News Category: Pain

People with complex regional pain syndrome (CRPS), a syndrome that causes pain usually after an injury to an arm or a leg, may also develop dystonia, or muscle spasms or twitches. More and more, researchers are finding that some patients with CRPS are developing these movement disorders (MDs).

Up to now, the number of patients affected with MDs after CRPS varies according to the study being discussed. In one study of 1,006 patients, 5 percent were reported to have some sort of MD. In another study of 145 patients, 30 percent of the patients were noted to have MDs.

There isn’t a lot of detail available for this patient group. It has been found, however, that dystonia with CRPS usually happens in the hand and causes the wrist and thumb to curl in, called flexion. In the leg, it starts in the foot, sometimes causing the toes to “claw.” Researchers also noticed that patients with CRPS and dystonia tend to be younger than patients with CRPS without dystonia, and the more extremities affected, the more can be affected. Dystonia can come on gradually or it can come on suddenly. It also usually begins on the same side as the injury before the CRPS.

There isn’t a connection between when the injury happened and when CRPS and the dystonia begins, so sometimes it is hard to tell what follows what. As well, it isn’t known if bracing or immobilizing an arm or a leg after injury makes it more likely for dystonia to develop. Researchers have also looked into the psychological aspect of CRPS and CRPS-related dystonia, but that, too, hasn’t found anything.

All the research results in there being no clear understanding of what causes some patients with CRPS to develop dystonia and not others. Because of this, no clear treatments have evolved. Medications don’t seem to help and while psychosocial interventions may help some patients, they don’t help all. Physiotherapy, tried with some patients, could make the situation worse, rather than better.

The author concludes that both CRPS and dystonia can be triggered together, but that they are two different illnesses. Studies of co-existing disorders like these two may “lead to new insights into the processes underlying each of them, and to fresh approaches to treatment.”

Complex regional pain syndrome (CRPS) is a condition of chronic pain and sensory changes that can occur after trauma to an arm or a leg. The initial injury may be minor or severe. Pain is the main feature of CRPS, but changes in blood flow to the skin, increased sweating, and swelling are common symptoms.

Movement disorders (MDs) such as tremor or dystonia develop in up to half the patients with CRPS. Dystonia is an abnormal twisting posture of the hand or foot. In this study from the Netherlands, patients with CRPS and dystonia are compared to patients with CRPS who do not have MDs.

The authors tried to find out what causes the MDs to develop. They looked at age, duration of symptoms, type of injury, and severity of symptoms as possible factors that cause MDs to develop. They were able to come to several conclusions after comparing the two groups.

First, the patients who developed dystonia were younger than patients in the group without dystonia. The length of time between the start of CRPS and the start of dystonia varies greatly. For some patients this interval of time was within one week. For others, the MD started up to five years later.

They found that once one extremity was affected, the chances of a second (or more) limb(s) developing dystonia increased greatly. It’s still not clear what causes dystonia to develop. It’s not linked to age, age, gender, or type of trauma. Disease duration or which limb is affected first doesn’t seem to make a difference either.

It looks like a central processing problem in the nervous system. There may be many neural circuits at multiple levels affected causing the problem. A change in function of nerve fibers capable of starting an inflammatory response may be the basis of the problem. The authors refer to this as a central circuit disorder.

There is a poor prognosis for CRPS patients who have dystonia. Finding out the underlying cause of the problem may help scientists find a way to prevent this from happening.

Chronic pain is a fact of life for many people. Studies show that fear of pain and avoidance of activity can cause further disability. In this study, researchers look at other patterns of activity and their impact on pain.

Almost 300 men and women with chronic pain were included. More than half had back pain. The rest had pain elsewhere in the body. There were patients with leg, shoulder, arm, neck, upper back, head, face, or mouth pain. Everyone filled out several surveys. Data was collected on pain levels, medication use, and work status. Questions were also asked about depression anxiety, activity levels, and acceptance of pain levels.

Analysis of the data showed three basic subgroups of behavior. These included avoidance, pacing, and confronting. Avoidance refers to the fact that the patient doesn’t do anything that might make the pain worse. Pacing means the patient uses lots of rest breaks in between activities. And confronting was described as not pushing to get things done despite the pain.

The authors were expecting that patients who used pacing would have better function. The results of this study showed quite the opposite. It turned out that pacing had strong elements of avoidance to it. Calling their actions pacing or pain management allowed some patients to actually avoid activities.

