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Intravenous Regional Guanethidine in the Treatment of Reflex Sympathetic Dystrophy/Causalgia: A Randomized, Double-Blind Study
Abstract
This double-blind, randomized, multicenter study was designed to determine the short-term and long-term efficacy of intravenous regional block with guanethidine in patients with reflex sympathetic dystrophy (RSD)/causalgia. Sixty patients were enrolled to receive four intravenous regional blocks at 4-day intervals with either guanethidine or placebo in 0.5% lidocaine. Each patient was randomized to receive either one, two, or four blocks with guanethidine. Follow-up visits were scheduled for 4 days, 1 mo, 3 mo, and 6 mo after their final block. At 4 days after the initial block, the group treated with placebo experienced a greater decrease in pain scores than those treated with guanethidine, although this difference was not statistically significant. On long-term followup there was no difference in pain scores between groups receiving one, two, or four guanethidine blocks. Overall, only 35% of patients experienced clinically significant relief on long-term followup even though all were treated early in the evolution of RSD.
(Anesth Analg 1995;81:718-23)
... Eight studies have been carried out into the effects of intravenous guanethidine on CRPS-I [23,[46][47][48][49][50][51][52]. The doses administered ranged from 10 to 30 mg. ...
... The doses administered ranged from 10 to 30 mg. Four of these studies (n = 9-60) were randomized, comparing guanethidine to a placebo (in most cases 0.9% NaCl) [46,48,50,52]. The remaining studies (n = 20-55) examining the effect of guanethidine report a temporary effect in approximately one-third of patients. ...
BMC Neurology 2010, 10:20 doi:10.1186/1471-2377-10-20
Published: 31 March 2010
Abstract
Background
Treatment of complex regional pain syndrome type I (CRPS-I) is subject to discussion. The purpose of this study was to develop multidisciplinary guidelines for treatment of CRPS-I.
Method
A multidisciplinary task force graded literature evaluating treatment effects for CRPS-I according to their strength of evidence, published between 1980 to June 2005. Treatment recommendations based on the literature findings were formulated and formally approved by all Dutch professional associations involved in CRPS-I treatment.
Results
For pain treatment, the WHO analgesic ladder is advised with the exception of strong opioids. For neuropathic pain, anticonvulsants and tricyclic antidepressants may be considered. For inflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. To promote peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used to increase blood flow in case vasodilatory medication has insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, vitamin C is recommended. Adequate perioperative analgesia, limitation of operating time, limited use of tourniquet, and use of regional anaesthetic techniques are recommended for secondary prevention of CRPS-I.
Conclusions
Based on the literature identified and the extent of evidence found for therapeutic interventions for CRPS-I, we conclude that further research is needed into each of the therapeutic modalities discussed in the guidelines.
... Eight studies have been carried out into the effects of intravenous guanethidine on CRPS-I [23,[46][47][48][49][50][51][52]. The doses administered ranged from 10 to 30 mg. ...
... The doses administered ranged from 10 to 30 mg. Four of these studies (n = 9-60) were randomized, comparing guanethidine to a placebo (in most cases 0.9% NaCl) [46,48,50,52]. The remaining studies (n = 20-55) examining the effect of guanethidine report a temporary effect in approximately one-third of patients. ...
Treatment of complex regional pain syndrome type I (CRPS-I) is subject to discussion. The purpose of this study was to develop multidisciplinary guidelines for treatment of CRPS-I.
A multidisciplinary task force graded literature evaluating treatment effects for CRPS-I according to their strength of evidence, published between 1980 to June 2005. Treatment recommendations based on the literature findings were formulated and formally approved by all Dutch professional associations involved in CRPS-I treatment.
For pain treatment, the WHO analgesic ladder is advised with the exception of strong opioids. For neuropathic pain, anticonvulsants and tricyclic antidepressants may be considered. For inflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. To promote peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used to increase blood flow in case vasodilatory medication has insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, vitamin C is recommended. Adequate perioperative analgesia, limitation of operating time, limited use of tourniquet, and use of regional anaesthetic techniques are recommended for secondary prevention of CRPS-I.
Based on the literature identified and the extent of evidence found for therapeutic interventions for CRPS-I, we conclude that further research is needed into each of the therapeutic modalities discussed in the guidelines.
... As terapêuticas farmacológicas são muitas, com variadas técnicas de aplicação. Classicamente, o bloqueio simpático é o mais utilizado 49,50 ; todavia, alguns estudos contestam a eficácia destas técnicas [51][52][53] , especialmente se não for confirmado o envolvimento do sistema nervoso autonômico. Entre as várias técnicas de bloqueio simpático, citam-se: bloqueio ganglionar simpático, infusão venosa de fentolamina ou lidocaína, bloqueio venoso regional com guanetidina, clonidina, dexmedetomidina, reserpina, bretílio ou corticóides [54][55][56] . ...
... There are several pharmacological therapies with different application techniques. Classically, sympathetic blockade is the most popular 49,50 ; however, some studies question the efficacy of such techniques [51][52][53] , especially if autonomic nervous system involvement is not confirmed. There are different sympathetic block techniques, among them: sympathetic ganglionary blockade, intravenous phentolamine or lidocaine infusion, intravenous regional block with guanethidine, clonidine, dexmedetomidine, reserpine, bretylium or steroids [54][55][56] . ...
The term Complex Regional Pain Syndrome (CRPS) was adopted as from 1994 by the International Association for Study of Pain (IASP) Consensus. It previously referred to by several other names, such as Reflex Sympathetic Dystrophy, Causalgia, Algodystrophy or Sudecks Atrophy, and is a disease where the understanding of clinical limits, pathophysiology and pathogenic implications is still very poor. Thus resulting in disappointment both for patients and for health professionals with regard to currently available therapies. This study aimed at reviewing the literature and updating information to improve the understanding of this severe painful syndrome.
This study is a literature review of several CRPS aspects, with emphasis in its causes, definition and taxonomy, pathophysiology, clinical characteristics, diagnostic tests and most recent therapies.
There are few well controlled, double blind and randomized CRPS studies with large samples, and there are still several questions about this disease. The treatment is usually empirical and the patient outcome is poor.
... Ramamurthy et al. performed a double blind, crossover, controlled outcome study with 60 CRPS I patients randomized to receive IVRA blocks every four days for a total of four blocks with either guanethidine (one, two, or four guanethidine blocks) or a placebo with 0.5% lidocaine. After the first block, placebo response was higher than guanethidine, and six months after the last block (up to four), 35% of patients had significant pain relief with no difference between placebo and guanethidine arms (level 2 evidence for lack of effect of guanethidine over placebo) [393]. Confounding factors in this study include the fact that the "placebo" group received an IVRA using local anesthetic (0.5% lidocaine) and a tourniquet (which may itself confer some type of analgesic effect following the block); thus in reality, the "placebo" control may be considered an active treatment comparison group. ...
