RSD Treatments, Page Two

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=168 BGCOLOR="#000000" TEXT="#F7F7FF" background="042a11c3.gif"> <div> <B>SITE MENU</B></div> <bR> <div> <A HREF="index.htm" TARGET="_top" TITLE="Home Page"><U><B>HOME  PAGE</B></U></A></div> <bR> <div> <A HREF="id43.htm" TARGET="_top" TITLE=" What is Pain??"><U><B>WHAT IS PAIN </B></U></A></div> <bR> <div> <A HREF="id34.htm" TARGET="_top" TITLE="Sympathetic Nervous System"><U><B>SYMPATHETIC NERVOUS SYSTEM</B></U></A></div> <bR> <div> <A HREF="id45.htm" TARGET="_top" TITLE="McGILL PAIN INDEX CHART"><U><B>McGILL PAIN INDEX CHART</B></U></A></div> <bR> <div> <A HREF="id54.htm" TARGET="_top" TITLE=" WHAT DOES RSD LOOK LIKE"><U><B>WHAT DOES RSD LOOK LIKE</B></U></A></div> <bR> <div> <A HREF="id21.htm" TARGET="_top" TITLE="Drug Dependence vs Addiction"><U><B>DRUG DEPENDENCE</B></U></A></div> <div> <A HREF="id21.htm" TARGET="_top" TITLE="Drug Dependence vs Addiction"><U><B>VS</B></U></A></div> <div> <A HREF="id21.htm" TARGET="_top" TITLE="Drug Dependence vs Addiction"><U><B>ADDICTION</B></U></A></div> <bR> <div> <A HREF="id22.htm" TARGET="_top" TITLE="RSD Treatments"><U><B>RSD TREATMENTS</B></U></A></div> <bR> <div> <A HREF="id23.htm" TARGET="_top" TITLE="RSD Treatments, Page Two"><U><B>RSD TREATMENTS</B></U></A></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="RSD Treatments, Page Two"><U><B>PAGE 2</B></U></A></div> <bR> <div> <A HREF="id26.htm" TARGET="_top" TITLE="Face to Face Groups "><U><B>FACE TO FACE</B></U></A></div> <div> <A HREF="id26.htm" TARGET="_top" TITLE="Face to Face Groups "><U><B>SUPPORT</B></U></A></div> <div> <A HREF="id26.htm" TARGET="_top" TITLE="Face to Face Groups "><U><B>GROUPS</B></U></A></div> <bR> <div> <A HREF="id25.htm" TARGET="_top" TITLE="Free Medication programs"><U><B>FREE MEDICATION PROGRAMS</B></U></A></div> <bR> <div> <A HREF="id40.htm" TARGET="_top" TITLE="Personally Recommended RSD Doctors"><U><B>PERSONALLY </B></U></A></div> <div> <A HREF="id40.htm" TARGET="_top" TITLE="Personally Recommended RSD Doctors"><U><B>RECOMMENDED</B></U></A></div> <div> <A HREF="id40.htm" TARGET="_top" TITLE="Personally Recommended RSD Doctors"><U><B>RSD   DRS.</B></U></A></div> <bR> <div> <A HREF="id44.htm" TARGET="_top" TITLE="How to Interview a New Dr."><U><B>HOW TO </B></U></A></div> <div> <A HREF="id44.htm" TARGET="_top" TITLE="How to Interview a New Dr."><U><B>INTERVIEW A</B></U></A></div> <div> <A HREF="id44.htm" TARGET="_top" TITLE="How to Interview a New Dr."><U><B>NEW DOCTOR</B></U></A></div> <bR> <div> <A HREF="id60.htm" TARGET="_top" TITLE="OPEN LETTER TO ALL MEDICAL PERSONEL"><U><B>OPEN LETTER TO ALL MEDICAL PERSONEL</B></U></A></div> <bR> <div> <A HREF="id39.htm" TARGET="_top" TITLE="Terror of Bad Doctors"><U><B>TERROR OF </B></U></A></div> <div> <A HREF="id39.htm" TARGET="_top" TITLE="Terror of Bad Doctors"><U><B>BAD DRS.</B></U></A></div> <bR> <div> <A HREF="id27.htm" TARGET="_top" TITLE="Workers Compensation and Legal Issues"><U><B>WORKERS </B></U></A></div> <div> <A HREF="id27.htm" TARGET="_top" TITLE="Workers Compensation and Legal Issues"><U><B>COMPENSATION</B></U></A></div> <div> <A HREF="id27.htm" TARGET="_top" TITLE="Workers Compensation and Legal Issues"><U><B>LEGAL  SITES</B></U></A></div> <bR> <div> <A HREF="id29.htm" TARGET="_top" TITLE="Our poetry corner"><U><B>OUR  POETRY</B></U></A></div> <div> <A HREF="id29.htm" TARGET="_top" TITLE="Our poetry corner"><U><B>CORNER</B></U></A></div> <bR> <div> <A HREF="id50.htm" TARGET="_top" TITLE="RSDVictim Bulletin Board"><U><B>OUR BULLETIN</B></U></A></div> <div> <A HREF="id50.htm" TARGET="_top" TITLE="RSDVictim Bulletin Board"><U><B>BOARD</B></U></A></div> <bR> <div> <A HREF="id47.htm" TARGET="_top" TITLE="RSDVictims Chat Room"><U><B>CHAT  ROOM</B></U></A></div> <bR> <div> <A HREF="id30.htm" TARGET="_top" TITLE="Photo Album"><U><B>PHOTO ALBUM</B></U></A></div> <bR> <div> <A HREF="id53.htm" TARGET="_top" TITLE="An Open Letter to Our Family Friends"><U><B>OPEN LETTER </B></U></A></div> <div> <A HREF="id53.htm" TARGET="_top" TITLE="An Open Letter to Our Family Friends"><U><B>TO OUR</B></U></A></div> <div> <A HREF="id53.htm" TARGET="_top" TITLE="An Open Letter to Our Family Friends"><U><B>FAMILIES</B></U></A></div> <bR> <div> <A HREF="id48.htm" TARGET="_top" TITLE=" Our Angels "><U><B>"OUR ANGELS"</B></U></A></div> <bR> <div> <A HREF="id49.htm" TARGET="_top" TITLE="In Memory of our Fallen RSDVictims"><U><B>MEMORIAL PAGE OF FALLEN</B></U></A></div> <div> <A