Category Archives: Treatment

Don’t stand so close to me…

Posted on by under Complex Regional Pain Syndrome, CRPS, Pain, Treatment

The Police song came to mind recently when I was thinking about how people protect themselves and their painful body parts, especially in cases of CRPS.

Pain is part of the the protective response initiated to promote survival and healing. We attend to the painful area and take action. This action can be conscious guarding by wearing a device (e.g. a boot or splint) and posturing to show that there is a problem and to avoid actual contact with other people.

We feel pain in our bodies although it is neuronal activity in the brain that underpins the experience of pain. In other words, we experience pain in our ‘physical self’ but it is the brain that constructs the feeling and gives it an anatomical location.

We have our bodies mapped in various cortical locations including the sensory and motor centres of the brain. These maps are very well defined under normal circumstances as far as we know. This accuracy changes in cases of persisting pain, thereby affecting our ability to know where we are being touched and controlling movement. Modern treatment of persisting pain states target these changes as well as promote tissue health and overall wellness.

More recently it has been discovered that we also have a virtual body that is mapped out in the brain, meaning that we can alter the physical experience and pain by positioning the limbs in the contralateral space. For some time we have known that there is extracorporeal awareness that changes when we have nasty pain. In other words, the space around us and in particular the painful area becomes protected as well. On approaching the affected limb in CRPS, often the individual will flinch and guard before the actual contact arrives. Sensible you may think. This can happen when they have their eyes closed as well.

So, as the song says, ‘Don’t stand, don’t stand, don’t stand so close to me’ is an important protective response driven by the salient network in the brain but needs to be addressed as part of a comprehensive desensitisation programme.

For further information about our treatment programmes for CRPS, please call 07932 689081 or visit our website here: Specialist Pain Physio Clinics, London.

CRPS Bugle Extra | CRPS Treatment | Systematic review 2013 #CRPS

Posted on by under Chronic pain, Complex Regional Pain Syndrome, CRPS, Research, RSD, Treatment

Specialist Pain Physio Clinics, LondonCossins et al. (2013) have just published a systematic review of the treatments for complex regional pain syndrome (CRPS).

Here is the abstract:

Complex regional pain syndrome (CRPS) is a disabling pain condition with sensory, motor and autonomic manifestations. Uncertainty remains about how CRPS can be effectively managed. We conducted a systematic review of randomized controlled trials (RCTs) for treatment and prophylactic interventions for CRPS published during the period 2000–2012, building on previous work by another group reviewing the period 1966–2000. Bibliographic database searches identified 173 papers which were filtered by three reviewers. This process generated 29 trials suitable for further analysis, each of which was reviewed and scored by two independent reviewers for methodological quality using a 15-item checklist. A number of novel and potentially effective treatments were investigated. Analysing the results from both review periods in combination, there was a steep rise in the number of published RCTs per review decade. There is evidence for the efficacy of 10 treatments (3¥ strong – bisphosphonates, repetitive transcranial magnetic stimulation and graded motor imagery, 1¥ moderate and 6¥ limited evidence), and against the efficacy of 15 treatments (1¥ strong, 1¥ moderate and ¥13 limited). The heterogeneity of trialled inter- ventions and the pilot nature of many trials militate against drawing clear conclusions about the clinical usefulness of most interventions. This and the observed phenomenon of excellent responses in CRPS subgroups would support the case for a network- and multi-centre approach in the conduct of future clinical trials. Most published trials in CRPS are small with a short follow-up period, although several novel interventions inves- tigated from 2000 to 2012 appear promising.

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Within the authors’ analysis they discuss medications, interventions and physiotherapy:

‘There is string evidence that rehabilitation/physiotherapy interventions can reduce pain and improve function for people with CRPS’

The problem with this is that it does not define what physiotherapy actually constitutes. This is with the exception of graded motor imagery (GMI) that is termed ‘a complex physiotherapy intervention’. I use GMI training for rehabilitation in CRPS, teaching individuals the principles of motor learning before guiding their training through the stages – see here. Typically alongside the GMI programme I run a range of strategies that are designed to develop resilience to the stress and anxiety associated with on-going pain. These techniques are skills that the individual learns and becomes accomplished at using to optimise their outcomes by grooving a positive mindset for rehabilitation. The benefits often pervade into other aspects of life as well as they become proficient at controlling attention and regulating emotion. This is a comprehensive and holistic approach to persisting pain using an integrated physical-cognitive-emotional model of care. Pain is multidimensional as is relief and both must be thought of in this way.

It is very useful to have a systematic review. The only omission as far as I can see is that of the effects of cognitive strategies in CRPS. In the general chronic pain literature there is a mass of evidence of the benefit and hence the absolute need to interlace such strategies into a programme.

Full article here: Treatment of CRPS | A systematic review

Visit our clinic page here: Specialist Pain Physio Clinics London

CRPS Review 20th February 2012

Posted on by under Brain and pain, Chronic pain, Complex Regional Pain Syndrome, Explain Pain, Pain, Pain Education, Treatment

A selection of papers to peruse:

Predictors of Pain Relieving Response to Sympathetic Blockade in Complex Regional Pain Syndrome Type 1

Anesthesiology: January 2012 – Volume 116 – Issue 1 – p 113–121
doi: 10.1097/ALN.0b013e31823da45f Pain Medicine

van Eijs, Frank M.D.*; Geurts, José M.Sc.†; van Kleef, Maarten M.D., Ph.D.‡; Faber, Catharina G. M.D., Ph.D.§; Perez, Roberto S. Ph.D.‖; Kessels, Alfons G.H. M.D., M.Sc.#; Van Zundert, Jan M.D., Ph.D.**

