BACKGROUND: Lidocaine, mexiletine, tocainide, and flecainide are local anesthetics which give an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain. Interest reappeared decades later when patient series and clinical trials reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients. With the recent publication of clinical trials with high quality standards, we have reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to update our knowledge, to measure their benefit and harm, and to better define their role in therapy.
OBJECTIVES: To evaluate pain relief and adverse effect rates between systemic local anesthetic-type drugs and other control interventions.
SEARCH METHODS: We searched MEDLINE (1966 through 15 May 2004), EMBASE (January 1980 to December 2002), Cancer Lit (through 15 December 2002), Cochrane Central Register of Controlled Trials (2nd Quarter, 2004), System for Information on Grey Literature in Europe (SIGLE), and LILACS, from January 1966 through March 2001. We also hand searched conference proceedings, textbooks, original articles and reviews.
SELECTION CRITERIA: We included trials with random allocation, that were double blinded, with a parallel or crossover design. The control intervention was a placebo or an analgesic drug for neuropathic pain from any cause.
DATA COLLECTION AND ANALYSIS: We collected efficacy and safety data from all published and unpublished trials. We calculated combined effect sizes using continuous and binary data for pain relief and adverse effects as primary and secondary outcome measurements, respectively.
MAIN RESULTS: Thirty-two controlled clinical trials met the selection criteria; two were duplicate articles. The treatment drugs were intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (one trial), and tocainide (one trial). Twenty-one trials were crossover studies, and nine were parallel. Lidocaine and mexiletine were superior to placebo [weighted mean difference (WMD) = -11; 95% CI: -15 to -7; P < 0.00001], and limited data showed no difference in efficacy (WMD = -0.6; 95% CI: -7 to 6), or adverse effects versus carbamazepine, amantadine, gabapentin or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life-threatening toxicities. Sensitivity analysis identified data distribution in three trials as a probable source of heterogeneity. There was no publication bias.
AUTHORS' CONCLUSIONS: Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. Future trials should enroll specific diseases and test novel lidocaine analogs with better toxicity profiles. More emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful.
BACKGROUND: This is an updated version of the original Cochrane Review published in 2010, Issue 9, and last updated in 2014, Issue 4. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS) and reduced impedance non-invasive cortical electrostimulation (RINCE).
OBJECTIVES: To evaluate the efficacy of non-invasive cortical stimulation techniques in the treatment of chronic pain.
SEARCH METHODS: For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, LILACS and clinical trials registers from July 2013 to October 2017.
SELECTION CRITERIA: Randomised and quasi-randomised studies of rTMS, CES, tDCS, RINCE and tRNS if they employed a sham stimulation control group, recruited patients over the age of 18 years with pain of three months' duration or more, and measured pain as an outcome. Outcomes of interest were pain intensity measured using visual analogue scales or numerical rating scales, disability, quality of life and adverse events.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted and verified data. Where possible we entered data into meta-analyses, excluding studies judged as high risk of bias. We used the GRADE system to assess the quality of evidence for core comparisons, and created three 'Summary of findings' tables.
