Lin Tchia Yeng

Repetitive Transcranial Magnetic Stimulation Is Efficacious as an Add-On to Pharmacological Therapy in Complex Regional Pain Syndrome (CRPS) Type I

UNLABELLED Single-session repetitive transcranial magnetic stimulation (rTMS) of the motor cortex (M1) is effective in the treatment of chronic pain patients, but the analgesic effect of repeated sessions is still unknown. We evaluated the effects of rTMS in patients with refractory pain due to complex regional pain syndrome (CRPS) type I. Twenty-three patients presenting CRPS type I of 1 upper limb were treated with the best medical treatment (analgesics and adjuvant medications, physical therapy) plus 10 daily sessions of either real (r-) or sham (s-) 10 Hz rTMS to the motor cortex (M1). Patients were assessed daily and after 1 week and 3 months after the last session using the Visual Analogical Scale (VAS), the McGill Pain Questionnaire (MPQ), the Health Survey-36 (SF-36), and the Hamilton Depression (HDRS). During treatment there was a significant reduction in the VAS scores favoring the r-rTMS group, mean reduction of 4.65 cm (50.9%) against 2.18 cm (24.7%) in the s-rTMS group. The highest reduction occurred at the tenth session and correlated to improvement in the affective and emotional subscores of the MPQ and SF-36. Real rTMS to the M1 produced analgesic effects and positive changes in affective aspects of pain in CRPS patients during the period of stimulation. PERSPECTIVE This study shows an efficacy of repetitive sessions of high-frequency rTMS as an add-on therapy to refractory CRPS type I patients. It had a positive effect in different aspects of pain (sensory-discriminative and emotional-affective). It opens the perspective for the clinical use of this technique.

