Brene Brown talks about worthiness and vulnerability. Arguably, when addressing chronic pain and health we must consider the sufferer’s sense of worthiness.
‘I am enough’.
Brene Brown talks about worthiness and vulnerability. Arguably, when addressing chronic pain and health we must consider the sufferer’s sense of worthiness.
‘I am enough’.
Welcome to the CRPS Bugle – an update on the latest research papers and other literature that is pushing forward our understanding of the condition.
Eisenberg E, Sandler I, Treister R, Suzan E, Haddad M.
BACKGROUND AND AIMS:
Evidence suggests tumor necrosis factor-alpha (TNF-α) mediates, at least in part, symptoms and signs in complex regional pain syndrome (CRPS). Here, we present a case series of patients with CRPS type 1, in whom the response to the anti-TNF-α adalimumab was assessed.
Ten patients with CRPS type 1 were recruited. Assessments were performed before treatment, at 1 week, and 1, 3, and 6 months following 3 biweekly subcutaneous injections (40 mg/0.8 mL) adalimumab (Humira® ) and included the followings: Pain intensity using a 0-10 cm visual analog scale; the Short Form of the McGill Pain Questionnaire; the Beck Depression Inventory; the SF-36 questionnaire and mechanical and thermal thresholds (Von frey hair and Thermal Sensory Analyzer, respectively). In addition to the description of individual patient responses, both intention to treat (ITT) and per-protocol (PP) analyses were performed for the entire group.
Three subgroups of patients were identified (3 patients in each): “nonresponders”, “partial responders”, and “robust responders” in whom improvement in almost all parameters was noted. Both the ITT and PP analyses demonstrated only a trend toward improvement in mechanical pain thresholds following treatment (ITT χ² = 13.83, P = 0.008; PP χ² = 10.29, P = 0.036).
These results suggest adalimumab, and possibly other anti-TNF-α, can be potentially useful in some (although not in all) patients with CRPS type 1. These preliminary results along with the growing body of evidence which points to the involvement of TNF-α in the pathogenesis of CRPS justify further studies in this area.
RS – interesting findings adding to the data on targeting the imune system for CRPS. We must bear in mind that this is a case series and not an RCT. Modern thinkers in pain talk about a neuroimmune system as the two have been shown to be interactive to the point that they can be viewed as one biological system. To tackle the problem of persisting pain, we must think about and test methods that target immune activity.
Logan DE, Williams SE, Carullo VP, Claar RL, Bruehl S, Berde CB.
BACKGROUND: Historically, in both adult and pediatric populations, a lack of knowledge regarding complex regional pain syndrome (CRPS) and absence of clear diagnostic criteria have contributed to the view that this is a primarily psychiatric condition.
OBJECTIVE: To test the hypothesis that children with CRPS are more functionally disabled, have more pain and are more psychologically distressed than children with other pain conditions.
METHODS: A total of 101 children evaluated in a tertiary care pediatric pain clinic who met the International Association for the Study of Pain consensus diagnostic criteria for CRPS participated in the present retrospective study. Comparison groups included 103 children with abdominal pain, 291 with headache and 119 with back pain. Children and parents completed self-report questionnaires assessing disability, somatization, pain coping, depression, anxiety and school attendance.
RESULTS: Children with CRPS reported higher pain intensity and more recent onset of pain at the initial tertiary pain clinic evaluation compared with children with other chronic pain conditions. They reported greater functional disability and more somatic symptoms than children with headaches or back pain. Scores on measures of depression and anxiety were within normal limits and similar to those of children in other pain diagnostic groups.
CONCLUSIONS: As a group, clinic-referred children with CRPS may be more functionally impaired and experience more somatic symptoms compared with children with other pain conditions. However, overall psychological functioning as assessed by self-report appears to be similar to that of children with other chronic pain diagnoses. Comprehensive assessment using a biopsychosocial framework is essential to understanding and appropriately treating children with symptoms of CRPS.
Eccleston C, Palermo TM, de C Williams AC, Lewandowski A, Morley S, Fisher E, Law E.