They also found that avoidance does lead to lower levels of physical activity and higher levels of anxiety. As might be expected, patients who reported high levels of activity combined with low avoidance behaviors had the best results. Avoiding activity didn’t promote healthy function in chronic pain patients.

The authors suggest several changes in behavioral management programs for chronic pain patients. First, using electronic activity monitors may help provide a better idea of patients’ true activity levels. Right now, researchers rely on each patient to remember and report activity level accurately.

Behavior management programs should help patients avoid extreme fluctuations. Going from pacing to avoiding should be replaced with steady rates of activity. This method might help patients become more functional in the long run.

And patients who confront their pain and overdo it may be unwilling to accept real limitations or see the need to change. They need guidance and direction to overcome this pattern. Chronic pain patients should be coached in behavior patterns that provide free and full functioning.

Scientists are working hard to understand how nerve pain works. The hope is to find a way to stop chronic nerve pain or even prevent it from occurring after a nerve injury.

In this animal study, rats were used to examine crushed nerve cells. The EphB/ephrinB system was the focus. This system is known to be part of the signaling mechanism for nerve pain.

Three groups of rats were included. One (experimental) group had a specific lumbar nerve root (L5) crushed. The second (sham) group had surgery to expose the nerve but nothing was done to it (no crush injury). The third (naive) group did not have any surgery done.

Nerve tissue was removed from all three groups and analyzed. The researchers were able to trace the levels of each protein and its receptor in the EphB/ephrinB system. They recorded the levels each day up to day 28 after surgery.

They found that ephrinB2 increased in the neurons (nerve cells) after nerve injury. It reached a maximum level on day seven and gradually decreased until day 28. Its receptor (EphB1) was increased in the spinal cord up to day 28.

In a second step of this experiment, a substance called small interference RNA (siRNA) was found to decrease pain levels. It does this by knocking out the ephrinB2.

The authors concluded that the ephrin system does play a role in nerve pain. It appears that there are specific receptors for ephrinB2 in the neurons of the spinal cord. These receptors are waiting for ephrinB2 to come along. If this signaling pathway can be interrupted, then scientists might be able to develop a drug using siRNA to block nerve pain.

Complex regional pain syndrome, or CRPS, can develop after an injury, but the cause isn’t yet understood. Researchers do know that inflammation plays a role and previous studies have suggested that the body’s reaction in CRPS can be similar to that of a burn. Researchers looking into burn treatment have found that giving high doses of vitamin C to burn patients helped reduced the amount of fluid they needed and reduced the swelling. With this in mind, the authors of this study wanted to see if giving vitamin C to patients with a new broken wrist would decrease their chances of developing CRPS.

The study took place at 3 hospitals in the Netherlands and involved 416 women who had a total of 427 wrist fractures. The patients were randomly chosen to receive vitamin C (317 women, 328 fractures) or placebo, a sugar pill, (99 women, 99 fractures). Among the women taking vitamin C, 96 took 200 mg, 114 took 500 mg and 118 took 1500 mg, per day. The patients did not know if they were taking the vitamin or the placebo. They were evaluated 1 week after the injury, when the cast was removed (at 4 or 5 weeks), again at 6 or 7 week, 12 weeks, and 26 weeks. They were evaluated one more time at 1 year by phone or by mail.

The researchers made a diagnosis of CRPS if the patient showed 4 of the following 5 symptoms at the affected wrist: unexplained pain out of proportion to the injury, skin color difference between the affected hand and the other hand, skin temperature difference between the affected hand and the other hand, swelling, and limited range of motion unrelated to the fracture.

The researchers found that 2.4 percent of the women in the vitamin C group developed CRPS while 10.1 percent in the placebo group did. When the researchers looked at the amount of vitamin C taken by the women, there wasn’t much of a difference between the women who took the lowest dose vitamin C (200 mg) and the women who took the placebo. But, there was a significant difference between the women who took the higher doses of the vitamin.

The average time for development of CRPS was 76 days (ranging from 30 to 166 days). One patient who had fractured both wrists developed CRPS in one, but not the other. She was taking 1500 mg of vitamin C. The researchers also found that when patients complained of discomfort from their casts, this could predict the development of CRPS. This was similar to findings from previous studies, according to the authors.

The authors point out some limitations in the study, including the number of patients and verification of patient compliance. Nonetheless, they conclude that administration of 500 mg of vitamin C following a wrist fracture, for 50 days, may prevent CRPS.