There have been some modest recent advancements in the research of Complex Regional Pain Syndrome, yet the amount and quality of the work in this complicated multifactorial disease remains low (with some notable exceptions; e.g., the recent work on the dorsal root ganglion stimulation). The semi-systematic (though in some cases narrative) approach to review is necessary so that we might treat our patients while waiting for "better research." This semi-systematic review was conducted by experts in the field, (deliberately) some of whom are promising young researchers supplemented by the experience of "elder statesman" researchers, who all mention the system they have used to examine the literature. What we found is generally low- to medium-quality research with small numbers of subjects; however, there are some recent exceptions to this. The primary reason for this paucity of research is the fact that this is a rare disease, and it is very difficult to acquire a sufficient sample size for statistical significance using traditional statistical approaches. Several larger trials have failed, probably due to using the broad general diagnostic criteria (the "Budapest" criteria) in a multifactorial/multi-mechanism disease. Responsive subsets can often be identified in these larger trials, but not sufficient to achieve statistically significant results in the general diagnostic grouping. This being the case the authors have necessarily included data from less compelling protocols, including trials such as case series and even in some instances case reports/empirical information. In the humanitarian spirit of treating our often desperate patients with this rare syndrome, without great evidence, we must take what data we can find (as in this work) and tailor a treatment regime for each patient.
... Interventional therapy ranges from minimally invasive to highly invasive. Minimally invasive blocks target sympathetic and somatic nerves and can be done single-shot or via a percutaneous catheter when prolonged analgesia is needed (1,4,6,7). Highly invasive therapy includes placement of tunneled neuraxial catheters, peripheral nerve / spinal cord stimulation and intrathecal drug delivery (1,4,8). These therapies combined with rehabilitation and psycholog- ...
... Unfortunately, several good quality investigations failed to fi nd a benefi cial effect from this therapy. 121,154,227,228,300 IV regional blockade offers placement of medication directly into the affected extremity, which is potentially * References 26,28,76,88,128,132,139,143,173,209,210,238,243,251,318,323 . Kemler and associates 147 reported no difference in outcome in a randomized study between CRPS-I patients who received a SCS and physical therapy and those who underwent 6 months of physical therapy alone when assessed 5 years later. ...
... In a double-blind, randomized, multicenter study, 60 RSD/ causalgia patients received 4 IV regional blocks at 4-day intervals with either guanethidine or placebo in 0.5% lidocaine. 46 Four days after the initial block, the group treated with placebo experienced a greater decrease in pain scores than those treated with IVRB guanethidine, although this difference was not statistically significant. On long-term follow-up, there was no difference in pain scores between groups receiving 1, 2, or 4 guanethidine blocks. ...
Complex regional pain syndrome (CRPS) remains a challenging clinical pain condition. Multidisciplinary approaches have been advocated for managing CRPS. Compared with spinal cord stimulation and intrathecal targeted therapy, IV treatments are less invasive and less costly. We aimed to systemically review the literature on IV therapies and determine the level of evidence to guide the management of CRPS. We searched PubMed, Embase, Scopus, and the Cochrane databases for articles published on IV therapies of CRPS up through February 2015. The search yielded 299 articles, of which 101 were deemed relevant by reading the titles and 63 by reading abstracts. All these 63 articles were retrieved for analysis and discussion. We evaluated the relevant studies and provided recommendations according to the level of evidence. We conclude that there is evidence to support the use of IV bisphosphonates, immunoglobulin, ketamine, or lidocaine as valuable interventions in selected patients with CRPS. However, high-quality studies are required to further evaluate the safety, efficacy, and cost-effectiveness of IV therapies for CRPS.
... Other good quality studies have also reported a negative outcome of IVRA. A double-blinded, crossover, RCT found no difference between placebo and guanethidine groups in terms of pain relief and therefore lack of effect of guanethidine over placebo in patients with CRPS-I [80]. Two other RCTs compared various agents with placebo (saline), but all failed to establish a difference in pain relief [81,82]. ...
Complex Regional Pain Syndrome (CRPS) remains one of the most challenging conditions in the field of pain
management in general and in the upper extremity in particular. The varied manifestations of phases, symptoms and
signs of CRPS have created florid grounds for trials of a number of treatment modalities. While some of these have
proven partially effective, many others have not been successful to date. It is very important therefore to establish a
multidisciplinary approach based on the best available literature in order to optimise the treatment outcome.
We present an evidence based comprehensive review of the management of CRPS stemming from its past, current
and most recent practises. It is essential to have guidelines that set an algorithm for the management of patients with
CRPS. However, what is more important is to emphasise that CRPS is only the correct diagnosis if all other structural
causes have been investigated and ruled out. Over-diagnosis of this condition has led some to question its existence.
Therefore, we present an independent opinion on the management of CRPS, with reference to collaborative guidelines
within the remits of the current literature.
... There were no differences between the three groups. In 1995, Ramamurthy et al. 30 attempted to determine the optimal number of blocks for an IVRB with guanethidine. Fifty-seven patients with a recent history of CRPS (\three months), who had not undergone prior IVRB, were randomized to receive one, two, or four IVRBs. ...
... Ramamurthy et al. did a double-blind, crossover, controlled outcome study with 60 CRPS I patients randomized to receive IVRA blocks every 4 days for a total of four blocks with either guanethidine (one, two, or four guanethidine blocks) or placebo in 0.5% lidocaine. After the first block, placebo response was higher than guanethidine and 6 months after the last block (up to four), 35% of patients had significant pain relief, without difference between placebo and guanethidine arms (level 2 evidence for lack of effect of guanethidine over placebo) [318]. Confounding factors in this study include the fact that the "placebo" group received an IVRA using local anesthetic (0.5% lidocaine) and a tourniquet, which may confer some type of analgesic effect following the block; thus, in reality, the "placebo" control is an active treatment comparison group. ...
Objective:
This is the fourth edition of diagnostic and treatment guidelines for complex regional pain syndrome (CRPS; aka reflex sympathetic dystrophy).
Methods:
Expert practitioners in each discipline traditionally utilized in the treatment of CRPS systematically reviewed the available and relevant literature; due to the paucity of levels 1 and 2 studies, less rigorous, preliminary research reports were included. The literature review was supplemented with knowledge gained from extensive empirical clinical experience, particularly in areas where high-quality evidence to guide therapy is lacking.
Results:
The research quality, clinical relevance, and "state of the art" of diagnostic criteria or treatment modalities are discussed, sometimes in considerable detail with an eye to the expert practitioner in each therapeutic area. Levels of evidence are mentioned when available, so that the practitioner can better assess and analyze the modality under discussion, and if desired, to personally consider the citations. Tables provide details on characteristics of studies in different subject domains described in the literature.
Conclusions:
In the humanitarian spirit of making the most of all current thinking in the area, balanced by a careful case-by-case analysis of the risk/cost vs benefit analysis, the authors offer these "practical" guidelines.
