Jan H. B. Geertzen

Evidence based guidelines for complex regional pain syndrome type 1

BackgroundTreatment of complex regional pain syndrome type I (CRPS-I) is subject to discussion. The purpose of this study was to develop multidisciplinary guidelines for treatment of CRPS-I.MethodA multidisciplinary task force graded literature evaluating treatment effects for CRPS-I according to their strength of evidence, published between 1980 to June 2005. Treatment recommendations based on the literature findings were formulated and formally approved by all Dutch professional associations involved in CRPS-I treatment.ResultsFor pain treatment, the WHO analgesic ladder is advised with the exception of strong opioids. For neuropathic pain, anticonvulsants and tricyclic antidepressants may be considered. For inflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. To promote peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used to increase blood flow in case vasodilatory medication has insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, vitamin C is recommended. Adequate perioperative analgesia, limitation of operating time, limited use of tourniquet, and use of regional anaesthetic techniques are recommended for secondary prevention of CRPS-I.ConclusionsBased on the literature identified and the extent of evidence found for therapeutic interventions for CRPS-I, we conclude that further research is needed into each of the therapeutic modalities discussed in the guidelines.

Prediction of Sickness Absence in Patients with Chronic Low Back Pain: A Systematic Review

Objectives: To provide evidence of predictors for sickness absence in patients with non-specific chronic low back pain (CLBP), distinguishing predictors aimed at the decision to report sick (absence threshold) and decision to return to work (return to work threshold). Methods: Medical and psychological databases were searched, as well as citations from relevant reviews. In- and exclusion criteria were applied. Two reviewers assessed the methodological quality of the papers independently. Results: Many different predictors were studied, and few factors were studied more than once. Consistent evidence was found for own expectations of recovery only as predictor for the decision to return to work. Patients with higher expectations had less sickness absence at the moment of follow-up measurement. As expected, different predictors were found aiming at the absence threshold or the return to work threshold. Furthermore, predictors varied also with the measurement instruments used, timing of follow-up measurements, and definition of outcomes. Until now, too few studies are available to overcome several potential sources of heterogeneity. Conclusions: No core set of predictors exists for sickness absence in general. The characteristics of the study including the decision to report sick or to return to work determined the influence of several predictors on sickness absence in patients with CLBP. Further research and use of a core set of measurements and uniform definitions are needed to predict sickness absence and return to work in patients with CLBP.

Incidence of complex regional pain syndrome type I after fractures of the distal radius

Aim of this study was to analyse the incidence CRPS‐I after a fracture of the distal radius and to analyse risk factors. Patients who visited the Emergency Unit of the University Hospital, with a fracture of distal radius were asked to participate. As risk factors for CRPS‐I, number of repositions (with or without local anaesthesia), additional cast changes and pain during the cast period, were assessed. In a structured interview social life events (SLEs) and psychological and/or psychiatric history were assessed. The patients filled out the Symptom Checklist‐90 (SCL‐90). In total 88 patients participated in the study. One female (1%, 95% CI: 0.2 to 6%), age 69 years with the following characteristics developed CRPS‐I: one set of local anaesthetics, one repositioning attempt, no additional cast changes, average pain scores, no life events and her total score on the SCL‐90 of 117, was slightly above average. Based on the results of this study it is concluded that the incidence of CRPS‐I may be low (1%, 95% CI: 0.2 to 6%) after fractures of the distal radius. Further the risk factors described in literature play a minor role in the development of CRPS‐I.

Complex regional pain syndrome type I : Use of the International Association for the Study of Pain diagnostic criteria defined in 1994

ObjectivesThe objective was to assess the reported use in recent publications of the diagnostic criteria for complex regional pain syndrome type I (CRPS I) proposed by the International Association for the Study of Pain (IASP) in 1994. MethodsA literature search of MEDLINE (January 1996 to July 2000) was performed with use of the medical subject heading “reflex sympathetic dystrophy” and the free texts words “complex,” “regional,” “pain,” and “syndrome.” Publications in English, German, and Dutch were analyzed. From the search, 65 original publications were selected. Another 27 publications (referenced publications) that were referenced in the 65 original publications for the description of diagnostic criteria for CRPS I also were included. A standard form was used to assess a total of 92 publications. A sensitivity analysis was performed by means of analyzing three scenarios in which the diagnostic criteria were used as proposed and two combinations of less stringent criteria. ResultsUse of the diagnostic criterion pain was reported in 35 (38%) of the analyzed publications. None of the original publications satisfied the proposed IASP diagnostic criteria. Four (15%) of the referenced publications satisfied the proposed IASP diagnostic criteria. Ten (15%) of the original publications referred correctly to the referenced publications. With the less strict criteria used in scenarios 2 and 3, 2 (3%) and 3 (5%), respectively, of the original publications fulfilled these criteria. ConclusionsIf the diagnostic criteria for CRPS I are not used uniformly, the populations in clinical studies may not be uniform either. Whether different authors are describing the same syndrome and whether their findings can be compared is open to question. On the basis of the results of this study, it is concluded that the IASP criteria for CRPS I are poorly used in clinical studies.

Gait in children with cerebral palsy : observer reliability of Physician Rating Scale and Edinburgh Visual Gait Analysis Interval Testing scale

The aim of this study was to test the inter- and intraobserver reliability of the Physician Rating Scale (PRS) and the Edinburgh Visual Gait Analysis Interval Testing (GAIT) scale for use in children with cerebral palsy (CP). Both assessment scales are quantitative observational scales, evaluating gait. The study involved 24 patients ages 3 to 10 years (mean age 6.7 years) with an abnormal gait caused by CP. They were all able to walk independently with or without walking aids. Of the children 15 had spastic diplegia and 9 had spastic hemiplegia. With a minimum time interval of 6 weeks, video recordings of the gait of these 24 patients were scored twice by three independent observers using the PRS and the GAIT scale. The study showed that both the GAIT scale and the PRS had excellent intraobserver reliability but poor interobserver reliability for children with CP. In the total scores of the GAIT scale and the PRS, the three observers showed systematic differences. Consequently, the authors recommend that longitudinal assessments of a patient should be done by one observer only.

