Nerve blocks in chronic pain therapy--are there any indications left?

Although diagnostic imaging is now highly developed, neural blockade provides another opportunity to test for a source of pain that may frequently leave no signature. Likewise, many neuropathic pains can not be tested by neurodiagnostic methods. This paper makes a case for the continued use of regional anesthesia to assist in the diagnosis and therapy of chronic pain. In particular, the example of autonomic blocks and blocks of the axial spine are emphasized. Nerve blocks require an understanding of the anatomy, physiology, pharmacology, and the ability to interpret critically their results.

Relaxation and music to reduce postsurgical pain.

AIMS: We investigated the effects of relaxation, music, and the combination of relaxation and music on postoperative pain, across and between two days and two activities (ambulation and rest) and across ambulation each day. This secondary analysis of a randomized controlled trial was conducted from 1995 to 1997. BACKGROUND: After surgery, patients do not always receive sufficient relief from opioids and may have undesired side-effects. More complete relief (10-30%) was found recently with adjuvant interventions of relaxation, music, and their combination. Comparison of effects between days and treatments have not been examined longitudinally. METHODS: With a repeated measures design, abdominal surgery patients (n = 468) in five US hospitals were assigned randomly to one of four groups; relaxation, music, their combination, and control. With institutional approval and written informed consent, subjects were interviewed and taught interventions preoperatively. Postoperative testing was at ambulation and rest on days 1 and 2 using visual analogue (VAS) sensation and distress of pain scales. RESULTS: Multivariate analysis indicated that although pain decreased by day 2, interventions were not different between days and activities. They were effective for pain across ambulation on each day, across ambulation and across rest over both days (all P < 0.001), and had similar effects by day and by activity. CONCLUSION: Nurses can safely recommend any of these interventions for pain on both postoperative days and at both ambulation and rest.

Pain outcomes after intestinal surgery.

Pain sensation and distress in 38 intestinal surgical patients were moderate to severe on postoperative day 1, ranging from 34 to 49 mm and 33 to 45 mm, respectively, on 100-mm scales. During ambulation, both increased from baseline to post-ambulation, P < 0.01. Half of the patients reported severe pain not relieved by analgesics, and although 44% learned a relaxation technique in the past, only 8% used one for pain after this surgery. Pain disturbed the sleep of 34% of the patients, and pain was related to respiratory, intestinal, febrile, and other complications in 18 (47%) subjects. Attentive analgesic use and nonpharmacologic therapies are recommended.

Sensation and Distress of Pain Scales: reliability, validity, and sensitivity.

Psychometric properties of the Sensation and Distress of Pain Visual Analogue Scales (VAS) are compared to dual numerical rating scales (NRS) with data from a randomized controlled trial of postoperative patients. On postoperative days 1 and 2, 15-minute test-retest reliability was .73 to .82 for the VAS and slightly lower for the NRS, r = .72 to .78, while convergent validity of the scales ranged from r = .90 to .92; construct validity of sensation and distress ranged from r = .72 to .85; and discriminant validity was lower, r = .65 to .78. Both instruments were significantly associated with pain reduction following treatment, p < .05 to .01. The VAS scores were significantly lower, p < .01 to .001, and more evenly distributed than NRS scores. It is recommended that the VAS be used in research to produce continuous scores that are more suited to parametric analysis.

Reflex sympathetic dystrophy: a sympathetically mediated pain syndrome or not?

Because of the controversy concerning the manner in which the sympathetic nervous system is involved in reflex sympathetic dystrophy (RSD), its name was changed to one having no mechanistic connotations. This article reviews the relevant literature in support of not only the taxonomical changes to complex regional pain syndrome (CRPS) but also provides evidence of sympathetic dysfunction demonstrated in animal models of neuropathic pain.

Complex regional pain syndrome (type I, RSD; type II, causalgia): controversies.

Introduction of the term complex regional pain syndromes (CRPS) as a replacement of the older terminology, reflex sympathetic dystrophy (RSD) and causalgia, has achieved two goals: it has focused attention on the diagnosis and treatment, and sent basic scientists back to their laboratories. The relation of sympathetically maintained pain and sympatholysis is examined, particularly as a neuropathic process that is found in many conditions, including CRPS. This review also focuses on recent observations proposing a pathologic basis in support of diagnosis and treatment of these disorders.

Pain after gynecologic surgery.

