Gutirrez Wong Viviana Elizabeth 4A

Scientific Articles | October 05, 2011

Therapy-Resistant Complex Regional Pain Syndrome Type I: To Amputate or Not?

Marlies I. Bodde, MD1; Pieter U. Dijkstra, PhD1; Wilfred F.A. den Dunnen, MD, PhD1; Jan H.B. Geertzen, MD, PhD1
1

Center for Rehabilitation, Department of Rehabilitation Medicine (M.I.B., P.U.D., and J.H.B.G.), and Department of Pathology and Medical Biology (W.F.A.d.D, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands. Email address for M.I. Bodde: m.i.bodde@rev.umcg.nl. E-mail address for P.U. Dijkstra: p.u.dijkstra@rev.umcg.nl. E-mail address for W.F.A. den Dunnen: w.f.a.den.dunnen@path.umcg.nl. E-mail address for J.H.B. Geertzen: j.h.b.geertzen@rev.umcg.nl View Disclosures and Other Information The Journal of Bone & Joint Surgery. 2011; 93:1799-1805 doi:10.2106/JBJS.J.01329 Article References text A A

Abstract

Background: Amputation for the treatment of long-standing, therapy-resistant complex regional pain syndrome type I (CRPS-I) is controversial. An evidence-based decision regarding whether or not to amputate is not possible on the basis of current guidelines. The aim of the current study was to systematically review the literature and summarize the beneficial and adverse effects of an amputation for the treatment of long-standing, therapy-resistant CRPS-I. Methods: A literature search, using MeSH terms and free text words, was performed with use of PubMed and EMBASE. Original studies published prior to January 2010 describing CRPSI as a reason for amputation were included. The reference lists of the identified studies were also searched for additional relevant studies. Studies were assessed with regard to

Gutirrez Wong Viviana Elizabeth 4A the criteria used to diagnose CRPS-I, level of amputation, amputation technique, rationale for the level of amputation, reason for amputation, recurrence of CRPS-I after the amputation, phantom pain, prosthesis fitting and use, and patient functional ability, satisfaction, and quality of life.

Results: One hundred and sixty articles were identified, and twenty-six studies with Level-IV evidence (involving 111 amputations in 107 patients) were included. Four studies applied CRPS-I diagnostic criteria proposed by the International Association for the Study of Pain, Bruehl et al., or Veldman et al. Thirteen studies described symptoms without noting whether the patient met diagnostic criteria for CRPS-I, and nine studies stated the diagnosis only. The primary reasons cited for amputation were pain (80%) and a dysfunctional limb (72%). Recurrence of CRPS-I in the stump occurred in thirty-one of sixty-five patients, and phantom pain occurred in fifteen patients. Thirty-six of forty-nine patients were fitted with a prosthesis, and fourteen of these patients used the prosthesis. Thirteen of forty-three patients had paid employment after the amputation. Patient satisfaction was reported in eight studies, but the nature of the satisfaction was often not clearly indicated. Changes in patient quality of life were reported in three studies (fifteen patients); quality of life improved in five patients and the joy of life improved in another six patients.

Conclusions: The previously published studies regarding CRPS-I as a reason for amputation all represent Level-IV evidence, and they do not clearly delineate the beneficial and adverse affects of an amputation performed for this diagnosis. Whether to amputate or not in order to treat long-standing, therapy-resistant CRPS-I remains an unanswered question.

Level of Evidence: Therapeutic Level IV. See instructions to Authors for a complete description of levels of evidence.

1. Choi B, Pak A. A Catalog of Biases in Questionnaires. Preventing Chronic Disease.2005;2:A13. doi: 10.1191/1479972305cd056oa. [PMC free article] [PubMed] [Cross Ref]

