Case report
Impact of the use of neurostimulation for the management of a patient with complex pain syndrome and severe trophic changes. Case report
Impacto del manejo con neuroestimulación en un paciente con síndrome doloroso complejo y cambios tróficos severos. Reporte de caso
Mario H. Villegas Pinedaa, Christian Herrerab, Tatiana León Martínezc, Vasco Ordoñez Fernándezc,
Corresponding author
vasof82@hotmail.com
Corresponding author at: Anaesthesia Department, Hospital Universitario del Valle Medical School – Calle 5 # 36-08 piso 4, Cali, Colombia.
Corresponding author at: Anaesthesia Department, Hospital Universitario del Valle Medical School – Calle 5 # 36-08 piso 4, Cali, Colombia.
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Reporte de caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 828 "Ancho" => 2333 "Tamanyo" => 131786 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Appearance of the hands one month after definitive placement of the neurostimulator.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The Complex Regional Pain Syndrome (CRPS) is a chronic progressive disease characterized by intense pain, oedema and trophic skin changes occurring more frequently after limb trauma or surgery. It may be classified as type I (with no evidence of nerve injury) and type 2 (with proven nerve injury),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the reported incidence ranges from 5.6 to 26.2 cases for every 100,000 inhabitants.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> It is more frequent in females than in males with a 4:1 ratio<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> and there is a high association with a triggering event such as trauma, bone fractures being the most frequently associated with it.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The pathophysiology of CRPS is still not fully understood. There are multiple mechanisms that play an important role in its onset and maintenance.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Several treatments have been proposed for pain relief, functional recovery and psychological improvement, but management is often difficult and the functionality of the affected limb may be compromised if not treated early on.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Patient information</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 55-year-old male patient, street vendor, with no important medical history, who fell from a 1-m height and sustained trauma to the right hand 8 years before. He then developed oedema and pain in the limb. When seen by the orthopaedic service, he was diagnosed with a “sprained wrist” and was ordered splinting, anti-inflammatory drugs and physical therapy, with no improvement. The patient came back, complaining of persistent pain and progressive oedema that required splint removal.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical findings</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient reported hyperesthesia and persistent hyperalgesia in dermatomes C5–C8, 5/10 on the visual analogue scale, increased oedema involving the hand, the forearm and the arm, and functional limitation of the distal portion of the right upper limb, with discoloration of the surrounding skin. These findings led to the diagnosis of CRPS type I and treatment was initiated with amitriptyline 35<span class="elsevierStyleHsp" style=""></span>mg/night, carbamazepine 800<span class="elsevierStyleHsp" style=""></span>mg/day, acetaminophen 1<span class="elsevierStyleHsp" style=""></span>g every 6<span class="elsevierStyleHsp" style=""></span>h, and tramadol 4 capsules/day without significant improvement. The patient was then lost to follow-up.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient returned three years later with worsened symptoms after sustaining new trauma. The patient showed nail atrophy, absence of hair (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), diaphoresis in the involved area, and marked allodynia besides the symptoms described above.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Therapeutic intervention</span><p id="par0025" class="elsevierStylePara elsevierViewall">For this relapse, the regimen selected was prednisolone for 10 days, hydrocodone 10<span class="elsevierStyleHsp" style=""></span>mg every 8<span class="elsevierStyleHsp" style=""></span>h, and a cervical sympathetic block (CSB). Two ipsilateral cervical sympathetic blocks were performed and the patient continued on oral medication, with a 5% subjective improvement. However, the patient recurred after some months and, at this point, it was decided to try neurostimulation and continue the management only with hydrocodone, gabapentin and acetaminophen.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The neurostimulation (NS) trial was performed with a 100% improvement and marked oedema reduction (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.)