Prevention of Complex Regional Pain Syndrome type 1 after conservative reatment of a distal radius fracture with a home exercise program: A proof-of-concept study.

Prevention of CRPS-1, a post-traumatic pain syndrome, after a distal radius fracture is important as this syndrome might lead to chronic pain and serious disabilities. In several studies, it was shown that CRPS-1 can be cured with exercise and graded activities. In a prospective cohort study, a home exercise program with progressive loading exercises was applied immediately after cast removal in patients with a distal radius fracture. After three months, patients were interviewed by telephone using the subjective Budapest diagnostic criteria for CRPS-1. In our study, 56 patients were included and 9 patients (16%) scored positive on the subjective diagnostic criteria. None of the 9 patients was diagnosed with CRPS-1. This study indicates that a home exercise program after conservative treatment of distal radius fracture is a safe and effective option to prevent CRPS-1. A larger study is needed to prove the preventive power of this home exercise program.

Perioperative Management of a Parturient with Complex Regional Pain Syndrome for Elective C-Section.

A 33 year-old female at 38 weeks gestation with a history of Complex Regional Pain Syndrome (CRPS) Type 1 of the upper extremities, diagnosed 13 years prior to this admission, was scheduled for an elective cesarean section (C-Section). She refused neuraxial anesthesia and requested general anesthesia. This abstract discusses the general anesthesia steps taken to pre-empt recurrence of CRPS symptoms.

[Complex regional pain syndrome type 1: negating the myth]. / Complex regionaal pijnsyndroom type 1: de mythe ontkracht.

Complex regional pain syndrome type 1 (CRPS-1) was identified in the Netherlands more than 30 years ago, but since then the arguments supporting this diagnosis have become weaker. Incidence has decreased, it is often not possible to make a definite diagnosis, the pathophysiology remains unclear and treatments are extremely diverse. Since the patient group is so heterogeneous, it is often unclear exactly which patients should be included. Disuse due to immobilization can give an identical clinical picture, including the inflammatory parameters that are seen in CRPS-1. CRPS-1 following injury can be prevented with exercise, and incidence is declining dramatically. Taking these factors into consideration, we support the view that CRPS-1 is not an illness but rather a 'disuse syndrome' as a result of immobilization, or there may be a missed underlying diagnosis.

Graded motor imagery and the impact on pain processing in a case of CRPS.

OBJECTIVE: Graded motor imagery (GMI) shows promising results for patients with complex regional pain syndrome (CRPS). METHODS: In a case with chronic unilateral CRPS type I, we applied GMI for 6 weeks and recorded clinical parameters and cerebral activation using functional magnetic resonance imaging (fMRI; pre-GMI, after each GMI block, and after 6 mo). Changes in fMRI activity were mapped during movement execution in areas associated with pain processing. A healthy participant served as a control for habituation effects. RESULTS: Pain intensity decreased over the course of GMI, and relief was maintained at follow-up. fMRI during movement execution revealed marked changes in S1 and S2 (areas of discriminative pain processing), which seemed to be associated with pain reduction, but none in the anterior insula and the anterior cingulate cortex (areas of affective pain processing). After mental rotation training, the activation intensity of the posterior parietal cortex was reduced to one third. DISCUSSION: Our case report develops a design capable of differentiating cerebral changes associated with behavioral therapy of CRPS type I study.

Functional orthosis in shoulder joint subluxation after ischaemic brain stroke to avoid post-hemiplegic shoulder-hand syndrome: a randomized clinical trial.

