Category Archives: Complex Regional Pain Syndrome (CRPS)

Enbrel (Etanercept) for CRPS – Professional Footballer, Nazair Jones, and his CRPS Story

Feature Image of Nazair Jones, Professional Footballer, sourced from:

https://bleacherreport.com/articles/2701835-unable-to-walk-at-16-unc-lineman-naz-jones-is-about-to-get-drafted-into-the-nfl

Dear Pain Matters readers,

Here is a patient story that may inspire, empower and offer hope.

This story is about a footballer named Nazair Jones who developed CRPS at only 15.  Amongst many treatments, Nazair received regular injections of Enbrel (Etanercept) and physiotherapy.  Details follow:

As a teenager, Nazair Jones always enjoyed playing football and basketball.  Unfortunately, his passion for competitive sports led to a number of injuries including torn anterior cruciate ligaments, shoulder surgeries and broken limbs.

On 5 November 2011, Nazair Jones (then 15) woke up to a body inexplicably paralyzed from his waist down.  He could not get out of bed to go to the bathroom.  His body was frozen in agony and he could not move his legs due to excruciating pain.

Quoting Nazair,

‘On a scale of 1 to 10, the pain was a 12.’

Terrified, he yelled to his mom for help.

In Nazair’s words,

 ‘It’s hard to explain…It was a shock…In my head, I’m saying ‘Walk.  Walk!  Why aren’t you walking?’  It was scary.’

Nazair’s mom called an ambulance to take him to Emergency.  He was discharged shortly after receiving an injection for pain.

Sadly, Nazair’s pain came back with a vengeance.  He was given injections including an epidural for pain.  Despite ultrasounds of his legs as well as nerve and blood tests, no one knew why Nazair had severe pain or why he could not walk.

Nazair’s ankle was extremely swollen.  The swelling would switch from one ankle to the other the following morning.  His swollen leg would also sweat profusely even while lying down.

In Nazair’s words,

‘They didn’t know what was wrong with me.  That was the worst part.’

Nazair was finally diagnosed with CRPS in December 2011.  He required a cane, a walker and ultimately a wheelchair for mobility. Doctors were unsure if he’d ever walk again, let alone play football again.

Despite his pain including allodynia* and mobility issues, Nazair never forgot his dream of becoming a professional footballer.

Motivated by his dream, Nazair started daily physiotherapy including walking exercises in the pool and mirror therapy.  Despite pain medication including ibuprofen, he suffered excruciating pain.  It would take Nazair an entire 30 to 60 minutes just to walk around the hospital floor.

Quoting Nazair,

It sounds easy to take a lap, but it was, by far, the worst pain.  You’re trying to get your body to do something—you want it to do it—but it’s just not doing it. You’re forcing yourself to move, and it just hurts. I can’t even explain the hurt. It just hurts … with all of that swelling, that was the most painful part …’

In 2013, Nazair started receiving weekly Enbrel (Etanercept) injections to manage the swelling in his ankles.

The good news is that Nazair was finally able to walk on his own again in May.  Two months later in July, he started playing sport again.

In his words,

‘… I just know I’ve been able to be myself with no pain.(Adelson, 2016; Adelson, 2017; Dunne, 2017; Supportive Care Matters, 2018).

 

Wishing all pain patients inspiration, hope and empowerment

Sabina Walker

Masters Appl. Science (Neuroscience)

Blogger, Pain Matters (in WordPress)

painmatters.wordpress.com

and

Author of soon-to-be published book called Pain Matters 

Twitter

@SabinaWalker18

KEY

* Allodyniis pain caused by a stimulus that is usually not painful.

REFERENCES

(1) Adelson, Andrea. UNC DL Nazair Jones was nearly paralyzed five years ago. ESPN (28 Sept 2016).

https://www.espn.com/college-football/story/_/id/17650219/north-carolina-dl-nazair-jones-was-nearly-paralyzed-five-years-ago

(2) Adelson, Eric. NFL draft prospect Nazair Jones on his rare disease: ‘On a scale of 1 to 10, the pain was a 12.’ Yahoo Sports (7 April 2017).

https://sports.yahoo.com/news/nfl-draft-prospect-nazair-jones-rare-disease-scale-1-10-pain-12-221557965.html

(3) Dunne, Tyler. Unable to Walk at 16, UNC Lineman Naz Jones Is About to Get Drafted into the NFL. Bleacher Report (6 April 2017).

https://bleacherreport.com/articles/2701835-unable-to-walk-at-16-unc-lineman-naz-jones-is-about-to-get-drafted-into-the-nfl

(4) Supportive Care Matters. Nazair Jones Goes from Chronic Disease to NFL Hopeful (2018).

A SINGLE Perispinal Etanercept Injection by Edward Tobinick MD for Severe Nerve Pain including Sciatica and Post-Stroke Pain (2/2)

Feature Image sourced from:

https://seekingalpha.com/article/3956875-invivos-therapy-verge-becoming-de-facto-treatment-spinal-cord-injury

 

Dear Pain Matters blog readers,

Introduction

Infliximab, Etanercept and other selective anti-TNF drugs are sometimes used to treat:

  • Lumbar radicular pain;
  • Sciatica;
  • Post-stroke pain;
  • Complex regional pain syndrome (CRPS);
  • Rheumatoid arthritis;
  • Crohn’s disease; and
  • Other painful conditions.

This blog post explores the pain-relieving effects of a single perispinal Etanercept injection in certain patients with sciatica, post-stroke pain and other severe nerve pain.

An earlier blog post discussed anti-TNF drugs (Infliximab) for CRPS:

Anti-TNF Drug (Infliximab) Therapy for CRPS and Other Chronic Pain Conditions (1/2)

A Single Perispinal Etanercept Injection for Pain in Back (Sciatica), Neck and after Stroke – 9 Patient Stories

A handful of pain patient stories (N=9) were selected from the Institute of Neurological Recovery’s (INR’s) website (that has over 300 patient videos).  This website also includes media stories, a blog and countless scientific publications by Dr Tobinick and his peers (see References).

https://www.nrimed.com

Please note the following disclaimer quoted from Dr Tobinick’s Patient YouTubes: 

‘Disclaimer: Individual results vary, not all patients respond. Additional doses may be necessary to maintain the clinical response. Treatment for these indications is innovative (“off-label”). The method of off-label treatment utilized is a patented invention of the INR®.’

 

(1) Kerry and Her Single Perispinal Etanercept Injection for Severe Leg and Back Pain

‘Kerry’ (not her real name) had intense right ankle, leg and back pain including burning pain for 6 months nonstop.  She walked very slowly with an abnormal gait to prevent the pain from shooting down her leg.  Her sleep was severely compromised.

Kerry was offered a single dose of perispinal Etanercept by Dr Tobinick at the Institute of Neurological Recovery, Florida, on 11 September 2009.

Kerry was immediately pain free at rest!  When her right leg was gently lifted, there was only a little pain. She said that this was likely due to not doing enough stretching exercises.   Kerry did not have pain in her buttocks nor lower back and her gait was vastly improved.

In Kerry’s words, ‘I feel good!  Thank you.  Yeah, I feel good.’

At her follow-up 2 weeks later on 25/9/2009, Kerry said that she felt excellent.  She slept well and was able to do all her normal activities.

Kerry attributed her complete recovery from pain and mobility to her single dose of Etanercept.

For more details, please view Immediate and sustained relief from severe pain (a 4-minute YouTube dated 25/11/2009 by the Institute of Neurological Recovery, Florida).

https://www.youtube.com/watch?v=Np62fRdIo1E

 

(2) Ana and Her Single Perispinal Etanercept Injection for Severe Back and Leg Pain

‘Ana’ (not her real name), a woman with a warm Spanish accent, suffered constant severe back and leg pain for 2 years.

Ana’s unrelenting pain affected her mobility and sleep.  Her husband had to help put on her shoes and underwear.  Ana tried different pain medications including Tramadol, Vicodinand Naproxen without success.  Ultimately,Ana lost her job because of her ongoing pain.

Ana booked an appointment with Dr Tobinick at the Institute of Neurological Recovery, Florida, on 4 May 2009. While seated during the examination, Ana’s left leg was gently raised.  This resulted in increased pain in her back that spread down her left leg. It was impossible to lift her other leg due to excruciating pain.

Thereafter, Ana received a single dose of perispinal Etanercept.  Three minutes afterward, Dr Tobinick stated,

‘All right now. … The dose was at 9 minutes after 4, and this … is 3 minutes [later].  What is happening?’

Ana said, ‘I can move my legs!  [She laughs, with tears of joy in her eyes.]  Oh God! Oh God!’

Dr Tobinick asked, ‘Is this different?’

‘Oh yeah!’, she exclaimed.

He continued, ‘When was the last time you felt like this?’

Ana replied, ‘I don’t know, about 2 or 3 years ago.  Oh my God! … I can’t believe this!  Two years of pain … Oh my God!  Wow!  You’ve given my life back!

Dr Tobinick asked, ‘What do you think?’

She tearfully said, ‘Thank you!’

Dr Tobinick continued,

‘How do your legs feel? … Before, it was hurting.’

She happily replied, ‘Oh, thank you … I have legs!’

He added, ‘Can you walk?’

She said, ‘Oh my God!’

Dr Tobinick said, ‘How do you feel?  Let’s go down the hall.’

Ana said, ‘Oh my God! … This is incredible!  Oh God.’

He asked, ‘Did it work?’

She enthusiastically replied, ‘Yes!! … Thank you so much!’

Ana (and her husband) had a follow-up visit with Dr Tobinick a week later on 11 May 2009.

Ana’s husband exclaimed,

‘… This is another person.  That was not her … I got her back! … The smile! … She’s alive! … She’s getting back into the game … She’s moving!’

Ana had another follow-up visit with Dr Tobinick 3 months later on 14 August 2009.

Dr Tobinick asked,

‘What kind of difference has this [single dose of perispinal Etanercept] made for your life?’

Ana replied, ‘Tremendous! … I’m holding my grandson and playing with him … I can have him in my lap and play with him. … And enjoy it!  I wasn’t able to do that before!  I’m doing a lot better!’

Dr Tobinick said, ‘Wonderful!’

‘Thank you, Dr Tobinick!’

‘You’re welcome!’

For more details, please view Immediate relief of 2 years of constant back pain and sciatica (an 8-minute YouTube dated 25/11/2009 by the Institute of Neurological Recovery, Florida).

https://www.youtube.com/watch?v=vP6Nw1_OGIg

 

(3) Brenda’s Single Perispinal Etanercept Injection Brings Fast Relief from Severe Sciatica

A young woman named ‘Brenda’ (not her real name) had a slipped disc in her 4th vertebra and severe sciatic pain for 5 months since December 2008.  Her gait was affected and she had severe pain from the right side of her lower back and buttocks that spread down both legs.  There was unbearable pain in her right leg down to her toes and less pain in her left leg.

Brenda was given Vicodin, steroids and morphine injections for her pain, to no avail.  When she was rushed to hospital for severe back pain (several times), the neurosurgeon told her that she needed emergency back surgery.

When Brenda went to see Dr Tobinick on 21 April 2009, he confirmed that the pain on the right side of Brenda’s back worsened when her left leg was lifted.  Thereafter, Brenda was offered a single dose of perispinal Etanercept.

Within only 1 minute after her injection, Brenda’s knee no longer hurt!  There was no pain in her back even as she lifted both legs.  When she stood up to walk around, there was nil pain and her gait was normal.

Happy to finally be pain free, she started dancing!

When asked by Dr Tobinick, ‘How much pain do you have?’

She replied, ‘I don’t have any pain!’

He confirmed, ‘Your pain is all gone?’

She answered cheerfully,

‘I’m not in pain!  Nope, I’m not in pain!  Nope! I’m good!  Before, I couldn’t stand on this leg … I feel good!  I feel great!’

For more details, please view Rapid relief after 5 months of severe sciatic pain (a 5-minute YouTube dated 7 Jan 2016 by the Institute of Neurological Recovery, Florida).

https://youtu.be/2K5yLrJSq0A

https://www.nrimed.com/videos-by-category/back-neck-pain/

 

(4) Tim’s Single Perispinal Etanercept Injection Offers Relief from Sciatica in Minutes

‘Tim’ (not his real name) went to see Dr Tobinick on 4 April 2007 for severe sciatica.  The intense pain was constant and unbearable for 3 weeks and affected his work, quality of life and sleep.  He had pain in his back and buttocks that extended down his left leg to his calf.

In Tim’s words, ‘It feels like somebody took a baseball bat and hit my leg.’

The pain increased in Tim’s left (not right) leg when Dr Tobinickgently moved his right leg.  Tim’s pain was more intense when seated and it lessened when he stood up.  He was able to walk ‘with a slight limp but real slow … real gently’.

Tim had pain relief within a 1 minute after Dr Tobinickinjected Etanercept perispinally.  

In response to Dr Tobinick’s question about how he was feeling right after the injection, Tim replied,

[The pain] feels kind of pulsating right now … down my leg.  It’s not a constant pain like it was.’

Dr Tobinick replied,

‘… So [the pain has] changed in character a little bit … already’

‘Correct,’ Tim replied.  ‘I feel it in my butt still but not down the leg.’

Dr Tobinick confirmed, ‘But you feel it in your lower back and in your butt?’ 

‘Correct.’

Dr Tobinick continued, ‘But you’re starting to feel a little bit more comfortable … in general?’

‘Yeah…yes!’

 ‘… And your leg?’

‘It’s a miracle.  It’s amazing.’

‘You’re walking a lot faster … Wow!’

Tim replied, ‘Yeah I’m loving this stuff.  Once again, it worked!’

Dr Tobinick phoned Tim 3 months later on 3 July 2007 to follow up.

‘I’m wondering now how you’re feeling?’

Tim replied, ‘I am feeling like a million bucks, doctor!’

Pleased for his patient, Dr Tobinick said, ‘I love it!’

Tim continued,

‘… By the time I got back to UCLA that day [of the perispinal Etanercept injection], I was better … You would have never known I had a back problem! …’

Dr Tobinick said, ‘That’s fantastic! … You know, you had some very interesting findings. That finding of moving your right leg, making your left leg hurt, that’s a very specific finding that indicates inflammation of the nerve root.  And so, it was clear what we were treating.  And that, of course, got better, very quickly … So, it’s very interesting, scientifically … You’re better, and you didn’t have to have surgery!’

Tim replied, ‘Yes, I am too. That’s wonderful stuff you got there.’

For more details, please view Improvement within minutes in sciatica (an 8-min YouTube dated 12 Nov 2009 by the Institute of Neurological Recovery, Florida).

https://www.youtube.com/watch?v=xyfSgMoNsKY#action=share

https://www.nrimed.com/videos-by-category/back-neck-pain/

 

(5) Gerry’s Single Perispinal Etanercept Injection Offers Pain Relief in Minutes after 5 Years of Sciatica

‘Gerry’ (not his real name) suffered from sciatic pain for 5 years nonstop.  In his words, he had pain ‘every day, all day’.  Gerry tried different treatments including chiropractic and decompression treatments.

Dr Tobinick treated Gerry for sciatica via a single dose of perispinal Etanercept.  It took ‘just a few minutes’ for the Etanercept to offer lasting pain relief (as confirmed at the follow-up 2 weeks later on 9 July 2009).

For more details, please view Relief in minutes after 5 years of constant pain (a 1-min YouTube dated 6 January 2016 by the Institute of Neurological Recovery, Florida).

https://youtu.be/d0WRKmrE9Bw

https://www.nrimed.com/videos-by-category/back-neck-pain/

 

(6) Mirabelle has Improved Hand Strength After A Single Dose of Perispinal Etanercept

‘Mirabelle’ (not her real name) suffered ongoing and never-ending severe pain for 15 years.  Walking and standing up caused pain in her hips and low back.  Mirabelle had pain in both hands.  Her left hand was weaker and more painful than her right hand ever since her ski accident in 1986 or 1988.

