Long-term biopsychosocial issues and health-related quality of life in young adolescents and adults treated for childhood Complex Regional Pain Syndrome, type 1.

OBJECTIVES: Treatment for childhood Complex Regional Pain Syndrome (CRPS) is associated with long-term recovery. The present study aimed to investigate the long-term biopsychosocial status and quality of life in young adolescents and adults after the treatment of childhood CRPS. METHODS: A 4 year follow-up of individuals with childhood-CRPS, type 1 (n=22; age:12 years (years) [median] at treatment and 17 years at follow-up) was completed. Biopsychosocial status and quality of life were assessed with structured interviews, using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the Strengths and Difficulties Questionnaire (SDQ), the Pediatric Pain Coping Inventory (PPCI), and the Pediatric Quality of Life Inventory (PedsQL). Comparisons were made with normative samples of age-matched controls. RESULTS: CRPS at follow-up was still present in seven out of 22, and non-CRPS pain symptoms were found in 12 out of 22 individuals. Signs of mental health pain-related problems, including phobias and obsessive-compulsive disorder, were observed in ten out of 19 individuals. Mental well-being, social functioning, and quality of life (SDQ and PedsQL) were independent of pain status (p>0.05). Adaptive pain coping strategies were utilized regardless of pain status (PPCI). Social functioning (p<0.01) and the quality of life (p=0.01) were attenuated and statistically significantly poorer than healthy age-matched young adults but better than for fibromyalgia subjects. CONCLUSIONS: A subset of individuals treated for childhood-CRPS, type 1 experiences long-term consequences of persistent pain, a decrease in quality of life indicators, and demonstrates significant psychosocial issues. Childhood-CRPS is suggested to be associated with long-term psychosocial consequences and poorer quality of life than found in age-related healthy peers. Subjects treated for childhood CRPS may need a longer clinical follow-up attempting to preclude relapse of CRPS and non-CRPS pain.

Can dogs and cats really help our spinal cord stimulation patients?

OBJECTIVES: Pet ownership has been shown to decrease morbidity and mortality in several aspects of health but has not been studied in chronic pain patients. We evaluate whether subjects who underwent spinal cord stimulation (SCS) and own a pet have improved outcomes compared to non-pet owners. METHODS: After obtaining IRB approval, we re-contacted 38 subjects who underwent SCS surgery with preoperative and 1-year postoperative data on Numerical Rating Scale (NRS), McGill Pain Questionnaire (MPQ), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), and Pain Catastrophizing scale (PCS). We examined influence of pets and pet ownership-specific behaviors on improvement in SCS outcomes. RESULTS: Patients included 24 males/14 females with a mean age of 59.9 ± 11.5 years. At mean follow-up of 12.2 months (range 10-14), there were improvements in NRS, ODI, BDI, PCS and MPQ. Twenty subjects owned pets and 18 did not; all believed pet ownership could improve health. Pet owners improved more on NRS-right now (p = 0.05) and BDI (p = 0.05), and were more satisfied with SCS (p = 0.04). No significant improvement was seen in ODI, MPQ, or PCS. However, PCS did improve in pet owners who exercised their pet (PCS-total, p < 0.01; PCS-helplessness, p < 0.01; PCS-rumination, p = 0.05; PCS-magnification, p = 0.02). CONCLUSIONS: We provide preliminary evidence that pet ownership is associated with improved pain, depression and SCS satisfaction. Exercising with a pet also appears to be beneficial in limiting pain catastrophizing. Pets show promise as a novel means to improve patient SCS outcomes.

The spectrum of pediatric amplified musculoskeletal pain syndrome.

