Physical Therapy
Part -II

H. Hooshmand, M.D.
Neurological Associate Pain Management Center
1255 37th Street, Suite B
Vero Beach, FL 32960

The best physical therapy for the patient is alternating resting and activity without exhausting themselves. The patient should be taught that in CRPS/RSD, no pain is all gain. This is just a sharp contrast to the somatic pain where no pain is no gain. The patient should learn to listen to their body, and the moment they start having pain because of prolonged sitting or standing, or prolonged bed rest, or prolonged activity, the patient should change position and stop the activity that is generating the pain.

The general rule of thumb is sitting for 15-20 minutes, standing for 10-15 minutes, walking for 10-15 minutes, and lying down at least every few hours.

The patient should understand that resting for long hours is going to be as much if not more harmful than doing too much activity.

If the patient wakes up in the middle of the night because of pain or discomfort, he or she should not just lay in bed. The patient should get out of bed and walk around. The patient will be surprised how soon the pain improves by walking after long periods of rest.

Anytime the patient is doing physical therapy or hydrotherapy, all the activities should be on both sides. The patient should not apply the treatment only on the side of the body that is painful. The main reason being that the nerves for temperature control of the body start from the central nervous system and go all the way down to the spinal cord. So, if the patient has a lateralized pain, spasm, or limitation of motion, the exercises should be done on both sides, otherwise there would be a temperature asymmetry causing improvement to temperature on one side at the expense of the other side becoming colder. This type of bilateral exercise also prevents spread of CRPS.

Physical Therapy For The Upper Extremity

The patient should use all different kinds of devices such as a tennis ball, rubber ball, silly putty, playdoh, springs, stress ball, a warm paraffin bar in the sink for the patient to tear the bar up into little pieces, and soaking the hands up to the forearms in the sink containing Epsom salt and warm water.

One of the biggest risk in CRPS is frozen should, also known as shoulder hand syndrome (The International Association for the Study of Pain- IASP- defines shoulder-hand syndrome as a manifestation of sympathetic nervous system dysfunction).

What is important for prevention of any frozen shoulder is to instruct the patient to make big circles with their arm and shoulder without flexing the wrist or elbow, and the circle should be a large circle with the patient starting with the hand pointed to the floor, and the reaching as far as he or she can to the ceiling and to complete the circle. This exercise should be done at least 15-20 times, 2-3 times a day ideally.

The physical therapist should apply hydrotherapy as well as active and passive motions of the extremities bilaterally.

On CRPS patients, the treating team should realize that there is a big difference between Functional Capacity Evaluation (FCE) and physiotherapy for the treatment of CRPS. FCE is a requirement for occupational therapy after the patient has reached maximum medical improvement. This is only a requirement for employment, and it is too traumatic for a CRPS patient in the process of recovery.

Hydrotherapy

Hydrotherapy is quite effective, especially because of the fact that immersing the body in the swimming pool reduces the effective weight of the patient by 50%. Obviously, suddenly changing the weight from 140 pounds to 70 pounds, helps with mobilization and reduction of pain.

If the patient is intolerant of weight bearing, he or she should be instructed to stand and walk on towels at the bottom of the swimming pool at the shallow part of the pool. Exercise in the pool is one of the best forms of treatment. What is important is the temperature of the water. Ideally, the temperature of the water should be over 90º F. Hydrotherapy in a Jacuzzi is very effective, but the patient should drink a lot of fruit juices before and during treatment in the Jacuzzi.

Hyperosmolar Therapy

Hyperosmolar therapy refers to the fact that some chemicals such as magnesium sulfate (Epsom salt) reduce the neuroinflammation, swelling, as well as flexor spasm of the small joints. This is achieved by the patient taking an Epsom salt bath in the bathtub or taking Milk of Magnesia, no more than 1-2 ounces a day. The magnesium being a calcium channel blocker as well as a very strong osmotic chemical extracts the calcium and facilitates the inflow of calcium through the skin. This form of treatment is very effective to counteract the neuroinflammatory edema of CRPS, as well as relieving the pain.