Centre for Pain Research, The University of Bath, Bath, UK. firstname.lastname@example.org
Chronic pain affects many children, who report severe pain, distressed mood, and disability. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This update adds recently published randomised controlled trials (RCTs) to the review published in 2009.
To assess the effectiveness of psychological therapies, principally cognitive behavioural therapy and behavioural therapy, for reducing pain, disability, and improving mood in children and adolescents with recurrent, episodic, or persistent pain. We also assessed the risk of bias and methodological quality of the included studies.
Searches were undertaken of MEDLINE, EMBASE, and PsycLIT. We searched for RCTs in references of all identified studies, meta-analyses and reviews. Date of most recent search: March 2012.
RCTs with at least 10 participants in each arm post-treatment comparing psychological therapies with active treatment were eligible for inclusion (waiting list or standard medical care) for children or adolescents with episodic, recurrent or persistent pain.
DATA COLLECTION AND ANALYSIS:
All included studies were analysed and the quality of the studies recorded. All treatments were combined into one class: psychological treatments; headache and non-headache outcomes were separately analysed on three outcomes: pain, disability, and mood. Data were extracted at two time points; post-treatment (immediately or the earliest data available following end of treatment) and at follow-up (at least three months after the post-treatment assessment point, but not more than 12 months).
Eight studies were added in this update of the review, giving a total of 37 studies. The total number of participants completing treatments was 1938. Twenty-one studies addressed treatments for headache (including migraine); seven for abdominal pain; four included mixed pain conditions including headache pain, two for fibromyalgia, two for pain associated with sickle cell disease, and one for juvenile idiopathic arthritis. Analyses revealed five significant effects. Pain was found to improve for headache and non-headache groups at post-treatment, and for the headache group at follow-up. Mood significantly improved for the headache group at follow-up, although, this should be interpreted with caution as there were only two small studies entered into the analysis. Finally, disability significantly improved in the non-headache group at post-treatment. There were no other significant effects.
Psychological treatments are effective in reducing pain intensity for children and adolescents (<18 years) with headache and benefits from therapy appear to be maintained. Psychological treatments also improve pain and disability for children with non-headache pain. There is limited evidence available to estimate the effects of psychological therapies on mood for children and adolescents with headache and non-headache pain. There is also limited evidence to estimate the effects on disability in children with headache. These conclusions replicate and add to those of the previous review which found psychological therapies were effective in reducing pain intensity for children with headache and non-headache pain conditions, and these effects were maintained at follow-up.
RS – Both of these pieces of work highlight the need for a comprehensive approach that target the physical, cognitive and emotional dimensions of pain.
Sam Harris challenges the notion that we have free will, the freedom to make choices and decisions. Here Sam presents his argument , that of his book entitled ‘Free Will’.
We are continually making decisions about the actions that we take, perhaps believing that we are in command of our thinking. This may not be the truth of the matter. At any given moment, we make a choice seemingly of our own free will, however, the choice is made on the background of what we know, what we don’t know that we know and what we don’t know that we don’t know.
The underpinning neuroimmune activity that emerges as a conscious thought or a decision is influenced by many factors, some more immediate such as how we are feeling, who we are with, what we have been doing and thinking, and some more inherent involving our beliefs about the world, our culture and other environmental factors and experiences that have sculpted our neural networks.
Understanding where our thinking, decision making and actions come from can be a very useful way of optimising these emergent properties. Cultivating the awareness without judgment permits one to stand back and observe the process in order to make changes that seek to enhance performance. A method that I employ with individuals can be termed the inner mentor or coach which is essentially the development of a range of tools that can be used to this end.
So, if you think that you have freely decided to read this blog, check out the lecture and the book and then perhaps think again. That is up to you. Or is it?
Complex Regional Pain Syndrome can be a complication after spinal surgery according to this study.
Wolter T, Knöller SM, Rommel O.
Complex regional pain syndrome (CRPS) has been reported following spinal surgery, but its frequency after spinal surgery is unknown. The aim of this study was to determine the frequency of spinal surgery preceding CRPS and to examine these patients regarding the course of the disease and prognostic factors.
