Unrelated but related - heel probs/podiatrist and CRPS
 

Hi folks

Well, I got my initial phone consult, a kindof triage call, from the podiatrist last week. I have a lump in the heelbone of my right heel (and probably left too although that hasn't been x-rayed) and it means I get very painful heels from walking. I've used heel lifts and backless shoes (my kids loooove the Crocs, not) and also tried Feldene gel through the GP. After telling the podiatrist this, he thinks I will probably need surgery on both heels, but in the meantime I'm to go see him next month. I am not very happy with the idea of surgery, because I really have to stay as mobile as possible to lose weight for the SCS. But, I also know that I've tried just about everything for this problem and it's already screwed up my mobility as much as my sciatica and CRPS has.

I received the letter over the weekend confirming the appointment to go see him and in it he says new patients should come dressed in shorts so he can assess their movement properly. This isn't going to happen with me, not just because I'd be mortified (I'm big lol) but because I wear leggings with everything to prevent anything touching my CRPS areas. Do you think wearing leggings instead would be okay?

Cheers

Kathy
xx

Kathy I can't at this moment find the 2000 paper, first as far as I know that said the use of pre-emptive analgesics prevented the spread of RSd during operations but I would suggest you print this out and insist he read it. Te full page is here. http://journals.lww.com/anesthesiolo...&type=fulltext

Timing of Surgery
Surgery on an extremity affected with CRPS is generally avoided because of the risk that the symptoms will recur or worsen.29–31 Unfortunately, as many as 6–10% of patients with CRPS may require surgery on the affected extremity.32 The optimal time to perform surgery in patients with a history of CRPS remains unknown and may also affect the recurrence rate. Lankford29 states that sympathetic blocks be performed and the RSD process must be allowed to “cool down” for at least 1 yr, during which time the patient should actively engage in physical therapy before any surgical procedure. For surgical procedures on the knee, Katz and Hungerford30 suggest that care should be taken to “wait until symptoms of reflex sympathetic dystrophy have subsided.” They also recommend physiotherapy and analgesic support with sympatholytic pharmacologic agents and sympathetic blocks before any surgical procedure. The mean time interval reported between resolution of CRPS symptoms and the first procedure to correct mechanical derangement of the knee was 5 months (range, 2–17 months). Under these conditions, 8 of 17 patients (47%) had recurrence of CRPS after surgery. Veldman and Goris31 “preferred to wait until the signs and symptoms of RSD decreased at rest and perfusion of the affected limb was optimized.” These authors emphasized that “surgery in the setting of a cold and/or edematous limb is contraindicated.” They recommended treating CRPS patients with peripheral vasodilators or blockade of the sympathetic nervous system to increase blood flow until skin temperature was normal before any surgical intervention. The authors did not specify the time interval before surgery, but the recurrence rate of CRPS was only 13% (6 of 47 patients). In postarthroplasty patients with CRPS, Katz et al.16 state that elective surgery to correct coexistent mechanical dysfunction (aseptic loosening, ligament imbalance, component malalignment) should be delayed until CRPS symptoms are “under good control.” The investigators recommended that these CRPS patients undergo a series of sympathetic blocks before the anticipated surgery.
It may be clinically useful to assess distress and pain intensity preoperatively in patients presenting for surgery without a history of CRPS. Preoperative pain has been shown to be a predictor of chronic pain after a variety of surgical procedures.33 Patients with greater pain before total joint arthroplasty were found to be at greater risk for heightened postoperative pain, irrespective of confounding issues, such as severity of preoperative disease or postoperative complications.14,34,35 Greater preoperative pain intensity could alter central nociceptive processing pathways, thereby leading to a greater likelihood of development of postsurgical CRPS.36 This theory was recently confirmed in a prospective study that demonstrated that patients presenting with increased preoperative pain had a higher predilection for the development of postoperative CRPS after total knee arthroplasty.14 Harden et al.14 suggested that it may be clinically useful to assess the intensity of pain preoperatively and, if it is increased, to implement appropriate interventions before surgery and to monitor such patients more closely for possible postoperative CRPS.
Although the consensus among physicians in the medical community is to wait for the signs and symptoms of CRPS to resolve before performing surgery, there is no evidence-based medical research to support this theory. Increased preoperative pain has been shown to play a significant role in the development of CRPS after total knee arthroplasty. Future prospective studies are needed to determine whether this holds true for other surgical procedures and whether reducing preoperative pain can decrease the incidence of postsurgical CRPS.
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Regional Blocks
It has been recommended that CRPS patients undergoing surgery should avoid general anesthesia because the disease process might be “rekindled by surgery under general anesthesia.”37 It has been postulated that regional anesthesia, by allowing the preoperative onset of sympathetic blockade, may be a more appropriate anesthetic choice for patients with sympathetically maintained pain because it may prevent the recurrence of this syndrome in the postoperative period.38 Several authors37,38 have reported cases in which patients with previous CRPS had recurrence during general but not regional anesthesia after surgical procedures. The regional techniques used were epidural anesthesia for lower extremity surgery and brachial plexus blockade for upper extremity surgery. It is important to realize that both of these regional techniques are associated with the preoperative onset of a sympathetic blockade, which could prevent the development of CRPS. The use of stellate ganglion block, intravenous regional block, and epidural block have all been reported as techniques that may be useful in decreasing the incidence of postoperative CRPS.

