H. Hooshmand, M.D.
Neurological Associate Pain
1255 37th Street,
Vero Beach, FL 32960
"There have been references in the
literature that physical therapy can aggravate pain and CRPS. Yet in every
outline of treatment for CRPS, the use of physical therapy is emphasized. These
two statements seem to be contradictory."
Both statements are absolutely true.
Excessive exercise and physical therapy that causes fatigue, pain, and distress
to any part of the body, only flares-up and aggravates the inflammation and pain
of CRPS. On the other hand, the commonest aggravators of CRPS are bed rest,
inactivity, application of ice, and the use of assistive devices. In CRPS, the
best treatment is eustress not distress.
Distress refers to the stress of
prolonged bed rest and inactivity on one extreme, and stress of overdoing
exercise on the other. Like any other machine, prolonged idling of the body is
distressful and causes damage to the body. Especially in CRPS, the prolonged bed
rest results in aggravation of pain and insomnia. The CRPS patients suffer from
severe chronic insomnia due to the constant allodynic pain as well as due to the
constriction of blood vessels secondary to inactivity. One of the earliest signs
of CRPS is a restless night with the patient constantly being fidgety and
changing position all night as well as having to get up and walk to get some
relief. The second form of distress is too much exercise, prolonged physical
The CRPS victim has to learn that they
will have pain with too much exercise, and with too much inactivity. The patient
will have to find a happy medium. The patient will have to rest and move around
alternatively and frequently. Monotherapy applied three days a week in a
Physical Therapy Department is not enough, the patient should follow the
instructions of the physical therapist and should carry on self-applied physical
therapy (proprioceptive therapy), from morning to night with equal periods of
rest and exercise.
Depending on the sub-specialist
physician, the treatment may be limited to only pain medications by one
specialist, only antidepressants by another specialist, or only nerve blocks by
a third specialist. The treatment should be attacking the disease in a
multidisciplinary fashion from all angles addressing all the four pathogenic
factors aggravating the pain:
1. For prevention allodynic pain, the
patient should receive Trazodone. Amitriptyline (Elavil) should be avoided
because it has a tendency to aggravate obesity, fatigue, low blood pressure and,
in rare cases cardiac irregularities.
2. For the problem of cold extremity,
(vasoconstriction), and movement disorder, ice should never be applied.
The patient should be treated with warm water and Epsom salt bath. The Epsom
salt is a hyperosmolar salt, and relieves the inflammation by acting as a
calcium channel blocker. Ice should never be used on any CRPS patient because
the use of ice aggravates vasoconstriction in the chronic CRPS. It causes
further hypothermia of the skin, and accelerates further deterioration. It
expands the mechanoreceptors zone of recruitment and hypersensitivity causing
intolerance to touch (allodynia) over the area surrounding the lesion (Torebjork
Principle). The so-called "ice and heat challenge" with alternate application of
ice and heat is of no use. There is no therapeutic value for the alternate use
of the two extremes of temperatures (hot or cold). The stress of the alternate
treatment only aggravates the disease further.
The use of ice or Capsaicin has been
shown to cause inflammation and death of the nerve fibers, especially the larger
myelinated nerve fibers. Then the unmyelinated nerves are left uninhibited and
unopposed with acceleration of CRPS pain (large myelinated fibers stop
conducting at 20c, but unmyelinated fibers keep conducting down to zero
3. To counteract the hypothermia in the
extremity due to the abnormal function of the sympathetic system, it is
essential to encourage the patient to get rid of assistive devices (wheelchair,
walker, cane, and crutches). The patient should be instructed to follow the
golden rule of perpetual motion. In CRPS the condition gets worse with prolonged
inactivity or the stress of too much activity.
4. The patient should be instructed to
learn from the human heart. The human heart beats for 90 years without one or
even two minutes of resting. A heart that beats 60 per minute, and on each
second the heart muscle contracts for half a second and rest for another half a
second. So of the 90 years heart span the heart works 45 years and rest for 45
The same principle should apply for
physical therapy. The patient should be instructed not to do any extensive
resting or exercise for a long span of time, but to constantly keep changing
position and alternating exercise with rest. If sitting up causes pain, then
walk. If walking causes pain, then lie down. If lying down causes pain, then go
back to the other forms of exercise, etc.
Inactivity gives the signal to the
sympathetic system to preserve the circulation in the inactive extremity by
vasoconstriction, which aggravates the CRPS.
In 1995, Doctor Koltzenburg had shown
that inactivity and immobilization of the extremity, such as the use of cast, a
brace, a wheelchair, etc., stimulates the so-called "sleeping nociceptors." Such
small c-fibers nociceptors are usually dormant but with inflammation or
increased muscle and deep tissue circulation, secondary to CRPS, they become
activated and aggravate the pain. These "sleeping nociceptors" are mainly
chemoreceptors c-fibers and comprise about 25% of all the chemoreceptors
c-fibers in subcutaneous and deep structures of the extremity. They become
hyperactive, and cause severe, intolerable deep pain if the patient is not
alternating rest and exercise. If the patient wakes up with severe pain, he or
she should get up and walk around.
MEDICAL NECESSITY OF MASSAGE
THERAPY AFTER NERVE BLOCKS
Nerve blocks are aimed at relieving
pain at the site of nerve irritation. Injection of local anesthetics combined
with anti-inflammatories relieves the pain at the site. The nerve blocks also
release the irritative chemicals such as Nitric Oxide, Substance P, etc., from
the areas of nerve irritation.
Massage therapy enhances the
transmission of these chemicals through the extracellular space, to the blood
system, and their excretion through the kidneys. Massage therapy is essential
for success of nerve blocks.