We examined 35 CRPS patients regarding the symptoms and signs of CRPS, the type of CRPS (I or II), the origin and grade of the disease, the type of surgeries prior to CRPS onset, the course of the disease, and the therapies following diagnosis of CRPS.
In 6 patients, CRPS began during the postoperative course (lumbar spine surgery, n = 5; cervical spine surgery, n = 1). Four of these patients suffered from CRPS II. The course of the disease in the 6 patients was not different from that of patients with CRPS of other origins. First symptoms of CRPS could be observed 1-14 days after surgery.
CRPS is a rare complication after spinal surgery, but spinal surgery precedes the onset of CRPS of the lower limb in almost one-third of the cases. The first typical symptoms of CRPS emerge within 2 weeks after spinal surgery.
Knoeller at al. (2011) report on a case of CRPS 1 following artificial disc surgery – bear in mind that this is a case study and hence the conclusions cannot be extrapolated to a wider population. These case histories are however, a vital part of a learning process and raise awareness.
We report a case of type 1 complex regional pain syndrome (CRPS I) of the left leg following the implantation of an artificial disc type in the L4/5 segment of the lumbar spine using a midline left-sided retroperitoneal approach. This approach included the mobilisation of the sympathetic trunk with incision and resection of the intervertebral disc. The perioperative and immediate postoperative periods were uneventful, but on the second postoperative day the patient complained of a progressive allodynia of the whole left leg in combination with weakness of the limb. Neurological examination did not reveal any radicular deficit or paresis. A sympathetic reaction following the mobilisation of the sympathetic trunk during the ventral preparation of the spine was suspected and investigated further. A diagnosis of CRPS I was proposed, and the patient was treated with analgesia, co-analgesics for pain alienation, and systemic corticosteroid therapy. A computed tomography-guided sympathetic block and lymphatic drainage were performed. Following conservative orthopaedic rehabilitation therapy, the degree of pain, allodynia, weakness, and swelling were reduced and the condition of the patient was ameliorated. The cost–benefit ratio of spinal arthroplasty is still controversial. The utility of this paper is to debate a possible cause of a painful complication, which can invalidate the results of a successful operation.
Veldman et al. in 1993 published this important paper in The Lancet, describing the signs and symptoms in CRPS.
Veldman PH, Reynen HM, Arntz IE, Goris RJ.
The pathogenesis of reflex sympathetic dystrophy–variously known as Sudeck’s atrophy, causalgia, algodystrophy, and peripheral trophoneurosis–is not yet understood, and diagnosing and treating patients is difficult. We have prospectively studied 829 patients, paying particular attention to early signs and symptoms. In its early phase, reflex sympathetic dystrophy is characterised by regional inflammation, which increases after muscular exercise. Pain was present in 93% of patients, and hypoaesthesia and hyperpathy were present in 69% and 75% respectively. With time, tissue atrophy may occur as well as involuntary movements, muscle spasms, or pseudoparalysis. Tremor was found in 49% and muscular incoordination in 54% of patients. Sympathetic signs such as hyperhidrosis are infrequent and therefore have no diagnostic value. We found no evidence consistent with the presence of three consecutive phases of the disease. Early symptoms are those of an inflammatory reaction and not of a disturbance of the sympathetic nervous system. These data support the concept of an exaggerated regional inflammatory response to injury or operation in reflex sympathetic dystrophy.
These two case study based papers demonstrate some benefit but this must be viewed with caution when considering the methodologies.
Pain Med. 2010 Sep;11(9):1415-8. doi: 10.1111/j.1526-4637.2010.00929.x. Epub 2010 Aug 23.
Safarpour D, Jabbari B.
To describe development of myofascial pain syndrome (MFPS) with trigger points in the proximal muscles of the patients with complex regional pain syndrome (CRPS1) and improvement of distal symptoms of CRPS 1 after successful treatment of proximal MFPS.
