Summer 2010 - The British Pain Society

More documents

Recommendations

Info

CHANGING PRACTICE Does Vitamin C have a role in the prevention of Complex Regional Pain Syndrome? Dr Michael J.E. Neil Ninewells Hospital Dundee mneil@nhs.net Complex regional pain syndrome (CRPS) is an important and commonly encountered neuropathic condition in the pain clinic. CRPS has a significant associated morbidity and is characterised by spontaneous pain, hypersensitivity, sudomotor dysfunction and functional loss. It can be triggered by potentially any stimulus but is most frequently seen following fracture, dislocation or surgery. The pathophysiology of CRPS is complex and no one intervention has been shown to have consistent and reliable efficacy in its management. In this regard, there has been a lot of work undertaken in recent years aimed at preventing the syndrome developing. Studies have examined many different therapies but unfortunately most have involved only small patient numbers with largely inconclusive results. However, there is some good quality evidence to suggest that vitamin C may have a significant role to play in attenuating the development of CRPS. Vitamin C is a simple water soluble sugar-like molecule that is an essential dietary component. Humans are unable to synthesise vitamin C due to a deficiency in the enzyme L-gulonolactone oxidase required in the last stage of its synthesis. The recommended adult daily intake of vitamin C is 75-90mg per day 1 and is relatively easily achieved as vitamin C is found in plentiful supply in fruit and vegetables. Historically however, deficiency of vitamin C, popularly known as scurvy, carried a significant mortality on long sea-faring voyages and even during land based conflicts as recently as world war one. Clinical characteristics include fatigue, myalgia and arthralgia in minor deficiency progressing to neuropathy, haemorrhage and convulsions in severe cases. Although it is rare to see frank vitamin C deficiency in modern practice, some evidence suggests that up to 30% of the population in North America may have sub-clinical deficiency 1 . Vitamin C is involved in a number of important physiological processes. Vitamin C is well known as an antioxidant that aids in the elimination of reactive oxygen species such as hydroxyl ions. This is important for the protection of capillary endothelium and in decreasing vascular permeability. Victims of polytrauma and severe sepsis, conditions that exert a very high oxidative stress on the body, have been found to have extremely low or absent levels of vitamin C in their plasma at an early stage following their injury 2 . Vitamin C is also a co-factor in at least eight different enzyme processes including collagen hydroxylation, norepinephrine synthesis, tyrosine metabolism and amidation of peptide hormones. Furthermore, animal studies indicate that vitamin C may have an effect on the glutaminergic system, of which the NMDA receptor plays a key role, leading to an anti-nociceptive effect 3 . The pathophysiology of CRPS involves a number of components including a neuroendocrine, inflammatory and sympathetic response. Increased free radical expression has been found to be a feature of CRPS and is associated with altered micro-angiopathic circulation and lipid membrane oxidation 4 . With other studies demonstrating the utility of vitamin C in decreasing membrane permeability and scavenging of free radicals 5 , there does therefore appear to be a rationale for its use in this condition. Evaluation of therapeutic interventions in pain medicine are often hampered by a paucity of good quality evidence from clinical studies. Vitamin C is a rare exception to this in that there have been three good quality randomised controlled trials examining the use of Vitamin C in the prevention of CRPS 6,7,8 . The first of these was published by Zollinger et al in 1999 with a second study by the same group in 2007. This later study was a double blind randomised-controlled, multi-centre study looking at the incidence of CRPS in patients following wrist fracture. Patients were randomised to receive a placebo or 200, 500 or 1500mg of vitamin C starting from the day of fracture for 50 days. 427 patients were enrolled in the study with a total of 317 randomised to receive vitamin C and 99 to receive placebo. The results of the trial were clinically and statistically significant. Using the International Association for the study of Pain (IASP) criteria for establishing the presence of CRPS, they found a total incidence of CRPS in the vitamin C group of 2.4% (8 of 317 patients) and 10.1% (10 of 99 patients) in the placebo group (p value 0.002). Examining differences between the vitamin C treatment groups revealed a prevalence of CRPS of 4.2% in the 200mg group and 1.8% and 1.7% in the 500mg and 1500mg group