Aware-RSD

Procedures & Tests

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Procedures & Treatments & Tests Performed for
RSD & Other Conditions
 
Note: These treatments are listed for Chronic Pain Conditions Only and not recommended by Aware-RSD (see disclaimer) 

Which Treatment Is Right for You?
Successful pain relief for chronic pain is rarely achieved with a single therapy or after a single treatment. Finding a treatment that works and works well depends as much on your condition and the options that your doctor offers as it does on your willingness to take an active role in your treatment.

Learn all you can about your condition and find a physician specializing in pain management. The Web and your local library are good sources. So is your doctor. Joining a patient support group can lift your spirits and provide you with important information about new therapies, pain specialists in your area and personal treatment successes.

Study the chronic pain treatment continuum. The chronic pain treatment continuum allows you to understand the many steps (treatments) that can be tried in order to achieve pain relief.

Explore current and emerging treatments. The Web is just one of a number of great resources, which also include patient support groups, and professional societies and organizations (like the Arthritis Foundation or the American Pain Foundation). Your health care team doctor, nurses, physician assistants and therapists may have information to share, too.

Enlist the help of friends and family. You do not suffer pain alone. Those who care about you suffer too. So dont be afraid to ask for help in researching and gathering information. Invite a spouse or friend to go with you to your next appointment. Family and friends often welcome the chance to help, especially in such a fundamentally important way. This will also help your family and friends to better understand what you are going through.

Talk to your doctor. Take all that you have learned and make a list of questions to discuss with your doctor. Ask your doctor to explain the pros and cons of treatment options in the context of your condition and according to accepted standards of care. You might also ask what your doctors experience has been in regard to chronic pain management.

The key to getting a right answer is knowing what questions to ask. And asking the right questions is an important step that you can take to find the right treatment for your specific chronic pain condition.

Treatment Continuum

Chronic pain treatment can be prescribed in a continuum or progression of care. This means that it often begins with simple and less expensive therapies such as bed rest, oral pain medications and physical therapy and continues along a progression of therapies such as opioids, nerve blocks, or surgery until sufficient pain relief is attained.

The treatment continuum ensures that your chronic pain is treated systematically and represents a multitude of available treatments. It is important to know that it is a generalized treatment strategy only, and that it can vary in order and magnitude depending on your individualized condition, your response to previous treatments and the recommendation of your pain physician.

First-Tier Pain Therapies
The first tier of therapies in the treatment continuum begins with conservative treatment and progresses to more aggressive approaches to relieving chronic pain.

Exercise Programs. The initial treatment for chronic pain may be light exercise such as walking. Exercise stimulates the release of the bodys natural pain relievers called endorphins. Exercise also promotes flexibility, strength, endurance and helps reduce stress. It also can strengthen unused or weak muscles to help take over the work of a muscle that is overworked and causing pain.

Over-the-Counter Pain Medications. Another early treatment for pain is an over-the-counter analgesic (aspirin or acetaminophen) or anti-inflammatory agent (ibuprofen), combined with bed rest.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs). When over-the-counter medications do not provide adequate relief, your doctor may prescribe an NSAID. NSAIDs may provide pain relief within the first 24 to 48 hours of treatment, but it may take up to three weeks to get full benefit from these drugs, which includes relief from pain, swelling and inflammation.

Rehabilitative Therapy. Rehabilitative therapy encompasses a variety of techniques physical therapy, occupational therapy, massage therapy, chiropractic therapy and retraining of physical activities to reduce pain and increase function. Therapists may use stretching exercises, heat or cold therapies, water therapy, muscle relaxation techniques, biofeedback, traction, or weight training and conditioning. Rehabilitative therapy is an important component of early pain treatment, and is often combined with other treatments, such as oral medications.

Transcutaneous Electrical Stimulation (TENS). In TENS therapy, electrical impulses are applied to the nerve endings through electrodes that are placed on the skin over the painful area. Although its mechanism of action is not completely understood, it is believed that the impulses temporarily interrupt the transmission of pain signals from small sensory nerves at the site of the pain. TENS may also stimulate the release of endorphins, which produce analgesia and feelings of well being.

Cognitive and Behavioral Modification. Chronic pain is a tremendous psychological burden, and a persons response to and tolerance of pain are directly related to issues of personality, culture and past pain experiences. Cognitive and behavioral therapies take these factors into account in an effort to help a patient learn new skills and strategies for dealing with chronic pain. These can include relaxation techniques, visualization exercises and one-on-one counseling sessions with the patient and family to build coping skills.