Choosing the right drug at the right time for each patient can be a difficult task. This is especially true when trying to find the right dose for patients suffering from chronic pain. The science behind such decisions is called pharmacogenomics.

New information about drug metabolism may change how medications are prescribed. Drug metabolism refers to how and when drugs are broken down and then used by the body. Scientists have found at least one enzyme called CYP2D6 that helps metabolize opioids . Opioids are narcotic pain relievers.

Some people metabolize drugs faster than others. Fast metabolizers may not get much benefit from the drug. Slow metabolizers may have a severe reaction because too much of the drug is in the body too long. The ideal effect of pain meds occurs with poor metabolizers because they have the highest steady-state concentration of the active ingredient.

A recent study of 61 chronic pain patients taking pain relievers showed that most patients were able to metabolize the drug because only one copy of the CYP2D6 gene was defective. Those who had a bad drug reaction to opioids had no working CYP2D6. Genetic testing from blood samples was used to analyze this enzyme.

In the future, genetic testing of this type will help doctors predict how patients will respond to a drug. It will make it easier to tailor specific treatment for each patient. And hopefully, adverse drug reactions can be prevented.

In the future, pharmacogenomics may open a new way to evaluate, predict, select, and monitor drug therapy for many diseases and conditions.

CRPS, or complex regional pain syndrome, is a pain disorder that causes constant, intense pain in the arms and legs, along with problems with the blood vessels and sweat glands. It was identified as early as the American Civil War, but was though to affect mostly adults and rarely children. Doctor’s don’t yet know what causes CRPS or how best to treat it. They do realize that children do have the disorder more than previously thought.

This study reviewed the medical records of 20 children diagnosed with CRPS over a four-year period at one specific hospital. The researchers noted past history, family history, the time it took from onset of symptoms to diagnosis and the time it took for the symptoms to go away. They also noted the type of treatment the children received, the length of any hospital stay, and any replapes.

All the children received the same treatment: intensive physiotherapy, hydrotherapy (exercise in water), massage, medications for pain, and counseling. Often the analgesics, or pain medications were needed before the children could take part in their physiotherapy session. Thirteen children were treated with other medications such as amitriptyline and three received gabapentin because these medications have been found to work for some people with chronic pain. The counseling, or psychotherapy, was given to help the children learn how to cope with the pain and other stressful situations. Two families refused counseling for their children.

Those children who were admitted to the hospital were not seeing any improvement with their therapy or their pain had increased to the point that it was felt that the pain could be better controlled better in the hospital environment. All the children were followed until their symptoms had gone, only two children were lost to follow-up.

Of the 20 children, 18 were girls. All the children ranged in age from 8 to 16 years. The average onset of the symptoms in girls was around age 12 years and in boys, almost 9 years. In 17 children, the pain was in the legs, 15 complained of foot pain, one of ankle pain and one of knee pain. Half of these children reported the pain to be on the left side. The pain was in the arms for three children: two complained of it in the right wrist and hand, and one in the entire left arm.

Sixteen of the children said that they had hurt themselves before the symptoms began, but the injuries were minor from falls or sprains. Only one injury was a fracture.

All the children began complaining of pain that seemed out of proportion to the injury. Most also had swelling, one side was warmer to touch than the other, and the skin color changed as well.

The researchers found that it took an average of about 13 and a half weeks from the time that the children experienced their first symptoms to the time they were finally diagnosed. The children would have seen anywhere from one to six specialists in orthopedics, pediatrics, rheumatology, neurology, emergency, and family physicians.

Four of the children had relapses after being symptom-free for at least three months.

The study showed that there were differences between the adults who have CRPS and children with the same disease. In adults, the legs are not as affected as with the children, and in adults, there were more men than there were boys in the children.

The authors of the study concluded there was a concern about the length of time between when the patients presented with the symptoms and the final diagnosis. It has improved from a decade ago when the length of time was as long as a year, to three months at the time of this study. That being said, it still took six months for three of the children in the study to be diagnosed. This is particularly important because the undiagnosed children are suffering from the pain, and findings show that children who are treated within three months of developing the symptoms respond better to treatment.

Complex regional pain syndrome (CRPS) is painful condition that occurs after surgery or trauma. As many as 10 per cent of patients with a wrist fracture develop CRPS.

Patients have painful swelling, extreme sensitivity of the skin, and temperature changes of the involved arm or leg. Pain can lead to loss of joint motion and decreased function.

CRPS can become chronic. Early diagnosis and treatment right away may help keep this condition from getting worse.

