RSD/CRPS – Here we go again… 4 Years Since Our Last Update

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Featured Article........................................1
POP Quiz................................................14
In The Spotlight........................................3
Quiz Answers....................................... 16
Wazzzzzz Up?..........................................6
ASHT Meeting........................................16
Valued Reader........................................ 8
What’s Up Doc?......................................19
Ergo Tips and Tricks...............................11
EHT’s Modality Course...........................20
In The Web ............................................14
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Featured Article RSD/CRPS – Here we go
again… 4 Years Since
Our Last Update
The last time we wrote to you,
our readers, about RSD/CRPS
was in Sept. 2001. And believe
it or not YES we do have some
updates! The first “International
Update on RSD / CRPS” was
held at the University of South
Florida on February 1 and
2, 2002. Nancy and I were
fortunate enough to attend that
meeting. Dr. Anthony Kirkpatrick
is the on the scientific advisory
committee and is the director of
research for the RSD foundation.
Dr. Kirkpatrick is right around
the corner from us working in
Tampa at USF Medical Center
and is avidly involved in RSD/
Nancy Falkenstein
OTR, CHT
Susan Weiss OTR, CHT
By Susan Weiss OTR/L, CHT
CRPS research. Since this
international meeting in 2002 the
foundation has written the third
edition of the Clinical Practice
Guidelines which was released
in 2003. So yes, we do have
some new stuff to share as well
as, of course, old stuff to review.
RSD / CRPS remains poorly
understood and is still often
unrecognized. It is estimated
that 1.5 million have RSD in the
US but it could be as many as
6 million! The development of
RSD / CRPS does not appear to
depend on the magnitude of the
injury (for example a small cut or
sliver in a finger can trigger the
disorder). In fact, the injury may
be so slight that the patient may
not recall ever having an injury.
There is no single laboratory
test to diagnose RSD /CRPS.
The best way to detect is with a
detailed clinical examination. If
undiagnosed
and
untreated,
RSD / CRPS
can spread
making
treatment
significantly more challenging.
If diagnosed early, physicians
can order early therapy and
sympathetic nerve blocks to
cure or mitigate the disease.
If untreated, RSD / CRPS can
become extremely difficult to
treat, expensive and can leave
the patient with chronic pain.
continued on page 3
The terms complex regional
pain syndrome (CRPS) type I
and type II were introduced in
1995, when the International
Association for the Study of
Pain (IASP) felt the names
reflex sympathetic dystrophy
and causalgia were inadequate
to represent the full spectrum
of signs and symptoms. The
term “Complex” was added to
convey the reality that RSD
and causalgia express varied
signs and symptoms. Many
publications, particularly older
ones, still use the names
RSD and causalgia. For this
article I will use RSD and
CRPS interchangeably.
if you suspect it? Here are
the 2003 diagnostic criteria,
from the new guidelines, that
were developed after the
international meeting in 2002.
• The presence of an
initiating noxious event, or
a cause of immobilization.
Continuing pain, allodynia
or hyperalgesia with which
the pain is disproportionate
to the inciting event.
• Evidence at some time for
edema, changes in skin blood
flow, abnormal sudomotor
activity, impairment of motor
function or changes in tissue
growth (dystrophy and atrophy)
in the region of the pain.
• This diagnosis is excluded by
the existence of conditions that
would otherwise account for the
degree of pain and dysfunction.
When you are treating a patient
you may wonder if they have
RSD. What should you do
So what does this mean? It
means that if your patient seems
to fit the listed criteria you better
talk to the treating Dr. and soon!
The earlier you get the show on
the road, the better chance of
recovery. If the previously stated
criteria are present on clinical
exam then you have a winner as
the clinical exam is still the best
way to diagnosis RSD. Other
diagnostic tests that
the Dr. might order
can include: triple
phase bone scan,
thermography, nerve
blocks, x-rays, EMG,
cat-scans or MRI’s.
The following is
a list of clinical
features seen in
continued on page 4
In the SPOTLIGHT!
