Robert van Dongen

Safety of "pain exposure" physical therapy in patients with complex regional pain syndrome type 1.

&NA; “Pain exposure” physical therapy (PEPT) is a new treatment for patients with complex regional pain syndrome type 1 (CRPS‐1) that consists of a progressive‐loading exercise program and management of pain‐avoidance behavior without the use of specific CRPS‐1 medication or analgesics. The aim of this study was to investigate primarily whether PEPT could be applied safely in patients with CRPS‐1. Twenty patients with CRPS‐1 were consecutively enrolled in the study after giving informed consent. The diagnosis of CRPS‐1 was defined using the Bruehl and Harden/IASP diagnostic criteria. CRPS‐1 was diagnosed between 3 and 18 months after the inciting event (trauma). According to a multiple single‐case design (baseline [A1], treatment [B], follow‐up [A2]), multiple baseline and follow‐up measurements were performed to evaluate changes in CRPS signs and symptoms and to assess functional parameters. When comparing the baseline with the follow‐up phase, patients improved significantly with respect to pain on the visual analogue scale (57%), pain intensity (48%), muscle strength (52%), arm/shoulder/hand disability (36%), 10‐meter walking speed (29%), pain disability index (60%), kinesiophobia (18%), and the domains of perceived health change in the SF‐36 survey (269%). Three patients initially showed increased vegetative signs but improved in all other CRPS parameters and showed good functional recovery at follow‐up. We conclude that PEPT is a safe and effective treatment for patients with CRPS‐1. A progressive‐loading exercise program and management of pain‐avoidance behavior without the use of specific medication (“pain exposure” physical therapy) is safe and effective for patients with complex regional pain syndrome.

Somatosensory Symptoms and Signs and Conditioned Pain Modulation in Chronic Post-Stroke Shoulder Pain

UNLABELLED Persistent shoulder pain is a common complication after stroke. Its etiology and underlying mechanisms are not well understood and treatment is generally unsatisfactory. The objective of this study was to assess the role of central sensitization and disinhibition in chronic stroke patients with chronic PSSP (n = 19), pain-free stroke patients (n = 29), and healthy controls (n = 23). Positive and negative somatosensory symptoms and signs were assessed using clinical examination and electrical and mechanical quantitative sensory testing (QST). Conditioned pain modulation (CPM) was assessed by comparing QST thresholds before and after applying a cold pressor test. Sensory abnormalities were more frequently observed and more severe in patients with PSSP, including positive signs such as allodynia at the affected side and generalized hyperalgesia at the unaffected side. CPM was similar in stroke patients and healthy controls. This study showed that chronic PSSP was associated with several positive and negative somatosensory signs, implicating a role for central sensitization and possibly for disinhibition. Since the causal relationship remains unclear, and may be related to either neuroplasticity induced by ongoing nociception as well as to the neuropathic brain lesion, prospective studies are warranted. PERSPECTIVE The assessment of somatosensory symptoms and signs and endogenous pain modulation demonstrated a role for central sensitization and possibly for disinhibition in chronic PSSP. Prevention and treatment of PSSP could benefit from a more detailed analysis of both peripheral and central pain mechanisms.

Persistent Shoulder Pain in the First 6 Months After Stroke: Results of a Prospective Cohort Study

OBJECTIVE To identify factors associated with persistent poststroke shoulder pain (pPSSP) in the first 6 months after stroke. DESIGN Prospective inception cohort study. SETTING Stroke units of 2 teaching hospitals. PARTICIPANTS Patients (N=31) with a clinical diagnosis of stroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The development of pPSSP within the first 6 months after stroke. Clinical assessment of motor, somatosensory, cognitive, emotional, and autonomic functions, undertaken within 2 weeks (t0), at 3 months (t1), and at 6 months (t2) after stroke. RESULTS Patients with pPSSP (n=9) were compared with patients without pPSSP (n=22). Bivariate logistic regression analyses showed that pPSSP was significantly associated with impaired voluntary motor control (t0, t1, t2), diminished proprioception (t0, t1), tactile extinction (t0), abnormal sensation (t1, t2), spasticity of the elbow flexor muscles (t1, t2), restricted range of motion (ROM) for both shoulder abduction (t2) and shoulder external rotation (t1, t2), trophic changes (t1), and type 2 diabetes mellitus (t0). CONCLUSIONS These findings suggest a multifactorial etiology of pPSSP. The association of pPSSP with restricted, passive, pain-free ROM and signs indicative of somatosensory sensitization may implicate a vicious cycle of repetitive (micro)trauma that can establish itself rapidly after stroke. Intervention should therefore be focused on maintaining and restoring joint ROM as well as preventing injury and somatosensory sensitization. In this perspective, strategies that aim to intervene simultaneously at various levels of function can be expected to be more effective than treatment directed at merely 1 level.