Second-Tier Pain Therapies
The second tier of therapies in the treatment continuum includes procedures or regimens that are more invasive and costly.

Nerve Blocks. Nerve blocks use a local anesthetic and/or steroids applied directly to the nerve that serves the area where the pain is felt. Nerve blocks are injected around the nerve and typically provide temporary relief of pain due to their anesthetic effect. They also can help decrease the swelling of tissues around the nerve that may be causing irritation of the nerve, which results in pain.

Systemic Opioids. Powerful pain medications known as opioids (narcotics) are often used in cases of severe chronic pain that has not responded to first-tier therapies, and for which surgery is either not an option or has failed. Opioids are effective in relieving the most

severe pain. However, side effects ranging from drowsiness and constipation to an increased risk of addiction are common, particularly when administered systemically by pills or skin patches.

Neurolysis. This involves the use of a chemical agent to disrupt the function of a nerve by destruction of nerve tissues. The chemical (usually alcohol or phenol) is injected into a specific spinal nerve that serves or activates the painful area. The goal is to stop the nerve from sending pain signals to the brain. This procedures is usually effective in relieving pain for a period of weeks or months.

Thermal Procedures. This involves the use of temperature to disrupt the function of a nerve and includes cryoanalgesia and radio-frequency (RF) lesioning. Cryoanalgesia is the application of extreme cold to an affected nerve to deliberately disrupt its ability to transmit pain signals. The degree the nerve is affected is controlled by the duration and intensity of its exposure to the cold. Outcomes can range from minimal damage that causes loss of sensory function for several weeks, to full destruction of the nerve and sensory tissue, which causes complete loss of sensory function and possible motor impairment. Cryoanalgesia is often used for chronic pain of the chest wall, face and other neuralgias.

RF lesioning uses high-frequency energy to produce heat and thermal coagulation of affected nerves to disrupt their ability to transmit pain signals. The RF energy is directed only at the affected nerve, which minimizes the risk of damaging adjacent nerves and tissues. RF lesioning can provide pain relief up to a year or more, and is repeatable. Note: RF lesioning should not be confused with RF spinal cord stimulation because they are different therapies.

Advanced Pain Therapies
Relieving stubborn pain takes time and patience, and successful treatment requires trial and error. Certain chronic pain conditions can be very resistant to first- or second-tier pain therapies. If this is the case, your doctor may consider more advanced treatments in an effort to bring about pain relief.

Surgery. Surgery may be performed to repair or correct an anatomic structure or illness, such as a laminectomy for a herniated disk. Or surgery may be performed on a nerve to interrupt the transmission of pain signals in a procedure called a sympathectomy. Surgery carries a greater risk than noninvasive procedures.

Neurostimulation. Neurostimulation uses low-level electrical impulses to interfere with or block pain signals from reaching the brain. The therapy causes painful sensations in the affected areas to be replaced with a tingling or massaging sensation. Neurostimulation devices include spinal cord stimulators (formerly known as dorsal column stimulators) that use electrodes placed in the space above the spinal cord (epidural space), and peripheral nerve stimulators that use electrodes placed directly over nerves located outside the central nervous system.

Implantable Drug Pumps. For certain types of pain, including persistent nociceptive pain and cancer pain, an implantable drug pump (also known as an intrathecal drug pump) is an appropriate therapy. Implantable drug pumps deliver pain medications directly to the fluid (cerebrospinal fluid) in the space (intrathecal space) surrounding the spinal cord. This direct approach allows powerful pain drugs, such as opioids, to be used in significantly smaller doses, minimizing the likelihood of unpleasant side effects that commonly occur with larger, systemic doses taken by mouth or skin patches.

Neuroablation. Neuroablation is a surgical technique that permanently blocks nerve pathways to the brain by destroying the nerves and tissue that are at the source of the chronic pain. Several procedures are used. Cordotomy is the surgical division (cutting) of a tract of the spinal cord. Rhizotomy involves selective destruction of a nerve close to the spinal cord. Thalamotomy uses electrocoagulation, or burning, of the thalamus area in the brain. In addition to the risk of causing inadvertent motor or sensory dysfunction in other than the affected area, neuroablation techniques are sometimes only temporarily successful, because pain can redevelop in an adjacent or different nerve pathway.

