Category Archives: Nerve Pain

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).

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

 

 

 

 

 

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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

Repetitive Sciatic Nerve Blocks May Reduce Nerve Pain

Dear Pain Matters blog readers,

Feature Image sourced from:

https://www.webmd.com/back-pain/ss/slideshow-low-back-pain-overview

Repetitive sciatic nerve blocks may offer substantial pain relief for some patients with nerve pain.

DETAILS

A 50-year-old woman (let’s call her ‘Jane’) suffered ongoing nerve pain in her left lower limb following surgery to remove a schwannoma* on her left S1 nerve root (aka sciatica nerve schwannoma).
Decades earlier aged only 27, Jane suffered ‘electric-like pain’ during intimacy.  Shortly afterward, surgery was performed to remove a cyst on her left ovary.  Despite surgery and nonsteroidal anti inflammatory drugs (NSAIDs), her pain persisted.
Several years later, a 3 cm surgical incision was performed to remove her left S1 nerve root at the plexus including a schwannoma.
Post-surgery, Jane endured pain upon sitting and touch.  She also had a limp in her left leg.
Jane was prescribed NSAIDs, antidepressant and pregabalin.  Despite these medications,  Jane suffered ongoing mild pain.  She also had intense pain at rest and movement as well as severe allodynia upon palpation in the area between S1 to L5 (VAS from 3 to 10).
Jane displayed mild motor weakness during nerve testing of her left lower leg (i.e. during leg abduction, foot eversion, plantar and toes flexion and in the hip extension).
Jane also had drastically reduced sensation in her foot, lower leg and thigh and buttocks.
A sciatic nerve block comprising an anesthetic mixture (20 mL) was injected at the ‘pain trigger point’ (located 1 cm above the midline of the incision).
RESULTS OF SCIATIC NERVE BLOCK
Guess what happened next??
Jane enjoyed immediate pain relief after this sciatic nerve block (VAS 1/10), after suffering years of pain!!
The sciatic nerve block’s pain relieving effects lasted 15 days.  Despite her nerve pain returning 15 days later, Jane’s pain had lost its original intensity (VAS decreased to 3/10).
To better manage Jane’s nerve pain, a repetitive sciatic nerve block was prescribed.
SUMMARY
Some nerve pain patients may benefit from repetitive sciatic nerve blocks.

Sabina Walker

Blogger, Pain Matters (in WordPress)

 

*Usually benign in nature, a schwannoma is a nerve sheath tumour that develop from the Schwann cell.

REFERENCES

(1) Naja Z et al. Repetitive nerve block for neuropathic pain management: a case report. Scand J Pain (26 Jan 2018);18(1):125-127.

doi: 10.1515/sjpain-2017-0155.

The Wandering Nerve And CRPS

Source of Featured Image of the vagus nerve (‘the wandering nerve’).

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

Dear Pain Matters blog readers,

As mentioned in earlier posts, Dr Katinka van der Merwe (aka Dr Katinka), a Doctor of Chiropractic at The Neurologic Relief Center, Arkansas, USA, specializes in chronic pain including CRPS.  Dr Katinka’s unique and non-invasive approach focuses on rebalancing the autonomic nervous system, with particular emphasis on the vagus nerve (‘the wandering nerve’).

18342291_1547231995308980_4613259570866324049_n.jpg

Source of photo of Dr Katinka:

https://www.facebook.com/TheNeurologicReliefCenter/?fref=mentions&pnref=stor

Dr Katinka has expertise in various non-invasive treatments including:

  • Upper Cervical Procedure (to stimulate the vagus nerve); and
  • Frequency Specific Microcurrent. 

These (and other) treatments may be beneficial for neuropathic pain and injury to the spinal cord and other painful conditions.

https://painmatters.wordpress.com/2017/04/29/woohoo-australias-one-girl-chantelle-baxter-is-finally-on-the-road-to-recovery-from-crps/

https://painmatters.wordpress.com/2017/06/20/frequency-specific-microcurrent-and-other-non-invasive-treatments-for-crps-by-dr-katinka/

This blog post discusses Jennifer, a CRPS patient who suffered pain levels up to ‘10’ on a daily basis for many years until she finally attended The Neurologic Relief Center (headed by Dr Katinka).  Happily, Jennifer obtained complete pain relief following non-invasive treatments for 5 weeks at this Center.

Jennifer’s CRPS 

Jennifer’s CRPS in her right foot occurred after a stress fracture to the top of her right foot in 2007/2008.  Her CRPS spread to her right arm, wrist and hand.  Jennifer also had spinal surgery 2 years ago that involved metal implants including a metal cage, plates and screws.