OBJECTIVE: To examine whether the use of a shoulder joint functional orthosis over four weeks can mitigate the development or progression of the shoulder-hand syndrome in patients with shoulder joint subluxation after stroke. DESIGN: Two-armed randomized controlled trial. SETTING: Rehabilitation unit of a neurological hospital, single centre. SUBJECTS: Forty-one patients with caudal subluxation of the glenohumeral joint and hemiparesis of the upper extremity after ischaemic brain stroke. INTERVENTIONS: Support by functional orthosis Neuro-Lux (Sporlastic, Nürtingen, Germany) on top of usual care according to current guidelines (experimental, n = 20) versus usual care alone (control, n = 21). MAIN MEASURES: Weekly shoulder-hand syndrome scores (severity of clinical symptoms ranging from 0 to 14), discomfort caused by the orthosis, and its usage rate. The primary outcome was the average shoulder-hand syndrome score on days 14, 21 and 28, adjusted for the baseline shoulder-hand syndrome score. RESULTS: The adjusted mean shoulder-hand syndrome score was lower by 3.1 in the intervention compared to the control subjects (95% confidence interval 1.9 to 4.3, P < 0.0001). Marginal or no discomfort from treatment with the orthosis was reported in 15 patients (75%), and only a single patient (5%) felt severe discomfort during the entire treatment. Use of the orthosis during the prescribed time was 89%. CONCLUSIONS: The orthosis examined in this trial has been successfully shown to reduce and prevent the development of clinical symptoms of shoulder-hand syndrome. Timing and duration of application of the orthosis as well as its combination with other therapeutic measures should be investigated in future clinical trials.

[Prophylaxis of CRPS I and recurrent CRPS I]. / Prophylaxe des CRPS I und des CRPS I-Rezidivs.

In the foreground of the avoidance of a CRPS as well as a recurrent CRPS, also pathophysiological considerations and use-possibilities of different drugs stand beside the observance of generally valid principles for treatment. Its consistent transposition cannot certainly prevent the CRPS in each case admittedly, the installment of the appearance or recurrence of a CRPS clearly lowers however.

[Complex regional pain syndrome (CRPS I) in hand surgery--misfortune of fate or avoidable? The viewpoint of a hand surgeon with many years of experience in this problem]. / Das komplexe regionale Schmerzsyndrom (CRPS I) in der Handchirurgie--schicksalshaft oder vermeidbar? Sichtweise eines Handchirurgen mit jahrzehntelanger Erfahrung mit dem Problem.

The complex regional pain syndrome type I (CRPS I) is a complication of the healing process of the whole body, not solely a part of it (e. g., the hand), which is caused by a multiplicity of factors. My conviction that the CRPS should less be considered as a misfortune of fate but rather can be avoided in the majority of cases is based on my experience from the last 25 years. The most important prognostic factor is the time period between the first symptoms and the beginning of the therapy.

Effect of vitamin C on prevention of complex regional pain syndrome type I in foot and ankle surgery.

BACKGROUND: The public health cost impact of complex regional pain syndrome type I (CRPS I) is considerable in both emergency and scheduled orthopaedic surgery. We proposed to assess the effectiveness of vitamin C in prevention of CRPS I in foot and ankle surgery. METHODS: We carried out a "before-after" quasi-experimental study comparing two chronologically successive groups without (Group I: July 2002-June 2003) and with (Group II: July 2003-June 2004) preventive 1g daily vitamin C treatment. All patients having surgery on the foot or ankle were enrolled, with the exception of diabetic foot cases. Several factors were analysed: sex, age, type of pathology, history of CRPS I, psychological context, tourniquet time, and cast immobilisation time. RESULTS: 420 feet (392 patients) were included in the study: 185 in Group I, 235 in Group II. CRPS I occurred in 18 cases in Group I (9.6%) and 4 cases in Group II (1.7%) (p<10(-4)), with history of CRPS I as a significantly correlated factor (relative risk=10.4). The psychological context (anxio-depressive state) showed a (sub-significant) tendency to increase the risk of CRPS I (relative risk=2.6). CONCLUSION: Vitamin C has been shown to be effective in preventing CRPS I secondary to wrist fracture, but few data are available with respect to foot and ankle cases. The present study demonstrates the effectiveness of vitamin C in preventing CRPS I of the foot and ankle-a frequent complication in our control group (9.6%). The authors recommend preventive management by vitamin C.

Use of calcitonin to prevent complex regional pain syndrome type I in severe hemiplegic patients after stroke.