</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results and follow-up</span><p id="par0035" class="elsevierStylePara elsevierViewall">After completing the trial, the patient again reported a pain score of 10/10 and all the symptoms returned. This finding led to the prescription of definitive implantation of the neurostimulator.</p><p id="par0040" class="elsevierStylePara elsevierViewall">After one month of definitive NS implantation, the patient reported “100% improvement of pain”. There was marked oedema reduction and progressive return to the normal appearance of the hand and reduced functional impairment. With physical therapy, the patient was able to take up work slowly after one year and the affected area acquired almost normal characteristics, with only mild residual limitation of finger flexion (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Several theories have been proposed to explain the cellular and biochemical events that might give rise to CRPS. These include peripheral mechanisms such as axonal and tissue hypoxia secondary to vasoconstriction associated with a nitric oxide synthesis imbalance and increased endothelin-1 and pro-inflammatory interleukin (IL6) production.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> The diagnosis of CRPS is based on clinical signs and symptoms found in the initial assessment. Since 1994, the International Association for the Study of Pain (IASP)<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> has proposed diagnostic criteria to provide very simple and accurate parameters that guide clinicians in the diagnosis of this disorder. More recently, Harden<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> proposed some diagnostic criteria based specifically on the symptomatology of this complex syndrome.</p><p id="par0050" class="elsevierStylePara elsevierViewall">CRPS shares treatment and management similarities with neuropathic pain. The usual treatments are tricyclic antidepressants, serotonin and noradrenalin reuptake inhibitors, first and second generation anticonvulsants and, occasionally, muscle relaxants.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> This was the first line of treatment used in our patient, with a very poor response. Opioids may play a limited role in the management of the intractable pain, which is characteristic of this disorder. Concomitant management with steroids may be effective given their anti-inflammatory effect, particularly during the early phase. Our patient received opioids initially with no improvement, and steroids were given in a later stage, which might explain the therapeutic failure of medication use. Interventional treatments are usually indicated when conventional therapy fails to control pain (persistence of pain >4/10 on the visual analogue scale) and the associated symptoms.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> It has been suggested that limb immobilization may be associated with the onset of CRPS as happened in this case, since it increases pressure, and that early complaints of compression are predictive factors for CRPS.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The initial work on electrical stimulation for the management of CRPS was based on the gating theory described by Melzak and Wall,<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> which suggests that intermittent stimulation of A-alpha and beta fibres localized in the spinal dorsal columns would break the vicious circle of central retransmission from peripheral nociceptors in C fibres. To this date, there is no strong evidence regarding the usefulness of spinal NS for the management of CRPS. Considering that some of the NS procedures are relatively new, there is still little evidence in relation to their use and cost- effectiveness.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Our patient's symptoms are consistent with the classical CRPS type 1 presentation where the management with multiple drugs and physical therapy did not lead to significant improvement, prompting the use of CSB with partial improvement. The decision to use a NS in this case was based on the transient success with this intervention followed by relapse.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> There are case reports that may support the use of this interventional treatment when medical therapies fail.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Several sympathetic, regional intravenous and epidural blocks may be given on an outpatient basis. However, responses to sympathetic blocks vary and they appear to be more effective than placebo in terms of duration but not so of the degree of pain relief.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> NS has been considered the definitive treatment of CRPS both through spinal stimulation for CRPS type I as well as through peripheral nerve stimulation for CRPS type II.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Forouzanfar studied the long-term effects of cervical and lumbar NS in patients with CRPS I and found that pain intensity was reduced after six months, one and two years after the implantation.