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Concept: Complex regional pain syndrome

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Animal and human studies indicate that electrical stimulation of DRG neurons may modulate neuropathic pain signals.ACCURATE, a pivotal, prospective, multi-center, randomized-comparative effectiveness trial, was conducted in 152 subjects diagnosed with complex regional pain syndrome (CRPS) or causalgia in the lower extremities. Subjects received neurostimulation of the DRG or dorsal column (SCS). The primary endpoint was a composite of safety and efficacy at 3 months and subjects were assessed through 12 months for long term outcomes and adverse events. The pre-defined primary composite endpoint of treatment success was met for subjects with a permanent implant who reported 50% or greater decrease in VAS from pre-implant baseline and who did not report any stimulation-related neurological deficits.No subjects reported stimulation-related neurological deficits. The percentage of subjects receiving ≥ 50% pain relief and treatment success was greater in the DRG arm (81.2%) versus the SCS arm (55.7%, p<0.001) at 3 months. Device-related and serious adverse events were not different between the 2 groups. DRG stimulation also demonstrated greater improvements in quality of life and psychological disposition. Finally, subjects using DRG stimulation reported less postural variation in paresthesia (p<0.001) and reduced extraneous stimulation in non-painful areas (p=0.014), indicating DRG stimulation provided more targeted therapy to painful parts of the lower extremities.As the largest prospective, randomized comparative effectiveness trial to date, the results show DRG stimulation provided a higher rate of treatment success with less postural variation in paresthesia intensity compared to SCS.

Concepts: Nervous system, Dorsal root ganglion, Neurology, Pain, Nociception, Suffering, Complex regional pain syndrome, Peripheral neuropathy

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The choroid plexus, located in brain ventricles, has received surprisingly little attention in clinical neuroscience. In morphometric brain analysis, we serendipitously found a 21% increase in choroid plexus volume in 12 patients suffering from complex regional pain syndrome (CRPS) compared with age- and gender-matched healthy subjects. No enlargement was observed in a group of 8 patients suffering from chronic pain of other etiologies. Our findings suggest involvement of the choroid plexus in the pathogenesis of CRPS. Since the choroid plexus can mediate interaction between peripheral and brain inflammation, our findings pinpoint the choroid plexus as an important target for future research of central pain mechanisms.

Concepts: Psychology, Medicine, Neuroscience, Pain, Cerebrospinal fluid, Complex regional pain syndrome, Ventricular system, Choroid plexus

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Complex regional pain syndrome (CRPS) is a debilitating neuropathic pain condition that has been extensively reported in the extremities following variable degrees of nerve trauma. CRPS has rarely been reported in the orofacial region. We report 2 orofacial pain patients whose clinical phenotypes fit the criteria for CRPS. Two cases of orofacial complex regional pain syndrome (CRPS) are described, both of which began following trigeminal nerve trauma. In case 1 the patient presented with redness of the ipsilateral ear during painful episodes, pain that extended into the ipsilateral arm and was associated with variations in the appearance of the ipsilateral hand. Symptoms also included “electric-burning pain” of the right side of the head, including the ear, teeth, jaw, eye, neck, and cheek. In case 2 the patient presented with intractable pain of the upper left face, head, and neck accompanied by color changes in the painful areas, which increased with exposure to cold.

Concepts: Head and neck, Patient, Left-wing politics, Pain, Cranial nerves, Myofascial pain syndrome, Complex regional pain syndrome, Peripheral neuropathy

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There is evidence that inflammatory processes are involved at least in the early phase of complex regional pain syndrome (CRPS). We compared a panel of pro- and anti-inflammatory cytokines in skin blister fluids and serum from patients with CRPS and patients with upper limb pain of other origin (non-CRPS) in the early stage (< 1 year) and after six months of pain treatment.

Concepts: Complex regional pain syndrome

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Complex regional pain syndrome (CRPS) is a disorder that is often challenging to treat and can be associated with a prolonged course of severe pain. Therapy of CRPS remains controversial; the pain often can be very difficult to control, and treatment includes medications, physical therapy, regional anesthesia, and neuromodulation.

Concepts: Pain, Myofascial pain syndrome, Complex regional pain syndrome

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Complex Regional Pain Syndrome (CRPS) is a neuropathic pain syndrome, which involves glial activation and central sensitization in the central nervous system. Here, we describe positive outcomes of two CRPS patients, after they were treated with low-dose naltrexone (a glial attenuator), in combination with other CRPS therapies. Prominent CRPS symptoms remitted in these two patients, including dystonic spasms and fixed dystonia (respectively), following treatment with low-dose naltrexone (LDN). LDN, which is known to antagonize the Toll-like Receptor 4 pathway and attenuate activated microglia, was utilized in these patients after conventional CRPS pharmacotherapy failed to suppress their recalcitrant CRPS symptoms.