In this article, orthopedic surgeons from Germany give an overall review of CRPS. Tests of nervous system function and imaging tests such as X-rays, MRIs, and bone scans are discussed in detail. Physical exam and lab tests are also presented.

The diagnosis often comes down to the patient history and clinical signs and symptoms. X-rays don’t show bone changes until late in the process. Nerve testing often makes the condition worse.

MRIs may show some early changes but it’s not clear if this is from CRPS or not. Bone scans may be the best tool to use early on. This type of imaging study shows increased blood flow into the affected arm or leg. But it is best done in the first weeks after the injury. Later, the test isn’t as helpful.

Delay in diagnosis and treatment of CRPS is common. The authors suggest early symptoms suggestive of CRPS in post-traumatic patients must be paid attention to. Repeated exams early and often after the surgery or trauma are advised. Symptoms that do not improve should raise the suspicion of CRPS.

Electrical nerve stimulation (ENS) is a treatment for chronic pain. The electrical energy is sent in various wave forms to the nerves. It is delivered through electrodes placed over the skin. It works by overriding or blocking signals from the nerves to the spinal cord and brain.

Whether or not ENS works for pain relief has been the subject of many studies. The results have not been consistent. The authors of this study thought the varied results may have been caused by studies that were too small. So they reviewed and combined all the studies from 1976 to 2006 that met their selection criteria. This method of studying the success of a particular treatment option is called a meta-analysis

The studies had to be published in English about patients who had chronic (more than three months) musculoskeletal pain. The main measure of outcome was pain at rest. Pain was measured before and after treatment.

Different types of ENS were used but all were either transcutaneous (through the skin) or percutaneous (under the skin). All studies included both pain patients and placebo (control) groups. Animal studies were not allowed in the data analysis.

The results showed that ENS provided three times the pain relief received by a placebo. Percutaneous ENS worked better than transcutaneous ENS. The authors concluded from these combined study results that ENS is an effective way to treat chronic musculoskeletal pain.

As opioids become increasingly accepted as an effective form of pain management for some types of chronic pain, doctors are concerned about the use of the opioids and the potential for their abuse. Studies have been done to find ways to identify behaviors of patients who may be prone to abusing opioids if given for chronic pain, but none have been done to develop an assessment for patients who are taking them for an extended length of time.

In this study, investigators took an initial pool of 177 items (statements or questions) that were developed with input from 26 pain management and addiction specialists. The pain experts were doctors, nurses, and psychologists. Twenty-two of the specialists rated the items for importance and relevance. The outcome was a 40-item alpha (first version) COMM, or Current Opioid Misuse Measure.

The patients who were recruited for the one-week study had be adults, receiving treatment currently for chronic, noncancer pain for at least six months, taking opioids for pain relief that were equal to or more than 20 mg of oxycodone per day, and not have any serious psychiatric impairment. These patients had already participated in a previously arranged study and this COMM study was part of the end follow-up of that first study.

The patients were asked to complete the COMM questionnaire and also to complete two other questionnaires. One was the Prescription Drug Use Questionnaire (PDUQ), which asked about pain, opioid use patterns, family and social factors, family history of pain, substance abuse, and psychiatric history. The second was the Marlow-Crowne social desirability scale (M-C). The physicians were asked to complete the Prescription Opioid Therapy Questionnaire (POTQ), which reflected the patients’ behaviors. Patients also supplied a urine sample for testing for evidence of a variety of opioids. The patients were classified on the Aberrant Drug Behavior Index to determine drug-related behavior.

The investigators found that of the 40 items, 17 appeared to be reliable in identifying which chronic pain patients who were currently taking opioids for pain management would show evidence of misuse or abuse of the opioids. A positive aspect of this test was that it was easy to understand and took little effort to score.

The authors point out that the cutoff score that was selected for the COMM was deliberate in order to over-identify misuse, not to mislabel incorrectly. They said, “We believe that it is more important to identify patents who have only a possibility of misusing their medications than to fail to identify those who are actually abusing their medication. Thus, the scale will result in false positives – patients identified as misusing their medications when they were not.”

The investigators note that the COMM is a tool to aid physicians in documenting compliance with the opioids. They say that it is important to have more studies, including a retest of the one-week period and then a three-month repeat as well.

Every year over 200 million prescriptions are written for opioids in the United States. An opioid is a chemical substance that acts like morphine in the body. It is used mainly for pain relief. Of the total 19 billion dollars spent annually just on pain meds, one-third of that money is spent on opioids for chronic pain.

