stage 1 cprs type I

[indytravl]

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hi,
does anyone have suggestions for management of early CPRS. Pt is 60yowf who had orthopedic surgery on R foot. ~4wk post-op, developed intermittent vasomotor instability (swelling, redness, sweating) in RLE. has intermittent mild-mod neuropathic pain & is currently only on her oxycodone prn. the orthopod has recognized it & is following her pretty closely & has ordered PT.

have read something about nutrition, vit c, & maintaining rom to help with it at this early stage of the condition. she's also putting the limb in ice intermittently or rubbing with towel (guess to desensitize). notes that heat actually aggravates it in the shower. have also read that ice is NOT a good thing to use.

can anyone suggest anything that may help limit/cure early rsd?

thanks

 

[caedmon]

The literature is not great for acute medical managment. I have seen and heard of other people getting good responses with oral steroid therapy. From a modality standpoint, contrast baths and compression with "isotoner glove" therapy work pretty well. For intractable cases, I belive some people are doing stellate ganglion blocks and even spinal cord stimulation.

 

[indytravl]

thanks for the input.

for oral steroids, could you be more specific? is it just a standard prednisone taper, or what dose. what about dexamethasone po?

contrast baths meaning alternating between hot & ice?

is there something that can be ordered that's an isotoner stocking since this is in pt's foot/leg?

nerve blocks have been mentioned but I had the impression that is in later stages. or is that too considered for such an early detected rsd?

appreciate your help.

 

[lobelsteve]

30mg bid x 3 weeks
20mg bid x 1 week
10mg bid x 1 week
10mg qd x 1 week

Lumbar sympathetic block weekly to allow PT desensitization, mobilization.
Opioids, adjuncts- Lyrica, Cymbalta, Neurontin, Elavil- take your pic.

Early intervention is critical to reducing long term sequela risk.

 

[drvlad2004]

thanks for the input.

for oral steroids, could you be more specific? is it just a standard prednisone taper, or what dose. what about dexamethasone po?

contrast baths meaning alternating between hot & ice?

is there something that can be ordered that's an isotoner stocking since this is in pt's foot/leg?

nerve blocks have been mentioned but I had the impression that is in later stages. or is that too considered for such an early detected rsd?

appreciate your help.

In our clinic, we tend to give a Medrol 5 day dose pack. Stellate ganglion, especially in the early stages, can be therapeutic and diagnostic.

 

[deleted185747]

Early intervention is critical to reducing long term sequela risk.

Most important

 

[arvanmed]

Gabapentin and Lyrica work well ( if no side effect), a slow release Opioid like OxyContin and percocet for flareups.

 

[indytravl]

again, thanks for the input...



pt's currently on oxycodone prn, outpt PT, massage, ted's, contrast baths at home/work



not really noting a lot of pain & has good rom since worked with PT postop anyway. does have intermittent mild (maybe to mod) neuropathic symptoms, but most of it seems to be autonomic dysfunction with intermittent edema, change in color (redness), & sweating. I don't think the diagnosis of rsd (just made a week or so ago) requires a diagnostic nerve block as the presentation is classic. is there any reason to consider doing it at this point?



is it necessary to add any other med at this point besides steroids? if so, do you suggest the following all together:

1. scheduled long-acting opioid + prn short acting

2. neuropathic agent (gabapentin, pregabalin, etc)

3. prednisone (as suggested by lobelsteve a slow weeks-long taper or medrol dose pack)

4. PT (already re-started for the desensitization)



appreciate

 

[rehab_sports_dr]

put in another vote for contrast baths

 

[lobelsteve]

I think the steroids are essential. Why not add in Lyrica (not a speaker for Pfizer) for the pain?

Topical lidocaine, neurontin, ketoprofen in a PLO or lipofil base. Apply to affected area 3-4 x daily.

As per crosspost in Pain Forum. LSB is not diagnositc in this situation (stellate is for upper extremity), it will be therapeutic and can be repeated weekly to allow further / more intense PT.

 

[Spine Specialist]

put in another vote for contrast baths

Never use cold water or ice in CRPS. Ice is contraindicated.

 

[indytravl]

appreciate continued input in this case of early rsd.

so, there's conflicting thought about contrast bath & ice at this stage.

to clarify at what point to try a sympathetic nerve block in this situation....
later if failed med therapy?
OR
now alongside the slow weeks-long prednisone taper?

dr.lobel,
you're thinking of starting pregabalin pre-emptively as there is an aspect of neuropathic pain currently & it is sympathetically-mediated pain?
question is how much meds to start on a regular basis in this pt whose rsd has been caught so early & who does not have limitations in movement but does have mild neuropathic pain, mild-mod somatic pain, & vasomotor instability?
any thoughts on need to change from short-acting prn oxycodone to scheduled long-acting + prn?

thank you everyone & please keep suggestions/thoughts coming

 

[Spine Specialist]

appreciate continued input in this case of early rsd.

so, there's conflicting thought about contrast bath & ice at this stage.

You can do more harm than help by recommending ice and contrast bath in early CRPS. Ice increases reflex vasospasm and vasomotor instability which worsens the situation leading to stage 2 CRPS.

 

[indytravl]

spine specialist,
so you suggest PT, not contrast baths, & ... what else?
thanks

 

[Spine Specialist]

spine specialist,
so you suggest PT, not contrast baths, & ... what else?
thanks

I have nothing much to add to other posters treatment suggestions. Lastly, I will give a lot of reassurance to the patient because this is a 'complex' disease which can be aggravated by psychological stress. Clinical psychology referral is not a bad idea if symptoms progress.

 

[ampaphb]

In our clinic, we tend to give a Medrol 5 day dose pack.

What is the proposed mechanism of action that would justify the use of steroids, either PO or via interventions, in these instances? It seems to me SMP is supposed to be an over-reaction of the system (ie. wind-up). Without an inflammatory component, I do not understand what the therapeutic role steroids play in these circumstances.

 

[FISHERMAN]

these are the most common management:
1-PT ROM,FIRST IN PAIN FREE ARC THEN WHEN PAIN DECREASED INCREASE ROM TO AVOID CONTRACTURE AND MUSCLE ATROPHY
2- YOU CAN START PREDNISON 40 MG PER DAY FOE 3-4 DAYS THEN 30 MG FOR 3 DAYS THEN 20 MG FOR 3 DAYS THEN 2O MG FOR 3 DAYS THEN 10 MG FOR 3 DAYS THEN 5 MG FOR 3 DAYS.
3- GABAPENTIN(NEURORENTIN) START BY 300 MG PO QHS FOE 3 DAYS IF EFFECTIVE CONTINUE ON THE SAME DOSAGE IF NOT INCRESE GRADUALLY TO 300 MG BID AND SO ON YOU CAN REACH UP TO 3600 MG PER DAY(1200MG PO TID) , ALSO YOU MAY USE PREGABLIN (LYRICA) 75 MG PO BID YOU CAN GO UP TO 400 MG.
4- FOR NUMBNESS AND TINGLING IN A DEFINED AREA YOU MAY USE CAPSACAIN OINT TO BE APPLIED BID ON THE AFFECTED FOOT.
5- aLSO mODALITIES AS CONTRAST BATH MAY BENFIT.