Pain, Pain Relief and Palliative Care

The research program Pain, Pain Relief and Palliative Care is part of the total research group of the department of Anesthesiology of the VU University Medical Center. This research program aims to gain basic and applied clinical knowledge with regard to the measurement and treatment of pain. The program includes literature research, epidemiology and clinical trials. The reserach program distinguishes three major themes:

Within these themes we focus in particularly on the Complex Regional Pain Syndrome (CRPS) and Palliative Care.

Contact
Are you interested in research within the area of Pain, Pain Relief and Palliative Care? 
Residents, (bio)medical students and technicians are invited to contact the researchcoordinator Roberto Perez.

Prof.dr. Roberto Perez
+31 ( 0) 20 444 0029

TREND (Trauma RElated Neuronal Dysfunction)

Complex Regional Pain Syndrome

Complex Regional Pain Syndrome I (CRPS I) is a difficult to treat syndrome which is characterized by sensoric, autonomic and motoric complaints. CRPS is frequently caused by trauma or surgery, especially of the extremities. Recent findings suggest that inflammatory processes may enhance sensitization of the neurons in the central nervous system, which deteriorates sensible, autonomic and motoric complaints.

The VU University Medical Center started a randomized doubleblind placebo-controlled study in order to determine whether intravenous magnesium, which is a competititive NMDA antagonist, is a safe and effective treatment for the neuronal complaints during CRPS I. Furthermore, we are involved in the development of diagnostic tools for this syndrome, by developing measurement instruments which are validated to follow the disease over time. This research is part of the national researchprogramme TREND (Trauma RElated Neuronal Dysfunction ) which focuses on CRPS I and related diseases. The research is part of the research institute EMGO .

Promovendi:Drs. Sigrid Fischer, Drs Stefania Barbalinardo and Drs. Maria Wertli

Treatment of low backpain

Blockade of the sacroiliac joint

In patients with lower backpain with a pseudoradicular character and pressure pain of the sacroiliac joint might benefit from injections of a local anesthetic in the joint. Furthermore, addition of corticosteroids to the local anesthetic may improve pain relief. Since the literature does not provide consensus regarding the choice of injected anesthetics for this particular pain complaint, we designed a randomized doubleblind placebo-controlled study in which we compare several treatment modalities. With this study we aim to contribute to an improved diagnosis and treatment of sacroiliac complaints.

This researchproject will be further elaborated by a retrospective analysis of patient data and anatomic and histologic analysis of the innervation of the sacroiliac joint. This research is embedded in the research institute EMGO.

Promovendi: Drs. K. Szadek

Diagnostics and treatment of chronic low back pain.

Patients with low back pain in the region of the SI joint of non-radicular character and pressure pain of the SI joint might benefit from intra-articular injections of a local anesthetic. Furthermore, addition of corticosteroids to local anesthetics may improve the magnitude and the duration of pain relief. Since the literature does not provide consensus regarding the choice of injected anesthetics for this particular pain complaint, we designed a randomized double blind, placebo-controlled study in which we compare three treatment modalities. With this study we aim to contribute to an improved diagnosis and treatment of SI complaints.

This research project will be further elaborated by a retrospective analysis of patient data and anatomic and immunohistologic analysis of the nociceptive (pain receptor) distribution in the SI joint. This research is embedded in the research institute EMGO.

Promovendi:Drs. K. Szadek

Karolina Szadek

Pain relief in total hip procedures

Locoregional pain relief

Ropivacaine and levobupivacaine are two non-racemic, long acting local anesthetics. The claimed advantage of these local anesthetics versus racemic substances like bupivacaine is a reduced cardiotoxicity and reduced toxic effects on the central nervous system. This specifically acounts for the administration of large volumina of local anesthetics, for instance during peripheral nerve blockade.

In a doubleblind, randomized study, ropivacaine, levobupivacaine and bupivacaine are compared in patients undergoing a total hip procedure. For this procedure, a combined psoas-ischiadic blockade is used together with general anesthesia. The study aims to investigate the effects of the distinct anesthetics on toxicity, plasmalevels of the local anesthetic, analgetic potency, motoric complaints, perioperative blood loss, hemodynamic alterations and side effects due to peripheral nerve blockade.

AMsterdam ROtterdam SEdatie project; Guidelines palliative sedation

AMROSE

Continuous deep sedation or palliative sedation is the conscious induction of sleep in patients nearing death, who suffer from refractory symptoms. The procedure may offer the patient and his or her relatives more peace in the process of dying. Although the Royal Dutch Medical Association (KNMG) has developed a national guideline for the use of palliative sedation in 2005, the practice has met with much discussion.

