The Clinical journal of pain
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Psychological and behavioral factors can exacerbate the pain and dysfunction associated with complex regional pain syndrome (CRPS) and could help maintain the condition in some patients. Effective management of CRPS requires that these psychosocial and behavioral aspects be addressed as part of an integrated multidisciplinary treatment approach. Well-controlled studies to guide the development of a psychological approach to CRPS management are not currently available. ⋯ All patients with chronic CRPS should receive a thorough psychological evaluation, followed by cognitive-behavioral pain management treatment, including relaxation training with biofeedback. Patients making insufficient overall treatment progress or in whom comorbid psychiatric disorders/major ongoing life stressors are identified should additionally receive general cognitive-behavioral therapy to address these issues. The psychological component of treatment can work synergistically with medical and physical/occupational therapies to improve function and increase patients' ability to manage the condition successfully.
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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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Few randomized controlled trials of oral pharmacotherapy have been performed in patients with complex regional pain syndrome (CRPS). The prevalence of CRPS is uncertain. Severe and advanced cases of CRPS are easily recognized but difficult to treat and constitute a minority compared with those who meet minimum criteria for the diagnosis. ⋯ Each has shown a broad enough spectrum of analgesic activity to be cautiously recommended for treatment of CRPS until adequate randomized controlled trials settle the issue. The relative benefit of oral medications compared with the widely used treatments of intensive physical therapy, nerve blocks, sympathectomy, intraspinally administered drugs, and neuromodulatory therapies (eg, spinal cord stimulation) remains uncertain. In summary, treatment of CRPS has received insufficient study and remains largely empirical.
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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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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.