Case Studies in Pain Management: Complex Regional Pain Complex Regional Pain Patient history Treatment plan
provided dramatic pain relief. This permit-
The last thing this 55-year-old female real-
ted the patient to tolerate well the occu-
to provide this patient desperately needed
pational therapy of her hand; it took only
carpal tunnel-release surgery was a seri-
respite from the pain but also to end the
three weeks of modalities and exercise to
ous complication. Yet that is precisely what
pain relief roller-coaster upon which she
restore the hand to near-normal function
found herself because of the short-acting
medications being taken. Both objectives
Discussion
reddened, almost completely dysfunctional
patient’s medications to provide continu-
This patient was fortunate in that her RSD
The referring physician prescribed short-
ous, 24-hour pain relief. Further, in so doing,
If intervention is started within the first
lets. He also wrapped her hand in a cast in
enough to tolerate occupational hand ther-
chances of achieving a complete cure are
an ill-advised attempt to force extension of
apy – something she required in order to
the fingers, which had locked into a balled-
restore function to the involved appendage.
being able to cure RSD drop to near zero.
Accordingly, we switched the patient’s
principal medication to a once-a-day, 120-
Case description
patient at that stage is to provide pain man-
agement. In truth, it is rare for RSD to be
signs of improvement, the patient’s ortho-
instructed the patient to only use those for
pedic surgeon referred her to us for help
believed the patient would benefit from tak-
given enough time and pain-relief medica-
The patient’s history and results of physi-
ing duloxetine, a very effective combination
tion, the problem will resolve on its own.
cal examination led us to suspect a form
mood stabilizer and nerve pain medication,
We issued our no-casting order to the hand
and so we prescribed that for her as well.
specialist for the reason that molding a shell
as reflex sympathetic dystrophy – RSD for
Then, three days after beginning the new
short. To begin the process of confirming
medication regimen, the patient was started
of the worst possible actions that can be
this suspicion, we ordered a triple-phase
on a therapeutic stellate ganglion blockade
taken: Immobilization causes sympathetic
of 0.25% bupivicaine (dosage 10 cc), after
nerve outflow to increase, causing exacer-
positive for RSD. However, a positive triple-
which we sent her to see a hand-specialized
phase bone scan by itself is not conclusive.
occupational therapist to help desensitize
To validate it, we then diagnostically admin-
the involved hand. Strict orders were given
istered stellate ganglion blockade injec-
to the hand specialist to not use casting.
tions. The patient reported substantial pain
relief in her hand immediately afterward.
Taken together, these results all pointed
with the morphine sulfate and duloxetine
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American Society for Clinical Pharmacology and Therapeutics RIMONABANT PHARMACOKINETICS IN HEALTHY ANDCYP3A5 BUT NOT CYP2D6 POLYMORPHISM AFFECTSOBESE SUBJECTS. S. Turpault, V. Kanamaluru, G. F. Lockwood,DEXTROPROPOXYPHENE DISPOSITION IN HUMAN SUB-D. Bonnet, J. Newton, sanofi-aventis, Malvern, PA. JECTS. M. S. Chow, PharmD, O. Q. Yin, PhD, B. Tomlinson, MD, BACKGROUND: Rimonabant is the fi
Case Studies in Pain Management: Complex Regional Pain