Abstract
Background: Sympathetic blockade with local anesthetics is used frequently in the management of complex regional pain syndrome type 1(CRPS-1), with variable degrees of success in pain relief. The current study investigated which signs or symptoms of CRPS-1 could be predictive of outcome. The incidence of side effects and complications of sympathetic blockade also were determined prospectively.
Methods: A prospective observational study was done of 49 patients with CRPS-1 in one extremity only and for less than 1-yr duration who had severe pain and persistent functional impairment with no response to standard treatment with medication and physical therapy.
Results: Fifteen (31%) patients had good or moderate response. The response rate was not different in patient groups with cold or warm type CRPS-1 or in those with more or less than 1.5°C differential increase in skin temperature after sympathetic blockade. Allodynia and hypoesthesia were negative predictors for treatment success in CRPS-1. There were no symptoms or signs of CRPS-1 that positively predicted treatment success. A majority of patients (84%) experienced transient side effects such as headache, dysphagia, increased pain, backache, nausea, blurred vision, groin pain, hoarseness, and hematoma at the puncture site. No major complications were reported.
Conclusions: The presence of allodynia and hypoesthesia are negative predictors for treatment success. The selection of sympathetic blockade as treatment for CRPS-1 should be balanced carefully between potential success and side effect ratio. The procedure is as likely to cause a transient increase in pain as a decrease in pain. Patients should be informed accordingly.

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Motor control in complex regional pain syndrome: A kinematic analysis

http://dx.doi.org/10.1016/j.pain.2011.12.018

  • J.C.M. Schildera, , ,
  • A.C. Schoutenb, c,
  • R.S.G.M. Perezd,
  • F.J.P.M. Huygene,
  • A. Dahanf,
  • L.P.J.J. Noldusg,
  • J.J. van Hiltena,
  • J. Marinusa

Abstract

This study evaluated movement velocity, frequency, and amplitude, as well as the number of arrests in three different subject groups, by kinematic analysis of repetitive movements during a finger tapping (FT) task. The most affected hands of 80 patients with complex regional pain syndrome (CRPS) were compared with the most affected hands of 60 patients with Parkinson disease (PD) as well as the nondominant hands of 75 healthy control (HC) subjects. Fifteen seconds of FT with thumb and index finger were recorded by a 60-Hz camera, which allowed the whole movement cycle to be evaluated and the above mentioned movement parameters to be calculated. We found that CRPS patients were slower and tapped with more arrests than the two other groups. Moreover, in comparison with the hands of the HC subjects, the unaffected hands of the CRPS patients were also impaired in these domains. Impairment was not related to pain. Dystonic CRPS patients performed less well than CRPS patients without dystonia. In conclusion, this study shows that voluntary motor control in CRPS patients is impaired at both the affected as well as the unaffected side, pointing at involvement of central motor processing circuits.

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Psychological factors associated with self-perceived pain-related disability among individuals diagnosed with complex regional pain syndrome

by Mann, Jeffrey C., Psy.D., ADLER SCHOOL OF PROFESSIONAL PSYCHOLOGY, 2010, 107 pages; 3452691

Abstract:

Over the last several decades the importance of psychological factors in understanding pain-related disability has grown tremendously. Research has explored many psychological constructs and their relationship to pain related disability with several constructs emerging as clinically significant. The research conducted to date has predominantly focused on individuals with conditions such as low-back, arthritis, or other forms of musculoskeletal pain. To date, there is no research examining the predominant psychological constructs with a population of individuals diagnosed with Complex Regional Pain Syndrome (CRPS). This study had two primary purposes: (a) To examine the relationship between pain catastrophizing, pain helplessness, active coping, passive coping and self-perceived, pain-related disability, (b) to determine the amount of variance in self-perceived, pain-related disability accounted for by pain catastrophizing, pain helplessness, active coping, and passive coping. The research sample included 102 individuals diagnosed with CRPS being treated at a pain clinic. The instruments used to measure the independent variables were: Pain Helplessness Index (PHI), Pain Catastrophizing Scale (PCS), and the Coping Strategies Questionnaire (CSQ). The dependent variable was measured with the Perceived Disability Scale (PDS). Correlation analysis indicated that pain catastrophizing, pain helplessness, and passive coping are all positively correlated with self-perceived, pain-related disability. Multiple regression results indicated that pain catastrophizing, and pain helplessness account for 15.3% of the variance in self-perceived, pain-related disability. Active coping and passive coping did not account for a statistically significant portion of the variance. The findings of this study demonstrate the importance of pain catastrophizing and pain helplessness when treating individuals diagnosed with CRPS and raises doubt about the utility of active coping and the detriment of passive coping. Further investigation is needed to determine the efficacy of interventions focused on modifying pain catastrophizing and pain helplessness as a indirect method of decreasing self-perceived disability.

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Mast Cells: Source of Inflammation in Complex Regional Pain Syndrome?

Mast Cells: Source of Inflammation in CRPS

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Targeting Cortical Representations in the Treatment of Chronic Pain: A Review

  1. G. Lorimer Moseley
  2. Herta Flor

Recent neuroscientific evidence has confirmed the important role of cognitive and behavioral factors in the development and treatment of chronic pain. Neuropathic and musculoskeletal pain are associated with substantial reorganization of the primary somatosensory and motor cortices as well as regions such as the anterior cingulate cortex and insula. What is more, in patients with chronic low back pain and fibromyalgia, the amount of reorganizational change increases with chronicity; in phantom limb pain and other neuropathic pain syndromes, cortical reorganization correlates with the magnitude of pain. These findings have implications for both our understanding of chronic pain and its prevention and treatment. For example, central alterations may be viewed as pain memories that modulate the processing of both noxious and nonnoxious input to the somatosensory system and outputs of the motor and other response systems. The cortical plasticity that is clearly important in chronic pain states also offers potential targets for rehabilitation. The authors review the cortical changes that are associated with chronic pain and the therapeutic approaches that have been shown to normalize representational changes and decrease pain and discuss future directions to train the brain to reduce chronic pain.