Marcus Allen, OTR/L, CHT
Q: What type of setting
do you work in?
A: Outpatient Hand Clinic
located in an ambulatory surgery
center (hospital based)
Q: How long have you been
doing hand therapy?
A: 23 years
Marcus Allen OTR/L, CHT
Q: Where did you receive
your OT degree from?
A: University of Missouri-Columbia
Q What state are you
currently practicing in?
A: Missouri
Q: What is your favorite
diagnosis and why?
A: Any type of post surgical
trauma because it requires me
to be astute in my evaluation and
to have foresight and accuracy in
the treatment planning process. I
also feel that that is a diagnostic
category that, as a Hand Therapist,
I have a significant impact on.
Q: What do
you find is
the most challenging
diagnosis you treat?
A: Cumulative trauma due to the
multiple factors that are involved.
Q: What areas of hand and
upper extremity rehab.
do you want to expand
your expertise in?
A: I would like to improve my
understanding of kinetic chain concepts
and movement analysis as it relates to
cumulative trauma. I am also interested
in pursuing a clinical research project
at some point in the near future.
Q: What accomplishments
would you like to share with
the hand therapy community?
Continued on page 6
4
RSD/CRPS. If your patient
seems to have a bunch of these
features don’t wait a couple
of weeks to see how they do
- call the referring Dr. and let
them know the signs/symptoms
you see and put the ball back
in their court right away as
early intervention is critical.
Here is what you might see:
• Pain - The hallmark of RSD is
pain out of proportion to what is
expected from the initial injury.
• Trophic changes - skin may
appear shiny (dystrophyatrophy), dry or scaly. Hair
may initially grow coarse and
then thin. Nails in the affected
extremity may be more
brittle, grow faster/slower
• Swelling - pitting or
brawny (hard)
tion.
person with a little extra instrucnew therapist, and even the lay
is friendly to the new user, the
Because of it's flexibility, the tape
respond to the skill of the user.
practice and has the flexibility to
This is a tool that responds to
or in palpating for a problem.
there is in myofascial techniques
there is art in the fingertips as
There is clearly a science, but
that particular layer of tissue.
your tape application to affect
are taping, and how you intend
clear in your own mind what you
know your anatomy, and to be
of the tissue. It helps, a lot, to
knowledge as well as the depth
that incorporates your depth of
there is a certain artistry to taping
injury differently. I've learned
• Movement Disorder - Patients
with RSD/
CRPS have
difficulty
moving
because
they hurt
when they
move.
• Spreading
Symptoms - Initially, RSD /
CRPS symptoms are generally
localized to the site of injury.
As time progresses, the pain
and symptoms can become
more diffuse and spread
• Bone changes - X-rays may
show wasting of bone (patchy
osteoporosis) or a bone
scan may show increased or
decreased uptake of a certain
radioactive substances in bones
after intravenous injection.
tape…and then I think of all the
realize what they can do with this
therapist's satisfaction when they
with the tape is seeing another
than seeing my patient's improve
The only thing more satisfying
toire for many years to come.
remain in my therapeutic reperinvention of Tex tape. It will
I couldn't be more grateful for the
rehabilitation.
Tex tape at some point in their
from at least one application of
than this, they could all benefit
Though I choose more judiciously
patients that stroll into our clinic.
could easily apply to 99% of the
Tex tape is the one tool that I
as well as the most versatile.
most powerful therapeutic tools
I still find Tex tape is one of the
Here it is several years later and
What is the deal with stages?
Are they in or out? Fact or
fiction? Stages are still referred
to despite the fact that that
this concept has died so we
will review them for historical
significance and in the event
that you still have Dr.’s that
use stages you will know
what they are talking about!
Acute (stage I)
1. Onset of severe, pain
lmited to the site of injury
2. Increased sensitivity of
skin to touch and light
pressure (hyperasthesia).
3. Local swelling
4. Muscle cramps
5. Stiffness and limited mobility
6. At onset, skin is usually
warm, red and dry and
Continued on page 12
gram in Oakland, CA.