Consenso brasileiro do tratamento da fibromialgia

Recebido em 06/10/2009. Aprovado, apos revisao, em 24/11/2009. Roberto Ezequiel Heymann e Eduardo dos Santos Paiva declaram ter recebido honorarios da Lilly, Janssen-Cilag, Boehringer, Apsen e Pfizer para palestras e consultoria; Milton Helfenstein Junior recebeu honorarios da Pfizer e Merck Sharp para palestras e consultoria; Daniel Feldman Pollak recebeu honorarios da Lilly, Pfizer e Merck Sharp; Jose Eduardo Martinez recebeu honorarios da Sanofi Aventis para palestras e da Pfizer para palestras e consultoria; Jose Roberto Provenza recebeu honorarios dos laboratorios Roche, Bristol, Ache e Pfizer para participar de pesquisas clinicas com novos farmacos na PUC-Campinas; Marcelo Cruz Rezende declara ter recebido honorarios da Lilly-Boehringer para a participacao em simposios e da Pfizer para ser palestrante e participar de simposios; valerio valim Cristo declara recebimento de honorarios por apresentacao, conferencia ou palestra pela Roche, alem de financiamento para a realizacao de pesquisa, organizacao de atividade de ensino ou comparecimento a simposios pela Lilly, Genzyme, Schering-Plough. os demais autores declararam nao haver conflitos de interesse.1. Coordenador do Ambulatorio de Fibromialgia da UNiFESP e assistente doutor da Disciplina de Reumatologia da UNiFESP2. Professor Assistente da Disciplina de Reumatologia, UFPR. Chefe do ambulatorio de fibromialgia do HC-UFPR3. Assistente doutor da Disciplina de Reumatologia da UNiFESP4. Professor Adjunto da Disciplina de Reumatologia da UNiFESP e chefe do Setor de reumatismos de partes moles da UNiFESP5. Professor titular do Departamento de Medicina da PUC-SP, doutor em Reumatologia pela UNiFESP e diretor da Faculdade de Medicina da PUC-SP6. Professor titular de Reumatologia da PUC-Campinas e chefe do Servico de Reumatologia do Hospital Universitario da PUC-Campinas7. Professora orientadora da pos-graduacao da Faculdade de Ciencias da Saude da UnB e chefe do centro de ambulatorios do Hospital Universitario de Brasilia8. Membro da Sociedade Brasileira de Reumatologia9. Mestre em Medicina pelo instituto de Ensino e Pesquisa da Santa Casa de Belo Horizonte, coordenador do Programa de Residencia Medica em Reumatologia e do Ambulatorio de Fibromialgia da Santa Casa de Belo Horizonte10. Ex-presidente da Sociedade Brasileira de Reumatologia, bienio 2007-200811. Professora colaboradora da Faculdade de Medicina da USP, assistente doutora do Servico de Reumatologia e responsavel pelo ambulatorio de Fibromialgia do Servico de Reumatologia do HC-FMUSP12. Responsavel pelo Setor de Reumatologia e Preceptor do programa de Residencia em Clinica Medica da Santa Casa de Campo Grande. Ex-presidente da Sociedade de Reumatologia do Mato Grosso do Sul13. Professor assistente de Reumatologia da Universidade Federal de Ciencias da Saude de Porto Alegre (UFCSPA) e mestre em Clinica Medica pela UFGRS14. Reumatologista com especializacao em Medicina Esportiva do setor de reabilitacao, procedimentos e coluna vertebral pela UNiFESP15. Ex-fellow da Universidade da virginia (EUA), mestre em Educacao e Ciencia e professora da UNiSUL16. Professora adjunto do Departamento de Clinica Medica, chefe do ambulatorio de fibromialgia e chefe do servico de Reumatologia do Hospital Universi-tario da Universidade Federal do Espirito Santo17. Doutora em Reumatologia pela UNiFESP, membro da Sociedade Brasileira de Reumatologia e da Sociedade Brasileira de Clinica Medica18. Membro da Sociedade Brasileira para o Estudo da Dor19. Presidente da Associacao Brasileira de Medicina Fisica e Reabilitacao, professora colaboradora da Faculdade de Medicina da Universidade de Sao Paulo e doutora em Medicina pela FMUSP20. Membro da Associacao Brasileira de Medicina Fisica e Reabilitacao21. Professor titular de Neurologia da Universidade Federal Fluminense (UFF), coordenador do Departamento de Dor da Academia Brasileira de Neurologia (ABN) e do Subcomite de Dor da European Neurological Society (ENS). Membro da Peripheral Nerve Society22. Doutor em ortopedia e Traumatologia pela Faculdade de Medicina da USP, medico Assistente do Grupo de Mao e professor colaborador da FMUSP23. Membro da Sociedade Brasileira de ortopedia e Traumatologia24. Membro da Consultoria Axia.Bio farmacoeconomia e pesquisa em saude25. Diretor executivo do Nucleo de Gestao de Pesquisas da UNiFESP, mestre em Ciencias pela UNiFESP e socio-pesquisador da Axia.Bio

Repetitive transcranial magnetic stimulation in chronic pain: a review of the literature.

OBJECTIVE To review the literature on the analgesic effects of repetitive transcranial magnetic stimulation (rTMS) in chronic pain according to different pain syndromes and stimulation parameters. DATA SOURCES Publications on rTMS and chronic pain were searched in PubMed and Google Scholar using the following key words: chronic pain, analgesia, transcranial magnetic stimulation, neuropathic pain, fibromyalgia, and complex regional pain syndrome. STUDY SELECTION This review only included double-blind, controlled studies with >10 participants in each arm that were published from 1996 to 2014 and written in English. Studies with relevant information for the understanding of the effects of rTMS were also cited. DATA EXTRACTION The following data were retained: type of pain syndrome, type of study, coil type, target, stimulation intensity, frequency, number of pulses, orientation of induced current, number of session, and a brief summary of intervention outcomes. DATA SYNTHESIS A total of 33 randomized trials were found. Many studies reported significant pain relief by rTMS, especially high-frequency stimulation over the primary motor cortex performed in consecutive treatment sessions. Pain relief was frequently >30% compared with control treatment. Neuropathic pain, fibromyalgia, and complex regional pain syndrome were the pain syndromes more frequently studied. However, among all published studies, only a few performed repetitive sessions of rTMS. CONCLUSIONS rTMS has potential utility in the management of chronic pain; however, studies using maintenance sessions of rTMS and assessing the effects of rTMS on the different aspects of chronic pain are needed to provide a more solid basis for its clinical application for pain relief.

