Pieter U. Dijkstra

Phantom pain and phantom sensations in upper limb amputees: an epidemiological study

&NA; Phantom pain in subjects with an amputated limb is a well‐known problem. However, estimates of the prevalence of phantom pain differ considerably in the literature. Various factors associated with phantom pain have been described including pain before the amputation, gender, dominance, and time elapsed since the amputation. The purposes of this study were to determine prevalence and factors associated with phantom pain and phantom sensations in upper limb amputees in The Netherlands. Additionally, the relationship between phantom pain, phantom sensations and prosthesis use in upper limb amputees was investigated. One hundred twenty‐four upper limb amputees participated in this study. Subjects were asked to fill out a self‐developed questionnaire scoring the following items: date, side, level, and reason of amputation, duration of experienced pain before amputation, frequencies with which phantom sensations, phantom pain, and stump pain are experienced, amount of trouble and suffering experienced, respectively, related to these sensations, type of phantom sensations, medical treatment received for phantom pain and/or stump pain, and the effects of the treatment, self medication, and prosthesis use. The response rate was 80%. The prevalence of phantom pain was 51%, of phantom sensations 76% and of stump pain 49%; 48% of the subjects experienced phantom pain a few times per day or more; 64% experienced moderate to very much suffering from the phantom pain. A significant association was found between phantom pain and phantom sensations (relative risk 11.3) and between phantom pain and stump pain (relative risk 1.9). No other factors associated with phantom pain or phantom sensations could be determined. Only four patients received medical treatment for their phantom pain. Phantom pain is a common problem in upper limb amputees that causes considerable suffering for the subjects involved. Only a minority of subjects are treated for phantom pain. Further research is needed to determine factors associated with phantom pain.

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.

Impairments, disabilities and health related quality of life after treatment for breast cancer : a follow-up study 2.7 years after surgery

Purpose: The aim of this study was to assess impairments, disabilities and health related Quality of Life (QOL) after treatment of breast cancer and to analyse the relationship between treatment modalities, impairments, disabilities and health related QOL. Method: Fifty-five patients who underwent a modified radical mastectomy or a segmental mastectomy with axillary lymph node dissection were retrospectively assessed with a mean follow up of 2.7 years after treatment. Impairments were assessed by means of measuring active shoulder range of motion, grip strength, arm volume and pain. Disabilities were assessed by means of the Shoulder Disability Questionnaire (SDQ) and health related QOL was assessed by means of the RAND 36-item Health Survey (RAND-36). Setting: University Hospital Groningen (The Netherlands). Results: Pain (60%) and reduction of grip-strength (40%) were the most frequent impairments found. The prevalence of impaired range of motion and oedema was 9 – 16% respectively 15%. Mean group score of the SDQ was 33.7 (sd: 32.1) and mean scores of the RAND-36 differed significantly for physical functioning, vitality and health perception to that of a female norm group. Radiotherapy and chemotherapy were significant factors in the prediction of impaired range of motion. Pain and restricted range of motion explained 61% respectively 12% of the variance in disability (SDQ). In the prediction of health related QOL, pain, grip strength and arm volume were significant factors respectively in six, three and two domains. Conclusions: Pain is the most frequent assessed impairment after breast cancer treatment with strong relationship to perceived disability and health related QOL. Disability is mild and health related QOL (RAND-36) differed in three of the nine domains with a female norm group.

Periodontal inflamed surface area: quantifying inflammatory burden

BACKGROUND Currently, a large variety of classifications is used for periodontitis as a risk factor for other diseases. None of these classifications quantifies the amount of inflamed periodontal tissue, while this information is needed to assess the inflammatory burden posed by periodontitis. AIM To develop a classification of periodontitis that quantifies the amount of inflamed periodontal tissue, which can be easily and broadly applied. MATERIAL AND METHODS A literature search was conducted to look for a classification of periodontitis that quantified the amount of inflamed periodontal tissue. A classification that quantified the root surface area affected by attachment loss was found. This classification did not quantify the surface area of inflamed periodontal tissue, however. Therefore, an Excel spreadsheet was developed in which the periodontal inflamed surface area (PISA) is calculated using clinical Attachment Level (CAL), recessions and bleeding on probing (BOP). RESULTS The PISA reflects the surface area of bleeding pocket epithelium in square millimetres. The surface area of bleeding pocket epithelium quantifies the amount of inflamed periodontal tissue. A freely downloadable spreadsheet is available to calculate the PISA. CONCLUSION PISA quantifies the inflammatory burden posed by periodontitis and can be easily and broadly applied.

