SnowWhyte -
Where you were injured only eight weeks ago,
it is vital that you immediately get started on an aggressive series of lumbar sympathetic blocks, combined with PT on the days after the block when you have maximum pain relief. But the window on starting this is really short, with the best evidence suggesting that the best chance of blocks making a difference is when you start them within three months on the onset of symptoms.
Now, because you've got it in the foot (as do I) the treatment would be a lumbar sympathetic block (LSB), performed under fluoroscopy. However, the same principles apply ;to treating CRPS in the arms, where the "stellate ganglion block" (SGB) is the most frequently applied. And with respect to the SGB research has shown the blocks are effective, if initiated roughly within 22 weeks on the onset of symptoms. See, e.g. Efficacy of stellate ganglion blockade for the management of type 1 complex regional pain syndrome, Ackerman WE, Zhang JM,
Southern Med J. 2006 Oct; 99(10): 1084-8, FULL ONLINE TEXT @
http://www.rsds.org/2/library/articl...lion_block.pdf
Abstract
INTRODUCTION: The purpose of this study was to examine the efficacy of stellate ganglion blockade (SGB) in patients with complex regional pain syndromes (CRPS I) of their hands.
METHODS: After IRB approval and patient informed consent, 25 subjects, with a clinical diagnosis of CRPS I of one hand as defined by the International Association for the Study of Pain (IASP) criteria, had three SGB's performed at weekly intervals. Laser Doppler fluxmetric hand perfusion studies were performed on the normal and CRPS I hands pre- and post-SGB therapy. No patient was included in this study if they used tobacco products or any medication or substance that could affect sympathetic function. The appropriate parametric and nonparametric data analyses were performed and a p value <0.05 was used to reject the null hypothesis.
RESULTS: Symptom onset of CRPS I until the initiation of SGB therapy ranged between 3 to 34 weeks. Following the SGB series, patient pain relief was as follows: group I, 10/25 (40%) had complete symptom relief; group II, 9/25 (36%) had partial relief and group III, 6/25 (24%) had no relief. The duration of symptoms until SGB therapy was: group I, 4.6 +/- 1.8 weeks, group II, 11.9 +/- 1.6 weeks and group III, 35.8 +/- 27 weeks. Compared with the normal control hand, the skin perfusion in the CRPS I affected hand was greater in group I and decreased in groups II and III.
DISCUSSION: The results of our study demonstrate that an inverse relationship exists between hand perfusion and the duration of symptoms of CRPS I. On the other hand, a positive correlation exists between SGB efficacy and how soon SGB therapy is initiated. A duration of symptoms greater than 16 weeks before the initial SGB and/or a decrease in skin perfusion of 22% between the normal and affected hands adversely affects the efficacy of SGB therapy.
PMID: 17100029 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/17100029
See, also, Complex regional pain syndrome type I: efficacy of stellate ganglion blockade, Yucel I, Demiraran Y, Ozturan K, Degirmenci E,
J. Orthop Traumatol. 2009 Dec;10(4):179-83. Epub 2009 Nov 4, FULL ONLINE TEXT @
http://www.ncbi.nlm.nih.gov/pmc/arti...Article_71.pdf
Abstract
BACKGROUND: This study was performed to evaluate the treatment of complex regional pain syndrome (CRPS) type I with stellate ganglion blockade.
MATERIALS AND METHODS: We performed three blockades at weekly intervals in 22 patients with CRPS type I in one hand. The patients were divided into two groups depending on the time between symptom onset and treatment initiation. Group 1and 2 patients had short and long symptom-onset-to-treatment intervals, respectively. Pain intensity, using a visual analog score (VAS), and range of motion (ROM) for the wrist joint were assessed before and 2 weeks after treatment and were compared using nonparametric statistical analysis.
RESULTS: Treatment produced a statistically significant difference in wrist ROM for all patients (P < 0.001). VAS values showed an overall decrease from 8 +/- 1 to 1 +/- 1 following treatment, and there was a significant difference in VAS value between groups 1 and 2 (P < 0.05).
CONCLUSIONS: We concluded that stellate ganglion blockade successfully decreased VAS and increased ROM of wrist joints in patients with CRPS type I. Further, the duration between symptom onset and therapy initiation was a major factor affecting blockade success.
PMID: 19888550 [PubMed - indexed for MEDLINE]PMCID: PMC2784060
http://www.ncbi.nlm.nih.gov/pubmed/19888550
Please note: Before these studies came out (and to an extent afterwards) blocks have gotten a lot of bad press as ineffectual for CRPS. But that was only because none of the studies has focused on the length of any patient’s illness. Not coincidently, over the last 5 years or so there has been an explosion of basic science, demonstrating that CRPS is propagated/maintained by very different processes just over the first 2 -3 years of the disease. (References available on request.)
Without putting too fine appoint on it, if your doctors are not offering you a series of LSBs with PT at this stage of your illness, it appears (at least at first blush) that you are not being well served by your current treating physicians.
Your best bet for finding a good pain specialist in your area may be someone who is board certified by the American Board of Pain Medicine, which accredits almost all pain fellowships in the U.S. To be board certified, a physician must complete such a one-year fellowship (after an appropriate residency) and then pass an 8-hour exam. Here’s a search engine that may assist you in locating someone in your area:
http://www.association-office.com/ab...dir/search.cfm There is one caveat, however. The search engine will show the doctor’s “underlying specialty of origin.” I would strongly urge you to avoid physical medicine/physiatry specialists for the treatment of CRPS. They may be great for lower back pain, but it just so happens that this is one of the most complicated problems in neurology today. My first choice would therefore be a pain specialist with training in neurology, with anesthesiology and psychiatry a close second.
And there are other therapies that have been shown to be effective only in the early stage of the disease, “mirror box therapy” for one. But it’s just past 3:30 am in LA and I’ve already bombarded you with enough.
Again, I’m happy to refer you to the appropriate articles on the RSDSA site, which suggest the rapidly changing nature of the disease in the first few years of affliction. Why it took this long for researchers to begin to consider duration of disease as a variable in looking at the effectiveness of not just blocks, but any treatment, is beyond me. But it is thus. Go back six years in the literature, and disease duration isn’t even considered!
Good luck. I realize that I haven’t addressed any of your questions on anesthesia, but in even the medium term, this is far more important.
Mike