimulation systems. Pain, function, mood, and quality of life, ratings were collected through 12 months postimplant.ResultsOf the 66 subjects enrolled, failed back surgery syndrome, peripheral nerve injury, and complex regional pain syndrome formed the largest etiologies. Permanent implants were placed in 86.2% subjects (56/65). After 12 months of treatment, average pain ratings in subjects' primary area of pain decreased from 8.0 cm at baseline to 4.1 cm, and 49% of subjects had 50% reduction in pain (visual analog scale). In addition, functional capacity was increased, and mood and quality of life improved. No confirmed lead migrations were observed, and there was a low rate of infection.ConclusionsDRG stimulation significantly reduced the severity of subjects' pain and enabled participatory changes that improved quality of life through 12-months postimplant.

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.

Introduction Complex Regional Pain Syndrome is a condition with a high degree of morbidity and health costs to the National Health Service (NHS), characterised by persistent pain, sensory, motor, trophic and autonomic signs and symptoms. The British Orthopaedic Association (BOA) and the Royal College of Physicians (RCP) have recommended treatment guidelines and care pathways for the management of acute Complex Regional Pain Syndrome. The objective of this scoping exercise was to use Freedom of Information (FOI) requests to ascertain whether NHS Trusts in England had such pathways and what they looked like. Methods FOI requests were sent to 126 English NHS Trusts on 9 March 2017 on behalf of the Complex Regional Pain Syndrome Clinical and Research Network UK, asking: “What does your acute Complex Regional Pain Care Syndrome pathway look like?” Results Replies were received by 95 NHS Trusts and of these 84 had relevant services but (82%) had no pathway or agreed initial management. Conclusions It appears to be common for no acute care pathway to exist for CRPS in NHS Trusts in England despite it being a domain in BOA national guidelines. The Royal College of Physicians guidelines also recommend integrated MDT care. Consequentially, BOA and Royal College of Physicians standards in acute CRPS management are not yet being followed in most acute NHS Trusts in England providing trauma care. Where there is a pathway agreed, it is rarely integrated and truly multidisciplinary.

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.

Introduction - Complex regional pain syndrome is a di-stressing neuropathic pain condition without known etiology and evidence based treatment. Case presentation - Here a posttraumatic severe case of complex regional pain syndrome is presented, successfully treated by amitriptyline monotherapy. Amitriptyline is one of the most effective evidence based treatments of peri-pheral diabetic neuropathic pain and other neuropathic pain syndromes. Discussion - Amitriptyline seems to be effective to decrease pain, autonomic and motor symptoms in chronic regional pain syndrome. Conclusion - Controlled trials may be warranted to test the effectiveness of amitriptyline in complex regional pain syndrome.

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 (CPRS) greatly affects the outcomes of distal radius fractures in terms of functional recovery, time away from work and patient satisfaction. The diagnosis is sometimes difficult to make in the immediate post-injury period. The disproportionate nature of the pain in the absence of differential diagnoses and the presence of a pain-free interval should arouse suspicion. The natural history consists of spontaneous improvement except in some refractory forms. The treatment is multidisciplinary combining a physician specializing in pain, therapist and psychologist coordinated by the surgeon who must not abandon the patient. Treatment aims to improve the patient's comfort and quality of life. Recent treatment approaches aimed at improving cortical reorganization have demonstrated their effectiveness. Surgery has to be considered even in the acute phase to address any causes of pain that can be resolved and address secondary stiffness. Significant progress has to be made in our understanding of the pathogenesis of CPRS to improve treatment and shift this condition to a regional pain syndrome.

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

Introduction Complex regional pain syndrome is a multifaceted condition, which is relatively common after distal radius fracture. Method A series of audits and service evaluations were conducted from 2004 to 2013 to investigate the incidence of complex regional pain syndrome type I and any correlation to tight, restrictive, over-flexed casts. Simple subsequent clinical and patient management changes were implemented and impact re-evaluated. Results These audits have contributed to organisational learning and a subsequent reduction in the incidence of complex regional pain syndrome type I in non-operatively managed distal radius fracture from 25%, in keeping with expected incidence in the relevant literature, to a rare event (Conclusion The authors suggest that careful attention to the prevention of complex regional pain syndrome through staff and patient awareness, vigilance for warning signs and minor modifications to the traditional management of distal radius fractures can significantly reduce the incidence of complex regional pain syndrome type I after distal radius fracture.