Jennifer suffered shooting and excruciating pain levels up to ‘10’, 24/7, as well as severe migraines.  Her pain made it difficult to do anything including walking, working and concentrating/focusing.  Her sleep was constantly interrupted by pain and she was unable to sleep with covers due to hypersensitivity.  Jennifer had difficulty wearing shoes in the daytime.  Needless to say, a life with severe and constant pain was very  debilitating for Jennifer.

Because pain is ‘invisible’, people who had no pain could not understand her (with the exception of her supportive husband).  It was hard for Jennifer to hear people tell her, ‘There’s nothing wrong with you’, when in fact she was in such agony and pain.

Jennifer tried various pain medications including Lyrica (at maximum dosages), morphine and Cymbalta.  Jennifer said that while these drugs made her think that her pain was better, they did not enable her to do anything or function properly.  Sadly, her pain never went away no matter how high the dosages were.

Dr Katinka’s Non-Invasive Treatment For Jennifer’s CRPS 

Dr Katinka does not treat CRPS directly.  In her words (quoting from both Youtubes, below):

‘The difference between how we treat RSD [CRPS], or the neurologic symptoms of RSD [CRPS], is that we do not treat pain.  We do not numb the pain.  We do not interrupt the pain signal.  We do not attack the pain signal.  We don’t try to interrupt the nerve signal … that is not what’s causing the RSD [CRPS].  The RSD [CRPS] is caused by a malfunction in the central nervous system.

We treat the central nervous system injury.  And unless you treat that, you will never, ever permanently get the RSD [CRPS] under control, in my opinion.’

Dr Katinka added that many patients have injuries in their upper cervical region or tailbone area. These types of injuries may affect the vagus nerve.  If left untreated, these injuries can affect the central nervous system, and in particular, the parasympathetic nervous system including the vagus nerve.  Ultimately, this may trigger CRPS.

As stated above, Dr Katinka’s team offered non-invasive treatment for Jennifer’s CRPS that includes a combination of:

  1. An upper cervical procedure – This involves gentle hands-on treatment of the very upper cervical region to release, stimulate and activate the vagus nerve.  This gentle treatment removes any pressure on the vagus nerve, hence instantly restoring vagus nerve function and reducing pro-inflammatories.  When this occurs, there can be an immediate decrease in pain.  This procedure is frequently repeated during the 10-week treatment period; and
  2. Frequency Specific Microcurrent (FSM) – This is done to treat:
    • Inflammation of the spinal cord including nerves and abnormal scar tissue (from Jennifer’s spinal fusion surgery 2 years ago);
    • Allergic reactions and toxicity – Jennifer’s back surgery involved metal implants in her spine including a metal cage, plates and screws.  These metal implants are at risk of releasing toxins that may trigger metal allergies; and
    • Stenosis (ie narrowing of the spinal canal).

Jennifer shared details of her 3rd week at the Center in the YouTube dated 26 July 2015 (see below). At this time, her CRPS-affected right foot was still swollen, compared to her unaffected foot.  Furthermore, her pain levels were at ‘8’ before beginning FSM.

Jennifer confirmed that her pain vanished during FSM treatment. Instead, she had a ‘hot/warm feeling of water on the foot, with no pain. Quoting Jennifer:

‘It feels funny … It just feels funny. I’ve been having pain for so long … You have to stop and think, ‘Look, there’s nothing [ie no pain] there.”

Pleased with Jennifer’s progress thus far, Dr Katinka stated:

We don’t have tissues here, do we? I must have made you cry [with happiness] … Oh, we do [have tissues].’

Jennifer added, ‘…It’s amazing … from one day to the next … how it feels…

After FSM treatment, Jennifer practiced walking slowly down a hallway under Dr Katinka’s caring supervision. Dr Katinka stated (quoting):

…You’re done with your treatment … And you are walking on your foot. Can you normally walk on it?

Jennifer answered, ‘Not very well. No. It really hurts … Yeah, this is really different…’

When Dr Katinka asked about her pain levels while walking down the hallway, Jennifer literally sang out, ‘A ‘2’!’

After 5 weeks of treatment, Jennifer’s right foot was still swollen and slightly sensitive. The good news was that Jennifer’s pain levels were now down to ZERO (ZILCH!) for the past 2 days! Wow!  What fun!  She was also able to sleep throughout the night now, something that she had not enjoyed for years. Woohoo!