SETTING AND DESIGN:
In our practice, we frequently encounter patients in whom a proximal myofascial pain syndrome develops ipsilateral to the distal limb of CRPS1 patients. We describe two such patients in detail with their treatment. PATIENT 1: A 48-year-old woman experienced severe allodynia, swelling and autonomic changes in the right hand after surgery for carpal tunnel syndrome. Over the succeeding months, she developed painful trigger points in the right trapezius and upper back muscles which was treated with administration of botulinum toxin A (BoNT-A) into the trigger points (20 unit/point). PATIENT 2: A 41-year-old woman following a traumatic forearm injury suffered from CRPS1 affecting the left hand and forearm. Proximal MFPS gradually developed on the same side over 12 months and was treated with administration of BoNT-A into the trapezius, splenius capitis, and rhomboid muscle trigger points.
In both patients treatment with BoNT-A improved the proximal pain of MFPS and the distal symptoms of CRPS1.
proximal MFPS develops ipsilateral to the distal painful limb in patients with CRPS1. Administration of BoNT-A into the affected proximal muscles may alleviate both MFPS and the distal allodynia, discoloration and, tissue swelling of CRPS.
Kharkar S, Ambady P, Venkatesh Y, Schwartzman RJ.
Pain associated with Complex Regional Pain Syndrome (CRPS) is frequently excruciating and intractable. The use of botulinum toxin for relief of CRPS-associated pain has not been well described.
To assess whether intramuscular botulinum toxin injections cause relief of pain caused by CRPS, and to assess the risks of this treatment.
Retrospective chart review.
37 patients with spasm/dystonia in the neck and/or upper limb girdle muscles.
EMG-guided injection of Botulinum Toxin – A (BtxA), 10-20 units per muscle. Total dose used was 100 units in each patient. Local pain score was measured on an 11-point Likert scale, 4 weeks after BtxA injections.
Mean pain score decreased by 43% (8.2 ± 0.8 to 4.5 ± 1.1, P < 0.001). 97% patients had significant pain relief. One patient had transient neck drop after the injections.
This is a retrospective study, it lacks a control group and hence the placebo effect cannot be eliminated. This study does not provide information on the efficacy of this treatment after 4 weeks.
Intramuscular injection of botulinum toxin in the upper limb girdle muscles was beneficial for short term relief of pain caused by CRPS. The incidence of complications was low (2.7%).
This blog caught my eye and piqued my interest as an honest account from an MD about pain. I think that the same points ring true for many in healthcare where pain education is minimal. This is extraordinary bearing in mind that the vast number of consultations that involve pain descriptions.
Simply, we need pain education to form a much bigger part of training healthcare professionals and high quality courses, seminars and discussion forums to further understanding as the science base changes Fortunately the science base is changing rapidly, meaning that we can tackle pain in many different ways, beginning with reconceptualising pain for patients. Developing a pain sufferer’s understanding of their experience is fundamental to moving forward, creating the fertile ground from where they can flourish and evolve a better quality of life. We are designed to change, the nervous system and immune systems both consistently learning and adapting . It is our job to help facilitate this process in pain and empower patients.
Hard Cases: The Traps of Treating Pain
I hadn’t seen Larry in a dozen years when he reappeared in my office a few months ago, grinning. We were both grinning. I always liked Larry, even though he was a bit of a hustler, a little erratic in his appointments, a persistent dabbler in a variety of illegal substances. But he was always careful to avoid the hard stuff; he said he had a bad problem as a teenager and was going to stay out of trouble.
It was to stay out of trouble that he left town all those years ago, and now he was back, grayer and thinner but still smiling. Then he pulled out a list of the medications he needed, and we both stopped smiling.
According to Larry’s list, he was now taking giant quantities of one of the most addictive painkillers around, an immensely popular black-market drug most doctors automatically avoid prescribing except under the most exceptional circumstances.
“I got a bad back now, Doc,” Larry said.
Doctors hate pain. Let me count the ways. We hate it because we are (mostly) kindhearted and hate to see people suffer. We hate it because it is invisible, cannot be measured or monitored, and varies wildly and unpredictably from person to person. We hate it because it can drag us closer to the perilous zones of illegal practice than any other complaint.
And we hate it most of all because unless we specifically seek out training in how to manage pain, we get virtually none at all, and wind up flying over all kinds of scary territory absolutely solo, without a map or a net.
