RSD Replies Part 1
Derek Kozar
Description
Collection
Title:
RSD Replies Part 1
Creator:
Derek Kozar
Date:
11/13/2001
Text:
Thanks to all who submitted advice....not sure what will happen with the
gentleman. Below are the replies.....
Thank You
Derek Kozar, M.Sc., C.O.(c)
I have dealt with quite a few RSD patients. Most responded best
to total contact orthoses - I have even wrapped thin pelite
formed tongues over the dorsum of the foot and ankle and the
results were even better for a few patients. I had
one who had tried a total contact AFO in the past and had
switched to a DAW KAFO before I saw her and she claimed that
she could not tolerate the contact, but I don't know if the
orthosis was well-made, etc. I would definitely try the total
contact AFO or even PTB orthosis first, even if the patient
has to be sedated for casting. I would strongly advise not
going the amputation route as the RSD will likely worsen or
migrate to other areas- have the patient contact the RSD associa-
tion of America (I think that's the name but I'm not sure on
that.) As to the thermoplastic orthosis - initially putting it
on may be difficult, but usually once it's on it is tolerated
well. Good luck.
I have worked w/ only 3 RSD cases in my 17 years as an orthotist. I have
found that a snug, total contact fit will be a great
aide in
reducing but not eliminating the pain. I typically have the client cast
while under anesthesia or some medication so I can take a
mold. None of my clients had this problem as distal on a lower extremity
as this person. I would look into a very rigid AFO w/
anterior shell, and fully lined. A CROW (Charco Restraint Orthotic
Walker) comes to mind as one alternative. Feel free to call
me if
you think I can help. Good luck.
I've dealt with a three RSD patients - one post
amputation.
The first thing I have to say is you have to stress
to the doctor concerned and the patient that
amputation is not a solution!!! I don't have any hard
facts, but I have heard it said that one third of RSD
patients have continued pain after amputation. In fact
this might be another good question to pose to the
group...how many successful RSD amputations have
people seen?
The patient I dealt with post amputation had terrible
phantom pain and stump pain, huge fluctations in stump
volume (requiring the use of no pelite liner in the
morning and by the evening requiring two pelite liners
and many socks), and the skin was hypersensitive.
Psychologically she was a mess...her cure turned
out to be a curse.
With the two other patients, I went down the path of
total immobilization of the joint. It is not an easy
solution. Yes, a total contact AFO. (If by this you
mean an AFO with an anterior section and posterior
section.)
Taking the cast _is_ difficult, and painful.
Fitting is difficult and painful.
The initial period of wear is difficult and painful,
and may even produce increased pain.
It will take time to see an improvement.
In both cases it was successful. They both were able
to walk and get back to normal after about 4-6
months.
I sympathize with you and your patient. I have had several RSD patients
with
LE problems and have not found a solution to this problem. At the knee
and
above, large areas of contact can reduce the discomfort associated with
RSD
patients that use orthoses. Around the foot, nothing seems to help. I
have
lined AFOs with Silipos adhesive gels and the patient cannot tolerate
the
pressure or contact on the foot or ankle.
A morphine pump seems to be the only recourse for these patients.
Casting is
a good trial to see if the patient can tolerate an orthosis. Lots of
drugs
and quick application of synthetic casting materials -- good luck
getting the
cast off without making a lifelong enemy!
This is a very difficult case which may not be solved even by
amputation. The pain may only migrate more proximally. If
bracing options fail, you may want to refer him to Dr. Lew Schon in
Baltimore who has extensive experience with an implanted
nerve stimulator procedure. The stim is applied to each nerve in the
leg. Usually a last resort procedure but it has produced
some life changing results. Dr. Schon's office 410-554-2891.
First get a compression stocking on that swollen limb. Just as phantom
pain is traced to edema and alleviated by a shrinker, I'll
bet
his pain will diminish using an off-the-shelf below-knee 18-25mmHg
compression stocking(Jobst, Sigvarus, etc.)
I have cared for one individual that elected transtibial amputation for
RSD--symptoms simply migrated proximally into the residual limb.
Needless
to say prosthetic fitting was-and is-a nightmare. The are number of
similar
cases documented in the literature (which I have note perused in several
years since I managed the above-mentioned individual). These are
extremely
difficult and frustrating cases. Hopefully, your patient has access to
a
comprehensive pain management program where you r orthotic expertise
will be
only one facet of a global approach to his pain management. You might
ask
your local reference librarian to conduct a Medline or Ovid search on
management of RSD to see the latest literature.