Other CRPS Patients Successfully Treated By Dr Katinka

For dozens of other CRPS success stories, please follow the links in:

https://painmatters.wordpress.com/2017/04/29/woohoo-australias-one-girl-chantelle-baxter-is-finally-on-the-road-to-recovery-from-crps/

and

https://www.facebook.com/TheNeurologicReliefCenter/?fref=mentions&pnref=stor

Summary

Dr Katinka’s non-invasive combination treatment that focuses on rebalancing the autonomic nervous system including vagus nerve may offer pain relief and improved function for some chronic pain patients including CRPS patients.

For more on Dr Katinka’s unique insights into CRPS, please click her following guest blog post on the RSDSA website:

Putting Out the Fire: A Brand New Approach to Treating RSD/CRPS (12 April 2016)

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

Thanks to Dr Katinka and her team, Jennifer is finally able to enjoy her life without painful CRPS!

Sabina Walker

Blogger, Pain Matters (in WordPress)

REFERENCES

Jennifer’s CRPS Story – 2 YouTubes by Dr Katinka van der Merwe

(1A) Jennifer’s CRPS Story (26 July 2015) (6-minute YouTube)

(1B) Jennifer’s CRPS Story (continued on 10 August 2015) (8-minute YouTube)

https://www.youtube.com/watch?v=PLkqMzLv9Xw

Frequency Specific Microcurrent for Pain 

(2A) McMakin, Carolyn. Frequency Specific Microcurrent in Pain Management (3 December 2010); Pages 1-256.

eBook ISBN: 9780702049255
Paperback ISBN: 9780443069765

https://www.elsevier.com/books/frequency-specific-microcurrent-in-pain-management/mcmakin/978-0-443-06976-5

(2B) McMakin, Carolyn. Nonpharmacologic Treatment of Neuropathic Pain Using Frequency Specific Microcurrent. The Pain Practitioner (2010); 20(3); 68-73.

(2C) Thomas, Brooke. Carolyn McMakin: The Resonance of Repair (A 68 Minute-Podcast Interview with Carolyn McMakin). Liberated Body (23 December 2014); LBP 030.
(2D) Treating RSD/CRPS With Frequency Specific Microcurrent (a 75-minute YouTube done 18 September 2014 by Dr Carolyn McMakin)
(2E) Other YouTubes By Dr Carolyn McMakin

 

 

 

 

 

 

Let’s Talk To An Inspirational Young Canadian Woman, Paula Orecklin, About CRPS, Sativex, Physiotherapy and Neuroplasticity

Featured Image provided by Paula Orecklin.

Sativex

Sativex is a cannabis-based mouth spray that is used for nerve pain relief in various painful conditions including cancer, complex regional pain syndrome (CRPS) and multiple sclerosis (MS).  It may also reduce spasticity, muscle spasms and sleep disturbances in MS patients (similar to the benefits of medical cannabis).

For more on Sativex, please see my blog post called ‘Medical Cannabis (Medical Marijuana) And Nerve Pain’.

For information about a cannibinoid called cannabidiol (CBD), please go to my blog post called ‘Chronic Pain and Cannabidiol (CBD) – ‘Cannabis With the Fun Bit Taken Out:  

https://painmatters.wordpress.com/2018/04/06/cannabidiol-cbd-oil-for-severe-chronic-pain-including-arthritis-osteoarthritis-and-ankylosing-spondylitis-in-the-back

A CRPS Patient, Paula Orecklin 

You may remember Paula Orecklin from my older blog post called ‘CRPS Video On CRPS By PARC’ (26/10/14).

I recently invited Paula to share more of her inspiring story including her challenges with severe chronic pain and her positive experiences with Sativex, physiotherapy and neuroplasticity work.  Paula immediately replied:

“I like being able to do something positive with all of this pain. If this can help other patients, I’m all over it. Sharing my story, talking to other people…I have to make something good out of all of this pain, you know? And I do have a lot of experience, I guess.”

Paula Orecklin (29) from Winnipeg, Manitoba, Canada, has complex regional pain syndrome (CRPS) that involves constant, severe pain in her right knee and lower right leg as a result of twisting her right ankle back in 2001 when she was only 13 years old. Thereafter, Paula couldn’t even put her right foot to the floor without triggering one vicious blast of pain after another, leaving her bedridden and literally screaming in bed for the next 2 weeks. Following this tragic and life-altering event, Paula had to resort to crutches (and later on, canes) for mobility and due to excess pain. She was wheelchair-dependent for a few months during 2004 – 2005 (caused by ‘blowing out her left knee’) and also for 3 years from 2013 to 2015 (due to unbearable pain leading to monthly ER visits for half a year).