A number of women who come to the clinic with a musculoskeletal complaint will describe other painful syndromes that involve other body systems (see Women and Pain blogs Part 1 & Part 2). These include irritable bowel syndrome (IBS), pelvic pain, dysmennorhoea, endometriosis, bladder dysfunction, jaw pain (TMJ), migraines and widespread musculoskeletal pain. Often hypermobility is also a feature (see blogs here and here) . These are termed functional pain syndromes and require a comprehensive approach to tackle the physical, cognitive and emotional dimensions of the pain and associated problems that impact upon quality of life.
This recent study looked at a cohort of women in Australia and showed that the presence of one condition is associated with the development of another. Certainly in functional pain syndromes we know about the underpinning central sensitisation that is a common theme that manifests in different end-organs or body systems to create the aforementioned conditions. Using strategies to cultivate health within the systems is important, but so is using therapies to target the central mechanisms and driving systems, i.e. the nervous system, the immune system and the endocrine system (including stress physiology).
Only through a detailed assessment and the creation of an environment that permits the patient’s narrative will this vital piece of the puzzle emerge (see Oliver Sack talk about narrative here).
Smith MD, Russell A, Hodges PW.
OBJECTIVES:: Recent studies suggest a relationship between incontinence, respiratory disorders, gastrointestinal (GI) symptoms, and back pain (BP). However, causality is difficult to infer. This longitudinal study aimed to determine whether the presence or development of one disorder increases risk for the development of another. METHODS:: Women from the Australian Longitudinal Study on Women’s Health were divided into subgroups; those with no BP (n=7259), no incontinence (n=18,480), no breathing problems (including allergy) (n=15,096), and no GI symptoms (n=17,623). Each subgroup was analyzed to determine the relationship between the development of the absent condition and the presence or development of the other conditions. Factors with a previously identified relationship with BP were included in analysis.
RESULTS:: Women with pre-existing and/or newly developed incontinence [prevalence ratios (PR): 1.26 to 2.12] and breathing problems (PR: 1.38 to 2.11) had an increased risk for the development of BP, and women with pre-existing and newly developed BP were more likely to develop incontinence and breathing problems (PR: 1.18 to 2.44 and 1.53 to 2.62, respectively). The presence of GI symptoms was also identified as a risk factor for the development of these conditions.
DISCUSSION:: This study provides evidence of a relationship between BP, incontinence, respiratory problems, and GI symptoms in which the presence of one symptom is associated with the development of another. This suggests that common factors may contribute to the development of symptoms across this range of conditions.
I am an avid follower of Oliver Sacks’ writings and an admirer of his approach to neurological conditions and human-beings. Here is a talk given recently on ‘narrative and medicine’ emphasising the story that must be told by the patients. All too often there is a lack of time in healthcare for the individual to tell their tale, using their own language and metaphor, or a concern for expressing such language for fear of disbelief.
Of course we need the objective information and data but we also must hear the case history and try to bring the two together. One is objective and the other subjective. An excellent paper was recently written on this by Mick Thacker & Lorimer Moseley, both whom have influenced my work and approach greatly – here is the article. Interestingly, Sacks refers to such concepts in his well known book ‘The Man Who Mistook His Wife For A Hat’.
Miami Beach, Fla.—Administration of local or regional anesthesia before some major surgeries can prevent long-term pain for patients at five to six months postoperatively, according to a recent meta-analysis.
“A large percentage of people have pain at six months, especially after thoracotomy, breast cancer surgery and cesarean section” Michael H. Andreae, MD, said in an interview at the Annual Fall Meeting of the American Society of Regional Anesthesia and Pain Medicine.
Dr. Andreae and his associate, Doerthe A. Andreae, MD, identified 23 double-blind, randomized controlled trials in the literature that compared local or regional anesthesia technology (epidural, spinal or local blocks) with conventional treatment of pain (nonsteroidal anti-inflammatory drugs [NSAIDS] or morphine) and grouped them according to the surgical intervention. Many studies showed that local or regional anesthesia can prevent chronic pain after different surgical interventions, but a meta-analysis could only be performed if there was more than one study in a surgical subgroup.
