Medical Articles - Medical Treatments
There are many different types of treatments for CRPS. New ones seem to pop up every day and what works for one typically does not work for the majority. This makes treating this disease even more difficult. Most physicians seem to agree that a combination of diet, exercise, physical therapy, and medication hold the key to treating the disease for the majority of patients. Exactly what that combination is and which medications those are remains a sticking point and a point of contention among pain management doctors. As to diet, many subscribe to the theory that the chronic pain diet is a very good starting point. You can find that by going to http.www.RSDRX.com , that was first developed by Dr Hooshang Hooshmand.
As to what treatments you can use in addition to the above? We have shared some examples below but there are many, many others out there. Before you try anything new we urge you to seek out as much research as possible. Llook for double-blind studies if available. Talk to as many patients as you can find who have had the procedure done, years ago if at all possible, and see what they think now. Try to stay away from invasive procedures if you can (surgical) since CRPS seems to be aggravated by anything invasive. Learn about the procedure before you have it, don't just assume the Dr knows best, and ASK questions!
If your Dr tells you "if you don't have this procedure I simply cannot help you", move on to another Dr. Chances are there is a vested interest there and it is not yours. Find someone who will put your best interests first, they are out there. There are MANY wonderful Pain Management Physicians out there who seek to provide pain relief to their patients first and foremost!
Remember, no one is going to care more about what happens to you in the end than you. So be proactive! You have access to the internet, use it. Do your due diligence.
As to what treatments you can use in addition to the above? We have shared some examples below but there are many, many others out there. Before you try anything new we urge you to seek out as much research as possible. Llook for double-blind studies if available. Talk to as many patients as you can find who have had the procedure done, years ago if at all possible, and see what they think now. Try to stay away from invasive procedures if you can (surgical) since CRPS seems to be aggravated by anything invasive. Learn about the procedure before you have it, don't just assume the Dr knows best, and ASK questions!
If your Dr tells you "if you don't have this procedure I simply cannot help you", move on to another Dr. Chances are there is a vested interest there and it is not yours. Find someone who will put your best interests first, they are out there. There are MANY wonderful Pain Management Physicians out there who seek to provide pain relief to their patients first and foremost!
Remember, no one is going to care more about what happens to you in the end than you. So be proactive! You have access to the internet, use it. Do your due diligence.
AQUATIC THERAPY OR AQUA THERAPY
Aquatic Therapy and CRPS: Should you fear to tread…water?
by Melanie E. Swan, OTR/L
What is aquatic therapy?
Aquatic therapy is therapeutic exercise performed in a body of water-generally a lap pool or a deep water pool. Aquatic therapy often occurs in a group/class setting, though it may also be part of an individual treatment session with a therapist. Aquatic therapy may be used for people with RSD/ CRPS who have limited movement and/or have low tolerance for resistive therapeutic activities.
Why do you use water for therapy?
Water provides a combination of buoyancy and resistance/challenge. The buoyancy of the water supports your body weight differently, making you feel lighter and taking some of the pressure off joints so you can move more freely. The movement of the water during exercise challenges balance, helping to strengthen core/abdominal muscles. Moving faster or slower changes the resistance of the water, making it harder or easier to complete the exercises. Aquatic equipment, such as kickboards, foam noodles, webbed gloves, or aqua fins, can also increase the resistance of exercises.
What is an aquatic therapy session like?
An occupational therapist or physical therapist designs a series of exercises to promote increased strength, balance, and range of motion or weight bearing. Some programs may even involve floatation for relaxation of muscles. These exercises are tailored to meet the needs of the patient and the aquatic environment available.
What should the temperature of the water be?
There is no specific water temperature that is ideal for everyone. Most indoor pools are kept between 78 to 82° if they are used for vigorous swimming or exercise. Temperatures of 83 to 88° are optimal for moderate exercise. Temperatures warmer than 88° promote increased relaxation and circulation but can increase muscle fatigue more rapidly during exercise.