Mirabelle was seen by nearly 30 different doctors including 10 or 11 pain specialists.

During her appointment with Dr Tobinick, Mirabelle received asingle dose of perispinal Etanercept.

When followed up 2 weeks later on 24 October 2007, Mirabelle had significantly more strength in both hands, compared to before Etanercept injection.  Her hands no longer had ‘that arthritic feeling’ (that she felt for weeks).

While there was some residual muscular pain, Mirabelle no longer had neck pain, post-Etanercept.

For more details, please view Hand improvement after treatment at the INR in 2007 (a 6-min YouTube dated 6 January 2016 by the Institute of Neurological Recovery, Florida).

https://youtu.be/6-rXP4ZEDXk

https://www.nrimed.com/videos-by-category/back-neck-pain/

 

(7) Caroline’s Sole Perispinal Etanercept Injection Relieves 25-Year Pain in 10 Minutes

At follow-up on 15 July 2009, 2 weeks after ‘Caroline’s’ (not her real name) single injection of perispinal Etanercept, Dr Tobinick asked,

‘What happened [after this injection]?’

Caroline replied, ‘… I got up … I felt … so much taller … I felt … this wonderful feeling … I stood up and it was just great … I was elated because Ihave been in pain for sooo long … [The pain was] like a knife going through you …’

Dr Tobinick continued, ‘And how long did you have the pain?’

Caroline answered, ‘Oh, I’ve had the pain … I started maybe 25 years ago …’

He asked, ‘How long?’

Caroline clarified, ‘This has been the worst, these last few years. … The last 4 years.’

Dr Tobinick asked, ‘Have you had it every day?’

She replied, ‘Just about!’

He continued, ‘Just about every day? And how many hours a day were you having the pain before you came in?’

Caroline answered, ‘Oh gosh, very, very often.’

He clarified, ‘So most of the day? …’

Caroline stated, ‘And this time when I had that injection, it’s unbelievable.’

‘How long did it take to work?’ he asked.

‘10 minutes!’

‘10 minutes,’ he confirmed.

She said, ‘Unbelievable.  It is.  It really is!

Dr Tobinick asked, ‘Has anything like this happened at all in the last few years?’   

‘No.  [Not] at all,’ she replied.  ‘It’s incredible.  I really did not believe this could happen …’

Dr Tobinick asked, ‘Have you had to take any pain medicine in the last 2 weeks?’

‘No,’ she answered.

‘Not a single … no pills?  Nothing?’ he confirmed.

‘Nothing!

‘Ok,’ he said.

‘It’s really great! …’, she said.  ‘…I’ve had … surgery … I got worse.’

Dr Tobinick asked, ‘You had surgery for your back?’

‘Yes!’

‘And you got worse?’

‘And I got worse … And yet I come to this, and it’s great! … It’s the greatest thing that’s come along. …’

‘… Alright, thank you very much,’ Dr Tobinick said.

For more details, please view the 4-minute video called Rapid pain relief after 25 years of pain July 15, 2009 (a 4-min YouTube dated 6 January 2016 by the Institute of Neurological Recovery, Florida).

https://www.youtube.com/watch?v=3ClVijm0MAA&feature=youtu.be&app=desktop

 

(8) Lola and Her Single Perispinal Etanercept Injection for Post-Stroke Pain

‘Lola’ (not her real name) suffered ongoing severe pain for almost 2 years after a stroke on 27 November 2016.  Her excruciating pain (10/10) affected the entire left side of her body including arm, breast, ribs, hip and leg.  She rarely moved her left arm nor left foot due to extreme pain.  Walking was next to impossible as her pain would only intensify with activity.

Lola tried Baclofen and Gabapentin for pain without success.

Lola booked an appointment with Dr Edward Tobinick on 20 November 2018, almost 2 years after her stroke.  After an assessment, Lola received a single perispinal Etanercept injection.

Lola enjoyed immediate pain reliefand improved left arm mobility within 10 minutes after her injection.  Her pain levels in her chest dropped to 6/10.  Lola was finally able to move her left arm without pain.  The spasticity in her left arm was also reduced.

Lola no longer had hip pain (that was 10/10 prior to injection).  The pain in her left leg and foot was gone, she was able to move her left foot for first time in 2 years and her balance was significantly improved.  Lola finally took her first steps without pain.

Overall, Lola enjoyed significantly less pain and enhanced mobility thanks to her single Etanercept injection.

According to her daughter, there was a new look in Lola’s eyes.

When Dr Tobinick asked, ‘Are you happy you’ve come?’,

Lola replied, ‘I’m very happy … And I hope I give hope to other patients too!’

For further details, please view Immediate improvement in chronic post-stroke pain nearly 2 years after stroke (a 3-minute YouTube dated 28/11/2018 by the Institute of Neurological Recovery, Florida).

https://www.youtube.com/watch?v=FLZhVil56qM

 

(9) Debbie and Her Single Perispinal Etanercept Injection for Post-Stroke Pain

‘Debbie’ (not her real name) had a massive stroke that led to mobility issues and severe, unrelenting pain in her neck, both shoulders and upper left arm.  While strong pain medication reduced some of her pain, it did not eliminate it.

Debbie was unable to get out of a chair without assistance and she required a wheelchair during shopping.  She had significant loss of function in her left hand and arm as well as loss of sensation in the left side of her body including face, hand and leg.

Debbie had her first appointment with Dr Tobinick 3 years after her stroke on 29 February 2012.

Dr Tobinick asked, ‘Do you have pain every day?’

‘Yes, every minute of every day, I’ve got pain.’

Dr Tobinick confirmed,

‘Every minute of every day?  You have constant pain?’

‘Yes’, she replied.

‘Even now, you’re in pain?’, he asked.

‘Yes, I am…’

Within only minutes after a single perispinal Etanercept injection, Debbie had significantly less pain and restored sensation to the left side of her body including face, hand and leg. The motor skills in her left hand were dramatically enhanced and she was finally able to get out of a chair without assistance.

‘How different is that from before?’

‘I can’t believe it.  It’s a miracle!’, she said with a big smile.  It’ll change my life totally!’

For further details, please view Rapid improvement in chronic post-stroke pain 3 years after stroke (a 4-minute YouTube by the Institute of Neurological Recovery, Florida).

https://www.youtube.com/watch?v=ic-6tk7MF5Y

 

Perispinal Etanercept Injections for Pain due to Bone Metastasis – Case Study (N=2)

Two patients received perispinal Etanercept injections near the site of bone metastases for pain.  This treatment led to (quoting) rapid, substantial, and sustained relief of chronic refractory pain at the treatment site’ in both patients (Tobinick, 2003).

 

Perispinal Etanercept Injections for Chronic Back and/or Neck Disc-Related Pain – A Study (N=143)

A study was done involving perispinal Etanercept injections into the spine of 143 patients with chronic back and/or neck disc-related pain.  This treatment led to significant reductions in pain, sensory dysfunction and weakness (Tobinick and Davoodifar, 2004).

 

An Australian Trial involving Perispinal Etanercept Injections for Stroke

Inspired by the outstanding results achieved after a single perispinal Etanercept injection by Dr Tobinick at the Institute of Neurological Recovery (INR), Florida, a clinical trial is now underway for stroke patients in Australia.

Quoting,

‘The project will enable more Australians of working age who have had a stroke to access new … treatment options to aid their recovery.’

 

While results are not yet finalised, further details are here:

 

  • $1 million to support the rehabilitation of stroke survivors (6 October 2018)

https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/1-million-to-support-the-rehabilitation-of-stroke-survivors            

http://www.nrimed.com/wp-content/uploads/GH134.pdf

 

  • Australian Government designates funds to advance Perispinal Etanercept stroke research in Australia (8 October 2018)

http://www.strokebreakthrough.com/blog-posts/uncategorized/australian-government-designates-funds-to-advance-perispinal-etanercept-stroke-research-in-australia/

Summary

More research into anti-TNF drug treatment for CRPS, sciatica, post-stroke pain and other nerve pain conditions is encouraged.  Such studies should confirm whether localised TNF levels are elevated in CRPS-affected limbs and other pain-affected areas in the first place.  If yes, analysis is necessary whether any anti-TNF drug treatment leads to a significant reduction in these elevated localised TNF levels, and if yes, whether this is also accompanied by reduced pain (etc).  Induced skin blisters or skin biopsies may be necessary to confirm localised TNF levels in CRPS-affected limbs and other pain-affected regions, both ‘before’ and ‘after’ anti-TNF drug treatment.

NOTE:  If localised TNF levels are already low to begin with (prior to anti-TNF drug treatment), anti-TNF drug treatment is (likely) not indicated.

Possible adverse effects also need to be considered prior to anti-TNF drug treatment.  Medical supervision is always advised.

 

Wishing all pain patients less pain,

Sabina Walker

Masters Appl. Science (Neuroscience)

Blogger, Pain Matters (in WordPress)

painmatters.wordpress.com

and

Author of soon-to-be published book called Pain Matters 

Twitter

@SabinaWalker18

 

For more information about Dr Tobinick’s treatment involving perispinal Etanercept for nerve pain, please see:

https://www.nrimed.com

Patient videos (N=307) by the Institute of Neurological Recovery, Florida:

https://www.nrimed.com/videos-by-category/

https://www.nrimed.com/videos-by-category/back-neck-pain/

https://www.nrimed.com/videos-by-category/stroke-pain-videos/

Scientific publications by Dr Tobinick and his peers:

https://www.nrimed.com/inr-scientific-publications/

Media stories:

http://www.nrimed.com/about/media-stories/

Blog by the Institute of Neurological Recovery, Florida:

https://www.nrimed.com/blog/

Please note that treatment involving perispinal Etanercept injection is protected by multiple patents owned by Edward Tobinick MD including U.S. patents 6 015 557; 6 177 077; 6 419 944; 6 537 549 and Australian patent 758 523 (Tobinick and Davoodifar, 2004).

 

PS YOU DON’T HAVE TO READ THE FOLLOWING UNLESS YOU ARE INTERESTED IN THE UNDERLYING SCIENCE 

POSSIBLE MECHANISMS OF ANTI-TNF DRUG THERAPY IN CRPS NERVE PAIN

Anti-TNF drugs (e.g. InfliximabEtanercept) are TNF monoclonal antibodies that selectively block TNF, hence limiting the pro-inflammatory process.

The reduction of TNF and other pro-inflammatory mediators (via anti-TNF drug therapy or otherwise) may alleviate certain painful symptoms in CRPS, sciatica, post-stroke pain and other severe nerve pain conditions.

Ongoing trials are warranted including analysis of side effects.

For further details, please refer to all papers by Edward Tobinick MD and his peers.

Other papers are also available in the References including 24-page Review Paper by Sabina Walker and Prof. Peter Drummond. In particular, please see pages 1790 – 1791, plus related references on page 1804 (included below).

 

REFERENCES

Selected Scientific Publications by Dr Tobinick and His Peers

https://www.nrimed.com/inr-scientific-publications/

(1A) Ignatowski TA et al. Perispinal Etanercept for Post-Stroke Neurological and Cognitive Dysfunction: Scientific Rationale and Current Evidence.CNS Drugs(August 2014); 28(8): 679-697.

https://www.strokebreakthrough.com/wp-content/uploads/PSE.post-stroke.Scientific-Rationale.August2014.pdf

(1B) Tobinick E and Davoodifar S.Efficacy of etanercept delivered by perispinal administration for chronic back and/or neck disc-related pain: a study of clinical observations in 143 patients. Davoodifar S. Curr Med Res Opin(July 2004); 20(7): 1075-85.

https://www.ncbi.nlm.nih.gov/pubmed/15265252

(1C) Tobinick, Edward et al. Immediate Neurological Recovery Following Perispinal Etanercept Years After Brain InjuryClin Drug Investig(May 2014); 34(5): 361-6.

https://www.ncbi.nlm.nih.gov/pubmed/24647830

(1D) Tobinick, Edward et al.On Overcoming Barriers to Application of Neuroinflammation Research. In: Abreu GEA, ed. Mechanisms of Neuroinflammation: InTechOpen; 2017.

https://www.nrimed.com/wp-content/uploads/Chapter7.overcoming.barriers.pdf

(1E) Tobinick, Edward. Perispinal Delivery of CNS Drugs. CNS Drugs (2016); 30(6): 469-80.

https://www.ncbi.nlm.nih.gov/pubmed/27120182

(1F) Tobinick, Edward. Perispinal etanercept advances as a neurotherapeutic.Expert Review of Neurotherapeutics (2018); 1-3.

https://www.nrimed.com/wp-content/uploads/Perispinal-etanercept-advances-as-a-neurotherapeutic-1.pdf

(1G) Tobinick, Edward. Perispinal etanercept: a new therapeutic paradigm in neurology.

Expert Review of Neurotherapeutics (June 2010); 10(6): 985-1002.

https://www.strokebreakthrough.com/wp-content/uploads/PSE.ERN2_2.pdf

(1H) Tobinick, Edward. Perispinal etanercept for neuroinflammatory disorders.Drug Discovery Today(Feb 2009); 14(3-4): 168-77.

https://www.ncbi.nlm.nih.gov/pubmed/19027875

(1I) Tobinick, Edward et al.Perispinal Etanercept for Traumatic Brain Injury.Chapter 7, pp. 109-29, in New Therapeutics for Traumatic Brain Injury, Cambridge, Mass.: Academic Press. 2017.

https://www.sciencedirect.com/science/article/pii/B9780128026861000079

(1J) Tobinick, Edward et al.Rapid intracerebroventricular delivery of Cu-DOTA-etanercept after peripheral administration demonstrated by PET imagingBMC Res Notes(27 Feb 2009); 2: 28.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2651903/pdf/1756-0500-2-28.pdf

(1K) Tobinick, Edward L. Targeted etanercept for treatment-refractory pain due to bone metastasis: two case reports. Clinical Therapeutics. (Aug 2003); 25(8): 2279-88.

https://www.ncbi.nlm.nih.gov/pubmed/14512134

(1L) Tuttolomondo et al.Studies of Selective TNF Inhibitors in the Treatment of Brain Injury from Stroke and Trauma: A Review of Evidence to Date. Drug Design, Development and Therapy(Nov 2014); 8: 2221-2239.

https://www.ncbi.nlm.nih.gov/pubmed/25422582

Other Scientific Publications 

(2) Karppinen et al; Tumor necrosis factor-alpha monoclonal antibody, infliximab, used to manage severe sciatica. Spine 2003;28:750–4.

(3) Manning; New and emerging pharmacological targets for neuropathic pain. Curr Pain Headache Rep 2004;8:192–8.

(4) Korhonen et al; The treatment of disc-herniation-induced sciatica with infliximab: One-year follow-up results of FIRST II, a randomized controlled trial. Spine 2006;31:2759–66.

(5) Burnett, Day; Recent advancements in the treatment of lumbar radicular pain. Curr Opin Anaesthesiol 2008;21:452–6.

(6) Cohen et al; Randomized, double-blind, placebo-controlled, dose-response, and preclinical safety study of transforaminal epidural etanercept for the treatment of sciatica. Anesthesiology 2009;110:1116–26.

(7) Lipsky et al; Infliximab and methotrexate in the treatment of rheumatoid arthritis. Anti-tumor necrosis factor trial in rheumatoid arthritis with concomitant therapy study group. N Engl J Med 2000;343:1594–602.

(8) Emery, Buch; Treating rheumatoid arthritis with tumor necrosis factor alpha blockade. BMJ 2002; 234:212–213.