Quoting from Paula’s 2013 YouTube (pre-Sativex treatment):

‘…Every single second, I am in pain, from my knee down to my toes. On my right leg, all there is is pain…there is always solid pain from my knee down. On top of that pain, I have other kinds, all different forms [of pain]…stabbing, shooting, burning, visceral, aching, throbbing…This is with all of my medications…’

See YouTube called ‘Paula Orecklin – UNE Patient Case Study – April 4, 2013’:

https://www.youtube.com/watch?v=_aAVOCGW5ac

Following 3 years in a wheelchair due to severe pain, Paula was offered Sativex for the first time in 2015.  In 2016, thanks to Sativex (and other medications), the support of a fantastic physiotherapist and neuroplasticity work with an excellent pain psychologist, Paula was finally able to trade in her wheelchair and crutches for walking canes!

unnamed-3.jpg

Image provided by Paula Orecklin.

However, despite Sativex, Paula still has constant, severe pain every single second of her life. In her words:

[CRPS] still has all sorts of horrible kinds of pain [despite Sativex]. I can be doing well and suddenly ‘a giant poker’ has been stabbed through my leg. I was at a meeting on Saturday and in the middle of it, my foot set on fire. I’m always in pain and then on top of that, there are all sorts of different kinds of pain that come on extraordinarily suddenly. What I said in the video [3 – 4 years ago] is exactly what [still] happens today.’

Thus, while Sativex does not eliminate Paula’s base level of constant and severe pain nor her initial sudden pain attacks from occurring, it can block the repetitive flare cycles. By preventing these ongoing vicious pain cycles in 5 minutes, Sativex enabled Paula to finally undergo physiotherapy to improve her function and mobility. In Paula’s words:

“…Sativex is good at keeping the huge flare cycles down… I’m doing better functionally, so much better. But it doesn’t really work on my constant level of pain.”

Before Sativex, Paula suffered from out-of-control pain levels due to sudden and repetitive waves of pain spikes that would combine with her initial pain spike. One pain spike would lead to another pain spike, and on and on it went. This vicious and ongoing pain spike cycle often led to extremely high pain levels until finally her other medications kicked in.

Paula started using Sativex sublingual mouth spray 2 years ago. While it ‘tastes pretty disgusting, like spraying mosquito repellent into your mouth’, Paula said that she was doing very well as Sativex helps her manage her pain levels better. Being a mouth spray, Sativex has the advantage of gaining faster access directly into the blood capillaries via diffusion through the tissues under the tongue.

Paula has a prescription for a refill bottle of Sativex every 8 days. Sativex is not covered by public healthcare where Paula lives in Manitoba, and at CDN256.05 a bottle, Sativex is not cheap. Even though Paula’s private insurance helps defray most of the cost, Paula is still left out-of-pocket CDN60 per bottle. Using up to 12 sprays a day (and even up to 15 sprays on very painful days), a bottle of 90 sprays can go very quickly.

Despite its costs, Paula finds Sativex’s ability to block the repetitive flare cycles worthwhile. For the first time in her life, Paula has finally found a way to stop the vicious and ongoing cycles of pain spikes before they even start. This enables Paula to do physiotherapy and neuroplasticity training despite ongoing, unrelenting and severe pain. For example, she is now able walk between 1 to 2.4 miles with the aid of 2 walking canes.

Paula does not have any side effects from Sativex other than feeling ‘fuzzy everywhere’ on ‘really bad days’ when more than 9 – 10 sprays and increased hydromorph IR are required.

While Paula has tried medical marijuana (medical cannabis), she found it ineffective against her painful flare-ups. In contrast, Sativex is able to stop her pain flares in 5 minutes hence preventing a vicious circle of painful flare-ups. Furthermore, because Sativex looks like a regular inhaler, it is easier for Paula to be seen using Sativex than, say, medical marijuana. In other words, Sativex is not associated with the social stigma associated with using medical marijuana for pain management.

[I’ve gone from being] forced … to leave university, to carrying the Olympic torch [see photo below], to helping found a local CRPS support group, to creating my own Disability holiday….that after 15 years I …still [attend]. I’m going to celebrate it again this March…after 16 years I’m actually going somewhere now.  I’ve managed to make as much of a life out of my circumstances as I can.”

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Image provided by Paula Orecklin.

On behalf of all Canadians with chronic pain, Paula was formally honoured and selected to be an Olympic torchbearer for the 2010 Vancouver Olympic Winter Games. Paula had to practice walking and holding up one of her old crutches (in lieu of the Olympic torch) for 6 – 7 months beforehand.

