Stroke, complex regional pain syndrome and phantom limb pain: Can commonalities direct future management?

AbstractBackground and purposeThis case of a 42 year old woman with lower extremity Complex Regional Pain Syndrome (CRPS) after a twisting injury of the ankle, effectively treated with the addition of mirror therapy to a rehabilitation programme, prompted a literature review of both CRPS and mirror therapy. Mirror therapy is a newer adjunct to other forms of pain control and functional restoration for treatment of CRPS as well as other difficult clinical problems. This was a required group project as part of a university based course in chronic pain for healthcare workers.Materials and methodsThe PubMed database up to September 26,2012 was reviewed using four search word groups: “CRPS mirror therapy”, “mirror CRPS”, “reflex sympathetic dystrophy OR Complex Regional Pain Syndrome AND mirror” and “reflex sympathetic dystrophy OR Complex Regional Pain Syndrome AND mirror + RCT”. Nine studies from PubMed met the criteria that this working group had chosen for inclusion in the analysis of mirror therapy as treatment. These references were supplemented by others on CRPS in order to generate an adequate review of both the syndrome CRPS and mirror therapy itself. Some references were specific for mirror therapy in the treatment of CRPS but others described mirror therapy for the treatment of phantom limb pain, brachial plexus avulsion pain, for physical rehabilitation of stroke related paresis and for rehabilitation after hand surgery.ResultsCriteria for the diagnosis of CRPS including the International Association for the Study of Pain criteria and the Budapest criteria are reviewed with an emphasis on the specificity and sensitivity of the various criteria for clinical and research purposes. The signs and symptoms of CRPS are a part of the criteria review.The main treatment strategy for CRPS is physical rehabilitation for return of function and mirror therapy is one of many possible strategies to aid in this goal.The patient in this case report had failed many of the adjunctive therapies and rehabilitation had been unsuccessful until the addition of mirror therapy. She then could progress with physical rehabilitation and return to a more normal life. Mirror therapy techniques are briefly described as part of a discussion of its success with relationship to signs and symptoms as well as to the duration of CRPS (and other syndromes). Some discussion of the theories of the central effects of both CRPS and phantom limb pain and how these are affected by mirror therapy is included.An analysis of the 9 most relevant articles plus a critique of each is present in table form for review.ConclusionsThere appears to be a clear indication for the use of mirror therapy to be included in the multidisciplinary treatment of CRPS types 1 and 2 with a positive effect on both pain and motor function. There is also evidence that mirror therapy can be helpful in other painful conditions such as post stroke pain and phantom limb pain.ImplicationsCRPS is often overlooked as an explanation for obscure pain problems. Prompt diagnosis is essential for effective treatment. Mirror therapy is a newer technique, easy to perform and can be a useful adjunct to aid physical rehabilitation and decrease pain in this population. Much further prospective research on mirror therapy in CRPS is ongoing and is needed to systematize the technique, to clarify the effects and to define the place of this therapy in the multidisciplinary management of CRPS.

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Lateral Spinal Cord Stimulation for Stump and Phantom Limb Pain Syndrome

10.26226/morressier.5ab3c881a874c600265593b4 ◽

2018 ◽

Author(s):

Ciro Visconti

Keyword(s):

Spinal Cord ◽

Spinal Cord Stimulation ◽

Phantom Limb Pain ◽

Pain Syndrome ◽

Phantom Limb ◽

Limb Pain

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Thermocoagulation of the Dorsal Root Entry Zone for the Treatment of Intractable Pain

Neurosurgery ◽

10.1097/00006123-198412000-00037 ◽

1984 ◽

Vol 15 (6) ◽

pp. 953-955 ◽

Cited By ~ 11

Author(s):

Madjid Samii ◽

Jean Richard Moringlane

Keyword(s):

Dorsal Root ◽

Phantom Limb Pain ◽

Pain Syndrome ◽

Phantom Limb ◽

Intractable Pain ◽

Limb Pain ◽

Entry Zone ◽

Dorsal Root Entry Zone ◽

Root Entry Zone ◽

Peripheral Nerve Lesions

Abstract The authors report the results of DREZ thermocoagulation in 35 patients since March 1980. This technique was applied not only in patients with deafferentation pain after brachial plexus avulsion, but also for postamputation phantom limb pain and pain caused by injury to the spine and spinal cord, by peripheral nerve lesions, and by multiple sclerosis. Independent of etiology, the duration of the pain syndrome, and the quality and projection of the pain, the overall results have been satisfactory and long-lasting.

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Spinal Cauda Equina Stimulation for Alternative Location of Spinal Cord Stimulation in Intractable Phantom Limb Pain Syndrome: A Case Report

The Korean Journal of Pain ◽

10.3344/kjp.2016.29.2.123 ◽

2016 ◽

Vol 29 (2) ◽

pp. 123 ◽

Cited By ~ 4

Author(s):

Pil Moo Lee ◽

Yun So ◽

Jung Min Park ◽

Chul Min Park ◽

Hae Kyoung Kim ◽

...