... En l'absence de connaissance suffisante de sa physiopathologie, aucun traitement curatif ne peut être actuellement proposé [3,6,14]. Seuls des traitements symptomatiques visant à limiter les douleurs et les séquelles articulaires sont utilisés [5,8,9,11,12,17]. L'oedème et la douleur chronique, les raideurs articulaires sont donc difficiles à traiter et sont sources de déficiences articulaires et d'incapacités fonctionnelles. ...
Objective: In spite of physical medicine and rehabilitation care, post-traumatic reflex sympathetic dystrophy can be at the origin of articular deficiency, which decrease the capacity to return to work. The aim of this study is to know the professional future of patients who present post-traumatic reflex sympathetic dystrophy.Material and method: Eighteen months prospective study, carried out from patients in age to work, hospitalized in physical medicine and rehabilitation unit for ostéo-articular traumatism complicated by reflex sympathetic dystrophy. Description of the population and comorbidity factors preventing professional resumption. Determination of the duration of medical certificate and the modalities of professional resumption.Results: From 16 patients in age to work, only 12 were able to resume a full time profession with an average period of 10.5 months ± 5. The importance of the, the distale articular location of reflex sympathetic dystrophy (wrist - hand, ankle - foot), the association with a comorbidity such as chronic alcoholism represent pejorative factors of working resumption. Organizations of workstation are often necessary in six cases over eight, if the job is not sedentary. In the most complicated cases, inaptitudes in the work are pronounced with demand of professional reclassifying.Conclusion: Post-traumatic reflex sympathetic dystrophy represents a real challenge for the rehabilitation team, to minimize deficiencies and to help the patient to become again a worker.
... As terapêuticas farmacológicas são muitas, com variadas técnicas de aplicação. Classicamente, o bloqueio simpático é o mais utilizado 49,50 ; todavia, alguns estudos contestam a eficácia destas técnicas 51-53 , especialmente se não for confirmado o envolvimento do sistema nervoso autonômico. Entre as várias técnicas de bloqueio simpático, citam-se: bloqueio ganglionar simpático, infusão venosa de fentolamina ou lidocaína, bloqueio venoso regional com guanetidina, clonidina, dexmedetomidina, reserpina, bretílio ou corticóides 54-56. ...
JUSTIFICATIVA E OBJETIVOS: A Síndrome Dolorosa Complexa Regional (SDCR), assim denominada a partir de 1994 pelo Consenso da Associação Internacional para o Estudo da Dor (AIED) e anteriormente denominada de várias formas, tais como Distrofia Simpático Reflexa, Causalgia, Algodistrofia ou Atrofia de Sudeck, é uma doença cuja compreensão dos limites clínicos, fisiopatologia e implicações de patogenia ainda é pobre. Disto resulta a enorme insatisfação não só para os pacientes como para os profissionais da saúde quanto aos métodos terapêuticos atualmente disponíveis. O objetivo deste trabalho é rever a literatura e atualizar um conjunto de informações com o intuito da melhor compreensão desta importante síndrome dolorosa. CONTEÚDO: Este é um trabalho de revisão da literatura nos diversos aspectos da SDCR, com ênfase em suas causas, definição e taxonomia, fisiopatologia, características clínicas, testes diagnósticos e propostas de tratamentos mais recentes. CONCLUSÕES: Poucos são os estudos controlados adequadamente, encobertos e aleatórios, publicados com grandes amostras, havendo muitas dúvidas sobre esta doença. Desta forma, ainda há enorme empirismo na sua terapêutica, e os resultados obtidos são insatisfatórios.
Interventional therapies are critical and integral parts of a multipronged strategy for pain relief and rehabilitation in patients with complex regional pain syndrome (CRPS). These therapies include intravenous drug infusion to a specific limb or as a systemic drug delivery route, sympathetic blocks, and neuromodulation modalities, such as peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and intrathecal drug delivery. This chapter focuses on the clinical evidence of efficacy of the interventional therapies for CRPS, as well as the essential skills in clinical practice of these interventions. There is level I evidence to support neuromodulation via dorsal root ganglion and spinal cord stimulation; level II evidence to support intrathecal drug therapy and sympathetic blocks; and substantial yet variable evidence to support peripheral nerve stimulation and intravenous therapies. It is imperative that interventional treatment is individualized, with an emphasis placed on improving quality of life and function.
CRPS bij kinderen in Kindertraumachirurgie. Tweede, herziene druk.
Publicatiedatum: 19 mrt. 2019
Bohn, Stafleu en van Loghum
Omschrijving publicatie:
In zestig hoofdstukken wordt door meer dan honderd specialisten een gedetailleerd en actueel overzicht gegeven over de preventie, diagnostiek en behandeling van ongevalsletsels bij kinderen.
Ik mocht meewerken aan hoofdstuk 52 over #CRPS bij kinderen.
Afin d'améliorer la sécurité des patients bénéficiant de soins médicaux, les sociétés savantes élaborent des référentiels. Notre objectif était d'évaluer leur implémentation, d'en déterminer les barrières et de proposer des mesures favorisantes. Une enquête de pratique était réalisée en 2007 auprès des anesthésistes lorrains sur le thème de l'anesthésie locorégionale (ALR) périphérique pour la chirurgie programmée de l'adulte. Les résultats étaient comparés aux recommandations pour la pratique clinique de l'ALR publiées par la SFAR en 2003. Les principales différences concernaient l'information donnée aux patients, l'hygiène, la surveillance, la pratique de l'ALR intraveineuse et l'évaluation des contre-indications. Les barrières retrouvées étaient similaires à celles relevées dans d'autres spécialités médicales, à savoir un défaut des connaissances des référentiels, un faible niveau de preuve, des habitudes immuables, un manque de confiance en soi et un manque de moyens. Certaines différences pouvaient également s'expliquer par l'arrivée de nouvelles données scientifiques ultérieures à la publication des RPC et venant les contredire. Ce travail montre ainsi l'intérêt de mettre au point des stratégies d'implémentation adaptées à chaque référentiel et basées sur des audits, des évaluations des pratiques professionnelles, des rappels et sur une grande rigueur dans la rédaction des recommandations. Cela pourrait probablement améliorer la sécurité des patients.