One very early morning on a cold wintry day at -30C in January 2010 in Virden, Manitoba, Paula successfully fulfilled her pledge to carry the Olympic torch for 500 meters without mobility aids! Needless to say, being chosen as an Olympic torchbearer for the 2010 Winter Olympics to represent all Canadians living with chronic pain was one of Paula’s proudest achievements.

Thanks to a multi-disciplinary approach to CRPS that involved:

  • Sativex treatment;
  • Hydromorph IR and other conventional pain medication;
  • Physiotherapy;
  • Neuroplasticity work (with her pain psychologist); and
  • Various other pain strategies,

Sativex made a huge difference to Paula’s quality of life by opening the door for the first time to physiotherapy, regular exercise and neuroplasticity work, leading to a dramatic improvement in her CRPS symptoms including repetitive painful flares.

In her own words:

‘I’ve found in the past few months that not only have I been able to do more, be out and see people, exercise and still not fall apart, but I’ve also been increasing my tolerance to everything. I’ve actually been using less breakthrough medication, both Sativex and my hydromorph IR. I’m genuinely doing better. I think I’m down to about a bottle every 13 days right now.’

‘Without Sativex, I would never have been able to get to where I am today.

The neuroplasticity would have helped with my own depression due to pain and my understanding of pain and just generally improved my mental state.

But no real improvement physically would have been possible without Sativex.’

‘I’m doing better than I have in a very long time. Sativex is absolutely critical to this upswing. With Sativex, I can give myself medication with every flare of pain. It kicks in in only 5 minutes. The pain doesn’t have a chance to build on itself but is cut down quickly. I can also give myself another spray in 5 minutes if the pain keeps getting worse or doesn’t go down enough.

I can take up to 12 sprays a day and there aren’t really any side effects. I can get a kind of drugged feeling, but it’s not a high nor is it particularly strong. I have to be careful to spray under different parts of my tongue (ie sometimes my tongue’s left side, sometimes up front in the middle, sometimes on the right) so I don’t get wounds under my tongue. However I’ve never had a single one develop. It’ll sting a little when I’ve used a ton of sprays in one spot, but that’s just a reminder to be sure to move it around. And this might be of clinical significance since my skin is very delicate and develops wounds from my CRPS. ….

I mean, the drug is no magical cure, but it’s been absolutely essential to my progress. Without it, I might have gotten some psychological benefit from the neuroplasticity, but I definitely couldn’t be able to move any better. I’d never have ever been in a place where I could work with my physiotherapist. Before Sativex, I was in my wheelchair for nearly everything. I was finally able to walk again because of [Sativex].’

‘I’ve been working with an amazing physiotherapist since this spring. I was finally able to start walking, but was doing it so unevenly I was hurting my good side’s hip. She’s made a big impact on getting me moving.’

‘…I just came home from the gym, did really well I was powering around the track, listening to music, just … moving. And that kind of feels like a medical miracle. I was in such horrible shape for so long, and it just feels so good. And painful of course, but that’s just a given.’ 

‘I’m doing better now than I have in so many years … I’ve never in my life been able to have sustained progress like this.  I’m still disabled, and there are so many things I still can’t do, but that’s not really what I’m concerned with right now. I’m just happy to see where I am now.’ 

‘Sativex has been really important in my life over the past two years, but I just don’t want it to come off like it’s a … well, miracle. It isn’t. It’s made a massive impact on my life, but I’d say that my massive improvement over the past year is only a third down to the spray.’

Paula added, ‘None of anything would have been possible without hydromorphone IR, nor the rest of my medications. Nothing would be possible without my pain specialist at the pain clinic. It really has been a team effort, and that’s not even counting my other physicians, or the essential support network I have. My parents support me 100%, and that’s both emotional and financial. My mother, in particular, is my caregiver and is a huge part of my life. I’m very lucky to have friends who understand and care too. My best friend’s support over the years has meant so much to me too.’ 

‘Now none of those other things helps in the same ways Sativex does. Without it, I wouldn’t be able to move forward and make sustained progress for what is literally the first time in my life since hurting my leg. I’d never managed to go forward at all, ever; plateauing was all I could hope for. But I still feel like all of those other things are coming together to really help me in way that Sativex alone couldn’t. In fact, what’s really amazing is that I’m actually not using as much Sativex as I used to. Everything’s coming together much better than I ever could have expected. My leg is actually dealing with things better, not needing the same amount of as-needed medications. For the first time too, I’m actually finding other non-medicinal things like heat packs are actually helping. Before, it was just way worse when I didn’t have them, but it didn’t lower the pain exactly. So you can say it is kind of a holistic thing – but one that needed Sativex to open the door to it, if that makes sense…’

Having said all of the above, Paula emphasized:

‘[I am] actually never without pain … Sativex helps to stop the vicious circle of escalating pain cycles in 5 minutes.’