BACKGROUND: Children presenting with musculoskeletal pain to pediatric rheumatology clinics are very heterogeneous and on a continuum from those with localized pain to total body pain. Many report intermittent, rather than constant, pain. We examined clinical and psychological characteristics of these children at presentation and specifically those who fulfilled the criteria for fibromyalgia. METHODS: We performed a retrospective, cross-sectional cohort study of children under ≤18 years old presenting to the pediatric rheumatology pain clinic between January 2015 and July 2019 and enrolled in a patient registry. We included children diagnosed with amplified pain, excluding those fulfilling criteria for complex regional pain syndrome. Abstracted data included clinical characteristics, pain symptoms, functional disability inventory (FDI), widespread pain index, and symptom severity scale. RESULTS: We analyzed 636 subjects, predominantly non-Hispanic Caucasian females. Using median split method, 54% had diffuse pain (≥ 5 body regions involved), but, of these, only 58% met criteria for fibromyalgia. Subjects with diffuse pain, compared to those with localized pain had a longer duration of pain (24 vs 12 months, p < 0.01), reported greater pain intensity (6/10 vs 5/10, p < 0.001), greater mental health burden, and poorer function (FDI 25 vs 19, p < 0.0001). Subjects with limited pain more often reported a history of trigger event (34% vs 24%, p < 0.01) but not autonomic changes (14% vs 14%, p = 0.94). The presence of adverse childhood experiences did not differ among those with limited versus diffuse pain except for parental divorce (16% vs 23%, p = 0.03). Intermittent pain was reported in 117 children (18%) and, compared to subjects with constant pain, they reported less pain (0/10 vs 6/10) and were more functional (FDI 13 vs 25) (both p < 0.0001). CONCLUSIONS: There exists a wide spectrum of pain manifestations among children with amplified pain including limited or diffuse and constant or intermittent pain. Most children who presented to our clinic did not fulfill criteria for fibromyalgia but nonetheless had significant symptoms and disability. Studies focusing on fibromyalgia may miss the full extent of childhood amplified pain. Additionally, research limited to those meeting the fibromyalgia criteria likely underestimate the significant impact of amplified pain among the pediatric population.

Complex regional pain syndrome: A case report and review of the literature.

Background: Complex regional pain syndrome (CRPS) is a rare neuropathic pain disorder associated with severe pain, muscle weakness, limb edema and hyperhidrosis. Predisposing factors include fracture, surgery, stroke and spinal cord injury. CRPS may recur in the same limb or spread to other limbs to complicate management. Case Report: A 20-year old female with CRPS Type-I had sequential spread to all four limbs despite different treatment modalities, including medical therapy, nerve block, radiofrequency ablation and surgical sympathectomy. We discuss the therapeutic challenges and reviewed recent literature on current treatment options for CRPS Type-I. Conclusion: A multidisciplinary approach is needed for effective management of CRPS, and refractory disease may respond to intrathecal baclofen with morphine.

RésuméContexte: Le syndrome douloureux régional complexe (SDRC) est un trouble neuropathique rare associé à une douleur intense, une faiblesse musculaire, un dème des membres et une hyperhidrose. Les facteurs prédisposants comprennent la fracture, la chirurgie, l'AVC et les lésions de la moelle épinière. Le SDRC peut se reproduire dans le même membre ou se propager à d'autres membres pour compliquer la gestion. Rapport de cas: une femme de 20 ans atteinte du SDRC de type I s'est propagée séquentiellement aux quatre membres malgré différentes modalités de traitement, y compris une thérapie médicale, un bloc nerveux, une ablation par radiofréquence et une sympathectomie chirurgicale. Nous discutons des défis thérapeutiques et avons passé en revue la littérature récente sur les options de traitement actuelles pour le SDRC de type I. Conclusion: Une approche multidisciplinaire est nécessaire pour une gestion efficace du SDRC, et la maladie réfractaire peut répondre au baclofène intrathécal avec de la morphine.

Complex syndromes of chronic pain, fatigue and cognitive impairment linked to autoimmune dysautonomia and small fiber neuropathy.

Chronic fatigue syndrome, postural orthostatic tachycardia syndrome, complex regional pain syndrome and silicone implant incompatibility syndrome are a subject of debate among clinicians and researchers. Both the pathogenesis and treatment of these disorders require further study. In this paper we summarize the evidence regarding the role of autoimmunity in these four syndromes with respect to immunogenetics, autoimmune co-morbidities, alteration in immune cell subsets, production of autoantibodies and presentation in animal models. These syndromes could be incorporated in a new concept of autoimmune neurosensory dysautonomia with the common denominators of autoantibodies against G-protein coupled receptors and small fiber neuropathy. Sjogren's syndrome, which is a classical autoimmune disease, could serve as a disease model, illustrating the concept. Development of this concept aims to identify an apparently autoimmune subgroup of the disputable disorders, addressed in the review, which may most benefit from the immunotherapy.