Samuel Merritt College’s Hand Therapy proTracey is currently an Adjunct Instructor for
level in Rheumatology and Hand Therapy.
the US including guest lectures at the University
in Canada and the US, taught seminars across
Tracey has presented at 6 national conferences
been an educator and a program developer.
1993. Throughout her career, she has always
Hand Center in Kentfield, CA since March,
She has been a Hand Therapist at Kentfield
opening The Arthritis Center in San Mateo, CA.
ogy. She then moved to California to join in
3 years in general orthopaedics, and rheumatolthe University of Calgary (Foothills) Hospital for
University of Alberta in Canada. She worked at
of Science in Occupational Therapy at the
Bachelor of Arts in Gerontology and a Bachelor
Tracey Airth-Edblom, OTR, CHT received a
grateful patients they will treat.
In the Spotlight (continued)
A: I am happily married to my wife Amy
for 23 years, I have 2 children, Maggie
(17) and Grant (13) that I find quite a
joy to have as a family. I am active in
my church & play music there weekly.
Q: How long have you
been educating?
A: For at least 10 years...
I forget when I started.
Q: How did you get involved in
teaching for EHT and why?
A: I got interested after reading the
website and newsletter. I got involved,
because I like teaching and like the
DVD/web-based format because I
feel it can reach a lot of
people and will be the
trend for the future.
Q: What do you do for fun
when you are not busy
in your hand clinic?
A: I enjoy vegetable gardening,
hiking/camping/canoeing/fishing,
biking, playing music and
coaching little league baseball.
Q: Do you have an area of
clinical expertise that you
can share with us such as a
tip or trick that we can try
in our clinical practice?
A: Consider home-made splint kits for
those custom splints splint makers.
You can have a technician or volunteer
put all of the necessary “ingredients”
of the splint, cut out and pre-measured
into a large zip lock baggie. It saves
time for frequently made splints
and time consuming splints.
Also, by pre-measuring, it can
assist with pricing of the materials
for those in the developmental
stages of a hand therapy clinic.
Thank you Marc!
Marc has a FANTASTIC course
on Joint Mobilization of the Upper
Extremity (from
the shoulder
to the finger)
available on
DVD, CD-ROM
or Internet.
order at:
www.liveconferences.com
“AOTA does not endorse specific course
content, products, or clinical procedures.”
Whazzz UP?
Thank you to all the
therapists
who sent
letters to the
DMEPOS
about the
Quality Standards draft.
We are patiently waiting
on the outcome. EHT
will keep you informed.
Keeping our fingers and
toes crossed that the
language is changed
to allow therapists
to continue to bill
for splint fabrication
and application.
Want To Pass the
Hand Therapy Exam?
Exploring Hand Therapy
Presents:
Basics & Beyond:
A Comprehensive Study of
Upper Extremity Rehabilitation
“I basically sacrificed buying new clothes for
the year to have the best materials out there”
D. Eber OTR/L, CHT
EHT also has 3 Practice Exams
to prepare for the big day.
ORDER at:
www.liveconferences.com
or
call: 727-341-1674
EHT is an AOTA Approved Provider
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From a Valued Reader!
Ganglion Cysts
The most common type of soft
tissue mass in the hand is a ganglion
cyst. A ganglion cyst is a type of
lump which appears near a joint
or tendon. It is similar to a sac or
balloon which is filled with a clear,
gel-like fluid. It may be soft or
hard, and sometimes can become
painful or even painless. They often
erratically appear and/or disappear,
and often with no apparent cause.
Ganglions are famous for appearing
and disappearing on there own, as
well as for getting bigger or smaller
spontaneously. They are also called
mucous cysts, or synovial cyst.
What causes it?
Our joints and tendons are lubricated
by a special liquid called synovial
fluid, which is contained in a
compartment. When we use our
By: Margaret Stenn Schwartz, OTR, CHT
hands for normal activities, our
muscles and joints squeeze the
fluid and create pressure in the
lubricating compartment. Often due
to arthritis, or injury, a small portion
of fluid leaks out of the compartment.