HREF="id49.htm" TARGET="_top" TITLE="In Memory of our Fallen RSDVictims"><U><B>RSDVICTIMS</B></U></A></div> <bR> <div> <A HREF="id55.htm" TARGET="_top" TITLE="Houston Pain Conference Pictures"><U><B>HOUSTON PAIN</B></U></A></div> <div> <A HREF="id55.htm" TARGET="_top" TITLE="Houston Pain Conference Pictures"><U><B>CONFERENCE</B></U></A></div> <bR> <div> <A HREF="id46.htm" TARGET="_top" TITLE="Awards"><U><B>AWARDS </B></U></A></div> <bR> <div> <A HREF="id56.htm" TARGET="_top" TITLE="RSDVictimsSpouses Only Group"><U><B>RSD SPOUSES</B></U></A></div> <div> <A HREF="id56.htm" TARGET="_top" TITLE="RSDVictimsSpouses Only Group"><U><B>ONLY  GROUP</B></U></A></div> <bR> <div> <A HREF="id20.htm" TARGET="_top" TITLE="DUCKYS STORY"><U><B>DUCKY'S STORY</B></U></A></div> <bR> <div> <A HREF="id18.htm" TARGET="_top" TITLE="Related Links"><U><B>RELATED LINKS</B></U></A></div> <bR> <div> <A HREF="id32.htm" TARGET="_top" TITLE="Sign our Guestbook"><U><B>SIGN OUR GUESTBOOK</B></U></A></div> <bR> <div> <A HREF="id57.htm" TARGET="_top" TITLE="Illegal Promotion of Neurontin"><U><B>ILLEGAL PROMOTION OF NEURONTIN</B></U></A></div> <bR> <div> <A HREF="id58.htm" TARGET="_top" TITLE="Patients Bill Of Rights"><U><B>PATIENTS BILL OF RIGHTS</B></U></A></div> <bR> <div> <A HREF="id59.htm" TARGET="_top" TITLE="RSD Hope Quilt Information"><U><B>RSDHOPE QUILT </B></U></A></div> <div> <A HREF="id59.htm" TARGET="_top" TITLE="RSD Hope Quilt Information"><U><B>PROJECT</B></U></A></div> </td> <td valign="top" BGCOLOR="#000000" TEXT="#F7F7FF"> <bR> <div> <IMG SRC="041f4010.gif" border=0 width="500" height="1" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <DIV ALIGN="LEFT"></DIV> <div> <U>RSD Treatments, Page Two</U></div> <bR> <div> <B>VARIOUS TREATMENT OPTIONS AND THE PRO'S AND CON'S.</B></div> <bR> <div> <B>1.  The most important thing we can stress when discussing the </B></div> <div> <B>      various treatment available for the suffers of reflex    </B></div> <div> <B>      sympathetic dystrophy is the self-education.</B></div> <bR> <div> <B>Your doctor should make very clear to you the possible benefits, the risks, alternatives as well of cost of each treatment available to you.</B></div> <div> <B>In the very beginning, make sure that all theraputic goals are clearly defined, and acceptable to you.</B></div> <bR> <bR> <div> <B>2.  Research and read everything you can get your hands on</B></div> <div> <B>      regarding your disease, and the treatments involved in </B></div> <div> <B>      treating this.</B></div> <bR> <div> <B>It is all too important that the patient be involved in every decision there is regarding thier treatment.  You must take control of your disease immediately.</B></div> <div> <B>Don't fall victim to the "Lets try this now" approach, due to the fact it clearly indicates that the physician has not defined a strategy to achieve specific goals in the shortest amount of time.</B></div> <div> <B>It will only cause you more confusion, depression, frustration, and anxiety which will only exacerbate your pain levels and greatly effect the doctor-patient relationship.</B></div> <div> <B>Always start with the simpliest and safest treatments first.  If this fails a series of 3-6 sympathetic nerve blocks are recommended.  These blocks are often improperly preformed and evaluated.  Never, let your physician give you more than 6 blocks as more than this runs a risk of a "virtual sympathectomy".</B></div> <div> <B>A proficient block should increase the temperature of the affected area without producing numbness or weakness.  Your pain levels should also decrease.  </B></div> <div> <B>If there is a great deal of pain relief following a sympathetic block, the patient is said to have sympathetically maintained pain.  </B></div> <div> <B>For RSD that is greatly advanced, a careful review of all data compiled should be carefully reviewed, as this would indicate that the patient suffers from a combination of physical and psychological or behavioral factors.  It is a this point when psychologists/psychiatrists often ask if the pain is imaginary or real.  You do need to be extremely cautious that your psychologist/psychiatrist is well rehearsed and educated in the field of RSD, otherwise effective treatment may be compromised or delayed.</B></div> <bR> <bR> <bR> <bR> <bR> <div> <B>2. Keep a written journal, this is so very important, we cannot  </B></div> <div> <B>     stress this enough.</B></div> <bR> <div> <B>Write down everything, no matter how minute it may seem to you.  