RS – out of these papers this is the one that I am most interested in reading. A number of the techniques that I use in the clinic for CRPS are targeting the changes in the brain, including Graded Motor Imagery, 2-point discrimination training, sensorimotor integration and mindfulness. We are both obliged and wise to consider why is it that the brain continues to protect a body part(s) and how has this happened? Herta Flor talks about learning and memory in pain and the conditioning process. Reinforcements for particular beliefs and behaviours can start early after an injury or initiation of a pain state. In these stages we must seek to prevent pathological beliefs developing by using focused education, promote useful behaviours that are reinforced and set goals that sit alongside processes of healing and recovery.

Specialist Pain Physio Clinics in London for CRPS

Pain mechanisms

Posted on by under Brain and pain, Chronic pain, Explain Pain, Neuropathic pain, Pain, Pain Education, Science, Treatment

Understanding pain mechanisms is the key to effective treatment. The mechanisms that have been studied, written about in science journals and discussed with patients include nociceptive pain, inflammatory pain, neuropathic pain and central sensitisation. Elucidating which are playing a role in the patient’s experience allows the doctor to prescribe the right medication and the modern physical therapist to address the issues of pain in a biopsychosocial manner. I will now clarify the latter point.

In taking a detailed history, observing patterns of movement and protection, assessing the state of the nervous system and health of the body systems, understanding behaviours and the beliefs behind them and learning of the influences upon the individual’s pain experience, one can know about the likely pain mechanisms underpinning the experience. From here the treatment strategies can be chosen to target these mechanisms. For example, top-down approaches for central sensitisation focus on the change in the properties of the central nervous system. The interventions themselves are observant of the amplification that occurs in the spinal cord and higher centres and would seek to dampen the responses with input to the brain that is perceived as normal or non-threatening. This could include sensory stimulation or movements outside of the receptive field, education to reduce fear of movement or imagery to name but a few. Inflammatory pain can also be treated with a top-down approach but local tissue based strategies would also be used. Just to note that the separation of the ‘top end’ (brain and spinal cord) from ‘bottom end’ (tissues) is really a false dichotomy as all conscious experiences are from the brain including what we see and what we feel.

Stephen McMahon and David Bennett, both experts in the field of pain science from King’s College London, produced a poster that describes these mechanisms – click here to visit the page in Nature Reviews Neuroscience. This is what they say about it:

Pain is an unpleasant sensation resulting from the intricate interplay between sensory and cognitive mechanisms. Chronic pain, resulting from disease or injury, affects nearly every fifth person in the Western world, constituting an enormous burden for the individual and society. Sensitization of pain signalling systems is a key feature of chronic pain and results in normally non-painful stimuli eliciting pain. Such sensory changes can occur not just at the sites of injury, but in surrounding normal tissues. This and other observations suggest that sensitization occurs within the CNS as well as within nociceptor terminals. Here we consider the consequences of noxious stimulus applied to our unfortunate builder’s hand, from sensory transduction to pain perception. We describe the structural and functional elements present at different levels of the nociceptive system, as well as some of the changes occurring in chronic pain states. Although our poster highlights a flow of information from the periphery to the CNS, it should be noted that higher brain centres exert both inhibitory and facilitatory controls on lower ones. The challenge for the next decade will be to effectively translate this knowledge into the development of novel analgesic agents for better pain relief.

Richmond Stace – Specialist Pain Physio Clinics, London & Surrey

“We – are – family….” Pain and significant others

Posted on by under Explain Pain, Pain, Treatment, Uncategorized

Although pain is personal and only felt by the individual, the effects pervade to those closely around. It appears to be a two-way street though, with significant others having an impact upon levels of physical activity and evidence of similar attentional biases in chronic pain patients and their caregivers. Have a look at the papers below:

Pain. 2012 Jan;153(1):62-7. Epub 2011 Oct 15.

Do main caregivers selectively attend to pain-related stimuli in the same way that patients do?

Source

Family Research Institute, Shahid Beheshti University, G.C., Tehran, Iran.

Abstract

Despite increasing interest in the attentional biases of pain patients towards pain-related stimuli, there have been no investigations of whether the main caregivers of chronic pain patients also selectively attend to pain-related information. We compared the attentional biases to painful or happy faces of 120 chronic pain patients, 118 caregivers, and 50 controls. Analyses found that both patients and caregivers demonstrated biases towards painful faces that were not observed in control participants or to happy faces. Those patients and caregivers who were high in fear of pain demonstrated greater biases than those low in fear of pain, and the biases of the high-in-fear-of-pain group differed significantly from zero. When sub-groups of caregivers were compared, it was found that biases towards painful faces were not observed for those caregivers who accurately identified the level of pain the patient currently reported. In contrast, those caregivers who overestimated or underestimated the patients’ pain demonstrated biases that were significantly greater than zero. These results add to the growing weight of evidence suggesting that biases towards pain-related stimuli are observed in chronic pain patients, but that the nature of the stimuli is important. In addition, the results suggest that caregivers, particularly those who either under- or overestimate the level of pain that the patient reports, also demonstrate similar biases. Future research should investigate the links between caregivers’ biases and the way in which caregivers respond to pain.

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Pain. 2011 Nov;152(11):2521-7. Epub 2011 Aug 27.

Factors contributing to physical activity in a chronic low back pain clinical sample: a comprehensive analysis using continuous ambulatory monitoring.

