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/

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.

Featured Article By Susan Weiss OTR/L, CHT

Exploring Hand Therapy, Inc (EHT) is dedicated to excellence in education at affordable prices. Many of our courses are presented in “movie” format. We also have online digital books at low prices. Earn your AOTA approved CEUs with Exploring Hand Therapy.New or soon to be released courses:

CRPS/RSDElbow , Unlocking the Hinge to FunctionClinical ActivitiesLASER Therapy: Let the Light ShineJoint Mobilization of the U.E.Myofascial Therapy: With Emphasis on U.E. Trigger PointsTherapeutic Taping of the U.EModalities (up to 40 CEUs depending on your state requirements).

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Order our courses at: www.liveconferences.com Join our EHT HAND CLUB & receive a free course. Enjoy communication with therapists, have all your questions answered, & receive discounts on courses. Join today. www.exploringhandtherapy.comEHT’s magazine is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. Always consult your supervisor before implementing ideas.Thank you to our sponsors for making this magazine possible. Please click the ads (if viewing online) or visit the websites.

From The Editors Desk

Nancy Falkenstein OTR, CHT

Susan Weiss OTR, CHT

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www.explor inghandtherapy.com

In This IssueFeatured Article .......................................1

In The Spotlight .......................................3

Wazzzzzz Up? .........................................6

Valued Reader ....................................... 8

Ergo Tips and Tricks ..............................11

In The Web ...........................................14

POP Quiz ...............................................14

Quiz Answers....................................... 16

ASHT Meeting .......................................16

What’s Up Doc? .....................................19

EHT’s Modality Course ..........................20

Volume 5, Issue 4 January 2006

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Q: Where did you receive your OT degree from?

A: University of Missouri-ColumbiaQ What state are you currently practicing in?

A: Missouri

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 yearsQ: 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?

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.

When you are treating a patient you may wonder if they have RSD. What should you do

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.

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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

In the SPOTLIGHT! Marcus Allen, OTR/L, CHT

Marcus Allen OTR/L, CHT

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injury differently. I've learnedthere is a certain artistry to tapingthat incorporates your depth ofknowledge as well as the depthof the tissue. It helps, a lot, toknow your anatomy, and to beclear in your own mind what youare taping, and how you intendyour tape application to affectthat particular layer of tissue.

There is clearly a science, butthere is art in the fingertips asthere is in myofascial techniquesor in palpating for a problem.This is a tool that responds topractice and has the flexibility torespond to the skill of the user.Because of it's flexibility, the tapeis friendly to the new user, thenew therapist, and even the layperson with a little extra instruc-tion.

Here it is several years later andI still find Tex tape is one of themost powerful therapeutic toolsas well as the most versatile.Tex tape is the one tool that Icould easily apply to 99% of thepatients that stroll into our clinic.Though I choose more judiciouslythan this, they could all benefitfrom at least one application ofTex tape at some point in theirrehabilitation.

I couldn't be more grateful for theinvention of Tex tape. It willremain in my therapeutic reper-toire for many years to come.The only thing more satisfyingthan seeing my patient's improvewith the tape is seeing anothertherapist's satisfaction when theyrealize what they can do with thistape…and then I think of all the

grateful patients they will treat.

Tracey Airth-Edblom, OTR, CHT received aBachelor of Arts in Gerontology and a Bachelorof Science in Occupational Therapy at theUniversity of Alberta in Canada. She worked atthe University of Calgary (Foothills) Hospital for3 years in general orthopaedics, and rheumatol-ogy. She then moved to California to join inopening The Arthritis Center in San Mateo, CA.She has been a Hand Therapist at KentfieldHand Center in Kentfield, CA since March,1993. Throughout her career, she has alwaysbeen an educator and a program developer.Tracey has presented at 6 national conferencesin Canada and the US, taught seminars acrossthe US including guest lectures at the Universitylevel in Rheumatology and Hand Therapy.Tracey is currently an Adjunct Instructor forSamuel Merritt College’s Hand Therapy pro-gram in Oakland, CA.

July Newsletter-jdc.qxp 6/23/2005 11:39 AM Page 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 (dystrophy-atrophy), dry or scaly. Hair may initially grow coarse and then thin. Nails in the affected extremity may be more brittle, grow faster/slowerSwelling - pitting or brawny (hard)

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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 spreadBone 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.

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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)Onset of severe, pain lmited to the site of injuryIncreased sensitivity of skin to touch and light pressure (hyperasthesia).Local swellingMuscle crampsStiffness and limited mobilityAt onset, skin is usually warm, red and dry and

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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.

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.”

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Whazzz UP?

