Complex regional pain syndrome medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [8]
Overview
The medical therapy of complex regional pain syndrome involves the use of a variety of drugs including antidepressants and anti-inflammatories such as corticosteroids. COX-inhibitors such as piroxicam and vasodilators can also be used. Other medications include GABA analogs such as gabapentin and pregabalin, and alpha or beta-adrenergic-blocking compounds. Local anesthetics like lidocaine are often the first step in treatment, but physical therapy is the most important part of treatment. Implantation of spinal cord stimulators, sympathectomy, EEG feedback, psychotherapy, and ketamine are amongst the newer forms of treatment.
Medical Therapy
Physicians use a variety of drugs to treat CRPS, including antidepressants, anti-inflammatories such as corticosteroids and COX-inhibitors such as piroxicam, vasodilators, GABA analogs such gabapentin and pregabalin, and alpha- or beta-adrenergic-blocking compounds.
Elevation of the extremity and physical therapy are also used to treat CRPS.
Injection of a local anesthetic such as lidocaine is often the first step in treatment. Injections are repeated as needed. However, early intervention with non-invasive management may be preferred to repeated nerve blockade. In most cases it is best to have blocks done above the highest level of vasomotor abnormality. The use of topical lidocaine patches has been shown to be of use in the treatment of CRPS-1 and -2 [1]. [2].
Neurostimulation (spinal cord stimulators) may also be surgically implanted to reduce the pain by directly stimulating the spinal cord. These devices place electrodes either in the epidural space (space above the spinal cord) or directly over nerves located outside the central nervous system. Implantable drug pumps may also be used to deliver pain medication directly to the cerebrospinal fluid which allows powerful opioids to be used in a much smaller dose than when taken orally.
Surgical, chemical, or radiofrequency sympathectomy — interruption of the affected portion of the sympathetic nervous system — can be used as a last resort in patients with impending tissue loss, edema, recurrent infection, or ischemic necrosis.[3] However, there is little evidence that these permanent interventions alter the pain symptoms of the affected patients.
Physical therapy is the most important part of treatment, though it should be noted that many patients are incapable of participating in physical therapy due to muscular and bone problems. People struggling with CRPS often develop guarding behaviors where they avoid using or touching the affected limb. Unfortunately, inactivity can exacerbate the disease and perpetuate the pain cycle. Physical therapy works best for most patients, especially goal-directed therapy, where the patient begins from an initial point, regardless of how minimal, and then endeavors to increase activity each week. Therapy should be directed at facilitating the patient to engage in physical therapy, movement and stimulation of the affected areas.
Some treating physicians have even initiated physical therapy under light general anesthesia, in an attempt to remobilize the extremity. While the unpredictability of this illness often causes a frustrating pattern of progress and regress. Physical therapy can be very dangerous too, if bone and tissue damage has already occurred. It should only be used with extreme caution.
A study in 2007 indicated that Collateral Meridian Therapy [4] was effective in lowering CRPS patient's VAS pain score.
EEG Biofeedback[5], various forms of psychotherapy[6], relaxation techniques and hypnosis [7] are adjunctive treatments which assist coping.
Ketamine Therapy
Ketamine, a potent anesthetic, is being used as an experimental and controversial treatment for Complex Regional Pain Syndrome. The theory of ketamine use in CRPS/RPS is primarily advanced by neurologist Dr Robert J. Schwartzman of Drexel University College of Medicine in Philadelphia, and researchers at the University of Tübingen in Germany. The hypothesis is that ketamine manipulates NMDA receptors which might reboot aberrant brain activity.
There are two treatment modalities; the first consist of a low dose ketamine infusion of between 25-90 mg per day, delivered over five days either in hospital or as an outpatient. This is called the awake technique.
Open label, prospective, pain journal evaluation of a 10-day infusion of intravenous ketamine (awake technique) in the CRPS patient concluded that "A four-hour ketamine infusion escalated from 40-80 mg over a 10-day period can result in a significant reduction of pain with increased mobility and a tendency to decreased autonomic dysregulation".[8]
The second treatment modality consists of putting the patient into a medically-induced coma, then administering an extremely high dosage of ketamine; typically between 600-900 mg.[9] This version, currently not allowed in the United States, is most commonly done in Germany but some treatments are now also taking place in Monterrey, Mexico.
According to Dr Schwartzman, 14 cases out of 41 patients in the induced-coma ketamine experiments were completely cured. "We haven't cured the original injury," he says, "but we have cured the RSD or kept it in remission. The RSD pain is gone."
"No one ever cured it before," he adds. "In 40 years, I have never seen anything like it. These are people who were disabled and in horrible pain. Most were completely incapacitated. They go back to work, back to school, and are doing everything they used to do. Most are on no medications at all. I have taken morphine pumps out of people. You turn off the pain and reset the whole system." [10]
No trials have been done for the coma induced method to date.
This method gained attention in pop culture through season 3 of the FOX television drama House, M.D., which opens a few months after the title character, Gregory House, was placed into a ketamine coma to treat ongoing neuropathy in his right leg. House is shown to have recovered significant use of his right leg (he even goes running regularly), but the treatment eventually wears off and House is once more left in pain and significantly disabled.
References
- ↑ Devers A, Galer BS. (2000). "Topical Lidocaine Patch Relieves a Variety of Neuropathic Pain Conditions: An Open-Label Study". Clinical Journal of Pain. 16: 205&ndash, 208.
- ↑ Frost, SG. (2003). "Treatment of Complex Regional Pain Syndrome Type 1 in a Pediatric Patient Using the Lidocaine Patch 5%: A Case Report". Current Therapeutic Research. 64 (8): 626&ndash, 629.
- ↑ Stanton-Hicks M, Baron R, Boas R, Gordh T, Harden N, Hendler N, Koltzenburg M, Raj P, Wilder R (1998). "Complex Regional Pain Syndromes: guidelines for therapy". Clin J Pain. 14 (2): 155–66. PMID 9647459.
- ↑ [1]Wong CS, Kuo CP, Fan YM, Ko SC. Collateral Meridian Therapy Dramatically Attenuates Pain and Improves Functional Activity of a Patient with Complex Regional Pain Syndrome. Anesthesia & Analgesia 2007;104:452.
- ↑ [2]webpage references: Grunert, BK, Devine, CA, Sanger, JR, Matloub, HS, Green, D. (1990). Thermal self-regulation for pain control in reflex sympathetic dystrophy syndrome. Journal of Hand Surgery. 1990; July 15(4): 615-618.
- ↑ [3]The Psychologist's Role in the Chronic Pain of Reflex Sympathetic Dystrophy. Rosemarie Scolaro Moser, Ph.D. Printed in New Jersey Psychologist, Spring 1999. Pages 24-25.
- ↑ [4] Am J Clin Hypn. 1992 Apr;34(4):227-32. Hypnotherapy for reflex sympathetic dystrophy. Gainer MJ
- ↑ [5] Goldberg ME, Domsky R, Scaringe D, Hirsh R, Dotson J, Sharaf I, Torjman MC, Schwartzman RJ. "Multi-day low dose ketamine infusion for the treatment of complex regional pain syndrome".Pain Physician. 2005 Apr;8(2):175-9.
- ↑ [6] CNN report on Ketamine therapy for CRPS/RSD September 1, 2006
- ↑ [7]Szalavitz, Maia. "Tackling depression with ketamine", New Scientist, January 20, 2007.