respectively. This gave a number needed to treat of 12 for the 500mg dose of Vitamin C. The most recent study to examine the role of vitamin C in preventing CRPS was conducted by Besse et al and looked at patients undergoing elective foot and ankle surgery. This study involved 392 patients divided between two groups. The first enrolled 177 patients having elective foot or ankle surgery over a one-year period and were given standard treatment. The second group were enrolled the following year and consisted of 215 patients given 1g of vitamin C from the first post-operative day for 45 days. Results were again significant revealing that patients in Group 1 had a prevalence of CRPS of 9.6% (18 patients) while those in Group 2 showed a prevalence of 1.7% (4 cases) with a p value of 0.0001. Although the results of these studies are persuasive there are a number of potential sources of error. Firstly, criticism of the later study could be directed at the fact that follow up was by case note review and not clinical examination. This raises questions of sensitivity of screening to pick up CRPS and does not include information on pain scoring and sensory testing that would have been helpful. The latter study also did not consider peri-operative anaesthetic management to identify if, for example, a regional technique 5 4 PAI N N E W S S U M M E R 2010
was employed as this may have had a bearing on outcome. Lastly, interpretation in both these studies are restricted by the fact that CRPS is still, overall, an uncommon condition giving wide confidence intervals in any statistical analysis. Nonetheless, these studies do seem to provide compelling evidence to support that vitamin C given in the acute setting can be efficacious in preventing CRPS. Despite the results of these studies, the use of vitamin C has not made its way into common practice. This may be due to poor recognition of the results of these studies or a general scepticism over the use of vitamin C in the clinical setting. This scepticism may be attributable, at least in part, to a hangover effect from the negative publicity that arose from the promotion of ‘mega-dose’ vitamin C in the past. Regardless of the arguments on the scientific basis for this form of therapy is that, even when taken in extremely high doses, vitamin C is a very safe and well tolerated agent. In conclusion CRPS remains a complicated and debilitating condition, that once established, requires multi-modal therapy to manage. The available evidence suggests that supplementary vitamin C may offer a very simple, cheap and safe therapeutic option for helping prevent the onset of this condition in certain circumstances. Further studies to verify these findings and more accurately quantify the benefit gained in terms of pain reduction and sensory disturbance would be helpful. This may give a basis for examining if vitamin C has any role in established CRPS or in the prevention of other post-surgical pain syndromes. Footnote: I would be interested to hear from anyone who uses vitamin C as part of a routine protocol in their peri-operative practice. References 1. Padayatty SJ, Levine M. New insights into the physiology and pharmacology of vitamin C. Canadian Medical Association Journal 2001;164(3):353-355 2. Long CL, Maull KI, Krishnan RS, Laws HL, Geiger BS, Borghese L, Franks W, Lawson TC, Sauberlich HE. Ascorbic acid dynamics in the seriously ill and injured. Journal of Surgical Research 2003; 109:144-148 3. Rosa KA, Gadotti VM, Roas AO, Rodrigues ALS, Calixto JB, Santos AKS. Evidence for the involvement of glutaminergic system in the antinociceptive effect of ascorbic acid. Neuroscience Letters 2005; 381: 185-188 4. Van der Laan L, Ter Laak HJ, Gabreels-Festen A, Gabreels F, Goris RJ. Complex regional pain syndrome type I (RSD): pathology of skeletal muscle and peripheral nerve. Neurology 1998;51(1):20-5 5. Reuben SS. Prventing the development of complex regional pain syndrome after surgery. Anesthesiology 2004; 101:1215-1224 6. Besse J-L, Gadeyne S, Galand- Desme S, Levat J-L, Moyen B. Effect of Vitamin C on prevention of CRPS Type 1 in foot and ankle surgery. Foot and ankle surgery 2009;15: 179-182 7. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fracture? Journal of bone and joint surgery of America 2007; 89:1424-1431. 8. