Chronic pain: Other

Physical Examination of the Patient with Neuropathic Pain: Pearls and Pitfalls

This refresher course is intended to provide clinicians and basic scientists interested in practical aspects of neuropathic pain diagnosis with a critical, real-life and evidence-based approach to the challenges in diagnosing and interpreting confirmatory tests for neuropathic pain. Emphasis will be given to practical history taking and physical examination of patients with didactic films, showing manoeuvres and signs that carry high diagnostic value in the differentiation of neuropathic pain from other chronic pain syndromes. Then, neurophysiological tests frequently ordered for these patients such as nerve conduction tests and laser evoked potentials will be explained, their main indications and short-comings will be discussed and real-life examples will be presented. Then practical aspects of skin biopsy will be discussed such as the proper region to perform them, how are result of intra-epidermal nerve fibre density interpreted and contextualized in a patient-centered perspective. At the end, an overview of how data from the clinical encounter, from neurophysiology tests and from nerve fibre counting can help detect potential responders to specific treatment choices based on the current scientific knowledge and recommendations.

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CRPS from Bedside to Bench

CRPS is an uncommon condition. For such reasons, it may be challenging for clinicians to gain experience and knowledge of the condition to provide adequate diagnostic assessment and intervention. These difficulties appear to apply worldwide. CRPS is also a complex condition, and the pathophysiology points to potentially multiple disease mechanisms, further compounding management.
The aim of the refresher course is to re-train course attendees in the clinical presentation of CRPS including the variability in the clinical picture, and to describe the current understanding of CRPS pathophysiology based on the most recent research findings. Finally, the session will teach attendees about current and future therapies, provide some simple tools for the assessment of clinical trials in CRPS, and outline the basic principles of rehabilitative treatment which is almost always needed. The overall aim is to improve diagnosis and treatment of CRPS worldwide.

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Bedside: Demonstration of Variability in Clinical CRPS Presentation and Efforts to Develop Subgroups

CRPS is characterized by a variety in clinical presentation. Both between patients and during the course of the disease within a patient. Traditionally, a distinction is made between CRPS1 and CRPS 2. Clinically, a distinction has also been made between warm and cold CRPS.

An increase in the understanding of the underlying pathophysiology makes it clear that different disease mechanisms may or may not play a role in the individual patient. Mechanisms involved are among others, auto inflammation, central sensitization and neuroplasticity with sensory, motor and autonomic disturbances, endothelial dysfunction and psychological factors. Clinical features aid in phenotyping. This creates the possibility to personalize the therapy. Prof. Huygen will provide guidelines on how to deal with this in daily clinical practice, based on current insights.

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Bench: Recent Advances and Cutting-edge Approaches in our Understanding of the CRPS Pathophysiology

In the last 2-3 years, the immune hypothesis in the development of CRPS has been strengthened. Prof. Birklein will talk about the most important work of his and other research groups on this topic. It could be shown that serum from CRPS patients is less or differently active in the degradation of inflammatory mediators and neuropeptides than serum from healthy individuals. Obviously, trauma seems to be responsible for this finding. It also fits that passive transfer of isolated IgM from patients with acute CRPS and isolated IgG from refractory patients with chronic CRPS sensitizes animals to pain when they have had prior trauma. These effects are mediated mainly by complement factors and cytokines in the spinal cord.

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Return to Function: Evidence and Advances in Functional Rehabilitation

Interdisciplinary functional rehabilitation is acknowledged as the gold standard for the treatment of CRPS. A review of the current evidence will determine what constitutes functional rehabilitation and how effective it is in improving patients outcomes. Recent clinical outcome data will be presented to establish whether there are differences in clinical outcomes between early or persistent CRPS following specialist rehabilitation. The implications of these findings will be discussed in the context of informing future clinical practice. Finally, latest advances in rehabilitation treatment approaches will be discussed  

 

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Neuropathic Pain Assessment in Real Life: From the Bedside to the Lab

This refresher course is intended to provide clinicians and basic scientists interested in practical aspects of neuropathic pain diagnosis with a critical, real-life and evidence-based approach to the challenges in diagnosing and interpreting confirmatory tests for neuropathic pain. Emphasis will be given to practical history taking and physical examination of patients with didactic films, showing manoeuvres and signs that carry high diagnostic value in the differentiation of neuropathic pain from other chronic pain syndromes. Then, neurophysiological tests frequently ordered for these patients such as nerve conduction tests and laser evoked potentials will be explained, their main indications and short-comings will be discussed and real-life examples will be presented. Then practical aspects of skin biopsy will be discussed such as the proper region to perform them, how are result of intra-epidermal nerve fibre density interpreted and contextualized in a patient-centered perspective. At the end, an overview of how data from the clinical encounter, from neurophysiology tests and from nerve fibre counting can help detect potential responders to specific treatment choices based on the current scientific knowledge and recommendations.

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From Lesion to Pain: Pain and Nociception Neurophysiology in a Nutshell

In presentation n° 2 Luis Garcia-Larrea will give a general view of neurophysiology tests commonly used in the diagnostic workout of neuropathic pain such as nerve conduction tests, small-fiber / spinothalamic related evoked potentials, and vegetative reactions. He will follow a practical approach to show what these tests can detect and what they cannot, when they should be used and when they can be omitted, and in particular, which is the profile of patients who will benefit from these confirmatory tests.

Key Insight: Neurophysiological techniques are widely accessible, rapid, inexpensive, and often provide the critical link between probable and definite neuropathic pain. But they are not always necessary, and should be used with discernment. They should always follow a good clinical exam (cf presentation 1) rather than precede it. A thorough understanding of the type of information that can be gathered from such exams, and of the patients who may benefit from them is the gateway to their useful utilization

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A Look at Skin Nerves: When Shall I Order Skin Biopsies and How do they Help to Diagnose Pain?

In this presentation we will highlight the main clinical issues related to skin biopsy. In particular we will discuss when skin biopsy is indicated in patients with pain, and show the basic methodological aspects of this technique, including practical issues regarding how the skin biopsy is performed, and the different immunostaining techniques for skin nerves. In this presentation we will also show recent studies and metanalysis dealing with the diagnostic yield of skin biopsy and provide a critical discussion about the diagnostic accuracy of skin biopsy in patients with small-fibre neuropathy. We will also present the current controversy on the role of small-fibre pathology as assessed with skin biopsy in patients with nociplastic pain; in particular we will show how specific skin biopsy variables might help in distinguishing small-fibre pathology and small-fibre neuropathy.

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Summary of Current Therapies and an Outlook to Trials and Future Treatment Approaches

Management of CRPS is directed by the patient’s clinical presentation and will almost always include rehabilitative approaches and medications; some patients may also benefit from interventional techniques including neuromodulation. No single drug treatment has achieved regulatory approval. Recent well-conducted drug trials were ‘negative’. Based on research advances, novel treatment technologies are emerging in the fields of prevention and rehabilitation, brain stimulation and neuromodulation, and immune drugs. Careful interpretation of efficacy trials for their relevance to clinical practice includes particularly an appreciation of the pertinent CRPS sub-groups.
This workshop-part aims to refresh our understanding of i) current treatment approaches for CRPS as directed by patient presentation, ii) treatments around the corner, ii) the interpretation of treatment-trial results.

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