Complex Regional Pain Checklist

Complex Regional Pain Syndrome Checklist

    Identifying the Source of pain (this is mainly to rule out other possible causes of pain)

    Mechanical Means of Breaking Pain Cycle (crutches, limited activity, Roll aBout scooters, accommodative padding, etc) Sympathetic nerve blocks are crucial as soon as possible.

  

    Oral Medications to Break Pain Cycle (typically lyrica, neurontin, cymbalta, elavil, etc)

    Topical Medications/Applications to Break Pain Cycle   (lidoderm patches, compounding meds, Neuro-Eze, and many, many more)

    Alternative (acupuncture, Calmare Pain Therapy, biofeedback, etc)

    Nutritional (Alpha Lipoic Acid, Vitamins C, B6, B12, Inositol, Natural Thyroid Supplement, omega 3 fish oil, etc)

    Rehabilitation of Limb Function (understanding of chronic and acute pain, when to push through pain and when to honor pain).

    Being Productive as possible (pain is overwhelming, need to focus part of the day on some productive task)

    Co morbidities (psychiatic counseling should be started immediately

    Other (Ketamine Infusions, meditation, prayer)

Nerve Pain and the Loss of Right Left Discrimination

I was just purchasing the laterality cards for one of my patients who does not use the internet from noigroup.com when I saw/remembered that they have an app. So I downloaded it and thought I would spread the word. When you have nerve pain in your foot you can lose the ability to discern if you are looking at your right foot or left foot. It is the brain trying to avoid pain, and as this process of avoidance gets rooted in your nervous system, it is hard to reverse. Laterality flash cards demonstrated by the app below, and purchased for around $50, can be for feet, hands, knees, etc. Depends where the nerve pain is. It is extremely helpful at preventing the nerve pain rewiring that is devastating to many. It is part of a process called graded motor imagery. 

                               Is this the right or left foot?

https://itunes.apple.com/us/app/recognise-feet/id500548834?mt=8

http://www.drblakeshealingsole.com/2012/12/crps-initiation-of-flashcards-for.html

Nerve Pain: Email Advice

Hi Dr. Blake,

I have been following your posts for months now.  Hope you can help in even giving me direction and whether seeing you or a different kind of doc would be best next step.

Out of the blue in Jan., I noticed a constant nagging sensation like my sock was uneven on bottom of left foot/big toe and irritating it.  When I took off sock, the foot was bright red, swollen and painful to touch esp. in the metatarsal area and more so on middle joint of big toe.  There also seem to be a lump on that joint and when I even lightly touched it, would send a radiating pain up my leg, into my back and up the right side into my neck.
Dr Blake's comment: You are talking about the femoral nerve which has a branch to the big toe and can radiate like that. I am assuming that something from that joint irritated the nerve causing the nervous system breakdown. 

And once the pain was activated, my entire central nervous system went into hyper gear and it was impossible for me to bring it down -- with many different supplements, topicals, even meditation, etc.  The other piece that went hand in hand were areas on ball of foot and around the big and second toe that were blue and even pieces of vein protruding that were the most painful areas.
Dr Blake's comment: This is sounding like RSD, which stands for Reflex Sympathetic Dystrophy.

Most of the acute symptoms have improved or disappeared since then although still some lingering issues that prevent me from going on a walk or doing even simple activities.
Dr Blake's comment: Sounds like you managed to create a nice pain free healing environment that is so important when the nervous system is barking soooo much!!

Since Jan. I have gone to a couple of different chiropractors who not only use activator, they also use techniques to break down fascia issues.  One thought that the major issue on big toe might have been capsulitis which also might be putting pressure on nerve.  I also went to osteopath.  He thought it was bursitis on big toe creating all the problems.  Also went to 2 different individuals that specialize in chiropractor neurology.  Their exam showed that the constant radiating pain had to do with pain center in brain not shutting off pain signals and my central nervous system had a hard time shifting to parasympathetic system.  Also X-ray of foot and back where taken.  No fractures in foot.  I have spinal stenosis I believe at L4/5 which I understand can trigger pain in first/second toe(???).  Also I do have a flat arch in the problem (left) foot.
Dr Blake's comment: This is helping with the whole picture. The L4 nerve root goes to the big toe. If this nerve is irritated at the back, and then irritated at the foot, a "double crush syndrome" occurs and the nervous system is very unhappy.

Practicing natural healing for decades, I have also done lots of remedies -- including vit. c, msm, an anti-inflammatory supplement with proteolitic enzymes, vit. B, B12, lion's man (medicinal mushroom for regrowing nerves), calc/mag + magnesium chloride (liquid and gel), comfrey compresses, castor oil compresses and the list goes on. I have also worked with feldenkrais practitioner and also try to stretch when id does not aggravate pain.
Dr Blake's comment: Neural Flossing or Gliding is great and relatively new to physical therapy world. It is a gentle way to stretch the involved nerves, not allowing scar tissue or swelling to collect around them. On my blog I have a video of one sciatic nerve flossing technique. 