In a close collaboration with the public health department of the Erasmus University Medical Center , the departments of Anaesthesiology and Nursing Home Medicine of the VU University Medical Center (VUMC) started the AMsterdam ROtterdam SEdatie (AMROSE) study. The goal of the study is to evaluate the current practice of palliative sedation after the introduction of the KNMG guideline, and assess possible problems that may arise for caregivers when using the guideline.

This study consists of two parts, whereby questionnaires and structured interviews will be used for caregivers throughout the field involved in the practice of palliative sedation for qualitative and quantitative assessment of palliative sedation practice. Secondly, the usefulness of observation scales used to monitor the depth of the sedation will be assessed in a palliative setting. This research has been funded by a Netherlands Organisation for Health Research and Development (ZonMw) grant.

Promovendi:Drs. Jimmy Arevalo-Romero

Clinical Prediction of Neuropathic Pain

Neuropathic Pain (NP) is pain arising as a direct consequence of a lesion or disease affecting the somatosensory system. NP is characterized by continuing pain and sensory symptoms, such as a reduced sensation to a painful stimulus and pain due to a stimulus that does not normally provoke pain. Within pain care, the treatment of neuropathic pain remains difficult, which results in major consequences for the patients’ daily routine, participation and quality of life.

In Chronic Neuropathic Pain (CNP) symptoms may persist for months or years. Knowledge about predictors for CNP may lead to timely identification of patients with a possible adverse disease course, and prompt preventive measures or result in more intensive treatment for patients at risk. In order to improve NP-care, it is important to identify predictors for CNP.

Therefore, the aim of this research project is the development and validation of a clinical prediction rule to predict a favourable or unfavourable course for NP patients. 
This study is part of the TREND research consortium and the research institute EMGO .

Promovendi:Drs S. Boogaard

NeuroSIPE – QDISC

NeuroSIPE – QDISC (Quantitative Diagnosis of Impaired of Spine Control)

27% of the Dutch adult population suffers from low-back pain (LBP) at any given time. The majority of LBP patients recovers fairly quickly without specific treatment. 60-75% are relapsing within one year. For 10% of the patients LBP becomes a chronic problem persisting even 1 year after the first visit to the general practitioner. With 1.7% of the gross national product (GNP) or in other words 4.1 billion euros is LBP the most costly health problems in the industrialized world. Most of LBP costs is due to chronic problems.

The problem is that in only 10% of the patients a specific diagnosis can be made. Therefore for most patients the primary cause remains unknown. The lacking diagnostic possibilities is leading to limited success of secondary prevention and treatment of chronic LBP.

The most common treatments focus on general prognostic factors for chronicity of LBP such as neuromuscular control, pain sensitization and pain related fear. Focusing on one treatment factor only is not successful for all patients. Therefore all aspects need to be considered together.

This NeuroSIPE – QDISC (Quantitative Diagnosis of Impaired of Spine Control) project (www.neurosipe.nl) will therefore focus on developing a diagnostic application which will provide quantitative assessment of neuromuscular control of trunk muscles, as well as effects of pain sensitization and pain related fear. This will provide means to individualize treatment, as well as contributing more targeted treatment of patients with chronic LBP and prevent chronicity in patients with sub-acute LBP.

Promovendi:Drs. Mariette Griffioen

This research is supported by the Dutch Technology Foundation STW, which is part of the Netherland Organisation for Scientific Research (NWO) and partly funded by the Ministry of Economic Affairs, Agriculture and Innovation.

MEDication management In the LAST phase of life

MEDILAST

 Patients in the palliative phase of a chronic disease often use multiple medications. With the occurrence of new diseases and symptoms medications are often added without reference to symptom- or disease-specific guidelines; increasing the risk of adverse effects and interactions. As death approaches, the use of these medications may become irrational and sometimes even harmful. Medical, emotional and ethical factors are responsible for difficulties with medication management in the last phase of life. There is currently a lack of knowledge over and guidelines for the appropriate management of medications when death approaches. When and how prescribed medications must be stopped, adjusted or added is the question that motivated our research project. Our aim is to describe the current practice of and to formulate recommendations to improve medication management in the last phase of life.

This research project is carried out in the framework of a grant provided by the Netherlands Organization for Health and Development (ZonMw) with the collaboration between VU University Medical Center, Erasmus Medical Center and St. Radboud University Medical Center. The project consists of four phases beginning with a literature review and patient file study to examine current knowledge and practice of medication management in the last phase of life. In the second phase we will carry out a clustered-interviews study to address the perspectives of patients, physicians, relatives and nurses with regard to problems encountered in the management of medication in the last three months of life. The third phase will consist of a survey study that will collect data from a broader population frame to validate the results of these interviews and a Delphi study to develop expert agreement focused on the current situation in the Netherlands. The results from these phases will be put together in the fourth phase which will focus on the identification and generation of clinically relevant recommendations to improve the practice of medication management in the last phase of life.

Promovendi:  Drs. Bregje Huisman