The Clinical journal of pain
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Invasive procedures have long held a place in the therapeutic armamentarium for the management of complex regional pain syndrome (CRPS). However, this has evolved considerably, particularly as research into the mechanisms of CRPS has called into question long-held presumptions about the key role of sympathetic dysfunction in the syndrome. This review summarizes some of the key information currently available about interventional treatments, including nerve blocks, spinal cord and peripheral nerve stimulation, chemical and surgical sympathectomies, and deep brain stimulation. The potential roles for these procedures in facilitating functional rehabilitation goals that are primary to the treatment of CRPS are emphasized.
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Comparative Study Clinical Trial
Local administration of norepinephrine in the stump evokes dose-dependent pain in amputees.
More than 50% of amputees report experiencing significant stump or phantom pain. Stump pain is often attributed to the formation of a neuroma at the amputation site. Experimental evidence shows that catecholamines and alpha-adrenoceptors play a role in the mechanisms of pain associated with neuromas. We investigated whether administration of physiological doses of norepinephrine (NE) in the distal stump in the region of a probable neuroma evoked pain and if local administration of phentolamine attenuated NE-evoked pain in patients with postamputation stump pain. ⋯ Our data suggest that alpha-adrenoceptor mechanisms contribute to stump pain, possibly associated with neuromas in amputees. Sympathectomy and adrenergic blockade should be explored in controlled clinical trials as therapeutic options in patients with postamputation pain.
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This review will discuss the relevant history of the taxonomy and eventual development of diagnostic criteria of what is currently called complex regional pain syndrome. The authors will take their discussion through the early days (at which time the disorder was called reflex sympathetic dystrophy) through consensus-developing conferences to the current conceptualization of the criteria as published by the International Association for the Study of Pain's Task Force on Taxonomy in 1994. The authors will also mention the recent work of the closed workshop held in Budapest in 2004, where clinical and research criteria were proposed; these criteria were published in 2005. The review will also address issues of staging and subtyping the syndrome, as well as a discussion of the salient signs, symptoms, and tests appropriate for use in the diagnosis.
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This review summarizes current information about diagnosis and treatment of complex regional pain syndrome (CRPS) in children. Although it has been widely held that CRPS in children is intrinsically different from adults, there appear to be relatively few differences. However, there is a marked preponderance of lower extremity cases in children. ⋯ Clinical judgment dictates the extent of medication or interventional therapy added to the treatment to facilitate rehabilitation. In many ways, the approach to the treatment of children mirrors that of adults, with perhaps greater restraint in the use of medications and invasive procedures. The rehabilitation of children with CRPS, like that of adults with CRPS, needs further rigorous investigation.
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Comparative Study
A systematic review of pain drawing literature: should pain drawings be used for psychologic screening?
The use of pain drawings to identify the psychologic "state" of patients has been advocated. They are used for psychologic screening before considering treatments, such as surgery. For pain drawings to be clinically useful as a psychologic screen they need good positive and negative predictive values. We systematically reviewed the literature that directly compared pain drawing scoring systems with measures of psychologic state. ⋯ We conclude that the available data do not support the assumption that unusual pain drawings or extensive marking indicate disturbed psychologic state. There is no high quality evidence to support pain-drawing use as a psychologic assessment tool; therefore, pain drawings are not recommended for this purpose.