Standards for the diagnosis and management of complex regional pain syndrome: Results of a European Pain Federation task force.

BACKGROUND: Complex regional pain syndrome is a painful and disabling post-traumatic primary pain disorder. Acute and chronic complex regional pain syndrome (CRPS) are major clinical challenges. In Europe, progress is hampered by significant heterogeneity in clinical practice. We sought to establish standards for the diagnosis and management of CRPS. METHODS: The European Pain Federation established a pan-European task force of experts in CRPS who followed a four-stage consensus challenge process to produce mandatory quality standards worded as grammatically imperative (must-do) statements. RESULTS: We developed 17 standards in 8 areas of care. There are 2 standards in diagnosis, 1 in multidisciplinary care, 1 in assessment, 3 for care pathways, 1 in information and education, 4 in pain management, 3 in physical rehabilitation and 2 on distress management. The standards are presented and summarized, and their generation and consequences were discussed. Also presented are domains of practice for which no agreement on a standard could be reached. Areas of research needed to improve the validity and uptake of these standards are discussed. CONCLUSION: The European Pain Federation task force present 17 standards of the diagnosis and management of CRPS for use in Europe. These are considered achievable for most countries and aspirational for a minority of countries depending on their healthcare resource and structures. SIGNIFICANCE: This position statement summarizes expert opinion on acceptable standards for CRPS care in Europe.

Complex Regional Pain Syndrome After Distal Radius Fracture Is Uncommon and Is Often Associated With Fibromyalgia.

BACKGROUND: Complex regional pain syndrome (CRPS) is frequently diagnosed in patients recovering from surgery or injury. The symptoms and signs included in consensus diagnostic criteria for CRPS are expected after injury. Categorizing symptoms and signs that occur on a continuum as disproportionate or not is subjective and prone to bias. Psychiatrists and psychologists do not diagnose CRPS and instead measure and treat anxiety and catastrophic thinking on its continuum. Given the expected variation in subjective diagnoses such as CRPS, this study addresses factors associated with use of this diagnosis and how it influences care. QUESTIONS/PURPOSES: (1) Among patients recovering from fracture of the distal radius, what factors are associated with the diagnosis of CRPS? (2) Are patients diagnosed with CRPS after distal radius fractures, as opposed to those without CRPS, more likely to have a bone scan, stellate ganglion block, therapy, or subsequent surgery? METHODS: Using the Truven database, we identified 59,765 patients treated for a distal radius fracture from 2012 to 2014, of whom 114 (0.19%) were diagnosed with CRPS. The Truven Health MarketScan database is an administrative claims data set of commercially insured patients and this analysis only included patients with complete enrollment from 2012 through 2014. Bivariate analyses sought differences between patients diagnosed with and patients not diagnosed with CRPS. All factors with p < 0.05 were included in a multivariable logistic regression model. RESULTS: The covariates older age (odds ratio [OR], 1.029; 95% confidence interval [CI], 1.011-1.048; p = 0.002), gender (women at greater risk, OR, 3.86; CI, 1.99-7.49; p < 0.001), concomitant fracture of the distal ulna (OR, 1.54; CI, 1.05-2.23; p = 0.029), open fracture (OR, 0.414; CI, 0.192-0.895; p = 0.025), and comorbid fibromyalgia (OR, 16.0; CI, 4.92-51.8; p < 0.001) were independently associated with a diagnosis of CRPS among patients recovering from a fracture of the distal radius. Patients diagnosed with CRPS are more likely than other patients with a distal radius fracture to have had a bone scan (OR, 66.0; CI, 8.19-532; p < 0.001), physical or occupational therapy (OR, 3.89; CI, 2.68-5.67; p < 0.001), and subsequent wrist surgery (OR, 2.52; CI, 1.65-3.84; p < 0.001). No one had a stellate ganglion injection. CONCLUSIONS: We found that a coded diagnosis of CPRS is uncommonly applied to patients on the higher range of pain, stiffness, and limitations after fracture of the distal radius-most commonly in women and in association with another nonspecific, objectively unverifiable diagnosis (fibromyalgia)-and that this label may lead to more testing and invasive treatment. Future research should address the utility and value of diagnoses that create subjective categories for aspects of human illness that occur on a continuum. LEVEL OF EVIDENCE: Level III, prognostic study.

