Reabilitação funcional e analgesia com uso de toxina botulínica A na síndrome dolorosa regional complexa tipo I do membro superior: relato de casos

Gabriela Rocha Lauretti; Fabrício dos Santos Veloso; Anita Leocádia de Mattos

doi:10.1590/S0034-70942005000200007

Clinical Information

Reabilitação funcional e analgesia com uso de toxina botulínica A na síndrome dolorosa regional complexa tipo I do membro superior: relato de casos

Functional rehabilitation and analgesia with botulinum toxin A in upper limb complex regional pain syndrome type I: case reports

Gabriela Rocha Lauretti; Fabrício dos Santos Veloso; Anita Leocádia de Mattos

http://dx.doi.org/10.1590/S0034-70942005000200007 Braz J Anesthesiol, vol.55, n2, p.207-211, 2005

PDF

Downloads: 0

Resumo

JUSTIFICATIVA E OBJETIVOS: Freqüentemente, soma-se ao quadro de alodínia e hiperalgesia em pacientes portadores de Síndrome Dolorosa Regional Complexa (SDRC) tipo I a incapacidade funcional do segmento acometido. Relatam-se dois casos de SDRC em que a aplicação de toxina botulínica-A como fármaco coadjuvante contribuiu na recuperação funcional motora do membro acometido. RELATO DOS CASOS: Duas pacientes portadoras de SDRC tipo I foram inicialmente avaliadas para controle da dor no membro superior direito. Ambas apresentavam incapacidade para abrir a mão e dor pela escala analógica numérica (EAN) de 10 em repouso ou quando a mão ou os dedos eram passivamente manipulados. Iniciou-se seqüência de 5 bloqueios, do gânglio estrelado ipsilateral a intervalos semanais, com clonidina e lidocaína. Simultaneamente, durante a realização do terceiro bloqueio do gânglio estrelado, foram administrados 75 UI de toxina botulínica-A nos músculos flexores das falanges e da articulação do punho. Uma semana após a aplicação da toxina botulínica-A, as pacientes apresentavam relaxamento das falanges e punho, relatavam facilidade para execução da fisioterapia passiva e a dor classificada foi como 2 (EAN) à manipulação passiva. Ao término da realização da seqüência de bloqueios do gânglio estrelado, as pacientes foram submetidas a 3 sessões semanais de administração por via venosa regional de clonidina, lidocaína e parecoxib. Após 8 meses de avaliação, as pacientes apresentaram 70% e 80% de recuperação motora e funcional do membro acometido. CONCLUSÕES: A aplicação por via muscular de toxina botulínica A resultou em melhora da movimentação do membro acometido, analgesia auxiliando na sua recuperação funcional.

Palavras-chave

DOR, Crônica, DROGAS

Abstract

BACKGROUND AND OBJECTIVES: Functional inability of the affected limb is often added to alodynia and hyperalgesia in Complex Regional Pain Syndrome (CRPS) type I. Two CRPS cases are reported in which botulinum toxin A as coadjuvant drug has contributed to motor and functional recovery of the affected limb. CASE REPORTS: Two CRPS type I patients were initially evaluated for upper limb pain control. Both were unable to open the hand and referred pain intensity by numeric analog scale (NAS) of 10 at rest or when hand and fingers were passively manipulated. A sequence of 5 weekly ipsilateral stellate ganglion blockade with clonidine and lidocaine was started. Simultaneously, during the third stellate ganglion blockade, 75 Ul botulinum toxin A was administered to flexor muscles of phalanges and wrist joint. One week after botulin toxin A administration patients presented phalanges and wrist relaxation, reported easy passive physical therapy and pain was classified as 2 (NAS) at passive manipulation. At stellate ganglion blockade sequence completion patients were submitted to 3 weekly regional intravenous clonidine, lidocaine and parecoxib. At 8 months evaluation patients presented 70% and 80% motor and functional recovery of the affected limb. CONCLUSIONS: Muscular botulin toxin A has resulted in movement improvement of the affected limb and analgesia, favoring functional recovery.

Keywords

DRUGS, PAIN, Chronic

Referencias

Wilson PR. Post-traumatic upper extremity reflex sympathetic dystrophy: Clinical course, staging, and classification of clinical forms. Hand Clin. 1997;13:367-372.

