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3:56 am
September 12, 2008
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Helper
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I have got a patient who had undergone physiotherapy for Right hemiplegia(operated for 8th nerve schwannoma extended till brain stem).
After few weeks he developed oedema and pain in his hand and wrist.
Shoulder and elbow pain also…
Skin color changes were there and little cool hand.
This is the presentation of patient to me.
I diagnosed and treating RSD or CRPS.
Presently getting better except pain in the lateral aspect of upper ARM below DELTOID tuberosity on abduction (>90 degree) and rotation movements (>40 degrees).
I know there is rotator cuff weakness and strengthening it.
Please give comments and advises over this.
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4:44 am
September 12, 2008
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Dolly
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RSD, now renamed Complex Regional Pain Syndrome (CRPS) to take away an emphasis on the sympathetic system is obviously not easy to manage. It is a multi-mechanism disorder which will includes processes in tissues, probably processes in periperhal nerves, unregulated CNS and altered responses via the sympathetic system.
One of the best articles ever published is -
Stanton- Hicks M et al 1998 Complex regional pain syndromes: Guidelines for therapy. The Clinical Journal of Pain 14: 155-166.
This is an important article as it is a consensus statement from many world authorities in sympathetic maintained pain. It is especially important for physical therapy as movement based therapy is regarded as the centerpiece of management.
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8:18 am
September 12, 2008
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James
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CRPS is certainly not the easiest condition to deal with. The reason being the involvement of sympathetic nervous system and complexity, varieties and progression stages.
Not only the treatment but even the diagnosis is made difficult because many of the symptoms overlap with other conditions. There is no specific blood test or other diagnostic test for RSD. X-rays can show thinning of bones (osteoporosis). Nuclear bone scans can show characteristic uptake patterns which help diagnose RSD
Again role of Physiotherapy is controversial since there are literatures suggesting PT aggravate the pain in RSD and also there are some advocating necessities of PT.
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8:19 am
September 12, 2008
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James
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Following are some points, which would of some help
For the problem of cold extremity, (vasoconstriction), and movement disorder, ice should never be applied. The patient should be treated with warm water and Epsom salt bath. The Epsom salt is a hyperosmolar salt, and relieves the inflammation by acting as a calcium channel blocker. There is no therapeutic value for the alternate use of Contrast bath. The stress of the alternate treatment only aggravates the disease further.
To counteract the hypothermia in the extremity due to the abnormal function of the sympathetic system, it is essential to encourage the patient to get rid of assistive devices (wheelchair, walker, cane, and crutches). The patient should be instructed to follow the golden rule of perpetual motion
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8:20 am
September 12, 2008
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James
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The patient should be instructed not to do any extensive resting or exercise for a long span of time, but to constantly keep changing position and alternating exercise with rest. Inactivity gives the signal to the sympathetic system to preserve the circulation in the inactive extremity by vasoconstriction, which aggravates the CRPS
The patient is alternating resting and activity without exhausting themselves. The patient should be taught that in CRPS/RSD, no pain is all gain. This is just a sharp contrast to the somatic pain where no pain is no gain.
The patient should understand that resting for long hours is going to be as much if not more harmful than doing too much activity.
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8:20 am
September 12, 2008
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James
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If the patient wakes up in the middle of the night because of pain or discomfort, he or she should not just lay in bed. The patient should get out of bed and walk around. The patient will be surprised how soon the pain improves by walking after long periods of rest
One of the biggest risks in CRPS is frozen shoulder, also known as shoulder hand syndrome
Active and passive motions of the extremities bilaterally.
Hydrotherapy is quite effective, especially because of the fact that immersing the body in the swimming pool reduces the effective weight of the patient by 50%. Obviously, suddenly changing the weight from 140 pounds to 70 pounds helps with mobilization and reduction of pain
Involving Sensory Integration also would be of great help to patient.
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