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: a randomised trial. Lancet 1999; 354:2025- 2028 New Members Ratified on 16 April 2010 by The British Pain Society Council Name Position Institution Mrs Sarah Louisa Weaving Acute Pain Team Southampton General Hospital Dr John O'Hanlon Consultant in Anaesthesia and Pain Mater Hospital, Belfast Dr Mohammed Akram Ali St5 Anaesthetics Royal Gwent Hospital Miss Felicity Conrad Staff nurse ITU Glenfield Hospital, Leicester Mr Anand Metha Pst Grad Research Student - Health Norwich University Science Mr Helen Mary Wood Acute Pain Sister Southampton General Hospital Mrs Wendy Hill Specialist OT in Pain Management Queen Elizabeth Hospital, Kings Lynn Ms Jill Fryer Clinical Nurse Specialist Sittingbourne Memorial Hospital, Kent Dr Orla Magee Anaesthesia trainee NHS Northern Ireland Mr Phillip Daniel Austin Osteopath/ Student Work, Stockholm, Sweden / University of Edinburgh Mr Andrew Oliver Clinical Specialist Physiotherapist New Cross Hospital, Wolverhampton Mrs Judith Rafferty Lead Nurse - Pain Services Ninewells Hospital, Dundee Dr Quazi Al Mahud Siddiqui SR in Anaesthetics & Pain Fellow Kent and Sussex Hospital, Tunbridge Wells Ms Deborah McDaid Specialist Nurse Pain Management Great Western Hospital, Swindon Dr Sivanesan Saravanan Locum Consultant Victoria Hospital, Blackpool Dr Karim Shoukrey SPR in Anaesthetics Peterborough Hospital Dr Theresa Knock F2 Anaesthetics Nottingham City Hospital Dr Devjit Srivastava Pain Fellow The Walton Centre Miss Claire Martin Clinical Nurse Specialist James Paget Hospital Dr Norman Kufakwaro SPR Anaesthetics Kent and Cantebury Hospital Dr Shoma Khan Grade 7 Pain Management UCL Pain Management Centre Psychologist Dr Sangeeta Das Anaesthetic Registrar Leeds Teaching Hospital Dr Gautham Srinivasan Advanced Pain trainee Medway Maritime Hospital, Gillingham Mr Christopher Halsey Staff Nurse Jersey General Hospital Dr Muralidhar Thondebhavi Anaesthetic trainee Ipswich Hospital NHS Trust Subbaramaiah Miss Faustina Aikins-Snyper Chronic Pain Nurse Specialist Royal National Orthopeadic Hospital Mrs Sarah Peat Senior Pain Management Formerly at Swindon Pain Clinic Physiotherapist Dr Caroline Davies Consultant in Paediatric Anaesthetics and Acute Pain Guy's and St Thomas' NHS Trust - Evelina Childrens Hospital Dr Seshu Tatikola SPR in Anaesthetics York District Hospital Mrs Shiji Thomas Staff Nurse, Chronic Pain unit Wythenshawe Hospital Dr David Beard Advanced Pain trainee Western General Hospital, Edinburgh Dr Andrew Lloyd Consultant Anaesthetist James Cook University Hospital Dr Vishal Aggarwal NIHR Clinician Scientist University of Manchester Dr Balajj Velayudam Anaesthetics Wirral University Teaching Hospital Dr Vijay Bandikatla Anaesthetics Queen Elizabeth Hospital, Kings Lynn Dr John Francis Consultant in Anaesthetics and Pain University Hospital of North Tees Management Dr Maliha Shaika Clinical Research Fellow Addenbrooke's Hospital Asst Prof Aatit Payngmali Lecturer in Physiotherapy Chaing Mai University Dr Patrick Schweder Fellow - neurosurgery John Radcliffe Hospital Miss Brenda Kosamu Nurse Kamuchanga District Hospital Dr Juliane Goeke-Glatzel Anaesthetics Pennine Acute Hospitals Trust Dr Anish Bahra Consultant Neurologist National Hospital for Neurology, University College NHS Fdn Dr Arumachalam Consultant Pennine Acute Hospitals Trust Swayamprakasam Mrs Joanne Jones Pain Clinic Staff Nurse Wirral Hospital NHS Trust Dr Ben Huntley Anaesthetics Gloucestershire Hospitals NHS Trust Dr Michelle Siobhan Conn Clinical Psychologist Frimley Park Hospital Dr Andrea Magides Consultant Anaesthetist South Devon Healthcare Trrust PAI N N E W S S P R I N G 2010 55
Page 1 and 2:
s u m m e r 2 0 1 0 pain news a pub
Page 3 and 4: 12 5 8 PAI N N E W S S U M M E R 20
Page 5 and 6: ecame squalid and violent. Opium wa
Page 7 and 8: is the National Pain Audit (http://
Page 9 and 10: The first licenced intranasal Fenta
Page 11 and 12: Breakthrough Cancer Pain (BTcP)* Fa
Page 13 and 14: PAI N N E W S S U M M E R 2010 13
Page 15 and 16: NEWS - ASM 2010 Citation for Profes
Page 17 and 18: NEWS - ASM 2010 NEWS - ASM 2010 A p
Page 19 and 20: Internationally the SIG is active w
Page 21 and 22: PAI N N E W S S U M M E R 2010 21
Page 23 and 24: Pain controlled Constipation restra
Page 25 and 26: will also be expected to produce an
Page 27 and 28: NEWS Napp Awards for Chronic Pain M
Page 29 and 30: i SAFE USE OF PAINKILLERS • When
Page 31 and 32: MultiGen RF Nerve Ablation Save Tim
Page 33 and 34: ® (tramadol) ONCE DAILY AT BEDTIME
Page 35 and 36: PRO-Diary® by A new electronic wri
Page 37 and 38: that is completely counter intuitiv
Page 39 and 40: advice in uncertain or complex case
Page 41 and 42: to carry out any treatment that a p
Page 43 and 44: I have to say that I can see no 'go
Page 45 and 46: PROFESSIONAL PERSPECTIVES Teaching
Page 47 and 48: Past Medical History This pain prob
Page 49 and 50: and “like having a blow torch on
Page 51 and 52: world, apart from someone who is ca
Page 53: the possession of narcotics. She pl
Page 57 and 58: the catastrophisation. Another inte
Page 59 and 60: BOOK REVIEW Oral feeding difficulti
Page 61 and 62: 3 studies ( n=25,34,56) looked at t
Page 63 and 64: R E S E A R C H & D E V E L O P M E
show all

Summer 2010 - The British Pain Society

Create successful ePaper yourself

Delete template?

Save as template?