Keep records of pain levels, treatments and responses to them, any conversations you have with any one involved in your treatments.</B></div> <div> <B>This is so very important especially if you are on workers compensation or even for your personal HMO or insurance company.</B></div> <bR> <bR> <bR> <div> <B>3.  Establish written treatment protocols.</B></div> <bR> <div> <B>A written protocol by your physician should be made available to you, medical providers, insurance carriers, case managers for workers compensation attorneys, etc.  Sharing this report will make everyone involved in the treatment focused on achieving appropriate therapeutic goals.</B></div> <div> <B>The typical treatment protocol was designed to rehabilitate the patient in the shortest amount of time.</B></div> <div> <B>If the patient fails to progress the following outlined treatments should be approached.</B></div> <div> <B>You should recieve first a series of 3 sympathetic nerve blocks, their are three main reasons for these, one, an attempt to treat the RSD, two, to diagnose if the pain is indeed sympathetically maintained, and three to provide prognostic information.  The sympathetic nerve block is described in detail below.</B></div> <div> <B>At this time the physician should compile the treatment protocol, describing the patients response to the sympathetic blocks and should include details of further treatment.</B></div> <div> <B>It should also address further rehabilitation needs of the patient.</B></div> <div> <B>A fully updated report should include the following areas of care:</B></div> <div> <B>     Procedures: (nerve blocks, e.g.)</B></div> <div> <B>     Medications</B></div> <div> <B>     Physical/occupational therapy</B></div> <div> <B>     Psychosocial issues</B></div> <div> <B>     Further laboratory tests or consult</B></div> <bR> <bR> <div> <B>Procedures involved in the treatment of reflex sympathetic dystrophy include:</B></div> <div> <B>     Nerve Blocks</B></div> <div> <B>     Physical Therapy</B></div> <div> <B>     Occupational Therapy</B></div> <div> <B>     Morphine Pump</B></div> <div> <B>     Spinal Column Stimulator  </B></div> <div> <B>     Photon Therapy                                                                                                                                                                                                                                                                                       Sympathectomy (Surgical or Chemical)   </B></div> <div> <B>     Acupuncture</B></div> <div> <B>     Hyperbaric Chamber</B></div> <div> <B>     Amputation</B></div> <div> <B>     Psychiatric Care</B></div> <bR> <div> <B>I will now outline in detail what is involved in the various procedures and treatments and try to include both pro's and con's of each one.</B></div> <div> <B>Please however, do not depend solely on what you read here, do your own investigating on each one, especially if it is being recommended for you in your treatment of RSD.</B></div> <bR> <div> <B>1.  Nerve Blocks:</B></div> <bR> <div> <B>     A. Sympathetic Ganglia block (SGB):  This block is preformed by inserting a small needle along side the windpipe (trachea).  Patients are informed that they may notice a temporary change in the tone of their voice following the block because some of the local anesthetic may partially numb the vocal cords.  They are also told that they should sip fluids and take small bites of food immediately after the block.  The numbness around the vocal cords temporarily places the patient at a slight risk of coughing in reponse to drinking and eating.  The patient may also notice a temporary drooping of their upper eye lid due to the SGB (Horners Sign).  </B></div> <div> <B>        A sympathetic block of the lower extremity is called a lumbar sympathetic block (LSB).  For patients comfort and safety, LSB's should be preformed with the aid of a fluoroscope (X-rays).  A video of an LSB being preformed can be found on the internet on the Web Site journal "Anesthesiology"</B></div> <div> <B>        At this point I will try to stress how virtually important it is to not  overtreat with nerve blocks.  If this type of block is repeated more than half a dozen times,  the needle insertion starts causing damage to the sympathetic ganglion cells resulting in eventual death of the majority of the sympathetic ganglion cells.  