Le Syndrome Douloureux Régional Complexe de type I plus connu sous le terme d'algodystrophie est une pathologie invalidante entraînant douleurs, troubles trophiques, raideurs et dysfonctions motrices. II est généralement secondaire à un traumatisme bénin. La durée d'évolution de ce syndrome est longue, il entraîne des incapacités et par conséquent des répercutions professionnelles et familiales sur l'individu. La physiopathologie et les thérapeutiques sont controversées, nous développons dans ce travail leurs actualités. Ce syndrome nécessite une prise en charge précoce associant rééducation fonctionnelle et traitements médicamenteux. La première partie de ce travail relate l'historique, les données épidémiologiques, les signes cliniques, la physiopathologie, les moyens diagnostiques et thérapeutiques actuels de ce syndrome. La deuxième partie rapporte les résultats d'une étude descriptive et rétrospective de 114 patients pris en charge pour algodystrophie dans un service de rhumatologie, un centre de rééducation et de réadaptation et un centre de traitement de la douleur. Ce travail montre que les prises en charge sont différentes selon que le patient est aiguillé vers l'un ou l'autre centre. L'absence de consensus actuel sur la thérapeutique conduit d'une part à une errance du patient avant la mise en route d'une thérapeutique, d'autre part souvent à la poursuite de traitements non efficaces au long court du fait de l'absence de moyens d'évaluation consensuels de ce syndrome. La prise en charge de ce syndrome devrait être multidisciplinaire, avec l'association dès le début des troubles à la fois de différents traitements médicaux et physiques. La pratique montre que les thérapeutiques se suivent souvent d'échec en échec. Seule une meilleure connaissance de la physiopathologie permettra à l'avenir de déboucher sur des nouvelles thérapeutiques qui, nous l'espérons déboucheront elles sur des études de meilleure qualité.
Interventional pain management procedures for complex regional pain syndrome (CRPS) are often utilized when conservative treatment options fail to provide adequate pain relief and restoration of function. Such procedures include sympathetic nerve blocks, chemical and surgical sympathectomy, intravenous regional anesthesia, intravenous infusion, spinal cord stimulation, intrathecal medication and amputation. The literature support for each procedure is reviewed herein.
The patients with Complex Regional Pain Syndrome (CRPS) have received different treatments with major or less success. In the present review we have achieved a systematic search in Internet, using the terms "Reflex Sympathetic Dystrophy" and "Complex Regional Pain Syndrome". The objective is to assess the diagnostic methods and therapeutics more effectives based on the best available scientific evidence, that allows a suitable control of patients with CRPS. The IASP establish the CRPS as a variety of pain conditions of regional finding, after one injury, with distal prevalence of unusual symptoms, exceeding in magnitude and duration to the clinic course expect of initial incident, producing an important impairment motor, with a variable progression in the time. The difference between CRPS I and CRPS II is in the presence of an injury in a peripheral nerve in the CRPS II. This Syndrome have some main signs and symptoms: strong pain, hyperesthesis, hyperalgesia, allodynia, sensorial deficiency, hyposthesis, tumefaction, changes of colour and temperature anomaly of sudation, changes in the skin: pallor, fibrosis, hyperkeratosis, brilliant and thin skin, trophic and vasomotor changes, muscular and bony atrophy. The diagnosis of CRPS I can be realized by clinic history and exploration [recommendation (R) B]. The diagnosis of CRPS I is based in the severity and duration of signs and symptoms [level of evidence (LE) III]. Some complementary test can assist to the differential diagnostic with other syndromes of chronic pain. We have evaluated different diagnostic approach although there arent reasons to recommend one over other (R C). The present guideline a recommend a multidisciplinary treatment with three essential elements: pain treatment, rehabilitation and psychological treatment. Treatment must be individualized according to characteristic of patient and to avoid pain, Joint rigidity, vasomotor reflex, Joint and bone sequel. The last objective must be the functional recovery without pain. Between treatments performed with some effectiveness there are: antiepileptic (LE II), antidepressant (LE III), nasal calcitonina (LE II), block of channel of calcium (LE IV), antiinflamatory nonsteroid, corticosteroid (LE I), patch of clonidina (LE IV), lidocaína intravenous (LE IV), cream of dimetil sulfoxide (LE IV), bifosfonates (LE II), ketamina intravenous (LE IV) and opioids. The regional endovenous block have efficacy: clonidina associated with lidocaína (LE III), bretilio associated with lidocaína (LE II), while guanetidine doesnt seem effective (LE I). Epidural block is effective: bupivacaína associated to opioids (LE III), clonidina (LE II), Other technical that seems effective are: chirurgical sympathectomy (LE IV), Transcutaneous electrical nerve stimulation (LE IV), medular electric stimulation in CRPS I (R A) and in CRPS II (R D), phisioterapy (LE IV) and occupational therapy (LE IV). Prevention of CRPS can be realized with early hospitalary rehabilitation (RC).
Die intensive Auseinandersetzung mit Komplikationen ist Teil der Qualitätssicherung. Trotz aller Vorsichtsmaßnahmen und fachgerechter Durchführung kann eine Komplikation selbst nach einer Bagatellverletzung auftreten (Abb. 17.1). Im unfallchirurgischen Patientenkollektiv muss mit einer Komplikationsrate von 3–8% gerechnet werden (Piltz u. Lob 1998), allerdings neigt jeder Arzt und Operateur dazu, seine eigene Komplikationsrate niedriger einzuschätzen als sie ist.
El sindrome de dolor regional complejo (SDRC) esta caracterizado clinicamente por dolor, regulacion anomala del flujo sanguineo y sudoracion, edema de la piel y tejidos subcutaneos, trastornos del movimiento activo y pasivo, cambios troficos de la piel, anejos de la piel y tejidos subcutaneos. Se clasifica en tipo I (anteriormente conocido como distrofia simpatico refleja) y tipo II (anteriormente conocido como causalgia).
Nach jahrzehntelangem Gebrauch des Begriffes „sympathische Reflexdystrophie“und ebenso langer Befassung mit den damit verbundenen klinischen Problematiken und therapeutischen Möglichkeiten konnten zunehmend mehr Kenntnisse zum Krankheitsbild und Erkenntnisse über die Begrenztheit zur Verfügung stehender Therapieansätze gewonnen werden. Insbesondere ist im Laufe der Zeit deutlich geworden, daß gerade auch in Verbindung mit dem breiten Einsatz der durch die Anästhesiologie vorgelegten Behandlungsmöglichkeiten Mängel in der Einheitlichkeit der Klinik der Krankheitsbilder weiterbestehen und demzufolge auch die Systematik nicht mehr befriedigen konnte. Kein Zweifel besteht an der Beteiligung des sympathischen Nervensystems an der Erkrankungsform. Jedoch wurde im Laufe der Zeit gesehen, daß Blockaden dieses Systems nicht immer therapeutisch greifen.
Interruption of the sympathetic nerve supply to the affected extremity has been used to treat certain pain syndromes for many years. These syndromes include complex regional pain syndromes (reflex sympathetic dystrophy (RSD) and causalgia), post-traumatic neuralgia, phantom limb pain and to a certain extent acute herpes zoster [1]. Two therapeutical techniques to block sympathetic nerves are currently used: (1) injections of a local anesthetic around sympathetic paravertebral ganglia that project to the affected body part (sympathetic ganglion blocks), and (2) regional intravenous application of guanethidine, bretylium or reserpine (which all deplete noradrenaline in the postganglionic axon) to an isolated extremity blocked with a tourniquet (intravenous regional sympatholysis). However, many authors do not support the concept that the sympathetic nervous system is actively involved in the generation of pain and propose, that the role of the sympathetic nervous system has to be reconsidered or even completely discarded [2, 3]. They claim that interventions that block sympathetic activity lack specificity and argue that the techniques and results of sympathetic blockade have rarely been adequately evaluated and are in most cases not placebo-controlled.