(9) Blam et al; Integrating anti-tumor necrosis factor in inflammatory bowel disease: current and future perspectives. Am J Gastroenterol 2001;96:1977–1997.

Scientific Publication by Sabina Walker (Blogger of Pain Matters) and Professor Peter Drummond

(10) Sabina Walker, Peter D. Drummond; Implications of a Local Overproduction of Tumor Necrosis Factor-α in Complex Regional Pain Syndrome [Review Paper, 24 pages]; Pain Medicine (Dec 2011), 12 (12), 1784–1807.

In particular, please refer to pages 1790 – 1791, plus related references on page 1804 (also listed above).

http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2011.01273.x/abstract

Smearing Pain Away with Ambroxol 20% Cream

Feature Image of Ambroxol molecule sourced from:

https://en.wikipedia.org/wiki/Ambroxol

Dear Pain Matters readers,

Treatment via topical* Ambroxol* 20% cream may offer significant pain relief from severe and localised nerve pain conditions including:

  • Complex regional pain syndrome (CRPS);
  • Trigeminal nerve pain;
  • Postherpetic nerve pain;
  • Phantom limb pain;
  • Deafferentation pain;
  • Post-surgical nerve pain;
  • Nerve pain in both feet; and
  • Multifocal neuropathy.

Prepared by a local pharmacist, topical Ambroxol 20% cream comprises:

  • Ambroxol;
  • Dimethyl sulfoxide; and
  • Linola cream (that includes linoleic acid).

Specifically, 50.0 g of topical Ambroxol 20% cream contains Ambroxol (10.0 g), dimethyl sulfoxide (5.0 g) and Linola cream (up to 50.0 g for the total mixture) (Kern & Weiser, 2015).

220px-Ambroxol_ball-and-stick.png

Ball-and-stick model of Ambroxol molecule sourced from:

https://en.wikipedia.org/wiki/Ambroxol

As a strong local anaesthetic, Ambroxol works by blocking sodium channels, and in particular, the TTX-resistant (TTX-r) Nav1.8 sodium channel.  In fact, Ambroxol is 40 times more potent than lidocaine.  Preferentially expressed in nociceptive C-fibres, Nav1.8 may be upregulated during inflammation and pain (Weiser, 2006).

Topical Ambroxol for Complex Regional Pain Syndrome 

Eight (8) patients who suffered from CRPS for less than a year received topical Ambroxol 20% cream, together with standard treatments.

Topical Ambroxol resulted in many therapeutic benefits including:

  • Less spontaneous pain and pain during movement (N=6);
  • Less allodynia and hyperalgesia (N=6 and N=7, respectively);
  • Decreased swelling and skin reddening (N=7 and N=4, respectively) as well as enhanced skin temperature (N=4); and
  • Improved motor dysfunction (N=6).

In summary, topical Ambroxol 20% cream may be a useful treatment option for CRPS (Maihöfner et al, 2018).

Topical Ambroxol for Trigeminal Nerve Pain 

Five (5) patients with trigeminal neuralgia suffered pain attacks while 3 of them also endured spontaneous pain.  Their facial pain levels ranged from 4 to 10 (out of 10, using the Numerical Rating Scale; NRS).

The good news:

All 5 patients enjoyed significant pain reductions including decreased pain attacks following application of topical Ambroxol 20% cream (in addition to standard treatment).  Specifically, their pain levels dropped between 2 to 8 points (out of 10, using NRS) within only 15 to 30 minutes following topical Ambroxol treatment.   Pain relief lasted 4 to 6 hours.

Pain was completely eliminated in one patient after a week of topical Ambroxol treatment, while 2 patients were able to reduce their medication intake.

There were no adverse effects nor skin reactions.

In summary, topical Ambroxol 20% cream can lead to significant pain relief from trigeminal neuralgia within 15 to 30 minutes following application thereof onto painful areas (Kern et al (2019).

Topical Ambroxol for Severe Chronic Pain – 7 Successful Cases

Overview

A German study reviewed the effects of topical Ambroxol on 7 patients (2 females; 5 males) with severe nerve pain.

Specifically, 2 patients had postherpetic nerve pain while the remaining 5 suffered from phantom limb pain, deafferentation pain, post-surgical nerve pain, nerve pain in both feet and multifocal neuropathy.  Their average pain levels ranged from 4 to 6, while their maximum pain reached 6 to 10 (NRS).

Four (4) patients had tried lidocaine 5% without success, while a 5th patient did not benefit from capsaicin 8%.

The good news:

All 7 pain patients enjoyed pain relief within 5 to 30 minutes after topical application of Ambroxol 20% cream onto painful areas (details follow).  The topical Ambroxol-evoked pain relief included reduced pain attacks and lasted 3 to 8 hours.  Four (4) patients had improved mobility, better sleep and other benefits.

There were no adverse effects nor skin changes during application of topical Ambroxol, even 4 years later.

Case 1 – Local Nerve Pain in Both Feet

A male patient named John** (born in 1942) suffered from nerve pain in both forefeet despite topical lidocaine 5 % plasters and other pain treatments.

The goods news:

John first started using topical Ambroxol in June 2011.  Within 5 minutes, the stabbing pain and allodynia (8/10) in both of his feet disappeared completely for more than 8 hours.  Furthermore, John was able to significantly reduce his Gabapentin intake and discontinue opiates altogether.

At follow-up after 4 years, John continued to be successfully treated with topical Ambroxol.  As a result, John was able to enjoy walking and gardening again.

Case 2 – A Double Amputee with Cold Phantom Limb Pain

Both of Joe’s** lower legs were amputated due to peripheral arterial occlusive disease and diabetes mellitus.

Joe regularly suffered severe cold phantom limb pain (7–9, out of 10) that shifted from his missing toes to the balls of his phantom feet.  These spontaneous bursts of pain usually lasted anywhere from a few minutes to many hours and even affected his sleep.

Joe’s pain treatment including opiates and anticonvulsants failed to offer pain relief.

One day, 15 minutes after applying topical Ambroxol 20% cream onto his stumps, Joe finally found significant relief from his cold phantom limb pain.  This pain relief that also included warmer phantom limbs lasted several hours.

At the 11-month follow-up, Joe continued to enjoy pain relief without skin changes nor other side effects thanks to regular application of topical Ambroxol 20% cream onto his stumps.

Case 3 – Chronic Knee Pain Following Total Knee Replacement 

After a total knee replacement in November 2010, Jan** (58) suffered ongoing nerve pain including allodynia and hyperalgesia in her knee.

Despite pain treatments including Tapentadol (that replaced Buprenorphine), lidocaine patches and capsaicin 8 % plasters, Jan was unable to find pain relief.

One day, within only 15 minutes following application of topical ambroxol 20% cream to her painful knee, Jan finally found (quoting) ‘clear pain relief’!  The burning and stabbing in her knee was significantly reduced while the ‘raging feeling’ in her knee was almost gone.

At follow-up almost one year later, Jan continued to enjoy substantial pain relief for 4 – 6 hours following repeated application of the topical ambroxol 20% cream.  Specifically, her average knee pain levels dropped from 8 down to 4 (and sometimes even lower, down to 1).  There were no skin changes nor other side effects.

Case 4 – Deafferentation Pain after a Motorbike Accident

A patient (38) named Allan** suffered deafferentation pain in his  left arm including allodynia in his hand and forearm due to a plexus lesion caused by a motorcycle accident in 1997.

Despite a nerve graft, ketamine, gabapentin, a lidocaine infusion and lidocaine plasters as well as mirror therapy, Allan’s pain was severe and relentless.

The sedative effects of amitriptyline treatment were intolerable, as were the psychoactive effects of cannabis.

Trigger point treatment and Tapentadol were also not tolerated.

Despite being on pregabalin and duloxetine, Allan suffered ‘burning pain’, ‘crushing underlying pain’ and ‘shooting tingling pains’, with pain levels ranging from 4 to 8 (of 10).

One day, topical Ambroxol 20% cream was applied over Allan’s pectoral muscle.

Guess what happened next?

The shooting and tingling pains dropped from 8/10 to 4/10!

Substantial pain relief would kick in within 15 minutes and last for 4 to 6 hours following regular application of topical Ambroxol 20% cream.  Allan’s sleep improved and his spasms and cramps disappeared.

Unfortunately, the ‘deep underlying pain’ persisted despite topical Ambroxol 20% cream treatment (and pregabalin and duloxetine).

Case 5 – Postherpetic Nerve Pain on Chest

A male patient named Pete** (55) suffered postherpetic nerve pain (5/10) and allodynia on the right side of his chest.

Whilst lidocaine plasters helped relieve his pain, the plasters could not cover all the painful skin regions.

One day, Pete added topical Ambroxol 20% cream to his pain management protocol.  Analgesia occurred in only 30 minutes after topical application of Ambroxol cream to areas not covered by lidocaine patches.  Pain attacks reduced from 6/10 to 4/10 and this pain relief was sustained for 4 to 6 hours. There were no skin reactions nor other side effects, even after 3 years of Ambroxol cream treatment.

Case 6 – Multifocal Neuropathy

A male patient named Sam** suffered nerve pain in the arch of his left foot as well as multifocal neuropathy*** caused by vasculitis.  Sam’s persistent pain including severe pain attacks (8/10, especially in the evenings and at night) prevented him from engaging in activities.

Although amitriptyline drops helped with sleep, lidocaine patches, peripheral analgesics and Tilidine did not offer pain relief.

In December 2013, Sam tried topical Ambroxol cream for the first time.

The good news:

Within only 15 minutes of topical Ambroxol application in the evening, Sam’s nerve pain levels were significantly reduced from 6/10 to 2/10.  This pain relief lasted more than 6 hours, hence improving his sleep.  Sam was also able to stop using Zolpidem.

After 4 months of topical Ambroxol cream treatment, Sam’s underlying pain during the daytime had almost vanished.

At the 17-month follow-up, Sam continued to obtain pain relief from topical Ambroxol treatment without any skin reactions nor other side effects.

Case 7 – Trigeminal Postherpetic Nerve Pain

A 91-year old female patient named Edith** suffered facial nerve pain up to 8/10 and poor sleep after a zoster infection of the maxillary branch of the left trigeminal nerve in June 2014.

While lidocaine patches offered pain relief, there were bad skin reactions.

Edith finally enjoyed pain relief and better sleep after starting topical Ambroxol 20% cream.

Repeated application led to consistent pain relief including a ‘calmer’ cheek within only 15 minutes, as confirmed at the 11-month follow-up.

There were no adverse effects.

Mechanisms

The Nav1.8 sodium channel plays a key role in certain pain mechanisms while TTX-sensitive sodium channels contribute to others.  Sodium channels including TTX-r Nav1.8 are upregulated during inflammation in many pain conditions (e.g. trigeminal neuralgia).

As a strong sodium channel blocker, Ambroxol preferentially blocks TTX-r Nav1.8.  Specifically, a study confirmed that Ambroxol blocked resting TTX-r sodium channels more potently than lidocaine, mexiletine or benzocaine.  Thus, Nav1.8-mediated nerve pain may be blocked by topical Ambroxol (Weiser, 2006).  Similar results were reported by other studies (Gaida et al, 2005; Hama et al, 2010; Moon et al, 2012).

Another local anesthetic called Mepivacaine also blocks Nav1.8, contrary to Bupivacaine that inhibits TTX-sensitive sodium channels instead (Leffler et al, 2010).

Warning: Possible Adverse Effects of Ambroxol

Like most drugs, Ambroxol can cause serious side effects (Kreicas, 2016; Combalia et al, 2017).

Studies reported that adverse effects usually arose after systemic intake (e.g. oral ingestion), as opposed to topical application, of Ambroxol (Monzón et al, 2009).

Where can Topical Ambroxol 20% Cream be Found?  

An Update

Sometimes I receive very inspiring comments from blog readers.  Here is a comment dated 29/11/19 that is worth repeating here (quoting):

‘Hi Tom [and other readers with pain],

I don’t know if you’ll see this but the cream is produced by the ABF Apotheke in Nuremberg, Germany. This is the same pharmacy that produces the cream for Dr. Christian Mainhöfner’s hospital. (Apotheke is the german word for pharmacy). You DO require a prescription. I’m not sure if they ship to Australia but they ship to my country. You can contact them through the email:
apotheke@a-b-f.de

Tiago Henriques’

Thank you, Tiago, for adding value to this blog post!

Summary

Ambroxol is a strong local anaesthetic and peripheral analgesic that selectively targets and potently blocks the TTX-r Nav1.8 that may play a role in many nerve pain conditions.

As such patients with localised nerve pain may obtain significant pain relief from topical Ambroxol cream that preferentially targets TTX-r Nav1.8.

Topical Ambroxol is non-addictive and relatively safe for long-term use (subject to medical supervision) (Kern & Weiser, 2015; Kern & Weiser, 2015 (Poster 239)****; Casale et al, 2017).

Now that’s a good way to cover up localised nerve pain!

Sabina Walker

Blogger, Pain Matters (in WordPress)

KEY

* Topical means locally through the skin.

* Ambroxol is sometimes called na872.

** Not his/her real name.

*** Multifocal neuropathy is sometimes called mononeuritis multiplex or mononeuropathy multiplex.

**** Poster 239 by Kern & Weiser (2015) outlines several more successful cases not mentioned above.  See Poster 239 for further details.

REFERENCES

Clinical Papers

Topical Ambroxol for Complex Regional Pain Syndrome 

(1A) Maihöfner et alSuccessful treatment of complex regional pain syndrome with topical ambroxol: a case series. Pain Management (

https://doi.org/10.2217/pmt-2018-0048

Topical Ambroxol for Trigeminal Nerve Pain  

(1B) Kern et al. Topical Ambroxol 20% for the Treatment of Classical Trigeminal Neuralgia – A New Option? Initial Clinical Case Observations. Headache The Journal of Head and Face Pain (17 January 2019);

https://www.researchgate.net/publication/330524533_Topical_Ambroxol_20_for_the_Treatment_of_Classical_Trigeminal_Neuralgia_-_A_New_Option_Initial_Clinical_Case_Observations

Topical Ambroxol for Severe Chronic Pain – 7 Successful Cases

(1C) Kern & Weiser. Topical ambroxol for the treatment of neuropathic pain. An initial clinical observation. [in German: Topisches Ambroxol zur Behandlung neuropathischer Schmerzen.] Schmerz (20 November 2015); 29 Suppl 3: S89-96.

doi: 10.1007/s00482-015-0060-y

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4701773/

(1D) Kern and Weiser. Topical Ambroxol for the treatment of neuropathic or severe nociceptive pain – First case reports. 9th Congress of the European Pain Federation (EFIC) (Sept 2015: Vienna); Poster 239.

doi: 10.13140/RG.2.2.35671.27041

https://www.researchgate.net/publication/308720424_Topical_Ambroxol_for_the_treatment_of_neuropathic_or_severe_nociceptive_pain_-_First_case_reports

Related Papers and Articles

(1E) Casale et al. Topical Treatments for Localized Neuropathic Pain. Curr Pain Headache Rep (2017); 21(3): 15.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340828/

Mechanisms

(2A) Weiser, T. Comparison of the effects of four Na+ channel analgesics on TTX-resistant Na+ currents in rat sensory neurons and recombinant Nav1.2 channels.  (13 March 2006); 395(3):179-84.

https://www.ncbi.nlm.nih.gov/pubmed/16293367

(2B) Gaida et al. Ambroxol, a Nav 1.8-preferring Na(+) channel blocker, effectively suppresses pain symptoms in animal models of chronic, neuropathic and inflammatory pain. Neuropharmacology (2005); 49: 1220–1227.

doi: 10.1016/j.neuropharm.2005.08.004.

https://www.ncbi.nlm.nih.gov/pubmed/16182323

(2C) Hama et al. Antinociceptive effect of ambroxol in rats with neuropathic spinal cord injury pain. Pharmacol Biochem Behav (2010); 97: 249–255.

doi: 10.1016/j.pbb.2010.08.006

https://www.ncbi.nlm.nih.gov/pubmed/20732348

(2D) Leffler et al. Block of sensory neuronal Na+ channels by the secreolytic ambroxol is associated with an interaction with local anesthetic binding sites. Eur J Pharmacol (2010)630:19–28.

doi: 10.1016/j.ejphar.2009.12.027

https://www.ncbi.nlm.nih.gov/pubmed/20044988

(2E) Moon et al. The differential effect of intrathecal Nav1.8 blockers on the induction and maintenance of capsaicin- and peripheral ischemia-induced mechanical allodynia and thermal hyperalgesia.  (Jan 2012); 114(1): 215-23.

doi: 10.1213/ANE.0b013e318238002e.

https://www.ncbi.nlm.nih.gov/pubmed/22127815

(2F) Weiser, Thomas. Ambroxol: a CNS drug?. CNS Neurosci Ther (2008); 14(1): 17-24.

doi 10.1111/j.1527-3458.2007.00032.x.

https://www.researchgate.net/publication/5369710_Ambroxol_a_CNS_drug

(2G) Weiser, Thomas. Nav1.8 channel blockade as an approach to the treatment of neuropathic pain. Drugs of the Future (July 2006); 31(7); 597.