These sympathetic ganglion cells are not just modulating the sympathetic function over the small area of nerve damage, but they also provide sympathetic function to the rest of the extremity.  Once they are damaged, then the disease spreads and becomes regional (hence called complex regional pain syndrome).</B></div> <bR> <div> <B>     B.  Bier Blocks:   This is another technique used to carry out a sympathetic block involving the injection of sympathetic blocking agents (e.g. guanethidine, bretylium, and clonidine) into an extremity and limiting spread of the agent to the entire body by applying a tourniquet to the extremity.  This method requires placing an IV in the painful extremity and may be technically extremely difficult due to severe swelling (edema) of the extremity.  The patient may not be able to confirm that they actually received a sypathetic block because the "cue", a warming sensation in the extremity, may not be felt.  </B></div> <div> <B>     There is no proof that this block is any less or more effective than the above described SGB block.</B></div> <div> <B>     This method could be considered as an option for patients who must take blood thinners (anticoagulants) where a SGB or a LSB block may cause major bleeding.</B></div> <bR> <bR> <div> <B>     C.  Spinal Blocks also called Lumbar/Cervical blocks are used to administer medication directly on the spine in an attempt to reduce nerve activity.  These are usually preformed in a series and very effective especially early on when the pain is sypathetically-mediated.</B></div> <bR> <div> <B>     D.  Indwelling Sympathetic Nerve Block (SNB):  This is a treatment which involves using an epideral catheter and dripping the medication continually over a period of hours or even days.  </B></div> <div> <B>     These are less effective for blocking the sympathetic nervous system and, therefore, they are not as useful for diagnostic and prognostic objectives.  The infusion of the local anesthetic through the epideral catheter may cause temporary weakness in the legs, making walking dangerous.  Placement of long-term epidural catheters to treat RSD/CRPS still occurs in practice.  This is perhaps due to the fast that anesthesiologists are more familiar with this technique rather than the selective sympathetic block technique.</B></div> <div> <B>     The long-term epidural catheter approach is more costly and patients are at a higher risk for certain rare life-threatening complications, e.g. infection (epideral abscess).   Often a short hospitalization will be nescessary to to determine the proper dose of medication for constanst infusion.   Dislodgement of the epidural catheter is a relatively common problem.  </B></div> <div> <B>     There is a place for the use of epidural and lumbar sympathetic catheters in the treatment of RSD/CRPS but the doctor should justify these techniques on a case by case basis.</B></div> <bR> <div> <B>     E.  Pentalomine Challenge:  This is a diagnostic procedure unlike the sympathetic block is a diagnostic, prognostic and therapeutic procedure.</B></div> <div> <B>Nevertheless,  the pentolomine test may be useful in the situation where a sympathetic block is not possible or when multiple extremities are involved.  </B></div> <div> <B>     In the late stages of RSD, the sympathetically maintained pain changes to sympathetically maintained pain and sympathetically independent pain or purely  sympathetically independent pain.  This may be due to the therapeutic trauma such as multiple nerve blocks or surgical procedures (surgery for carpel tunnel, tarsal tunnel syndrome, or thoracic outlet syndrome), or simply long-standing vasoconstriction of the region of the CRPS (Chronic regional pain syndrome) causing long standing hypoxia involving somatic as well as sympathetic nerves.  The end result is that frequently after several months or a few years, the CRPS pain is not sympathetically maintained anymore, it then becomes independently maintained pain.  Which is what we refer to as total body reflex sympathetic dystrophy.</B></div> <bR> <bR> <div> <B>2.  Physical Therapy:   It is extremely important for you to educate yourself by the use of physical therapy on how to use your effected body part through activities of daily living, e.g., RSD patients with lower extremity RSD/CRPS need to learn to weight bearing exercises versus non-weight bearing exercises.</B></div> <div> <B>Hydrotherapy is usually medically necessary for muscle (myofascial)pain and spasms.  