MAIN RESULTS: We included an additional 38 trials (involving 1225 randomised participants) in this update, making a total of 94 trials in the review (involving 2983 randomised participants). This update included a total of 42 rTMS studies, 11 CES, 36 tDCS, two RINCE and two tRNS. One study evaluated both rTMS and tDCS. We judged only four studies as low risk of bias across all key criteria. Using the GRADE criteria we judged the quality of evidence for each outcome, and for all comparisons as low or very low; in large part this was due to issues of blinding and of precision.rTMSMeta-analysis of rTMS studies versus sham for pain intensity at short-term follow-up (0 to < 1 week postintervention), (27 studies, involving 655 participants), demonstrated a small effect with heterogeneity (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.29 to -0.16, low-quality evidence). This equates to a 7% (95% CI 5% to 9%) reduction in pain, or a 0.40 (95% CI 0.53 to 0.32) point reduction on a 0 to 10 pain intensity scale, which does not meet the minimum clinically important difference threshold of 15% or greater. Pre-specified subgroup analyses did not find a difference between low-frequency stimulation (low-quality evidence) and rTMS applied to the prefrontal cortex compared to sham for reducing pain intensity at short-term follow-up (very low-quality evidence). High-frequency stimulation of the motor cortex in single-dose studies was associated with a small short-term reduction in pain intensity at short-term follow-up (low-quality evidence, pooled n = 249, SMD -0.38 95% CI -0.49 to -0.27). This equates to a 12% (95% CI 9% to 16%) reduction in pain, or a 0.77 (95% CI 0.55 to 0.99) point change on a 0 to 10 pain intensity scale, which does not achieve the minimum clinically important difference threshold of 15% or greater. The results from multiple-dose studies were heterogeneous and there was no evidence of an effect in this subgroup (very low-quality evidence). We did not find evidence that rTMS improved disability. Meta-analysis of studies of rTMS versus sham for quality of life (measured using the Fibromyalgia Impact Questionnaire (FIQ) at short-term follow-up demonstrated a positive effect (MD -10.80 95% CI -15.04 to -6.55, low-quality evidence).CESFor CES (five studies, 270 participants) we found no evidence of a difference between active stimulation and sham (SMD -0.24, 95% CI -0.48 to 0.01, low-quality evidence) for pain intensity. We found no evidence relating to the effectiveness of CES on disability. One study (36 participants) of CES versus sham for quality of life (measured using the FIQ) at short-term follow-up demonstrated a positive effect (MD -25.05 95% CI -37.82 to -12.28, very low-quality evidence).tDCSAnalysis of tDCS studies (27 studies, 747 participants) showed heterogeneity and a difference between active and sham stimulation (SMD -0.43 95% CI -0.63 to -0.22, very low-quality evidence) for pain intensity. This equates to a reduction of 0.82 (95% CI 0.42 to 1.2) points, or a percentage change of 17% (95% CI 9% to 25%) of the control group outcome. This point estimate meets our threshold for a minimum clinically important difference, though the lower confidence interval is substantially below that threshold. We found evidence of small study bias in the tDCS analyses. We did not find evidence that tDCS improved disability. Meta-analysis of studies of tDCS versus sham for quality of life (measured using different scales across studies) at short-term follow-up demonstrated a positive effect (SMD 0.66 95% CI 0.21 to 1.11, low-quality evidence).Adverse eventsAll forms of non-invasive brain stimulation and sham stimulation appear to be frequently associated with minor or transient side effects and there were two reported incidences of seizure, both related to the active rTMS intervention in the included studies. However many studies did not adequately report adverse events.
AUTHORS' CONCLUSIONS: There is very low-quality evidence that single doses of high-frequency rTMS of the motor cortex and tDCS may have short-term effects on chronic pain and quality of life but multiple sources of bias exist that may have influenced the observed effects. We did not find evidence that low-frequency rTMS, rTMS applied to the dorsolateral prefrontal cortex and CES are effective for reducing pain intensity in chronic pain. The broad conclusions of this review have not changed substantially for this update. There remains a need for substantially larger, rigorously designed studies, particularly of longer courses of stimulation. Future evidence may substantially impact upon the presented results.
BACKGROUND: Gabapentin is commonly used to treat neuropathic pain (pain due to nerve damage). This review updates a review published in 2014, and previous reviews published in 2011, 2005 and 2000.
OBJECTIVES: To assess the analgesic efficacy and adverse effects of gabapentin in chronic neuropathic pain in adults.
SEARCH METHODS: For this update we searched CENTRAL), MEDLINE, and Embase for randomised controlled trials from January 2014 to January 2017. We also searched the reference lists of retrieved studies and reviews, and online clinical trials registries.