Keyword(s):

Spinal Cord ◽

Case Report ◽

Spinal Cord Stimulation ◽

Cauda Equina ◽

Phantom Limb Pain ◽

Pain Syndrome ◽

Phantom Limb ◽

Limb Pain ◽

Alternative Location

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ACUPUNCTURE AS THERAPY OF TRAUMATIC AFFECTIVE DISORDERS AND OF PHANTOM LIMB PAIN SYNDROME

Acupuncture & Electro-Therapeutics Research ◽

10.3727/036012989816358452 ◽

1989 ◽

Vol 14 (2) ◽

pp. 121-129 ◽

Cited By ~ 3

Author(s):

Simon Freed

Keyword(s):

Affective Disorders ◽

Phantom Limb Pain ◽

Pain Syndrome ◽

Phantom Limb ◽

Limb Pain

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Haunting of the phantom limb pain abolished by buprenorphine/naloxone

BMJ Case Reports ◽

10.1136/bcr-2020-237009 ◽

2021 ◽

Vol 14 (2) ◽

pp. e237009

Author(s):

Una Srejic ◽

Faried Banimahd

Keyword(s):

Receptor Antagonist ◽

Opioid Receptor ◽

Drug Effects ◽

Phantom Limb Pain ◽

Pain Syndrome ◽

Local Anaesthetics ◽

Phantom Limb ◽

Limb Pain ◽

Long Acting ◽

Strong Opioids

Neuropathic opioid refractory phantom limb pain (PLP) following amputation can be a life long debilitating chronic pain syndrome capable of completely destroying a patient’s life. The pain, its associated depression and sleep deprivation can make many patients suicidal. Ever changing and relentless, it is notoriously unresponsive to traditional cocktails of strong opioids, adjuvant pain medications, antidepressants, local anaesthetics, nerve stimulators, hypnotics and psychotropics. Drug effects are seldom more effective than placebo. We describe a successful sustained rescue of a difficult 2-year-long PLP case with sublingual buprenorphine/naloxone using the drug’s potent multimodal mechanisms of action: potent long-acting mu agonist/antagonist, kapa receptor antagonist, delta receptor antagonist and novel opioid receptor-like 1 (OR-L1) agonist effects. Traditional escalating pure mu-opioid receptor agonists and adjuvant neuropathic pain cocktails often have disappointing efficacy in the treatment of resistant PLP. We suggest introducing buprenorphine/naloxone as an early effective opioid choice in PLP management.

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Quality of life after amputation in patients with advanced complex regional pain syndrome: a systematic review

EFORT Open Reviews ◽

10.1302/2058-5241.4.190008 ◽

2019 ◽

Vol 4 (9) ◽

pp. 533-540 ◽

Cited By ~ 3

Author(s):

Brijesh Ayyaswamy ◽

Bilal Saeed ◽

Anoop Anand ◽

Lai Chan ◽

Vishwanath Shetty

Keyword(s):

Quality Of Life ◽

Complex Regional Pain Syndrome ◽

Phantom Limb Pain ◽

Pain Syndrome ◽

Poor Quality ◽

Severe Form ◽

Phantom Limb ◽

Treatment Modalities ◽

Phantom Pain

The majority of included studies (8 out of 11, n = 54) supported the concept of considering amputation for selected, unresponsive cases of complex regional pain syndrome (CRPS) as a justifiable alternative to an unsuccessful multimodality nonoperative option. Of patients who underwent amputation, 66% experienced improvement in quality of life (QOL) and 37% were able to use a prosthesis, 16% had an obvious decline in QOL and for 12% of patients, no clear details were given, although it was suggested by authors that these patients also encountered deterioration after amputation. Complications of phantom limb pain, recurrence of CRPS and stump pain were predominant risks and were noticed in 65%, 45% and 30% of cases after amputation, respectively and two-thirds of patients were satisfied. Amputation can be considered by clinicians and patients as an option to improve QOL and to relieve agonizing, excruciating pain of severe, resistant CRPS at a specialized centre after multidisclipinary involvement but it must be acknowledged that evidence is limited, and the there are risks of aggravating or recurrence of CRPS, phantom pain and unpredictable consequences of rehabilitation. Amputation, if considered for resistant CRPS, should be carried out at specialist centres and after MDT involvement before and after surgery. It should only be considered if requested by patients with poor quality of life who have failed to improve after multiple treatment modalities. Further high quality and comprehensive research is needed to understand the severe form of CRPS which behaves differently form less severe stages. Cite this article: EFORT Open Rev 2019;4:533-540. DOI: 10.1302/2058-5241.4.190008

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