For a history of the evolution and scientific basis for diagnostic criteria for RSD / CRPS:

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The staging of RSD / CRPS is a concept that has died.(Reference 53)

The course of the disease seems to be so unpredictable between various patients that staging is not helpful in the diagnosis and treatment of RSD / CRPS. The following stages are presented in these guidelines merely for historical significance.

Figure 2 illustrates a typical treatment protocol that was designed to rehabilitate the patient in the shortest possible time. Initiate the safest, simplest, and most cost-effective therapies first. If the patient fails to progress in mobilizing the extremity, it is essential to offer the patient a series of 3 sympathetic blocks immediately. The purpose of the sympathetic blocks is three-fold: to treat, to diagnose if the pain is sympathetically maintained and to provide prognostic information. The sympathetic block provides a prognostic indicator if sympathectomy or other treatment modalities would be the next appropriate step. Sympathetic blocks are discussed in detail below.

After the physician has completed a defined course of treatment (e.g. a series of 3-6 sympathetic blocks), it would be helpful to prepare an update report that would document the patient's response to the course of treatment. The report should reflect a basis for further treatment and it should address future rehabilitation needs. Sharing a copy of the update report with the patient will help ensure that all parties are kept informed. Sharing the report with the patient helps keep the patient and physician focused on achieving appropriate therapeutic goals. An update report should address five areas of care:

Psychiatric illness or personality disorder does not cause RSD / CRPS but it is likely that personality contributes to the disease.^14,15 Patients with severe, advanced stage RSD / CRPS usually undergo a psychosocial evaluation during the series of sympathetic blocks or prior to offering the patient more invasive treatments. In some cases, a formal psychosocial evaluation should be initiated much earlier in the course of treatment. For example, children with RSD / CRPS may require a thorough evaluation to determine the family support structure and the coping mechanisms needed by the family for optimal rehabilitation of the child.

The psychosocial evaluation should always be done by an expert in chronic pain and should always include an assessment of pain coping skills and drug abuse potential. Stress is a known cause of exacerbation of this disease, making emergency treatment more necessary. A lot of memorials sent to fund RSD / CRPS research are the result of suicides!The potential for committing suicide needs to be assessed.A report onCNN News points to the problem of suicide in children with RSD / CRPS.

The patient may need to participate in a formal pain management program as an outpatient or an inpatient. Chronic pain patients referred for a psychosocial evaluation tend to be defensive. An MMPI or other psychological test can help identify the psychosocial problems. Patients must be properly motivated to improve their coping skills; otherwise, application of these psychosocial modalities is a waste of time. Relaxation techniques (e.g. breathing exercises) as well as biofeedback and self-hypnosis may be appropriate treatment modalities for some patients.

Try to initiate sequential trials for each modality of therapy. The application of multiple therapies at the same time, a shotgun approach, makes it almost impossible to evaluate and optimize an individual therapy for safety and efficacy. Patients must be advised that the optimal dose for medications varies greatly among patients. Therefore, it is usually necessary to gradually increase the dose of their medication to the point of a side effect in order to determine optimal dose. The dose is then reduced to the next lower level. Thus it is important for the patient to become familiar with all of the potential side effects of a medication before trying it. Sequential trials with many different drugs may be required to determine the best medication for the patient.

Medications are generally prescribed according to the following characteristics of the pain:

"Off-labeling" prescribing means that a government (e.g., the U.S. Food and Drug Administration - FDA) approved the medication for one purpose but it is used by physicians for another purpose. For example, aspirin is a pain medication but it can also be used to decrease the risk of a heart attack by inhibiting the aggregation of platelets. Off-label prescribing is a common practice in treating various chronic pain problems. Some of these drugs have been proven to be effective in decreasing pain due to nerve injury (neuropathic pain) in well-controlled clinical trials. Since RSD / CRPS is believed to be caused by nerve injury (neuropathic pain), these drugs are used to treat this condition as well. The patient should consider weaning themselves from these various medications periodically with the treating physician's knowledge to determine for themselves that the medication is actually helping to alleviate their symptoms. Some medications need to be weaned slowly (e.g. narcotics, baclofen) to minimize withdrawal symptoms.

Medications commonly used to treat RSD / CRPS based on the type of pain include:

Patients may require immediate and adequate pain relief. In some cases it may take time to transpire from the time of the patients first visit to the time of adequate treatment. In all probability, the pain and degenerative cycle would progress. Since the abuse potential is minimal when narcotics are used for severe pain, practitioners should not withhold narcotic treatment, if the patient demonstrates pain relief with this medication. For a free video on the use of opioids to treat RSD / CRPS

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Transcript of Live 2-Hour Conference

For the treatment of sympathetically maintained pain (SMP)

Clonidine Patch. Studies suggest that clonidine may decrease pain in RSD /CRPS by inhibiting the sympathetic nervous system.^21,22 A treatment protocol for using the Clonidine Patch to treat RSD / CRPS can be found in the journal Regional Anesthesia.²³

Video Presentations of Sympathetic Nerve Blocks

To view a sympathetic nerve block to the face and upper extremity

Stellate Ganglia Block in Adult

To view a sympathetic nerve block to the lower extremity

Lumbar Sympathetic Block in Adult

To view "bowing of needle technique" for a lumbar sympathetic block

Anesthesiology. 89(6):1606-1607, 1998

Bowing Technique

Sympathetic Nerve Blocks in Children -- NEW

Stellate Ganglia Block in Children

Lumbar Sympathetic Block in Children

Illustrations

by Lisa Clark

Clark Medical Illustrations

A temporary trial, with a temporary electrode, should be performed first before implanting permanent electrode(s). Given that SCS is a relatively invasive, costly procedure and given that RSD / CRPS patients are often desperate and frustrated, a baseline psychosocial evaluation that addresses pain management issues should be considered. Although rare, spinal infection and paralysis are potential complications. The ability to insert the electrode through a small needle has reduced the risk of the procedure and has facilitated the trial with a temporary electrode.

Treating RSD / CRPS with SCS poses unusual clinical and technical problems. RSD / CRPS tends to be an unpredictable disease from a technical standpoint. The need to focus SCS on the most painful region must be kept in mind, which is more difficult in RSD / CRPS, because the location of the worst pain may change. Furthermore, the pain from RSD / CRPS may spread to distant parts of the body, requiring multiple successive implanted stimulators to cover the largest possible area. Therefore, even when RSD / CRPS is limited to one extremity, it is wise to widen stimulation to zones to which the pain might spread.

Because of the risks and high costs of spinal cord stimulation, the treatment is reserved for severely disabled patients. A recent well-controlled study shows that with careful selection of patients and successful test stimulation, SCS is safe, reduces pain, and improves the health-related quality of life in patients with severe RSD / CRPS.^46,47

~ NEW ~

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Advances In Neurostimulation Systems

 

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Transcript of Video

 

 

References

 

 

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