H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

BOARD CERTIFIED IN ELECTROMYOGRAPHY  

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

RSD PUZZLE #41
THEY HAVE TRIED EVERY KIND OF NERVE BLOCK, NARCOTIC,  ANTIDEPRESSANT WITH NO SUCCESS. WHAT SHOULD BE DONE NOW.

Dear Dr. Hooshmand:

My name is Brenda and I am writing you about my RSD.

The disease started after a right ankle injury to multiple ligaments and nerve injury on March 10, 1994. since then I have had physical therapy, and all sorts of blocks: lumbar sympathetic blocks, epidurals, BIER blocks, Popliteal blocks, epidural Duramorph (single shot), and IV Lidocaine. These blocks last practically 4 hours and then I 'm back where I started.

I have been treated with Tricyclic antidepressants, Hytrin, Mexetill, Neurontin, Motrin, narcotic, etc., with no success.

My RSD has now spread from my right hip and buttock down to the right leg and foot. I have tendency for developing attacks of cellulitis around the areas of epidural shots. My doctor says that my immune system is shot.

Sincerely,

Brenda

Dear Brenda:

Your RSD has been diagnosed relatively early and it has been treated with the best of intentions with multiple blocks. However, by virtue of the fact the blocks last no more than 4 hours, most likely the main substance used has been local anesthetic such as Lidocaine. You need to have other chemicals such as Celestone or Depo-Medrol® add to the lidocaine.

The main problems that you are facing at this stage are the spread of the disease and the strong tendency for inflammation which is part and parcel of RSD.

The following suggestions may help bring the condition under better control:

1. Avoidance of ice during physical therapy.

2. Intermittent exercise of frequent nature, independent of the physical therapy. Learn from your heart. It beats 60 times a minute and never takes a vacation for 90 years. that's because half a second it works and half a second it rests. So, from morning to night, it is resting and exercising. Don't rely on the physical therapist to do the exercise for you.

3. For the problem of the inflammation, treatment with ACTH which is not a corticosteroid but stimulates the formation of endorphins, may be quite helpful to just calm down your inflammatory reaction. This can be done in conservative doses such as 40 units IM 3 times a week to be taken along with one Zantac a day.

4. Frequent Epsom salt and hot water baths help contain the inflammatory reaction.

5. Discontinuation of the addicting narcotics and replacing them with non-addicting pain medication such as Stadol, Nubain, or less addicting medications such as Talacin. It is true that Stadol has been abused by some patients but that is not the same addiction, and the use of the above mentioned Morphine antagonists helps the body build up its own endorphines and endo-BZ's.

6. After the above is done, you will notice the disease subsiding and becoming more focalized to the lower extremities. Then repetitive nerve blocks through the insertion will help a lot. These nerve blocks should have more than just local anesthetic in it.

7. I have noticed one major omission of medication in your treatment of RSD. You have not been on NEWER ANTIDEPRESSANTS. Obviously, the tricyclic antidepressants have not done anything for you. You need to be on medications such as Trazodone 150 to 300 mg at bedtime, or Fluoxetine 20 to 40 mg in the mornings. These antidepressants are analgesic of choice for chronic pain. Unless you take such antidepressants on a long-term basis, your pain will never get better. In RSD instead of no pain, no gain, the formula is no pain all gain.

With best wishes,

H.Hooshmand, M.D.