SELECTION CRITERIA: We included randomised, double-blind trials of two weeks' duration or longer, comparing gabapentin (any route of administration) with placebo or another active treatment for neuropathic pain, with participant-reported pain assessment.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed trial quality and potential bias. Primary outcomes were participants with substantial pain relief (at least 50% pain relief over baseline or very much improved on Patient Global Impression of Change scale (PGIC)), or moderate pain relief (at least 30% pain relief over baseline or much or very much improved on PGIC). We performed a pooled analysis for any substantial or moderate benefit. Where pooled analysis was possible, we used dichotomous data to calculate risk ratio (RR) and number needed to treat for an additional beneficial outcome (NNT) or harmful outcome (NNH). We assessed the quality of the evidence using GRADE and created 'Summary of findings' tables.
MAIN RESULTS: We included four new studies (530 participants), and excluded three previously included studies (126 participants). In all, 37 studies provided information on 5914 participants. Most studies used oral gabapentin or gabapentin encarbil at doses of 1200 mg or more daily in different neuropathic pain conditions, predominantly postherpetic neuralgia and painful diabetic neuropathy. Study duration was typically four to 12 weeks. Not all studies reported important outcomes of interest. High risk of bias occurred mainly due to small size (especially in cross-over studies), and handling of data after study withdrawal.In postherpetic neuralgia, more participants (32%) had substantial benefit (at least 50% pain relief or PGIC very much improved) with gabapentin at 1200 mg daily or greater than with placebo (17%) (RR 1.8 (95% CI 1.5 to 2.1); NNT 6.7 (5.4 to 8.7); 8 studies, 2260 participants, moderate-quality evidence). More participants (46%) had moderate benefit (at least 30% pain relief or PGIC much or very much improved) with gabapentin at 1200 mg daily or greater than with placebo (25%) (RR 1.8 (95% CI 1.6 to 2.0); NNT 4.8 (4.1 to 6.0); 8 studies, 2260 participants, moderate-quality evidence).In painful diabetic neuropathy, more participants (38%) had substantial benefit (at least 50% pain relief or PGIC very much improved) with gabapentin at 1200 mg daily or greater than with placebo (21%) (RR 1.9 (95% CI 1.5 to 2.3); NNT 5.9 (4.6 to 8.3); 6 studies, 1277 participants, moderate-quality evidence). More participants (52%) had moderate benefit (at least 30% pain relief or PGIC much or very much improved) with gabapentin at 1200 mg daily or greater than with placebo (37%) (RR 1.4 (95% CI 1.3 to 1.6); NNT 6.6 (4.9 to 9.9); 7 studies, 1439 participants, moderate-quality evidence).For all conditions combined, adverse event withdrawals were more common with gabapentin (11%) than with placebo (8.2%) (RR 1.4 (95% CI 1.1 to 1.7); NNH 30 (20 to 65); 22 studies, 4346 participants, high-quality evidence). Serious adverse events were no more common with gabapentin (3.2%) than with placebo (2.8%) (RR 1.2 (95% CI 0.8 to 1.7); 19 studies, 3948 participants, moderate-quality evidence); there were eight deaths (very low-quality evidence). Participants experiencing at least one adverse event were more common with gabapentin (63%) than with placebo (49%) (RR 1.3 (95% CI 1.2 to 1.4); NNH 7.5 (6.1 to 9.6); 18 studies, 4279 participants, moderate-quality evidence). Individual adverse events occurred significantly more often with gabapentin. Participants taking gabapentin experienced dizziness (19%), somnolence (14%), peripheral oedema (7%), and gait disturbance (14%).
AUTHORS' CONCLUSIONS: Gabapentin at doses of 1800 mg to 3600 mg daily (1200 mg to 3600 mg gabapentin encarbil) can provide good levels of pain relief to some people with postherpetic neuralgia and peripheral diabetic neuropathy. Evidence for other types of neuropathic pain is very limited. The outcome of at least 50% pain intensity reduction is regarded as a useful outcome of treatment by patients, and the achievement of this degree of pain relief is associated with important beneficial effects on sleep interference, fatigue, and depression, as well as quality of life, function, and work. Around 3 or 4 out of 10 participants achieved this degree of pain relief with gabapentin, compared with 1 or 2 out of 10 for placebo. Over half of those treated with gabapentin will not have worthwhile pain relief but may experience adverse events. Conclusions have not changed since the previous update of this review.