Info on Neurostimulation

If you or someone you care about has been living with chronic intractable pain, neurostimulation may provide new hope. Neurostimulation is a medical treatment for people suffering from chronic pain. Thousands of people have been treated successfully with neurostimulation.

Neurostimulation is actually one of a number of emerging medical technologies called neuromodulation. Neuromodulation therapies are used to attain pain relief or symptom relief for certain types of chronic pain and neurological disorders.

Neuromodulation: Getting at the Source of the Pain
Neuromodulation uses an implanted device an implanted drug pump or a neurostimulator (spinal cord stimulator) to deliver small doses of drugs or low-levels of electricity directly to nerve fibers. This direct approach to treating neurological problems at their source can be very effective in modulating, or lessening, symptoms of pain or motor dysfunction.

A Treatment with Real Advantages
Neuromodulation has two significant advantages. First, it can be very effective for certain conditions. Second, the implanted device can be easily removed. If you dont achieve the desired level of pain or symptom relief, you can decide to have the implant removed.

What Is It?

Neurostimulation, also called electrostimulation, is a form of neuromodulation. It has been approved by the United States Food and Drug Administration (FDA) as a treatment for certain types of chronic pain associated with the trunk and/or limbs. The therapy involves applying very small amounts of electricity directly to selected nerves or anatomic structures. The electricity triggers a neurological response that interferes with the transmission of unwanted pain or motor dysfunction signals to the brain.

Types of Neurostimulation
Medical professionals divide neurostimulation into subcategories based upon the type of nerve that is being stimulated. Nerves within the brain or spinal cord make up the central nervous system. One type of central nervous system neurostimulators is spinal cord stimulation.

  • Spinal cord stimulation (SCS) involves the stimulation of nerves in the spinal cord by placing electrodes in the space above the spinal cord (epidural space). Spinal cord stimulation is sometimes referred to by its older name dorsal column stimulation. Spinal cord stimulation is indicated for the treatment of chronic pain of the trunk and/or limbs.

Nerves outside of the central nervous system make up the peripheral nervous system. Peripheral nerves can also be stimulated. For example, sacral nerve stimulation (SNS) involves the stimulation of nerves in the sacral (pelvic) area.

  • Peripheral nerve stimulation (PNS) involves stimulation of nerves of the peripheral nervous system which are outside of the central nervous system (spinal cord and brain).

The type of neurostimulation that might be appropriate for your condition depends upon many factors, including the cause of your pain or neurologic disorder, as well as its type and location. Some indications are approved by the FDA and other regulatory bodies, and others are not. See the indications section of this site for more information on approved indications.

Spinal Cord Stimulation (SCS) for Chronic Pain Relief
Spinal cord stimulation (SCS) is a type of neurostimulation that has been used for decades to treat chronic pain of the trunk and/or limbs. Spinal cord stimulation can be effective in relieving persistent or severe neuropathic pain.

Spinal cord stimulators typically consist of three components designed to work together as a system: two implanted components (a power source and leads); and an external controller. The power source generates electrical pulses, which are carried by the lead to electrodes at the end of the lead. The external controller allows the doctor to program the power source to generate pulses customized for the individual receiving the therapy.

A relatively short noninvasive surgical procedure is required to place the electrodes in the space above of the spinal column (epidural space). When the power source is turned on, the electrodes will stimulate the nerve fibers that are associated with the areas of the body affected by pain. For many people, this stimulation of the targeted nerves effectively changes pain messages and some patients describe the feeling that replaces the pain as a tingling or massaging sensation called paresthesia. For many patients, paresthesia is much more pleasant than the pain in this case, spinal cord stimulation is a good option. However, for some patients paresthesia is not a pleasant sensation. A trial procedure is normally performed to determine a patients response to spinal cord stimulation.

Peripheral Nerve Stimulation (PNS): Applying Proven Technology to Challenging Pain Problems
Peripheral nerve stimulation (PNS) is similar to spinal cord stimulation. The difference is that PNS electrodes stimulate nerves outside the central nervous system, whereas spinal cord stimulation target nerves in the central nervous system. The treatments are believed to work similarly. They trigger a neurological response that interferes with the transmission of unwanted pain or motor dysfunction signals.

Who Can It Help?

Neurostimulation is not for everyone.

First, you may be able to obtain relief from more conservative, less invasive or less expensive treatment options. Many doctors believe that other pain therapies including analgesics, NSAIDs, and sometimes even surgery should be tried and fail before offering patients the opportunity to try neurostimulation.