‘…I’m still in rough shape. But when that rough shape is so much better than the rougher shape I was in [before Sativex]…

‘[CRPS] is still incredibly disabling. But when you start so low, every few inches up makes a big difference.

Paula’s positive experience with Sativex may offer hope and inspiration to other pain patients to also add Sativex into their overall pain management therapy.

Thank you, Paula, for sharing your beautiful story with us! Despite living with constant, severe pain, your strength and inner beauty never cease to amaze me! People like you are the inspiration and main driving force behind this blog.

With positive thoughts coming your way from everywhere and everyone,

Sabina Walker

Blogger, Pain Matters

Conversations Between Colin Froy, A British Foot Nerve Pain Patient (1952-2013), His Pain Team And The Pain Researchers

Featured Image taken from The Pain Detective (Video), courtesy of Mosaic

Dear Pain Matters readers,

So what is it really like to have nerve pain??  The best way to find out is to actually talk to a patient who suffers from nerve pain.  And that is exactly what the excellent video called ‘The Pain Detective‘ (by Barry Gibb, film maker) did.

Colin Froy, one of the millions of nerve pain sufferers in the world and a policeman who retired in 2011, was diagnosed with myeloma type cancer in the blood (light chain deposition) in 2004.  He received chemotherapy for 6 months including thalidomide drug treatment.  Unfortunately, the latter led to ‘tingling toes syndrome’.

The term ‘tingling toes’ does not do justice to the severity of Colin’s nerve pain.  This term drastically understated the intensity of Colin’s thalidomide-induced nerve pain in his toes from 2004 until his passing in 2013.  In Colin’s words:

‘… the side-effects of thalidomide, they call it tingly toes. Because tingly toes, you think, you know, you get sort of tingle and it goes away, but it’s not like that [laughs], it’s painful toes. I mean, the nerve endings are all shot to pieces, like a dead tree. It gets worse and worse, and you just can’t walk as far as you used to. Now, if I’m lying in bed sometimes, I get this sensation as if someone’s just pushing a needle through the toes, and it lasts for four or five seconds and then it’s gone…’

(Above quoted from ‘The Pain Detective Transcript’:

https://mosaicscience.com/extra/pain-detective-transcript )

The video added that the economic cost of pain in the USA alone is around USD635 billion per year, more than the costs of cancer and cardiovascular disease combined.  In fact, pain is the Number One Reason why people see their GP.

Without further ado, I urge readers to simply watch the 30-minute video (and also read the narrative) that presents many interesting, lively and heart-warming conversations between Colin Froy (1952 – 2013), his caring pain management team and a talented pool of pain researchers who are passionate about their goal to ease nerve pain and suffering (see video link and references, below).

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Images taken from The Pain Detective (Video), courtesy of Mosaic

Despite his unrelenting severe nerve pain, Colin had a positive outlook on life, where ‘his glass was always half full’ instead of ‘half empty’.  Although his nerve pain was enduring until his final days in 2013, his sense of humour and warm smile will always be endearing.

May his message, and that of others with chronic pain, reach our collective heart and soul so that all this pain and suffering is not in vain.

Sabina Walker

Pain Matters Blogger

VIDEO LINK AND REFERENCES

(1) Gibb, Barry J. The Pain Detective (Video) – On The Hunt For New Ways To Treat Pain. Mosaic – The Science of Life (24 June 2014).

https://mosaicscience.com/story/pain-detective

(2) Gibb, Barry J. The Pain Detective Transcript. Mosaic – The Science of Life (24 June 2014).

https://mosaicscience.com/extra/pain-detective-transcript

(3) Gibb, Barry J. Making The Pain Detective. Mosaic – The Science of Life (24 June 2014).

https://mosaicscience.com/extra/making-pain-detective

Patching up Pain with a Lidocaine 5% Patch

Dear Pain Matters readers,

Treatment via a lidocaine 5% patch may offer significant pain relief for patients including cancer patients with focal nerve pain.

