painfre

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I have a patient referred to me after Left ulnar nerve transposition( 6 months ago) with subsequent infection and I&D and now developed CRPS symptoms. My first option is to do stellate ganglion block. Most of my Patients who received block in the past reported about 3-4 days or max 1 week relief with inj. Does any one do cervical epidurals with corticosteroid in these patients with out using any local ? any thoughts of injecting at the transposition site with Local and corticosteroid?

Thanks
 

lobelsteve

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Stellate every 1 to 2 weeks only if aggressive PT.

If done with PT or has not been through PT, this is mandatory.

SCS. No role for ESI or peripheral blocks if CRPS.
 

joshmir

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Yes Steve is correct; no role for peripheral blocks for CRPS

What I meant to say was place interscalene catheter lowish and slowly bolus until you get a Horner's syndrome/sympathectomy if you feel you want to effect a stellate ganglion continous block

But if the guy does not get great prolonged benefit from stellate, I would move quickly to SCS
 

clubdeac

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I agree, no role for ESI. And not to steal but I will, does anyone have any papers showing better outcome with early use of stim for CRPS vs late use. I had a neurologist ask me this and told him, the earlier the better but I couldn't find any data to back it up...
 

PinchandBurn

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Stellate every 1 to 2 weeks only if aggressive PT.

If done with PT or has not been through PT, this is mandatory.

SCS. No role for ESI or peripheral blocks if CRPS.
Not completely accurate.

Please google, Kenneth Candido and Alon Winnie's chapters in Raj's Textbook for pain management. Actually, peripheral brachial plexus blocks (supra clav, infraclav, etc) are in some circles thought to be better than a SGB for CRPS. The main reason is that they also get the nerves of Kuntz. Additionally, they've done studies on this (check out pubmed) and O2 supply to distal extremities have been much more increased and more profound increase in temp s/p brachial plexus. Furthermore, some would argue safer than SGB.

I've talked to some guys at an ASRA meeting about epidurals for CRPS. I completely agree SGB and brachial plexus blocks are the mainstay for sympathetically meeted pain. however, these academic guys stated that epidurals can cause more of a stronger sympathetectomy, which can be more profound than a LSB or even SGB. Most anesthesiologists know this because when we did OB anesthesia we woudl see this all teh time. The reason that epidurals are NOT favored is that at the doses needed it obviously causes motor paralysis,etc.....
 

lobelsteve

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Not completely accurate.

Please google, Kenneth Candido and Alon Winnie's chapters in Raj's Textbook for pain management. Actually, peripheral brachial plexus blocks (supra clav, infraclav, etc) are in some circles thought to be better than a SGB for CRPS. The main reason is that they also get the nerves of Kuntz. Additionally, they've done studies on this (check out pubmed) and O2 supply to distal extremities have been much more increased and more profound increase in temp s/p brachial plexus. Furthermore, some would argue safer than SGB.

I've talked to some guys at an ASRA meeting about epidurals for CRPS. I completely agree SGB and brachial plexus blocks are the mainstay for sympathetically meeted pain. however, these academic guys stated that epidurals can cause more of a stronger sympathetectomy, which can be more profound than a LSB or even SGB. Most anesthesiologists know this because when we did OB anesthesia we woudl see this all teh time. The reason that epidurals are NOT favored is that at the doses needed it obviously causes motor paralysis,etc.....
Sorry, ESI may be useful in inpatients with tunnelled catheters. Infection rates as high as 31% (but generally lower). BPB case reports only.

Many have adopted epidural infusion techniques as next- line therapy for patients failing intermittent blocks with moderate evidence for efficacy of epidural clonidine. This
34procedure is technically easy to perform, with level 3 evi- dence supporting epidural clonidine infusion as outlined earlier. Some centers have utilized the plexus infusions described earlier, but the epidural techniques are more common. The main drawback to these infusion tech- niques is the rate of infection, which remains to be defined by further prospective study on infusion techniques in CRPS patients.

