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Wednesday, August 13, 2014

Complex Regional Pain Syndrome: Lessons learned so far

Lessons learned from the treatment of Complex Regional Pain  Syndrome

Dr Rich Blake (podiatrist)
Saint Francis Memorial Hospital, San Francisco, CA

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I am treating many patients right now with a diagnosis of Complex Regional Pain Syndrome. It is a gross understatement to say I am treating them, since they can only be treated by a team of people since it is too complex. The most important person on that team is the patient, and they really call the shots, and hopefully I can help with direction and technical issues. If you are given that diagnosis, also known as Reflex Sympathetic Dystrophy or RSD, you are scared. The doctors and therapists who treat you are scared for you. The quicker the diagnosis is made and appropriate treatment is started, the better the response, but even those whose diagnosis is made at a snail's pace can get better. I love to see these patients every 2 weeks since there is so much to do and get organized. The visits should be a constant exploration and expansion of these Mainstays of Treatment: Identifying the source of pain, completely eliminating the pain cycle, nutrition, rehabilitation of limb function, being as productive as possible, and handling co-morbidities of anxiety and depression. I hope this summary does help those suffering make sure nothing is being forgotten, and every visit to the managing doc is as productive as possible.

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The Mainstays of Treatment are:
·       Identifying Source of Pain
1.      MRI/CT Scans
2.      Bone Scan
3.      Diagnostic Injections (local or into the back)
4.      Nerve Conduction Studies
5.      Lab Tests
           §         Sed Rate
           §         CBC
           §         Free T4 and TSH
           §         Vit B12 and D3 Levels
           §         HgbA1c
           §         Morning Fasting Blood Sugars

·       Completely eliminating/breaking the Pain Cycle
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1.     Mechanical Means
           §         Roll A Bout Scooter
           §         AFO (Ankle Foot Orthotic)
           §         Crutches
           §         Tibia Wt Bearing Brace (Freedom Brace or Zero G Types)
           §         Activity Modification
           §         Custom Made Orthotics to stabilize an injured area (Hannaford based orthotic with memory
                      Foam best to start). Some patients can take no arch pressure initially and need some
                      Version of taping to get support.
           §         Taping (Kinesiotape or Support the Foot, but no complete enclosure)
 
2.     Oral Medications
          §         Anti-Seizure (ie Lyrica)
          §         Anti-Depressant (ie Nortriptyline)
          §         Others through Pain Management Specialists
          §         Low Dose Naltrexone (1-4.5 mg/day)
          §         Sublingual Ketamine for flare-ups


3.      Topical Medications/ Applications (gels and lotions best for ease of application)
          §         Warm Compresses
          §         Non Painful Massage
          §         Parafin Wax (Target sells, but heat must feel great)
          §         Chinese Herbs
          §         Lidoderm Patches (especially for sleeping, can be above the sore area)
          §         Neuro-Eze (OTC applied 3 times daily—buy online)
          §         50% DMSO cream 99.9% Pure (mixed with other medicines as below)
          §         Multiple Compounding Medications which include (usually not all of these):
                     ü      Ketamine 10%
                     ü      Clonidine 0.2%
                     ü      Gabapentin 6%
                     ü      Baclofen 2%
                     ü      Nifedipine 2%
                     ü      Lidocaine 2%

4.     Alternative (only in category, very main stream for this condition)
          §         Biofeedback (Thermal to increase circulation)
          §         Hypnosis
          §         Meditation (30 minutes to 1 hour per day)
          §         Acupuncture (can be to opposite limb or ear)
          §         Graded Motor Imagery (laterality flashcards and mirror therapy)
          §         Somatic Experience technique
          

·       Nutritional (next 3-12 months)
1.      Alpha Lipoic Acid 300mg 2x/day
2.      Acety-L-Carnitine 2000 mg/day
3.      Inositol 500-1000mg/day
4.      Vit B1 (5-30 mg/day)
5.      Vit B6 50mg/day
6.      Vit B12 1000mg/day
7.      Vit E (up to 1,600units/day)
8.      Vitamin C (500 mg/day for 45 days)
9.      Vitamin D 3  (1000 units/day)  --have blood level drawn and get to 45-50 level
10.    Thyroid Natural Supplements

·       Rehabilitation of Limb Function
1.      Lower Extremities (keep strong as long as pain free) Physical Therapist must be skilled in Neuropathic Pain treatment, not just musculo-skeletal.  There are times to Honor Pain and times to Push through Pain, that can change from day to day.
2.      Core (support feet and legs from above with less pressure on feet overall)
3.      Cardio (improve overall circulation and health)
4.      Whole Body (must address physical, emotional, spiritual sides together)
5.      Swimming in a Warm Water Pool is one of the best forms of rehab out there for CRPS
6.      Patient must learn how to avoid triggers (sometimes cold drafts, loud noise, etc).
7.      Patient must have thorough understanding of the concept of neural tension and how to protect the sciatic nerve (or how not to irritate).
8.     Neural Gliding or Flossing 3 times a day with Spine Neutral
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·       Being as Productive as Possible (while nerves are healing) Can Help Nerves Heal
1.      Part Time Work
2.      Volunteer
3.      Projects

·            Dealing with CoMorbities of Anxiety and Depression

Possible Sources of Information/Support/Inspiration
                   ü      American Chronic Pain Association
                   ü      American Academy of Pain Management
                   ü      Reflex Sympathetic Dystrophy Syndrome Association
                   ü      How To Cope With Pain blog
Psychological Workup/Treatment for Biofeedback/Depression/Anxiety

·        Other Important Treatment Options
1.     As the symptoms from the CRPS calms down, focus again may be necessary on the original injury which could serve as a trigger for flares.
2.    Sympathetic Blocks are crucial in the first year, and their effectiveness wanes more and more as time goes on.
3.    Consider Ketamine Infusion and Calmare Pain Therapy (if there are centers in your area) over the more aggressive Spinal Cord Stimulators. Both of these require initial 10 day commitments, but have great potential. 
4.    Neuro Prolotherapy injections are a great help to patients. 

1 comment:

  1. One of the best Dr posts on CRPS I've ever read. You definitely know what you're talking about. Your patients are blessed!

    ReplyDelete

Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.