The assessment and management of pain in the demented and non-demented elderly patient

Persistent pain is a frequent health problem in the elderly. Its prevalence ranges from 45% to 80%. Chronic diseases, such as depression, cardiovascular disease, cancer and osteoporosis have a higher prevalence in aged individuals and increase the risk of developing chronic pain. The presence of pain is known to be associated with sleep disorders in these patients, as well as functional impairment, decreased sociability and greater use of the health system, with consequent increase in costs. Alzheimers disease patients seem to have a normal pain discriminative capacity and they may probably have weaker emotional and affective experience of pain when compared to other types of dementia. Many patients have language deficits and thus cannot properly describe its characteristics. In more advanced cases, it becomes even difficult to determine whether pain is present or not. Therefore, the evaluation of these patients should be performed in a systematic way. There are three ways to measure the presence of pain: by direct questioning (self-report), by direct behavioral observation and by interviews with caregivers or informants. In recent years, many pain scales and questionnaires have been published and validated specifically for the elderly population. Some are specific to patients with cognitive decline, allowing pain evaluation to be conducted in a structured and reproducible way. The next step is to determine the type of painful syndrome and discuss the bases of the pharmacological management, the use of multiple medications and the presence of comorbidities demand the use of smaller doses and impose contra-indications against some drug classes. A multiprofessional approach is the rule in the management of these patients.

Failed back surgery pain syndrome: therapeutic approach descriptive study in 56 patients

OBJECTIVE The authors show the clinical evaluation and follow-up results in 56 patients diagnosed with a failed back surgery pain syndrome. METHODS Descriptive and prospective study conducted over a one-year period. In this study, 56 patients with a failed back surgery pain syndrome were assessed in our facility. The age ranged from 28 to 76 years (mean, 48.8 ± 13.9 years). The pain was assessed through a Visual Analog Scale (VAS). RESULTS Postoperative pain was more severe (mean VAS score 8.3) than preoperative pain (7.2). Myofascial pain syndromes (MPS) were diagnosed in 85.7% of patients; neuropathic abnormalities associated or not with MPS were found in 73.3%. Drug therapy associated with physical medicine treatment provided > 50% pain improvement in 57.2% of cases; trigger point injection in 60.1%, and epidural infusion of morphine with lidocaína in 69.3% of refractory cases. CONCLUSION In patients with a post-laminectomy syndrome, postoperative pain was more severe than preoperative pain from a herniated disk. A miofascial component was found in most patients.

Pain Relief and Functional Recovery in Patients with Complex Regional Pain Syndrome after Motor Cortex Stimulation

In addition to pain and neurovegetative symptoms, patients with severe forms of complex regional pain syndrome (CRPS) develop a broad range of symptoms, including sensory disturbances, motor impairment and dystonic posturing. While most patients respond to medical therapy, some are considered refractory and become surgical candidates. To date, the most commonly used surgical procedure for CRPS has been spinal cord stimulation. This therapy often leads to important analgesic effects, but no sensory or motor improvements. We report on 2 patients with pain related to CRPS and severe functional deficits treated with motor cortex stimulation (MCS) who not only had significant analgesic effects, but also improvements in sensory and motor symptoms. In the long term (27 and 36 months after surgery), visual analog scale pain scores were improved by 60–70% as compared to baseline. There was also a significant increase in the range of motion in the joints of the affected limbs and an improvement in allodynia, hyperpathia and hypoesthesia. Positron emission tomography scan in both subjects revealed that MCS influenced regions involved in the circuitry of pain.

Neuropathic pain after brachial plexus avulsion--central and peripheral mechanisms.