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Kemler conducted a two-year study to assess the impact of NS on CRPS and found pain reduction and improved quality of life.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Other favourable outcomes have been observed with the use of NS in CRPS including the absence of hyperpathia, normalized temperature sustainability, improved functionality when combine with physical therapy, and a noticeable reduction in the use of analgesics.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,24</span></a> Our patient showed improvement of all his symptoms after the interventional procedure, with just a mild reduction of finger mobility on flexion and extension.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion, we suggest that NS may have a noticeable impact on the course of CRPS in patients with recurrent symptoms despite medical management and even despite the use of classical interventional strategies. The rapid onset and development of associated trophic changes could be an indication to intervene early on because of the functional and psychological repercussions for these patients who are usually in the productive stage of their lives. Our patient improved of his symptoms thanks to his therapeutic management, and was able to return to work. He still attends the pain clinic and gave his consent to the publication of his case.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres371169" "titulo" => array:4 [ 0 => "Abstract" 1 => "Introduction" 2 => "Case description and results" 3 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec350336" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres371168" "titulo" => array:4 [ 0 => "Resumen" 1 => "Introducción" 2 => "Descripción del caso y resultados" 3 => "Conclusión" ] ] 3 => array:2 [ "identificador" => "xpalclavsec350335" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patient information" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical findings" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Therapeutic intervention" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Results and follow-up" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-06-23" "fechaAceptado" => "2014-04-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec350336" "palabras" => array:3 [ 0 => "Complex regional pain syndrome" 1 => "Neurostimulation" 2 => "Causalgia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec350335" "palabras" => array:3 [ 0 => "Síndrome doloroso regional complejo" 1 => "Neuroestimulación" 2 => "Causalgia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Limb trauma and surgery are frequent causes of complex regional pain syndrome (CRPS). Some cases are very difficult to manage despite the use of high-dose analgesics, anti-inflammatory agents and physical therapy; hence the need to look for interventional therapies to slow its progression.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Case description and results</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We present the case of a patient diagnosed with CRPS type I with severe trophic changes and marked functional limitation, managed with multiple pharmacological therapies and nerve blocks without apparent improvement. The patient decided to try neurostimulation with favourable results and substantial improvement months later reported as “100% improvement” of pain; reduced oedema; progressive recovery of the normal appearance of the hand; partial recovery of strength, and improved function attributable to the use of this additional therapy.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Neurostimulation has a noticeable impact on the course of the complex regional pain syndrome accompanied by trophic changes in patients with a poor response to the recommended pharmacological management. Early initiation of this intervention facilitates functional and psychological recovery of the patients, who are usually in the productive stage of their lives.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0030">Introducción</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Causas frecuentes de síndrome doloroso regional complejo (SDRC) son el trauma y la cirugía en extremidades. Algunos casos resultan de muy difícil manejo a pesar de la utilización de altas dosis de analgésicos, antiinflamatorios y terapia física lo cual motiva la búsqueda de terapias intervencionistas que frenen su progresión.</p> <span class="elsevierStyleSectionTitle" id="sect0035">Descripción del caso y resultados</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de un paciente a quien se le diagnosticó SDRC tipo i con cambios tróficos severos y marcada limitación funcional, que fue manejado con múltiples terapias farmacológicas y bloqueos nerviosos sin mejoría evidente, a quien posteriormente se decidió realizar una prueba con neuroestimulación, la cual fue favorable. Meses después se obtuvo una mejoría sustancial ya que presentó mejoría del dolor «de un100%»; disminución del edema y retorno progresivo al aspecto normal de la mano, recuperación parcial de la fuerza y disminución de su limitación funcional, explicable por la adición de esta terapia de manera definitiva.