BACKGROUND: This review is an update of a previously published review in the Cochrane Database of Systematic Reviews, 2005, Issue 4 (and last updated in the Cochrane Database of Systematic Reviews, 2013 issue 8), on local anaesthetic blockade (LASB) of the sympathetic chain to treat people with complex regional pain syndrome (CRPS).
OBJECTIVES: To assess the efficacy of LASB for the treatment of pain in CRPS and to evaluate the incidence of adverse effects of the procedure.
SEARCH METHODS: For this update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 9), MEDLINE (Ovid), EMBASE (Ovid), LILACS (Birme), conference abstracts of the World Congresses of the International Association for the Study of Pain, and various clinical trial registers up to September 2015. We also searched bibliographies from retrieved articles for additional studies.
SELECTION CRITERIA: We considered randomised controlled trials (RCTs) that evaluated the effect of sympathetic blockade with local anaesthetics in children or adults with CRPS compared to placebo, no treatment, or alternative treatments.
DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. The outcomes of interest were reduction in pain intensity, the proportion who achieved moderate or substantial pain relief, the duration of pain relief, and the presence of adverse effects in each treatment arm. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created a 'Summary of findings' table.
MAIN RESULTS: We included an additional four studies (N = 154) in this update. For this update, we excluded studies that did not follow up patients for more than 48 hours. As a result, we excluded four studies from the previous review in this update. Overall we included 12 studies (N = 461), all of which we judged to be at high or unclear risk of bias. Overall, the quality of evidence was low to very low, downgraded due to limitations, inconsistency, imprecision, indirectness, or a combination of these.Two small studies compared LASB to placebo/sham (N = 32). They did not demonstrate significant short-term benefit for LASB for pain intensity (moderate quality evidence).One small study (N = 36) at high risk of bias compared thoracic sympathetic block with corticosteroid and local anaesthetic versus injection of the same agents into the subcutaneous space, reporting statistically significant and clinically important differences in pain intensity at one-year follow-up but not at short term follow-up (very low quality evidence).Of two studies that investigated LASB as an addition to rehabilitation treatment, the only study that reported pain outcomes demonstrated no additional benefit from LASB (very low quality evidence).Eight small randomised studies compared sympathetic blockade to various other active interventions. Most studies found no difference in pain outcomes between sympathetic block versus other active treatments (low to very low quality evidence).One small study compared ultrasound-guided LASB with non-guided LASB and found no clinically important difference in pain outcomes (very low quality evidence).Six studies reported adverse events, all with minor effects reported.
AUTHORS' CONCLUSIONS: This update's results are similar to the previous versions of this systematic review, and the main conclusions are unchanged. There remains a scarcity of published evidence and a lack of high quality evidence to support or refute the use of local anaesthetic sympathetic blockade for CRPS. From the existing evidence, it is not possible to draw firm conclusions regarding the efficacy or safety of this intervention, but the limited data available do not suggest that LASB is effective for reducing pain in CRPS.
HINTERGRUND: Diese Bewertung ist ein Update von einer Bewertung zuerst in Heft 2, 2003, die im Wesentlichen in Ausgabe 7 aktualisiert wurde 2010 veröffentlicht. Das Konzept, dass viele neuropathischen Schmerzsyndromen (traditionell diese Definition würde eine komplexe regionale Schmerzsyndrome (CRPS) gehören) "liebevoll gepflegt Schmerzen" sind seit jeher um Behandlungen, die das sympathische Nervensystem unterbrechen geführt. Chemische Sympathektomien Alkohol oder Phenol-Injektionen zu Ganglien des sympathischen Kette zu zerstören, während chirurgischen Ablation durch offene Entfernung oder Elektrokoagulation des sympathischen Kette oder durch minimal-invasive Verfahren mittels thermischer oder Laser Unterbrechung durchgeführt wird.
ZIELE: Um die Evidenz aus randomisierten, doppelblinden, kontrollierten Studien zur Wirksamkeit und Sicherheit von chemischen und chirurgischen Sympathektomie bei neuropathischen Schmerzen, einschließlich komplexen regionalen Schmerzsyndrom überprüfen. Sympathektomie mit Placebo (Schein-) oder anderen aktiven Behandlung verglichen werden kann, vorausgesetzt, beide Teilnehmer und Ergebnis Beisitzer sind blind für Behandlungsgruppe Zuteilung.