ReviewThe pain that commonly occurs after brachial plexus avulsion poses an additional burden on the quality of life of patients already impaired by motor, sensory and autonomic deficits. Evidence-based treatments for the pain associated with brachial plexus avulsion are scarce, thus frequently leaving the condition refractory to treatment with the standard methods used to manage neuropathic pain. Unfortunately, little is known about the pathophysiology of brachial plexus avulsion. Available evidence indicates that besides primary nerve root injury, central lesions related to the abrupt disconnection of nerve roots from the spinal cord may play an important role in the genesis of neuropathic pain in these patients and may explain in part its refractoriness to treatment.ConclusionsThe understanding of both central and peripheral mechanisms that contribute to the development of pain is of major importance in order to propose more effective treatments for brachial plexus avulsion-related pain. This review focuses on the current understanding about the occurrence of neuropathic pain in these patients and the role played by peripheral and central mechanisms that provides insights into its treatment.SummaryPain after brachial plexus avulsion involves both peripheral and central components; thereby it is characterized as a mixed (central and peripheral) neuropathic pain syndrome.

Thoracic sympathetic block for the treatment of complex regional pain syndrome type I: a double-blind randomized controlled study.

&NA; Seventeen chronic upper limb complex regional pain syndrome type I patients treated with thoracic sympathetic block were better than 19 treated with active‐control regarding pain, quality of life and mood at 1, 2, and 12 months. &NA; Pain relief in complex regional pain syndrome (CRPS) remains a major challenge, in part due to the lack of evidence‐based treatment trials specific for this condition. We performed a long‐term randomized, double‐blinded active‐control study to evaluate the efficacy of thoracic sympathetic block (TSB) for upper limb type I CRPS. The study objective was to evaluate the analgesic effect of TSB in CRPS. Patients with CRPS type I were treated with standardized pharmacological and physical therapy and were randomized to either TSB or control procedure as an add‐on treatment. Clinical data, pain intensity, and interference (Brief Pain Inventory), pain dimensions (McGill Pain Questionnaire [MPQ]), neuropathic characteristics (Neuropathic Pain Symptom Inventory [NPSI]), mood, upper limb function (Disabilities of Arm, Shoulder and Hand), and quality of life were assessed before, and at 1 month and 12 months after the procedure. Thirty‐six patients (19 female, 44.7 ± 11.1 years of age) underwent the procedure (17 in the TSB group). Average pain intensity at 1 month was not significantly different after TSB (3.5 ± 3.2) compared to control procedure (4.8 ± 2.7; P = 0.249). At 12 months, however, the average pain item was significantly lower in the TSB group (3.47 ± 3.5) compared to the control group (5.86 ± 2.9; P = 0.046). Scores from the MPQ, evoked‐pain symptoms subscores (NPSI), and depression scores (Hospital Anxiety and Depression Scale) were significantly lower in the TSB group compared to the control group at 1 and at 12 months. Other measurements were not influenced by the treatment. Quality of life was only slightly improved by TSB. No major adverse events occurred. Larger, multicentric trials should be performed to confirm these original findings.

Use of low intensity laser treatment in neuropathic pain refractory to clinical treatment in amputation stumps

Debilitating stump pain following amputation surgery is a major problem when it affects the patient’s quality of life, often making the patient totally dependent on others for their day-to-day care. Attempts have been made to treat those patients through pharmacological, psychological, and physical therapies, but in many cases these fail to relieve the pain. This article focuses on three patients with chronic, intense, and debilitating stump pain who were previously treated with pain medications, but with little success. These patients underwent nine sessions of low-intensity laser therapy (LILT) to the stump – this is a new treatment that has been used to treat other pain disorders. All patients reported a decrease in the intensity of their pain and increased ability to perform daily living activities during a 4-month follow-up.

Utilização da imagem infravermelha em reumatologia

Infrared thermography is unique objective imaging procedure for the quantitative assessment of local inflammatory reactions in parts of the locomotor system. For differential diagnosis the thermographic results should be evaluated in conjuction with clinical examination and other technical procedures. As a means of monitoring the course of the local inflammatory activity, however, quantitative infrared thermography is a useful tool in itself, particularly during the application of local and systemic anti-inflammatory therapy.