Complex regional pain syndrome (CRPS) is characterized by continuous pain, disproportional to the initial trauma. It usually spreads to the distal parts of the affected limb. Besides continuing pain, a mix of sensory, sudo- and vasomotor disturbances, motor dysfunction, and trophic changes is responsible for physical complaints. Vasomotor disturbance is characterized by changes in skin temperature and color. In CRPS patients with a cold extremity, a decrease in blood flow can cause decreased tissue saturation and tissue acidosis, resulting in ischemic pain. The pathophysiology of vasomotor disturbances is not completely understood. Temperature asymmetry is generally assumed as a result of disturbance in the sympathetic nervous system. Vasodilating drugs and sympathetic blockade have been cornerstones of therapy in cold CRPS for years. However, only a limited part of these patients improve on this kind of therapies. Research has shown a pivotal role for inflammation in the pathophysiology of CRPS. Inflammation can result in endothelial dysfunction. Endothelial function plays an important role in the local regulation of vascular tone. Endothelial dysfunction could be another mechanism responsible for the vasomotor disturbances in cold CRPS. An important goal in the treatment of cold-type CRPS is the restoration of a normal blood flow. Consequently it is important to distinguish the underlying pathophysiological mechanisms of vasomotor disturbances. A disturbance of the sympathetic nervous system may require another type of treatment than inflammation-induced endothelial dysfunction. Diagnostic tools to distinguish these underlying pathophysiological mechanisms of vasomotor disturbances would enable a mechanism-based treatment and improve clinical outcome.
La algodistrofia, en la actualidad llamada síndrome doloroso regional de tipo 1, es una afección de discutida patogenia, que asocia anomalías del sistema nervioso periférico y central. Se caracteriza por dolores de tipo neuropático y alteraciones vasculares y tróficas. La afectación del pie y el tobillo es frecuente, en ocasiones postraumática. En este artículo se analizan las particularidades de las formas frías y migratorias. Numerosos tratamientos, que se pensaban eran eficaces con base en estudios abiertos no controlados, no han demostrado eficacia en estudios aleatorizados controlados. El tratamiento de las algodistrofias debe ser precoz, pluridisciplinario y adaptado a la forma y a los signos clínicos. No está basado sólo en los medicamentos. Son útiles la información al paciente y su atención psicológica. La reeducación funcional es esencial para mantener o recuperar las funciones y para evitar la exclusión funcional del miembro.
La algodistrofia simpática refleja se define como un síndrome doloroso articular y periarticular vinculado a trastornos vasomotores y desencadenado por diversas causas, que evoluciona en forma típica desde una fase aguda hiperémica y dolorosa hasta una fase secundaria distrófica con rigidez y retracciones. La algodistrofia se observa con frecuencia en enfermedades neurológicas o del aparato locomotor. La fisiopatología no es clara, pero la acción de los sistemas simpáticos de control central del dolor parece ser determinante. Sólo el diagnóstico clínico en fase precoz, confirmado por un aumento de captación regional en la gammagrafía ósea, permite aplicar un tratamiento combinando reeducación funcional y medicamentos. El objetivo del tratamiento en fase inicial caliente es movilizar la zona afectada y prevenir la formación de retracciones y adherencias, drenar el edema de los tejidos blandos, preservar la función y evitar la exclusión funcional del miembro afectado. A esto se añade la prescripción de diversos medicamentos que han demostrado ser eficaces: corticoterapia transitoria, calcitonina en inyecciones subcutáneas o intramusculares, y difosfonatos. El efecto y la indicación de los bloqueos simpáticos posganglionares (guanetidina, buflomedil) o ganglionares (bloqueo del ganglio estrellado o de la cadena simpática lumbar) son motivo de controversia y no pueden constituir la vía terapéutica única o predominante. La algodistrofia es un síndrome doloroso que se observa en algunas enfermedades del aparato locomotor, en el que la prescripción temprana de reeducación y de medicamentos adecuados, así como la excelencia en la coordinación de las medidas terapéuticas, son indispensables para combatir con éxito esta anomalía que, en caso de adoptarse medidas tardías y/o incoordinadas, suele avanzar de forma prolongada e invalidante.
Reflex sympathetic dystrophy is a painful disorder that may develop as a disproportionate consequence of a minor trauma affecting the limbs or after a bone fracture. Causalgia occurs secondary to an injury of a major nerve. Reflex sympathetic dystrophy and causalgia are now called “complex regional pain syndromes (CRPS).” In CRPS type I (reflex sympathetic dystrophy), minor injuries to a limb or lesions in remote body areas precede the onset of symptoms. CRPS type II (causalgia) develops after injury to a major peripheral nerve. Patients with CRPS type I develop asymmetrical distal extremity pain and swelling after a trauma without presenting an overt nerve lesion. Precipitating events include fracture or minor soft tissue trauma as well as stroke and myocardial infarction. The swelling and pain often develop at a site remote from the inciting injury and there may be no obvious local tissue damaging process at the site of pain and swelling. CRPS type I patients often report a burning spontaneous pain felt in the distal part of the affected extremity.
Diabetic neuropathy is one of the most common forms of polyneuropathy. The prevalence among diabetics has been reported as
30% (Tesfaye et al., 1996), and it occurs as a complication of type I (insulin dependent diabetes mellitus, IDDM) as well as type II (non-insulin dependent
diabetes mellitus, NIDDM). Its incidence increases with age and duration of diabetes. Diabetic neuropathy affects small and
large nerve fibers with varying proportions. In some cases small nerve fiber dysfunction is predominant, leading to autonomic
symptoms and disturbance of wound healing. There are several different clinical manifestations with subtypes in terms of the
pattern of neurological disturbances, which are presented in the following paragraphs. However, mixed forms of these manifestations
occur (Sommer, Donaghy & Wiethölter, 1996).
Doel De effectiviteit van in de literatuur beschreven behandelingen van sympathische reflexdystrofie is onderzocht.
Methode Er is een systematisch literatuuronderzoek gedaan met een uitgebreide zoekstrategie in Medline en het Cochrane Controlled Trial Register. Onderzoeken naar het effect van een behandeling voor sympathische reflexdystrofie die een interventie vergelijken met een controlegroep, werden ingesloten.
Resultaten Er werden 28 onderzoeken gevonden, waaronder 16 RCT's. Zeven RCT's (n 20-135) waren van goede methodologische kwaliteit. Deze RCT's onderzochten uiteenlopende interventies voornamelijk gericht op de botopbouw (bifosfonaten en calcitonine), de zenuwgeleiding (intraveneuze regionale blokkades en elektrische ruggenmergblokkade), het ontstekingsproces (antioxidant) en op revalidatie (fysiotherapie, ergotherapie en maatschappelijk werk).Voor geen van de 19 onderzochte interventies was overtuigend bewijs voor effectiviteit voorhanden. Opvallend was het geringe aantal onderzoeken per interventie.