Suchmethoden: Am 2. Juli 2013 suchten wir CENTRAL, MEDLINE, EMBASE und die Oxford Pain Relief Database. Wir haben die Bibliographien aller randomisierten Studien identifiziert und von Übersichtsarbeiten und auch nach zwei klinischen Studie Datenbanken ClinicalTrials.gov und der internationalen WHO Clinical Trials Registry Platform, um zusätzliche veröffentlichten und unveröffentlichten Daten zu identifizieren. Wir gescreent Referenzen in den gefundenen Artikel und Literatur Bewertungen und kontaktiert Experten auf dem Gebiet des neuropathischen Schmerzes.
Auswahlkriterien: Randomisierte, doppelblinde, Placebo-kontrollierte Studien oder aktive Beurteilung der Auswirkungen der Sympathektomie bei neuropathischen Schmerzen und CRPS.
Datensammlung und-analyse: Zwei Rezension Autoren unabhängig voneinander die Studienqualität und Gültigkeit bewertet und extrahierten Daten. Kein gepoolten Analyse der Daten möglich war.
MAIN ERGEBNISSE: Nur eine Studie zufrieden unsere Einschlusskriterien, Vergleich perkutane Radiofrequenz thermische Lumbalsympathektomie mit lumbalen sympathischen Neurolyse mit Phenol in 20 Teilnehmer mit CRPS. Es war kein Vergleich gegenüber Sympathektomie Schein oder Placebo. Keine Schmerzen dichotome Ergebnisse gemeldet wurden. Durchschnittliche Baseline-Werte von 8-9/10 auf mehreren Schmerzskalen fiel auf etwa 4/10 zunächst (1 Tag) und blieb bei 3-5/10 über vier Monate. Es gab keine signifikanten Unterschiede zwischen den Gruppen, mit Ausnahme von "unangenehmes Gefühl", die höher mit Radiofrequenz-Ablation war. Ein Teilnehmer in der Gruppe Phenol erfahrenen Beitrag Sympathektomie Neuralgie, während zwei in der Radiofrequenz-Gruppe und einer in der Phenol-Gruppe klagte über Parästhesien während Nadelpositionierung. Alle Teilnehmer hatten Schmerzen an der Injektionsstelle.
Schlussfolgerungen der Autoren: Die Praxis der chirurgischen und chemischen Sympathektomie bei neuropathischen Schmerzen und CRPS ist auf sehr wenig hochwertige Evidenz. Sympathektomie sollte vorsichtig in der klinischen Praxis verwendet werden, in sorgfältig ausgewählten Patienten und wahrscheinlich erst nach Versagen anderer Behandlungsmöglichkeiten. Unter diesen Umständen kann zur Schaffung eines klinischen Registers der Sympathektomie helfen, Behandlungsmöglichkeiten auf jeden einzelnen Patienten zu informieren.