There is a lot of controversy around these medications. There are concerns about side effects, especially addiction. Many doctors avoid using these drugs. Or they under medicate patients who actually need higher doses.

Part of the problem is a lack of data to identify long-term benefits and side effects with opioid use. And when studies are done, patients often quit early because they are afraid of becoming a drug addict.

Some patients leave a study without giving a reason. They may be afraid to be honest. Or they are unwilling to let their doctor know how unhappy they are with the treatment. Some just want to see if they can manage the pain on their own without using opioids.

The authors of this report review the results of other studies of patients taking opioids. They briefly mention the small, short-term study they conducted with 36 patients. Only a few patients showed signs of abusive pattern of medication use. Men used higher dosages of the drug, especially during the first month.

Further studies are needed to identify the best dosages of opioids to use. Until this information is available, doctors and patients must work together to determine the best pain reliever to use. Likewise, dose is symptom dependent and may need to be changed (increased or decreased) until the patient is comfortable.

Oxycodone is an opioid (narcotic) drug used to help patients with moderate to severe pain. Patients with chronic back pain, diabetic neuropathy, or arthritis are often helped by opioids. Because opioids can be addictive, there’s been some concern about the long-term effects of this drug.

In this study 233 patients with chronic pain taking controlled-release oxycodone were followed for up to three years. Researchers collected information about dose used, pain levels, and adverse side effects from the drug. They also noted any drug-related behavior. These included asking for more drug or repeatedly losing the prescription.

The sponsor ended the study early. And more than half the patients withdrew from the study early for various reasons. Some had enough side effects from the drug to quit taking it. Others did not get the pain relief they needed.

Despite these difficulties, some general patterns were observed from the data. First, it’s not uncommon for patients taking pain relievers for chronic pain to stop taking them after about six months of use. The reasons for this aren’t always very clear.

Second, the need for increasing doses of drug to get the needed pain relief occurred during the first three months. This is called dose titration. It does take a short period of time to get the right dose for medications that can be addictive.

Third, those patients who still had a pattern of increasing drug use after the first three months were not receiving the right amount of medication.

The authors conclude that there is a group of chronic pain patients who can benefit from long-term opioid therapy. They are able to get pain relief over time without the negative side effects. Anyone who is not helped by opioids after three months should be re-examined.

This study points out the difficulty of doing drug-related research. More studies are needed of the long-term effects and benefits of opioids for control of chronic pain.

Opium has been used for thousands of years and is still available today in various forms. In the early twentieth century in the United States, physicians became aware of the pain-relieving qualities of the substance and eventually learned of its effectiveness in treating acute and terminal cancer pain. At that point, physicians thought that the addiction rate in this group, which was low, would be repeated in patients with chronic pain and they began to prescribe opioids to that patient group as well. This, however, wasn’t the case. This review, which looks at several studies of pain relief and addiction, tries to explain the multidimensional aspect of addiction as it relates to pain relief.

After many studies, researchers have concluded that drug addiction is a chronic neurobiologic disease that results from repeated exposure to the addictive drug. Because much of the addiction is the reward the body feels after consuming the drug, the changes that occur in the brain are not just from the drug, but from the behaviors that the person associates with getting the drug, consuming it, and the resulting sensation.

There are three domains that contribute to addiction: psychosocial, drug, and genetic. In the psychosocial domain, researchers have determined that there are many factors, such as depression, anxiety, personality disorder, and atypical stress response, among others. In the drug domain, the initial part is the stimulation of the reward circuitry and how the drug is taken; in the maintenance part, there is the tolerance and dependence that may result, and the enduring adaptations of the neurons associated with lifelong craving; and finally, the withdrawal and abstinence part that is the anhedonic (loss of feeling) state and negative reinforcement. In the genetic domain, we find family history of addiction, personality disorder, genetic changes that might affect impulse control and risk taking behavior, and atypical stress response.

There are stages that result in addiction to drugs:

1- Initiation of drug use.
2- Intermittent use.
3- Regular use.
4- Dependence or addiction.
5- Withdrawal.
7- Perhaps stopping the drug use.
6- Frequently, relapse.
Chronic pain, which can be hard to treat, is considered to be a pain that lasts for at least three months, maybe longer according to different guidelines. There’s a common thread between people with chronic pain and mental disorders, such as depression, anxiety, substance use disorders, and personality disorders. According to one study, between 18 percent and 32 percent of patients with chronic back pain also had major depression during the treatment period. The average US rate for depression among the general population is only 5 percent.