Will the water harm my CRPS if it feels cold?
Many people with RSD/CRPS prefer slightly warmer water during exercise, as often they are more sensitive to cold. Cooler water may initially produce some constriction of blood vessels; however, this is not harmful as it is your body's natural mechanism to conserve body heat. This response can be reduced by performing a few minutes of vigorous exercise to increase muscle activity and circulation. Neither heat nor cold has proven to be more effective in the progression of aquatic exercise. Varying water temperatures during exercise is also an excellent way to work on temperature desensitization.
Is there a difference between aquatic therapy in a lap pool or deep water pool?
Lap pools are relatively shallow (approximately 3.5 to 4.5 feet deep) but offer a greater ability for patients to work on weight bearing and balance exercises during ambulation activity-walking, side-stepping, running, hopping, etc. Deep water pools offer greater ability to perform exercises while treading water or wearing a floatation device. This allows a greater amount of the body to be submerged below the water surface and provides greater resistance to upper body activity. However, most exercises can be completed in either setting with the use of aquatic equipment and modification or creativity.
Is there a difference between aquatic exercises and therapeutic activities outside of the water?
The water provides a place to try new activities, to improve ease of movement, to decrease muscle guarding and begin working on strength and balance. However, these activities need to be transitioned into a land-based exercise program to improve daily function. Aquatic therapy may be a good place to start therapeutic exercise; however, it should not be the only therapeutic exercise used during the treatment of RSD/CRPS as the buoyancy of the water prevents full weight bearing or loading of the affected area. Should I have aquatic therapy for my CRPS?
You should consult your physician before beginning any exercise program. Your physician or your Physical Therapist/Occupational Therapist can help determine if aquatic therapy is the right intervention for you.
Melanie E. Swan, OTR/L is a Resource Clinician at the Rehabilitation Institute of Chicago , Chronic Pain Care Center, 1030 N. Clark Street, Suite 647, Chicago, IL 60610.
Aquatic Therapy and CRPS: Should you fear to tread…water?
by Melanie E. Swan, OTR/L
What is aquatic therapy?
Aquatic therapy is therapeutic exercise performed in a body of water-generally a lap pool or a deep water pool. Aquatic therapy often occurs in a group/class setting, though it may also be part of an individual treatment session with a therapist. Aquatic therapy may be used for people with RSD/ CRPS who have limited movement and/or have low tolerance for resistive therapeutic activities.
Why do you use water for therapy?
Water provides a combination of buoyancy and resistance/challenge. The buoyancy of the water supports your body weight differently, making you feel lighter and taking some of the pressure off joints so you can move more freely. The movement of the water during exercise challenges balance, helping to strengthen core/abdominal muscles. Moving faster or slower changes the resistance of the water, making it harder or easier to complete the exercises. Aquatic equipment, such as kickboards, foam noodles, webbed gloves, or aqua fins, can also increase the resistance of exercises.
What is an aquatic therapy session like?
An occupational therapist or physical therapist designs a series of exercises to promote increased strength, balance, and range of motion or weight bearing. Some programs may even involve floatation for relaxation of muscles. These exercises are tailored to meet the needs of the patient and the aquatic environment available.
What should the temperature of the water be?
There is no specific water temperature that is ideal for everyone. Most indoor pools are kept between 78 to 82° if they are used for vigorous swimming or exercise. Temperatures of 83 to 88° are optimal for moderate exercise. Temperatures warmer than 88° promote increased relaxation and circulation but can increase muscle fatigue more rapidly during exercise.
Will the water harm my CRPS if it feels cold?
Many people with RSD/CRPS prefer slightly warmer water during exercise, as often they are more sensitive to cold. Cooler water may initially produce some constriction of blood vessels; however, this is not harmful as it is your body's natural mechanism to conserve body heat. This response can be reduced by performing a few minutes of vigorous exercise to increase muscle activity and circulation. Neither heat nor cold has proven to be more effective in the progression of aquatic exercise. Varying water temperatures during exercise is also an excellent way to work on temperature desensitization.
