Sympathetic blocks for complex regional pain syndrome

Based largely on his clinical experience, the founding father of modern pain medicine, John J. Bonica, recommended that complex regional pain syndrome (CRPS) be treated with a series of sympathetic blocks as soon as possible after symptoms develop. Although this sometimes seems to work well, the value of this approach has been questioned because of the failure in randomised double-blind placebo-controlled trials to verify consistent treatment benefits. There could be good reasons for this – for example, some of the placebo-controlled trials had small samples, possibly too small to identify positive responses in a subgroup of responsive patients; sympathetic blocks might alleviate only part of the problem in CRPS; or placebo procedures might produce powerful treatment effects, at least temporarily, that conceal benefits of sympathetic blockade. Alternatively, sympathetic blocks might simply be ineffective.

Some of these issues were addressed recently in a study by de Oliveira Rocha and colleagues (2014). They selected participants with CRPS type I whose pain had failed to respond adequately to standard rehabilitation or drug treatments. The participants received a single thoracic sympathetic block (injection of 10 mL local anaesthetic and corticosteroid solution into the thoracic sympathetic chain) or a control procedure (injection of the same drugs under the skin in the thoracic region of the back). The participants were then treated with physiotherapy and analgesic medication over the next 12 months.

Remarkably, benefits of sympathetic blockade on pain and depressed mood were detected not only at one month but also 12 months later. In particular, scores on the McGill Pain Inventory were lower in the sympathetic block than control group at both time points, and at 12 months depression scores on the Hospital Anxiety and Depression Scale were 9% lower in the sympathetic block group than in controls. Average pain intensity was similar in both groups at one month, but was significantly lower at 12 months in patients who had received the sympathetic block than in controls. Effect sizes might have been inflated by small group sizes (19 in the control group and 17 who received sympathetic blockade). Nevertheless, the consistency of effects across multiple measures and time points suggests that the intervention was effective. Why the sympathetic block worked so well is a mystery, but perhaps an anti-inflammatory effect of local anaesthetic agents and corticosteroids around the sympathetic chain or dorsal root ganglia inhibited pain enough for participants to benefit from analgesic medications and to engage more fully in physiotherapy.

Animal studies provide convincing evidence that the sympathetic nervous system is involved in certain forms of chronic pain. De Oliveira Rocha’s findings strengthen the case that the sympathetic nervous system contributes to CRPS type I in humans. Obviously more research is needed to identify the optimal treatment parameters (e.g., the number of sympathetic blocks; the best time to administer them; the volume and contents of the injected solution; who is likely to benefit most from sympathetic blockade; components of post-block rehabilitation). However, De Oliveira Rocha’s findings already offer some hope for people having to deal with a remorseless, intractable condition.

About Peter Drummond

Peter DrummondProfessor Peter Drummond is a clinical psychologist and Professor of Psychology at Murdoch University, where he has worked since 1987. He has worked closely for many years with neurologists and pain specialists to investigate headache mechanisms and the physiological basis of complex regional pain syndrome. The focus of his more recent studies has been to clarify mechanisms of interaction between the sensory and sympathetic nervous system both in normal circumstances and after tissue injury and inflammation.

Reference

de Oliveira Rocha R, Teixeira MJ, Yeng LT, Cantara MG, Faria VG, Liggieri V, Loduca A, Müller BM, Souza AC, & de Andrade DC (2014). Thoracic sympathetic block for the treatment of complex regional pain syndrome type I: a double-blind randomized controlled study. Pain, 155 (11), 2274-81 PMID: 25149143

Comments

  1. Thanks all for your comments on this post. Lisa requested that her comments be removed which we have done.

  2. James Jarman says:

    Sympathetic blocks do not use narcotics. They are a way of avoiding narcotics, which carry all the problems you mention.

    Multiple sympathetic blocks does seem crazy. They are currently out of favour but this study may mean they make a comeback. If used, most doctors in australia would use at most 5 blocks, usually 1 or 2.

    EG Reply:

    “I believe we know enough, and we need to put what we know into action”

    Right on. 100% with you on that.

    Money needs to be spent on training and skill development… only this time, training the right skills. Skills that actually help the client.

  3. When we or patients have a sympathetic block it is a very invasive procedure with an injection to try to block the nerve in the lumbar area. First of all, if a patient is given too may blocks in a short amount of time this can affect their adrenal system and in rare instances patients can end up with Arachnoiditis. There are more studies in different countries that are showing that Sympathetic Blocks should not be a routine treatment for Chronic Pain or CRPS.

    I personally went through 13 lumbar sympathetic blocks in a very short amount of time and it did cause my adrenals to shut down. This is more common than most patients know. I have spoken to a few CRPS/RSD patient that were put through upwards of 100+ sympathetic blocks because the doctors didn’t know what else to offer them.

    If you are not getting relief from a procedure then do not do it. Do your research, speak to your doctors and don’t be afraid to do your own research. Think outside of the box, but remember to communicate with your physician(s).

    When I was at the peak of dealing with my CRPS I left the US to be treated in Germany. There we had a completely different approach. We looked at boosting the immune system and treated it more like an autoimmune disease.

