Pain Relief: The L.A. Pain Clinic Guideby Sota Omoigui

REFLEX SYMPATHETIC DYSTROPHY

Reflex Sympathetic Dystrophy/Complex Regional Pain Syndrome or RSD/CRPS may be initiated by minor injury with or without damage to a nerve. Such injury results in release of inflammatory chemicals e.g. cytokines. The origin of RSD/CRPS like every other pain syndrome is inflammation and the inflammatory response (Sota Omoigui’s Law of Pain). Most of the literature states that RSD/CRPS is a dysfunction of the sympathetic nervous system. This occurs as a secondary effect of activation of the inflammation pathway in the sympathetic as well as the somatic nerves. The sympathetic system is responsible for our ‘automatic’ response during fright or flight. A prolonged activation of these system results in poor circulation, burning pain and pain that feels like electrical shock. Increased nerve activity results in release of inflammatory neuropeptides such as bradykinin and substance P by the nerves which adds to the inflammatory soup. Other theories of RSD/CRPS state that the disease is due to increased sensitivity of adrenergic receptors for catecholamines in the affected limbs. Another theory is that RSD/CRPS is due to an exaggerated inflammatory response after an injury due to free radical damage to the muscles and nerves. Oxygen derived free radicals and inflammatory neuropeptides are responsible for the breakdown of our bodies, including the joints, skin and organs. Aging, joint, muscle and tissue inflammation, plus poor functioning of the circulatory system, nervous system and immune system often result from free radical damage. Other RSD/CRPS symptoms may include sensitivity to touch, swelling, discoloration, increased sweating, initial warmth followed by coolness of the affected extremity, limited range of motion. Various neurologic signs may also be present such as weakness, tremors, incoordination, myoclonus and muscle spasm. Pain is a manifestation of RSD but severe unrelieved pain can lead to structural or physical damage. This may occur by vicious cycle of pain spasm decreased blood flow impaired usage muscle wasting more pain.
Early intervention and regular check ups with your doctor will help to break the cycle of pain and prevent RSD from progressing.
One of the effective treatments of RSD/CRPS is called a sympathetic block. Your doctor may perform this by injecting local anesthetic in the back, neck or affected nerve. The anesthetics block the sympathetic nervous system and allow the poor circulation to get better. Drugs that help control RSD/CRPS nerve, tissue and bone inflammation include subcutaneous injection of the biologic drug Kineret as well as an intravenous (IV) or intramuscular (IM) injection of cortisone, plus an IV infusion of the anti-seizure drug Depacon combined with IV infusion of magnesium sulfate and IV mini bolus doses of Ketamine. Other medications that help control pain include antispasm/anti-inflammatory drugs such as Zanaflex, anti-seizure drugs like Trileptal, Topamax, Lyrica or Gabapentin, sympathetic blocking oral medication such as clonidine or guanethidine, anti-inflammatory drugs like Tolmetin or Diclofenac, or antidepressant drugs like Lexapro, Vivactil or St. John’s Wort (a herbal antidepressant). Due to pain arising from bone inflammation and bone resorption, IV infusions of osteoporosis anti-inflammatory bisphosphonate medications such as Zometa (Zoledronic acid) which stop the breakdown of bone are an essential part of the treatment. These other medications may significantly increase the pain relief. The antidepressant medication may also help in improving your moods. If your pain returns before the next dose of pain medications is due, you will need long acting strong pain medications to provide background pain relief while still using the short-acting pain medications for any breakthrough pain. In such case your physician may prescribe long acting Morphine, Methadone or Oxycontin tablets to be taken one to two times daily and short acting Vicodin ES or Percocet to be taken every four to six hours as needed. The long acting pain medications need to be taken regularly even when you feel you do not have a lot of pain. A new long acting painkiller your doctor may want to use is a skin patch called Duragesic. This is a very strong pain killer (stronger than morphine) that you wear as a patch over your chest or back. It releases medication slowly through the skin and should be replaced every two to three days. Your short acting pain medications may be used in between. Anesthetic ointments such as Lidocaine or an anti itch cream called Zonalon (Doxepin) may also be used to numb the area of pain. Recently many patients have experienced significant relief from burning skin or nerve pain by applying Dimethylsulfoxide (DMSO),ointment or specially compounded ointments containing