Zyluk A, Zyluk B. Neurological disorders in post-traumatic algodystrophy of the upper extremity. Neurol Neurochir Pol. 2002;36:33-46.

Bruehl S, Harden RN, Galer BS. Complex regional pain syndrome: are there distinct subtypes and sequential stages of the syndrome?. Pain. 2002;95:119-124.

Maihofner C, Handwerker HO, Neundorfer B. Patterns of cortical reorganization in complex regional pain syndrome. Neurology. 2003;61:1707-1715.

Schwenkreis P, Janssen F, Rommel O. Bilateral motor cortex disinhibition in complex regional pain syndrome (CRPS) type I of the hand. Neurology. 2003;61:515-519.

Chaturvedi A, Dash HH. Sympathetic blockade for the relief of chronic pain. J Indian Med Assoc. 2001;99:698-703.

Wasner G, Schattschneider J, Binder A. Complex regional pain syndrome-diagnostic, mechanisms, CNS involvement and therapy. Spinal Cord. 2003;41:61-75.

Lauretti GR, Frade LC, Lima ICPR. The antinociceptive effect of local or systemic parecoxib combined with lidocaine/clonidine intravenous regional analgesia in complex regional pain syndrome. . .

Suresh S, Wheeler M, Patel A. Case series: IV regional anesthesia with ketorolac and lidocaine: is it effective for the management of complex regional pain syndrome 1 in children and adolescents?. Anesth Analg. 2003;96:694-695.

Birklein F, Weber M, Neundorfer B. Increased skin lactate in complex regional pain syndrome: evidence for tissue hypoxia?. Neurology. 2000;55:1213-1215.

Koban M, Leis S, Schultze-Mosgau S. Tissue hypoxia in complex regional pain syndrome. Pain. 2003;104:149-157.

Tan EC, de Keijzer MH, Goris RJ. Capillary blood gas analysis in complex regional pain syndrome: a pilot study. Ann Clin Biochem. 2003;40:569-571.

Mitchell JA, Akarasereenont P, Thiemermann C. Selectivity of nonsteroidal antiinflammatory drugs as inhibitors of constitutive and inducible cyclooxygenase. Proc Natl Acad Sci USA. 1993;90:11693-11697.

Leis S, Weber M, Isselman A. Substance-P-induced protein extravasation is bilaterally increased in complex regional pain syndrome. Exp Neurol. 2003;183:197-204.

Teasell RW, Arnold JM. Alpha-1 adrenoceptor hyperrespon- siveness in three neuropathic pain states: complex regional pain syndrome 1, diabetic peripheral neuropathic pain and central pain states following spinal cord injury. Pain Res Manag. 2004;9:89-97.

Moseley GL. Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain. 2004;108:192-198.

Cordivari C, Misra VP, Catania S. Treatment of dystonic clenched fist with botulinum toxinin. Mov Disord. 2001;16:907-913.

Wallen MA, O'flaherty SJ, Waugh MC. Functional outcomes of intramuscular botulinum toxin type A in the upper limbs of children with cerebral palsy: a phase II trial. Arch Phys Med Rehabil. 2004;85:192-200.

Keller JE, Cai F, Neale EA. Uptake of botulin neurotoxin into cultured neurons. Biochemistry. 2004;43:526-532.

Gracies JM. Physiological effects of botulinum toxin in spasticity. Mov Disord. 2004;19(^s8):S120-S128.

Argoff CE. A focused review on the use of botulinum toxins for neuropathic pain. Clin J Pain. 2002;18(^s6):S177-S181.

Klein AW. The therapeutic potential of botulin toxin. Dermatol Surg. 2004;30:452-455.

Voller B, Sycha T, Gustorff B. A randomized, double-blind, placebo controlled study on analgesic effects of botulinum toxin A. Neurology. 2003;61:940-944.

Aoki KR. Evidence for antinociceptive activity of botulinum toxin type A in pain management. Headache. 2003;43(^s1):S9-S15.

Reabilitação funcional e analgesia com uso de toxina botulínica A na síndrome dolorosa regional complexa tipo I do membro superior: relato de casos

Functional rehabilitation and analgesia with botulinum toxin A in upper limb complex regional pain syndrome type I: case reports

Gabriela Rocha Lauretti; Fabrício dos Santos Veloso; Anita Leocádia de Mattos

Resumo

Palavras-chave

Abstract

Keywords

Referencias

Links

compartir

Braz J Anesthesiol