In the Spotlight (continued)

North Coast Medical • 18305 Sutter Boulevard • Morgan Hill, CA 95037 • Toll-Free: 800-821-9319Toll-Free Fax: 877-213-9300 • Local/Int’l: 408-776-5000 • www.ncmedical.com

What makes a great flavor? Something that appeals to a lot ofdifferent tastes. NCM Vanillaithermoplastic accommodatesa variety of splinting styles and can be handled lightly or

aggressively. And, NCM Vanillai is ideal for most splinting applications. It’s agreat choice for clinics that want to stock a single, all-purpose thermoplastic.

NCM Vanillai has moderate characteristics that allow the splinter to controlthe material with ease throughout the molding process, offering ample timeto form the splint, remove it and make final positioningadjustments. NCM Vanillai is a versatile thermoplastic thatsuits all experience levels and is ideal for almost any typeof splint. Call for a free sample, 800-821-9319.

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From a Valued Reader! By: Margaret Stenn Schwartz, OTR, CHT

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.

Whatcausesit?

Our joints and tendons are lubricated by a special liquid called synovial fluid, which is contained in a compartment. When we use our

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 �0% 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.

Commonsitesforganglionsare: The most common site is the back of the wrist and is called a dorsal wrist ganglion, which accounts for 60-�0%. 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 from

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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 anti-inflammatory 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

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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 carllpeg@msn.com

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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.

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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.

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MEMBERSHIP INCLUDES all this and MORE...

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Compiled from OSHA

www.allardusa.comPhone 888-678-6548

Allard has light weight splinting material. The material is cotton based (Biodegradable), has excellent ventilation, and is light weight. X-lite and Classic are the two products Nancy is familiar with. Try them, you'll like them.Visit: http://www.allardusa.com/

Ergo Tips and Tricks

then it may change to a blue (cyanotic) in appearance.Increased sweating (hyperhydrosis).In mild cases this stage lasts a few weeks, then subsides spontaneously or responds rapidly to treatment.

Dystrophic (stage II)Pain becomes even more severe and more diffuseSwelling tends to spread and often changes from a soft to hard (brawny) typeHair may become coarse then scant, nails may grow faster then grow slower and become brittle, cracked and heavily groovedSpotty wasting of bone (osteoporosis) occurs and may become severe and diffuseMuscle wasting begins

Atrophic (stage III)Marked wasting of tissue eventually become irreversible.For many patients the pain becomes intractable and may involve the entire limb.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.

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Educate about therapy goals Educate them about blocks and early interventionEncourage 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

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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:

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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,

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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

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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.

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The third edition of the Clinical Practice Guidelines for RSD/CRPS was written in what year?

A patient must have pain to be diagnosed with CRPS. True or False

What is the best assessment method to detect CRPS?

Dry or scaly skin is described as what type of symptom?

Stages are still used frequently and are the best way to classify CRPS patients. True or False

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Nerve blocks can be used as a diagnostic tool or prognostic tool. True or False

Can nutrition make a difference when treating CRPS? Yes or No

SIP can be effectively treated with nerve blocks. True or False?

The phrase “no pain no gain” is applicable in the clinical treatment of CRPS. True of False

In reference to #9: what is a better phrase to use when treating CRPS patients?

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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.

Answers on page 16

JOB LISTINGThe 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-�68-4469.

EHT has a GREAT updated CRPS Course.

Instructors: Dr. David Baras,

Susan Weiss, & Nancy Falkenstein

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IN THE WEB

Test Your Knoweledge... POP Quiz!

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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

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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 �2% 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 diagnostic-prognostic 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

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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 visited us or attended

our courses or lectures.

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.

1. 2003

2. True

3. Clinical Exam

4 Trophic changes

5. False

6. True

�. Yes

8. False

9. False10. “hurt is not to harm”

Test Your Knowledge Answers ASHT MEETING..... September 2005

EHT will be in Philadelphia in March. Check out the ad on page 9, It is a

fantastic program. See you in PHILLY.

EHT’s Booth

View from our hotel window

River Walk

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.

info@exploringhandtherapy.com

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.

Susan Weiss

Joint Mobilization: Get Them MovingFantastic “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

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727-341-1674

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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 pre-fabricated 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

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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.

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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.

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Splinting Tips and Tricks

Dynasplint Wrist Splint

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Question: Typically, what discipline administers blocks?

Answer: Usually an anesthesiologist and sometimes a physiatrist will administer Stellate Ganglion blocksQuestion: What is the typical time span between blocks per patient?

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.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?

Answer: Blocks, oral medication, occupational/physical therapy and patient education. Psychological intervention must be considered in all cases.Question: Do you use the same medications when treating children with RSD?

Answer: Similar program as the adults, but usually a decreased dosage because medication is based on a person’s weight.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

What’s Up Doc? ... RSDThis month’s featured expert... David Baras, MD