Inefficacy of high‐dose transdermal fentanyl in a patient with neuropathic pain a case report

Pain partially responsive to opioids can lead to rapid escalating dosages due to tolerance development. In this report the case of a 58‐year‐old female with neuropathic pain using increasing transdermal (TTS) fentanyl dosages to a maximum dose of 3400 μg/h resulting in fentanyl plasma levels of 173 ng/ml is described. For pain relief an epidural infusion at the level T1–2 with bupivacaine was started. Immediate pain relief was accompanied by short lasting respiratory depression and drowsiness.

Pain exposure physical therapy (PEPT) compared to conventional treatment in complex regional pain syndrome type 1: a randomised controlled trial

Objective To compare the effectiveness of pain exposure physical therapy (PEPT) with conventional treatment in patients with complex regional pain syndrome type 1 (CRPS-1) in a randomised controlled trial with a blinded assessor. Setting The study was conducted at a level 1 trauma centre in the Netherlands. Participants 56 adult patients with CRPS-1 participated. Three patients were lost to follow-up. Interventions Patients received either PEPT in a maximum of five treatment sessions, or conventional treatment following the Dutch multidisciplinary guideline. Measurements Outcomes were assessed at baseline and at 3, 6 and 9 months after randomisation. The primary outcome measure was the Impairment level Sum Score—Restricted Version (ISS-RV), consisting of visual analogue scale for pain (VAS-pain), McGill Pain Questionnaire, active range of motion (AROM) and skin temperature. Secondary outcome measures included Pain Disability Index (PDI); muscle strength; Short Form 36 (SF-36); disability of arm, shoulder and hand; Lower Limb Tasks Questionnaire (LLTQ); 10 m walk test; timed up-and-go test (TUG) and EuroQol-5D. Results The intention-to-treat analysis showed a clinically relevant decrease in ISS-RV (6.7 points for PEPT and 6.2 points for conventional treatment), but the between-group difference was not significant (0.96, 95% CI −1.56 to 3.48). Participants allocated to PEPT experienced a greater improvement in AROM (between-group difference 0.51, 95% CI 0.07 to 0.94; p=0.02). The per protocol analysis showed larger and significant between-group effects on ISS-RV, VAS-pain, AROM, PDI, SF-36, LLTQ and TUG. Conclusions We cannot conclude that PEPT is superior to conventional treatment for patients with CRPS-1. Further high-quality research on the effects of PEPT is warranted given the potential effects as indicated by the per protocol analysis. Trial registration numbers NCT00817128 and NTR 2090.

18.Painful Diabetic Polyneuropathy

In the industrialized world, polyneuropathy induced by diabetes mellitus (DM) is one of the most prevalent forms of neuropathy. Diabetic neuropathy can result from a direct toxic effect of glucose on nerve cells. Additionally, the damage of the nerve structures (central and peripheral) is accompanied by a microvascular dysfunction, which damages the vasa nervorum. More than 80% of the patients with DM‐induced polyneuropathy have a distal and symmetric presentation. The initial symptoms are: signs of diminished sensation, burning feet, which may occur particularly during the night and worsen when touched, and tingling sensation in the feet. Attacks of shooting pain may also occur.

The effectiveness and cost evaluation of pain exposure physical therapy and conventional therapy in patients with complex regional pain syndrome type 1. Rationale and design of a randomized controlled trial.