The synovial fluid is the lubricating
liquid which has special proteins and
therefore is not easily reabsorbed
once it has leaked. The liquid can
become thickened and harder
with time and becomes more of a
“lump” that can be seen or felt.
Occurrence is higher in women with
70% between the
ages of 20 and
40, but can occur
at any age or
gender. Ganglions
occurring
at the DIPJ (mucous cyst) are
associated with Osteoarthritis
and older ages. Occult ganglia
can occur in young gymnast due
to joint stress onto the wrists.
Common sites for ganglions are:
• The most common site is the
back of the wrist and is called
a dorsal wrist ganglion, which
accounts
for 6070%.
These
can arise
from
the wrist joint spaces, most
often the scaphoid-luncate
interval and are sometimes
irritated by a wrist sprain.
• Palm side of the wrist or volar
wrist ganglion, or sometimes
on the thumb side. These arise
Continued page 10
from
one of the wrist joints, and
often aggravated by a sprain.
• The palm at the base of
the finger at the flexor
tendon sheath. Often
due to inflammation
around the tendons.
• The distal joint of the finger
(DIPJ), usually due to arthritis
What can the patients do?
Wait and see if it gets smaller and
reabsorbed. Non-steroidal antiinflammatory medication (NSAID),
such as aspirin, Ibuprofen, or
Naprosyn can be helpful.
Historically, an old “non-medical”
remedy was to hit the lump with
a heavy book, in order to rupture
the cyst. This can cause injury,
even if successful in eliminating
the cyst, the lump may return and
it may be larger than the first. The
legend is that treatment involved
using a Bible, thus the name
“Gideon’s disease” was born.
What can a therapist do?
Provide a special hand or finger
splint to support the area or
prevent deformity (DIP). Suggest
ergonomic modifications to daily
activities or work duties which
may be problematic. If patient
is experiencing pain, teach pain
management techniques.
What can a doctor do?
Confirm the diagnosis is a
Ganglion cyst and r/o anything
more serious. Drain or aspirate the
fluid from the cyst with a needle,
and possibly inject the area with
cortisone. This works well for
cysts coming from the tendon.
Perform surgery to remove the
cyst and clean out the area
where the cyst comes from.
This information is not meant as
a self help directory or for the
purposes of dispensing medical
advice. Any use of medication or
treatment of a suspected problem
or symptom should be done only
after consulting ones’ physician.
It is important that if you suspect
any problem to consult your
medical doctor first, or possibly a
Hand Surgeon which specializes
in the treatment of the Hand.
Thank you Margaret for your
valuable contribution.!!
• Reference: E-HAND.COM THE ELECTRONIC
TEXTBOOK of HAND SURGERY
maintained by Charles Eaton, MD
Ms. Schwartz is an OTR, CHT working in
private practice in Elizabeth and Edison N.J.
She graduated from Towson University. She
can be reached at [email protected]
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Ergo Tips and Tricks
Problem: Poor posture at
a computer desk causing
neck, back and hand pain.
Solution: In order to set up the
best computer workstation, it is
helpful to understand the concept
of neutral body positioning. Neutral
body positioning is a comfortable
working posture in which your joints
are naturally aligned. Working
with the body in a neutral position
reduces stress and strain on the
muscles, tendons, and skeletal
system and reduces your risk of
developing a musculoskeletal
disorder (MSD). The following are
important considerations when
attempting to maintain neutral
body postures while working
at the computer workstation:
• Hands, wrists, and forearms
are straight, in-line and
roughly parallel to the floor.
• Head is level, or bent slightly
forward, forward facing,
and balanced. Generally it
is in-line with the torso.
• Shoulders are relaxed and
upper arms hang normally
at the side of the body.
• Elbows stay in close to the
body and are bent between
90 and 120 degrees.
• Feet are fully supported
by floor or footrest.
• Back is fully supported with
appropriate lumbar support
when sitting vertical or
leaning back slightly.
• Thighs and hips are supported
by a well-padded “water fall” seat
and generally parallel to the floor.
• Knees are about the same
height as the hips with the
feet slightly forward.