Second, you may have a type of pain that does not respond well to neurostimulation. Neurostimulation in particular, spinal cord stimulation (dorsal column stimulation) works best for neuropathic pain. Neurostimulation is generally considered to be ineffective in treating nociceptive pain.

That said, if you have tried other therapies and are not satisfied with the results, then it might be time for you to consider other options, such as neurostimulation. The best way to determine whether or not neurostimulation might help you is to try it through a trial stimulation.

How It Works

To understand how neurostimulation works, it is helpful to understand the components of a neurostimulation system. Specific parts may vary according to the type of stimulator and the application, but a neurostimulator system generally has three main components:

  • The lead(s), are very thin cables consisting of metal electrodes at one end connected by wires to an electrical connector at the other. The leads are surgically placed in the space above the spinal cord (epidural space) or near the nerve to be stimulated, and then tunneled through the soft tissue and connected to the power supply. In some cases, it is necessary to use a fourth component, an extension, to extend the cable back to the power supply. The connector on the lead will be plugged into the power supply or into an extension.

The number of leads placed, the number of electrodes placed, and the placement of the electrodes depends upon the type of stimulator and the condition being treated.

For example, a complex back pain condition might require two leads with 16 electrodes to be placed in the epidural space of the spine.

  • A power supply, which can be implanted under the skin or worn outside of your body, to supply the energy to generate stimulation therapy.
  • A programmer, which is used to program the power supply. The program(s) are the various electrical settings of the stimulation pulses (amplitude, frequency, pulse width and polarity) that are transmitted to each electrode on the lead. The stimulation pulses that are generated ultimately change the signals that are sent to the brain. Instead of feeling pain, it is reported that you generally feel a different kind of sensation in the affected areas. Most people describe this sensation as a tingling or a pleasant massaging effect. The technical name for this sensation is paresthesia.

  • Leads and Extensions

    Leads are very thin cables, which consist of metal electrodes at one end. The electrodes are connected by thin wires to an electrical connector at the other end of the lead. Manufacturers offer a variety of leads to meet the neurostimulation needs of patients and doctors. Variations include:

    • Lead type: percutaneous or surgical
    • Number of electrodes: 4, 8, 16
    • Electrode shape, configuration and spacing
    • Lead length

    Types of Leads
    Percutaneous leads are leads that can be implanted through a needle without the need for a surgical incision. The advantages of percutaneous leads are that they are faster and easier to place, and less traumatic to the patient. Their disadvantages are that they are more prone to move (migrate) as compared to surgical leads, and their cylindrical electrode shape makes them less energy efficient.

    Surgical leads, also called paddle leads, are larger leads that require a small surgical incision. Their advantages are that they are less prone to move (migrate) as compared to percutaneous leads, and their flat electrode shape makes them more energy efficient. The disadvantage is that they do require a surgical procedure to place (implant).

    Percutaneous leads are almost always used for     trial stimulation, whereas either percutaneous or surgical leads can be used for permanent implantations.

    Number of Electrodes
    Each lead has at least four electrodes, but a lead can contain as many as 16 electrodes. The number of electrodes used depends upon the condition being treated, as well as the doctors preference. For example, more complex pain patterns, such as those involving multiple sites (multi-focal) and multi-extremities involve more nerve structures. Additional electrodes are often required to stimulate all of these structures. Implanting fewer electrodes than you need can result in less pain relief.

    Many doctors believe that it is best to implant extra electrodes, just in case the pain pattern changes or the leads move (migrate). If a change or migration occurs and extra electrodes are available, it is often possible for your doctor to reestablish pain relief by electronically repositioning the electrodes. This is accomplished by reprogramming the power supply, which requires an office visit to see your doctor.

    However, if the leads migrate and extra electrodes are not available, then you may have to undergo another surgical procedure to surgically reposition the leads. Thus, placing extra electrodes is like buying insurance, providing you and your doctor with some protection against possible future problems.

     
     

    Electrode Size, Shape and Configuration
    The size, shape and configuration of the electrode(s) affect the path that the electricity takes as it travels through the nerve structures and the surrounding tissue. Cylindrical electrodes, such as those found on percutaneous leads, allow electricity to flow in all directions. Flat electrodes, on the other hand, such as those found on surgical or paddle leads, allow electricity to be directed in just one direction.