Chronic Disease and Sexuality: A Generic Conceptual Framework

Although sexual dysfunctions are frequently comorbid with many chronic diseases and their treatments, until recently, these dysfunctions have been neglected in both research and clinical practice. Fortunately, sexual functioning in the context of chronic disease has now begun to receive more scientific attention. Studies in the field are, however, quite diverse in terms of topics and methodology, not only making comparisons across studies on a single disease difficult, but also making comparisons across different diseases impossible. In an attempt to inspire researchers, this article presents a “generic” conceptual framework regarding the impact of chronic diseases (and their treatments) on sexual function. The major goals of this conceptual framework are to provide an in-depth analysis of, and insight into, the process by which disease-related psychological and relational factors impact the sexual functioning and well-being of patients, their partners, and their relationships. Some of the associations within the conceptual framework have already been supported by the results of empirical studies on various diseases. This review ends with an overview of the limitations of previous research, proposes a research agenda for the field, and presents a research tool that may be helpful in developing new studies investigating the association between chronic diseases and sexuality.

Psychometric properties of Chronic Pain Acceptance Questionnaires: A systematic review

Background: Theoretically, acceptance of chronic pain (CP) is an important determinant in the functional status and well‐being of patients with CP. Several questionnaires that aim to measure acceptance of CP have been developed. An overview of the psychometric properties of these questionnaires is unavailable.

Short and Long Term Mortality Rates after a Lower Limb Amputation

OBJECTIVE To determine mortality rates after a first lower limb amputation and explore the rates for different subpopulations. METHODS Retrospective cohort study of all people who underwent a first amputation at or proximal to transtibial level, in an area of 1.7 million people. Analysis with Kaplan-Meier curves and Log Rank tests for univariate associations of psycho-social and health variables. Logistic regression for odds of death at 30-days, 1-year and 5-years. RESULTS 299 people were included. Median time to death was 20.3 months (95%CI: 13.1; 27.5). 30-day mortality = 22%; odds of death 2.3 times higher in people with history of cerebrovascular disease (95%CI: 1.2; 4.7, P = 0.016). 1 year mortality = 44%; odds of death 3.5 times higher for people with renal disease (95%CI: 1.8; 7.0, P < 0.001). 5-years mortality = 77%; odds of death 5.4 times higher for people with renal disease (95%CI: 1.8; 16.0,P = 0.003). Variation in mortality rates was most apparent in different age groups; people 75-84 years having better short term outcomes than those younger and older. CONCLUSIONS Mortality rates demonstrated the frailty of this population, with almost one quarter of people dying within 30-days, and almost half at 1 year. People with cerebrovascular had higher odds of death at 30 days, and those with renal disease and 1 and 5 years, respectively.

Mirror box therapy added to cognitive behavioural therapy in three chronic complex regional pain syndrome type I patients: a pilot study

Complex regional pain syndrome type I is a disorder of the extremities with disability and pain as the most prominent features. This paper describes the results of cognitive behavioural therapy combined with mirror box therapy in three patients with chronic complex regional pain syndrome type I. Before, during and at follow-up the following measurements were assessed: pain (visual analogue scale, 0–100), range of motion, muscle strength, and the areas of allodynia and of hyperalgesia. Furthermore, patients were asked for their feelings and thoughts about mirror box therapy and about the affected limb. Pain at rest, pain after measuring allodynia/hyperalgesia and pain after measuring strength decreased. Range of motion improved in two patients. Strength improved in one patient. The area of hyperalgesia increased for all three patients, whereas the area of allodynia remained stable in two patients and decreased in one patient. Two patients felt that their affected limb still belonged to them, one did not. Cognitive behavioural therapy combined with mirror box therapy for patients with chronic complex regional pain syndrome type I may facilitate rehabilitation. Measuring whether the affected limb still belongs in the patients body scheme could be of prognostic value in the treatment of chronic complex regional pain syndrome type I patients.

Determinants of Skin Problems of the Stump in Lower-Limb Amputees

OBJECTIVE To identify determinants of skin problems in lower-limb amputees. DESIGN Survey, using a questionnaire. SETTING Not applicable. PARTICIPANTS Lower-limb amputees (N=2039) who either obtained their prosthesis through the Orthopedische Instrument Makerij (a group of orthopedic workshops in the Netherlands) or were a member of the (Dutch) National Society of Amputees (Landelijke Vereniging van Geamputeerden) were invited to participate. In total, 872 lower-limb amputees agreed to participate. INTERVENTION Amputees filled in the questionnaire to assess characteristics of the amputation and prosthesis, level of activity, stump and prosthesis hygiene, and skin problems. Stepwise backward logistic regression was performed to analyze determinants of skin problems. MAIN OUTCOME MEASURE Skin problems in the month prior to completing the questionnaire. RESULTS A total of 816 questionnaires were received. Eventually 805 questionnaires were suitable for statistical analysis. Protective determinants were (in order of magnitude of association) older age, male sex, and amputation because of peripheral arterial disease and/or diabetes. Provocative determinants were (in order of magnitude of association) use of antibacterial soap, smoking, and washing the stump 4 times a week or more often. In total, 63% of the participants (95% confidence interval, 60%-67%) reported 1 or more skin problems. CONCLUSIONS The provocative determinants identified in this study--use of antibacterial soap, smoking, and stump washing frequency--have to be studied for their clinical relevance.