IVRA
IVRA has been used for years to empirically treat CRPS [317]. Numerous IVRA medications alone and in combi- nation have been reported to have efficacy in treating CRPS. IVRA with guanethidine, lidocaine, bretylium, cloni- dine, droperidol, ketanserin, or reserpine have been described and reviewed critically by Perez et al., Forouza- nfar et al., and Kingery [46,134,197].
Perez et al. undertook a meta-analysis of the highest quality (blinded, with re-evaluation of included trials, sta- tistical methodology, and inclusion only of trials meeting strict inclusion criterion such as randomization, blinding, sample size, dropout rate, and others), finding 11 accept- able trials of "sympathetic suppressors," nine being IVRA studies and six concerning guanethidine in particular [197]. Perez et al. applied a quantitative analysis of effect size that compares the difference in pain relief between experimental and control groups, with a correction factor applied for trial size. This method has become acceptable in meta-analysis to analyze aggregate treatment effect from numerous studies. Their aggregate analysis showed lack of proven effect of IVRA and lack of proven effect more specifically of guanethidine IVRA (thus level 1 evi- dence for lack of proven effect of these therapies).

SCS if lesser options fail.
 
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epidural man

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Stellate every 1 to 2 weeks only if aggressive PT.

If done with PT or has not been through PT, this is mandatory.

SCS. No role for ESI or peripheral blocks if CRPS.
There is no data for aggressive PT that shows any benefit for CRPS - unless you are talking about Graded Motor Imagery physical therapy, or PT with mirror therapy. GMT and mirror have pretty good evidence - everything else has evidence that shows it doesn't work - and basically we are torturing our patients with PT. GMT works great - but I have yet met a PMR doc or physical therapist that know how to do it.

There certainly is a role for epidural (not ESI) deposition of local anesthetic or clonidine. Also, there certainly is a role for peripheral blocks. In fact, the level of evidence for epidural or peripheral nerve deposition equals that of the evidence for sympathetic blocks.

They all suck in evidence actually - Level 2C+. The best evidence (2B+) is SCS.

Epidural
Cooper et. al. 1992, J Bone Joint Surg A (2 to 3 days of LA in 14 patients. 11/14 had complete resolution of symptoms)
Rauch et. al. 1993, Anesthesiology - used clonidine (blinded RCT).
Buchheit et. Al. 2000, Reg Anesth Pain Med (30 patients) - good results 6 weeks post infusion
Moufawad et. Al. 2002, Pain Practice (37 patients - they noted improvement if treated CRPS within 1 year)

Peripheral block
Ribbers et. al. 1997, Int J Rehabil Res
Gibbons et. al. 1992, Clin J Pain

There is even the same level of evidence (2C+) for peripheral nerve stim for CRPS.
 

epidural man

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I agree, no role for ESI. And not to steal but I will, does anyone have any papers showing better outcome with early use of stim for CRPS vs late use. I had a neurologist ask me this and told him, the earlier the better but I couldn't find any data to back it up...
The biggest trial to date that shows SCS works for CRPS (5 year data) was from the Kemler et al. 2oo8 J Neurosurg article. In this trial, the duration of symptoms at the onset of the trial didn't seem to matter at response rates. I think other SCS trials support this as well.
 

PinchandBurn

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Sorry, ESI may be useful in inpatients with tunnelled catheters. Infection rates as high as 31% (but generally lower). BPB case reports only.

Many have adopted epidural infusion techniques as next- line therapy for patients failing intermittent blocks with moderate evidence for efficacy of epidural clonidine. This
34procedure is technically easy to perform, with level 3 evi- dence supporting epidural clonidine infusion as outlined earlier. Some centers have utilized the plexus infusions described earlier, but the epidural techniques are more common. The main drawback to these infusion tech- niques is the rate of infection, which remains to be defined by further prospective study on infusion techniques in CRPS patients.

IVRA
IVRA has been used for years to empirically treat CRPS [317]. Numerous IVRA medications alone and in combi- nation have been reported to have efficacy in treating CRPS. IVRA with guanethidine, lidocaine, bretylium, cloni- dine, droperidol, ketanserin, or reserpine have been described and reviewed critically by Perez et al., Forouza- nfar et al., and Kingery [46,134,197].
Perez et al. undertook a meta-analysis of the highest quality (blinded, with re-evaluation of included trials, sta- tistical methodology, and inclusion only of trials meeting strict inclusion criterion such as randomization, blinding, sample size, dropout rate, and others), finding 11 accept- able trials of “sympathetic suppressors,” nine being IVRA studies and six concerning guanethidine in particular [197]. Perez et al. applied a quantitative analysis of effect size that compares the difference in pain relief between experimental and control groups, with a correction factor applied for trial size. This method has become acceptable in meta-analysis to analyze aggregate treatment effect from numerous studies. Their aggregate analysis showed lack of proven effect of IVRA and lack of proven effect more specifically of guanethidine IVRA (thus level 1 evi- dence for lack of proven effect of these therapies).