Massage and moist heat applications can sometimes relieve severe muscle cramps. </B></div> <div> <B>The physical therapist can also teach the patient the use of the TENS unit (a non invasive electrical device that stimulates the surface of the skin.  Paraffin wax machines have their place also in the physical therapy treatments.  </B></div> <div> <B>Pool therapy can be very effective in improving mobility.</B></div> <div> <B>The most single important thing to remember in physical therapy is the "no pain, no gain" does not apply to RSD.  DO NOT ALLOW A THERAPIST TO PUSH YOU TO PAINFUL LIMITS.  The minute you start to feel even the slightest discomfort, you stop the excercise you are doing.</B></div> <div> <B>Although physical therapy is an important treatment modality, significant misuse and overuse of this modality may occur.</B></div> <div> <B>The goal of physical therapy should be to create independence from the health care system in the shortest possible time.  Learning that "to hurt is not to harm" is difficult, but it is essential to avoid reinjury.</B></div> <bR> <bR> <div> <B>3.   Occupational therapy:  Occupational Therapists (OTR/Ls) provide vital treatment services to individuals with upper extremity RSD.</B></div> <bR> <bR> <div> <B>4. Morphine or Baclofen Pump:  This is a drip irrigation type pump which places morphine, or Baclofen, directly into the spinal fluid, in smaller doses than would be necessary if given orally.</B></div> <div> <B>It is well-recognized that a single injection of morphine directly into the spinal fluid (within the intrathecal space) produces a selective pain-blocking effect of the spinal cord.  This method spares the patient from many of the serious side-effects caused by morphine taken orally.</B></div> <div> <B>This method of treatment became increasingly popular, especially after Medicare began to approve this surgical procedure for reimbursement.</B></div> <div> <B>This procedure is highly invasive and expensive.  There is no evidence that the long-term use of the morphine pump offers any advantage over the oral use.  In fact, may patients with the pump, also must use the oral medications also, to obtain sufficient pain relief.   This is over 20 years of testing.  The same complications associated with oral morphine use are also found with the morphine pump, such as development of drug tolerance, nausea, constipation weight gain, decreased sex appetitie(libido), swollen legs (edema), and increased sweating.</B></div> <div> <B>In addition, malfunction of the pump system (dislodgement of the catheter) can be a significant problem.</B></div> <div> <B>One are of concern about morphine pumps you should be aware of is  that some patients have difficulty in obtaining adequate oral medications (especially morphine and other opioids) to effective treat RSD/CPRS due to the threat real or imagined of reprisals from State licensing boards.</B></div> <div> <B>Many physicians may skirt this issue b implanting pumps as a "cover" for prescribing these pain medications.</B></div> <div> <B>   </B></div> <div> <B>5.  Spinal Column Stimulator (SCS or DCS):  These devices are implanted under the skin and send out electrical signals to "block" the signals the RSD-affected nerves are sending out to the brain.  This mechanism consist of an implanted lead, powered by an implanted battery or receiver, is placed against your spinal cord.  This system sends electrical pulses to the brain.  This source of pain control works very well for some patients.  It uses a low intensity, electrical impulses to trigger selected nerve fibers along the spinal cord (dorsal columns), which are believed to stop the pain messages from being transferred to the brain.  The SCS replaces the area of intense pain with a more pleasant tingling sensation called paresthesia.  The tingling sensation should remain steady and uninterupted and not hurt.  Some experiments  that have been done, suggest that the SCS may inhance the flow of blood to the affected extremity by blocking the sympathetic nervous system.</B></div> <div> <B>Before the SCS is implanted a trial is done.  The RSD patient often desperate and frustrated, are ordered to undergo a baseline psychosocial evaluation that addresses pain management issues.  </B></div> <div> <B>RSD/CRPS are very difficult to treat with the SCS as the device is intended to control pain in a definate location and RSD pain is never in the same location.  This may require multiple successive implanted stimulators to cover the largest possible area.  