This article provides a descriptive profile of pain in 80 women during the first 2 days after gynecologic surgery in 4 hospitals. Surgical procedures included abdominal hysterectomy, oophorectomy, and laparotomy. Average pain was moderate on both days, but paired t tests indicated that pain increased significantly during ambulation on day 1 (P = .009, sensation; P < .001, distress) and on day 2 (P = .007, sensation; P = .030, distress). They both (P = .001) decreased significantly during rest on day 1, but not on day 2. Analysis of quartiles indicated that one fourth of the sample suffered severe sensation pain at all points on day 1 (60 to 74 mm on a 100-mm visual analogue scale), and moderate to severe sensation on day 2 (40 to 60 mm). The lowest quartile had mild pain on both days (11 to 28 mm on day 1, and 7 to 14 mm on day 2). Some patients (30%) reported that pain interrupted their sleep on the first 2 nights, and difficulty sleeping on the first postoperative night for any reason (65%) was related to greater pain during the next 2 days (r = .25 to .43). Although 41% of the women had previously used relaxation techniques for stress or pain, only 9% used it for pain after surgery. Results suggest that postoperative patients have moderate to severe pain that is incompletely relieved with patient-controlled analgesia. Nurses should encourage patients to press the patient-controlled analgesia button more often, report unrelieved pain, and use nonpharmacologic interventions.

Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive?

This is a multisite study examining the internal validity and comprehensiveness of the International Association for the Study of Pain (IASP) diagnostic criteria for Complex Regional Pain Syndrome (CRPS). A standardized sign/symptom checklist was used in patient evaluations to obtain data on CRPS-related signs and symptoms in a series of 123 patients meeting IASP criteria for CRPS. Principal components factor analysis (PCA) was used to detect statistical groupings of signs/symptoms (factors). CRPS signs and symptoms grouped together statistically in a manner somewhat different than in current IASP/CRPS criteria. As in current criteria, a separate pain/sensation criterion was supported. However, unlike in current criteria, PCA indicated that vasomotor symptoms form a factor distinct from a sudomotor/edema factor. Changes in range of motion, motor dysfunction, and trophic changes, which are not included in the IASP criteria, formed a distinct fourth factor. Scores on the pain/sensation factor correlated positively with pain duration (P<0. 001), but there was a negative correlation between the sudomotor/edema factor scores and pain duration (P<0.05). The motor/trophic factor predicted positive responses to sympathetic block (P<0.05). These results suggest that the internal validity of the IASP/CRPS criteria could be improved by separating vasomotor signs/symptoms (e.g. temperature and skin color asymmetry) from those reflecting sudomotor dysfunction (e.g. sweating changes) and edema. Results also indicate motor and trophic changes may be an important and distinct component of CRPS which is not currently incorporated in the IASP criteria. An experimental revision of CRPS diagnostic criteria for research purposes is proposed. Implications for diagnostic sensitivity and specificity are discussed.

External validation of IASP diagnostic criteria for Complex Regional Pain Syndrome and proposed research diagnostic criteria. International Association for the Study of Pain.

Recent work in our research consortium has raised internal validity concerns regarding the current IASP criteria for Complex Regional Pain Syndrome (CRPS), suggesting problems with inadequate sensitivity and specificity. The current study explored the external validity of these IASP criteria for CRPS. A standardized evaluation of signs and symptoms of CRPS was conducted by study physicians in 117 patients meeting IASP criteria for CRPS, and 43 patients experiencing neuropathic pain with established non-CRPS etiology (e.g. diabetic neuropathy, post-herpetic neuralgia). Multiple discriminant function analyses were used to test the ability of the IASP diagnostic criteria and decision rules, as well as proposed research modifications of these criteria, to discriminate between CRPS patients and those experiencing non-CRPS neuropathic pain. Current IASP criteria and decision rules (e.g. signs or symptoms of edema, or color changes or sweating changes satisfy criterion 3) discriminated significantly between groups (P < 0.001). However, although sensitivity was quite high (0.98), specificity was poor (0.36), and a positive diagnosis of CRPS was likely to be correct in as few as 40% of cases. Empirically-based research modifications to the criteria, which are more comprehensive and require presence of signs and symptoms, were also tested. These modified criteria were also able to discriminate significantly, between the CRPS and non-CRPS groups (P < 0.001). A decision rule, requiring at least two sign categories and four symptom categories to be positive optimized diagnostic efficiency, with a diagnosis of CRPS likely to be accurate in up to 84% of cases, and a diagnosis of non-CRPS neuropathic pain likely to be accurate in up to 88% of cases. These results indicate that the current IASP criteria for CRPS have inadequate specificity and are likely to lead to overdiagnosis. Proposed modifications to these criteria substantially improve their external validity and merit further evaluation.

