New trauma, new fears.
 

Dislocated my shoulder in a fall, and am afraid it will trigger or exacerbate my

existing RSD (right ankle sprain 2006). My arm is immobilized and despite apparent chips of bone from my

humerus or glenoid making matters worse, I am not having surgery.

Who here has also suffered second traumas subsequent to developing RSD, and

what happened? Thanks.


-steve

Sorry that I don't have an answer for you, Steve.

I do have a similar question of my own d/t pain out of proportion to the original injury continuing after a bad ankle sprain.

How long before doctors will consider a spread of RSD ? How long til the redness /skin sx's appear ?

Hi Steve,

So sorry to here about your shoulder problem, believe me I feel your pain. But to answer your question I had a serious elbow inquiry which required more than 1 surgery but it took me a few surgeons to find the right one. So I had been diagnosed with RSD and then had to still have surgeries to correct by elbow problem including having a titanium implant to replace one of the parts that broke so badly it could not even be pinned together, it was a mess. When I finally found the correct doctors who could help both my pain doctor and surgeon worked in the same hospital and worked on many other case together so it was very systematic how they handled the RSD so I could have the surgeries. The first surgery they did was a pretty major like 7 hours, he did a lot in one operation including nerve transposition surgery. For the first surgery with these doctors I was given Stellate Ganglion Blocks, they stopped PT, my prior doctors had be going for almost a year, just basically tried to calm the arm down. After about 6-8 months they felt the RSD was calm enough to do this big surgery. Believe me I was freightened out of mind. I did recover pretty good from the surgery and after many months got almost my full range of motion back which prior to this doctor working with me I could hardly move my arm, fingers almost nothing. Unfortunatly the RSD did get worse so we started doing in-patient ketamine infusions which helped but I also have PN. So after I had experience with the ketamine that is what they would use as part of the anesthetic during 2 and 3rd surgeries. After 5 years since my last surgery I am doing ok it took a long time I only work PT can not do the FT anymore just don't have the endurance to use the arm nomally.

Hi Steve,

Sorry to hear about your injury. I hope it heals quickly and without further problems.

My RSD started in my ankle when I was 12 after an ankle sprain. 4 months later, it spread to my right arm after I fell getting out of the bath tub and badly bruised my arm.

Earlier this year, the weather was icy and I was going to get into a cab to go to school and fell on the ice and managed to land on my shoulder. The RSD spread to that shoulder after a few days.

I've been collapsing a lot lately and fell out of bed and landed on my back really hard. My back has been really swollen, painful, red and bruised ever since (injury happened about 6 weeks ago). Not sure if thats RSD as it seems to be a different pain ... waiting for an MRI scan.

My Doctor told me that I have to be really careful with any injuries as I am really prone to the RSD spreading.

It's important that you try moving as much as possible. Obviously thats really hard with your dislocated shoulder but I would try it when your Doctor says for you to do so as it might help. Start off doing small exercises then build up when you feel up to it.

If you suspect the RSD spreading, call your PM Doctor asap (if you have one)! DON'T leave it as quick treatment is critical and can help put it into remission. Your Doctor may be able to prescribe more medications / blocks if your pain worsens.

I hope you are feeling better now. If you ever want to talk, i'm here. I know first hand just how scary this illness is.

Alison.

Unfortunately predicting RSD spread is tough. Everyone is different & every new injury is different. My RSD started in my right arm from an unknown injury. While detoxing from some of my pain meds, I passed out in the shower & apparently hit my foot on the drain in the tub/shower. That caused the RSD to spread to my right foot. However, I have had several bad falls since that & it didnt cause spread. RSD has also spread into my back, stomach, & heart and I don't know why. My best advice is to keep your stress as low as possible so your nervous system isnt in high gear. I wish you luck!! As soon as you can, get your injured area moving as much as possible. I wish I could help you more!!!

Hi Steve - I had a 2nd surgery which exacerbated my RSD - intensive use of ice and aggressive PT were just the icing on the cake. I was diagnosed by my surgeon about 6 weeks after the procedure.

I knew something was STILL wrong with me (the first surgery had failed to fix the problem) within days.

Gabbycakes saw an excellent RSD doctor in NYC at the Hospital for Special Surgery. If you live in South Jersey, I would highly recommend Dr. Getson of Marlton. A really good, experienced RSD doc can help you the best at this point.

The best of luck to you. Sandy

Thanks everyone! All of your stories were helpful. I am still wearing an

immobilizer, but look forward to some light PT in a few weeks. And,while I do

have pain in the other shoulder, it isn't burning.

-steve

Steve -

I strongly recommend that you follow Sandy's advice and make an appointment to see Dr. Getson as soon as possible.