10.1358/dof.2006.031.07.1005296.

https://www.researchgate.net/publication/274516492_Nav18_channel_blockade_as_an_approach_to_the_treatment_of_neuropathic_pain

Warning: Possible Adverse Effects of Ambroxol

(3A) Kreicas, Leonard. Topical ambroxol possible treatment of neuropathic pain. Nerve Neuropathy (1/6/2016).

http://nerveneuropathy.com/topical-ambroxol-possible-treatment-of-neuropathic-pain/

(3B) Combalia et al. Stevens–Johnson syndrome probably induced by ambroxol. CED (24 April 2017); 42(4): 465-467.

doi.org/10.1111/ced.13094

https://onlinelibrary.wiley.com/doi/full/10.1111/ced.13094

(3C) Monzón et al (2009). Ambroxol-induced systemic contact dermatitis confirmed by positive patch test. Allergologia et immunopathologia (2009); 37: 167-8.

doi: 10.1016/S0301-0546(09)71730-6

https://www.researchgate.net/publication/26827245_Ambroxol-induced_systemic_contact_dermatitis_confirmed_by_positive_patch_test

(3D) Benstetter, Monika. Ambroxol and bromhexine expectorants: safety information to be updated. European Medicines Agency (27/02/2015).

https://www.ema.europa.eu/en/news/ambroxol-bromhexine-expectorants-safety-information-be-updated

 

 

 

 

 

A Young Cadet, Timely Diagnosis of CRPS due to Ankle Injury, her Anaesthetist, a 4-Day Nerve Block … et voila … No Pain!

Feature Image sourced from:

https://www.medicalnewstoday.com/articles/184338.php

Dear Pain Matters blog readers,

INTRODUCTION

I really like this case!  This is because it explores the outcome of 2 different nerve blocks done on a young cadet (‘Sue’) with complex regional pain syndrome (CRPS) in her lower right leg.

Sue’s 1st nerve block via lateral sciatic catheter resulted in improved but incomplete pain relief.  This 1st nerve block had inadvertently missed a certain branch of the sciatic nerve (more later).

As such, a 2nd (i.e. replacement) nerve block via posterior sciatic catheter was required.

Fortunately for Sue, ALL of her pain due to CRPS was finally eliminated once her replacement continuous sciatic catheter was correctly placed.          

PRELIMINARY DETAILS

Sue, a young 17-year old female US Military Academy cadet, had a right ankle sprain due to an inversion injury during training.  This sprain led to severe pain that radiated upward from her ankle.  Sue’s ankle was swollen and the lateral part* of her lower leg and foot was numb.  Her foot’s range of motion was very limited.

Within only 1 week, Sue’s orthopaedic surgeon diagnosed early CRPS after confirming severe pain and allodynia as well as vasomotor dysfunction.  After 2 weeks of unsuccessful pain medicine treatment, Sue was transferred to Walter Reed Army Medical Center (WRAMC).

By now, Sue’s right foot was red, warm and swollen while her lower right leg displayed colour changes.  Her lower leg, particularly the lateral side, and the top of her foot were sensitive to light touch.  She had allodynia in the L5 and S1 dermatomes.

1448614031285.png

Distribution of dermatomes including L5 and S1 dermatomes (Hancock, 2011)

https://www.raynersmale.com/blog/2015/11/27/surgery-for-sciatica-a-clinical-commentary

After a failed lumbar sympathetic block that did nothing for her pain, Sue received a ketamine infusion (that was titrated up to the maximum dose the following day).

1st CONTINUOUS SCIATIC NERVE BLOCK VIA LATERAL SCIATIC CATHETER 

When Sue was admitted to the Surgical Intensive Care Unit (ICU) for a continuous lateral sciatic catheter placement, her pain levels were 8 out of 10.

Once Sue’s sciatic nerve was located in the popliteal fossa (i.e. knee pit),* and after this nerve’s division into its tibial and common peroneal nerve branches was identified,* the continuous nerve block catheter was placed proximal* to this nerve’s division.  The correct placement of this catheter was necessary to achieve a continuous lateral sciatic nerve block.  

The needle was then placed next to the sciatic nerve and a single dose of 20 mL 1.5% Mepivacaine with Epinephrine was injected into the nerve sheath.

Thereafter, a continuous infusion of 0.2% Ropivacaine was commenced (10 mL per hour).  Sue was also given the option of adding a patient-controlled bolus dose of 3 mL every 20 minutes.

Sue was unable to move her foot up and down shortly after the Ropivacaine infusion started.

Guess what happened next??

Within only 15 minutes, Sue’s pain levels dropped from 8 to 1 (out of 10)!  Wow!!  

The Ropivacaine and Ketamine infusions continued throughout the night.

The next day, Sue continued to enjoy excellent pain relief in most of her CRPS-affected lower leg, with one notable exception:

 

There was burning pain and allodynia on the lateral part of her lower leg, just beneath her knee.

The pain in this particular dermatome can not be blocked by the 1st block called a lateral sciatic nerve block.  Instead, a different kind of sciatic nerve block was needed.

As such, the Ropivacaine infusion was stopped for 8 hours (during which time Sue’s pain levels rose to 5/10).  During this time, a ‘new and improved’ continuous posterior sciatic catheter was placed.  This 2nd catheter was precisely located to also target the cutaneous branch of the sciatic nerve (that had inadvertently been overlooked by the 1st catheter).

2nd CONTINUOUS SCIATIC NERVE BLOCK VIA POSTERIOR SCIATIC CATHETER 

Guess what happened after the first catheter was replaced and bolus of 30 mL of 0.5% Ropivacaine was released??

Sue finally had nil pain!  Nada!  Zilch!  Zero!  Even the lateral part of her lower leg was finally pain free!  OMG!   

The next morning, Sue was also able to move her foot without pain.

While her Ketamine and Ropivacaine infusions continued for another 3 days, Sue continued to enjoy complete pain relief.

Despite cessation of both infusions after the 4th day, Sue remained completely pain free.  

Sue had physiotherapy and was able to bear weight on her CRPS-affected ankle without pain.  Her ankle joint had full range of motion.

Upon discharge, Sue returned to cadet training.  Half a year later, she was still pain free and able to perform all her cadet duties.  Sue also enjoyed running without pain and was training for a marathon.

SUMMARY

This case highlights the importance of:

  1. Early diagnosis; and
  2. Timely and effective pain treatment

in CRPS.

1. The Importance of Early Diagnosis

Specifically, the earlier a diagnosis of CRPS is made, the less pain and suffering.

Early diagnosis of CRPS is a prerequisite to timely and effective treatment thereof.

In Sue’s case, her orthopaedic surgeon (one of her guardian angels!) diagnosed CRPS within only 1 week (!) after her ankle sprain.

Think about that!  Only 1 week!!  

2. The Importance of Timely and Effective Pain Treatment 

If treatment for CRPS (via a precision nerve block or otherwise) is both timely and effective, this can lead to rapid recovery from CRPS.

Sometimes different treatments need to be tried out before the most effective treatment protocol is found.

Here, we learned that whilst partially effective, the 1st catheter (i.e. lateral sciatic catheter) was unable to block the residual pain on the lateral side of her lower leg, just underneath her knee.

In other words, Sue’s 1st Ropivacaine infusion was not properly placed to also block the cutaneous branches of the common peroneal nerve branches that innervate the lateral area of her lower leg, just below her knee.

As such, the anaesthetist (another one of Sue’s guardian angels!) replaced the original lateral sciatic catheter with a new posterior sciatic catheter (Everett et al, 2009).

It is clear that with a dedicated, professional and caring pain management team, the chances of recovery from CRPS are greatly enhanced.

In Sue’s case, her pain due to CRPS was completely eliminated within only 1 month.  As such, Sue was able to return to an active and rewarding life and career shortly after.

This is good news for everyone!

KEY

* Lateral is the side of the body or limb that is away from the middle (i.e. farther from the middle).

* A popliteal fossa (a.k.a. knee pit) is a shallow depression behind the knee joint and knee cap.

* The sciatic nerve’s division into its tibial and common peroneal nerve branches was initially identified via ultrasound guidance.  

This nerve’s division was identified via neurostimulation when the replacement posterior sciatic catheter was placed.

* Proximal means closer to the centre of the body.

REFERENCES

Peer-Reviewed Paper

(1) Everett et al. A Unique Presentation of Complex Regional Pain Syndrome Type I Treated with a Continuous Sciatic Peripheral Nerve Block and Parenteral Ketamine Infusion: A Case Report. Pain Med (2009);10(6):1136-9.

doi: 10.1111/j.1526-4637.2009.00684.x.

https://rsds.org/wp-content/uploads/2015/02/Everett_Mclean_Plunkett.pdf

Diagram

(2) Hancock et al. Diagnostic accuracy of the clinical examination in identifying the level of herniation in patients with sciatica. Spine (2011);36(11):E712-E719.

Unlocking Pain by Blocking Pain using Nerve Blocks for CRPS

Feature Image of ‘The Innervation of the Upper Limb’

NB The roots and branches of the brachial plexus in the arm are shown below.

Source:  Chelly JE, ed. Peripheral Nerve Blocks: A Color Atlas. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009: 32.

https://aneskey.com/overview-of-peripheral-nerve-blocks/

INTRODUCTION

Dear Pain Matters blog readers,

This blog post explores studies involving both children and adults with complex regional pain syndrome (CRPS) who underwent peripheral nerve blocks for pain relief.

ANATOMY OF A PERIPHERAL NERVE BLOCK

Peripheral nerve blocks are useful for diagnostic and/or therapeutic purposes.  

13x06-2.jpg

An example of a brachial plexus infusion kit used for continuous nerve block

Source: https://www.nysora.com/foundations-of-regional-anesthesia/equipment/equipment-continuous-peripheral-nerve-blocks/

Peripheral nerve blocks may be done either:

  • Continuously via infusion pump filled with a local anaesthetic; or
  • Via single injection of a local anaesthetic.

Local anaesthetics may include Bupivacaine**, Lidocaine, Mepivacaine** or Ropivacaine (Ropivacaine having less toxicity – see ‘Ropivacaine vs Bupivacaine’ section for more details).

There are many kinds of peripheral nerve blocks (e.g. upper limb blocks, lower limb blocks). 

The brachial plexus is shown below.  This comprises a complex network of nerves including roots and branches – some of which may targeted by a nerve block:

00182-3

Chelly JE, ed. Peripheral Nerve Blocks: A Color Atlas. 2nd ed. Philadelphia, PA, Lippincott Williams & Wilkins; 2009: 20

https://aneskey.com/overview-of-peripheral-nerve-blocks/

The Feature Image at the top shows the innervation of the upper limb, some that may be affected by a nerve block.  

Below, the branches of the lumbar plexus (left) and sacral plexus (right) that innervate the lower limb are shown, some that may be the precise target of a nerve block:

 

 

 

From Chelly JE, ed. Peripheral Nerve Blocks: A Color Atlas. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009: 76 and 79.

https://aneskey.com/overview-of-peripheral-nerve-blocks/

Below, we can see the innervation of the lower limb, parts of which may be subject to a nerve block.  

00186-1

Chelly JE, ed. Peripheral Nerve Blocks: A Color Atlas. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009: 74

https://aneskey.com/overview-of-peripheral-nerve-blocks/

There are many videos about peripheral nerve blocks including the following 2 short videos:

(1) Peripheral Nerve Block 

(2) How Nerve Blocks and Nerve Sheath Catheters Work  

https://www.marshfieldclinic.org/specialties/anesthesia/anesthesiology-nerve-block

NERVE BLOCKS FOR CHILDREN WITH CRPS

(1) A French Study Shows 100% Success Including Nil Pain Following 4-Day Continuous Nerve Block for Children with CRPS (N=13)

Details of French study

Introduction

According to a French study by Dadure et al (2005), recurring or intractable CRPS1 is not rare in children.

In this study, (the lesser toxic) Ropivacaine was used for performing continuous peripheral nerve block infusions in children with CRPS1 (N=13).  Ropivacaine is considered less toxic than other local anaesthetics (see ‘Ropivacaine vs Bupivacaine’ section, below).

The average age of the children was 13, with ages ranging from 9 to 16.

The VAS Pain Scores prior to 4-day continual peripheral nerve block ranged from 8 to 10.  This severe nerve pain was accompanied by allodynia, numbness, swelling and vasomotor disturbances.

The inciting event(s) for CRPS1 included sprains and traumas to ankles and wrists that occurred 6 to 8 months prior to peripheral nerve block.

 

4-Day Continuous Peripheral Nerve Block

While under general anaesthesia, nerve block was commenced by using a nerve stimulator to precisely locate the affected nerve.  Once the catheter was in place, 0.5 ml/kg of a mixture on a 1:1 basis of 0.5% Ropivacaine and 1% Lidocaine (with Epinephrine) was injected via the catheter for 5 minutes.

Thereafter, a 20-minute Bier block* that involved anaesthesia of a limb was performed.  A Bier block is sometimes called intravenous regional anaesthesia.  

Specifically, the Bier block that led to regional anaesthesia involved draining blood out of the limb (via exsanguination), inflating a tourniquet* and intravenously injecting a local anaesthetic (0.2 ml/kg lidocaine, 1%) and other medication.

General anaesthesia was discontinued after completion of the Bier block.

A 96-hour ambulatory continuous 0.2% Ropivacaine infusion was commenced.  Twelve (12) children had popliteal nerve blocks* while the 13th child was given an axillary nerve block*.

Results

Postoperative pain relief was excellent in all 13 children with CRPS1!

VAS Pain Scores decreased from 8 – 10 to NIL following 4-day ambulatory continual peripheral nerve block in ALL 13 children with CRPS1.

Motor nerve block was minimal before 12 hours, and non-existent thereafter.  All children were able to walk after 24 hours.

Early discharge from hospital and continuation of the 4-day peripheral nerve block at home was rendered possible via the use of disposable catheter pumps.

Follow-Up 

All 13 children had nil pain nor other symptom of intractable or recurrent CRPS1 at the 2-month follow-up.

Summary

The authors concluded that disposable continuous peripheral nerve block with Ropivacaine infusions may be an effective treatment for recurring or intractable CRPS1.    