Zeitung»International journal of rehabilitation research. Internationale Zeitschrift für Rehabilitationsforschung. Revue internationale de recherches de réadaptation
Das Ziel dieser Studie war es, die klinischen Aspekte der Spiegel-Therapie (MT) Interventionen nach Schlaganfall, Phantomschmerzen und komplexen regionalen Schmerzsyndrom bewerten. Eine systematische Literaturrecherche der Cochrane Database of kontrollierten Studien wurde PubMed / Medline, CINAHL, EMBASE, PsycINFO, Pedro RehabTrials-und Rehadat, die von zwei Forschern unabhängig (ASR und MJ) gemacht. Keine Einschränkungen wurden hinsichtlich Studiendesign und Art oder Lokalisation des Schlaganfalls, komplexes regionales Schmerzsyndrom und Amputation. Nur Studien, die MT als Langzeit-Behandlung hatte wurden eingeschlossen. Zwei Autoren (ASR und SMB) unabhängig beurteilt Studien für die Förderfähigkeit und Bias-Risiko mit dem Amsterdam-Maastricht Consensus Liste. Zehn randomisierte Studien, sieben Patienten-Serie und vier Single-Fallstudien wurden eingeschlossen. Die Studien waren heterogen in Bezug auf Design, Größe, studierte Bedingungen und die Ergebnisse Maßnahmen. Methodische Qualität vielfältig, nur wenige Studien waren von hoher Qualität. Wichtige klinische Aspekte, wie beispielsweise der Beurteilung der möglichen Nebenwirkungen waren nur unzureichend angesprochen. Für Hub gibt es eine moderate Qualität der Beweise dafür, dass MT als zusätzliche Intervention Erholung der Arm-Funktion und eine niedrige Qualität der Evidenz bezüglich der unteren Extremität Funktion und Schmerz nach Schlaganfall verbessert. Die Qualität der Evidenz bei Patienten mit komplexen regionalen Schmerzsyndrom und Phantomschmerzen ist ebenfalls gering. Konkrete Schlussfolgerungen konnte nicht erstellt werden. Wenig ist bekannt über die Patienten wahrscheinlich am meisten von MT profitieren, und wie MT sollte vorzugsweise angewendet werden. Zukünftige Studien mit klaren Beschreibungen der Intervention Protokolle sollten auf standardisierten Ergebnis Maßnahmen zu konzentrieren und systematisch registrieren Nebenwirkungen.
Ziel: Die N-Methyl-D-Aspartat (NMDA)-Rezeptor als ein primäres Ziel für die Behandlung von neuropathischen Schmerzen vorgeschlagen worden. Das Ziel der vorliegenden Studie war es, eine Meta-Analyse Evaluierung der Auswirkungen der (individuellen) NMDA-Rezeptor-Antagonisten auf neuropathische Schmerzen, und die Antwort (Empfindlichkeit) von einzelnen Erkrankungen zu neuropathischen Schmerzen NMDA-Rezeptor-Antagonisten-Therapie durchzuführen.
DESIGN: PubMed (MEDLINE ua), EMBASE und CENTRAL wurden bis 26. Oktober 2009 für randomisierten, placebokontrollierten Studien (RCT) auf neuropathische Schmerzen gesucht. Die methodische Qualität der eingeschlossenen Studien wurde unabhängig voneinander von zwei Autoren mit dem Delphi-Liste bewertet. Feste oder zufällige Effekte Modell verwendet wurden, um die Zusammenfassung Effektgröße mit Hedges 'g zu berechnen.
EINSTELLUNG: NA.
PATIENTEN: Die Patienten für die Studie verwendet wurden, waren Patienten, neuropathische Schmerzen.
Interventionen: Die Eingriffe verwendet wurden, waren NMDA-Rezeptorantagonisten.
Outcome-Messungen: Das Ergebnis der Messungen war die Reduktion der spontanen Schmerzen.
ERGEBNISSE: Achtundzwanzig Studien wurden einbezogen, die den Einschlusskriterien. Zusammenfassung Effektstärken wurden für Untergruppen von Studien, die Ketamin-IV in komplexen regionalen Schmerzsyndrom (CRPS), orale Memantin in postherptic Neuralgie, beziehungsweise Ketamin IV und orale Memantin in postamputation Schmerzen berechnet. Die Behandlung mit Ketamin deutlich reduziert Schmerzen in postamputation Schmerzen (gepoolte Zusammenfassung Effekt Größe: -1,18 [Konfidenzintervall (CI) 95% -1,98, -0,37], p = 0,004). Kein signifikanter Effekt auf Schmerzreduktion konnte für Ketamin IV bei CRPS etabliert (-0,65 [95% CI -1,47, 0,16], p = 0,11) in oraler Memantin postherptic Neuralgie (0,03 [CI 95% -0,51, 0,56], P = werden 0,92) und für die orale Memantin in postamputation Schmerzen (0,38 [CI 95% -0,21, 0,98], P = 0,21).