Alternatively, you may which to seek out the services of an anesthesiologist in your area who is board certified by the American Board of Pain Medicine, the organization that supervises all pain management fellowships in the U.S. Its search engine can be found at: http://www.association-office.com/ab...dir/search.cfm In light of the urgency of your situation, I would seek out - under the heading "Demographics" - someone with a background in anesthesiology, although a neurologist who has completed a pain management fellowship would be fine too. (For CRPS, I avoid physiatrists as a matter of principle, as great as they may be for lower back pain.)

Quite simply, each new "spread" to a previously unaffected limb is, in effect, a fresh case of RSD. See generally, Intravenous Immunoglobulin Treatment of the Complex Regional Pain Syndrome - A Randomized Trial, Goebel A, Baranowski A, Maurer K, Ghial A, McCabe C, Ambler G, Ann Intern Med. 2010;152:152-158, FULL TEXT @ http://www.rsds.org/2/library/articl...rnMed_2010.pdf:

There is evidence, however, for immune activation in the affected limb, peripheral blood, and cerebrospinal fluid (8 –10). This suggests that modulating the immune system may alleviate CRPS. In keeping with this possibility and stimulated by a chance observation, we examined the benefit of treating CRPS with intravenous immunoglobulin (IVIG).

* * *

The study physician judged whether eligible patients had stable CRPS of 6 to 30 months’ duration. Patients with a longer duration of disease were eligible if they reported that disease had spread to a previously uninvolved limb within the past 30 months. [Citations partially omitted.]

Notes
8. Huygen FJ, De Bruijn AG, De Bruin MT, Groeneweg JG, Klein J, Zijlstra
FJ. Evidence for local inflammation in complex regional pain syndrome type 1.
Mediators Inflamm. 2002;11:47-51. [PMID: 11930962] [FULL TEXT @ http://www.ncbi.nlm.nih.gov/pmc/arti...f/11930962.pdf]
9. Uçeyler N, Eberle T, Rolke R, Birklein F, Sommer C. Differential expression
patterns of cytokines in complex regional pain syndrome. Pain. 2007;132:195-205. [PMID: 17890011] [ABSTRACT @ http://www.ncbi.nlm.nih.gov/pubmed/17890011]
10. Alexander GM, van Rijn MA, van Hilten JJ, Perreault MJ, Schwartzman
RJ. Changes in cerebrospinal fluid levels of pro-inflammatory cytokines in CRPS. Pain. 2005;116:213-9. [PMID: 15964681] [ABSTRACT @ http://www.ncbi.nlm.nih.gov/pubmed/15964681]

Translation: After 30 months CRPS is no longer a function of the immune system, except in the case of spread to a previously unaffected limb, in which case the clock is reset.

Unfortunately, the results with IVIG are not terribly spectacular, indeed they are subject to open doubt. See, IVIG Shown to Relieve Complex Regional Pain Syndrome But Study Has Limitations, Experts Say, Valeo T, Neurology Today. 2010 March 14. FULL TEXT @ http://www.rsds.org/2/library/articl..._IVIG_2010.pdf

To the best if my understanding, by far and away the best odds for knocking out a fresh case of CRPS in the upper extremities lies in a Stellate Ganglion Block. But there (as with the lumbarsympathetic block for lower extremities) time is absolutely of the essence. See, Efficacy of Stellate Ganglion Blockade for the Management of Type 1 Complex Regional Pain Syndrome, Ackerman WE, Zhang JM, South Med J. 2006;99:1084-1088, FULL 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. [Emphasis added.]

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, Istemi Yucel, Yavuz Demiraran, Kutay Ozturan, Erdem Degirmenci, J Orthopaed Traumatol (2009) 10:179–183, FULL TEXT @ http://www.ncbi.nlm.nih.gov/pmc/arti...Article_71.pdf

Bottom line: time is not on your side if you wait to have PT. And in that regard, I wouldn't rule out surgery if properly performed with something called continuous regional anesthesia, which Dr. Getson or another specialist can explain to you. Frankly, it would be my guess that you stand the best chance in the long run of avoiding CRPS spread with surgery using continuous regional anesthesia, than in spending the rest of your life being subject to irritation from bone chips. I know one lady on this board who, with more or less chronic CRPS, was nevertheless considerably relieved when a loose orthopedic screw from a prior procedure was surgically removed using continuous regional anesthesia.

In any event, an ASAP consultation can't hurt.

Good luck!

Mike


PS And as a general rule, beware immobilization.

This is a continuing problem for me. Any severe pain never really goes away. I still feel an angioplasty, shot in right arm, cut ear, and sprained ankle. I even feel a nerve block once in a while.