Is there a difference between aquatic therapy in a lap pool or deep water pool?
Lap pools are relatively shallow (approximately 3.5 to 4.5 feet deep) but offer a greater ability for patients to work on weight bearing and balance exercises during ambulation activity-walking, side-stepping, running, hopping, etc. Deep water pools offer greater ability to perform exercises while treading water or wearing a floatation device. This allows a greater amount of the body to be submerged below the water surface and provides greater resistance to upper body activity. However, most exercises can be completed in either setting with the use of aquatic equipment and modification or creativity.
Is there a difference between aquatic exercises and therapeutic activities outside of the water?
The water provides a place to try new activities, to improve ease of movement, to decrease muscle guarding and begin working on strength and balance. However, these activities need to be transitioned into a land-based exercise program to improve daily function. Aquatic therapy may be a good place to start therapeutic exercise; however, it should not be the only therapeutic exercise used during the treatment of RSD/CRPS as the buoyancy of the water prevents full weight bearing or loading of the affected area. Should I have aquatic therapy for my CRPS?
You should consult your physician before beginning any exercise program. Your physician or your Physical Therapist/Occupational Therapist can help determine if aquatic therapy is the right intervention for you.
Melanie E. Swan, OTR/L is a Resource Clinician at the Rehabilitation Institute of Chicago , Chronic Pain Care Center, 1030 N. Clark Street, Suite 647, Chicago, IL 60610.
HYPNOSIS AND CRPS
The use of Hypnosis in the treatment of RSD is somewhat controversial and has had mixed results. Some of this stems from the fact that RSD patients are wary of any treatment that might possibly insinuate the pain is in your head and that reported positive results have been few and far between. Because of the recent work by Dr Flemming though, some of these ideas need to be re-considered. He has had some very positive results but cautions that if done incorrectly, it can cause more harm than good. I recently had a discussion with him regarding this and he shared his results with me as follows. In RSD, hypnosis is the generation of images in the mind that can alter function of the autonomic nervous system. This is a normal ability -- examples include generation of images of food leading to salivation, imagining something scary which can lead to fast heart rate and so on. In a normal population, some people are totally fluent at this, some can barely do it at all. Most people have an average capacity, they can use images to alter autonomic function moderately well.
If RSD is vectored by autonomic function, (which it definitely is) one might not be surprised if using appropriate images can alter both symptoms and physical signs of RSD. My jaw hit the floor when I saw this happen the first time. The woman had long established RSD with her left arm contracted so it was stuck at her right shoulder with the head pulled down to the left. Using specific images, her arm relaxed totally, it became totally pain free, the muscular spasm faded and she regained full movement of her arm, shoulder neck and head. More importantly the vascular spasm released so the arm and hand became normally perfused. After recovering composure, I decided to explore this technique on a series of patients at the Univesity of Chicago, and in my first 13 patients, saw long term remission in about two thirds. We put these cases into the American Pain Society annual meeting as a poster presentation in about 1992, and at this meeting, found Michael Gainer, a psychologist who had been using similar techniques on a series of patients in Akron, Ohio. He and I decided to form a free-standing clinic specifically to treat RSD and this opened in 1994. We continued work until 1999 and closed after selling the clinic to a physician's practice management group.
Over these years, we saw approximately 1000 patients with RSD. Almost all these patients had been credibly diagnosed at academic pain treatment centers in the Chicago area and all had failed in conventional treatment protocols. We applied a seamlessly integration of standard medicine, advanced hypnotic and psycological methods together with rehabilitative therapy including massage therapy (not a la Craig's List). We were able to follow up firstly on about 42 patients in whom we saw the same outcome as our initial 13, and then on the 250 with whom we could still communicate. Again, 60% were able to gain long term remission as defined by loss of symptoms, absent need for medications and resotration of function. We published in the Clinical Bulletin of Myofascial Therapy (such a waste) and did a more extensive poster presentation at the APS.