Therefore it is wise to woiden stimulation zones to which the pain may spread if only one extremity is involved.</B></div> <div> <B>Some things to consider when a SCS is suggested to you are:</B></div> <div> <B>     1.  Side effects:  Risk of Infection.  No stimulation or intermittent </B></div> <div> <B>          stimulation.  Stimulation in the wrong location.  Loss of pain </B></div> <div> <B>          relieving effect.</B></div> <div> <B>     2.  The internal battery has to be replaced by a surgical procedure</B></div> <div> <B>          and the life span of the battery varies from patient to patient.</B></div> <div> <B>     3.  It is recommended by the SCS manufacturer that you do not drive</B></div> <div> <B>          with your SCS turned on.  And long car trips are not recommeded</B></div> <div> <B>          because they say you should avoid sitting for long peroids of time.</B></div> <div> <B>     4.  Other things to avoid are theft detectors, airport/security </B></div> <div> <B>          screening devices, large stereo speakers with magnets, electric </B></div> <div> <B>          arc welding equipment, high power voltage lines and electric</B></div> <div> <B>          substations/power generators.  Magnets can turn an IPG ON or </B></div> <div> <B>          OFF, but will not change the stimulation settings.</B></div> <div> <B>     5.  Medical procedures that should be avoided with an SCS are  MRI,</B></div> <div> <B>          Pacemakers, Therapeutic X-rays, Ultrasound, Defibrillator, </B></div> <div> <B>          Diathermy.  With proper precautions, most medical procedures</B></div> <div> <B>          are unlikely to interfere with an SCS.  Always tell any medical</B></div> <div> <B>          personel that you have an implanted SCS system.</B></div> <bR> <div> <B>6.  Photon Therapy:  This is aimed at using infrared and red heat on the thermoreceptor nerves in the wall of the microscopic blood vessels in the nerve damaged areas.  This gives a signal to the thermoreceptor sensory nerve fibers (which originate the pain and poor circulation) that everything is back to normal and the thermoreceptors will not fire electrical impulses constantly and will not cause the constant  pain of RSD.</B></div> <bR> <bR> <div> <B>7.  Sympathectomy:  These were once thought to be "the answer" to the pain and is now shown, according to the National Survey of RSDS Patients conducted in 1998, to have a very low rate of long-term success and in three out of four patients makes the RSDS spread and/or worsen.</B></div> <div> <B>This procedure is irreversible.  Cutting these nerve fibers is going to bypass the painful nerve impulse to the adjacent nerve roots and it is going to result in the spread of the CRPS.</B></div> <div> <B>     A:  Chemical Sympathectomy:  This is also called a chemical nerve block or lytic blocks because they melt down every soft tissue in the are atht the chemical (Phenol, alchol, etc.) is injected.  The relief from this kind of block lasts no more than 1-2 months, but then the pain recurs with vengeance because of the fact that the chemicals do not limit themselves to block the nerves conveying abnormal function, but they block other nerves in the adjacent areas so the pain becomes more severe and spreads because of involvement of the perfectly intact adjacent nerves.  The only time these are justified is in cancer patients who have only a few months to live and any type of treatment tht gives them a few months of pain relief is only humane and should be done.</B></div> <div> <B>    B:  Surgical Sympathectomy:  Only patients with SMP (sympathetically maintained pain) should be considered for a  sympathectomy.  You should pay very close attention to the amount of pain relief and improvement in function following a sympathetic nerve block, as you should expect no more relief of your pain from a permanent sympathectomy as you received from your sympathetic block.</B></div> <div> <B>This is a relatively invasive procedure with potential complications and should be pursued by you only if you are certain about the temporary therapeutic benefits from your sympathetic nerve block.</B></div> <div> <B>Recently, laproscopic sympathectomy has been developed for sympathectomy of the upper extremity.  This requires the placement of three small holes temporarily in the side of the chest wall while you are under general anesthesia.  