Schlussfolgerung: Auf der Grundlage dieser systematischen Überprüfung, noch keine Schlüsse über die Wirksamkeit von NMDA-Rezeptor-Antagonisten auf neuropathische Schmerzen gemacht werden. Zusätzliche RCTs in homogenen Gruppen von Schmerzpatienten sind erforderlich, um das therapeutische Potenzial von NMDA-Rezeptor-Antagonisten bei neuropathischen Schmerzen zu erkunden.
ZWECK: Diese Erzählung Beitrag fasst die Ergebnisse aus randomisierten kontrollierten Studien im Zusammenhang mit der Behandlung des komplexen regionalen Schmerzsyndrom (CRPS) abgeleitet.
QUELLE: Mit der MEDLINE (Januar 1950 bis April 2009) und EMBASE (Januar 1980 bis April 2009) Datenbanken wurden folgende Medical Subject Headings (MeSH) gesucht: "Complex Regional Pain Syndrome", "sympathische Reflexdystrophie", und "Kausalgie "sowie die Schlüsselworte" Algodystrophie "," Morbus Sudeck "," Schulter-Hand-Syndrom "," neurodystrophy "," neuroalgodystrophy "," Reflex neuromuskuläre Dystrophie ", und" posttraumatische Dystrophie ". Die Ergebnisse wurden auf randomisierte kontrollierte Studien (RCT) am Menschen, in englischer Sprache verfasst, in begutachteten Fachzeitschriften veröffentlicht und einschlägige auf die Behandlung durchgeführt begrenzt.
Wichtigste Ergebnisse: Die Suchkriterien ergaben 41 RCTs mit einem Mittelwert von 31,7 Patienten pro Studie. Verblindete und Stichprobengröße Rechtfertigung wurden in 70,7% und 19,5% der RCTs vorgesehen. Nur Bisphosphonate scheinen klare Vorteile für Patienten mit CRPS bieten. Verbesserung wurde mit Dimethylsulfoxid, Steroiden, epidurale Clonidin, intrathekale Baclofen, Spinal Cord Stimulation, und Bewegungsvorstellung Programme berichtet worden, aber weitere Studien erforderlich sind. Die verfügbaren Daten nicht unterstützt die Verwendung von Calcitonin, Vasodilatatoren oder Sympatholytika und neuromodulative intravenöse regionale Blockade. Klare Vorteile sind nicht mit sternförmigen / lumbalen sympathischen Blöcke, Mannit, Gabapentin, und körperliche / Ergotherapie berichtet worden.
FAZIT: Veröffentlicht RCTs können nur einen begrenzten Beweise, um Empfehlungen für die Behandlung des CRPS zu formulieren. Bei dieser Überprüfung wurde keine Studie basierend auf Faktoren wie die Stichprobengröße Rechtfertigung, statistische Power, Verblindung, Definition der Intervention Zuteilung oder klinische Ergebnisse ausgeschlossen. So können Erkenntnisse aus "schwächeren" Studien abgeleitet überbetont werden. Weitere gut konzipierte RCTs gerechtfertigt sind.
ZIELE: In mehreren Studien festgestellt, dass Bisphosphonate lokal erhöhter Knochenresorption und die damit verbundenen Schmerzen entgegen zu wirken bei Patienten mit komplexen regionalen Schmerzsyndrom I (CRPS I). Wir führten eine systematische Überprüfung aller randomisierten kontrollierten Studien, um den Nutzen von Bisphosphonaten bei der Behandlung von Patienten mit CRPS I Knochenverlust zu beurteilen.
DATENQUELLEN: Wir suchten Medline, Embase (April 2007) und der Cochrane Library und geschirmte Bibliographien der eingeschlossenen Studien.
Review-Verfahren: Wir haben uns für randomisierte Studien zum Vergleich Bisphosphonate mit Placebo, mit dem Ziel der Verbesserung der Schmerzen, Funktion und Lebensqualität bei Patienten mit CRPS I. zwei Gutachter unabhängig Versuch Förder-und Qualitätskriterien beurteilt, und extrahierten Daten. Wo Daten unvollständig oder unklar waren, wurden Konflikte mit Diskussion und / oder Gerichtsverfahren Autoren aufgelöst wurden für weitere Details kontaktiert. Wir berechneten die Studie gewichtet zusammengefasst bedeutet Reduktion der Schmerzintensität (gemessen mit einer visuellen Analogskala (VAS)).