Relief of postoperative pain with jaw relaxation, music and their combination.

The aim of this randomized controlled trial was to determine the effect of jaw relaxation, music and the combination of relaxation and music on postoperative pain after major abdominal surgery during ambulation and rest on postoperative days 1 and 2. Opioid medication provided for pain, following abdominal surgery, does not always give sufficient relief and can cause undesired side effects. Thus, additional interventions such as music and relaxation may provide more complete relief. Previous studies have found mixed results due to small sample sizes and other methodological problems. In a rigorous experimental design, 500 subjects aged 18-70 in five Midwestern hospitals were randomly assigned by minimization to a relaxation, music, relaxation plus music, or control group. Interventions were taught preoperatively and tested postoperatively. The same amount of time was spent with subjects in the control group. Pain was measured with the visual analogue sensation and distress of pain scales. Demographic and surgical variables, and milligrams of parenteral or oral opioids in effect at the time of testing were not significantly different between the groups, nor did they correlate with pain scores. Controlling for pretest sensation and distress, orthogonal a priori contrasts and multivariate analysis of covariance indicated that the three treatment groups had significantly less pain than the controls, (P = 0.028-0.000) which was confirmed by the univariate analysis of covariance (P = 0.018-0.000). Post hoc multivariate analysis revealed that the combination group had significantly less sensation and distress of pain than the control group on all post-tests (P = 0.035-0.000), and the relaxation and music groups had significantly less on all tests (P = 0.022-0.000) except after ambulation. At post ambulation those using relaxation did not have significantly less pain than the controls on both days and those using music did not on day 1, although there were some univariate effects. A corresponding significant decrease in mastery of the interventions from pre to post ambulation suggests the need for reminders to focus on the intervention during this increased activity. Physicians and nurses preparing patients for surgery and caring for them afterward, should encourage patients to use relaxation and music as adjuvants to medication for postoperative pain.

Spinal cord stimulation for the management of complex regional pain syndromes.

The following account discusses the possible mechanisms by which spinal cord stimulation can control symptoms of Complex Regional Pain Syndromes. A review of the literature with a methodology for its incorporation in a treatment algorithm and associated technical aspects is suggested.

Complex Regional Pain Syndromes: guidelines for therapy.

This report aims to present an orderly approach to the treatment of Chronic Regional Pain Syndrome (CRPS) types I and II through an algorithm. The central theme is functional restoration: a coordinated but progressive approach that introduces each of the treatment modalities needed to achieve both remission and rehabilitation. Reaching objective and measurable rehabilitation goals is an essential element. Specific exercise therapy to reestablish function after musculoskeletal injury is central to this functional restoration. Its application to CRPS is more contingent on varying rates of progress that characterize the restoration of function in patients with CRPS. Also, the various modalities that may be used, including analgesia by pharmacologic means or regional anesthesia or the use of neuromodulation, behavioral management, and the qualitatively different approaches that are unique to the management of children with CRPS, are provided only to facilitate functional improvement in a stepwise but methodical manner. Patients with CRPS need an individual approach that requires extreme flexibility. This distinguishes the management of these conditions from other well-described medical conditions having a known pathophysiology. In particular, the special biopsychosocial factors that are critical to achieving a successful outcome are emphasized. This algorithm is a departure from the contemporary heterogeneous approach to treatment of patients with CRPS. The underlying principles are motivation, mobilization, and desensitization facilitated by the relief of pain and the use of pharmacologic and interventional procedures to treat specific signs and symptoms. Self-management techniques are emphasized, and functional rehabilitation is the key to the success of this algorithm.

Complex regional pain syndrome of the breast in a patient after breast reduction.