Chronic Regional Pain Syndrome (CRPS) is a condition that physical therapists may encounter in an outpatient orthopedic setting. In physical therapy (PT) treatment of CRPS addresses pain and the changes observed in the brain through the use of graded motor imagery (GMI).A 57-year-old female presented to an outpatient PT clinic with CRPS type 1. Complicating psychosocial factors such as kinesiophobia and catastrophization were present. The patient engaged in a treatment plan including GMI: pain neuroscience education (PNE), laterality training, motor imagery, and mirror training. As symptoms improved, graded functional exposure and functional restoration occurred.The patient was seen for a total of 26 visits over a 9-month period. FAAM measures exceeded reported clinically important change that was sustained at two-year follow-up. Long term outcomes showed no functional deficits related to her foot or ankle and minimal to no catastrophizing and fear avoidance behaviors.This case report showcases the use of GMI with a patient with CRPS type 1 in an outpatient orthopedic clinic. Clinicians may consider the use of GMI to progress a patient toward maximal functional gains.

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.

Chronic regional pain syndrome (CRPS) is a neuropathic pain syndrome that involves both peripheral and central sensitization. Described in the literature as early as 1872, CRPS has been described using different names and different symptoms over the years. Since many neuropathic pain syndromes are rare, complex, and exhibit overlapping signs and symptoms, diagnosing CRPS has been challenging. Recently the Orlando Criteria in 1993, the subsequent Budapest Criteria in 2003 have attempted to provide a more helpful and robust diagnostic framework. However, the multiplicity of signs and symptoms and allowable variations have resulted in a diagnostic template that accommodates what may actually be a wide variety of conditions and obscures a better understanding of CRPS. The Budapest Criteria make CRPS ultimately a diagnosis of exclusion, leaving clinicians with patients who may be CRPS Type I, CRPS Type II or the new CRPS-NOS. CRPS can be challenging to treat and many treatments are ineffective, possibly owing to the fact that the syndrome is currently defined in such a diffuse way. The current diagnostic criteria of CRPS have even called the entire syndrome into question. There is an urgent need to better define and describe CRPS so that it can be appropriately diagnosed and its mechanisms elucidated. That step will lead to better treatment.

The author presents a highly detailed case of a young man with a regional pain syndrome (CRPS), following a discrete episode of trauma to his hand. The pain itself became increasingly complicated to manage. It was compounded by difficulties in the acquisition and coordination of specialized consultative services that proved to be unavailable for patients managed in that county’s health system. This patient’s social isolation and low level of social function (much attributed to his symptomatic chronicity) added to the challenges of delivering care focused on his pain and its functional consequences.

Chronic pelvic pain, in its many forms, commonly has a myofascial component that must be considered in the evaluation and treatment of women and men seeking medical care. Myofascial pain syndrome is a regional pain syndrome characterized by myofascial trigger points. At this time, the exact mechanism surrounding the formation of a trigger point is not known. Myofascial pelvic pain can develop as a result of a trigger point within the pelvic floor musculature or from extra-pelvic muscles that can refer into the pelvic region. Identification and appropriate therapeutic management of the myofascial trigger points is paramount to successful treatment of the pain and symptoms associated with chronic pelvic pain.

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.

Chronic regional pain syndrome (CRPS) is a relatively common diagnosis that causes severe pain out of proportion to the stimuli as well as physical changes which is most commonly seen in the upper extremity. The diagnosis of CRPS is made on a clinical basis using the Orlando or Budapest criteria, with imaging being used as an adjunct or to rule out other causes of pain. Treatment should be started as soon as possible using a multidisciplinary approach including physical therapy, psychological therapy, topical or oral medications, and/or procedural interventions for severe cases.

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 number of people suffering from motor impairment is increasing as incidence involving limb injuries can easily happen. These injuries may be traumatic injuries, congenital deformities, neurological and arthritic conditions or regional pain syndrome. Some of these injuries need operative procedure, whilst others use interventive methods. Regardless of the treatment performed, a vital component in the road to recovery should include physical rehabilitation. This paper proposes the design of a Kinect-based framework for motor rehabilitation. Originally introduced as an add-on for the Xbox gaming console, Kinect offers the capability to track the motion of a human body in real time. This research makes use of that capability to combine the Kinect with an easily modifiable application to produce an individually customized home rehabilitation system that will motivate, provide feedback and track the progress of the rehabilitation patient. This paper also proposes an evaluation framework to evaluate the Kinect based home rehabilitation system based on the technology acceptance, the motivation of the patient, and the patient's learning style.

Functional, often called psychogenic, disorders are common in neurological practice. We illustrate clinical issues and highlight some recent research findings using six case studies of functional neurological disorders. We discuss dizziness as a functional disorder, describing the relatively new consensus term Persistent Posturo-Perceptual Dizziness (PPPD), axial jerking/myoclonus as a functional movement disorder, functional speech symptoms, post-concussion disorder with functional cognitive symptoms and finally advances in treatment of dissociative seizures and functional motor disorders.

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.