For lower extremities,  you will have a choice of dissolving (destroying) the sympathetic nerves with phenol injected through a needle while you are awake or a surgical sympathectomy under general anethesia.  </B></div> <div> <B>You must consider carefully the pros and cons of each approach.</B></div> <div> <B>       Post-sympathetic pain (neuralgia) is a potential complication of all types of sympathectomy.  You will think that your RSD/CRPS has spread to a new region after the sympathectomy due to the fact the pain feels just like your original RSD/CRPS pain.  The post-sympathectomy pain usually resolves on its own or with 1-3 sympathetic blocks.  So generally a sympathectomy is a two-step procedure: destruction of the sympathetic nerves followed by a sympathetic block.</B></div> <bR> <bR> <div> <B>8.  Acupuncture:   This is an acute invasive procedure.  The duration of pain relief from acupuncture for the neuropathic pain patient, is not any longer than a maximum of 1-2 hours.  This is almost as useless as trigger point injections.   The short duration of pain relief, do not make this procedure worth while.</B></div> <div> <B>     Risks and Disadvantages of this procedure include: </B></div> <div> <B>     1.  Causes bleeding in the internal structures, including the guts.</B></div> <div> <B>     2.  May introduce hepatitis virus</B></div> <div> <B>     3.  Chance of transmitting HIV infection (AIDS)</B></div> <div> <B>     4.  Infection</B></div> <div> <B>     5.  Acupuncture can mask the progressively deteriorating original</B></div> <div> <B>          pathology such as cancer, or nerve impairment.  This can cause</B></div> <div> <B>          delay in diagnosis of cancer, CRPS, and other pathologic </B></div> <div> <B>          conditions that cannot be cured by simple acupuncture.</B></div> <div> <B>     6.  Gives the patient and the acupuncturist a false sense of security</B></div> <div> <B>           that the procedure is going to cure the condition.</B></div> <div> <B>     7.  The needle insertion in the proximity to the original injury can  </B></div> <div> <B>           become a new source of pain and can aggravate the disease.</B></div> <div> <B>     Advantages of this procedure:</B></div> <div> <B>     1. It can and does block the pain in the distal original are of injury, </B></div> <div> <B>         and even improve the circulation to the extremities practically </B></div> <div> <B>         almost as effectively as a nerve block.</B></div> <bR> <bR> <div> <B>9.  Hyperbaric Chamber:  The use of the hyperbaric chamber is still in research as far as its use to control the RSD pain.</B></div> <bR> <bR> <div> <B>10. Amputation:  This is no longer considered a treatment for RSD.  It was the answer to the pain for the soldiers during the civil war days.  Thhe RSD would establish itself after the soldier would experience shrapnel wounds.  However, after the amputation, the patient would experience "Phantom Limb" pain and would still experience the burning pain as if the extremity were still there.</B></div> <bR> <bR> <div> <B>11. Psychiatric Care:  This is a definite treatment that every RSD suffer should have.  It helps you to cope with the chronic pain.  Remember: this disease is Physiological NOT Psychological.</B></div> <div> <B>     The patient needs to develop realistic expectations for therapy.  You will need to realize that if you can get a 50% decrease in your pain level that is considered excellent.  The other 50% will be up to you and how hard you are willing to work to achieve it.  This will mean you need to get up and get going, be willing to give up your "natural" tendency to maintain pain, dysfunction, distress and disability.   You will need to replace these with healthy functional behaviors.   Even with the therapies available for advanced RSD/CPRS, your attempt to achieve a pain free state may result in significant side effects or adverse complications.</B></div> <div> <B>Most RSD advanced sufferers have a mixture of physical and psychologic or behavioral facters and all need to be addressed.  A qualified psychologist or psychiatrist will decide if environmental contingencies or psychological factors are reinforcing the pain and disability.  </B></div> <div> <B>If you are an advanced  suffer of RSD, you should undergo an evalutation during the series of sympathetic blocks or prior to obtaining more invasive treatments.</B></div> <div> <B>Children who suffer from RSD, 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.