It’s not always easy to determine if someone has become addicted to a prescribed medication, like an opioid. Some researchers have tried to determine guidelines, but they have not been formally adopted by any group. Despite all the research, the medical community is still uncertain regarding the frequency of opioid dependency with chronic pain. Several studies uphold the idea that the pain actually works against the opioids, preventing true addiction.

The way the drug is metabolized, or absorbed and broken down in the body, and how quickly this happens plays a role in its addictive properties. Drugs with a rapid onset have a higher potential for addiction, for example. For this reason, the longer-acting opioids are now being used more for the management of chronic or cancer pain.

The authors conclude that the initial idea that addiction would be rare among patients with chronic pain is incorrect and that problematic and attention-seeking behaviors can and do occur in a sub-group of patients with chronic pain. The development, or clinical progression, from a patient with chronic pain to a patient with chronic pain who is addicted to an opioid differs very much from people who use the drug illegally and those who use it for pain relief. It appears to be a much more subtle progression and is more difficult to identify.

More research needs to be done in this field. Researchers need to find a better way of identifying patients with chronic pain who would be at risk of becoming addicted and to find medications that would not have addictive qualities but still offer adequate pain relief.

Chronic non-cancer pain is fairly common in the US. Current statistics show that it affects around 20 percent of the population. Physicians who are trying to manage the pain for their patients are using more opioids as treatment, but some pain specialists are concerned about this increased use. In order to use opioids for adequate pain control, there must be a balance between the risk factors and the need for pain relief.

Researchers did a secondary data analysis of data from the years 2000 to 2005 from regional Veterans’ Affairs. The researchers wanted to identify risk factors for developing opioid abuse or dependence. Four groups of risk factors were identified and studied: non-opioid abuse disorders, painful physical health disorders, mental health disorders, and socio-demographic factors.

The sample included 15,160 chronic users of opioids, not including methadone, for chronic non-cancer pain. To determine chronic opioid use, the researchers used a cut-off point of 91 days or more for opioid use within a 12-month period. Of the sample group, 45.3 percent were diagnosed with a mental health disorder and 7.6 percent were diagnosed with non-opioid substance abuse. Sixty-eight percent of participants were diagnosed with arthritis, 53.6 percent with back pain, and 8.4 percent with headaches.

The results of the study showed that 2 percent of patients who used chronic opioids who were not abusing or were not dependent upon opioids in 2002 were clinically recognized with opioid abuse or dependence in 2003 to 2005. The researchers found that those who had abuse of other substances, other than opioids, or those who had mental disorders had a higher chance of developing the abuse or dependence.

Three percent of patients with mental disorders were found to have clinical symptoms of abuse or dependence. Younger age also played a role in abuse or dependence. The researchers also found that the more a patient was prescribed an opioid, the higher the abuse risk. For example, patients who received at least 211 days’ supply were more likely to develop abuse or dependence than were those who received only a 90- or 120-day supply.

With these study findings, physicians must keep in mind the chance of abuse or dependence, but keeping opioids from patients who could be relieved from their chronic pain by holding opioids in general may be too drastic. Keeping this in mind, physicians are urged to carefully screen patients for predisposing factors that may lead to opioid abuse or dependence.

Complex regional pain syndrome (CRPS)-Type I is not yet well understood by the medical community. In fact, there are some who feel that it is not a neuropathic disorder at all, while others feel that it may be more common than thought. Regardless of the incidence, it’s important that doctors recognize it as early as possible in order for the affected patients to receive proper treatment.

Up to now, there has only been one epidemiological study that looked in to who were the most likely people to develop CRPS and what might cause it. This month, a second such study was published that both contradicted and agreed with findings from the first study, published in 2002.

Some of the differences were most likely the result of the 2007 study being quite a bit larger than the 2002 study, 217,653 patients compared with 106,470 patients, respectively. The author of this editorial also points out that the 2007 study began following publication of official diagnostic criteria for CRPS, which could have affected the findings.

The 2007 study, using diagnosis from the patients’ original treating physicians, found a higher incidence of patients with CRPS: 26.2 new cases per 100,000 people per year compared with the 2002 finding of 5.46 new cases per 100,000 people per year. When the 2007 study researchers looked at new cases that were diagnosed by specialists rather than by the original physicians, they still found a higher number of new cases than did the 2002 findings, at 16.8 new cases per 100,000 patients per year.