See the remainder of the article here
Pain control after surgery is a very important part of the recovery process. This may sounds obvious but the trajectory of the recovery can be affected by early severe pain. Pre-surgical assessment of pain, the condition and the person is vital in planning how the symptoms are going to be controlled, allowing for adaptive and positive behaviours, thinking and actions to begin swiftly after the operation.
Of the many interesting topics covered at the congress, the talk by Laurent Boullet stood out. He is a Belgian concert painist who experienced focal hand dystonia himself. Now Laurent works with muscians who also suffer focal hand dystonia, using a programme to retain normal control of movement. He follows the principles of rehabilitation, gradually building the challenge of movement and precision required for playing the piano.
A graph that Laurent displayed showed how there is extra and early activity in the muscular system, a feature that is most significant with dystonia – too much activity and at the wrong time. The training seeks to change this patterning and restore the more discrete control.
Laurent has noticed that children often display similar movement patterns to those who have focal hand dystonia. I found this point to be highly relevant as I use the analogy that when there is an issue with movement, we lose precision and perform actions much like a young child, grasping rather than the refined movements of an adult with skill (although we do not often think about our movements as ‘skill’, this is indeed what they must be for success). Of course, precision must be learned by children and re-learned by adults with dystonia.
Recognising that there are changes in the brain functioning that underpin dystonia, there was a focus upon targeting these adaptations. Of course, any learning is a brain-based activity, whether it be a language or a musical instrument.
Two further observations by Laurent were the fact that muscle fibre switching may take place (fast & slow twitch fibres) and that the overall patterning of movement changes including the postural muscles. In respect of the latter, he referred to the work of Hodges et al. (click here), ‘Experimental muscle pain changes feedforward postural responses of the trunk muscles’ that shows how the feedforward system changes postural activity, relating that to dystonia.
In summary, although the problem manifests about the hand we are really thinking about a whole body strategy to move the arm to a certain place where the hand can perform intricate and timed activity. The automatic nature of movement changes and becomes increasingly conscious and therefore where our attention lies is important. The classic example is the yips (a later blog on this fascinating area). In focal hand dystonia we must consider this overall patterning but also the cognitive and emotional dimensions, similar to pain, addressing how these aspects of being human affect movement.
There is a growing trend to ‘neuroscience-up’ as a way of powering information and concepts. This is no bad thing as it means that current research is being applied to enhance our understanding of who we are, what we do, why we do it and how we can best go about it. Certainly in the world of business the concept of neuroleadership has emerged as a force. The notion can also be used to optimise the self and achieve healthy aims.
Employing the notion of neuroscience in health means that we can understand the functioning and interaction between the body systems (nervous, immune, endocrine, autonomic etc), cognitions and emotions. From there, healthy strategies evolve, pointing our natural compass towards wellness. This of course can include how we function as work, developing clarity of thought and resilience in the face of problems that emerge.
Understanding how we can use the body as a yardstick of wellness, for example noting the sensations as a way of detecting a threat, in one of many ways of ‘neuro-self-regulation’ (I just made that term up – it shows how easy it is to ne neuro). We can feel ‘tingling’ in the stomach which is noted as anxiety. Then we need to work out why we are anxious and this may be obvious or may require some thought. This is ironic as anxiety stems from thinking about something that is potentially threatening, albeit on many occasions it emerges from subconscious activity, becoming conscious when we need to attend to the matter. This is ‘self neuroleadership’ – the development of your own toolbox, facilitating a flourishing and flowing lifestyle at home, work and play.
Good quality education that is delivered in a way that brains can absorb, process and apply is a further example. Creating the right environment, atmosphere, delivery approach and range of tasks will impact upon the outcomes.
In summary, the neuro-revolution is an important step forward. The science is moving on and we can follow the developments to employ in health and business, and where the two meet. Of course we must look at the science with a critical eye and check the robustness of the data, ensuring we understand the messages before imparting them in an education arena.
Exciting times. Neuro times! (and immune, endocrine, autonomic….)