This is a summary of what we learned:
1. RSD seemed to affect people at either of the extremes of hypnotic ability. An average hypnotic ability seemed to afford immunity to the disease.
2. People at the high end of the scale were able to modify symptoms with fluency. 85% of patients had an extreme hypnotic ability. 15% had essentially none.
3. People at the low end of the scale had no capacity to modify symptoms. None of these patients recovered.
4. The extent to which patients were able to reduce symptoms during their first experience of hypnosis was predictive of their ability to gain long term remission.
5. Patients able to reduce symptoms using hypnosis fell into 3 approximately even groups:
a. Group 1 -- patients quickly learned these techniques -- they essentially gained recovery during their first 2 weeks of treatment.
b. Group 2 -- in which RSD was kept alive by diagnosable sources of pain, such as nerve entrapment, mononeuropathy, arthritis and so on. I only remember one smoker who recovered -- nicotine stimulates sympathetic activity and makes it more difficult to take control using hypnosis.
c. Group 3 -- in which the symptoms of RSD formed the presentation of behavioral issues.
We were left convinced that hypnosis, when integrated with standard medical management and rehabilitative therapy has an extremely powerful role in the management of RSD.
Points to remember:
First -- it is difficult to discern which patient will fit into which group early in evaluation.
Second -- If a patient has a psychological/behavioral component to RSD, a lay hypnotist can cause SERIOUS DAMAGE by attempting to coax remission without addressing the psychological issues. This work requires EXTREME SKILL and must be taken VERY SERIOUSLY.
Third -- RSD is definitely a physical disease. However behavioral involvement is clear -- for example most patients describe worsening of symptoms with stress, the placebo response is about 60%, people with average hypnotizability don't seem to suffer from RSD, patients receiving specific forms of behavioral therapy seem to gain remission much more commonly than those who do not. Behavioral components do not necessily indicate psychological disease -- Again, behaviors can be normal responses to life's situations, but they can suggest routes to remission.
DO NOT BE AFRAID of psychological/behavioral issues to do with RSD. It does NOT mean that RSD is "all in your head." RSD is definitely a physical disease, but behavioral components do exist, as they do in practically all illnesses, and addressing them may be vital to gaining remission. The above represents only the tip of the iceberg of information applicable to this field. Please let me know if you would like more information, and if you would like me to send the text and figures from our scientific presentations. I am aware, of course, of the controversy in which various teams suggest that behavioral components exist vs. do not exist. Each side to this argument has merit, the most important feature of this note is the implied invitiation for the various contenders to begin sensible dialogue.
Best regards,
David Flemming, MD.
The use of Hypnosis in the treatment of RSD is somewhat controversial and has had mixed results. Some of this stems from the fact that RSD patients are wary of any treatment that might possibly insinuate the pain is in your head and that reported positive results have been few and far between. Because of the recent work by Dr Flemming though, some of these ideas need to be re-considered. He has had some very positive results but cautions that if done incorrectly, it can cause more harm than good. I recently had a discussion with him regarding this and he shared his results with me as follows. In RSD, hypnosis is the generation of images in the mind that can alter function of the autonomic nervous system. This is a normal ability -- examples include generation of images of food leading to salivation, imagining something scary which can lead to fast heart rate and so on. In a normal population, some people are totally fluent at this, some can barely do it at all. Most people have an average capacity, they can use images to alter autonomic function moderately well.