PURPOSE: To evaluate the effects of calcitonin in preventing complex regional pain syndrome type I (CRPS) in patients with severe hemiplegia following stroke. METHODS: In this observer-blinded, controlled study comparison with historical controls between April 2003 and May 2004, subjects comprised consecutive patients with post-stroke hemiplegia admitted between June 2004 and September 2005, with any upper limb or finger graded as Brunnstrom stage (BrST) III or below. One group was administered intramuscular injection of 20 units of elcatonin (EL) (Asu(1-7) eel calcitonin) weekly from immediately after admission to discharge, together with rehabilitation therapy. The control group received rehabilitation therapy alone. Patients were observed during the in-hospital rehabilitation period. The main outcome measure was onset of CRPS. RESULTS: Incidence of CRPS in all patients with post-stroke hemiplegia during the control period was about 8.2%, similar to recent studies. Limited to serious hemiplegic patients graded as BrST III or below, incidence of CRPS was significantly lower in the EL group (12.5%) than in controls (57.1%). No significant differences in patient background were seen between groups. CRPS was completely prevented when EL injection was started 6 weeks after stroke. CONCLUSION: Intramuscular calcitonin appears to suppress onset of CRPS after stroke, particularly when started early after stroke.

Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study.

BACKGROUND: Complex regional pain syndrome type I is treated symptomatically. A protective effect of vitamin C (ascorbic acid) has been reported previously. A dose-response study was designed to evaluate its effect in patients with wrist fractures. METHODS: In a double-blind, prospective, multicenter trial, 416 patients with 427 wrist fractures were randomly allocated to treatment with placebo or treatment with 200, 500, or 1500 mg of vitamin C daily for fifty days. The effect of gender, age, fracture type, and cast-related complaints on the occurrence of complex regional pain syndrome was analyzed. RESULTS: Three hundred and seventeen patients with 328 fractures were randomized to receive vitamin C, and ninety-nine patients with ninety-nine fractures were randomized to receive a placebo. The prevalence of complex regional pain syndrome was 2.4% (eight of 328) in the vitamin C group and 10.1% (ten of ninety-nine) in the placebo group (p=0.002); all of the affected patients were elderly women. Analysis of the different doses of vitamin C showed that the prevalence of complex regional pain syndrome was 4.2% (four of ninety-six) in the 200-mg group (relative risk, 0.41; 95% confidence interval, 0.13 to 1.27), 1.8% (two of 114) in the 500-mg group (relative risk, 0.17; 95% confidence interval, 0.04 to 0.77), and 1.7% (two of 118) in the 1500-mg group (relative risk, 0.17; 95% confidence interval, 0.04 to 0.75). Early cast-related complaints predicted the development of complex regional pain syndrome (relative risk, 5.35; 95% confidence interval, 2.13 to 13.42). CONCLUSIONS: Vitamin C reduces the prevalence of complex regional pain syndrome after wrist fractures. A daily dose of 500 mg for fifty days is recommended.

Chronic pain after surgery: what can we do to prevent it.

The development of chronic pain after surgery is not an uncommon event. Despite increased attention devoted to this topic in the recent medical literature, little is known about the underlying mechanisms, natural history, and response to therapy of each syndrome. Central nervous system plasticity that occurs in response to tissue injury may contribute to the development of persistent postsurgical pain. As evidence continues to accumulate concerning the role of central sensitization in the prolongation of postoperative pain, many researchers have focused on methods to prevent central neuroplastic changes from occurring through the use of preemptive or preventative analgesic techniques. Effective preventative analgesic techniques may be useful in reducing not only acute pain but also chronic postsurgical pain and disability. This review examines the efficacy of using a variety of analgesic techniques aimed at preventing or reducing chronic pain after surgery. Specific chronic postsurgical pain syndromes evaluated include complex regional pain syndrome, phantom limb pain, chronic donor site pain, post-thoracotomy pain syndrome, and postmastectomy pain syndrome.

[Prevention of algodystrophy of the upper limb]. / Zapobieganie algodystrofii koniczyny górnej.

Treatment of algodystrophy is a challenge. Early recognition and immediate commencement of effective therapy gives a real chance of recovery, whereas progression into chronic phase is associated with poor prognosis and disability of the limb. Prevention of the condition is a reasonable approach, but little is known about it. Some authors have claimed that careful operative technique, anatomic dissection, avoidance of nerve traction, proper postoperative care and early mobilization of the limb after trauma or operation can reduce risk the frequency of algodystrophy, but this has not been scientifically confirmed. This paper presents current knowledge about prophylaxis of algodystrophy, based on literature and author's own experience. It was stated that, as yet, no specific, effective measures are known to prevent algodystrophy. Administration of 0.5 g vitamin C for 50 days after fracture of the distal radius reduces risk of the condition, but is was reported in only one study. Operation of unstable distal radial fractures, avoiding of tight, uncomfortable plaster casts and painful, forced physiotherapy is believed to reduce risk of algodystrophy, but it is based on observation rather than scientific evidence. Patients who recovered form algodystrophy are not more susceptible to recurrence after further trauma or surgery. An early recognition of incipient algodystrophy and immediate commencement of effective therapy (i.e., with Mannitol and Dexamethasone) was found to be the most important part of prophylaxis of the development of the florid condition.