Complex regional pain syndrome: new concepts regarding diagnosis and treatment

Antecedentes: Los autores presentan una revisión crítica sobre el cuadro clínico, el diagnóstico, clasificación y tratamientodel síndrome de dolor regional complejo, discutiendo todos los métodos de tratamiento y haciendo hincapié en que la reabilitación debe ser empleada con el fin de obtener un mejor resultado. Aspecto psicológico debe ser discutido en el tratamiento y también se anima equipo multidisciplinario para participar en él.

Background: The authors presented a critical review about the clinical picture, diagnosis, classification and treatment ofcomplex regional pain syndrome, discussing all methods of treatment and emphasizing that the reabiltation must be employed in order to obtain a better result. Psychological aspect must be involved in the treatment and also multidisciplinary team is encouraged to take part on it.

[Chronic pain : Perception, reward and neural processing]. / Chronischer Schmerz : Wahrnehmung, Belohnung und neurale Verarbeitung.

Many chronic pain syndromes are characterized by enhanced perception of painful stimuli as well as alterations in cortical processing in sensory and motor regions. In this review article the alterations in muscle pain and neuropathic pain are described. Alterations in patients with fibromyalgia and chronic back pain are described as examples for musculoskeletal pain and also in patients with phantom limb pain after amputation and complex regional pain syndrome as examples for neuropathic pain. In addition to altered pain perception, cumulative evidence on alterations in the processing of reward and the underlying mechanisms in chronic pain has been described. A description is given of what is known on how pain and reward interact and affect each other. The relevance of such interactions for chronic pain is discussed. The implications of these findings for therapeutic approaches are delineated with respect to sensorimotor training and behavioral therapy, focusing on the effectiveness of these approaches, mechanisms and future developments. In particular, we discuss operant behavioral therapy in patients with chronic back pain and fibromyalgia as well as prosthesis training in patients with phantom limb pain and discrimination, mirror and imaginary training in patients with phantom limb pain and complex regional pain syndrome. With respect to the processing of reward, the focus of the discussion is on the role of reward and associated learning in pain therapy.

Complex Regional Pain Type 1.

Complex regional pain syndrome is increasingly recognized in the pediatric population. Owing to the nature of presentation with pain, many of these children present to the emergency setting at different stages of the syndrome with or without numerous prior interactions with health professionals. Complex regional pain syndrome type 1 (CRPS1) is a clinical syndrome characterized by amplified musculoskeletal limb pain that is out of proportion to the history and physical findings, or pain due to non-noxious stimuli (allodynia/hyperalgesia), and accompanied by one or more signs of autonomic dysfunction. Differential diagnosis may include significant trauma (eg, fractures), inflammatory conditions, malignancies, and systemic illness. The diagnosis is clinical. The treatment goals for CRPS1 are restoration of function and relief of pain. Education, physical, and occupational therapy with psychotherapy and defined goals of achievement with reward are the mainstay of treatment for this population. Most children with CRPS1 will have a favorable outcome.

Complex regional pain syndrome type I in children. Clinical description and quality of life.