Conclusie Op basis van het bestaand onderzoek kan (nog) geen behandeling worden aangewezen die duidelijk effectiever is dan de behandeling van een controlegroep.
A blinded meta analysis was performed on randomized clinical trials (RCT) on the medicinal treatment of reflex sympathetic dystrophy (complex regional pain syndrome type I) to assess the methodological quality and quantify the analgesic effect of treatments by calculating individual and summary effect sizes. The internal validity of 21 RCTs was investigated and the quality weighted summary effect size was calculated using a fixed effect model (Glass Δ). The methodological quality ranged from moderate to good (average 46%). Differences were found between the trials in inclusion/exclusion criteria, treatment methods, duration of treatments and trials, and measurement instruments. Statistical analysis was possible for four subgroups; one evaluating the analgesic effects of sympathetic suppressors in general (n = 12), one subgroup concerning the analgesic effects of guanethidine (n = 6), one investigating the analgesic effect of intravenous regional sympathetic blocks (n = 9), and one subgroup (n = 5) evaluating the analgesic effect of calcitonin. Except for the calcitonin subgroup (P = 0.002), the quality-weighted summary effect size of these subgroups were not significant. No significant analgesic effect by sympathetic suppressing agents could be established. Calcitonin seems to provide effective pain relief in reflex sympathetic dystrophy patients. The results of the present study show that weighting methodological quality influences the magnitude of the effect sizes of specific treatment methods. Future studies should control for methodological quality.
There is currently no strong consensus regarding the optimal management of complex regional pain syndrome although a multitude of interventions have been described and are commonly used.
To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the effectiveness of any therapeutic intervention used to reduce pain, disability or both in adults with complex regional pain syndrome (CRPS).
We identified Cochrane reviews and non-Cochrane reviews through a systematic search of the following databases: Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Ovid MEDLINE, Ovid EMBASE, CINAHL, LILACS and PEDro. We included non-Cochrane systematic reviews where they contained evidence not covered by identified Cochrane reviews. The methodological quality of reviews was assessed using the AMSTAR tool.We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes of quality of life, emotional well being and participants' ratings of satisfaction or improvement. Only evidence arising from randomised controlled trials was considered. We used the GRADE system to assess the quality of evidence.
We included six Cochrane reviews and 13 non-Cochrane systematic reviews. Cochrane reviews demonstrated better methodological quality than non-Cochrane reviews. Trials were typically small and the quality variable.There is moderate quality evidence that intravenous regional blockade with guanethidine is not effective in CRPS and that the procedure appears to be associated with the risk of significant adverse events.There is low quality evidence that bisphosphonates, calcitonin or a daily course of intravenous ketamine may be effective for pain when compared with placebo; graded motor imagery may be effective for pain and function when compared with usual care; and that mirror therapy may be effective for pain in post-stroke CRPS compared with a 'covered mirror' control. This evidence should be interpreted with caution. There is low quality evidence that local anaesthetic sympathetic blockade is not effective. Low quality evidence suggests that physiotherapy or occupational therapy are associated with small positive effects that are unlikely to be clinically important at one year follow up when compared with a social work passive attention control.For a wide range of other interventions, there is either no evidence or very low quality evidence available from which no conclusions should be drawn.
There is a critical lack of high quality evidence for the effectiveness of most therapies for CRPS. Until further larger trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult.
IntroductionThe Typical PatientCommon Pain ConditionsHow Do Patients Present?Why Do Patients Consult?Why Do Family Physicians Refer Patients to Specialists?References
Introduction The current understanding of relevant pathophysiology Epidemiology Risk factors Treatment Cost of treatment and cost-benefit How to produce evidence of effectiveness in future Authors' recommendations References
Over the last few years, the mechanisms of pain due to peripheral nerve injury have been the subject of extensive clinical and fundamental investigation. Several types of peripheral mechanisms have been described in animal models of peripheral nerve injury. Abnormal (ectopic) neuronal activity has been reported in primary afferents and in the dorsal root ganglion, and appears related to dysregulation of the synthesis and/or the functioning of sodium channels (notably the tetrodotoxin-resistant channel). Fiber interactions (ephaptic or cross-excitation), nociceptor sensitization and sympathetic sensory coupling may also be involved in some cases. Peripheral nerve lesions can also induce central changes; this has essentially been investigated at the spinal cord level in animals. Three major types of modifications could induce a pathologic activation of central nociceptive neurons: modification of the moduhtory controls of the transmission of nociceptive messages; anatomic reorganization (neuro-plasticity) of the central nociceptive neurons, and thus their pathologic activation; and central sensitization (hyperexcitability) of nociceptive neurons to produce modifications of their electrophysiologic properties. Central sensitization probably depends critically on intracellular changes induced by the activation of N methyl-D-aspartate (NMDA) receptors by excitatory amino acids released by primary afferents. Due to the multiplicity of mechanisms, it is unlikely that neuropathic pain corresponds to a unique entity. Each of the painful symptoms may correspond to distinct mechanisms and thus respond to specific treatments.
Le nombre de plus en plus grand des travaux consacrés chaque année à l'étude de la douleur, attestent que ce domaine de recherche
est plus que jamais d'actualité. Cette revue vise à résumer, sans prétendre à l'exhaustivité, les résultats de travaux récents
concernant les aspects fondamentaux, cliniques et thérapeutiques de la douleur, qui nous semblent constituer des avancées
significatives.
The number of works devoted to pain is increasing every year, showing the major interest for pain in the scientific community.
In this review are summarized some recent data that, in our opinion, have significantly contributed to our understanding of
the basic, clinical and therapeutical aspects of pain.
Objectives: To construct a set of instruments to measure the level of impairment in reflex sympathetic dystrophy (RSD), to convert the scores for each instrument into one score and to derive a compounded impairment level sumscore (ISS), and to evaluate reliability, validity, and responsiveness of the ISS.
To determine the prevalence, type of complication, predisposing factors, and treatment for severe complications in a population of reflex sympathetic dystrophy (RSD) patients.
Retrospective analysis of the data from RSD patients collected over a 12-year period, to investigate the involvement of predisposing factors in an RSD population without severe complications compared with an RSD population with severe complications.
Outpatient clinic of a department of surgery of a university hospital.
A total of 1,006 patients with the diagnosis of RSD established according to prospectively defined criteria.
The signs and symptoms of every RSD patient who visited the department were prospectively documented in the medical history; these data were retrospectively analyzed with special regard to RSD with severe complications-infection, ulcers, chronic edema, dystonia, and/or myoclonus-for prevalence, type of complication, and treatment.
Seventy-four RSD patients who were mostly young and female developed severe complications. More than one complication occurred in 91% of the affected extremities. Severe complications developed more frequently in the lower extremity (65%). In patients in whom the acute RSD started with a decreased skin temperature of the affected extremity, severe complications developed significantly more often than in acute RSD patients with a warm skin temperature of the extremity from the onset of the disease (p < .001).