Source

Department of Psychology, Eastern Michigan University, Ypsilanti, MI, USA. kalschul@uw.edu

Abstract

Back pain is one of the most common causes of disability in industrialized nations. Despite this, the variables that contribute to disability are not well understood and optimal measurement strategies of disability have not yet been determined. The present study sought to comprehensively assess the strongest predictors of physical activity as a proxy for disability. New patients in a chronic pain specialty clinic completed questionnaires to assess the predictors of physical activity and engaged in 5 days of home data collection wearing an accelerometer to assess physical activity in daily life, which is how disability was operationalised in this study. Analysis of repeated measures patient data revealed that, of 3 composite variables each representing a theoretical model, the model representative of operant factors significantly predicted physical activity. Subsequent analyses showed that pain sensitivity, fear avoidance, and solicitous spousal responses account for a significant amount of the variance in physical activity. These findings suggest that external sources of reinforcement or punishment may serve to influence physical behavior beyond that of internal cues such as fear avoidance or pain. Implications for treatment are discussed, including the potential benefits of specifically incorporating the patient’s sources of operant reinforcement or punishment into treatment.

RS Comment:

To be truly biopsychosocial, significant others and their influences must be considered. Positive strategies to involve and educate care givers, families and friends should form part of the treatment programme. I recommend that all those involved should develop an understanding of the issues of pain. We often listen to and subscribe to the beliefs of those closest to us and this powerful dynamic can be of real benefit. On occasion I am asked whether partners can attend the sessions. I encourage this participation as well as teaching techniques that are required to be used regularly at home, for example desensitisation strategies.

Neuropathic Pain: The pharmacological management of neuropathic pain in adults in non-specialist settings (3/10)

Posted on by under Chronic pain, Complex Regional Pain Syndrome, CRPS, Neuropathic pain, Pain, Pain Education, Treatment

Neuropathic Pain

The Pharmacological Management of Neuropathic Pain in Adults in Non-Specialist Settings

Click here for the NICE Guidelines: Neuropathic Pain 2010

NICE Clinical Guidelines, No. 96

Centre for Clinical Practice at NICE (UK).

Copyright © 2010, National Institute for Health and Clinical Excellence.

Excerpt

This clinical guideline covers the management of neuropathic pain conditions in adults (aged 18 or over) in primary care and secondary care, excluding specialist pain management clinics. The aim of the guideline is to provide clear recommendations to healthcare professionals in non-specialist settings on the treatment and management of neuropathic pain. This includes recommendations on appropriate and timely referral to specialist pain services and/or condition-specific services. In general, regarding neuropathic pain as a ‘blanket condition’, irrespective of the underlying cause, is helpful and practical for both non-specialist healthcare professionals and patients. However, condition-specific recommendations and research recommendations have been made where robust evidence on clinical and cost effectiveness exists for specific conditions, or where the evidence is clearly uncertain. The guideline excludes acute pain arising directly (in the first 3 months) from trauma or orthopaedic surgical procedures.

CRPS & pain – some things you may not have realised

Posted on by under Brain, Brain and pain, Explain Pain, Illusions, Imagery, Mirror therapy, Pain Education, Physiotherapy, Science, Treatment

Pain is multidimensional. Pain is 100% produced by the brain in response to a perceived threat. The brain allocates a location using the cortical maps, hence why we feel pain in our backs or knees. The brain tries to make sense of the situation, scrutinising what is going on on the basis of past experience (learning) and comparing to the information being received from ALL body systems. This is the reason for the term ‘multisystem output’ as a way of describing what is happening when we are in pain.

The most obvious reason why the pain worsens is that we move, exercise or sit for too long. All of these activities are ‘physical’, asking the tissues to take the strain either rapidly or gradually. On reaching a certain level of strain, lower than normal in cases of sensitivity, nerves start sending danger signals to the spinal cord. From the spinal cord messages are relayed to the brain, still on the subject of danger. Theses are not pain signals. It is only when the brain interprets the information as threatening that the experience of pain is produced – an output from the brain. This is typical in acute situations when the injury or problem is new. The pain is vital, useful and motivates action.

A key point to understand is that the brain does not actually need the tissues to produce pain. Think about phantom limb pain. There is no limb. There are no tissues. But it hurts. It seriously hurts in may cases. So, there are other ‘triggers’ for pain besides actually moving or asking the tissues (muscles, tendons, ligaments, bones etc) to take the strain. Common ‘non-tissue’ circumstances that can amplify pain include stress, circadian rhythms, menstrual cycle, fatigue and thoughts. I think that to take this on board is an enlightening experience. To understand that your pain can be as a result of other reasons besides what you are doing physically can help to explain why it hurts at times when you have not done anything differently and you really cannot comprehend why the pain has increased.

A further influential player in our experiences is vision. I’m really interested in this as the process of ‘seeing’ is much aligned to the way pain is experienced. Information is received by the brain via the optic nerve. The brain must make sense of this data and create a credible outcome, again very much using past experience to judge the present. We still see a bird in his cage despite slender lines dividing his body (the struts of the cage). We don’t see ‘slices’ of a bird. Also consider optical illusions. A great deal of work has been done looking at the use of vision for therapeutic effect, i.e. the graded motor imagery programme. Clearly the mirror box is creating the illusion that the affected side is moving and appearing to be normal. Imagined movements requires us to ‘see’ and feel movement although we are keeping very still. The premotor cortex is very active during these imagined movements, and this part of the brain is involved in the production of pain.