Regardless of how good your
working posture is, working in the
same posture or sitting still for
prolonged periods is not healthy.
You should change your working
position frequently throughout
the day in the following ways:
• Make small adjustments to your
chair or backrest every hour.
• Stretch your fingers, hands,
arms, and torso 4X in 8 hours.
• Stand up and walk around for
a few minutes periodically.
• Every 20 minutes, look away
from the computer, blink and
stretch arms for 20 seconds.
Compiled from OSHA
11
then it may change to a blue
(cyanotic) in appearance.
. Increased sweating
(hyperhydrosis).
8. In mild cases this stage lasts
a few weeks, then subsides
spontaneously or responds
rapidly to treatment.
Dystrophic (stage II)
1. Pain becomes even more
severe and more diffuse
2. Swelling tends to spread
and often changes from a
soft to hard (brawny) type
3. Hair may become coarse
then scant, nails may grow
faster then grow slower and
become brittle, cracked
and heavily grooved
4. Spotty wasting of bone
(osteoporosis) occurs
and may become
severe and diffuse
5. Muscle wasting begins
Atrophic (stage III)
1. Marked wasting of
tissue eventually
become irreversible.
2. For many patients the pain
becomes intractable and
may involve the entire limb.
3. Spreading and total body
RSD can occur at this point
O.K you know your patient
has it… now what?
The single
most
important
treatment for
the patient
with CRPS
is education.
12
• Educate about therapy goals
• Educate them about blocks
and early intervention
• Encourage normal
use of the limb
• Minimize pain
• Teach them to “hurt
is not to harm”
• Determine the contribution
of the sympathetic nervous
system to the patient’s pain
Remember, the cornerstone in
the treatment of RSD / CRPS is
normal use of the affected part.
Therefore, all drug treatment,
nerve blocks, TENS, therapy,
etc. are utilized to facilitate
movement and functional use of
the affected region of the body.
Although therapy is an important
treatment modality, significant
misuse and overuse of therapy
can occur. It is important that
the therapist encourage the
patient to use the affected part
but not to cause them pain
with aggressive mobilization
techniques or they may cause
irreversible damage. In EHT’s
newly released course about
RSD/CRPS Nancy discusses
a case of this occurring (By the
way, this is a fantastic course
and you will not want to miss it).
The primary goal of the therapist
is to teach the patient how to
use their affected body part and
provide them with the ability to
do this with minimal discomfort.
What about medication?
Medications are generally
prescribed according to
symptoms they report. For
example if a patient reports
trouble sleeping a sleeping pill
will be prescribed. Many of the
medications used to treat RSD/
CRPS are used in an “off label”
fashion. “Off-labeling” prescribing
means that the government
(e.g., the U.S. Food and Drug
Administration - FDA) approved
the medication for one purpose
but it is used by physicians for
another purpose. For example,
aspirin is a pain medication but
it can also be used to decrease
the risk of a heart attack by
inhibiting the aggregation of
platelets. Off-label prescribing
is a common practice in treating
various chronic pain problems.
Medications commonly
used to treat RSD / CRPS
based on the type of pain
may include the following:
For constant pain associated
with inflammation:
Continued on page 13
• Nonsteroidal anti-inflammatory
agents (e.g. aspirin, ibuprofen,
naproxen, indomethacin, etc).
For constant pain not
caused by inflammation:
• Agents acting on the central
nervous system by an atypical
mechanism (e.g. tramadol)
For constant pain or
spontaneous (paroxysmal)
jabs and sleep disturbances;
• Anti-depressants (e.g.
amitriptyline, doxepin,
nortriptyline, trazodone, etc)
• Oral lidocaine (mexilitine some what experimental)
For spontaneous
(paroxysmal) jabs
• Anti-convulsants
(e.g. carbamazepine,
gabapentin may relieve
constant pain as well)
For the treatment
of sympathetically
maintained pain (SMP):
• Clonidine Patch. Studies
suggest that clonidine may
decrease pain in CRPS by
inhibiting the sympathetic
nervous system. A treatment
protocol for using the Clonidine
Patch to treat CRPS can
be found in the journal
Regional Anesthesia.