Since Jan. I have not been able to use my customized orthotics, as areas where raised, trigger pain so I have gotten a cushy "not customized" orthotic from Walking Shoe Company that molds to foot and provides arch support.  That seems to work for now and does not trigger pain.
Dr Blake's comment: This a great idea, you have to remove any abnormal nerve stimulation.

I tried walking about 12 min. on dirt on Sunday (first time I tried to go for short walk) and couples of hours later I felt increased pain sensitivity.  Not unbearable,  rather a reminder something is still going on and simple activities still problematic. In Jan. pain level and intensity were probably a solid 10. now about 2-3 as long as I keep walking to minimum and not engage any other activities to aggravate it.

Sorry about long email.  Final comment .... being self employed, I have a very high deductible which essential means all of my medical expenses are paid out of my pocket.  Unfortunately, that piece does enter the equation of what I can do.

Thanks,
Deb (name changed)

Dear Deb,

     Thank you so very much for the email. You sound like you are at where one of my patients is right now: Wanting to remove the source since it could trigger it all over again. I do not blame you. You may have to save up your money so when you feel free to spend through your deductible (next year???) you can get the MRI or CT scan to identify the lump in your foot, and treat it. At the same time, you need to work on your back to get that as stable as possible (less chance irritating the L4 nerve root. All this can easily max a high deductible quickly, leaving 11 months to have the insurance doing the rest of the paying. I am so proud of how you dealt with the initial flare of RSD. Please send me 5-10 bullet points on the key things you felt were crucial getting this to 0-2 pain. Rich

Severe Foot Injury with CRPS and Possible Injections: Email Advice

 I received this email today 7/24/13. This patient is in very capable hands, with only some of the facts coming to my attention. My answers are only with great concern for the patient since it is impossible to really know what direction to answer some of the questions. Patients who develop CRPS truly suffer and need to trust their doctors. In my answer I give general guidelines, but they are only guidelines. Every guideline has exceptions, and individual situations sometimes demand taking risks. This patient is in an extreme situation where sometimes risks are worth it. So, in my answer I have many questions. I agonize over what is right.  

 I suffered a severely crushed foot one year ago today. All five metatarsal joints were fractured into many many pieces and soft tissue damage was severe. Surgery to repair them resulted in an external fixator for 8 weeks, hard cast for 2 weeks, boot for another 4 weeks ( non-weight bearing for close to 4 months). Temporary pin was removed 4 months later resulting in confirmed diagnosis of RSD/CRPS which I've been under pain management care, the surgeon's care and continuous PT.

     Foot developed severe arthritis almost immediately with osteoporosis now confirmed this week with MRI. The reason they finally did an MRI last week was because of the continued anterior ankle pain and stiffness that wasn't responding to PT and Massage therapy. I've complained about it repeatedly since I started weight-bearing last November, but no one paid any attention until last week when my foot surgeon ordered the MRI on foot plus one on the ankle. MRI confirmed a "partial thickness longitudinal split tear within the infra malleolar peroneus brevis tendon"..
Dr Blake's comment: This is tough since the peroneal tendon is along the outside of your ankle, and you describe the pain being in the front of your ankle. Also, get an ultrasound imaging of the peroneus brevis, since MRIs miscall this all the time. Let us make sure this is really a major source of your pain. 

     Surgeon immediately wanted to schedule operation to fix the tear then almost immediately remembered I was an active RSD patient. So absolutely "no surgeries" while RSD is active (which clearly could be forever). Even if RSD goes into remission and he could do surgery, it most likely would bring another attack of RSD (which is a horrible horrible disease). I still do not understand how or why the original MRI done when injured didn't mention this tear and the exact pain I have has been the same since first day of weight-bearing, so It didn't happen "latter on". I am also not convinced that this particular injury "may" be the main culprit of my RSD.
Dr Blake's comment: Unfortunately, CRPS can just develop with this scenario of severe injury and immobilization. And definitely you want to have more than one person say with certainity that your symptoms are related with this possible tear. And, if you need surgery, there are pre and post surgery protocols to limit the risk of another attack for RSD patients. 

    So -- he suggested cortisone shot which would not fix tear but "perhaps" would allow for asymtomatic pain relief until such time I could have surgical repair. I immediately said that I "thought" cortisone was harmful to tendons and ligments and he said "only if injected directly into the tendon or ligament -- he is injecting into the tendon "sheath" and that won't cause a problem he says.
Dr Blake's comment: If there is a tear, the cortisone will go into the tendon from the fluid around the tendon where it is injected into. I would be very nervous. Does cortisone going into your tendon cause a rupture all the time, definitely not. I am not sure the odds. 5% or 10%. Please ask the surgeon. You weigh those odds, with the odds of the shot helping you. Only your surgeon would have some idea. I can really only raise the questions, give generalizations, etc. Not a cop out, just reality from where I sit. 