INTRODUCTION: Complex regional pain syndrome type 1 (CRPS I) in children differs from its adult counterpart and relevant literature is scarce. Our aim was to investigate potential risk factors and to assess midterm outcome and quality of life. MATERIAL AND METHODS: Medical records of patients diagnosed with CRPS I between 2004 and 2012 were analyzed. Patients and parents were called for a phone interview including the PEDS Quality of Life 4-0 questionnaire. Results were compared to a control group matched for age, gender and socio-economic status. RESULTS: Seventy-three patients were included (64 girls, 9 boys). Mean age at diagnosis was 11.5 years and mean time to diagnosis was 14.2 months. The lower limb was affected in 89% of cases. Allodynia, coldness and cyanosis were noted in 95%, 81% and of 74% of cases, respectively. Forty-nine percent of patients reported a physical injury. Multivariate analysis showed a strong association with being anxious (OR = 44.9, 95% CI [7.4-273]), presence of an atopic background (OR = 25.0, 95% CI: [4.6-135]), being good to excellent school performers (OR = 8.4 95% CI [1.3-52.1]), and having trouble falling asleep (OR = 5.3, 95% CI [1.6-17.0]). At a mean 37 months' follow-up (12-102), PEDS QL 4-0 score was significantly lower in CRPS patients compared to controls. Fifty-seven percent of patients acknowledged healing and 55% had presented a relapse. CONCLUSION: Childhood onset CRPS I affects predominantly preadolescent girls at the ankle. The present study highlights the relatively poor outcome, especially its physical and emotional aspects and the large role of psychology. LEVEL OF EVIDENCE: IV.

Pain and rehabilitation problems after single-event multilevel surgery including bony foot surgery in cerebral palsy. A series of 7 children.

BACKGROUND AND PURPOSE: Surgical correction of foot deformities as part of single-event multilevel surgery (SEMLS) to optimize postoperative training is sometimes indicated in ambulatory children with cerebral palsy. We have, however, experienced excessive postoperative pain and rehabilitation problems in a number of these patients. We therefore investigated children who underwent such procedures regarding postoperative rehabilitation and pain, gait parameters 1 year after surgery, and mobility 5 years after surgery. PATIENTS AND METHODS: 9 children with diplegic cerebral palsy who had also undergone bony foot surgery were identified from a cohort of 70 children treated with SEMLS according to a standardized protocol. 2 children were excluded due to mental retardation and atypical surgery, and 7 patients (4 of them boys) were included. The children and their parents underwent a semi-structured interview on average 5 (3-7) years after the surgery. Gait parameters preoperatively and 1 year postoperatively were compared. RESULTS: 5 children had experienced regional pain syndrome and considerable sociopsychological problems during the first postoperative year. 5 years after surgery, 4 of the 5 children still had hypersensitive and painful feet, 2 had lost their ability to walk, 1 child was no longer self-reliant in daily care, and 3 were wheelchair bound. There were, however, no clinically significant differences in functional mobility scale (FMS) or gait parameters preoperatively and 1 year postoperatively. INTERPRETATION: We found troublesome postoperative rehabilitation and poor outcomes in this series of children who had undergone simultaneous multilevel surgeries and bony foot corrections. Caution is warranted when treating marginally ambulatory children with bilateral spastic cerebral palsy and foot deformities.

Brain neuroplastic changes accompany anxiety and memory deficits in a model of complex regional pain syndrome.

BACKGROUND: Complex regional pain syndrome (CRPS) is a painful condition with approximately 50,000 annual new cases in the United States. It is a major cause of work-related disability, chronic pain after limb fractures, and persistent pain after extremity surgery. Additionally, CRPS patients often experience cognitive changes, anxiety, and depression. The supraspinal mechanisms linked to these CRPS-related comorbidities remain poorly understood. METHODS: The authors used a previously characterized mouse model of tibia fracture/cast immobilization showing the principal stigmata of CRPS (n = 8 to 20 per group) observed in humans. The central hypothesis was that fracture/cast mice manifest changes in measures of thigmotaxis (indicative of anxiety) and working memory reflected in neuroplastic changes in amygdala, perirhinal cortex, and hippocampus. RESULTS: The authors demonstrate that nociceptive sensitization in these mice is accompanied by altered thigmotactic behaviors in the zero maze but not open field assay, and working memory dysfunction in novel object recognition and social memory but not in novel location recognition. Furthermore, the authors found evidence of structural changes and synaptic plasticity including changes in dendritic architecture and decreased levels of synaptophysin and brain-derived neurotrophic factor in specific brain regions. CONCLUSIONS: The study findings provide novel observations regarding behavioral changes and brain plasticity in a mouse model of CRPS. In addition to elucidating some of the supraspinal correlates of the syndrome, this work supports the potential use of therapeutic interventions that not only directly target sensory input and other peripheral mechanisms, but also attempt to ameliorate the broader pain experience by modifying its associated cognitive and emotional comorbidities.