Specifically, patients with severe and localised nerve pain including one of the following painful conditions may benefit from a lidocaine 5% patch that topically delivers lidocaine:

  • Postherpetic neuralgia and herpes zoster (shingles);
  • Non-diabetic and diabetic peripheral neuropathy;
  • Trigeminal (orofacial) neuropathic pain;
  • Erythromelalgia;
  • Chronic low back pain (Hines et al, 2002);
  • Post-surgical neuropathic pain (e.g. following surgery for cancer or otherwise); and
  • Neuropathic pain directly attributable to cancer.

Lidocaine works by blocking sodium channels including Nav1.7 that underlie many nerve pain conditions (and other mechanisms).  The release of very small amounts of lidocaine transdermally via the patch ensures that motor and cardiac functions remain unaffected.

While topical lidocaine patches leads to pain relief in 29%-80% of treated patients, likely via small-fiber block, it is not clear why lidocaine patches may work better in some patients than in others (Krumova et al, 2012).

The topical lidocaine patch, measuring 10 cm X 14 cm, should only be applied on top of unbroken skin and where the pain is the greatest.  Patches should only be used by patients who are not allergic to local anaesthetics including lidocaine and who are not sensitive to the adhesive material itself.

The recommended maximum daily dose is 3 patches worn simultaneously for 12 hours at a time.  Since the lidocaine patch can only be worn for 12 hours at a time each day, other pain medications may be necessary, especially during sleep.

Lidocaine 5% Patch Treatment for Severe Chronic Pain – Successful Cases

Four Patients with Severe Low Back Pain

Four (4) patients aged 30 to 64 had successful lidocaine 5% patch treatment for severe low back pain as well as leg pain, foot pain (including CRPS, left foot) and/or neck pain.  Their pain included burning and stabbing nerve pain.  Specifically:

(1) A 53-year old woman had severe low back pain since a motor vehicle accident in July 2000.  She also endured right leg pain and some right foot numbness.  The patient said that the lidocaine 5% patch treatment ‘helped about 80%’.

(2) A 30-year old woman suffered low back pain, neck pain and right leg pain including burning and stabbing nerve pain.  She had a lifting and twisting injury in 1996.  The patient stated that her pain had dropped from ‘8’ to ‘5’ thanks to lidocaine 5% patch treatment.

(3) A 64-year old man suffered low back pain after a lifting injury in 1987.  He also suffered CRPS in his left lower leg and foot.  Lidocaine 5% patch treatment offered effective pain relief for his CRPS, left foot, and his painful lower back.  Furthermore, he was able to stop all other pain medication.

(4) A 50-year old woman suffered low back pain and right leg pain including aching and burning pain for 22 years.  Lidocaine 5% patch treatment offered effective pain relief.

There were no adverse effects resulting from lidocaine 5% patch treatment (Hines et al, 2002).   

A Young Patient With Episodic Erythromelalgia In Both Feet

A 15-year old Caucasian girl who suffered disabling pain during episodes of erythromelalgia in both feet derived complete pain relief almost immediately after applying lidocaine 5% patches to the top of both of her feet, both at rest and during almost normal levels of activity.  

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Post-lidocaine patch treatment, the young patient was able to run around the track at school, play soccer, return to her physical education class, march in the school band and walk around the shopping mall for almost an hour.  As long as she did not overdo her activities, she was able to obtain 100% relief during the 12 hours of lidocaine patch use, plus another 2-3 hours after patch removal.  The patient slept without the patches.

Whilst offering complete local pain relief and no side effects, the lidocaine patch was unable to prevent the other symptoms of erythromelalgia from occurring including bright red skin and over-heated feet following physical exertion.

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(Davis & Sandroni, 2002, including both images).

Two (2) Patients With Nerve Pain       

1st Patient – A 74-Year Old Female Patient With Herpes Zoster (Shingles)

Despite prompt treatment for a herpes zoster skin rash, a 74-year old woman developed stabbing and burning pain in her rash-affected area.  The patient was offered 2 lidocaine patches daily to cover the painful region.  Within 4 weeks treatment, the patient obtained 75% relief from pain caused by her herpes zoster skin rash.  Most of her systemic pain medications were stopped.

2nd Patient – A 56-Year Old Man With Severe Neuropathic Pain Syndrome Following Microsurgery For A Neuroma in Right Foot 

A 56-year old man suffered severe nerve pain shortly after microsurgery to his right foot due to an interdigital neuroma.  His painful symptoms included severe burning pain, mechanical hyperalgesia and allodynia, together with other symptoms.  As a result, he could no longer work, was unable to wear socks and shoes (only sandals) and withdrew from his family and friends.