The 4-day Ropivacaine infusion offered complete pain relief and rapid mobility.  This resulted in early discharge from hospital for all 13 children with CRPS1 (Dadure et al, 2005).

A happy child is a happy life.  

NERVE BLOCKS FOR ADULTS WITH CRPS

(2) A New Zealand Study – Peripheral Nerve Block for CRPS Patients (N=9) 

Details

Nine (9) patients (5 females; 4 males) had severe CRPS including hyperalgesia and allodynia.  The VAS Pain Scores were 9 or 10 (‘Worst Pain’) for 7 patients, and 7 or 8 (‘Severe Pain’) for the remaining 2 patients.

Many patients suffered pins and needles, tingling, numbness, redness of skin, sweating, hot or cold skin temperatures in their CRPS-affected limb as well as sleep disturbances.

The causes for CRPS varied greatly.  Inciting events and injuries that led to CRPS included elbow injuries and traumas caused by crutching machine, blunt blows, a forklift blow and forceful gripping.  CRPS also resulted following an injection into a thumb, a knee twisting injury, a fall onto a knee and an incident involving a hand and a 4WD door.

Treatment 

These 9 CRPS patients (aged 22 to 61) were offered:

  • Peripheral nerve blocks;
  • Pain medications (e.g. carbamazepine, opiates); and
  • Bupivacaine (Marcain) trigger point injections for myofascial pain (in some patients)

from 2002 to 2003.

Peripheral Nerve Blocks

Three ml (3ml) of Bupivacaine was injected proximalto the site of nerve pain.  This was repeated every 2 – 3 weeks (maximum 3 injections).  Treatment occurred in Invercargill (N=7) and Wellington, New Zealand (N=2).

Results

Seven (7) of 9 CRPS patients enjoyed significantly less hyperalgesia and allodynia after peripheral nerve blocks and other pain treatments.

Specifically, 5 patients enjoyed NIL pain more than 1 year after discharge.  Another 2 patients had VAS Pain Score reductions from 9 to 1 or 2 two years after discharge (Kanji, 2006).

Conclusion of New Zealand Study

Peripheral nerve blocks together with pain medication may be a promising pain treatment for some CRPS patients.

(3) A Dutch Study – Continuous Axillary Brachial Plexus Blockade with Bupivacaine for 6 CRPS Patients (3 Successfully Treated) 

Introduction 

Axillary brachial plexus blockade* was offered for patients with severe upper limb CRPS (N=6).

Specifically, an indwelling catheter was placed within the neuromuscular sheath.

Regional anaesthesia was done either:

  • Continuously via portable infusion pump filled with Bupivacaine (0.5%, 3ml/hour); or alternatively,
  • Via a daily single dose of 20 ml Bupivacaine (0.25%) half an hour before therapy.*

Half (N=3) of the 6 Dutch CRPS patients benefited from brachial plexus blockade.

Details of all 6 patients follow:

Patient 1 (Unsuccessful Nerve Block due to Irritation at Catheter Insertion Site)

Sadly, Patient 1 (let’s call her ‘Eliza’) did not permanently benefit from brachial plexus blockade.

Eliza was 31 when she had right hand surgery for morbus Quervain.*  Following casting, Eliza’s forearm was swollen and cold.  Additionally, she had persistent and intense burning pain and severe allodynia in the right arm.  A diagnosis of reflex sympathetic dystrophy (RSD; now called CRPS1) was made.  Conventional pain intervention did not offer any relief and her arm lost all function due to severe muscle weakness.

Eliza was offered a continuous axillary brachial plexus blockade 2 years after she was first diagnosed with RSD.

The good news:

Within only hours of the continuous axillary brachial plexus blockade, Eliza’s right arm became warm, her pain decreased and the range of motion in her RSD-affected joints almost returned to normal.  

The bad news:

Sadly, due to irritation at the catheter insertion site, Eliza’s continuous axillary brachial plexus blockade was stopped.  Instead, she received a daily single dose of Bupivacaine.  

Despite this, all of Eliza’s severe RSD symptoms returned within weeks after her continuous axillary brachial plexus blockade was discontinued.

Patient 2 (Successful Nerve Block)

Patient 2 (let’s call her ‘Alina’) was 39 when she suffered trauma including dislocation to her left shoulder during an epileptic seizure.  After her dislocated left shoulder was repositioned, Alina felt a ‘burning diffuse pain’ in her left arm that was also swollen.  Despite pain medication, Alina suffered severe allodynia and continuous burning pain in her entire left arm.  Her left arm remained swollen, red, warm and sweaty.  Her left hand’s range of motion was severely restricted and painful.

Nerve tests via electroneuromyography showed a small left brachial plexus lesion as well as deficient motor and sensory conduction velocity in her ulnar nerve.  Alina was diagnosed with RSD following three-phase bone scanning.

Despite conventional pain treatment for 2 months, Alina’s RSD symptoms did not improve.

As such, Alina was offered a daily single dose of Bupivacaine.  

The good news:

After receiving her first injection of Bupivacaine, she immediately enjoyed significant pain relief, reduced swelling and enhanced mobility.  Her left hand function also improved.  

After completing 2 sessions, Alina’s Bupivacaine treatment were no longer necessary.  Alina’s RSD symptoms were vastly improved and lasting, as indicated at the follow-up appointment more than 1 year later.  

Patient 3 (Unsuccessful Nerve Block due to Infection and Abscess)

Sadly, Patient 3 (let’s call her ‘Abby’) did not permanently benefit from brachial plexus blockade.

At 41 and while carrying glass bottles, Abby accidentally fell and severed 4 extensor tendons in her right wrist.  Her forearm was casted following reconstructive surgery.  Almost immediately afterward, her forearm became swollen.  Furthermore, it switched from being red and warm to cold and blue.  The cast had to be removed due to severe allodynia and continuous burning pain.

Despite conventional pain treatment for 2 months, Abby’s severe pain and swelling persisted.  There was also excess hair and nail growth as well as wasting of skin.

Abby was diagnosed with RSD following three-phase bone scanning.

The good news:

Within a few hours of the continuous axillary brachial plexus blockade, Abby’s right forearm and hand became warm with significantly less pain and swelling.  Abby was finally able to undertake physiotherapy.    

The bad news:

Sadly, due to local infection at the catheter insertion site that spread to an abscess below the skin, Abby’s continuous axillary brachial plexus blockade was stopped after 3 sessions.  

Following discontinuation of her nerve block, Abby’s severe pain and all of her other RSD symptoms and disability returned.

Patient 4 (Successful Nerve Block)

At 52, Patient 4 (let’s call her ‘Erin’) had right hand surgery due to Dupuytren contractures.*  This was following up with a second hand operation to correct hand function.  Erin had severe burning pain in her entire right arm that prevented her from sleeping, performing domestic chores and playing the piano.

Four (4) months later, Erin had severe pain, reduced sensation and swelling in her right hand.  She was diagnosed with RSD following three-phase bone scanning.

The good news:

Erin underwent 3 sessions of continuous axillary brachial plexus blockade, during which she was pain free and able to do physiotherapy.  

Despite minor contractures in several finger joints in her right hand (that compromised her ability to play the piano), her muscle strength fully recovered.      

Patient 5 (Successful Nerve Block)

At 57, Patient 5 (let’s call her ‘Janet’) underwent casting following bilateral Colles fractures.*  Her right hand remained painful.

Seven (7) later, Janet was diagnosed with RSD via three-phase bone scanning.

Janet received 4 sessions of daily single dose of Bupivacaine.  

The good news:

These injections led to significant pain relief and enhanced muscle strength in her right hand.

After 2 months, all of her pain had vanished and her hand function including writing ability was restored.

The same results were confirmed at her 21-month follow-up appointment.

Patient 6 (Unsuccessful Nerve Block)

Sadly, Patient 6 (let’s call her ‘Lina’) did not permanently benefit from brachial plexus blockade.

At 43, Lina had RSD in her right leg for 7 years.

More recently and for unclear reasons, her right hand became painful, warm, red and swollen.  Lina was diagnosed with RSD in her right hand.

Despite 7 months of conventional pain treatment, Lina had continuous burning pain and allodynia in her right forearm that was also cold.  There was skin, nail and muscle wasting as well as severe contractures in her wrist and hand joints.  Functional use of her right hand was impossible.

The good news:

Lina enjoyed immediate benefits upon commencing daily single dose of Bupivacaine.  Her right hand became warm and the pain was reduced.  After 3 sessions of Bupivacaine injections, Lina was able to perform activities using both hands.       

The bad news:

Within only weeks after stopping Bupivacaine injection treatment, Lina’s pain and other RSD symptoms returned and functional activities using her hands were no longer possible.    

Conclusion of Dutch Study

Three (3) of 6 CRPS patients (50%) benefited from axillary brachial plexus blockade.  

Interestingly, the remaining 3 CRPS patients temporarily benefited from brachial plexus blockade.  However, as soon as continuous axillary brachial plexus blockade was stopped (either due to irritation or local infection/abscess, as in Patients 1 and 3, respectively), pain and other symptoms of RSD returned.  

Instead of a continuous axillary brachial plexus blockade, the 6th patient received daily single dose Bupivacaine injections.

The authors of this Dutch study asked a very interesting question (quoting):

‘Would continuous pain reduction with continuous axillary brachial plexus blockade (BPB1) have resulted in better functional use of the affected hand in activities of daily life and thereby improve long term effect?  Continuous axillary brachial plexus blockade seems more effective than daily single dose Bupivacaine injections (BPB2) in interrupting a … vicious [inserted: pain] circle and in preventing centralization and seems first choice when axillary brachial plexus blockade (BPB) is considered in treating severe RSD of an upper exteremity in which … exercises are not tolerated … Further studies are needed …’ (Ribbers et al, 1997; Ribbers, 2001).

In other words, would a better outcome have occurred if all 6 patients had continuous axillary brachial plexus blockade (assuming nil complications)?

(4) The English Patient with RSD

A 37-year old woman (let’s call her ‘Anne’) suffered neck (i.e. cervical) and shoulder pain as well as an occipital headache* following a car accident.

Six (6) weeks later, Anne endured pain in her left hand that was cold, blue, swollen and weak with reduced sensation.

Six (6) months later, Anne’s left hand was continuously painful (8/10), swollen, cold and in a semi-claw position.  Following various tests, a diagnosis of RSD was made for the first time.  (Unfortunately, Anne’s pregnancy had to be terminated following exposure to diagnostic tests that may have resulted in birth defects.)

Almost a year after her car accident, Anne was successfully treated with a 48-hour continuous axillary brachial plexus Bupivacaine block via a catheter inserted into her axillary sheath.

 

The good news:

Anne was finally free of pain during the Bupivacaine infusion!  She was able to regain some movement of her hand and fingers during the next 2 weeks.

Since some of the pain in her left hand had returned, 2 more 24- to 48-hour continuous axillary brachial plexus Bupivacaine blocks were added to her care.

Six (6) hours after the infusion, Anne was (again) pain free.  Furthermore, she regained a full range of movement in her left hand.

At her follow-up appointment 2 months later, Anne’s pain in her left hand was ‘minimal’ (1/10) and she continued to enjoy full movement of her left hand and fingers (Murray et al, 1995).

(5) An American Study – Continuous Infusion of Lidocaine Leads to Pain Relief in 5 CRPS Patients   

Nine (9) patients with CRPS were selected for continuous subcutaneous 10% lidocaine infusion treatment.  Four (4) patients had to discontinue this treatment.

Of the 5 who actually completed this treatment for 4 – 8 weeks, 4 were female (average age 47) while 1 was male.  All 5 were diagnosed with CRPS 2.5 to 8 years earlier before commencing this treatment.

Post-continuous lidocaine infusion treatment , all 5 CRPS patients enjoyed less pain and allodynia.  Their VAS Pain Scores decreased from 7 – 10 to 2 – 5.

There were also improvements in other CRPS symptoms (Linchitz & Raheb, 1999).

(6) A CRPS Patient in Saudi Arabia: Single Injection Nerve Block for CRPS

A 34-year old female patient (let’s call her ‘Azza’) suffered severe pain and allodynia (9 – 10 out of 10) in her left hand and wrist that was swollen, pale, cool, clammy, numb and weak.  Azza also had limited movement in her left shoulder.  Azza’s symptoms started 5 months ago although she could not remember any cause.

A diagnosis of CRPS1 was made.

Azza received an ultrasound-guided nerve block (i.e. interscalene brachial plexus block*).  This nerve block that involved a single injection shot of 30ml Bupivacaine 0.25% resulted in complete pain relief in her left hand within a week.

Azza was also given a trigger point injection for spasms in her trapezius muscle that caused neck pain.  At first, the trigger point injection involved lidocaine 2% infiltration.  Two weeks later, Azza was offered another trigger point injection using botulinum toxin (BTX-A 100u; Botox) that finally led to lasting pain relief in myofascial trigger points in her trapezius muscle in her shoulder.

Azza’s functional mobility was restored via physiotherapy.

In summary and as confirmed at her 3-month follow-up, Azza enjoyed 100% pain relief from CRPS1, left hand, and full limb mobility following a single interscalene injection using Bupivacaine.

Azza’s neck pain caused by trapezius muscle spasms was completely resolved by a myofascial trigger point injection using Botox (Fallatah, 2014).

(7) Ulnar Nerve Block for RSD

A patient was diagnosed with upper limb RSD following radiography of blood vessels in the brain via the subclavian artery*.  To enhance imaging, contrast injections are necessary.

Using a stimulator to identify the ulnar nerve in the axillary bundle, low volume injections including Bupivacaine 0.5% were given.

These injections led to pain relief and reversal of other RSD symptoms (Klein & Klein, 1991).

(8) A Slovenian Study Involving Continuous Sensory Analgesia for CRPS, Upper Limb 

This review explores 21 CRPS patients who were screened for treatment involving continuous sensory analgesia via brachial plexus blockade.

In the first 2 days, all 21 patients underwent non-invasive therapy that included elevation of the CRPS-affected limb, cryotherapy and active exercises.  Cryotherapy involves placing ice and cold packs near a painful area to reduce inflammation and soothe pain.

While 5 patients benefited from this non-interventional treatment, 16 did not.

As such, these 16 CRPS patient had continuous sensory analgesia of brachial plexus.  This nerve block was done within 1 to 6 months after the inciting injury.

Patients were followed up from 3 months to 3 years after continuous sensory analgesia.  Two (2) patients enjoyed excellent results (i.e. a completely normal hand), 11 patients had good results while 3 had poor results (Margić & Pirc (2003).

ROPIVACAINE vs BUPIVACAINE

Toxicity of Bupivacaine to Muscle Cells

Ropivacaine is a less potent local anaesthetic with an improved safety profile including lower muscle toxicity compared to Bupivacaine (Kaur et al, 2015).

An animal study found that Bupivacaine was toxic to muscle cells, especially in young rats.

Specifically, Bupivacaine led to bioenergetic alterations within the mitochondria* in muscle cells.  This led to severe abnormalities in the muscle ultrastructure including damaged sarcomeres inside the muscle cells themselves (Nouette-Gaulain et al, 2009).

Selectivity of Ropivacaine for Sensory Nerves – Not Motor Nerves

Furthermore, at lower concentrations, motor nerves may remain unaffected throughout a Ropivacaine blockade (compared to Bupivacaine that initially blocks both sensory and motor nerves).  This is due to the selectivity of Ropivacaine blockade for sensory nerves only.

Thus, reduced or nil pain sensation and unaffected motor nerves following a sensory nerve block with Ropivacaine may facilitate physiotherapy (Markham & Faulds, 1996).

SUMMARY

In summary, peripheral nerve blocks (together with other pain treatments) may offer significant relief from pain and other symptoms of CRPS.