Whatever you do, don't use this paper with any medical professionals. The guy who wrote it, Scott Reubens, was a complete fraud. He admitted eventually that he hadn't actually carried out any of his many clinical trials and had just made up all of the contents and results. It set back CRPS research enormously. His papers have all been pulled from web based journals and sources and any other papers that relied on his papers have had those aspects rendered equally meaningless and null. This made the mainstream news media at the time and I can remember RSDSA announcing that they were pulling all his papers from their site because they were fabricated.

Google his name and you will see the extent of his fraud.

I had no idea about tha twhy does the Jounal of the American Society of Anesthesiologists still have it on their websites.
The basic information is still good and in other papers recommending no surgery unless the situation is life threatening

You would have to ask them that - as you can see, its certainly no secret that he was a scam artist and fraudster. He fabricated his trial data many times over many years. Perhaps they choose to preserve online versions of their paper journals in exactly the same format as the paper ones were published. In that case there is usually a retraction of any dodgy papers that have already been published in future versions. Not so helpful if you don't know about it and come across retracted papers via search engine.

Where the underlying info is good and reliable, then use those papers to support your requests. Just don't use anything by Reubens or rely on any parts of future papers that rely on references to his research.

Kathy,

I'm guessing that if he has to assess your heels, he's going to be planning on touching your legs (for instance, holding up your lower leg so that he can see the movement of the muscles of your lower leg and foot when he asks you to flex/dorsiflex your foot, etc). If you have skin discoloration in your RSD affected areas, seeing it might be able to help him handle/touch your legs without touching the painful areas.

I'm not a petite gal myself, so I do understand the desire to "cover" things. I don't have RSD of the lower extremities, I can't imagine shaving my legs near an RSD area, which would also make me want to cover up. You might consider a long loose skirt that you could hike up during the exam or wear the shorts underneath.

NC, not that it matters much, but was that not peer-reviewed prior to publication?

That particular online Journal doesn't give any information about whether the paper was peer reviewed either prior to or post publication. Its something you would have to ask the Journal editors. Its not unusual for papers to be published prior to peer review and then to be edited, amended or have comments added after peer review has happened. In scientific areas where there is very little research volume, peer review may not even happen. Even if trial results can be replicated, where this happens in very small scale trials and/or those with flawed or less than ideal methodologies, it is possible for coincidence to result in outcomes which appear on the face of it to be supportive of the initial trial results. Sadly, even today, it is not unusual to find research conducted with all sorts of flaws in the methodologies, processes, assumptions and the conclusions drawn by the researchers. This is where the likes of good quality, large scale meta-analysis research and especially the likes of the Cochrane Reviews are so valuable. Unfortunately people just assume that all published research is all carried out "properly", is peer-reviewed and can, therefore, whatever the conclusions are can always be relied upon but unfortunately, that just isn't the case. Not all research is created equal and not all journals that publish research have equal weight or standing.

When the story broke about this guy admitting that he had fabricated countless published papers and had completely made-up his trial results, it was big news, not just in the CRPS or pain management world (not all his research was on CRPS). He certainly set CRPS research back considerably.