From the book 'Explain Pain' by D Butler & L Moseley

What we are seeing is deemed to be an illusion in some quarters. We all have different experiences and backgrounds. Our beliefs about life and ourselves vary. This will influence what we ‘see’. If you have just watched a scary movie and then go outside into the dark to put the rubbish out, a shadow could be ‘seen’ as something more dangerous than if you have just laughed at a comedy show. Also consider when we see someone injure themselves, again on TV or watching sport. We often wince, grab our corresponding body part or take some other defensive action. Our brains are interpreting someone else’s danger and imprinting this onto our experience, perhaps as a way of helping us to learn that it is dangerous to be in their situation. This is likely due to the mirror neuron network and that when we watch someone else move or position themselves, our virtual body that exists in the brain mimics that position. There are also aspects of empathy in sharing someone’s pain. But, if that position is ‘threatening’ to our brain, we will hurt.

What do we do about that? We use strategies to desensitise and habituate, similar to dealing with any fear. The modern way of tackling pain states, especially those that persist, is using a biobehavioral approach. This means that as well as addressing tissue health with movement and treatment, we must concurrently target the brain and other systems that are involved in the pain experience, e.g. immune, endocrine. It is called ‘top-down’ – ‘bottom-up’. Top-down referring to the brain and our beliefs, understanding, thoughts, how the brain is controlling movement and protecting us; bottom-up signifying the need to nourish the tissues with movement. These exist on a spectrum and both are addressed in a contemporary biopsychosocial treatment programme – see http://www.specialistpainphysio.com/treatment

Below are some interesting abstracts in relation to this blog:

Pain. 2010 Feb;148(2):268-74. Epub 2009 Dec 11.

Pain sensation evoked by observing injury in others.

Source

School of Psychology, University of Birmingham, Edgbaston, UK.

Abstract

Observing someone else in pain produces a shared emotional experience that predominantly activates brain areas processing the emotional component of pain. Occasionally, however, sensory areas are also activated and there are anecdotal reports of people sharing both the somatic and emotional components of someone else’s pain. Here we presented a series of images or short clips depicting noxious events to a large group of normal controls. Approximately one-third of this sample reported an actual noxious somatic experience in response to one or more of the images or clips. Ten of these pain responders were subsequently recruited and matched with 10 non-responders to take part in an fMRI study. The subjects were scanned while observing static images of noxious events. In contrast with emotional images not containing noxious events the responders activated emotional and sensory brain regions associated with pain while the non-responders activated very little. These findings provide convincing evidence that some people can readily experience both the emotional and sensory components of pain during observation of other’s pain resulting in a shared physical pain experience.

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J Cogn Neurosci. 2007 Jan;19(1):42-58.

The neural substrate of human empathy: effects of perspective-taking and cognitive appraisal.

Source

INSERM Unit 280, France.

Abstract

Whether observation of distress in others leads to empathic concern and altruistic motivation, or to personal distress and egoistic motivation, seems to depend upon the capacity for self-other differentiation and cognitive appraisal. In this experiment, behavioral measures and event-related functional magnetic resonance imaging were used to investigate the effects of perspective-taking and cognitive appraisal while participants observed the facial expression of pain resulting from medical treatment. Video clips showing the faces of patients were presented either with the instruction to imagine the feelings of the patient (“imagine other”) or to imagine oneself to be in the patient’s situation (“imagine self”). Cognitive appraisal was manipulated by providing information that the medical treatment had or had not been successful. Behavioral measures demonstrated that perspective-taking and treatment effectiveness instructions affected participants’ affective responses to the observed pain. Hemodynamic changes were detected in the insular cortices, anterior medial cingulate cortex (aMCC), amygdala, and in visual areas including the fusiform gyrus. Graded responses related to the perspective-taking instructions were observed in middle insula, aMCC, medial and lateral premotor areas, and selectively in left and right parietal cortices. Treatment effectiveness resulted in signal changes in the perigenual anterior cingulate cortex, in the ventromedial orbito-frontal cortex, in the right lateral middle frontal gyrus, and in the cerebellum. These findings support the view that humans’ responses to the pain of others can be modulated by cognitive and motivational processes, which influence whether observing a conspecific in need of help will result in empathic concern, an important instigator for helping behavior.

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Hum Brain Mapp. 2009 Oct;30(10):3227-37.

Empathic neural responses to others’ pain are modulated by emotional contexts.

Source

Department of Psychology, Peking University, Beijing 100871, People’s Republic of China. shan@pku.edu.cn

Abstract

Recent brain imaging studies indicate that empathy for pain relies upon both the affective and/or the sensorimotor nodes of the pain matrix, and empathic neural responses are modulated by stimulus reality, personal experience, and affective link with others. The current work investigated whether and how empathic neural responses are modulated by emotional contexts in which painful stimulations are perceived. Using functional magnetic resonance imaging (fMRI), we first showed that perceiving a painful stimulation (needle penetration) applied to a face with neutral expression induced activation in the anterior cingulate cortex (ACC) relative to nonpainful stimulation (Q-tip touch). However, when observation of the painful stimuli delivered to a neutral face was intermixed with observation of painful or happy faces, the ACC activity decreased while the activity in the face area of the secondary somatosensory cortex increased to the painful stimulation. Moreover, the secondary somatosensory activity associated with the painful stimulation decreased when the painful stimulation was applied to faces with happy and painful expressions. The findings suggest that observing painful stimuli in an emotional context weakens affective responses but increases sensory responses to perceived pain and implies possible interactions between the affective and sensory components of the pain matrix during empathy for pain.

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Neuron. 2007 Aug 2;55(3):377-91.

The cerebral signature for pain perception and its modulation.