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Conclusión</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La neuroestimulación ejerce un impacto notable sobre la evolución del SDRC con cambios tróficos en pacientes con pobre respuesta al manejo farmacológico indicado. El inicio temprano de esta intervención facilita la recuperación funcional y psicológica al paciente que, usualmente, se encuentra en una etapa productiva de su vida.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Villegas Pineda MH, Herrera C, Martínez TL, Fernández VO. Impacto del manejo con neuroestimulación en un paciente con síndrome doloroso complejo y cambios tróficos severos. Reporte de caso. Rev Colomb Anestesiol. 2014;42:321–324.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 549 "Ancho" => 1500 "Tamanyo" => 127382 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Limb appearance three years after the initial trauma, and one week after the neurostimulation trial.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Authors" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 828 "Ancho" => 2333 "Tamanyo" => 131786 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Appearance of the hands one month after definitive placement of the neurostimulator.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reflex sympathetic dystrophy: changing concepts and taxonomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 1 | 2 |
| 2024 October | 7 | 6 | 13 |
| 2024 September | 10 | 7 | 17 |
| 2024 August | 15 | 2 | 17 |
| 2024 July | 21 | 4 | 25 |
| 2024 June | 16 | 6 | 22 |
| 2024 May | 23 | 1 | 24 |
| 2024 April | 17 | 7 | 24 |
| 2024 March | 21 | 8 | 29 |
| 2024 February | 15 | 8 | 23 |
| 2024 January | 11 | 2 | 13 |
| 2023 December | 18 | 9 | 27 |
| 2023 November | 16 | 10 | 26 |
| 2023 October | 21 | 12 | 33 |
| 2023 September | 16 | 12 | 28 |
| 2023 August | 21 | 2 | 23 |
| 2023 July | 11 | 4 | 15 |
| 2023 June | 20 | 0 | 20 |
| 2023 May | 33 | 3 | 36 |
| 2023 April | 52 | 2 | 54 |
| 2023 March | 49 | 2 | 51 |
| 2023 February | 21 | 0 | 21 |
| 2023 January | 7 | 7 | 14 |
| 2022 December | 6 | 3 | 9 |
| 2022 November | 7 | 5 | 12 |
| 2022 October | 6 | 5 | 11 |
| 2022 September | 7 | 4 | 11 |
| 2022 August | 8 | 6 | 14 |
| 2022 July | 7 | 7 | 14 |
| 2022 June | 6 | 4 | 10 |
| 2022 May | 7 | 10 | 17 |
| 2022 April | 22 | 11 | 33 |
| 2022 March | 21 | 11 | 32 |
| 2022 February | 13 | 4 | 17 |
| 2022 January | 33 | 4 | 37 |
| 2021 December | 14 | 7 | 21 |
| 2021 November | 6 | 8 | 14 |
| 2021 October | 11 | 11 | 22 |
| 2021 September | 12 | 6 | 18 |
| 2021 August | 38 | 9 | 47 |
| 2021 July | 16 | 2 | 18 |
| 2021 June | 7 | 6 | 13 |
| 2021 May | 5 | 7 | 12 |
| 2021 April | 56 | 7 | 63 |
| 2021 March | 12 | 5 | 17 |
| 2021 February | 14 | 7 | 21 |
| 2021 January | 22 | 5 | 27 |
| 2020 December | 9 | 7 | 16 |
| 2020 November | 12 | 3 | 15 |
| 2020 October | 8 | 5 | 13 |
| 2020 September | 3 | 6 | 9 |
| 2020 August | 5 | 5 | 10 |
| 2020 July | 6 | 5 | 11 |
| 2020 June | 3 | 4 | 7 |
| 2020 May | 2 | 3 | 5 |
| 2020 April | 3 | 2 | 5 |
| 2020 March | 4 | 2 | 6 |
| 2020 February | 2 | 4 | 6 |
| 2020 January | 3 | 3 | 6 |
| 2019 December | 4 | 5 | 9 |
| 2019 November | 0 | 2 | 2 |
| 2019 October | 3 | 4 | 7 |
| 2019 September | 0 | 1 | 1 |
| 2019 July | 1 | 10 | 11 |
| 2019 June | 0 | 2 | 2 |
| 2019 May | 3 | 13 | 16 |
| 2018 December | 1 | 0 | 1 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 2 | 3 | 5 |
| 2018 May | 26 | 6 | 32 |
| 2018 April | 32 | 7 | 39 |
| 2018 March | 25 | 14 | 39 |
| 2018 February | 23 | 9 | 32 |
| 2018 January | 36 | 9 | 45 |
| 2017 December | 23 | 8 | 31 |
| 2017 November | 29 | 3 | 32 |
| 2017 October | 26 | 15 | 41 |
| 2017 September | 32 | 9 | 41 |
| 2017 August | 50 | 11 | 61 |
| 2017 July | 49 | 8 | 57 |
| 2017 June | 56 | 10 | 66 |
| 2017 May | 54 | 9 | 63 |
| 2017 April | 48 | 15 | 63 |
| 2017 March | 33 | 6 | 39 |
| 2017 February | 21 | 9 | 30 |
| 2017 January | 10 | 5 | 15 |
| 2016 December | 40 | 18 | 58 |
| 2016 November | 44 | 12 | 56 |
| 2016 October | 27 | 15 | 42 |
| 2016 September | 54 | 7 | 61 |
| 2016 August | 45 | 9 | 54 |
| 2016 July | 23 | 6 | 29 |
| 2016 June | 2 | 9 | 11 |
| 2016 May | 2 | 18 | 20 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 0 | 17 | 17 |
| 2016 January | 0 | 14 | 14 |
| 2015 December | 18 | 6 | 24 |
| 2015 November | 46 | 11 | 57 |
| 2015 October | 55 | 11 | 66 |
| 2015 September | 38 | 11 | 49 |
| 2015 August | 33 | 5 | 38 |
| 2015 July | 38 | 8 | 46 |
| 2015 June | 28 | 5 | 33 |
| 2015 May | 34 | 9 | 43 |
| 2015 April | 23 | 8 | 31 |
| 2015 March | 39 | 20 | 59 |
| 2015 February | 39 | 12 | 51 |
| 2015 January | 43 | 11 | 54 |
| 2014 December | 69 | 15 | 84 |
| 2014 November | 43 | 9 | 52 |
| 2014 October | 55 | 18 | 73 |
| 2014 September | 15 | 7 | 22 |
Show all