SCS if lesser options fail.
Steve-

I agree SCS is a good option, no question.

In fact even Prithi Raj was doing brachial plexus bloks for CRPS.

I agree with you that IVregional Anesthesia is of minimal benefit, I'm not advocating that. That is very different from Brachial Plexus blocks...
 

drf

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I've used peripheral nerve blocks to diagnose specific lesions and then sent the patient to a nerve surgeon for surgical cure of CRPS.

Pt with typical pain and SSx of CRPS. Pain out of single nerve or dermatome. Diagnostic blockade of various nerves until one or two actually take the pain away. Cut and bury the nerve.

That stated I probably undiagnose more CRPS then diagnose CRPS on referrals. However I've been surprised that even the autonomic symptoms abated with a single nerve block in the periphery.

So I still go fishing for a lesion in these folks even if I think it's a central process.

I will also say I've had CRPS pts in which a spinal didnt take the pain away.
 

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There is no data for aggressive PT that shows any benefit for CRPS - unless you are talking about Graded Motor Imagery physical therapy, or PT with mirror therapy. GMT and mirror have pretty good evidence - everything else has evidence that shows it doesn't work - and basically we are torturing our patients with PT. GMT works great - but I have yet met a PMR doc or physical therapist that know how to do it.
it depends on your review of the literature - consensus seems that, there are limited well done studies, but PT of some sort (desensitization therapy is what i recommend) seems to be considered a mandatory part of therapy. a very quick google search, more to follow when not so late...

PT and cognitive therapy for CRPS

Conclusion of article is lack of evidence is not sign of lack of benefit
 

pastafan

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Arrow makes a continuous brachial plexus catheter and I have found it an effective treatment for CRPS. Catheter is placed, dosed, and then the patient gets re-bolused daily for a total of 3-5 days depending on response. We combine this with PT while the block provides some analgesia.
 

drf

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Arrow makes a continuous brachial plexus catheter and I have found it an effective treatment for CRPS. Catheter is placed, dosed, and then the patient gets re-bolused daily for a total of 3-5 days depending on response. We combine this with PT while the block provides some analgesia.
Consider an On-Q pump. A little ball with 400 ml of local and you can dial in a rate of your choice. Usually good for 2-3 days. And outpt.
 

epidural man

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it depends on your review of the literature - consensus seems that, there are limited well done studies, but PT of some sort (desensitization therapy is what i recommend) seems to be considered a mandatory part of therapy. a very quick google search, more to follow when not so late...

PT and cognitive therapy for CRPS

Conclusion of article is lack of evidence is not sign of lack of benefit
I don't think CRPS in kids is comparable to adult CRPS - so probably that study isn't applicable.

Attached is a nice review on physiotherapy and CRPS. Although I agree with you that lack of evidence is not a sign of lack of benefit - the review included several articles with okay level of evidence that demonstrate a lack of benefit for traditional PT.

What I find interesting is that I had always learned - as strict dogma - that PT was the true savior for PT - yet no one could provide any good evidence to it. When I went looking (finally - can't believe it took me so long...so against my nature to just accept dogma) - it was shocking to me that the question HAS been looked at - and it turns out I was mostly just torturing my patients with PT.

I still send them to PT, but only if it is tolerable and not completely miserable for them.
 

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Ducttape

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I don't think CRPS in kids is comparable to adult CRPS - so probably that study isn't applicable.

Attached is a nice review on physiotherapy and CRPS. Although I agree with you that lack of evidence is not a sign of lack of benefit - the review included several articles with okay level of evidence that demonstrate a lack of benefit for traditional PT.

What I find interesting is that I had always learned - as strict dogma - that PT was the true savior for PT - yet no one could provide any good evidence to it. When I went looking (finally - can't believe it took me so long...so against my nature to just accept dogma) - it was shocking to me that the question HAS been looked at - and it turns out I was mostly just torturing my patients with PT.

I still send them to PT, but only if it is tolerable and not completely miserable for them.
the devil again is in the details. They look at many studies, note they cannot pool data, then draw conclusions essentially by pooling studies.

regardless, their endcriteria for evidence of benefit is in the area of pain, not in the arena of functionality. the studies almost to a whole were patients with upper extremity CRPS type 1, and not lower extremity or type 2.