Complex regional pain syndrome (CRPS) is characterized by devastating pain, swelling, and cutaneous discoloration that result from vasomotor dysfunction caused by an abnormally accelerating sympathetic loop reflex after trauma or surgery. Although in the extremities CRPS is well documented as reflex sympathetic dystrophy, it only has been reported anecdotally in the breast after modified radical mastectomy and never reported after breast reduction. We report CRPS in the right breast of a 27-year-old woman after revision breast reduction surgery. The patient had signs of CRPS and symptoms of pain, swelling, epidermal scaling, and cutaneous temperature changes lasting more than 1 year. Liquid crystal thermographic scanning revealed a persistent, clinically significant hypothermic region in the affected breast. Intravenous phentolamine temporarily relieved the symptoms. Subsequent sympathetic blockade of the stellate ganglion alleviated chronic CRPS symptoms. Surgeons should be alert that CRPS may need to be considered in the differential diagnosis of chronic disproportionate pain after breast surgery. Early identification and treatment will help alleviate persistent CRPS symptoms and avoid soft-tissue changes.

Stimulation of the central and peripheral nervous system for the control of pain.

After suffering some setbacks since its introduction in 1967, stimulation of the spinal and peripheral nervous systems has undergone rapid development in the last ten years. Based on principles enunciated in the Gate Control Hypothesis that was published in 1968, stimulation-produced analgesia [SPA] has been subjected to intensive laboratory and clinical investigation. Historically, most new clinical ideas in medicine have tended to follow a three-tiered course. Initial enthusiasm gives way to a reappraisal of the treatment or modality as side-effects or unanticipated problems arise. The last and third phase proceeds at a more measured pace as the treatment is refined by experience. This review is divided into three parts as it traces the progress of spinal cord stimulation [SCS] and peripheral nerve stimulation [PNS]. The review commences with a discussion of the theory of SCS and PNS, and is followed by early reports during which it became apparent that the modality is essentially only effective in the treatment of neuropathic pain. The last section describes the modern experience including efficacy in specific types of pain and concludes with recent accomplishments that dramatize the relief of pain which can be achieved in nonoperable peripheral vascular disease or myocardial ischemia. Over the years, a search for those transmitters that might be influenced by spinal cord stimulation focused on somatostatin, cholecystokinin (CCK), vasoactive intestinal polypeptide (VIP), neurotensin and other amines, although only substance "P" was implicated. More recently, in animal studies, evidence that GABA-ergic systems are affected may explain the frequent successful suppression of allodynia that follows spinal cord stimulation. During the past eight years, much attention has been directed to studies that use a chronic neuropathic pain model. While PNS held significant promise as a pain relieving modality, early electrode systems and their surgical implantation yielded variable results due to evolving technical and surgical skills. These results dramatically reduced the continued development of PNS, which then gave way to a preoccupation with SCS. Modern development of SCS with outcome studies, particularly in relation to failed back surgery syndrome [FBSS] and the outcome of peripheral nerve surgery for chronic regional pain syndromes, has earned both modalities a place in the ongoing management of patients with intractable neuropathic pain. The last section, dealing with pain of peripheral vascular and myocardial ischemia, is perhaps one of the more exciting developments in stimulation produced analgesia and as the papers discussed demonstrate, can provide a level of analgesia and efficacy that is unattainable by other treatment modalities. SCS and PNS has an important role to play in the management of conditions that are otherwise refractory to conservative or other conventional management.

Long-term results of peripheral nerve stimulation for reflex sympathetic dystrophy.

This prospective, consecutive series describes peripheral nerve stimulation (PNS) for treatment of severe reflex sympathetic dystrophy (RSD) or complex regional pain syndrome, in patients with symptoms entirely or mainly in the distribution of one major peripheral nerve. Plate-type electrodes were placed surgically on affected nerves and tested for 2 to 4 days. Programmable generators were implanted if 50% or more pain reduction and objective improvement in physical changes were achieved. Patients were followed for 2 to 4 years and a disinterested third-party interviewer performed final patient evaluations. Of 32 patients tested, 30 (94%) underwent permanent PNS placement. Long-term good or fair relief was experienced in 19 (63%) of 30 patients. In successfully treated patients, allodynic and spontaneous pain was reduced on a scale of 10 from 8.3 +/- 0.3 preimplantation to 3.5 +/- 0.4 (mean +/- standard error of the mean) at latest follow up (p<0.001). Changes in vasomotor tone and patient activity levels were markedly improved but motor weakness and trophic changes showed less improvement. Six (20%) of the 30 patients undergoing PNS placement returned to part-time or full-time work after being unemployed prestimulator implantation. Initial involvement of more than one major peripheral nerve correlated with a poor or no relief rating (p<0.01). Operative modifications that minimize technical complications are described. This study indicates that PNS can provide good relief for RSD that is limited to the distribution of one major nerve.