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CASE DISCUSSION
I would like to ask for your help.
Pat. ca. 67yrs with neuropathic pain stage IV (CRPS, mechanical allodynia, nocturnal pain) 14 wks after Dupuytren surgery (9 wks SSR therapy).
Pain meds he has not tolerated/no effect. Current meds: lyrica, CPD drops, sylnox, neurodol patch high wrist palmar.
Allodynia is decreasing.
But currently stagnant on Rainbow violet for 1Mt.
From the beginning, the patient reported "attacks" of stiffness, burning, very strong itching in the allodynic area 2x in 24h at certain times. Do you know these reactions? What do they mean? At the moment it helps to immobilize the hand in a positioning splint and running water or a hand bath.
We have started with vibration since approx. 1 Mt. taken to it. Could this have something to do with the stagnation? He has also been doing contrast stimulation since a month ago not only on the dermatome but also occasionally on the family of the lateral cord of brachial plexus. Is this correct?
Comments
Hello,
In order to try to answer your question, particularly about the remote vibrotactile counter-stimulation zone, could you please tell us which cutaneous branch is injured?
Feelings of burning and stiffness in a joint are characteristic of a CRPS. (If your patient has a CRPS, it is a Stage V axonal injury Ab. Stage IV is that of incessant neuralgia).
I have often noticed that the itching sensation is felt at the end of treatment of an allodynia, just before the secondary hypoesthesia is revealed... As in your case, with a severity of 15 grams...
Is it possible that the positioning splint is rubbing against the area and that this is responsible for the stagnation of the status you describe?
I'm looking forward to hearing more...
Beautiful day.
Géraldine
(translated by deppl if I ever write weird things... )
Thank you for your answer!
The affected nerve branch is the nervi digitales comunnes et proprii N. medianus & N. ulnae (Dig. IV, palmar).
Now he has one more week of consistent sparing of the allodynic area and removed counter stimulation. I have no longer noticed any allodynia!!!!
So now I will continue with secondary aestesiography as you mentioned.
I have one more question about the medications. What do you recommend to the doctors/patients. In this case, the patient has still CRPS.
Translated with www.DeepL.com/Translator (free version)
Dear Rebekka,
Great for your patient! This is great news!
Regarding your question about medication and although it is highly recommended that the clinician in sensitive rehabilitation have a thorough understanding of the pharmacological treatments prescribed, I must admit that I do not have a good grasp of the subject.
I will therefore plunge into the 4th edition of the book of our method (pages 140 to 143 and page 298) to try to answer your question, summarizing as much as possible. I feel a little uncomfortable quoting only a few elements because everything is important in this chapter and I don't find it correct with regard to the authors as well. I am only addressing my answer to you to give you a draft answer, hoping that other people will give you explanations and nuances as well.
a) "Basic drug treatments
Among the main drugs prescribed for Peripheral Neuropathic Pain Syndrome and CRPS as per official recommendations, the authors selected the following four:
For CRPS; + Calcitonin (Miacalcic)
b) Medical treatments in sensitive rehabilitation.
Have a good treatment with your patient and see you soon....
Géraldine
Translated with www.DeepL.com/Translator (free version)
In a article in the Lancet Neurology (Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis
N. Finnerup, N. Attal, +2 authors M. Wallace
Published 2015)
To my knowledge a lot of doctors use those recommendations.
kind regards
Karin Lüthi