For muscle cramps (spasms
and dystonia) which can
be very difficult to treat.
• Klonopin (clonazepam),
Baclofen
For localized pain related
to nerve injury:
• Capsaicin cream. (This
medication is applied to the
skin and behaves like hot
peppers. The effectiveness
of capsaicin cream in the
treatment of RSD / CRPS
has not been determined).
What about the use
of Nerve Blocks?
There are three reasons
to consider sympathetic
blockade to facilitate the
management of RSD / CRPS.
• First, the sympathetic block
may provide a permanent
cure or partial remission
of RSD / CRPS.
continued on page 15
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13
IN THE WEB
Below is a great site for everyone
to learn about RSD/CRPS
http://www.rsds.org/
This is a very current and accurate up-to-date
site with great info - it is updated frequently.
http://rsdfoundation.org/
This site has a lot of info and some different
info ie: nutritional, medications and more
http://www.rsdrx.com/index.html
Most important about RSD/CRPS websites is to be careful of
what your patients see - the web can be very dangerous and they
can be led down a very scary path. Stick with some of the main
sites and the patients can learn but not become petrified.
EHT has a GREAT updated CRPS Course.
Instructors: Dr. David Baras,
Susan Weiss, & Nancy Falkenstein
Order Now! www.liveconferences.com
JOB LISTING
Test Your Knoweledge... POP Quiz!
1. The third edition of the Clinical
6. Nerve blocks
Practice Guidelines for RSD/
can be used
CRPS was written in what year?
as a diagnostic
tool or
2. A patient must have pain
prognostic tool.
to be diagnosed with
True or False
CRPS. True or False
. Can nutrition make a
3. What is the best assessment
difference when treating
method
CRPS? Yes or No
to detect
CRPS?
8. SIP can be effectively
treated with nerve
4. Dry or
blocks. True or False?
scaly skin
is described as what
9. The phrase “no pain no
type of symptom?
gain” is applicable in
the clinical treatment of
5. Stages are still used frequently
CRPS. True of False
and are the best way
to classify CRPS
10. In reference to #9: what is a
patients. True or False
better phrase to use when
treating CRPS patients?
Answers on page 16
14
The Philadelphia Hand Center
is currently seeking an Occupational or
Physical Therapist, CHT preferred with
shoulder experience, to work in our Center
City Philadelphia location. The position
offers an exceptional opportunity to
work with highly skilled Hand Therapists
and world renowned Hand Surgeons
at one of the most well known and
respected Hand Centers in the country.
Position responsibilities include
evaluation and management of a varied
case load with an emphasis on shoulder
rehabilitation. Patients are seen from
the pre-operative to post-operative to
the return to work stages. In addition
to a stimulating clinical experience, the
position offers outstanding learning
and academic opportunities.
Competitive salary and benefits.
Contact Terri Skirven OTR/L, CHT, Director
of Therapy at 610-768-4468, &/or send
your curriculum vitae email: tskirven@
handcenters.com or FAX to 610-768-4469.
• Second, by selectively blocking
the sympathetic nervous
system the patient (and
physician) will gain further
diagnostic information about
what is causing the pain.
The sympathetic block helps
determine
what portion
of the patient’s
pain is being
caused by
malfunction
of their
sympathetic
nervous
system.
If they
do not respond to a good
block the pain my not be
sympathetic in nature.
• Third, the patient’s response to
a sympathetic block provides
prognostic information
about the potential merits
of other treatments.
There is evidence that there
might be a role for sympathetic
blocks in preventing RSD. A
retrospective study demonstrated
that the prophylactic use of
sympathetic blocks in patients
with a history of RSD decreased
the occurrence rate of the
disease from 72% to 10% after
re-operation on the affected
extremity. I think somebody
needs to set up a study to
perform blocks on patients
that present on the first visit as
possible RSD patients to see if
any go on to develop RSD or if it
prevents the development of it.