    With percutaneous leads, some of the electricity is wasted with cylindrical electrodes because some of the electricity is directed away from the targeted nerve tissues. In addition, nerve tissues that were not targeted can be inadvertently activated, which may interfere with the quality and comfort of the stimulation. Experienced neurostimulation practitioners understand these and other issues associated with electrode size, shape and configuration, and consider these issues in selecting the appropriate type of lead(s) for each individual patient.

    Lead Length
    Lead length refers to the length of wire between the electrodes and the electrical connector. Doctors select lead lengths based upon the electrode implantation site, the physical size of the neurostimulation patient, the distance between the stimulation site and the power source implantation site, as well as their personal preferences. Some doctors choose to use shorter leads because they find them to be easier to maneuver into position than longer leads, or because they want to anchor the lead in several locations to reduce the chance of migration. Other doctors prefer to use longer leads to avoid the use of extensions (extensions are discussed below).

    Extensions
    Extensions are thin cables consisting of connectors at both ends connected by very thin wires. They are used whenever the lead is not long enough to reach the power supply. In that sense, extensions are used just like you would use an extension cord around the house. Some neurostimulation systems can be implanted without using any extensions. In most cases, doctors prefer to use as few extensions as possible because the connectors are usually larger than the cable, and some patients find these connector lumps to be uncomfortable. Another consideration is that each extension creates another electrical connection which has the potential to become disconnected.

  • Power Source IPG and RF Systems

    All neurostimulators require a power source. There are two types of power sources: implantable pulse generator (IPG) and radio frequency (RF). The systems are similar in that they both require at least one implanted lead and an external programmer. They are distinguished from each other by, among other things, the location of the battery.

    • Implantable pulse generator, or IPG. With an IPG, the power source consists of a battery and related electronics that are contained in a single metal container. The IPG is completely implanted under the skin. The leads (or extensions) are plugged into the IPG.
    • Radio frequency, or RF, power sources have two components: a receiver that is implanted under the skin, and a transmitter that is worn externally, much like a cell phone or pager. The receiver contains a metal antenna and related electronics that are contained in a small container but NO battery. The receiver is completely implanted under the skin. The leads (or extensions) are plugged into the receiver. The transmitter contains an antenna and related electronics, including the battery. Electrical energy is transmitted by radio waves from the transmitter through the skin and into the receiver.
     
     
     
     

    There are advantages and disadvantages to each type of system. If you are being considered for a neurostimulator, you and your doctor will decide which system is most appropriate for your situation. The decision is based on the pattern and complexity of your condition, your lifestyle, as well as how much electrical energy is required to provide adequate pain relief.

IPGs Better Suited for Low-Power Applications Like Simple Pain

Simple pain is defined as pain in a single region or a single extremity, which is not expected to migrate, change, or worsen. If only a single extremity is involved, it is called unilateral pain. Simple, unilateral pain can often be managed with a minimal number of electrodes, relatively low power output levels and a single stimulation program. In other words, these are ideal applications for a fully implantable spinal cord stimulation system the implantable pulse generator (IPG).

A major advantage of the IPG is that it is totally implanted. Thus, it is more discreet, and it is possible to bathe, shower, or swim while receiving stimulation. Some people find this more convenient and cosmetically acceptable.

The key disadvantage of the IPG is that it has a fixed battery life. When the battery runs out, the IPG needs to be replaced. Replacing the battery means another trip to the operating room, and the discomfort, cost and inconvenience of IPG replacement surgery. Another disadvantage of the IPG is that the battery adds to the size and weight of the device. This can be an issue in smaller or more slender people, by limiting appropriate implantation sites available to your doctor.

The primary issue in determining if the IPG is the best option for you is not strictly your pain pattern or diagnosis, but rather how long the battery will last given the electrical energy required to attain adequate pain relief.

The battery life of an IPG varies from patient to patient. It depends on your pain pattern, how often you use the stimulator, the amount of electrical energy that your spinal cord stimulation prescription requires, and how and if your pain pattern changes over time.

The battery in an IPG can last up to five years, but it is more common to expect a life of two to three years. However, it is not unheard of for an IPG to require replacement in less than nine months because of battery depletion. If you are being considered for spinal cord stimulation with an IPG, talk to your doctor about estimating the battery life of your device given your stimulation requirements as determined in your stimulation trial. This will help you both to decide if an IPG is a good treatment option for you.

 

 

Thank you to Nih  & Medlineplus for the following information