After applying half of a lidocaine 5% patch daily onto his painful skin region, the patient reported positive results.  After 8 weeks of lidocaine patch treatment, the patient enjoyed an 80% reduction in overall pain levels and consequently returned to work.  There were no side effects and the patients was able to stop all other analgesics (Hans et al, 2010).

Trigeminal (Orofacial) Neuropathic Pain And Lidocaine Patch Treatment

A British study revealed that lidocaine 5% patch treatment led to improved pain levels in 12 of 14 trigeminal pain patients including oral surgery patients.  Nine (9) of the 12 patients were able to reduce or stop their intake of other pain medications.  Given that the majority (12/14) patients with trigeminal nerve pain benefited from lidocaine 5% patch treatment, further studies are warranted (Khawaja et al, 2013).

Cancer Patients And Lidocaine Patch Treatment

A large Australian study in a comprehensive cancer centre revealed that lidocaine 5% patch treatment had a ‘potent analgesic effect’ in 24 of 95 (25%) patients while another 23 patients (24%) reported a ‘partial effect’.  Given that almost half (47/95, or 49%) of all cancer patients with nerve pain benefited from lidocaine 5% patch treatment, further research is warranted (Fleming and O’Connor, 2009).

Current Study Involving Lidocaine Patch for Lower Limb Amputation Pain

A Belgium-based trial is currently recruiting up to 20 patients with pain following above- or below-knee amputation to assess the effectiveness of lidocaine patch treatment for peripherally-mediated phantom limb pain and/or stump scar hyperalgesia (Hatem, 2016).  Stay tuned for updates…

Summary

While lidocaine 5% patch treatment is expensive and there is a small risk of a skin rash, many patients with focal nerve pain obtain significant pain relief from the lidocaine 5% patch, a targeted peripheral analgesic that is non-addictive and safe for long-term use.  

Now that’s a good way to patch up pain!

Sabina Walker

Blogger, Pain Matters

REFERENCES

(1) Davis, Mark D P; Sandroni, Paola. Lidocaine Patch for Pain of Erythromelalgia; Arch Dermatol. Jan 2002;138(1):17-19

doi:10.1001/archderm.138.1.17

http://jamanetwork.com/journals/jamadermatology/fullarticle/478622

(2) Fleming JA, O’Connor BD.

Use of lidocaine patches for neuropathic pain in a comprehensive cancer centre.

(Utilisation des timbres de lidocaïne pour la douleur neuropathique dans un centre d’oncologie)

Pain Research & Management : The Journal of the Canadian Pain Society. 2009;14(5):381-388

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779156/#!po=28.7879

(3) Hans G, Robert D, Verhulst J, Vercauteren M. Lidocaine 5% patch for localized neuropathic pain: progress for the patient, a new approach for the physician. Clinical pharmacology : advances and applications. 2010;2:65-70

doi: 10.2147/CPAA.S9795

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3262358/

(4) Hines R, Keaney D, Moskowitz MH, Prakken S. Use of Lidocaine Patch 5% for Chronic Low Back Pain: A Report of Four Cases. Pain Med 2002; 3 (4): 361-365

doi: 10.1046/j.1526-4637.2002.02051.x

https://academic.oup.com/painmedicine/article-lookup/doi/10.1046/j.1526-4637.2002.02051.x

(5) Khawaja N, Yilmaz Z, Renton T. Case studies illustrating the management of trigeminal neuropathic pain using topical 5% lidocaine plasters. British Journal of Pain. 2013;7(2):107-113.

doi:10.1177/2049463713483459

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590123/#!po=23.6842

(6) Hatem, Samar; A Trial of Lidocaine Patch for Lower Limb Amputation Pain (Trial ongoing since 2016); Brugmann University Hospital

https://clinicaltrials.gov/ct2/show/study/NCT02696720?view=results

(7) Krumova EK1, Zeller M, Westermann A, Maier C. Lidocaine patch (5%) produces a selective, but incomplete block of Aδ and C fibers. Pain. 2012 Feb;153(2):273-80.

doi: 10.1016/j.pain.2011.08.020.

https://www.ncbi.nlm.nih.gov/pubmed/21995882

(8) Devers A, Galer BS. Topical lidocaine patch relieves a variety of neuropathic pain conditions: an open-label study. Clin J Pain. 2000 Sep;16(3):205-8.

https://www.ncbi.nlm.nih.gov/pubmed/11014393

(9) Many Other Lidocaine Patch/Pain Studies Can Be Found Here:

http://www.druglib.com/druginfo/lidoderm/abstracts/