Informed Decision-Making Regarding Amputation for Complex Regional Pain Syndrome Type I.

BACKGROUND: Literature on complex regional pain syndrome type I (CRPS-I) discussing the decision to amputate or not, the level of amputation, or the timing of the amputation is scarce. We evaluated informed decision-making regarding amputation for CRPS-I. METHODS: We describe our findings in a retrospective study of the decision-making process of thirty-six patients who underwent amputation for CRPS-I at our university medical center from 2000 to 2012. Additionally, we present the incidents preceding the CRPS-I, the reasons for and the levels of the amputation, and the outcomes after the amputations. RESULTS: Team members and the patient decided together whether or not to amputate and the level of amputation. Issues such as level of pain or allodynia, infection, desired length of the residual limb, joint range of motion, strength of all extremities, ability to use walking aids, and psychological "green, yellow, and red flags" were weighed in this process. There were no complications during the amputation surgery, a 22% rate of complications (infection in all but one patient) immediately postoperatively (reamputation not required), a 72% rate of phantom pain immediately after or within the first three months after the amputation, and a 77% rate of phantom pain more than one year after the amputation. CONCLUSIONS: Informed decision-making regarding amputation for CRPS-I remains a complex process for which little evidence is available to support patient choices; patient-specific outcomes are not predictable. However, amputation should not be ignored as a treatment option for long-standing therapy-resistant CRPS-I. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Please don't hurt me!: a plea against invasive procedures in children and adolescents with complex regional pain syndrome (CRPS)]. / Bitte nicht noch mehr verletzen! : Plädoyer gegen eine invasive Schmerztherapie bei Kindern mit komplexem regionalem Schmerzsyndrom (CRPS).

BACKGROUND: Complex regional pain syndrome (CRPS; formerly known as Morbus Sudeck/reflex dystrophy) is diagnosed in children and adolescents, but the clinical presentation is often atypical. Unfortunately, potentially harmful, invasive treatments are used in pediatric patients. PATIENTS AND METHODS: A retrospective chart study of pediatric chronic pain patients with CRPS was performed. RESULTS: Over the course of 6 years, 37 (35 girls) children and adolescents took part in a multidisciplinary chronic pain inpatient program. At admission, patients took on average 4.4 (range 1-10) different medications and 29 different pharmaceuticals were used overall. Prior to admission, invasive pain treatments were performed without success in 16 of the children (43%). At least 13 children received two or more invasive treatments. Although sympathetic blocks were most prevalent, operations and regional anesthesia were also used. CONCLUSION: Despite a lack of evidence for invasive procedures, these continue to be used in children and adolescents with CRPS, who later respond positively to conventional treatment. The English full-text version of this article is available at SpringerLink (under "Supplemental").

Endoneurial pathology of the needlestick-nerve-injury model of Complex Regional Pain Syndrome, including rats with and without pain behaviors.

Current rodent models of neuropathic pain produce pain hypersensitivity in almost all lesioned animals and not all identified experimental effects are pain specific. 18G needlestick-nerve-injury (NNI) to one tibial nerve of outbred Sprague-Dawley rats models the phenotype of Complex Regional Pain Syndrome (CRPS), a post-traumatic neuropathic pain syndrome, leaving roughly half of NNI rats with hyperalgesia. We compared endoneurial data from these divergent endophenotypes searching for pathological changes specifically associated with pain-behaviors. Tibial, sural, and common sciatic nerves from 12 NNI rats plus 10 nerves from sham-operated controls were removed 14 days post-surgery for morphometric analysis. PGP9.5(+) unmyelinated-fibers were quantitated in plantar hindpaw skin. Distal tibial nerves of NNI rats had endoneurial edema, 30% fewer axons, twice as many mast cells, and thicker blood-vessel walls than uninjured tibial nerves. However the only significant difference between nerves from hyperalgesic versus non-hyperalgesic NNI rats was greater endoneurial edema in hyperalgesic rats (p < 0.01). We also discovered significant axonal losses in uninjured ipsilateral sural nerves of NNI rats, demonstrating spread of neuropathy to nearby nerves formerly thought spared. Tibial and sural nerves contralateral to NNI had significant changes in endoneurial blood-vessels. Similar pathological changes have been identified in CRPS-I patients. The current findings suggest that severity of endoneurial vasculopathy and inflammation may correlate better with neuropathic pain behaviors than degree of axonal loss. Spread of pathological changes to nearby ipsilateral and contralateral nerves might potentially contribute to extraterritorial pain in CRPS.