If sympathetic blocks are
not properly performed and
evaluated, time and money
will be wasted, and diagnosticprognostic information will be
lost. A good sympathetic block
should increase the temperature
of the extremity without
producing increased numbness
or weakness. If the block causes
numbness or weakness, more
than just the sympathetic nerves
were blocked. The amount of
pain relief and improvement in
range of motion and in exercise
tolerance after the block, should
be documented by the therapist.
The maximum sustained benefit
from a series of sympathetic
blocks is usually apparent after
a series of 3-6 blocks. If there
is a significant decrease in pain
Continued on page 17
15
Test Your Knowledge Answers
ASHT MEETING..... September 2005
1. 2003
Can you believe Exploring
Hand Therapy went from FL
to Texas and ended up in a
Hurricane! We had a great time
in San Antonio, TX - Sept. 23 &
24, 2005 despite the weather!
Thank
you to
everyone
who
stopped
by and
River Walk
visited
us or
attended
our courses or lectures.
2. True
3. Clinical Exam
4 Trophic changes
5. False
6. True
7. Yes
8. False
9. False
10. “hurt is not to harm”
A special thanks to Jaime
Schier, OTR, Patty Reitz PT and
Sylvia Boddener OTR, CHT for
helping in the booth and making
our show a great success.
16
EHT’s Booth
View from our hotel window
EHT will be in Philadelphia in March.
Check out the ad on page 9, It is a
fantastic program. See you in PHILLY.
following the sympathetic block,
the patient is said to have
sympathetically maintained pain
(SMP). If there is not a significant
decrease in pain, the patient often
has sympathetically independent
pain (SIP). Only patients with
SMP should be considered for
a sympathectomy. Patients are
advised to expect no more relief of
their pain from a permanent block
such as a sympathectomy, than
they received from either a SGB.
Alright, back to therapy now.
What can you
do for this
patient other
then educate
them and
encourage
functional use
of the arm?
LOTS! Let me share a few ideas
including diaphragmatic breathing,
splinting when appropriate,
desenstitization, biofeedback,
CPM, mobilization, neural gliding,
nutritional counseling, soft tissue
mobilization, edema management
and much more. Want to learn
all about it? We have a great
course on the physicians and
therapists approach to evaluating
and managing RSD/CRPS.
You can watch it on CD-rom
or DVD. It will be released
in the next few weeks and is
very comprehensive. Visit our
website at: www.liveconferences.
com to learn more about this
course. You will learn lots of
details on management of this
potentially devastating disorder.
EXCELLENT
Opportunity
Want to help @ the Philadelphia
2006 Surgery & Rehabilitation
of the Hand Course?
This is a great opportunity to
network with people in the
industry. You will have an
opportunity to visit all the booths
and attend some general session
meetings. Email us for details
on this fantastic opportunity.
[email protected]
Susan Weiss
Joint Mobilization: Get Them Moving
Fantastic “Movie” CEU course
Instructor: Marc Allen OTR, CHT
Learn joint mobilization techniques, tips and tricks
to help mobilize joints and return to function.
Evidenced Based Approach for successful outcomes
Order Now!
www.liveconferences.com
727-341-1674
17
Splinting Tips and Tricks
• Neoprene splinting is a good
alternative to thermoplastic
splinting for a patient with
CRPS; as it provides soft
support yet allows motion
and functional use.
• When you cut down prefabricated neoprene splints;
ensure the stitching is not
compromised to limit or
prevent fraying of the material.
If you cut the stitching then
your splints may unravel.
• If you use dynamic splinting
with CRPS patients, you may
need to modify your typical
protocol from 8-10 hours a
day to using the device to
as little as only 30 minutes
3x’s a day; similar to a static
progressive type of protocol.
This will help prevent the
avoidance of functional use of
the extremity while splinting
which can be very detrimental
to a patient with CRPS.
• Dynamic splints can also be
used at night on patients with
CRPS if it does not interfere
with sleep as this will allow
time in the splint and not
prevent functional use of the
hand/arm during the day.