</B></div> <div> <B>The evalutions should always include an assessment of pain coping skills and drug abuse potential.  You also may require a pain management program as either an inpatient or outpatient.  Patients referred for psychological testing tend to be defensive.</B></div> <div> <B>The psychologist/psychiatrist can also teach you relaxation techniques (e.g. breathing excercises, biofeedback, self-hypnosis, and guided imagery.</B></div> <bR> <bR> <div> <B>12. Misc. Treatments:  </B></div> <div> <B>      A. Neurolysis:  This is another form of a nerve block, which is so called "release of adhesions".  This is done quite often to a patient who has had direct peripheral nerve or to nerves in the spine.  Unfortunately, this have a tendency to cause more damage to the nerves, blood vessels,  and adjacent normal tissures which causes a new source of pain.</B></div> <bR> <div> <B>      B. Another form of this kind of block has become in use recently.  </B></div> <div> <B>It is called a caudel release of adhesions.  This procedure consists of under fluoroscopy and air myelography of the sacral canal.   The procedure consists of  under fluoroscopy and with a fiberglass scope which is inserted into the spinal canal, the doctor looks at the areas that there are some minimal connective tissue looking like scar tissue.  He thens tries to cut those and to clean up the specific nerve root that is surrounded with more of these fibers.</B></div> <bR> <bR> <div> <B>WHAT NOT TO DO:  This is probably the most important part of treatments of RSD, is to be aware of the dangerous treatments and why they so often fail.</B></div> <bR> <div> <B>A.   Anyone that says "RSD burns itself out and goes away, is either lying or has no idea whatsoever what it is.</B></div> <bR> <div> <B>B.   Allowing yourself prematurely into a wheelchair, splints, etc., that do not allow you to keep the extremity moving.  Do not  fall victim to t his due to your pain.</B></div> <bR> <div> <B>C.   Applying a Clonidine patch to the area of RSD in the extremity rather than in the cervical or lumbar area.</B></div> <bR> <div> <B>D.   Only recieving one or two trigger point injections for a frozen shoulder.</B></div> <bR> <div> <B>E.   Bier block injections directly into the area of flared up RSD.</B></div> <bR> <div> <B>F.   Treating RSD with ice.</B></div> <bR> <div> <B>G.   Hot and cold challenge treatments.</B></div> <bR> <div> <B>H.   Insufficient amount of depressant medication per day.</B></div> <bR> <div> <B>I.   Too many sympathetic nerve blocks, as I stated to you previously not</B></div> <div> <B>      more than 3-6 should ever be given to any patient.</B></div> <bR> <div> <B>J.   Monotherapy with nerve block, or opioid medication.</B></div> <bR> <div> <B>K.   Misuse of Neurontin, this medication should only be administered </B></div> <div> <B>      for the burning pain associated with RSD.</B></div> <bR> <div> <B>L.   Bathing while wearing the Clonidine patch.</B></div> <bR> <div> <B>M.  Mistaking paravertabral blocks for articular facet injections.</B></div> <bR> <div> <B>N.   Giving diagnostic sympathetic nerve blocks with simple Marcaine </B></div> <div> <B>       injection as a theraputic block.</B></div> <bR> <div> <B>O.   Treating high blood pressure with newer anti-hypertensives rather </B></div> <div> <B>       than the alpha blockers.</B></div> <bR> <div> <B>P.   Recieving trigger point injections and nerve blocks in the nerve</B></div> <div> <B>      damaged area.</B></div> <bR> <div> <B>Q.   Do not read too much into phentolamine blcoks.</B></div> <bR> <div> <B>R.   Amputation is no longer used to treat RSD pain.</B></div> <bR> <bR> <bR> <div> <B>In conclusion I would just like to add that the single most important thing you can do for your RSD/CRPS is to educate yourself thoroughly.  Make sure you keep track of everything, carry a journal with you to every appointment concerning your RSD.  Know the treatments and the pros and cons of each one, and go into it with your eyes open.  There are so many Doctors who will tell you that they are very experienced in the RSD treatments.  Don't fall for this, check it out completely.</B></div> <div> <B>Know the dangerous treatments and refuse to be a victim of this, as you are the only one who will suffer from the mistreating and diagnosing of your condition.</B></div> <bR> <div> This matterial comes from excerpts of the book I am currently attempting to put together.   Ducky</div> </td> </tr></table></body>