Source

Centre for Functional Magnetic Resonance Imaging of the Brain, Clinical Neurology and Nuffield Department of Anaesthetics, Oxford University, OX3 9DU Oxford, England, UK. irene@fmrib.ox.ac.uk

Abstract

Our understanding of the neural correlates of pain perception in humans has increased significantly since the advent of neuroimaging. Relating neural activity changes to the varied pain experiences has led to an increased awareness of how factors (e.g., cognition, emotion, context, injury) can separately influence pain perception. Tying this body of knowledge in humans to work in animal models of pain provides an opportunity to determine common features that reliably contribute to pain perception and its modulation. One key system that underpins the ability to change pain intensity is the brainstem’s descending modulatory network with its pro- and antinociceptive components. We discuss not only the latest data describing the cerebral signature of pain and its modulation in humans, but also suggest that the brainstem plays a pivotal role in gating the degree of nociceptive transmission so that the resultant pain experienced is appropriate for the particular situation of the individual.

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Neuroimage. 2009 Sep;47(3):987-94. Epub 2009 May 28.

The influence of negative emotions on pain: behavioral effects and neural mechanisms.

Source

Nuffield Department of Anaesthetics, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK. kwiech@fmrib.ox.ac.uk

Abstract

The idea that pain can lead to feelings of frustration, worry, anxiety and depression seems obvious, particularly if it is of a chronic nature. However, there is also evidence for the reverse causal relationship in which negative mood and emotion can lead to pain or exacerbate it. Here, we review findings from studies on the modulation of pain by experimentally induced mood changes and clinical mood disorders. We discuss possible neural mechanisms underlying this modulatory influence focusing on the periaqueductal grey (PAG), amygdala, anterior cingulate cortex (ACC) and anterior insula as key players in both, pain and affective processing.

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Disclaimer: this blog is for informational purposes only. If you are concerned or unsure about your pain or condition, you must consult with your GP or a health professional.

CRPS Research Update December 2012

Posted on by under Complex Regional Pain Syndrome, CRPS, Research, Science, Treatment

Welcome to the December research update for CRPS and related issues:

J Med Case Reports. 2011 Aug 4;5:349.

Improvement of pain and regional osteoporotic changes in the foot and ankle by low-dose bisphosphonate therapy for complex regional pain syndrome type I: a case series.
Abe Y, Iba K, Takada J, Wada T, Yamashita T.
Source

Department of Orthopedic Surgery, Sapporo Medical University School of Medicine, Sapporo 060-8543, Japan. iba@sapmed.ac.jp.
INTRODUCTION:

Complex regional pain syndrome is characterized by pain, allodynia, hyperalgesia, edema, signs of vasomotor instability, movement disorders, joint stiffness, and regional osteopenia. It is recognized to be difficult to treat, despite various methods of treatment, including physiotherapy, calcitonin, corticosteroids, sympathetic blockade, and nonsteroidal anti-inflammatory drugs. Pathophysiologically, complex regional pain syndrome reveals enhanced regional bone resorption and high bone turnover, and so bisphosphonates, which have a potent inhibitory effect on bone resorption, were proposed for the treatment of complex regional pain syndrome.
CASE PRESENTATION:

A 48-year-old Japanese man with complex regional pain syndrome type I had severe right ankle pain with a visual analog scale score of 59 out of 100 regardless of treatment with physiotherapy and nonsteroidal anti-inflammatory drugs for five months. Radiographs showed marked regional osteoporotic changes and bone scintigraphy revealed a marked increase in radioactivity in his ankle. One month after the start of oral administration of risedronate (2.5 mg per day), his bone pain had fallen from a VAS score of 59 out of 100 to 18 out of 100. Bone scintigraphy at 12 months showed a marked reduction in radioactivity to a level comparable to that in his normal, left ankle. On the basis of these results, the treatment was discontinued at 15 months. At 32 months, our patient had almost no pain and radiographic findings revealed that the regional osteoporotic change had returned to normal.A second 48-year-old Japanese man with complex regional pain syndrome type I had severe right foot pain with a visual analog scale score of 83 out of 100 regardless of treatment with physiotherapy and nonsteroidal anti-inflammatory drugs for nine months. Radiographs showed regional osteoporotic change in his phalanges, metatarsals, and tarsals, and bone scintigraphy revealed a marked increase in radioactivity in his foot. One month after the start of oral administration of alendronate (35 mg per week), his bone pain had fallen from a visual analog scale score of 83 out of 100 to 30 out of 100 and, at nine months, was further reduced to 3 out of 100. The treatment was discontinued at 15 months because of successful pain reduction. At 30 months, our patient had no pain and the radiographic findings revealed marked improvement in regional osteoporotic changes.
CONCLUSIONS:

We believe low-dose oral administration of bisphosphonate is worth considering for the treatment of idiopathic complex regional pain syndrome type I accompanied by regional osteoporotic change.

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J Hand Surg Am. 2011 Dec 14. [Epub ahead of print]

Meta-Analysis of the Imaging Techniques for the Diagnosis of Complex Regional Pain Syndrome Type I.

Source

School of Medicine and the Division of Plastic Surgery, University of Louisville, Louisville, KY; and the Department of Orthopedics, University of Michigan, Ann Arbor, MI.

Abstract

PURPOSE:

To compare the effectiveness of imaging techniques in aiding and confirming the diagnosis of complex regional pain syndrome (CRPS) type I.

METHODS:

We conducted a meta-analysis of randomized controlled studies that evaluated the effectiveness of 3 different imaging techniques in aiding the diagnosis of CRPS type I. A systematic search in bibliographical databases resulted in 24 studies with 1,916 participants.

RESULTS:

To determine the effectiveness of each imaging technique, we determined the average specificity, sensitivity, negative predictive value, and positive predictive value and then statistically compared them using the analysis of variance statistical test, which indicated that compared with magnetic resonance imaging and plain film radiography, triple-phase bone scan had a significantly better sensitivity and negative predictive values. However, there appeared to be no statistical significance between imaging techniques when we evaluated specificity and positive predictive value using the analysis of variance test.