Dynasplint Wrist Splint
18
• Static progressive splinting
(SPS) is another approach
when treating CRPS. SPS
allows for patient control
and the protocol is applied
in 30 minute sessions.
• If your CRPS patient is
hypersensitive and needs
a splint, try protecting
the area with an otoform
mold, gel sheets, or mole
skin under the splint.
• If your CRPS patient uses
liniments for pain control,
be careful using them
under splints, as the heat
and perspiration may
activate the liniments and
generate intolerable heat.
Just a word of caution.
What’s Up Doc? ... RSD
This month’s featured expert... David Baras, MD
Question: Typically, what
discipline administers blocks?
Answer: Usually an anesthesiologist
and sometimes a physiatrist will
administer Stellate Ganglion blocks
Answer: Blocks, oral medication,
occupational/physical therapy
and patient education.
Psychological intervention must
be considered in all cases.
Question: What is the
typical time span between
blocks per patient?
Question: Do you use the
same medications when
treating children with RSD?
Answer: Typically, I prescribe 1X
week for 3 weeks. If patient positively
responds to the series and if clinically
needed, I will then prescribe another
block in about a month and reassess.
Answer: Similar program as the
adults, but usually a decreased
dosage because medication is
based on a person’s weight.
Question: What should
the therapist do if they
think a patient has RSD
but the referring doctor
has not recognized it
despite hints in notes?
Answer: The most important thing I
can relay to therapists is to pick up
the phone and communicate with
the doctor. Remember, it is HOW
you present the information more
than WHAT you say. Report to the
referring physician with the patient’s
clinical signs and symptoms in a
medical fashion and then hopefully
he/she would be receptive because
you are a part of the management
team. Calling is most effective
because many notes go un-read
and just filed. Don’t be timid to
communicate with the physician as
you are a professional treating his/her
patient. If you are having a difficult
time communicating with the referring
physician you may want to suggest
the patient to seek another opinion.
Question: What do you
think is the most effective
treatment technique when
treating early RSD?
Question: When treating RSD
what is the typical “team”
involved in the management?
Answer: The team should consist
of physician(s), psychologist,
anesthesiologist, case worker,
pharmacological and therapist(s). You
also have to consider the family and
employer when looking at the team.
Question: Is a pain
management center
guaranteed to have a
team approach?
Answer: Unfortunately, in a pain
management facility the patient may
only receive injections and medication.
It is important to research a center
and see that they are using a team
approach for the best results.
Question: What do you do
with the cases that do not
respond to therapy or blocks?
Answer: That can be a challenge.
I would then consider even
more aggressive treatments that
may consist of dorsal column
stimulator, sympathectomy using
a chemical sympathectomy first.
Questions: What are your
views on non-traditional
treatment; such as
acupuncture, nutrition,
yoga, and herbal?
Answer: Non-traditional intervention
can be helpful with pain, mobilization
and psychological management in
CONJUNCTION with the proven
treatments. What I don’t agree with is
when the non-traditional treatments are
used to replace the proven treatments.
Question: Any tips or tricks
you would like to give
therapists treating RSD?
Answer: The best word of advice is
open communication. As I stated, your
therapy notes may not get read by the
physician. So get on the phone and
present the medial facts. Encourage
active patient and family involvement
in treatments. Provide educational
material to all parties involved. Be
aggressive with this medical disorder!
Question: What should a
therapist be aware of if a
patient is prescribed an
“off label” medication?
Example: hypertension
medication but patient
doesn’t have hypertension.
Answer: Be aware of what
medications the patient is taking and
possible side effects and be aware of
the signs of trouble; in this case, if your
patient complains of dizziness or is light
headed when standing you will want to
be careful as their blood pressure may
drop and can cause the patient to pass
out. If you notice signs and symptoms,
document and call the physician.
Thank you Dr. Baras!
Dr. Baras is our featured speaker in
the new released CRPS course
www.liveconferences.com
19
Keep scrolling to see the great deal on EHT's Modalities course
You can apply the 20% discount code to this course if you order
before January 2, 2006.
ORDER NOW!!!