BackgroundPain Exposure Physical Therapy is a new treatment option for patients with Complex Regional Pain Syndrome type 1. It has been evaluated in retrospective as well as in prospective studies and proven to be safe and possibly effective. This indicates that Pain Exposure Physical Therapy is now ready for clinical evaluation. The results of an earlier performed pilot study with an n = 1 design, in which 20 patients with Complex Regional Pain Syndrome type 1 were treated with Pain Exposure Physical Therapy, were used for the design and power calculation of the present study.After completion and evaluation of this phase III study, a multi-centre implementation study will be conducted.The aim of this study is to determine whether Pain Exposure Physical Therapy can improve functional outcomes in patients with Complex Regional Pain Syndrome type 1.Methods/designThis study is designed as a single-blinded, randomized clinical trial. 62 patients will be randomized with a follow-up of 9 months to demonstrate the expected treatment effect. Complex Regional Pain Syndrome type 1 is diagnosed in accordance with the Bruehl/International Association for the Study of Pain criteria. Conventional therapy in accordance with the Dutch guideline will be compared with Pain Exposure Physical Therapy. Primary outcome measure is the Impairment level SumScore, restricted version.DiscussionThis is the first randomized controlled study with single blinding that has ever been planned in patients with Complex Regional Pain Syndrome type 1 and does not focus on a single aspect of the pain syndrome but compares treatment strategies based on completely different pathophysiological and cognitive theories.Trial registrationClinical trials NCT00817128; National Trial Register NTR2090

Ischemic Pain in the Extremities and Raynaud's Phenomenon

Two important groups of disorders result from an insufficient blood supply to the extremities: critical vascular disease and the Raynaud’s phenomenon. The latter can be subdivided into a primary and a secondary type. Critical ischemic disease is often caused by arteriosclerosis due to hypertension or diabetes. Primary Raynaud’s is idiopathic and will be diagnosed as such if underlying systemic pathology has been excluded. Secondary Raynaud’s is often a manifestation of a systemic disease. It is essential to try to establish a diagnosis as soon as possible in order to influence the evolution of the disease.

Sustained Treatment Effect of Spinal Cord Stimulation in Painful Diabetic Peripheral Neuropathy: 24-Month Follow-up of a Prospective Two-Center Randomized Controlled Trial

Spinal cord stimulation (SCS) has been demonstrated to serve as a successful second-line treatment modality for painful diabetic peripheral neuropathy (PDPN), as documented in two randomized clinical trials (RCTs) (1,2). Besides the fact that these two RCTs demonstrate a pain-relieving effect for a period of 6 months after the start of SCS treatment, only small observational studies suggest a long-term sustained effect in PDPN (3–5). In this article, we present the 24-month follow-up data of our recently published RCT in Diabetes Care (1). Thirty-six patients were enrolled in this study, and after randomization, 22 patients with PDPN in the lower limbs (15 male, mean age 57.1 years [SD 12.4], years of PDPN 6.0 [SD 5.1]) were assigned to the SCS group. A 2-week trial stimulation was performed to evaluate sufficient pain relief. After 6 …

Multimodal and Widespread Somatosensory Abnormalities in Persistent Shoulder Pain in the First 6 Months After Stroke: An Exploratory Study

OBJECTIVE To explore the role of multimodal and widespread somatosensory abnormalities in the development of persistent poststroke shoulder pain (pPSSP) in the first 6 months after stroke. DESIGN Prospective inception cohort study. SETTING Stroke units of 2 teaching hospitals. PARTICIPANTS The data of a strict selection of patients (N=31) with a clinical diagnosis of stroke were analyzed. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The development of pPSSP within the first 6 months after stroke. Bilateral sensation and pain thresholds at 3 (t1) and 6 (t2) months, and conditioned pain modulation (CPM) at 3 months after stroke. Clinical examination within 2 weeks after stroke (t0), at t1, and at t2. RESULTS pPSSP (n=9) was associated with increased sensation and pain threshold ratios at the affected side (t1, t2), and with reduced cold pain tolerance at the unaffected side (t1). CPM was not different from patients without pPSSP (n=22). Notably, in patients with pPSSP reporting increased sensation on clinical examination, multiple body sites across multiple stimulus modalities were involved, and increased sensation persisted from t1 to t2. CONCLUSIONS pPSSP in the first 6 months after stroke was associated with somatosensory loss to both innocuous and noxious stimuli (affected side). In addition, pPSSP was associated with sensitization to cold pain (unaffected side) and with widespread sensitization to multimodal innocuous stimuli (affected side). The results support the notion that central somatosensory sensitization could play an important role in the development of pPSSP, the maintenance of pPSSP, or both.