Concepts: Central nervous system, Nervous system, Brain, Neurology, Microglia, Low dose naltrexone, Complex regional pain syndrome, Peripheral neuropathy

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Complex Regional Pain Syndrome (CRPS) is a persistent pain condition that remains incompletely understood and challenging to treat. Historically, a wide range of different outcome measures have been used to capture the multidimensional nature of CRPS. This has been a significant limiting factor in the advancement of our understanding of the mechanisms and management of CRPS.In 2013, an international consortium of patients, clinicians, researchers and industry representatives was established, to develop and agree on a minimum core set of standardised outcome measures for use in future CRPS clinical research, including but not limited to clinical trials within adult populationsThe development of a core measurement set was informed through workshops and supplementary work, using an iterative consensus process. ‘What is the clinical presentation and course of CRPS, and what factors influence it?’ was agreed as the most pertinent research question that our standardised set of patient-reported outcome measures should be selected to answer. The domains encompassing the key concepts necessary to answer the research question were agreed as: pain, disease severity, participation and physical function, emotional and psychological function, self efficacy, catastrophizing and patient’s global impression of change. The final core measurement set included the optimum generic or condition-specific patient-reported questionnaire outcome measures, which captured the essence of each domain, and one clinician reported outcome measure to capture the degree of severity of CRPS. The next step is to test the feasibility and acceptability of collecting outcome measure data using the core measurement set in the CRPS population internationally.

Concepts: Clinical trial, Informed consent, The Canon of Medicine, Avicenna, Clinical research, Clinical trial protocol, Clinical data acquisition, Complex regional pain syndrome

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Complex regional pain syndrome (CRPS) is a chronic, intensified localized pain condition that can affect children and adolescents as well as adults, but is more common among adolescent girls. Symptoms include limb pain; allodynia; hyperalgesia; swelling and/or changes in skin color of the affected limb; dry, mottled skin; hyperhidrosis and trophic changes of the nails and hair. The exact mechanism of CRPS is unknown, although several different mechanisms have been suggested. The diagnosis is clinical, with the aid of the adult criteria for CRPS. Standard care consists of a multidisciplinary approach with the implementation of intensive physical therapy in conjunction with psychological counseling. Pharmacological treatments may aid in reducing pain in order to allow the patient to participate fully in intensive physiotherapy. The prognosis in pediatric CRPS is favorable.

Concepts: Medicine, The Canon of Medicine, Therapy, Syndromes, Pain, Complex regional pain syndrome, Kanye West, Counseling psychology

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Complex Regional Pain Syndrome (CRPS) is associated with non-dermatomal patterns of pain, unusual movement disorders, and somatovisceral dysfunctions. These symptoms are viewed by some neurologists and psychiatrists as being psychogenic in origin. Recent evidence, however, suggests that an autoimmune attack on self-antigens found in the peripheral and central nervous system may underlie a number of CRPS symptoms. From both animal and human studies, evidence is accumulating that neuroinflammation can spread, either anterograde or retrograde, via axonal projections in the CNS, thereby establishing neuroinflammatory tracks and secondary neuroinflammatory foci within the neuraxis. These findings suggest that neuroinflammatory lesions, as well as their associated functional consequences, should be evaluated during the differential diagnosis of non-dermatomal pain presentations, atypical movement disorders, as well as other “medically unexplained symptoms”, which are often attributed to psychogenic illness.

Concepts: Central nervous system, Nervous system, Brain, Medical terms, Neuroscience, Neurology, Axon, Complex regional pain syndrome

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Complex regional pain syndrome (CRPS) is a chronic pain condition associating sensory, motor, trophic and autonomic symptoms in one limb. Cognitive difficulties have also been reported, affecting the patients' ability to mentally represent, perceive and use their affected limb. However, the nature of these deficits is still a matter of debate. Recent studies suggest that cognitive deficits are limited to body-related information and body perception, while not extending to external space. Here we challenge that statement, by using temporal order judgment (TOJ) tasks with tactile (i.e. body) or visual (i.e. extra-body) stimuli in patients with upper-limb CRPS. TOJ tasks allow characterizing cognitive biases to the advantage of one of the two sides of space. While the tactile TOJ tasks did not show any significant results, significant cognitive biases were observed in the visual TOJ tasks, affecting mostly the perception of visual stimuli occurring in the immediate vicinity of the affected limb. Our results clearly demonstrate the presence of visuospatial deficits in CRPS, corroborating the cortical contribution to the CRPS pathophysiology, and supporting the utility of developing rehabilitation techniques modifying visuospatial abilities to treat chronic pain.

Concepts: Cognition, Perception, Pain, Sensory system, Sense, Cognitive bias, Complex regional pain syndrome, Bias