Complex regional pain syndrome after hand surgery.

Complex regional pain syndrome (CRPS) after an emergent or elective upper extremity surgery may complicate recovery, delay return to work, diminish health-related quality of life, and increase the likelihood of poor outcomes and/or litigation. CRPS after hand surgery is not uncommon and may complicate postoperative care. Early diagnosis and treatment of CRPS is critical for optimal patient outcomes. This article discusses the diagnosis, physiology, and management of postsurgical CRPS that occurs after hand surgery.

Biofeedback in pain management: Bier blocks for complex regional pain syndrome.

This feature presents information for patients in a question and answer format. It is written to simulate actual questions that many pain patients ask and to provide answers in a context and language that most pain patients will comprehend. Issues addressed in this issue are the role of the biofeedback in pain management and Bier blocks for complex regional pain syndrome.

[Influence of changes to daily dose of opioids on aspects of cognitive and psychomotor performance involved in driving]. / Einfluss von Anderungen der Opioidtagesdosis auf fahrrelevante kognitive und psychomotorische Leistungen.

INTRODUCTION: It has been shown that long-term treatment with opioids does not necessarily impair driving ability in patients suffering from chronic pain. However, few studies are so far available on how increases in daily opioid dosage affect driving ability. METHODS: A prospective trial was conducted in patients suffering from chronic noncancer pain, to examine the effects of the daily dose of opioids on psychomotor and cognitive functions. A computerized test system was administered to patients before and 7 days after alteration of their opioid therapy, to determine performance affecting driving ability at each time point. The test design was based on both international and national recommendations for the examination of driving safety. RESULTS: Raising the daily dose of opioids and/or changing to an opioid at a higher WHO level had no effect on the functions relevant to driving ability in the group context. Pain intensity and serum concentrations of morphine influenced only few items in the test battery. CONCLUSION: Seven days after an increase in the daily dose of an opioid or after the initiation of opioid therapy there was no general deterioration in patients' driving ability at group level.

Disability and quality of life in patients with fibromyalgia.

BACKGROUND: Patients with fibromyalgia often feel disabled in the performance of daily activities. Psychological factors seem to play a pronounced disabling role in fibromyalgia. The objectives of the study are: Firstly, to investigate contributing factors for disability in fibromyalgia. Secondly, to study psychological distress in patients with fibromyalgia as compared to other nonspecific pain syndromes. And finally, to explore the impact of fibromyalgia on a patient's quality of life. METHODS: In this cross sectional study, explaining factors for disability were studied based on a regression analysis with gender, mental health, physical and social functioning as independent variables. For the assessment of disability in fibromyalgia the FIQ was used. The levels of psychological distress in patients with fibromyalgia, Complex Regional Pain Syndrome (CRPS) and chronic low back pain (CLBP) were compared based on scores on the Symptom Checklist (SCL90). Quality of life of patients with fibromyalgia was compared with scores (SF36) of both patients with fibromyalgia and other health conditions as derived from the literature. RESULTS: Disability in fibromyalgia seemed best explained by a patients mental health condition (beta = -0.360 p = 0.02). The level of psychological distress was higher in patients with fibromyalgia as compared to patients with CRPS or CLBP (p < 0.01). The impact of fibromyalgia on quality of life appeared to be high as compared to the impact of other health conditions. CONCLUSION: Patients with fibromyalgia report a considerable impact on their quality of life and their perceived disability level seems influenced by their mental health condition. In comparison with patients with other pain conditions psychological distress is higher.