The researchers in the 2002 study used signs and symptoms that had been documented in the patients’ records to diagnose 74 patients with CRPS. This study was done restrospectively, or looking back. The researchers in the 2007 study used signs and symptoms that were evaluated by pain specialists and that included specialized tests that weren’t available to the researchers in the earlier study. The 2007 researchers found 95 patients with CRPS.

Because of the differing findings, the researchers from the second study have formally recommended that the criteria used to diagnose CRPS be reviewed.

The two studies did have some findings in common. Both noted that CRPS happened in significantly more women than men and among people between 50 and 70 years old. It was also found that CRPS seemed to be triggered after a patient had sustained a fracture or a sprain.

The author of this editorial concluded that, conservatively, it can be estimated that there may be 50,000 newly diagnosed cases of CRPS every year in the United States. By understanding who is at most risk of developing the disorder, doctors can be better prepared to diagnose and treat it, resulting in an improved quality of life for patients.

Many people in the United States are living with chronic pain. The cause can range from injury to bone and joint diseases to cancer. When all other treatment fails, some doctors turn to opioid therapy to help their patients.

Opioids are narcotic medications used to treat pain. They work well but because people can get addicted to them, they aren’t used when they could help. For anyone with chronic pain using opioids, the goal is to get the most pain relief with the fewest side effects.

One way to do this is to combine an opioid with other nonnarcotic pain relievers. And an antidepressant added to the mix may also be helpful. Pharmacists and physicians who specialize in pain control are the best health care providers to advise patients on the use of opioids. They know what dose to use, when and how to rotate drugs, and how long to use them.

Some people are at greater risk for problems taking opioids compared to others. You may not be a good candidate for opioids if you’ve ever had a previous history of substance abuse. And caution is advised if you have other health problems. Studies show that patients with other illnesses are more likely to have adverse side effects from opioids.

If you’ve tried opioids and they’re no longer working, there may be another option. Extended-release opioids such as oxymorphone can help patients with moderate to severe pain. Studies show that patients can take a stable dose and get good results for up to three months or longer.

A stable dose means they can get the same amount of pain relief with the same dose every day. This avoids the problem that can occur with other opioids of less and less pain relief while taking more and more drug. For the best results, your doctor will start you out on the lowest dose possible and gradually increase the amount. For a smoother transition, a short-acting opioid can be used during this process.

A lot has been written about psychosocial factors and their effect on chronic pain. Few studies have defined the factors that are important and at what level. In fact, studies that have taken place have looked at different factors in different situations, resulting in little consistency in the findings and trial outcomes.

In this topical review, the authors discuss the need for well-controlled studies to determine consistent findings. While doctors know that there is a connection between pain and psychosocial, behavioral and social factors, they don’t know much about the actual connections. The authors say that the lack of definitions, or poorly defined definitions, of psychosocial factors may be partly to blame. By having poorly defined parameters with which to work, researchers can choose what they will follow and how.
Many things can affect psychosocial factors, including socio-economic status, workplace (work and actual environment), personal relationships, and access to professional help. Some studies have investigated one or two of the factors, but no study has been found that investigates them all. This hasn’t allowed the researchers to get a full picture of all factors.

A study should define and explain exactly what happened, even if there are multiple causes, and outcomes. It should identify the risk factor levels and determine data that needs to be collected at each level of influence. Each study should follow the same criteria to see if they find similar outcomes.

The better the model with which to work, the easier it would be for the researchers to identify important elements and findings from the studies. Researchers need to pay attention to the measurement of psychosocial risk factors. For example, if researchers are studying workplace stress, there is not only the actual stress that needs to be evaluated but also the workers’ perception of the stress. What is stressful to one person may not be to another.

When discussing the evaluation and treatment of pain, people in different roles (patient, spouse, doctor, employer) have different views of pain. This can affect the understanding of pain and the causes.
The authors conclude that further study is required to identify and clarify what is to be treated if and when psychological factors are taken into consideration. Researchers need a clearer model and n consistency about what is being tested. Specific parameters need to be adhered to to then allow a testable hypothesis when applied to other areas.

If these are taken into account and put into practice, doctors may be better able to see and understand the pathways of causal factors that are involved in developing pain, resulting in better treatment.