CONCLUSIONS:

The findings of this meta-analysis support the use of triple-phase bone scan in ruling out CRPS type I, owing to its greater sensitivity and higher negative predictive value than both magnetic resonance imaging and plain film radiography.

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J Pain. 2011 Dec 13. [Epub ahead of print]

Changes in Plasma Cytokines and Their Soluble Receptors in Complex Regional Pain Syndrome.

Source

Department of Neurology, Drexel University College of Medicine, Philadelphia, Pennsylvania.

Abstract

Complex Regional Pain Syndrome (CRPS) is a chronic and often disabling pain disorder. There is evidence demonstrating that neurogenic inflammation and activation of the immune system play a significant role in the pathophysiology of CRPS. This study evaluated the plasma levels of cytokines, chemokines, and their soluble receptors in 148 subjects afflicted with CRPS and in 60 gender- and age-matched healthy controls. Significant changes in plasma cytokines, chemokines, and their soluble receptors were found in subjects with CRPS as compared with healthy controls. For most analytes, these changes resulted from a distinct subset of the CRPS subjects. When the plasma data from the CRPS subjects was subjected to cluster analysis, it revealed 2 clusters within the CRPS population. The category identified as most important for cluster separation by the clustering algorithm was TNFα. Cluster 1 consisted of 64% of CRPS subjects and demonstrated analyte values similar to the healthy control individuals. Cluster 2 consisted of 36% of the CRPS subjects and demonstrated significantly elevated levels of most analytes and in addition, it showed that the increased plasma analyte levels in this cluster were correlated with disease duration and severity. PERSPECTIVE: The identification of biomarkers that define disease subgroups can be of great value in the design of specific therapies and of great benefit to the design of clinical trials. It may also aid in advancing our understanding of the mechanisms involved in the pathophysiology of CRPS, which may lead to novel treatments for this very severe condition.

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J Transl Med. 2011 Nov 10;9:195.

MicroRNA modulation in complex regional pain syndrome.

Source

Pharmacology & Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, USA. seena.ajit@drexelmed.edu.

Abstract

ABSTRACT:

BACKGROUND:

Aberrant expression of small noncoding RNAs called microRNAs (miRNAs) is a common feature of several human diseases. The objective of the study was to identify miRNA modulation in patients with complex regional pain syndrome (CRPS) a chronic pain condition resulting from dysfunction in the central and/or peripheral nervous systems. Due to a multitude of inciting pathologies, symptoms and treatment conditions, the CRPS patient population is very heterogeneous. Our goal was to identify differentially expressed miRNAs in blood and explore their utility in patient stratification.

METHODS:

We profiled miRNAs in whole blood from 41 patients with CRPS and 20 controls using TaqMan low density array cards. Since neurogenic inflammation is known to play a significant role in CRPS we measured inflammatory markers including chemokines, cytokines, and their soluble receptors in blood from the same individuals. Correlation analyses were performed for miRNAs, inflammatory markers and other parameters including disease symptoms, medication, and comorbid conditions.

RESULTS:

Three different groups emerged from miRNA profiling. One group was comprised of 60% of CRPS patients and contained no control subjects. miRNA profiles from the remaining patients were interspersed among control samples in the other two groups. We identified differential expression of 18 miRNAs in CRPS patients. Analysis of inflammatory markers showed that vascular endothelial growth factor (VEGF), interleukin1 receptor antagonist (IL1Ra) and monocyte chemotactic protein-1 (MCP1) were significantly elevated in CRPS patients. VEGF and IL1Ra showed significant correlation with the patients reported pain levels. Analysis of the patients who were clustered according to their miRNA profile revealed correlations that were not significant in the total patient population. Correlation analysis of miRNAs detected in blood with additional parameters identified miRNAs associated with comorbidities such as headache, thyroid disorder and use of narcotics and antiepileptic drugs.

CONCLUSIONS:

miRNA profiles can be useful in patient stratification and have utility as potential biomarkers for pain. Differentially expressed miRNAs can provide molecular insights into gene regulation and could lead to new therapeutic intervention strategies for CRPS.

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Pain. 2011 Dec 9. [Epub ahead of print]

Sensory signs in complex regional pain syndrome and peripheral nerve injury.

Source

Division of Neurological Pain Research and Therapy, Department of Neurology, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany.

Abstract

This study determined patterns of sensory signs in complex regional pain syndrome (CRPS) type I and II and peripheral nerve injury (PNI). Patients with upper-limb CRPS-I (n=298), CRPS-II (n=46), and PNI (n=72) were examined with quantitative sensory testing according to the protocol of the German Research Network on Neuropathic Pain. The majority of patients (66%-69%) exhibited a combination of sensory loss and gain. Patients with CRPS-I had more sensory gain (heat and pressure pain) and less sensory loss than patients with PNI (thermal and mechanical detection, hypoalgesia to heat or pinprick). CRPS-II patients shared features of CRPS-I and PNI. CRPS-I and CRPS-II had almost identical somatosensory profiles, with the exception of a stronger loss of mechanical detection in CRPS-II. In CRPS-I and -II, cold hyperalgesia/allodynia (28%-31%) and dynamic mechanical allodynia (24%-28%) were less frequent than heat or pressure hyperalgesia (36%-44%, 67%-73%), and mechanical hypoesthesia (31%-55%) was more frequent than thermal hypoesthesia (30%-44%). About 82% of PNI patients had at least one type of sensory gain. QST demonstrates more sensory loss in CRPS-I than hitherto considered, suggesting either minimal nerve injury or central inhibition. Sensory profiles suggest that CRPS-I and CRPS-II may represent one disease continuum. However, in contrast to recent suggestions, small fiber deficits were less frequent than large fiber deficits. Sensory gain is highly prevalent in PNI, indicating a better similarity of animal models to human patients than previously thought. These sensory profiles should help prioritize approaches for translation between animal and human research.