This can only be good news!!

Sabina Walker

Blogger, Pain Matters (in WordPress)

KEY

* Mitochondria are the cells’ powerhouse or engine room and even have their own DNA.

* Sarcomeres are the ‘building blocks’ of our skeletal muscle cells.

* An axillary brachial plexus block (or axillary nerve block) is a nerve block for the lower arm (i.e. forearm) including elbow, wrist and hand.  

An axillary corresponds to an armpit or part thereof.

Brachial pertains to the arm or part thereof.

* Exsanguination forces blood out of the limb, or part thereof.  The use of an inflatable tourniquet prevents the return of blood flow into this area until desired.

 

* In a Bier block, a tourniquet is used to restrict local anaesthetic to a certain limb area and hence prevent it from entering circulation.

* A popliteal nerve block is a distal sciatic nerve block that leads to anaesthesia of the lower leg including calf, tibia, fibula, ankle, and foot.

Distal means further from the centre of the body.

* Proximal means closer to the centre of the body (e.g. spinal cord).

* Morbus Quervain, or de Quervain syndrome, involves pain and inflammation in the thumb including its tendons.

Dupuytren’s contracture involves knots of tissue that form under the skin of the palm of a hand that leads to a deformed hand.

* A Colles fracture is a distal forearm fracture (ie broken wrist).

* Occipital headache may be caused by injury to head, neck and upper cervical spine that adversely affects the occipital nerves.

* An interscalene brachial plexus block is a proximal block of the brachial plexus.

* The subclavian artery delivers oxygenated blood from the base of the neck to the brain.

Bupivacaine treatment was offered for a maximum of 2 weeks, followed by a 1-week ‘rest’ period.  This was done to prevent infection, scar tissue and fibrosis as well as other complications at the catheter insertion and/or injection site.  These 3-week cycles (aka sessions) were repeated as necessary.

** The local anesthetic, Mepivacaine, preferentially blocks sodium channel Nav1.8, while Bupivacaine inhibits TTX-sensitive sodium channels (Leffler et al, 2010).

REFERENCES

NERVE BLOCKS FOR CHILDREN WITH CRPS

(1) Dadure et al. Continuous Peripheral Nerve Blocks at Home for Treatment of Recurrent Complex Regional Pain Syndrome I in Children. Anesthesiology (Feb 2005);102(2):387–91.

NERVE BLOCKS FOR ADULTS WITH CRPS

(2) Kanji, Giresh. Treatment of Complex Regional Pain Syndrome with Peripheral Nerve Blocks: A Case Series of Nine Patients. Australasian Musculskeletal Medicine (June 2006); pages 1-10.

https://rsds.org/wp-content/uploads/2015/02/Kanji_2010.pdf

(3A) Ribbers et al. Axillary brachial plexus blockade for the reflex sympathetic dystrophy syndrome. International Journal of Rehabilitation Research (1997); 20; 371-380.

https://www.ncbi.nlm.nih.gov/pubmed/9459103

(3B) The above Dutch paper also forms part of this 150-page thesis paper:

Ribbers, Gerardus Maria. Complex Regional Pain Syndrome I – A Study on Pain and Motor Impairments (2001); Go to Chapter 5, pages 69 to 84.

ISBN: 90-74443-33-8

https://repub.eur.nl/pub/23547/011024_Ribbers,%20Gerardus%20Maria.pdf

(4) Murray et al. Continuous axillary brachial plexus blockade for reflex sympathetic dystrophy. Anaesth 1995;50:633-5.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2044.1995.tb15117.x

(5A) Linchitz RM & Raheb JC. Subcutaneous Infusion of Lidocaine Provides Effective Pain Relief for CRPS Patients. The Clinical Journal of Pain (1999); 15: 67-72.

https://www.ncbi.nlm.nih.gov/pubmed/10206569

(5B) Martin, Craig. Subcutaneous Lidocaine Infusion as Treatment for Complex Regional Pain Syndrome (CRPS). WorkSafeBC (October 2016); Pages 1-5.

(6) Fallatah, Summayah MA. Successful management of complex regional pain syndrome type 1 using single injection interscalene brachial plexus block. Saudi J Anaesth (Oct-Dec 2014); 8(4): 559–561.

doi: 10.4103/1658-354X.140903

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4236948/#__ffn_sectitle

(7) Klein & Klein. Low-volume ulnar nerve block within the axillary sheath for the treatment of reflex sympathetic dystrophy. Can J Anaesth (Sept 1991);38(6):764-6.

(8) Margić & Pirc. The treatment of complex regional pain syndrome (CRPS) involving upper extremity with continuous sensory analgesia. European Journal of Pain (2003); 7(1):

https://doi.org/10.1016/S1090-3801(02)00052-6

https://onlinelibrary.wiley.com/doi/abs/10.1016/S1090-3801%2802%2900052-6

ROPIVACAINE, BUPIVACAINE and Mepivacaine

(9) Nouette-Gaulain et al. Age-dependent bupivacaine-induced muscle toxicity during continuous peripheral nerve block in rats. Anesthesiology (Nov 2009);111(5):1120-7.

doi: 10.1097/ALN.0b013e3181bbc949

https://www.pubfacts.com/detail/19809284/Age-dependent-bupivacaine-induced-muscle-toxicity-during-continuous-peripheral-nerve-block-in-rats

(10) Kaur et al. Comparision between bupivacaine and ropivacaine in patients undergoing forearm surgeries under axillary brachial plexus block: a prospective randomized study. J Clin Diagn Res (2015);9(1):UC01-6.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4347153/pdf/jcdr-9-UC01.pdf

(11) Markham A & Faulds D. Ropivacaine. A review of its pharmacology and therapeutic use in regional anaesthesia. Drugs (1996); 52: 429–49.

https://www.ncbi.nlm.nih.gov/pubmed/8875132

(12) Leffler et al. Block of sensory neuronal Na+ channels by the secreolytic ambroxol is associated with an interaction with local anesthetic binding sites. Eur J Pharmacol (2010)630:19–28.

doi: 10.1016/j.ejphar.2009.12.027

https://www.ncbi.nlm.nih.gov/pubmed/20044988

Hyperbaric Oxygen Therapy for Pain

Feature Image sourced from:

https://pixabay.com/en/diving-air-oxygen-kringel-air-ring-378214/

Dear Pain Matters blog readers,

INTRODUCTION

Hyperbaric oxygen therapy (HBOT) involves the delivery of 100% oxygen at increased atmospheric pressures inside a pressure chamber.

Pressures greater than normal air pressure (i.e. 1 Atmosphere Absolute, or 1 ATA) may be offered by trained personnel.  Many patients are exposed to 2 to 2.4 ATA per session.  Each session may last 1.5 to 2 hours and patients may complete a total of 20 to 30 HBOT sessions.

For those of you who have scuba dived, free dived or snorkelled, 2 ATA is the pressure that one would feel 10 meters (33 feet) under the ocean.  Thus, every 10 meters (33 feet) of sea water is equivalent to an increase of 1 ATA of pressure.

http://www.vhbo2.com/companion/hyperbaric-oxygen-therapy/understanding-hbot/

88232418.jpg

Source:

https://media.gettyimages.com/photos/students-breath-oxygen-in-a-hyperbaric-oxygen-chamber-to-help-relax-picture-id88232418?k=6&m=88232418&s=612×612&w=0&h=tCQk-S4brc2Dv7E9mF5XGVPp-USamsbrQgspKAf_agE=

Also called hyperbaric medicine or hyperbaric treatment, HBOT can increase oxygen concentration, reduce inflammation and decrease the number and sensitivity of tender and painful points.

This is a cute 2-minute video of a dog inside a pressure chamber (with great background music):

Hyperbaric oxygen therapy can alleviate chronic pain in:

  • Complex regional pain syndrome;
  • Fibromyalgia;
  • Myofascial pain syndrome;
  • Idiopathic trigeminal neuralgia;
  • Migraines and cluster headaches; and
  • Other pain conditions (Yildiz et al, 2006; Yildiz et al, 2006; Efrati et al, 2015)

as well as reduce pain following crush injuries.

PAINFUL CONDITIONS TREATED BY HYPERBARIC OXYGEN THERAPY

LOWER LIMB COMPLEX REGIONAL PAIN SYNDROME (CASE 1) 

A 41-year old man, ‘G.G.’, suffered from Complex Regional Pain Syndrome Type 2 (CRPS Type 2), left foot, caused by a traumatic ‘Weber B’ left ankle fracture that occurred more than a year ago on 21 February 2014.  Specifically, G.G. slipped and fell on ice in a parking lot at the end of a working day.  He immediately suffered severe pain in his left ankle and foot.

Two days later, on 23 February 2014, G.G. had surgery involving open reduction internal fixation of his ankle.  Complications set in including a cellulitis infection that was treated with antibiotics.

Post-surgery, G.G. endured ongoing and severe pain including intermittent shooting pains and severe electric shocks in his left ankle and foot.  Other symptoms included allodynia, swelling, temperature changes and discoloured skin in the left lower limb.

Despite undergoing a rehabilitation program and taking pain medication including pregabalin (75 mg twice daily), acetaminophen and NSAIDs (as needed), multivitamins, calcium, magnesium and glucosamine, G.G.’s severe pain persisted.

A diagnosis of CRPS, left foot, was made in April 2014.

On 5 February 2015, almost one year after his injury, G.G. had surgery to remove the plateau in his left lower limb in an effort to relieve his pain.  Sadly, G.G.’s symptoms including pain and allodynia, swelling, purple discolouration, lower skin temperature as well as muscle weakness in his left lower leg and ankle continued.  With average pain levels at 6 that often rose to 8, G.G. described his pain as (quoting) ‘constant, dull, aching pain with intermittent shooting sensations’.   

Desperate for some pain relief, G.G. decided to try HBOT for his CRPS in his left foot.

After 15 HBOT sessions over 3 weeks, G.G. had significantly less pain and allodynia, reduced swelling, enhanced skin colour and improved range of motion in his left foot.  Following 3 weeks of HBOT, G.G. was able to return to work after more than a year off due to severe left foot pain.

Hyperbaric oxygen therapy may be a valuable therapeutic option for treating chronic CRPS (Katznelson, 2016).

LOWER LIMB COMPLEX REGIONAL PAIN SYNDROME (CASE 2)

A 44-year old woman had CRPS, left foot and ankle.  Her foot and ankle had restricted range of motion, appeared cyanotic and was tender and cool upon touch.

Within only 15 minutes of her first HBOT treatment, she enjoyed complete pain relief in her foot!  Furthermore, her foot felt warm on palpation and (quoting her) ‘pinker than it’s been in years’.  The foot remained pink and warm for 8 hours.  Best of all, she enjoyed nil pain for 18 hours after her first HBOT treatment!

Following amendments to her second HBOT session on the following day, her foot became pink and warm for 1 hour as well as painless for 2 hours.

Further adjustments made to her third HBOT protocol in the following week resulted in her foot remaining painless, warm and pink for 30 hours (!) (Peach, 1995).

COMPLEX REGIONAL PAIN SYNDROME

A double-blind, randomized, placebo-controlled study compared 37 CRPS patients who had HBOT treatment against 34 CRPS patients who received normal air (Control Group).  All 71 CRPS patients underwent 15 sessions inside a hyperbaric chamber.

The HBOT-treated patients enjoyed significantly less pain and edema as well as enhanced range of motion of the wrist. 

Hyperbaric oxygen therapy may offer pain relief, decreased swelling and improved range of motion in CRPS patients (Kiralp et al, 2004).

FIBROMYALGIA

A study involving 60 women aged 21 to 67 who suffered fibromyalgia for more than 2 years underwent 40 HBOT sessions.  These 90-minute sessions were offered 5 days a week and each session involved 100% oxygen at 2 ATA.  Hyperbaric oxygen therapy led to significant improvement in all fibromyalgia symptoms including improved quality of life (Efrati et al, 2015).

MYOFASCIAL PAIN SYNDROME

A study evaluated the effects of HBOT on 20 patients with myofascial pain syndrome (MPS) compared to 10 patients in the control group.  The patients in the HBOT group were offered 10 HBOT sessions over 2 weeks.

There were no complications following hyperbaric oxygen therapy.  The pain threshold was significantly improved as were visual analogue scale (VAS) scores in patients in the HBOT group.  

The researchers concluded that HBOT may offer benefits for patients with MPS (Kiralp et al, 2009).

IDIOPATHIC TRIGEMINAL NEURALGIA

Patients with severe nerve facial pain (i.e. idiopathic trigeminal neuralgia) were offered HBOT sessions for 10 consecutive days.  Specifically, 42 patients aged 40 to 70 (8 men, 34 women) who suffered trigeminal neuralgia for 2 to 20 years were selected for this study.

The researchers concluded that HBOT treatment offered quick, dose-dependent and lasting pain relief.  Thus, HBOT may be an effective treatment for some nerve pain conditions including trigeminal neuralgia (Gu et al, 2012).

MIGRAINES 

Female migraine sufferers were offered either:

  • 100% oxygen and nil pressure (control group); or
  • Hyperbaric oxygen therapy comprising 100% oxygen and pressure.

The HBOT-treated migraineurs enjoyed some pain relief.  Pain levels remained unchanged in the control group.  

Hyperbaric oxygen therapy may reduce the intensity of migraines and headaches (Wilson et al, 1998).

CRUSH INJURY

Due to their traumatic nature, crush injuries can result in severe injury and pain to various body regions.  Crush injuries can range from minor contusions to limbs facing amputation due to tissue necrosis.

Crush injuries may affect different tissue regions including skin, subcutaneous layers, muscle, tendons, ligaments, cartilage, vasculature including capilliaries, nerves, bones and joints.  Physical trauma can lead to prolonged swelling and edema, stasis and/or internal bleeding including bleeding within myofascial envelopes.  The latter may lead to increased tissue fluid pressure in the skeletal muscle compartment.

Affected tissues may become ischemic due to hypoxia if the tissue fluid pressure (edema) exceeds the capillary perfusion pressure to the muscles and nerves inside the skeletal muscle compartment.

Ongoing edema may result in increased pressure as well as severely compromised microcirculation and limited or nil oxygen transfer across the capillary endothelium.  This may ultimately lead to ischemia and hypoxia.

Complex regional pain syndrome, skeletal muscle compartment syndrome and other painful conditions may develop and/or limb amputation may occur if urgent and effective treatment to prevent hypoxia and ischemia following crush injury is not provided.

Thus, time is of the essence that appropriate treatments are undertaken to reduce localised inflammation and swelling.

Importantly, hyperbaric oxygen may be used as an adjunct treatment to reverse ischemic and hypoxic conditions in crush injuries.  

https://www.uhms.org/4-crush-injury-compartment-syndrome-and-other-acute-traumatic-ischemias.html

WHY MIGHT HYPERBARIC OXYGEN THERAPY WORK?

Note:  This section is written for scientifically-minded readers, and may be skipped altogether by others who may not be so inclined. 

Animal research shows that HBOT blocks the production of tumor necrosis factor (TNF)-α in rats with chronic constriction injury.  Reduced TNF-α levels may lead to decreased nerve pain (Li et al, 2011).  Local overproduction of TNF-α, on the other hand, may play a role in promoting CRPS (Walker and Drummond, 2011).

Many chronic pain conditions include an inflammatory component that may lead to tissue hypoxia, ischemia and microvascular deficits (i.e. inflammatory hypoxia).  Re-oxygenation of injured or diseased tissues is a prerequisite before regeneration can occur.  Therapies such as HBOT may promote tissue re-oxygenation, reversal of inflammatory hypoxia and regeneration (Perdrizet, 2017) that may lead to pain relief.