"The data contained in Table 8b illustrate that significant
changes between pre and post measurements were gained for
two types of physiotherapy. Sensorimotor treatment reduced pain
and increased tactile discrimination (Pleger et al., 2005) whereas a
graded exposure in vivo program significantly reduced pain related
fear and pain disability (de Jong et al., 2005). Mirror visual feedback
appears to reduce the perception of pain in early CRPS-1
and stiffness in intermediate CRPS-1 (Table 8b) (McCabe et al.,
2003) and an interdisciplinary pain management program increases
function in CRPS-1 (Table 5) (Singh et al., 2004)."
my take home message - this review doesnt say anything about lower ext. crps, and the primary outcomes measures were pain ones, not those dealing with functionality.

the study by Singh does support PT in a interdisciplinary pain management program....
 

ampaphb

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Complex regional pain syndrome type I: efficacy of stellate ganglion blockade.
J Orthop Traumatol. 2009 Dec;10(4):179-83.
Yucel I, Demiraran Y, Ozturan K, Degirmenci E.

MATERIALS AND METHODS: We performed three blockades at weekly intervals in 22 patients with CRPS type I in one hand. The patients were divided into two groups depending on the time between symptom onset and treatment initiation. Group 1and 2 patients had short and long symptom-onset-to-treatment intervals, respectively. Pain intensity, using a visual analog score (VAS), and range of motion (ROM) for the wrist joint were assessed before and 2 weeks after treatment and were compared using nonparametric statistical analysis.

RESULTS: Treatment produced a statistically significant difference in wrist ROM for all patients (P < 0.001). VAS values showed an overall decrease from 8 +/- 1 to 1 +/- 1 following treatment, and there was a significant difference in VAS value between groups 1 and 2 (P < 0.05).

CONCLUSIONS: We concluded that stellate ganglion blockade successfully decreased VAS and increased ROM of wrist joints in patients with CRPS type I. Further, the duration between symptom onset and therapy initiation was a major factor affecting blockade success.
 
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clubdeac

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Complex regional pain syndrome type I: efficacy of stellate ganglion blockade.
J Orthop Traumatol. 2009 Dec;10(4):179-83.
Yucel I, Demiraran Y, Ozturan K, Degirmenci E.

MATERIALS AND METHODS: We performed three blockades at weekly intervals in 22 patients with CRPS type I in one hand. The patients were divided into two groups depending on the time between symptom onset and treatment initiation. Group 1and 2 patients had short and long symptom-onset-to-treatment intervals, respectively. Pain intensity, using a visual analog score (VAS), and range of motion (ROM) for the wrist joint were assessed before and 2 weeks after treatment and were compared using nonparametric statistical analysis.

RESULTS: Treatment produced a statistically significant difference in wrist ROM for all patients (P < 0.001). VAS values showed an overall decrease from 8 +/- 1 to 1 +/- 1 following treatment, and there was a significant difference in VAS value between groups 1 and 2 (P < 0.05).

CONCLUSIONS: We concluded that stellate ganglion blockade successfully decreased VAS and increased ROM of wrist joints in patients with CRPS type I. Further, the duration between symptom onset and therapy initiation was a major factor affecting blockade success.
Thanks Peter!
 

jesspt

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There is no data for aggressive PT that shows any benefit for CRPS - unless you are talking about Graded Motor Imagery physical therapy, or PT with mirror therapy. GMT and mirror have pretty good evidence - everything else has evidence that shows it doesn't work - and basically we are torturing our patients with PT. GMT works great - but I have yet met a PMR doc or physical therapist that know how to do it.There certainly is a role for epidural (not ESI) deposition of local anesthetic or clonidine. Also, there certainly is a role for peripheral blocks. In fact, the level of evidence for epidural or peripheral nerve deposition equals that of the evidence for sympathetic blocks.

They all suck in evidence actually - Level 2C+. The best evidence (2B+) is SCS.