various combinations of Ketamine, Neurontin, Ketoprofen or Clonidine. Ketamine is a drug that given intravenously can produce complete anesthesia. It is effective in treating RSD/CRPS but not very popular as it tends to produce hallucinations. These side-effects are not seen with use of the ointment in the proper doses. Relief with Ketamine ointment has been comparable or even superior to that obtained from sympathetic blocks. Local treatment with DMSO ointment in the RSD/CRPS extremity has been reported to be effective. DMSO is a free radical scavenger that is used to promote healing in diabetic ulcers. Take herbal supplements such as Quercetin, Rutin, Curcumin, Red Wine tablets, Cinnamon and Ground Clove Extracts. Eat a diet rich in plants, fruits and vegetables flavored with herbal spices and extracts. They contain polyphenols which are the best anti-inflammatory agents that nature has provided to us. A herbal pill that is a free radical scavenger is pycnogenol, which is an extract of the pine bark. The active ingredients are also found in grape seed extract. Pycnogenol is 50 times more potent as a free radical remover (scavenger) than Vitamin E and 20 times more powerful than Vitamin C. Medications used in special situations include intravenous (IV) or intramuscular (IM) injections of painkillers. These are often used in a hospital or nursing home. There are new machines for hospital and home use called PCA (Patient Controlled Analgesia) pumps. These machines have a user button which when pressed injects a small amount of the pain killer medication through the IV tubing. After an injection, the PCA pump will not deliver medication for a programmed (lockout) period of time e.g. 10 minutes even if the button is pressed. After the lockout time, the PCA pump will deliver medication with the next press of the button. The PCA pump reduces pain medication side effects by allowing you to give yourself frequent small doses rather than occasional big doses. If you have nerve pain, anticonvulsant medications e.g. Neurontin, Tegretol, Valproic acid or Dilantin may help ease the pain. Take the medications regularly. Some of these medications may decrease the production of blood cells so your physician may have to check your blood every few weeks. Occasionally some of these medications may produce a skin rash. Other medications that are used in treating nerve pain include antidepressants like Paxil, St. John’s Wort and strong pain relievers like Vicodin or Oxycontin. Dextromethorphan is a morphine like drug that is used in cough medications to reduce coughing. It does not produce any pain relief by itself. However it prevents development of tolerance to the pain relieving effects of opioids. When used in combination with opioids dextromethorphan may enable a decrease of up to 50% in the amount of opioid required, thus enabling pain relief with fewer side effects e.g. drowsiness. Dextromethorphan may be prepared in a pure form by a compounding pharmacist. Commercially it is often combined with other ingredients such as antihistamines in cough syrups. Local anesthetics used alone or combined with opioids or clonidine may be injected directly into the back using a small tube called an epidural or intrathecal catheter. This may provide long lasting pain relief because the medication acts right at the site of the pain receptors in the spinal cord. Some people have had significant relief of their pain from hyperbaric oxygen treatment. This improves oxygenation of the tissues, removes free radicals, and may help to break the vicious pain cycle. It involves placing a person in a special chamber that administers oxygen at high-pressures such as you get when diving underwater. Learn coping skills to deal with the pain. These skills range from distraction to increasing your activity level. Become busy in something not pain related. Acupuncture and electrical stimulation therapies are sometimes helpful by increasing the body’s production of natural pain killing hormones. Mind body therapies help in pain control by promoting relaxation, hope, control and optimism. These include relaxation training, controlled breathing, meditation, repetitive prayer, visualization, and imagery/distraction techniques, yoga and music therapy. Your doctor may also help you learn to relax by using biofeedback, behavioral modification or hypnosis. Join support groups. These are helpful as they enable you talk to others who have the same problems. You will be able to share your feelings and practice stress reduction and pain control techniques. If you are depressed you may need antidepressant medication and counseling.

Call your Doctor: stop your medications if you have a reaction to any of your medications.

National Organization: The Reflex Sympathetic Dystrophy Syndrome Association of America ( www.rsds.org ). You may request educational booklets