PAIN MEDICINE FOR THE NON-PAIN SPECIALIST 2017
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1 PAIN MEDICINE FOR THE NON-PAIN SPECIALIST 2017 FEBRUARY 16-18, 2017 JW MARRIOTT DESERT SPRINGS RESORT & SPA PALM DESERT, CALIFORNIA Learn the latest treatment strategies and multidisciplinary management options for patients with acute and chronic pain MFMER
2 Complex Regional Pain Syndrome (CRPS) Halena M. Gazelka, MD Anesthesiology and Perioperative Medicine Division of Pain Medicine Mayo Clinic, Rochester, MN February 17, MFMER
3 Disclosure No financial disclosures I will discuss off label use of some medications 2016 MFMER
4 Objectives Recognize the criteria for diagnosis of CRPS Review diagnostic studies utilized in CRPS Discuss current treatment strategies 2016 MFMER
5 17 th Century King Charles IX 2016 MFMER
6 19 th Century Silas Weir Mitchell 2016 MFMER
7 2016 MFMER
8 CRPS PAINFUL neuropathic condition Occurs following trauma Remains after healing Out of proportion to initial injury *No other explanation for the signs/symptoms * 2016 MFMER
9 Two types Type I: initial event may or may not have been painful (no overt nerve injury) Type II: definable nerve injury present 2016 MFMER
10 Stats Women > men Middle age Upper extremities Fracture most common inciting event De Mos, et al. Pain. 2007;129: Sandroni, et al. Pain. 2003;103: MFMER
11 Mrs S Healthy 56 y.o. Bunionectomy Presented to follow up w/podiatrist describing: terrible burning pain in my foot! It s swollen, bright red, and hot! 2016 MFMER
12 2016 MFMER
13 Signs/Symptoms 1. Sensory: allodynia (non-painful touch is painful) hyperalgesia (painful stimuli hurt more) neuropathic pain (burning, lancinating, etc) 2. Vasomotor: temp asymmetry (hotter or colder than other limb) skin color change 3. Sudomotor/edema: edema sweating changes 4. Motor /trophic: decreased range of motion motor dysfunction (weakness, tremor, etc) trophic changes (hair, nails, skin) 2016 MFMER
14 Diagnosis CRPS is a CLINICAL diagnosis Diagnosis of exclusion Some tests may be useful/supportive Sweat test Useful in the evaluation of small fiber neuropathy May help document presence/absence of sudomotor dysfunction Thermography Infrared thermometer measures multiple points on extremities Difference of 1 0 C is considered significant QSART Measures sweat output to a cholinergic challenge Measure sweat bilaterally and symmetrically Bone densitometry Decreased bone mineral density and bone mineral content 3 Phase bone scan Increased periarticular activity = increased bone metabolism Sensitivity and specificity of 80% 2016 MFMER
15 But what causes CRPS? 2016 MFMER
16 2016 MFMER
17 Pathophysiology of CRPS Lots of theories. Sympathetically maintained pain Somatic nervous system Inflammation Hypoxia/Endothelial dysfunction Likely an interplay of nervous system dysfunctions MFMER
18 Treatment of CRPS MFMER
19 Treatment of CRPS Physical therapy/restoration Medical Interventional Neuromodulation 2016 MFMER
20 Treatment of CRPS Goals: reduce pain preserve limb function return to activity = FUNCTIONAL RESTORATION 2016 MFMER
21 2016 MFMER
22 Medical Treatment of CRPS Opioids Oral corticosteroids Ca 2+ channel blockers Anticonvulsants IVIG Sildenafil Cannabanoids Botulinum toxin Topical agents (capsacin) Epidural infusions Ketamine infusions Vit C Bisphosphonates 2016 MFMER
23 Practical medical therapy of CRPS Neuropathic agent: gabapentin or pregabalin TCA: nortriptyline or amitriptyline SNRI: duloxetine (lowest efficacious dose = 60 mg) Topical agents: lidocaine (5% patch FDA approved) ketamine (compounded products) capsaicin (Qutenza) IV: Bisphosphonates (improvement in pain.? Improvement in osteopenia) 2016 MFMER
24 Interventional therapies Upper extremity stellate ganglion block Lower extremity lumbar sympathetic block 2016 MFMER
25 Neuromodulation Spinal cord stimulation FDA approved good evidence Effective therapy for non-responders Cost effective Early, rather than late 2016 MFMER
26 2016 MFMER
27 Mr S Very motivated patient! Aggressive, early intervention PT desensitization Pregabalin 225 mg twice daily Nortriptyline 75 mg nightly Off of all meds within 9 mos of diagnosis 2016 MFMER
28 Summary CRPS: a type of neuropathic pain Diagnosis is clinical Focus: functional restoration Medical therapy similar to other neuropathic pain Spinal cord stimulation can be life changing for nonresponders to more conservative therapy 2016 MFMER
29 MFMER
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