    We utilized ozone therapy, IPT (utilizing small amounts of pain medications), PK protocol, Myers Cocktail IVs, Thymus Therapy, Stem Cells (Autologous – using my own blood to pull stem cells from and then they were grown in a lab for approximately a week until I had over 1 million of my own stem cells.), Regional Hyperthermia (this actually shrunk the area of the pain and decreased the pain over time), and several other protocols. This set of therapies over several trips to Germany did help me but over the long run it did not hold.

    I was finally referred to someone that was working with hypnosis, the neuroplasticity of the brain, biofeedback, light/sound therapy, cell memory and some other modalities. The reasoning behind this treatment made sense. When we are dealing with chronic pain, CRPS/RSD or neuropathic pain – the area in our body that is affected is receiving an erroneous signal from our nerves. Where is this signal coming from? OUR BRAIN. Yes, this is real pain because it is a signal coming from our brain, more specifically an area of the brain called the “Limbic System”. Therefore, if we can break the chronic pain signal, work with the neuroplasticity of the brain and cell memory then we can correct what is happening in our body.

    Guess what – it worked and it works! That was 2 years ago and after a 1 week intensive I walked away pain free for the first time in 6+ years.

    I am now treating CRPS/RSD patient, Fibromyalgia patients, neuropathic pain, chronic migraines, etc… with this same methodology and seeing amazing results. People from all over the US and Internationally have been able to significantly decrease their pain levels and most have been able to get their pain levels down to a “0” (zero) for the first time since they were diagnosed.

    We currently follow the patients that we see and collect data to ensure the accuracy and viability of the treatment protocol.

    Please feel free to reach out to me should you have any questions on this or questions regarding my journey with CRPS.

    Best Wishes – Traci
    Traci@AdvancedPathways.com

  4. As usual, Professor Peter Drummond’s amazing insight, inspiration, dedication, professionalism, academic leadership, and compassion toward people living with chronic pain including CRPS1 is something we can all be grateful for. With people like him, and many, many others that also share his genuine commitment and passion to help chronic pain patients, unrelieved pain may (hopefully) one day be a thing of the past. Sabina Walker

  5. Rielle says:

    the study does not seem robust enough to me as evidence for the sympathetic block , since the patients additionally received analgesia and physiotherapy for 12 months – How is known which of the 3 treatment approaches created the long lasting effect . It might be depending on how the physiotherapy was carried out – depending on how the therapist was working with settling the sympathetic nervous system and the exercises chosen that are having an integrating autonomic nervous system effect,

    James Jarman Reply:

    Rielle both groups got exactly the same physiotherapy and analgesia. The only difference was a real block compared to a sham block. Therefore any difference is due to the block

  6. Sympathetic blocks for CRPS patients can help a small percentage, but what about those that aren’t helped? Studies talk about 9% and some show even lower percentages.

    When do physicians and hospitals come together to offer this demographic of patient a treatment option that is drug-free, proven and effective?

    I currently treat CRPS type 1 and type 2 patients that are sent to me when all else fails. They are treated with hypnosis/hypnotherapy and a multi-therapeutic approach that includes biofeedback, light/sound therapy, EMDR, etc. This technique breaks the chronic pain loop.

    When the basic treatment options fail then patients need to be given viable treatment options that can help them.

    As a former CRPS patient that went through Lumbar Sympathetic Blocks, PT, medications, SCS and so much more I think I can truly attest to this.

    Thank You,
    Traci

  7. Dr. Drummond, it is impressive that there was a significant reduction in pain intensity at 1 year – what were the reasons for thoracic sympathetic blockade (vs targeting cervical chain) ? Could you elaborate on your mention of targeting dorsal root ganglion as potential reason for reduction in pain and inflammation? Thanks.
    Stu

  8. Just wondering, is 9% improvement enough? Maybe significant numbers wise ,but is it the equivalent of a patient saying, ” yeh,kind of, maybe feels a bit better”

    Annette Merkley Reply:

    A dear family member has been suffering with this disease for about 4 years now. She had two nerve block injections about a year and a half after the diagnosis. Not only did it make her pain worse but the disease has now spread to both her arms and the other leg. I am so angry with the medical profession for not working harder to help people with this disease!

    Traci Patterson Reply:

    Annette,
    There currently are treatment options available for RSD/CRPS. They are not considered “traditional” treatments.

    As a CRPS patient myself, this is what got me into remission and got my life back. I have been pain free and in remission for 2 years now. Please look outside the box for your answers and you will find them.

    I treat CRPS/RSD patients, neuropathic pain, fibromyalgia and other chronic pain patients successfully. It is called, “Hypnosis Combined Therapy”, and it is a combination of hypnosis/hypnotherapy, biofeedback, light/sound therapy, neuroplasticity training, cell memory and more.

    Please take a peak at my website for more information. http://www.AdvancedPathways.com

    There is also something called, Calmare Therapy, available. There are some that have great success with it and others that I have spoken with that have little success. With most CRPS/RSD patients this treatment does require follow-up treatment to stay pain free or in remission.

    I hope this helps.

    My Best,

    Traci Patterson, CH, CI