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Possible Complex Regional Pain Syndrome? Advice please.

Discussion in 'General Issues and Discussion Forum' started by Leah Claydon, Apr 11, 2014.

  1. Leah Claydon

    Leah Claydon Active Member


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    Any advice on the following case would be gratefully received.

    Female aged 50. BMI ~ 27
    RTA 2009 riding pillion on motorbike, bus pulled out of layby and she was knocked off.
    Concussion and severe damage to R/Knee
    Much physio post accident.
    Hx of congenital pes planus - has EVA orthoses prescribed by local hospital orthoses department - full contact, medial phlange, minimal correction.
    Post accident transference pressure to L/knee which began to hurt followed by L/ankle which has become equisitely painful - ie putting a sock on is agony. Light touch is unbearable.
    Focus of pain is over sinus tarsi and along lateral border of foot to 4th 5th toes and plantar calcaneal area - dermotomal distribution L5/S1.
    Hx of back pain post RTA at L5/SI but is bilateral.

    X-ray - revealed small amount of swelling at insertion of R/achilles - LF OK.
    L-ankle nothing remarkable on MRI. Previous Hx of brain scan - normal
    R/knee small amount of O/A

    Sleeps OK. Wakes OK. Pain starts as soon as she begins to weightbear.
    No parasthesia or numbness.
    Circulation is poor in affected foot - toes cyanosed, foot oedematous, cold to touch.
    Has to walk with stick now.
    Previously lived life to full and was well.


    She is receiving treatment by physios for "Phantom Pain"
    This pain, in my opinion, is very real. When she was distracted, looking away and speaking animatedly to her carer (she has to have a carer assist her) I gently touched her foot; result she 'squealed'.

    There is an ongoing Insurance legal case

    I think this is Complex Regional Pain Syndrome brought about by the accident and transference pressure - possibly combined with the hyperpronation and poss a bit of sinus tarsi impingement. I wonder if anyone has any experience of this condition? Any ideas?

    In the meantime, I sought consent from her to post this thread and suggested she might try Capsaicin Cream. I am not sure that more orthoses will make much difference. She's desperate, the NHS don't seem to have anything else to offer which is why "she's looking outside the box now". Any thoughts on acupuncture?

    I attach a photo of her feet.

    Any advice appreciated.
     

    Attached Files:

  2. musmed

    musmed Active Member

    Dear Leah

    The definition of complex regional pain syndrome is that it has two components.
    one is hyperalgesia. That is a stimulus that would normally be painful is felt as super painful and the second is that of allodynia. allodynia means 'other force'.

    This is a stimulus that would in normal cases be felt as non painful, but in these souls the stimulus is felt as painful.

    Another component is that of brush allodynia.

    The only thing you can do that is not felt as painful is to rub say your forearm with your knuckles quite firmly= it does not feel painful but if you stop rubbing suddenly with the same force it will be felt as painful. This allows us to rub sore spots.

    Many but not all with CRPS cannot do this without feeling pain. This is why massage or any forms of hands on or therapies= surgery, injections etc. only make things worse.

    Most other criteria you have listed are secondary changes and are not essential for the diagnosis of CRPS.

    These include: hot/cold cold/hot= that is the patient has these sensations but when touched they feel the opposite. Sweating mild to profuse, loss of hair, colour changes; brittle nails; spreading of the pain to the affected limb. In some poor souls it can engulf their entire body. Currently I have 2 such people. Some souls develop osteoporosis in the affected limb

    Many develop sensory wind up. This is where they develop: tinnitis; BP; diabetes; gluten intolerance; heavy periods requiring hysterectomy. Basically you name it.

    Treatments are basically impossible.

    CRPS is a spinal cord and brain condition where amongst many things the DNA is activated and the morhpine, ATP, MNDA + other receptor sites are removed and thus drugs such as morphine and derivatives, Lyrica and the like just do not work as there are no receptor site for these drugs to work upon. Often the patient has to take so many drugs they cannot function.

    This poor soul needs to see a pain management centre that uses spinal cord stimulators. These have a moderate success in peripheral lower limb CRPS but unfortunately as the problem becomes closer to the spinal cord they do not work.

    Like any medical machinery it is an extremely expensive procedure. I would say roughly 90,000 aussie dollars.

    The patient needs to have 2 stimulators. One is the trial one to see if it will work and then if the patient is lucky enough to get great benefit from it a permanent one is then inserted.

    a classic result is the patient has a 15 out of 10 pain, turn on the stimulator and instantly they have a 0 or 1 out of 10. Amazing to see the facial changes in these poor souls.

    Good luck with her case.

    By the way, phantom limb pain only occurs in those who have lost a limb or in those who have had a rare thalamic stroke which usually occurs in 70+ year old men.

    A good read if you can get it due to its costs, is Bonica's Management of Pain. This tome covers everything that produces pain. It is over 2400 pages and has many many authors.

    Regards
    Paul Conneely
    MB BS, Masterof Pain Medicine and musculoskeletal Medicine.

    we now are in our 22 day of rain. Currently there is a very strong southerly bringing more pelting down rain. Hope the sun comes out before winter!
     
  3. Paul gave a good review of complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD) and causalgia and Sudeck's atrophy. I also see quite a few cases of CRPS, most of them caused by crush injuries and/or trauma to the foot and/or ankle. Work-related (i.e. industrial) injuries make up about a third of my podiatric practice.

    As Paul stated, these cases, if caught early, can be treated with some success but as they become more chronic they become harder to treat. I refer many of these patients to a pain management specialist.

    Probably the best reading on CRPS that I have seen specific to podiatry is this roundtable article:

    Unraveling The Mystery of CRPS
     
  4. Leah Claydon

    Leah Claydon Active Member

    Thank you both SO much, for your comprehensive and useful posts. This kind of response really demonstrates the power of podiatry-arena. I am truly grateful.

    I feel desperate for this patient. I shall contact her and communicate your thoughts and advice; at the very least she'll have another avenue to explore.

    Leah
     
  5. i-man

    i-man Member

    CRPS is probably one of the most common motivators for legal action if cause can be identified. From my experience the only way to deal with this condition is to do so on multiple fronts. This patient will need a pain specialist consult. In USA, spinal injections are not uncommon. But to rely on the "short circuit" of the pain receptors independently is to discount the cause of the injury to the part. So PT, temporary immobilization followed by graduated PT, if this is what the patient can tolerate, will address the actual injury causing the CRPS. Finally, consideration of the individual's psychological make-up. This is an area for a psychologist or psychiatrist to participate. This recommendation is in no way meant to insinuate that the patient is mentally imbalanced, it's meant to address a conscious, real anticipation and perception of pain that influences a persons response to stimulus. The normal pain-response action has lost its linear path and is now cyclical, no beginning, no end. If CRPS is identified very early, sometimes the psychological aspect is not ingrained enough to not be overcome by dealing with the other 2 parts, but if the injury was in 2009, you can't discount it.
     
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