Ten divers (9 males, 1 female) underwent pressures of 1, 2, 3 and 4 ATA in a supine position for 10 minutes per pressure in a hyperbaric chamber.  The Spanish study found that as the pressure increased, heart rate (HR) decreased and heart rate variability (HRV) moved into the high frequency range, especially after 2, 3 and 4 ATA.  Pressure-evoked increased HRV is indicative of enhanced parasympathetic (vagal) activity  (Barbosa et al, 2010).  Increased parasympathetic activity including enhanced vagal tone may lead to reduced pain, decreased inflammation and other medical benefits (Walker and Drummond, 2011).

Researchers recently suggested that nerve cells may actually communicate via mechanical pulses instead of electric pulses (Fox, 2018).  If true, is it possible that increased atmospheric pressures via HBOT inside a pressure chamber may lead to increased mechanical pulses?  If so, could this result in increased cutaneous sympathetic vasoconstrictor activity?  If yes, could this induce tissue re-oxygenation and reversal of inflammatory hypoxia in some pain patients including CRPS patients?  Research is warranted.

SUMMARY

Hyperbaric oxygen therapy may offer pain relief for some pain patients.

Please ensure that HBOT is done under medical supervision only and by trained personnel.  Refer to References for complications that may arise from HBOT. 

Sabina Walker

Blogger, Pain Matters (in WordPress)

PS Please feel free to share your personal experience with HBOT via this blog. 

REFERENCES

TEXTBOOK

(1) Undersea and Hyperbaric Medical Society (UHMS). Hyperbaric Oxygen Therapy Indications, Thirteenth Edition (April 2014).

ISBN 978-1930536-73-9

https://www.bestpub.com/books/hyperbaric-a-undersea-medicine/product/436-hyperbaric-oxygen-therapy-indications-thirteenth-edition/category_pathway-31.html

PAIN CONDITIONS TREATED BY HBOT

Complex Regional Pain Syndrome

(2A) Katznelson. Successful Treatment of Lower Limb Complex Regional Pain Syndrome following Three Weeks of Hyperbaric Oxygen Therapy. Pain Research and Management (2016); Volume 2016, Article ID 3458371, 4 pages.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4904619/

https://www.hindawi.com/journals/prm/2016/3458371/

(2B) Peach G. Hyperbaric oxygen and the reflex sympathetic dystrophy syndrome: a case report. Undersea Hyperb Med. 1995; 22(4): 407–8.

https://www.o2oasis.com/wp-content/uploads/2014/11/RSD-Case-Report.pdf

(2C) Kiralp et al. Effectiveness of hyperbaric oxygen therapy in the treatment of complex regional pain syndrome. J Int Med Res. (May-June 2004); 32(3): 258-62.

https://www.ncbi.nlm.nih.gov/pubmed/15174218

Fibromyalgia

(3) Efrati et al. Hyperbaric Oxygen Therapy Can Diminish Fibromyalgia Syndrome – Prospective Clinical Trial. PLoS ONE (26 May 2015); 10(5): e0127012.

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0127012

Myofascial Pain Syndrome

(4) Kiralp et al. A novel treatment modality for myofascial pain syndrome: hyperbaric oxygen therapy. J Natl Med Assoc. (Jan 2009); 101(1): 77-80.

https://www.ncbi.nlm.nih.gov/pubmed/19245076

Idiopathic Trigeminal Neuralgia

(5) Gu et al. Hyperbaric oxygen therapy attenuates neuropathic hyperalgesia in rats and idiopathic trigeminal neuralgia in patients. Eur J Pain. (2012); 16(8): 1094–105.

https://onlinelibrary.wiley.com/doi/epdf/10.1002/j.1532-2149.2012.00113.x

Migraines 

(6) Wilson JR, Foresman BH, Gamber RG, Wright T. Hyperbaric oxygen in the treatment of migraine with aura. Headache. 1998; 38(2): 112–5.

https://www.ncbi.nlm.nih.gov/pubmed/9529766

Crush Injury

(1) Crush Injury, Compartment Syndrome and Other Acute Traumatic Ischemias. Undersea and Hyperbaric Medical Society (UHMS).

https://www.uhms.org/4-crush-injury-compartment-syndrome-and-other-acute-traumatic-ischemias.html

Other Pain Conditions

NB The following 2 papers are not discussed in this blog post:

(7A) Yildiz et al. Hyperbaric oxygen therapy in chronic pain management.  Curr Pain Headache Rep. (May 2006); 10(2): 95-100.

https://www.researchgate.net/publication/7238531_Hyperbaric_oxygen_therapy_in_chronic_pain_management

(7B) Yildiz et al. Pain management and hyperbaric oxygen therapy. Therapy (2006); 3(5): 597–603.

https://pdfs.semanticscholar.org/6776/ae1e93f42de7371a28774221967dcf67fa0e.pdf

Possible Complications

(1) Complications of Hyperbaric Oxygen Treatment.  Johns Hopkins Medicine

https://www.hopkinsmedicine.org/healthlibrary/conditions/physical_medicine_and_rehabilitation/complications_of_hyperbaric_oxygen_treatment_134,148

Why Might Hyperbaric Oxygen Therapy Offer Pain Relief? 

(1) Li et al. Hyperbaric oxygenation therapy alleviates chronic constrictive injury-induced neuropathic pain and reduces tumor necrosis factor-alpha production. Anesth Analg. (Sept 2011); 113(3): 626-33.

https://www.ncbi.nlm.nih.gov/pubmed/21596875

(2) Perdrizet. Chronic Diseases as Barriers to Oxygen Delivery: A Unifying Hypothesis of Tissue Reoxygenation Therapy. Adv Exp Med Biol. (2017); 977: 15-20.

https://www.ncbi.nlm.nih.gov/pubmed/28685422

(3) Barbosa et al. Effect of hyperbaric pressure during scuba diving on autonomic modulation of the cardiac response: application of the continuous wavelet transform to the analysis of heart rate variability. Mil Med. (Jan 2010); 175(1): 61-4.

https://www.ncbi.nlm.nih.gov/pubmed/20108844

(4) Sabina Walker, Peter D. Drummond; Implications of a Local Overproduction of Tumor Necrosis Factor-α in Complex Regional Pain Syndrome [Review Paper, 24 pages]; Pain Medicine (Dec 2011), 12 (12), 1784–1807.

http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2011.01273.x/abstract

(5) Fox, Douglas. The Brain, Reimagined. Scientific American (April 2018); 318(4): 60-67.

http://www.nature.com/scientificamerican/journal/v318/n4/full/scientificamerican0418-60.html

 

Thanks To Dr Katinka’s Non-Invasive Treatments, Many CRPS Patients Are Enjoying Significant Recovery From CRPS

Feature Image of Dr Katinka van der Merwe sourced from:

About Katinka

Dear Pain Matters blog readers,

As mentioned in earlier posts, Dr Katinka van der Merwe (aka Dr Katinka), a Chiropractor at The Neurologic Relief Center (aka Spero Clinic), Arkansas, USA, specializes in chronic pain including complex regional pain syndrome (CRPS).  Dr Katinka’s novel and non-invasive approach focuses on restoring balance in the autonomic nervous system, with particular emphasis on the vagus nerve (‘the wandering nerve’).  As a result, Dr Katinka’s treatments may successfully reduce, and even eliminate, pain and inflammation as well as enhance function and mobility in many CRPS and other pain patients.  In doing so, she has literally given back their lives!

Dr Katinka’s unique medical talents for treating chronic pain are amongst the best in the world.  Furthermore, Dr Katinka’s compassion and empathy for each of her patients adds a touch of humanity to a field of medicine that (all-too-often) appears disengaged and disconnected with the actual depth of pain and suffering endured by so many chronic pain patients.

This blog post will review 10 CRPS patients who were successfully treated by Dr Katinka.  I urge the reader to watch at least some of the YouTube links.  Like me, you will (likely) be very touched by their stories of recovery from CRPS.

It is exciting to reveal that 7 of these 10 patients achieved COMPLETE pain relief following Dr Katinka’s 10-week treatment program!  Please click on the following table to view a summary of 7 CRPS patients who now enjoy nil pain.

Table – 7 CRPS Patients Who Recovered From CRPS

The following 3 CRPS patients enjoyed significantly less pain following completion of Dr Katinka’s 10-week treatment program:

  1. Debbie (retired), whose pain levels no longer exceed 2;
  2. Kristin, whose pain levels were 2, post-treatment, compared to 7, pre-treatment; and
  3. Billi, who was finally able to extend her left leg, post-treatment.

Details of 10 CRPS Patients Successfully Treated By Dr Katinka

1. Carlos’ CRPS Story

Carlos was in a serious auto accident in 2005 that resulted in spinal cord injury and other injuries as well as constant and severe pain for 7 years.  He was formally diagnosed with CRPS 2 years later in 2007.  His CRPS started in his abdominal area and affected his entire digestive system.  His CRPS spread throughout his entire body following TENS treatment.

Carlos had to use a wheelchair and a cane due to severe pain from CRPS.  He was unable to eat solid food.  Drinking water even hurt.  His eyes had a constant burning sensation and he became sensitive to light.  Having said that, he was grateful that his vision remained unaltered.

Carlos tried everything to control his pain including pain medications, spinal injections, epidurals and a spinal stimulator implant.  Unfortunately, his severe pain levels exceeding 10 continued to torture him.

Despite Carlos having given up on hope and even on life itself, his wife convinced him to see Dr Katinka as a last resort.  When Dr Katinka met Carlos for the first time, he was unable to eat more than a couple spoons of chicken broth at a time.  The latter even caused hours of excruciating pain for Carlos.

Quoting Dr Katinka,

Carlos was white as a sheet, and utterly without hope. His pain was carved into his face for the world to see. He came in with his wife. She told me that she was afraid that Carlos would take his own life if they could not find relief soon. She had convinced him to try just one more doctor. With them that day was their nine-month old baby, Sean. I remember looking at that little boy and trying to imagine his life without his father in it to see him grow up. Carlos finally looked up and said: ‘You can’t help me. No one can help me. I am here because my wife asked me to come.’

Despite his dire state of health, Dr Katinka proceeded with her gentle upper cervical treatment on him.  To both of their surprise and for the first time in 6 years, his pain levels dropped dramatically from a 10 to a 3 following her manual procedure of his upper neck area!  Carlos finally obtained relief from his constant burning pain within the first 15 minutes of his first treatment!  What a pleasant surprise after suffering severe and constant pain due to full-body CRPS for 6 entire years!  To top this off, Carlos celebrated this milestone by finally eating a full-course dinner without pain for the first time in 5 years.

He was a changed man when he came back for his second day of treatment.  His colour had returned as did his ‘life spark’.

After his 3rd day during Week 1 and after only 3 treatment sessions with Dr Katinka, his pain levels dropped to a 2 … and then to a 1.  In fact, some parts of his body were not even sensing pain anymore!

After Week 6 at the Center, he was down to only one pain medication (from several pain medications).  Furthermore, his pain levels remained at 1 or 2.

Twelve weeks later, Carlos was completely pain-free.

Three (3) years later, Carlos stated that he was still 99% better, and that he no longer needed any pain medications.  This demonstrates the lasting benefits of Dr Katinka’s 10-week pain program.

Almost five years later in 2016, Carlos is still pain-free.  He is now working as a pastor and travels all over the world.  Whilst he has faced physical challenges since then including gallbladder surgery, he has no sign of CRPS returning.

(Carlos was interviewed 3 times by Dr Katinka – twice during his 10-week pain treatment program and a third time 3 years after his successful treatment for CRPS.)

https://www.youtube.com/watch?v=pYE0aW1cTh8

https://youtu.be/tC_JyDfvexM

http://seeingyouwell.com/testimonials/

http://rsds.org/new-approach-rsd-crps/

2. Brock’s CRPS Story

Brock suffered CRPS for 10 months following a broken ankle in January 2015.  Brock was bedridden for 10 weeks due to excess pain from CRPS that also spread to his other leg.  Brock was on crutches for 7 months.  By now, his CRPS-affected leg comprised mainly of skin and bone, with only a little bit of calf and thigh remaining.  The bulk of his muscle mass in his CRPS-affected leg was gone.  Somewhere along the way, Brock also lost his job.  Needless to say, CRPS significantly changed his life for the worse in every conceivable way.

In addition to ‘tonnes of medication’, he had 4 sympathetic nerve blocks.  Unfortunately, this did not offer the pain relief that Brock needed in order to function properly.

When asked about any neck injuries by Dr Katinka, Brock confirmed that, in fact, he did have a prior neck injury prior to developing CRPS.

Brock described his first treatment during his trial week with Dr Katinka that involved gentle hands-on upper cervical manipulation as follows (quoting):

‘…completely painless, … I’ve had no side effects … no pains from the treatments  … Nothing … Amazing.’

Dr Katinka asked him, ‘So your pain level right now is?’

Brock answered, ‘I’m  a zero … zero.’  (He laughs.)

Dr Katinka enquired, ‘How does it feel?’

Brock happily replied ‘I’m smiling for the first time in a long time.  I haven’t been at a zero in almost a year now … and I’ve been amazed … 5 seconds into the first treatment … I was pain-free.’

Dr Katinka stated, ‘I’m so excited!’

Brock chuckled, ‘Me too … me too!’  

https://www.youtube.com/watch?v=MU7ggYcdJO4

3. David’s CRPS Story

David suffered CRPS in his right foot for almost 3 years following right foot surgery to remove a bunion and straighten out a ‘hammer toe’.  This was followed by a second surgery to remove a nerve from his right foot due to pain.  After these surgeries, David started having severe pain and swelling in his CRPS-affected right foot.

Post-CRPS, David walked with a cane, crutches and/or used a wheelchair due to pain.  He has his own wheelchair ramp built behind his house.  David was no longer able to drive or do anything else.  David was afraid to move for fear of making the pain worse than it already was.

As a result of the severe and unrelenting pain, David became extremely depressed.  Quoting David,

‘Depression … got so bad that, twice, I took very seriously about taking my own life … but … [my wife] … told me that there is only one that can give live and one has the authority to take life…’ 

Whilst his CRPS did not spread, his severe pain levels ranged from 11 to 13 (out of 10).

Quoting David, ‘The pain medications just numb the pain.  You have to keep it up, you’re drugged out … can’t do anything … your life is gone.’

In addition to morphine, Oxycontin and Hydromorphone, David also tried nerve blocks, without success.

On his first day at the Center, Dr Katinka asked David to lie on the treatment table for a diagnostic test.  As she chatted to David, Dr Katinka applied pressure to his neck and underneath his skull.  As she continued to apply gentle pressure in this area, his pain levels started to decrease dramatically until they reached a 2!  The pain levels did not, however, stop there.  Instead, they dropped even further as Dr Katinka continued to apply gentle pressure.  Guess what happened next??  David’s pain levels were finally at zero!  Imagine that!!  Zilch pain!!  Wow!!

After completing his trial (first) week at The Neurologic Relief Center, his right foot no longer appeared red and swollen.

Five (5) weeks later at the Center, David finally enjoyed complete pain relief and his right foot was not swollen.  David’s story of recovery from CRPS in his right foot is nothing short of amazing!

During his last 2 days at the Center, David intentionally left his walking cane in his motel room.  He was now able to walk on his own 2 feet without pain.

David’s wife, Debbie, said to Dr Katinka, ‘You have … a special heart for people in chronic pain, and it shows.’

Dr Katinka answered softly, ‘Thank you.  I do.  Especially RSD…’   

Before seeing Dr Katinka, David was in so much pain and pain-induced stress.  Now that his pain, and the stress relating thereto, was gone, David is finally looking forward to going fishing again on his own fishing boat.