Epidural
Cooper et. al. 1992, J Bone Joint Surg A (2 to 3 days of LA in 14 patients. 11/14 had complete resolution of symptoms)
Rauch et. al. 1993, Anesthesiology - used clonidine (blinded RCT).
Buchheit et. Al. 2000, Reg Anesth Pain Med (30 patients) - good results 6 weeks post infusion
Moufawad et. Al. 2002, Pain Practice (37 patients - they noted improvement if treated CRPS within 1 year)

Peripheral block
Ribbers et. al. 1997, Int J Rehabil Res
Gibbons et. al. 1992, Clin J Pain

There is even the same level of evidence (2C+) for peripheral nerve stim for CRPS.
From a PT perspective, I could never understand how making a patient with sympathetic or centrally mediated symptoms more painful with a treatment was going to improve their pain or function over time. So, I would totally agree with the statement that "traditional" or "aggresive" PT is a waste of time unless your goal by referring to PT is to make the patient hate the therapist and, possibly, you. And, I've never seen any convincing data that suggests otherwise.

I do think that Graded Motor Imagery offers some hope to patients with CRPS, but that research is in it's infancy, and is currently conflicting. Here is the best repository of papers regarding its use that I have come accross: http://www.bodyinmind.org/resources/journal-articles/gmi-articles/ There is a wealth of great information about chronic pain available on the site.

And in regards to the use of GMI in the clinic, and finding a practitioner who can do it, I've had a hard time finding any physicians who know what it is, let alone what its indications for use might be. It's a non-sexy, non-pharmacological treatment for a condition that is frustrating for clinicians of all walks of life to treat. That doesn't exactly make for widespread awareness.
 

SSdoc33

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From a PT perspective, I could never understand how making a patient with sympathetic or centrally mediated symptoms more painful with a treatment was going to improve their pain or function over time. So, I would totally agree with the statement that "traditional" or "aggresive" PT is a waste of time unless your goal by referring to PT is to make the patient hate the therapist and, possibly, you. And, I've never seen any convincing data that suggests otherwise.

I do think that Graded Motor Imagery offers some hope to patients with CRPS, but that research is in it's infancy, and is currently conflicting. Here is the best repository of papers regarding its use that I have come accross: http://www.bodyinmind.org/resources/journal-articles/gmi-articles/ There is a wealth of great information about chronic pain available on the site.

And in regards to the use of GMI in the clinic, and finding a practitioner who can do it, I've had a hard time finding any physicians who know what it is, let alone what its indications for use might be. It's a non-sexy, non-pharmacological treatment for a condition that is frustrating for clinicians of all walks of life to treat. That doesn't exactly make for widespread awareness.
so, as a therapist, you would advocate against PT for CRPS? just let the hand turn to stone? ROM to prevent contractures, functional activites to to to prevent muscle wasting, etc? its gonna hurt, but everything PM&R teaches says that therapy is a necessary part of treatment. i find it difficult not referring these patients
 

lonelobo

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From a PT perspective, I could never understand how making a patient with sympathetic or centrally mediated symptoms more painful with a treatment was going to improve their pain or function over time. So, I would totally agree with the statement that "traditional" or "aggresive" PT is a waste of time unless your goal by referring to PT is to make the patient hate the therapist and, possibly, you. And, I've never seen any convincing data that suggests otherwise.

.
How about contrast baths, paraffin , fluidotherapy, desentization treatments as part of PT for these issues?

If you base your treatments on convincing studies in regards to Physical Therapy effiicacy in general, think you should look for a different field.
 

jesspt

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so, as a therapist, you would advocate against PT for CRPS? just let the hand turn to stone? ROM to prevent contractures, functional activites to to to prevent muscle wasting, etc? its gonna hurt, but everything PM&R teaches says that therapy is a necessary part of treatment. i find it difficult not referring these patients
I think I did a poor job of getting my point accross. I'd recommend against referring a patient with CRPS for "aggressive" rehabilitation. I can't see how making a patient with a condition that is sympathetically and centrally mediated significantly more uncomfortable is going to help them at all. But, I do think that a graded exercise program, gentle/minimally noxious desensitization massage that provides novel tactile unpit, and use of Graded Motor Imagery can help with improving ROM, preventing or ******ing disuse atrophy, and may improve some functional use of the affected extremity.
 

jesspt

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How about contrast baths, paraffin , fluidotherapy, desentization treatments as part of PT for these issues?

If you base your treatments on convincing studies in regards to Physical Therapy effiicacy in general, think you should look for a different field.
See my above response. I usually avoid contrast baths, as heating up an extremity that has impaired sympathetic function is often a nice way to make a swollen, purplish extremity more swollen.

And you're right about research re: many PT interventions. I try to apply evidenced based medicine to PT practice, which means applying the current best evidence, not the current perfect evidence. I'm working with what I have...