If RSD is vectored by autonomic function, (which it definitely is) one might not be surprised if using appropriate images can alter both symptoms and physical signs of RSD. My jaw hit the floor when I saw this happen the first time. The woman had long established RSD with her left arm contracted so it was stuck at her right shoulder with the head pulled down to the left. Using specific images, her arm relaxed totally, it became totally pain free, the muscular spasm faded and she regained full movement of her arm, shoulder neck and head. More importantly the vascular spasm released so the arm and hand became normally perfused. After recovering composure, I decided to explore this technique on a series of patients at the Univesity of Chicago, and in my first 13 patients, saw long term remission in about two thirds. We put these cases into the American Pain Society annual meeting as a poster presentation in about 1992, and at this meeting, found Michael Gainer, a psychologist who had been using similar techniques on a series of patients in Akron, Ohio. He and I decided to form a free-standing clinic specifically to treat RSD and this opened in 1994. We continued work until 1999 and closed after selling the clinic to a physician's practice management group.
Over these years, we saw approximately 1000 patients with RSD. Almost all these patients had been credibly diagnosed at academic pain treatment centers in the Chicago area and all had failed in conventional treatment protocols. We applied a seamlessly integration of standard medicine, advanced hypnotic and psycological methods together with rehabilitative therapy including massage therapy (not a la Craig's List). We were able to follow up firstly on about 42 patients in whom we saw the same outcome as our initial 13, and then on the 250 with whom we could still communicate. Again, 60% were able to gain long term remission as defined by loss of symptoms, absent need for medications and resotration of function. We published in the Clinical Bulletin of Myofascial Therapy (such a waste) and did a more extensive poster presentation at the APS.
This is a summary of what we learned:
1. RSD seemed to affect people at either of the extremes of hypnotic ability. An average hypnotic ability seemed to afford immunity to the disease.
2. People at the high end of the scale were able to modify symptoms with fluency. 85% of patients had an extreme hypnotic ability. 15% had essentially none.
3. People at the low end of the scale had no capacity to modify symptoms. None of these patients recovered.
4. The extent to which patients were able to reduce symptoms during their first experience of hypnosis was predictive of their ability to gain long term remission.
5. Patients able to reduce symptoms using hypnosis fell into 3 approximately even groups:
a. Group 1 -- patients quickly learned these techniques -- they essentially gained recovery during their first 2 weeks of treatment.
b. Group 2 -- in which RSD was kept alive by diagnosable sources of pain, such as nerve entrapment, mononeuropathy, arthritis and so on. I only remember one smoker who recovered -- nicotine stimulates sympathetic activity and makes it more difficult to take control using hypnosis.
c. Group 3 -- in which the symptoms of RSD formed the presentation of behavioral issues.
We were left convinced that hypnosis, when integrated with standard medical management and rehabilitative therapy has an extremely powerful role in the management of RSD.
Points to remember:
First -- it is difficult to discern which patient will fit into which group early in evaluation.
Second -- If a patient has a psychological/behavioral component to RSD, a lay hypnotist can cause SERIOUS DAMAGE by attempting to coax remission without addressing the psychological issues. This work requires EXTREME SKILL and must be taken VERY SERIOUSLY.
Third -- RSD is definitely a physical disease. However behavioral involvement is clear -- for example most patients describe worsening of symptoms with stress, the placebo response is about 60%, people with average hypnotizability don't seem to suffer from RSD, patients receiving specific forms of behavioral therapy seem to gain remission much more commonly than those who do not. Behavioral components do not necessily indicate psychological disease -- Again, behaviors can be normal responses to life's situations, but they can suggest routes to remission.
DO NOT BE AFRAID of psychological/behavioral issues to do with RSD. It does NOT mean that RSD is "all in your head." RSD is definitely a physical disease, but behavioral components do exist, as they do in practically all illnesses, and addressing them may be vital to gaining remission. The above represents only the tip of the iceberg of information applicable to this field. Please let me know if you would like more information, and if you would like me to send the text and figures from our scientific presentations. I am aware, of course, of the controversy in which various teams suggest that behavioral components exist vs. do not exist. Each side to this argument has merit, the most important feature of this note is the implied invitiation for the various contenders to begin sensible dialogue.
Best regards,
David Flemming, MD.
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