It is important to recognize "cold" RSD immediately at the onset of the disease because this group of RSD patients has a higher risk of developing a severe complication, mostly followed by a severe disability that is resistant to therapy.
Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy is a pain syndrome with an unclear pathophysiology and unpredictable clinical course. The disease is often therapy resistant, the natural course not always favorable. The diagnosis of CRPS is based on signs and symptoms derived from medical history and physical examination. Pharmacological pain management and physical rehabilitation of limb function are the main pillars of therapy and should be started as early as possible. If, however, there is no improvement of limb function and persistent severe pain, interventional pain management techniques may be considered.
Intravenous regional blocks with guanethidine did not prove superior to placebo but frequent side effects occurred.Therefore this technique receives a negative recommendation (2 A–). Sympathetic block is the interventional treatment of first choice and has a 2 B+ rating. Ganglion stellatum (stellate ganglion) block with repeated local anesthetic injections or by radiofrequency denervation after positive diagnostic block is documented in prospective and retrospective trials in patients suffering from upper limb CRPS. Lumbar sympathetic blocks can be performed with repeated local anesthetic injections. For a more prolonged lumbar sympathetic block radiofrequency treatment is preferred over phenol neurolysis because effects are comparable whereas the risk for side effects is lower (2 B+). For patients suffering from CRPS refractory to conventional treatment and sympathetic blocks, plexus brachialis block or continuous epidural infusion analgesia coupled with exercise therapy may be tried (2 C+). Spinal cord stimulation is recommended if other treatments fail to improve pain and dysfunction (2 B+). Alternatively peripheral nerve stimulation can be considered, preferentially in study conditions (2 C+).
Although the term 'reflex sympathetic dystrophy' has been replaced by 'complex regional pain syndrome' (CRPS) type I, there remains a widespread presumption that the sympathetic nervous system is actively involved in mediating chronic neuropathic pain ["sympathetically maintained pain" (SMP)], even in the absence of detectable neuropathophysiology.
We have used microneurography to evaluate possible electrophysiological interactions in 24 patients diagnosed with CRPS I (n=13), or CRPS II (n=11) by simultaneously recording from single identified sympathetic efferent fibers and C nociceptors, while provoking sympathetic neural discharges in cutaneous nerves.
We assessed potential effects of sympathetic activity upon 35 polymodal nociceptors and 19 mechano-insensitive nociceptors, recorded in CRPS I (26 nociceptors) and CRPS II patients (28 nociceptors). No evidence of activation of nociceptors related to sympathetic discharge was found, although nociceptors in six CRPS II patients exhibited unrelated spontaneous pathological nerve impulse activity.
We conclude that activation of nociceptors by sympathetic efferent discharges is not a cardinal pathogenic event in either CRPS I or CRPS II patients.
This study shows that sympathetic-nociceptor interactions, if they exist in patients communicating chronic neuropathic pain, must be the exception.
This narrative review summarizes the evidence derived from randomized controlled trials pertaining to the treatment of complex regional pain syndrome (CRPS).
Using the MEDLINE (January 1950 to April 2009) and EMBASE (January 1980 to April 2009) databases, the following medical subject headings (MeSH) were searched: "Complex Regional Pain Syndrome", "Reflex Sympathetic Dystrophy", and "causalgia" as well as the key words "algodystrophy", "Sudeck's atrophy", "shoulder hand syndrome", "neurodystrophy", "neuroalgodystrophy", "reflex neuromuscular dystrophy", and "posttraumatic dystrophy". Results were limited to randomized controlled trials (RCTs) conducted on human subjects, written in English, published in peer-reviewed journals, and pertinent to treatment.
The search criteria yielded 41 RCTs with a mean of 31.7 subjects per study. Blinded assessment and sample size justification were provided in 70.7% and 19.5% of RCTs, respectively. Only biphosphonates appear to offer clear benefits for patients with CRPS. Improvement has been reported with dimethyl sulfoxide, steroids, epidural clonidine, intrathecal baclofen, spinal cord stimulation, and motor imagery programs, but further trials are required. The available evidence does not support the use of calcitonin, vasodilators, or sympatholytic and neuromodulative intravenous regional blockade. Clear benefits have not been reported with stellate/lumbar sympathetic blocks, mannitol, gabapentin, and physical/occupational therapy.
Published RCTs can only provide limited evidence to formulate recommendations for treatment of CRPS. In this review, no study was excluded based on factors such as sample size justification, statistical power, blinding, definition of intervention allocation, or clinical outcomes. Thus, evidence derived from "weaker" trials may be overemphasized. Further well-designed RCTs are warranted.
Complex regional pain syndrome - in the past called sympathetic reflex dystrophy - is, in its pathophysiology, still not fully understood. However, research in the last few years has led to a better understanding of the illness and the beginning of a pathophysiologically- orientated therapy. The core hypothesis is based on neuropeptide release, neurogenic inflammation and its sympathetic dependence. Therapy should be based on current pathophysiological concepts regarding CRPS and neuropathic pain and could thereby lead to a good outcome of the illness.
This chapter describes complex regional pain syndrome (CRPS) as changes of muscles and bones distant from the primary tissue damage. It causes both acute pain and excitation of the sympathetic nervous system. The chapter classifies CRPS into two clinical types: the “primarily warm” type, which usually develops post-traumatically and in which skin temperature is increased on the affected side; and CRPS cases, which manifest with a cold skin from the beginning. This “primarily cold” type more often develops after minor trauma or even spontaneously. The chapter reviews that “primary cold” CRPS is harder to treat and tends to become chronic. Symptoms of CRPS are not stable; they change and evolve from acute to chronic CRPS stages. In primarily warm CRPS skin temperature becomes cold, edema dwindles, and a trophic sign like increased hair and nail growth normalizes with progression. Cold CRPS, in contrast, appears much more stable. Skin color remains bluish, edema and trophic changes are often less present, and skin temperature may remain cold for years. Nevertheless, sensory and motor symptoms also change in chronic cases. The chapter discusses that treatment of CRPS must have two aims: to relieve pain and hyperalgesia, and to maintain or return function of the affected extremity. To achieve this, treatment has to start as soon as possible.
In December of 1987, the American Association for Hand Surgery (AAHS) organized an ad hoc committee to study reflex sympathetic dystrophy and specifically to make recommendations for a workable clinical definition of the condition
As a result of experience at the Montreal General Hospital, it has been found that intravenous guanethidine blockade of extremities has therapeutic, prophylactic and diagnostic value in conditions where the aetiology is a disorder of sympathetic nervous conduction.
The properties of guanethidine, namely its selective action on blocking the sympathetic nervous system peripherally, together with its long half time and rapid tissue fixation, render it a very useful drug in techniques where an isolated limb is blocked with guanethidine.
Experience on an 18-month basis suggests that the procedure of intravenous guanethidine blockade offers exceptionally good results for a non-invasive technique.