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Anesthesiology. 2011 Dec 2. [Epub ahead of print]

Predictors of Pain Relieving Response to Sympathetic Blockade in Complex Regional Pain Syndrome Type 1.

Source

* Consultant Anesthesiologist, Department of Anesthesiology and Pain Management, St. Elisabeth Hospital, Tilburg, The Netherlands. † Research Associate, ‡ Professor, Department of Anesthesiology and Pain Medicine, § Associate Professor, Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands. ‖ Associate Professor, Department of Anesthesiology and Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands. # Biostatistician, Epidemiologist, Department of Clinical Epidemiology and Medical Technology Assessment, University Hospital Maastricht, Maastricht, The Netherlands. ** Consultant Anesthesiologist, Department of Anesthesiology and Multidisciplinary Pain Centre, Hospital Oost-Limburg, Genk, Belgium.

Abstract

BACKGROUND:

Sympathetic blockade with local anesthetics is used frequently in the management of complex regional pain syndrome type 1(CRPS-1), with variable degrees of success in pain relief. The current study investigated which signs or symptoms of CRPS-1 could be predictive of outcome. The incidence of side effects and complications of sympathetic blockade also were determined prospectively.

METHODS:

A prospective observational study was done of 49 patients with CRPS-1 in one extremity only and for less than 1-yr duration who had severe pain and persistent functional impairment with no response to standard treatment with medication and physical therapy.

RESULTS:

Fifteen (31%) patients had good or moderate response. The response rate was not different in patient groups with cold or warm type CRPS-1 or in those with more or less than 1.5°C differential increase in skin temperature after sympathetic blockade. Allodynia and hypoesthesia were negative predictors for treatment success in CRPS-1. There were no symptoms or signs of CRPS-1 that positively predicted treatment success. A majority of patients (84%) experienced transient side effects such as headache, dysphagia, increased pain, backache, nausea, blurred vision, groin pain, hoarseness, and hematoma at the puncture site. No major complications were reported.

CONCLUSIONS:

The presence of allodynia and hypoesthesia are negative predictors for treatment success. The selection of sympathetic blockade as treatment for CRPS-1 should be balanced carefully between potential success and side effect ratio. The procedure is as likely to cause a transient increase in pain as a decrease in pain. Patients should be informed accordingly.

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CNS Drugs. 2011 Dec 1. doi: 10.2165/11595200-000000000-00000. [Epub ahead of print]

Efficacy and Safety of Ketamine in Patients with Complex Regional Pain Syndrome: A Systematic Review.

Source

Department of Anesthesiology, Division of Pain Management, Duke University School of Medicine, Durham, NC, USA.

Abstract

Despite being a recognized clinical entity for over 140 years, complex regional pain syndrome (CRPS) remains a difficult-to-treat condition. While there have been multiple therapies explored in the treatment of CRPS, NMDA antagonists such as ketamine continue to hold significant interest because of their potential ability to alter the central sensitization noted in chronic pain states. The objective of this review is to identify published literature for evidence of the efficacy and safety of ketamine in the treatment of CRPS. PubMed and the Cochrane Controlled Trials Register were searched (final search 26 May 2011) using the MeSH terms ‘ketamine’, ‘complex regional pain syndrome’, ‘analgesia’ and ‘pain’ in the English literature. The manuscript bibliographies were then reviewed to identify additional relevant papers. Observational trials were evaluated using the Agency for Healthcare Research and Quality criteria; randomized trials were evaluated using the methodological assessment of randomized clinical trials. The search methodology yielded three randomized, placebo-controlled trials, seven observational studies and nine case studies/reports. In aggregate, the data available reveal ketamine as a promising treatment for CRPS. The optimum dose, route and timing of administration remain to be determined. Randomized controlled trials are needed to establish the efficacy and safety of ketamine and to determine its long-term benefit in CRPS.

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Disclaimer

The resources on this site should not be used as a substitute for professional medical care or advice. Users seeking information about CRPS should consult with a qualified healthcare professional.

 

Laugh

Posted on by under Brain, Brain and pain, Chronic pain, Complex Regional Pain Syndrome, CRPS, Pain Education, Treatment


I really like to laugh. It is great. How do you feel when you laugh? Does it affect your pain? Certainly when we feel good, pain can be less intrusive and impacting as we access chemicals stored in our brain that suppress unpleasant feelings and emotions. Norman Cousins found this out when he took responsibility for his condition and used laughter along with vitamin C to deal with his predicament. He wrote about his experience causing uproar in certain quarters at the time–click here. However, there are some strong messages about his approach.

**Please note that any undiagnosed condition should be assessed by a medical practitioner.

Here is a sketch that makes me laugh. Probably relevant because it is to do with brains!

Graded Motor Imagery

Posted on by under Brain, Brain and pain, Complex Regional Pain Syndrome, CRPS, Neuroscience, Pain, Rehabilitation, Research, Treatment

I use Graded Motor Imagery commonly for a range of painful conditions including CRPS. In essence, GMI is brain training that targets mechanisms that we know are involved in ongoing pain states. Here is David Butler talking about GMI, mirrors and neuroscience.

 
Part 1

Part 2

Part 3

Part 4

Mirror Therapy

Neurodynamics and neuroscience

For more information about treatment of CRPS and other chronic and complex pain states, visit www.specialistpainphysio.com