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.

Stressful life events and psychological dysfunction in complex regional pain syndrome type I

OBJECTIVE To determine to what extent stressful life events and psychological dysfunction play a role in the pathogenesis of Complex Regional Pain Syndrome type I (CRPS). DESIGN A comparative study between a CRPS group and a control group. Stressful life events and psychological dysfunction evaluation was performed with a life event rating list and the Symptom Checklist-90 (SCL-90). SETTING A university hospital. SUBJECTS The CRPS group consisted of 24 patients with a history of upper extremity CRPS of less than 3 months. The control group consisted of 42 hand pathology patients waiting for elective hand surgery within the next 24 hours. MAIN OUTCOME MEASURES Stressful life event rating was measured using the Social Readjustment Rating Scale. Psychological dysfunction was measured using the SCL-90. RESULTS Stressful life events were experienced by 19 patients (79.2%) in the CRPS group and by 9 patients (21.4%) in the control group. This difference was significant. Testing of psychological dysfunction (SCL-90) in CRPS patients and the control group demonstrated some significant differences: male patients were more anxious than male controls; female patients were statistically more depressed, had feelings of inadequacy, and were emotionally less stable than female controls. In multivariate analysis, no significant differences were found across gender, age, or gender x group interactions. Of the SCL-90 dimensions, only insomnia correlated with the experienced stressful life events. CONCLUSION Stressful life events are more common in the CRPS group, which indicates that there may be a multiconditional model of CRPS. The experience of stressful life events besides trauma or surgery are risk factors, not causes, in such a model.

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.

Treatment-Related Upper Limb Morbidity 1 Year after Sentinel Lymph Node Biopsy or Axillary Lymph Node Dissection for Stage I or II Breast Cancer

Background: In a prospective study, upper limb morbidity and perceived disability/activities of daily life (ADLs) were assessed before and 1 year after sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND).Methods: A total of 204 patients with stage I/II breast cancer (mean age, 55.6 years; SD, 11.6 years) entered the study, and 189 patients (93%) could be evaluated after 1 year. Fifty-eight patients (31%) underwent only SLNB, and 131 (69%) underwent ALND. Assessments performed before surgery (t0) and 1 year after surgery (t1), included pain, shoulder range of motion, muscle strength, upper arm/forearm circumference, and perceived shoulder disability/ADL.Results: Considerable treatment-related upper limb morbidity was observed. Significant (P < .05) changes between t0 and t1 were found in all assessments except strength of elbow flexors. Patients in the ALND group showed significantly more changes in the range of motion in forward flexion, abduction, and abduction/external rotation; grip strength and strength of shoulder abductors; circumference of upper arm and forearm; and perceived shoulder disability in ADLs compared with the SLNB group. Multivariate linear regression analysis showed that ALND could predict a decrease of range of motion in forward flexion, abduction, strength of shoulder abductors, grip strength, and shoulder-related ADLs and an increase in the circumference of the upper arm. Radiation of the axilla (19 patients) predicts an additional decrease in shoulder range of motion.Conclusions: One year after treatment of breast cancer, there is significantly less upper limb morbidity after SLNB compared with ALND. ALND is a predictor for upper limb morbidity.

Short-term morbidity of the upper limb after sentinel lymph node biopsy or axillary lymph node dissection for Stage I or II breast carcinoma.

The goals of sentinel lymph node biopsy (SLNB) are to improve axillary staging and reduce unnecessary axillary lymph node dissections (ALND), thereby reducing treatment‐related upper‐limb morbidity. In the current prospective study, short‐term upper‐limb morbidity was assessed after SLNB and/or ALND.