Complex regional pain syndrome (CRPS) is a painful disorder that is not yet well understood by the medical community. In the past, CRPS has also been called Sudecks dystrophy and reflex sympathetic dystrophy. Because there are many symptoms to CRPS, patients aren’t treated by any one specialty of doctors, and different patients may be seen by different specialists, like anesthesiologists, orthopedic surgeons, neurologists, rheumatologists, general physicians, and rehabilitation specialists. These doctors all bring different backgrounds and approaches to the disorder.

This study was retrospective, or looking back, and the researchers identified cases that were then verified by information provided by both treating specialists and general physicians. The researchers’ aim was to determine how many people were afflicted with CRPS and which populations were more likely to develop it. A study done a few years earlier was also done retrospectively, but with the file records alone.

In this study, the records of 217,653 patients were examined and 238 patients were identified as having CRPS; 177 were diagnosed by specialists and the specialists most often involved in care were anesthesiologists.

The researchers found that most of the patients had sustained either a fracture (most common) or a sprain (second most common) before the onset of CRPS. Other trauma, like surgery, had occurred in a few people, but in 10 percent of the cases, there were no apparent traumas. Women were affected almost three times more often than were men and more patients were in the 61 to 70 year old age group. This is also the postmenopausal period for women.

Four times more people in this study were found to have CRPS than were found in the earlier study that was published in 2002. And, even though the number was higher in the second study, the researchers said that their incidence rates may still be an underestimation of the true number.

The researchers concluded that there would be 26.2 new cases of CRPS per 100,000 people per year and it would be better if there were more uniform and consistent criteria on which to base a diagnosis.

Narrowing of the spinal canal is called spinal stenosis. This condition is common in older adults. It causes back and leg pain and difficulty walking. Treatment begins with nonsteroidal antiinflammatory drugs (NSAIDs), change in activity, and physical therapy.

Epidural steroid injection (ESI) is another nonsurgical treatment option. In this study, surgeons looked at the size of the spinal canal. They wanted to know if ESI would be successful more often if there was a larger opening around the spinal cord and spinal nerves.

Eighty-four (84) patients with lumbar spinal stenosis were included. CT scans were taken and measurements made of the spinal canal and nerve openings. They all got an ESI once a week for three weeks. They also received NSAIDs and physical therapy. Everyone was followed for at least two years.

The authors were surprised that canal dimensions did not predict patient response. Fifty (50) patients were no better and had to have surgery. Thirty-four (34) improved after ESI. Patients with large and small diameter canal openings were just as likely to be in one group as the other. The size of the spinal canal opening didn’t seem to make a difference.

Based on the results of this study, CT scans of spinal canal dimensions are not useful in predicting results of treatment with ESI.

Many people who experience chronic pain search for alternative methods of pain relief. In this article, researchers review four studies that investigated the effectiveness of acupuncture among people with migraines, tension-type headaches, chronic lower back pain, or osteoarthritis of the knee.

At the start of each study, patients were asked about their ideas of acupuncture and its effectiveness. Many said that they were confident that the acupuncture would help relieve their pain. However, patients in headache groups tended to have a less optimistic view of acupuncture than did those in the back pain or osteoarthritis groups. Researchers believed that those patients who had high expectations of the treatment would have better outcomes than would those who had doubts regarding the treatment.

In three of the studies, the patients were assigned to either an acupuncture group or a superficial needling group to mimic the acupuncture; the patients were blinded as to which group they were in. The migraine study also had the two groups and a third control group. Patients in all of the study groups, other than the control group, received either acupuncture or minimal needling for 30 minutes, once a week for 12 weeks. The patients were allowed to take pain relievers for acute pain if needed.

Overall, 864 patients participated and those patients who had been confident that the acupuncture would provide relief reported significantly better pain relief than did those who had not been confident. The odds ratios for response between patients who thought acupuncture was effective and those who did not share this belief was 1.67 (95% confidence interval 1.20-2.32). For personal expectations and confidence after the third session, odds ratios were 2.03 (1.26-3.26) and 2.35 (1.68-3.30), respectively. This was true during the study time and at follow-up four to six months later, and held true for both the acupuncture and the minimal needling groups. The researchers found that the patients in the osteoarthritis and the lower back pain groups reported more success from the acupuncture than did those in the headache groups.

Although there are still many questions, such as whether patients who had higher expectations regarding acupuncture had as much pain as those who didn’t, the researchers conclude that these studies show that there is an effect from patient expectations regarding pain relief for chronic pain. More studies need to be undertaken in order to find ways to measure patient expectations and the researchers recommend that in future studies, investigators ask about expectations as part of their study protocols.