Neurological Associates

Pain Management Center

Vero Beach, Florida

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

 

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RSD PUZZLE #90
RSD AND TREATMENT OF TROPHIC ULCERS

To Whom It May Concern:

At the request of the patients, I am writing a protocol of treatment. The patient has developed trophic ulcers over their extremities. RSD has been diagnosed by the patient's physicians.

Trophic ulcers are not unusual in RSD, being a sympathetic nervous system dysfunction, manifests itself as follows:

1. Hyperpathic and allodynic pain ( pain accompanied by change in vital signs, sweating and pain that becomes worse with simple touch or a breeze).

2. The response to the pain is in the form of motor response the spinal cord resulting in constriction of blood vessels, cold extremities, muscle spasm, tremor and flexion deformity.

3. Disturbance of the immune system. The sympathetic system regulates the immune system. The sympathetic system is responsible for control of body temperature, control of vital signs and control of the immune system. Any kind of stress that stimulates the sympathetic system, also stimulates the immune system.

This disturbance of the immune system manifests in inflammation, spontaneous bruising and black and blue spots over the skin, neurodermatitis, edema and swelling that mimics conditions such as carpal tunnel and tarsal tunnel syndrome. In addition, the immune system disturbance in more severe cases not only cause neurodermatitis, but also cause trophic ulcers. Trophic ulcers usually develop after treatment with cast immobilization, wheelchair immobilization, surgical treatment or application of ice. At, times, the trophic ulcer and immune system disturbance are caused by incomplete pain management.

Once trophic ulcers develop, the following should be the protocol of treatment:

1. Treatment with IV Mannitol 100 grams in 1000 cc D5W.

2. Treatment with Decadron Dose-Pack for one week.

3. After one week, the Decadron Dose Pack should be replaced with IM ACTH, which does not cause suppression of adrenal cortical function and instead stimulates the adrenal gland to secrete it's own cortical steroids. The ACTH should be given 40 units IM twice a week, along with the patient taking some form of antacid, such as Zantac or Cimetidine on a daily basis ACTH will be continued in 12-20 weeks.

4. Epsom salt and warm water bath. The magnesium sulfate works as an hyperostotic agent. It reduces swelling and inflammation. In addition, magnesium sulfate increases the level of serum magnesium and acts as a calcium channel blocker, helping the healing of the cells in correcting the inflammation.

5. Most importantly, the pain should become under control. In the regard, addicting narcotics are contraindicated. they can cause withdrawal (rebound) pain, which is a s harmful as the original pain cause by the disease.

I am enclosing a list of controlled and non-controlled drugs. As is noted, Class V, which is totally not controlled, non-addicting and contains medications such as aspirin, Tylenol, etc., and also includes Buprenex. Buprenex has been used for years to help in detoxification of Heroine, Methadone, Morphine, and Cocaine addicts. Buprenex has no tendency for drug dependence and no tendency for withdrawal pain or tolerance.

Whereas the neuropathic pain usually does not respond properly to treatment with endorphins, it responds quite nicely to treatment with Buprenex, which is a morphine antagonist.

If the patient cannot take Buprenex, then Stadol NS or Nubain would be the other, less preferred, morphine antagonist.

6. Even more important than analgesics for control of pain, is the use of analgesic type anti-depressants. Ideally, Desipramine 25 mg bid and 50 mg qhs can be used. Anafranil and Tofranil should not be used because they cause obesity, fatigue and drop of blood pressure and pulse.

Another very effective analgesic/ antidepressant is Trazodone at the dosage of 50 to 300 mg daily, which does have the above mentioned side effects of tricyclic anti-depressants. The dose should start at 50 mg at bedtime and every night an extra 50 mg should be added, until the pain is so well under control that the patient can sleep eight hours a night.

7. The area of ulcers should be treated not only with epsom salt and warm water bath, but also with Maalox liquid alternated Zonalon (Sinequan) cream and alternated with corticosporin lotion.

8. None of the above treatments will work unless the patient stays very active and exercises as much as possible. The reason being the lack of exercise causes stimulation of the chemoreceptors in the extremities and it aggravates the pain and inflammation.

9. Any use of ice or surgical procedures should be absolutely avoided.



H. Hooshmand, M.D.

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Copyright 1997-2014 H. Hooshmand, M.D. No part of this publication may be reproduced, transmitted, stored in a retrieval system other than this specific media, transcribed, or translated into any language without the expressed written permission from the author; H. Hooshmand, M.D. and Eric Phillips and CMNE. This material is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician.


Send e-mail to Eric Phillips: utopia33@prodigy.net with questions or comments about this media and content.

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The material on the Neurological Associates Pain Management Center Homepage and all it's associated, linked or reference pages is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician. H. Hooshmand, M.D., Neurological Associates Pain Management Center and Associates will not be held liable for any damage or loss as a result of information provided on this page or associated documentation. Again, this WEB SITE is simply published as an information source and should not be used to treat or make judgments on RSD/CRPS. All associated material on this web site may not be copied, reproduced or quoted without expressed written permission from the owner; Copyright 1999-2014 H. Hooshmand, M.D.

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Web Site designed and maintained by:

Eric M. Phillips; E-mail: utopia33@prodigy.net

This page was last updated on 3/11/2000.
                  
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