Work is now in progress to study the possible use of guanethidine in the treatment of phantom limb pain, and also to see whether other drugs, such as thymoxamine, could be used in a similar fashion to guanethidine.
The diagnosis of sympathetically maintained pain (SMP) is typically established by assessment of pain relief during local anesthetic blockade of the sympathetic ganglia that innervate the painful body part. To determine if systemic alpha-adrenergic blockade with phentolamine can be used to diagnose SMP, we compared the effects on pain of local anesthetic sympathetic ganglion blocks (LASB) and phentolamine blocks (PhB) in 20 patients with chronic pain and hyperalgesia that were suspected to be sympathetically maintained. The blocks were done in random order on separate days. Patients rated the intensity of ongoing and stimulus-evoked pain every 5 min before, during, and after the LASB and PhB. Patients and the investigator assessing pain levels were blinded to the time of intravenous administration of phentolamine (total dose 25-35 mg). The pain relief achieved by LASB and PhB correlated closely (r = 0.84), and there was no significant difference in the maximum pain relief achieved with the two blocks (t = 0.19, P greater than 0.8). Nine patients experienced a greater than 50% relief of pain and hyperalgesia from both LASB and PhB and were considered to have a clinically significant component of SMP. We conclude that alpha-adrenergic blockade with intravenous phentolamine is a sensitive alternative test to identify patients with SMP.
In some patients, ongoing and evoked neurogenic pain is relieved by pharmacological or destructive block of the sympathetic innervation of the affected part. In others, sympatholysis is ineffective. The present report shows that these two groups of patients can be distinguished by a safe and simple diagnostic test. Individuals in whom the pain was transiently relieved by intravenous phentolamine (Regitine) were very likely to respond favourably to subsequent sympatholytic treatment with i.v. regional guanethidine. Individuals in whom the phentolamine test was negative did not enjoy pain relief from this type of sympatholysis.
This double-blind, randomized study was designed to compare the effectiveness of intravenous regional sympatholysis using guanethidine, reserpine and normal saline. Twenty-one patients with reflex sympathetic dystrophy of an upper or lower extremity were enrolled and received intravenous regional blockade (IVRB) with one of the three medications. There was significant pain relief in all three groups at 30 min. There were no significant differences among the three groups in the degree of pain relief, the number of patients obtaining pain relief in the 30 min after the block, or the number of patients reporting more than 50% pain relief for more than 24 hr. The saline group's high rate of pain relief could be partially due to a mechanism of tourniquet-induced analgesia.
Both regional intravenous guanethidine and reserpine have been reported as effective in the treatment of reflex sympathetic dystrophy. Reserpine depletes storage of norepinephrine, and guanethidine interferes with transport of norepinephrine while depleting storage in the sympathetic nerve terminal. The purpose of this study was to compare drug efficacy in double-blind fashion. Twelve patients, 10 of whom had previous stellate or lumbar sympathetic blocks, were entered into this double-blind cross-over study. Each patient successively received 20 mg guanethidine in 50 ml 0.5% lidocaine, 1.25 mg reserpine in 50 ml 0.5% lidocaine, and 50 ml 0.5% lidocaine with a 1-week interval between medications. At the end of the study and before the code was broken, each patient had the option of continuing treatment with any of the three drugs: the patient merely asked for the first, second, or third drug. Pain assessment used verbal ordinal, numeric, and visual analog scales. Follow-up lasted for a minimum of 6 months. Changes in pain intensity for the first 3 days did not differ significantly among guanethidine, reserpine, and control groups. Pain relief from 2 to 14 months was achieved in two patients receiving reserpine, one receiving guanethidine, and none receiving lidocaine. None of the patients experienced permanent relief. No difference was found between reserpine and guanethidine.
Twenty patients with documented reflex sympathetic dystrophy were treated with a series of regional intravenous guanethidine blocks. The mean delay between the first clinical symptoms and the start of guanethidine blocks was 3.6 months. The overall result was good in 11 patients, moderate in two patients and poor in seven patients. Poor results are due mainly to incorrect diagnosis and to application either too late in the third phase or too early in the first phase when only signs of increased blood flow are part of the symptomatology. Side effects, except pain after the injection, were few and of minor importance. The tolerance of the procedure may be improved by preceding the injection of guanethidine by an injection of a local anaesthetic agent. It may be concluded that with correct diagnosis and indication, guanethidine injections may play an important part in the treatment of reflex sympathetic dystrophy and may replace sympathetic blocks with local anaesthetics because of the longer duration of action and lower incidence of serious side-effects.
We investigated the effects of intravenous regional injection of guanethidine and reserpine in a prospective, randomized, double-blind study of seven volunteers. The sympatholytic activities of these drugs were assessed separately for cholinergic and adrenergic function. Cold challenge was employed to magnify the effect on digital temperatures and alterations in pulse-volume. Only guanethidine significantly increased temperature (p less than 0.025) after cold challenge, this effect lasting for three days. No anticholinergic effect was found. Intravenous regional guanethidine may be useful in the treatment of vasospastic disorders and as prophylaxis for surgically treated patients in whom this complication may be expected to occur.
Guanethidine was infused by the regional intravenous technique into upper and lower limbs of patients with painful hyperpathic states, due to peripheral or central lesions. The relief of pain and hyperpathia occurred within 20 minutes of infusion and lasted between three and 128 hours; in a few patients, the relief has lasted for months. Great reduction in skin conductance and vasodilatation occurred, there being marked variation in the time of onset and duration of these effects. In some cases there was marked pilo-erection. Guanethidine given in this way did not completely block the sympathetic control of digital blood-vessels. There were no effects on sensibility of normally innervated regions.
The first aim was a systematic review of intravenous regional sympathetic blocks (IRSBs) in patients with reflex sympathetic dystrophy (RSD). Randomized controlled trials (RCTs) of IRSBs in patients with RSD were identified by MEDLINE search (1966 to May 1993) and by hand search of 30 journals (1950 to May 1993). Authors of eligible trials were asked for information on additional trials and for unpublished data. Seven RCTs of IRSBs in RSD were found. Four used guanethidine; none showed significant analgesic effect in IRSBs to relieve pain due to RSD. Two reports, one using ketanserin and one bretylium, with 17 patients in total, showed some advantage of IRSBs over control. RCT results were not combined because of the variety of different drugs and outcome measures and because of methodological deficiencies in most of the reports. The second aim was a randomized, double-blind, crossover study to assess the effectiveness of IRSBs with guanethidine. Patients fulfilling diagnostic criteria for RSD and who had reported pain relief after an open IRSB with guanethidine received IRSBs with guanethidine high dose, guanethidine low dose, and normal saline. Pain intensity and relief, adverse effects, mood, duration of analgesia, and global scores were recorded. Sixteen patients with diagnosis of RSD were recruited, but only nine entered the double-blind phase. The trial was stopped prematurely because of the severity of the adverse effects. No significant difference was found between guanethidine and placebo on any of the outcome measures.(ABSTRACT TRUNCATED AT 250 WORDS)