ERGEBNISSE: Vier Studien mit mäßiger Qualität erfüllt unsere Einschlusskriterien. In Bezug auf Funktion und der Lebensqualität gab es einen Trend zugunsten der Bisphosphonate, aber Unterschiede in der Beurteilung Ergebnis behindert die Bündelung der Ergebnisse. Zwei Studien haben ausreichende Daten zu bündeln Schmerz Ergebnisse. Bisphosphonate verringert Schmerzintensität von 22,4 und 21,6 mm auf einer VAS nach 4 und 12 Wochen Follow-up. Die Daten über unerwünschte Wirkungen waren knapp.
FAZIT: Die sehr begrenzte Daten zeigten, dass Bisphosphonate bewertet das Potenzial, Schmerzen im Zusammenhang mit Knochenschwund bei Patienten mit CRPS I jedoch zu reduzieren haben, gibt es derzeit keine ausreichenden Beweise für ihre Verwendung in der Praxis zu empfehlen.
Lidocaine, mexiletine, tocainide, and flecainide are local anesthetics which give an analgesic effect when administered orally or parenterally. Early reports described the use of intravenous lidocaine or procaine to relieve cancer and postoperative pain. Interest reappeared decades later when patient series and clinical trials reported that parenteral lidocaine and its oral analogs tocainide, mexiletine, and flecainide relieved neuropathic pain in some patients. With the recent publication of clinical trials with high quality standards, we have reviewed the use of systemic lidocaine and its oral analogs in neuropathic pain to update our knowledge, to measure their benefit and harm, and to better define their role in therapy.
OBJECTIVES:
To evaluate pain relief and adverse effect rates between systemic local anesthetic-type drugs and other control interventions.
SEARCH METHODS:
We searched MEDLINE (1966 through 15 May 2004), EMBASE (January 1980 to December 2002), Cancer Lit (through 15 December 2002), Cochrane Central Register of Controlled Trials (2nd Quarter, 2004), System for Information on Grey Literature in Europe (SIGLE), and LILACS, from January 1966 through March 2001. We also hand searched conference proceedings, textbooks, original articles and reviews.
SELECTION CRITERIA:
We included trials with random allocation, that were double blinded, with a parallel or crossover design. The control intervention was a placebo or an analgesic drug for neuropathic pain from any cause.
DATA COLLECTION AND ANALYSIS:
We collected efficacy and safety data from all published and unpublished trials. We calculated combined effect sizes using continuous and binary data for pain relief and adverse effects as primary and secondary outcome measurements, respectively.
MAIN RESULTS:
Thirty-two controlled clinical trials met the selection criteria; two were duplicate articles. The treatment drugs were intravenous lidocaine (16 trials), mexiletine (12 trials), lidocaine plus mexiletine sequentially (one trial), and tocainide (one trial). Twenty-one trials were crossover studies, and nine were parallel. Lidocaine and mexiletine were superior to placebo [weighted mean difference (WMD) = -11; 95% CI.: -15 to -7; P < 0.00001], and limited data showed no difference in efficacy (WMD = -0.6; 95% CI.: -7 to 6), or adverse effects versus carbamazepine, amantadine, gabapentin or morphine. In these trials, systemic local anesthetics were safe, with no deaths or life-threatening toxicities. Sensitivity analysis identified data distribution in three trials as a probable source of heterogeneity. There was no publication bias.
AUTHORS' CONCLUSIONS:
Lidocaine and oral analogs were safe drugs in controlled clinical trials for neuropathic pain, were better than placebo, and were as effective as other analgesics. Future trials should enroll specific diseases and test novel lidocaine analogs with better toxicity profiles. More emphasis is necessary on outcomes measuring patient satisfaction to assess if statistically significant pain relief is clinically meaningful.