Current management of reflex sympathetic dystrophy syndrome (complex regional pain syndrome type I).

Although no major advances have occurred in the curative treatment of reflex sympathetic dystrophy syndrome (RSDS), new pathogenic insights may soon lead to innovative approaches, which may also prove effective in alleviating some forms of neuropathic pain. Preventing nerve compression and ischemia-reperfusion injury constitute valuable measures for preventing RSDS. Vitamin C administration can also prevent RSDS, together with clonidine in high-risk patients. Short-term glucocorticoid therapy has been found effective in preventing RSDS after stroke but has not been evaluated in other situations. Beneficial effects of bisphosphonates have been documented in several placebo-controlled trials. Placebo-controlled trials of ketamine and spinal cord stimulation are in order to confirm or refute the promising results obtained in open-label studies. Mirror visual feedback was introduced recently for the rehabilitation of patients with RSDS but needs to be evaluated in randomized controlled trials.

A case of recurrent and migratory complex regional pain syndrome type I: Prevention by gabapentin.

Complex regional pain syndrome type I (CRPS I) or reflex sympathetic dystrophy (RSD) is a painful and disabling neuropathic pain syndrome. We report a case of a patient who has experienced CRPS I four times with an unidentified cause for all recurrences. The patient responded well to a combination of physiotherapy and intravenous regional sympathetic block in the first two attacks, but not in the fourth one. Gabapentin was effective in the last two attacks. Gabapentin was gradually discontinued 12 months after the last attack and no other recurrence was observed for a follow-up period of 9 months. This case suggests that gabapentin might be considered in the treatment and prevention of CRPS I.

Continuous peripheral nerve blocks at home for treatment of recurrent complex regional pain syndrome I in children.

BACKGROUND: Recurrent complex regional pain syndrome I is not rare in the pediatric population. The authors conducted this study to evaluate the efficacy of continuous peripheral nerve blocks with elastomeric disposable pumps associated with initial Bier blocks for the treatment of recurrent complex regional pain syndrome I in children. METHODS: After parental informed consent, 13 children who did not respond to conventional complex regional pain syndrome treatment were included (mean age, 13 yr; range, 9-16 yr). After general anesthesia, peripheral nerve block was performed using 0.5 ml/kg lidocaine, 1%, with epinephrine and 0.5% ropivacaine injected in the peripheral nerve block catheter. Then, a 20-min Bier block was performed using a tourniquet and 0.2 ml/kg lidocaine, 1%; 3 ml/kg hydroxyethyl starch 130/06; and 5 mg/kg buflomedil injected intravenously. A solution of 0.1 ml . kg . h continuous ropivacaine, 0.2%, was infused through the catheter using an elastomeric pump for 96 h. Need for rescue analgesia, occurrence of side effects, and status of motor and sensory block were recorded at hours 1, 6, 12, 24, 48, 72, and 96. Children and parents completed a satisfaction assessment. All of the children had follow-up visits after 2 months. RESULTS: Postoperative analgesia was excellent. The median pain score was 0 for each period studied. Motor blockade was minimal before 12 h (median, 1) and absent thereafter. One child needed rescue analgesia. All children were able to walk easily after the initial 24-h period (walking score, > 4). Children and parents were all satisfied. Children returned home under parental surveillance beginning in the 24th hour. Neither peripheral nerve block nor Bier block caused side effects. After 2 months, none of the children exhibited any clinical symptom of recurrent complex regional pain syndrome. CONCLUSION: Ambulatory continuous peripheral nerve block associated with an initial Bier block seems to be a significant and novel contribution to treat recurrent pediatric complex regional pain syndrome I. It allows complete pain relief, early mobilization, and rapid return home, representing a psychological advantage for these children.