    I am assuming it will be a long-acting cortisone. Also ice can not be used due to the RSD, so your "icing" after injection would not be possible for me. You also say I should be immobilized for 3 days - how??? Put in a brace or something? I saw your blog page where you say "never" inject long-lasting cortisone into a tendon or into it's sheath so now I am extremely confused/ worried/ and scared of more permanent damage as I already live with large level of disability with the RSD, the crushed foot, (and also my back was broken and I had a kyphroplasty to repair two crushed vertebraes).
Dr Blake's comment: Yes, do no harm. One idea is to inject long acting local anesthetic into the sheath, after 30 minutes of Synera Patch, and use an ankle brace to protect the ankle for the next 6 hours. This will tell you diagnostically if the peroneal tendon is the source of your pain. Be prepared for a 4 day flare of RSD which can be eased by the understanding that it will past, meditating, see if you can get sublingual Ketamine for the flare, and getting off your foot for several days. Definitely talk to the pain specialist and surgeon about how you will handle a flare post shot so you all have a plan. 

    Since my surgeon is actually "internationally" well-known as one of the best in the business today, I worry about constantly questioning him or telling him I read this or that that contradicts what he says to me, etc.
Dr Blake's comment: You have to feel that what you are getting done is the best. There are so many conflicting bits of information, that I constantly doubt my decisions, but at some point my patients and I have to make them. There is many rights and many wrongs. And, we all get tunnel vision in one approach. What does the pain specialist say? Does he understand about RSD pre and post surgical protocols? What are all the treatments for CRPS you are undergoing? Are you going to consider Ketamine Infusions? If you can get the CRPS calmed down, I would feel a lot better talking about injections, etc.

   " Short-acting shots normally are beneficial for 3 days and are used to quickly reduce inflammation. They are commonly betamethasone (6mg/ml) or dexamethasone (4mg/ml) formulas. Since even short-acting cortisone can cause damage/weakness to tendons, if given into tendon sheaths the body part should be immobilized for the 3 days. It is the long-acting shots that are the true healers when the inflammation is out of control, and normally what people are talking about when it comes to a cortisone shot. Long-acting cortisone shots should never be given into tendon or tendon sheaths (the covering of the tendon) since they are associated with tendon ruptures. It is important to keep the cortisone as far away from the neighboring tendons as possible." (excerpt from Dr Blake's blog).

    Since your "blog" page is from May of 2010, I am wondering if the cortisone issue has more recently been rethought and would appreciate any updated thoughts you may have. I really have encountered so much conflicting information, I feel like just giving up any hope of returning to how I was before the accident.
Dr Blake's comment: This is still my thoughts, and there has been no change in cortisone makeup or tendon anatomy. I would focus right now on getting a possible local anesthetic shot first as mentioned above, if your pain specialist feels that a shot can be safely given with perhaps sublingual Ketamine, to prove you may be a candidate for peroneal injection. Only then, should be again weigh the odds of cortisone into a tendon sheath. I hope this helps you some. Answering an email like this always makes me feel small, humble, somewhat stupid, and unbelievably touched with a sacredness. Thank you. Rich

Graded Motor Imagery: Chronic Pain Tool and Loss of Body Sensation Tool

I would like to introduce a fascinating topic called "Graded Motor Imagery". I have several patients who have used the technique to help with their pain or nerve syndromes, several patients who have been exposed to it, and many more that I will now expose and emphasize as part of their pain treatment. The Noi Group has a well organized website to let you get started. The photos below are part of the process of laterality--recognizing which side of the body a photo is taken. Amazingly, in many nerve injuries, we lose the ability of our nervous system to process this.  I hope the videos, websites, and photos are a good enough start to help you or a loved one in the overwhelming process of healing when all seems to be losted. It is many times that the spouse or friend must help the patient take the initial steps towards healing. This is a process that can be done alone, or helped tremendously with another.




http://www.gradedmotorimagery.com/

http://www.noigroup.com/en/Category/BT

http://www.ncbi.nlm.nih.gov/pubmed/15109523


These photos are part of the first and very vital steps in Graded Motor Imagery called Laterality. The links above contain the website to login and begin the process now. The patient is asked to identify which foot is being shown, and later asked to imagine their foot in that position.

David Butler is a physiotherapist in Australia. After you hear this 40 minute presentation broken in 4 parts, you will want to have him over and make him your best friend. What a character!! I believe the main parts of this process are adequately introduced. 

Here a patient with complex regional pain syndrome explains her use of mirror therapy in a touching manner.