David finally has his life back!  What could be better than that?? 

https://www.youtube.com/watch?v=hWIaMBhcvA0&sns=em

4. Madi’s CRPS Story

Madi, a teenager from Arkansas, sustained serious injuries including a fractured arm in a roll-over car accident 6 years ago when she was only 13.  Thereafter, Madi developed CRPS in her fractured arm that spread to her middle to lower part of her back as well as her entire left leg.  Her pain was sometimes so severe that she had difficulty walking.

Madi tried many different pain treatments including nerve blocks and lumbar blocks.  She has 2 stimulators surgically implanted in her back as well as a pump.  Sadly, the 2 stimulators did not reduce her pain levels at all.  While the pump offered some relief from her pain, it did not offer the amount of pain relief that she had hoped for or that she needed in order to function properly.

Madi underwent a chemical ablation (ie Phenol neurolysis) to burn her sympathethic nerve.  Sadly, this medical procedure only made her pain worse.  Madi took medication to help her sleep through the night despite the pain.

Madi felt guilty for being in pain all the time.  She felt like a burden to her family.

Understandably, Madi was sceptical about seeing Dr Katinka for the first time.  After all, no one else had been able to help her since her serious car accident 6 years ago.

However, Madi’s doubts quickly vanished after her first appointment.  When Dr Katinka performed a diagnostic test involving a gentle and non-invasive upper neck manipulation, Madi’s pain levels dropped to zero for the first time in 6 years since her car accident!  Wow!! This 100% pain relief lasted for an entire 40 minutes.

Needless to say, after her first day at the Center, Madi was eager to return for more treatments!  Even after 2 weeks (including during her YouTube interview), Madi stated that her pain levels were nil!  This is great news!

In closing, Madi’s mom said (quoting),

‘There is no amount of money that could ever give us what we have now, and it’s [Dr Katinka] that gave us that … And we talked about how her pain was locked, and how [Dr Katinka had] the key that unlocked it and made it go away…’

(Madi had just completed 2 weeks of her 10-week pain program at the Center when this interview was done.)

https://www.youtube.com/watch?v=IVqSGHwmf-E

5. Scott’s CRPS Story

Scott suffered from CRPS for 2 years following carpal tunnel surgery to his right hand.  Scott’s pain extended from his fingertips in his right hand up his right arm and to his neck.  His pain levels in his right hand were excruciating and would always reach 8 to 10 by afternoon.  Consequently, by the end of each day, he did not want to do anything at all.

Scott’s daily pain medications included massive amounts of Gabapentin and Ibuprofen.  He also tried numerous nerve blocks as well as 5 ketamine infusions.  While the effects of the first ketamine infusions seemed promising, the actual pain relief offered by the remaining 4 ketamine infusions lasted only 2-3 weeks each.

After only 4 days of treatment with Dr Katinka, the pain from Scott’s right wrist to his neck vanished.  While there was some lingering pain in his fingers in his right hand (with pain levels at 1), this was significantly more tolerable than before.

During her gentle hands-on upper cervical manipulation, Dr Katinka confirmed that the right side of Scott’s neck had felt a bit abnormal.  Dr Katinka’s chiropractic treatment of Scott’s upper cervical area aimed to ease the pressure on his vagus nerve.  In so doing, she increased the activity of his vagus nerve.

Research by Dr Kevin Tracey shows that increased efferent vagal activity can lead to drastically reduced localised inflammation (Walker & Drummond, 2011).  This would, of course, include any inflammation in David’s CRPS-affected right hand including fingers.  Decreased inflammation often leads to less pain, and in some cases, nil pain.

And this is exactly what happened to Scott during the upper cervical procedure!

In response to her question, ‘What is your pain like?’, Scott replied,

‘Right now it’s a zero.’

Dr Katinka said, ‘Zero! That’s awesome!‘

When Scott was asked whether he had ever experienced nil pain in the past 2 years, he replied that until now, the only time he could not feel his pain was during sleep.

https://www.youtube.com/watch?v=3p1dOOHDuio

6. Barbara Wall’s CRPS Story

Barbara Wall worked as a registered nurse for 25 years.  In 2005, Barbara suffered a broken neck due to a severe injury to her cervical spine as well as other injuries.  She was also diagnosed with full-body CRPS.  Thereafter, Barbara was forced to quit nursing in order to focus on her health issues and constant pain resulting from CRPS, her broken neck and other injuries.

Barbara underwent daily physical, occupational and pool therapy.  In addition, she was offered various pain medications, numerous stellate ganglion blocks, lumbar sympathetic blocks and cervical epidural steroid injections, without any success.

Following a successful spinal cord stimulator (SCS) trial, Barbara received an SCS implant.  This finally offered some pain relief enabling Barbara to continue with daily physiotherapy plus 2 hours of pool therapy.

Barbara describes 10 years of full-body CRPS as ‘mind blowing, traumatic, overwhelming, and most of all changing’.

Then one day in June 2015, Barbara’s CRPS worsened when she ‘made a simple movement with [her] neck and felt a horrible pop with lightning pain … the pain was intense’.  Barbara’s SCS was no longer able to provide pain relief leading to weeks of sleepless nights.  Tests finally revealed that 2 of her discs in her neck were so badly damaged that her SCS paddle had shifted to the right, rendering it completely ineffective on the left side.  Corrective surgery was considered too risky as it could make her CRPS even worse.

Barbara’s pain levels were at 8 out of 10 when she met Dr Katinka for the first time on 12 October 2015.  These pain levels dropped to 4 after her first non-invasive, drug-free and painless treatment with Dr Katinka.

Following completion of Dr Katinka’s 10-week pain program, Barbara’s pain levels are now zero most of the time.  Barbara was also able to stop all of her pain medications.

Quoting Barbara:

‘…there is hope in hopeless situations.  Even with my continued spine issues and the need for surgery on my cervical spine, I have been able to maintain low to no pain with my RSD.  I cannot tell you how amazing it is after ten years of chronic pain to actually sleep throughout the night, to not feel like you are burning from within…’

http://rsds.org/journey-back-health-rsd/

7. Brenda’s CRPS Story

Brenda suffered from CRPS since January 2010 and her pain levels used to range between 8 to 10 ‘pretty much all the time’.

After 4 weeks of non-invasive treatment at the Center, Brenda no longer takes any pain medication.  Best of all, Brenda no longer has pain.

(No other details were provided during this short 1-minute YouTube interview.)

http://seeingyouwell.com/testimonials/

8. Debbie’s CRPS Story

Debbie suffered from CRPS for 12 years following a surgical procedure in March 2004.  The anesthesiologist had hit a nerve while numbing her frozen shoulder.  As a result of severe pain due to CRPS, Debbie was no longer able to work.  She also became hypersensitive to clothing including sleeves.

Debbie took many different pain medications including Lyrica and Gabapentin.  She also underwent a spinal cord stimulator operation for her pain.

Debbie received frequency specific microcurrent and other non-invasive treatments at the Center from the end of February to May 2016.

Post-treatment at the Center, Debbie feels as if she ‘has a new lease on life … a second chance’.  Debbie and her husband were finally able to go on a 3-week road trip that included many rigorous activities such as 5-mile walks.

Debbie’s pain levels are now minimal and no longer exceed 2.  Debbie added that she no longer needs Lyrica, Gabapentin nor any other pain medication.  She has not turned on her spinal cord stimulator since February 2016.

In Debbie’s words, ‘It’s just amazing!’

(This interview occurred 6 months after Debbie’s successful treatment for CRPS at the Center in 2016.)

https://www.youtube.com/watch?v=yxgG6RfcrRY

9. Kristin’s CRPS Story

Kristin from Pennsylvania suffered from full-body CRPS for 9 years after injuring her T-spine at work.

Kristin tried many different treatments including a spinal cord stimulator trial.  However, the spinal cord stimulator had to be removed urgently due to the pain that it caused.  Sadly, during its removal, ‘they really yanked on it’.  This may have injured the lining of her spinal cord, making her pain worse.

After that, Kristin had numbness and tingling in both hands and arms, both feet and legs as well as on the left side of her face.  There was also increased burning pain and she bruised more easily.  She couldn’t work anymore due to CRPS.  Kristin could only sit and watch TV as well as sleep in the same recliner for years.  Sleeping in her bed was no longer a comfortable option.

After treatment by Kr Katinka, Kristen stated, ‘It’s basically been like a miracle.  It really has. … The first day, you were able to get rid of pain that I had in my mid back for 9 years.’

Overcome by emotion, Kristin started crying.  She continued, ‘I have so much less pain now … my RSD symptoms are still there … but cutting down on medication … I came in at a 7 and today I am leaving at a 2.’

She added, ‘It was definitely worth the 1,200 mile trip that we need, and the money, to come and see you … [Dr Katinka] is the best!’

(Kristin was interviewed on her last day at the Center after completion of Dr Katinka’s 10-week pain program.)

https://www.youtube.com/watch?v=ltc8fUKhmZM

10. Billi’s CRPS Story

Billi is a mother and a flight attendant who can no longer work due to pain from CRPS.  Her CRPS affected her entire left arm including hand, wrist, arm and left shoulder for the past 4 years.  Billi’s pain levels averaged 3 to 4.  Different factors affected her pain levels including daily temperature and activities.  Sometimes Billi woke up without pain.  However, as soon as she got up and moved around, her pain levels spiked.

Billi tried many pain treatments including bioenergy healing, biofeedback, acupuncture and lumbar injections.

One day, Billi accidentally fell backwards while going down some stairs in Paris, France.  This resulted in a hyperstretched nerve in her left leg that prevented her from extending out her left leg while walking.

Amongst different treatments offered at the Center, Billi had frequency specific microcurrent on her left leg.  After this treatment, Billi was finally able to stretch and extend out her left leg while sitting and walking.

When asked what CRPS took away from her, Billi replied that CRPS took away her entire life including her beloved job as a flight attendant.  She added that she would love to go back to her job.  CRPS had also drastically changed her role as a mom.

Dr Katinka added, ‘Our goal is so much bigger than getting you out of pain.  It’s getting you back to your life.’

Billi started to weep softly upon hearing these kind and compassionate words.  Touched by Billi’s tears of hope and gratitude, it didn’t take long for tears to also start welling up in Dr Katinka’s eyes.

(This interview was done at the end of Billi’s first week at the Center, with more treatments planned and further progress expected for Billi.)

https://www.youtube.com/watch?v=TpMSqe_aXk0

Summary

Dr Katinka strongly emphasizes that The Neurologic Relief Center (aka Spero Clinic) does not aim to:

  • Numb the pain;
  • Use calmare;
  • Use ketamine; or
  • Claim to cure CRPS.

Instead, the Center aims to re-balance the central nervous system (CNS), and in particular, the autonomic nervous system including the parasympathetic nervous system (i.e. the vagus nerve).  This will allow for optimal healing from within the body.  Once the autonomic nervous system balance is restored and vagal outflow increases, reduced inflammation, significant and/or complete pain relief as well as improved function and mobility may arise.

Dr Katinka’s non-invasive treatments for neuropathic pain and injury to the spinal cord include an upper cervical procedure to stimulate the vagus nerve – see below – and frequency specific microcurrent.

Patients who respond positively to the non-invasive treatments via a dramatic decrease in their pain levels during their first week (‘trial week’) at the Centre are invited to complete the 10-week pain program.

Upper Cervical Procedure To Stimulate The Vagus Nerve

Dr Katinka believes that CRPS is like ‘a perfect storm’ that may arise in the presence of an underactive vagus nerve.  This may occur following a neck or tailbone injury that could compromise its function.  In other words, Dr Katinka believes that an injury to the CNS that could affect the vagus nerve is a major risk factor (amongst other factors) for CRPS in some patients.

Dr Katinka’s gentle hands-on upper cervical diagnostic procedure is performed on each CRPS patient during the first day of the ‘trial 1-week’.  During this diagnostic test, CRPS patients are requested to lay on the treatment table.  This non-invasive and painless procedure enables Dr Katinka to diagnose whether an underactive vagus nerve exists.

In Dr Katinka’s experience, most, if not all, CRPS patients present with a hypoactive vagus nerve.  Furthermore, in her opinion, unless the problem in the CNS (being an underactive vagus nerve) is properly addressed, many may never get to the bottom of CRPS.  In other words, if one only treats the symptoms of CRPS including pain (via pain medications, ketamine, spinal blocks, spinal cord stimulator, etc), instead of addressing the actual cause for these symptoms (such as an injury in the CNS that affects the vagus nerve), one may never be able to help CRPS patients.

Dr Katinka’s gentle manipulation of the patient’s upper cervical region often results in stimulation of the vagus nerve.  In turn, this can reduce localized inflammation almost immediately that may lead to pain relief.  These manipulations are repeated throughout the 10-week program, as necessary.

Thanks to Dr Katinka and her team, many CRPS patients are finally able to enjoy their lives without pain, while many more CRPS patients benefit from reduced pain and increased function and mobility.

Often dreams become reality at The Neurologic Relief Center (Spero Clinic), Arkansas, thanks to Dr Katinka and her team!

https://thesperoclinic.com

Sabina Walker

Blogger, Pain Matters (in WordPress)

 

REFERENCES

Other Pain Matter Blog Links and References of Dr Katinka

The Wandering Nerve And CRPS

Frequency Specific Microcurrent And Other Non-Invasive Treatments For CRPS By Dr Katinka

Woohoo! Australia’s ‘One Girl’, Chantelle Baxter, Is Finally On The Road To Recovery From CRPS, Along With Other CRPS Patients, Thanks To Their Own Guardian Angel, Dr Katinka! 

Putting Out the Fire: A Brand New Approach to Treating RSD/CRPS (guest blog post, RSDSA website (12 April 2016)

http://rsds.org/new-approach-rsd-crps/

Academic References on the Efferent Vagus Nerve, Inflammation, Pain, etc

Walker, Sabina, Drummond, Peter D. Implications of a Local Overproduction of Tumor Necrosis Factor-α in Complex Regional Pain Syndrome [Review Paper]. Pain Medicine (Dec 2011); 12(12): 1784–1807 (24 pages).

http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2011.01273.x/abstract

Patient YouTube Links and References of CRPS Patients

  1. Carlos’ CRPS Story

https://www.youtube.com/watch?v=pYE0aW1cTh8 (23 January 2015)

https://youtu.be/tC_JyDfvexM (8 June 2011)

http://seeingyouwell.com/testimonials/

Putting Out the Fire: A Brand New Approach to Treating RSD/CRPS (guest blog post, RSDSA website (12 April 2016)

http://rsds.org/new-approach-rsd-crps/

  1. Brock’s CRPS Story

https://www.youtube.com/watch?v=MU7ggYcdJO4 (21 December 2015)

  1. David’s CRPS Story

Groundbreaking CRPS Treatment by Dr Katinka

https://www.youtube.com/watch?v=hWIaMBhcvA0&sns=em (30 October 2015)

  1. Madi’s CRPS Story

https://www.youtube.com/watch?v=IVqSGHwmf-E (7 August 2015)

  1. Scott’s CRPS Story

https://www.youtube.com/watch?v=3p1dOOHDuio (28 May 2016)

  1. Barbara Wall’s CRPS Story

My Journey Back to Health: Barbara Wall and RSD (3 May 2016)

http://rsds.org/journey-back-health-rsd/

  1. Brenda’s CRPS Story

http://seeingyouwell.com/testimonials/ (a 1-minute YouTube)

  1. Debbie’s CRPS Story

https://www.youtube.com/watch?v=yxgG6RfcrRY (27 October 2016)

  1. Kristin’s CRPS Story

https://www.youtube.com/watch?v=ltc8fUKhmZM (30 May 2016)

  1. Billi’s CRPS Story

https://www.youtube.com/watch?v=TpMSqe_aXk0 (20 March 2015)