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2. Bauman A, Chen XC, Chapman S. Protecting children in cars from tobacco smoke. BMJ.1995;311:1164. [PMC free article] [PubMed] 3. Norman GJ, Ribisl KM, Howard-Pitney B, Howard KA. Smoking bans in the home and car: Do those who really need them have them? Prev Med. 1999;29:581589. doi: 10.1006/pmed.1999.0574. [PubMed] [Cross Ref] 4. Walsh RA, Tzelepis F, Paul CL, McKenzie J. Environmental tobacco smoke in homes, motor vehicles and licensed premises: community attitudes and practices. Aust N Z J Public Health.2002;26:536542. doi: 10.1111/j.1467-842X.2002.tb00363.x. [PubMed] [Cross Ref] 5. Kegler MC, Malcoe LH. Smoking restrictions in the home and car among rural Native American and white families with young children. Prev Med. 2002;35:334342. doi: 10.1006/pmed.2002.1091. [PubMed] [Cross Ref] 6. Binns HJ, O'Neil J, Benuck I, Ariza AJ. Pediatric Practice Research Group. Influences on parents' decisions for home and automobile smoking bans in households with smokers.Patient Educ Couns. 2009;74:272276. doi: 10.1016/j.pec.2008.09.001. [PubMed] [Cross Ref] 7. King G, Mallett R, Kozlowski L, Bendel RB, Nahata S. Personal space smoking restrictions among African Americans. Am J Prev Med. 2005;28:3340. doi: 10.1016/j.amepre.2004.09.025. [PubMed] [Cross Ref] 8. McMillen R, Breen J, Cosby AG. Rural-urban differences in the social climate surrounding environmental tobacco smoke: a report from the 2002 Social Climate Survey of Tobacco Control. J Rural Health. 2004;20:716. doi: 10.1111/j.17480361.2004.tb00002.x. [PubMed][Cross Ref] 9. Gonzales M, Malcoe LH, Kegler MC, Espinoza J. Prevalence and predictors of home and automobile smoking bans and child environmental tobacco smoke exposure: a crosssectional study of U.S.- and Mexico-born Hispanic women with young children. BMC Public Health. 2006;6:265. doi: 10.1186/1471-2458-6-265. [PMC free article] [PubMed] [Cross Ref] 10. Walsh RA, Paul CL, Tzelepis F, Stojanovski E, Tang A. Is government action out-of-step with public opinion on tobacco control? Results of a New South Wales population survey. Aust N Z J Public Health. 2008;32:482488. doi: 10.1111/j.17536405.2008.00284.x. [PubMed][Cross Ref]

Gutirrez Wong Viviana Elizabeth 4A Antecedentes: La Amputacin para el tratamiento de larga duracin, resistente a la terapia regional complejo tipo I sndrome de dolor (SDRC-I) es controversial. Una decisin basada en la evidencia sobre si procede o no que amputar no es posible sobre la base de las directrices actuales. El objetivo de este estudio fue revisar sistemticamente la literatura y resumir los efectos beneficiosos y adversos de una amputacin para el tratamiento de larga duracin, resistentes a la terapia SDRC-I.

Material y mtodos: Una bsqueda en la literatura, utilizando los trminos MeSH y palabras de texto libre, se llev a cabo con el uso de PubMed y EMBASE. Estudios originales publicados antes de enero 2010 que describe SDRC-I como una razn para la amputacin fueron incluidos. Se revisaron Las listas de referencias de los estudios identificados, en busca de artculos adicionales. Los estudios se evaluaron con respecto a los criterios utilizados para diagnosticar SDRC-I, nivel de amputacin, la tcnica de amputacin, la justificacin para el nivel de amputacin, razn por la amputacin, la recurrencia de SDRC-I despus de la amputacin, el dolor fantasma, Colocacin de prtesis y uso, y la capacidad funcional del paciente, la satisfaccin y la calidad de vida.

Resultados: Ciento sesenta Artculos fueron identificados, los veintisis estudios con evidencia de nivel IV (con la participacin 111 amputaciones en 107 pacientes) fueron incluidos. Cuatro estudios aplicaron criterios diagnsticos SDRC-I propuestos por la Asociacin Internacional para el Estudio del Dolor, Bruehl et al., O Veldman et al. En trece estudios se describen los sntomas, sin sealar si el paciente cumpla los criterios diagnsticos para el SDRC-I, y nueve estudios mencionaron solamente el diagnstico. Las principales razones citadas para la amputacin fueron: dolor (80%) y un rgano disfuncional (72%). La recurrencia de SDRC-I en el mun se produjo en treinta y uno de sesenta y cinco pacientes, y el dolor fantasma se produjo en quince pacientes. Treinta y seis de cuarenta y nueve pacientes fueron equipados con una prtesis, y catorce de estos pacientes utilizan la prtesis. Trece de los cuarenta y tres pacientes tenan un trabajo remunerado despus de la amputacin. La satisfaccin del paciente se inform en ocho estudios, pero la naturaleza de

Gutirrez Wong Viviana Elizabeth 4A la satisfaccin con frecuencia no se indica claramente. Cambios en la calidad de vida del paciente se registraron en tres estudios (quince pacientes), la calidad de vida mejor en cinco pacientes y la alegra de vivir mejor en otros seis pacientes.

Conclusiones: Los estudios publicados con anterioridad en relacin con SDRC-I como una razn para la amputacin, todos representaron evidencia de nivel IV, y no delimitaron claramente los efectos beneficiosos y adversos de una amputacin utilizada para este diagnstico. Si amputar o no con el fin de que sea tratamiento de larga duracin, la terapia para resistencia de SDRC-I siguen siendo una pregunta sin respuesta.

Nivel de evidencia: Teraputico Nivel IV.