Yoiu have to look at this as a long term process and be sure that your
patient and his payer and case manager sign on to the
process and agree to abide by it. First you gradually introduce total
contact to the limb below the knee with any one of the
following modalities (in increasing fashion): a simple sock, then a
tighter sock, a 24 length of compressogrip, a low
compression surgical hose (12mm Hg), a moderate compression hose (20-30
mm Hg), a 30-40 compression hose, a serial
cast with compressogrip or hose as the skin interface. Once the patient
is tolerating the constant buit non-weight bearing
pressure you fabricate an AFO that utilizes a neoprene liner surrounding
the circumference of the limb at the proximal medial
tibial flair and the undercut of the calf muscle. I use TPE because it
is very flexible and lends itself to being manipulated to
circumferencial pressure. With velcro you simply hold the limb up and
gradually increase the pressure on the plantar and
medial aspects of the foot. I have use
d this system very successfully for about six patients. You can also use
different thicknesses of socks to vary the presssure.
Above all, be positive that you can relieve the pain but relentless in
your insistance that the patient be patient and play the
treatment out as his tolerance for pressure allows. Let me know if you
need anymore info.
********************
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should not be sent to the entire oandp-l list.
gentleman. Below are the replies.....
Thank You
Derek Kozar, M.Sc., C.O.(c)
I have dealt with quite a few RSD patients. Most responded best
to total contact orthoses - I have even wrapped thin pelite
formed tongues over the dorsum of the foot and ankle and the
results were even better for a few patients. I had
one who had tried a total contact AFO in the past and had
switched to a DAW KAFO before I saw her and she claimed that
she could not tolerate the contact, but I don't know if the
orthosis was well-made, etc. I would definitely try the total
contact AFO or even PTB orthosis first, even if the patient
has to be sedated for casting. I would strongly advise not
going the amputation route as the RSD will likely worsen or
migrate to other areas- have the patient contact the RSD associa-
tion of America (I think that's the name but I'm not sure on
that.) As to the thermoplastic orthosis - initially putting it
on may be difficult, but usually once it's on it is tolerated
well. Good luck.
I have worked w/ only 3 RSD cases in my 17 years as an orthotist. I have
found that a snug, total contact fit will be a great
aide in
reducing but not eliminating the pain. I typically have the client cast
while under anesthesia or some medication so I can take a
mold. None of my clients had this problem as distal on a lower extremity
as this person. I would look into a very rigid AFO w/
anterior shell, and fully lined. A CROW (Charco Restraint Orthotic
Walker) comes to mind as one alternative. Feel free to call
me if
you think I can help. Good luck.
I've dealt with a three RSD patients - one post
amputation.
The first thing I have to say is you have to stress
to the doctor concerned and the patient that
amputation is not a solution!!! I don't have any hard
facts, but I have heard it said that one third of RSD
patients have continued pain after amputation. In fact
this might be another good question to pose to the
group...how many successful RSD amputations have
people seen?
The patient I dealt with post amputation had terrible
phantom pain and stump pain, huge fluctations in stump
volume (requiring the use of no pelite liner in the
morning and by the evening requiring two pelite liners
and many socks), and the skin was hypersensitive.
Psychologically she was a mess...her cure turned
out to be a curse.
With the two other patients, I went down the path of
total immobilization of the joint. It is not an easy
solution. Yes, a total contact AFO. (If by this you
mean an AFO with an anterior section and posterior
section.)
Taking the cast _is_ difficult, and painful.
Fitting is difficult and painful.
The initial period of wear is difficult and painful,
and may even produce increased pain.
It will take time to see an improvement.
In both cases it was successful. They both were able
to walk and get back to normal after about 4-6
months.
I sympathize with you and your patient. I have had several RSD patients
with
LE problems and have not found a solution to this problem. At the knee
and
above, large areas of contact can reduce the discomfort associated with
RSD
patients that use orthoses. Around the foot, nothing seems to help. I
have
lined AFOs with Silipos adhesive gels and the patient cannot tolerate
the
pressure or contact on the foot or ankle.
A morphine pump seems to be the only recourse for these patients.
Casting is
a good trial to see if the patient can tolerate an orthosis. Lots of
drugs
and quick application of synthetic casting materials -- good luck
getting the
cast off without making a lifelong enemy!
This is a very difficult case which may not be solved even by
amputation. The pain may only migrate more proximally. If
bracing options fail, you may want to refer him to Dr. Lew Schon in
Baltimore who has extensive experience with an implanted
nerve stimulator procedure. The stim is applied to each nerve in the
leg. Usually a last resort procedure but it has produced
some life changing results. Dr. Schon's office 410-554-2891.
First get a compression stocking on that swollen limb. Just as phantom
pain is traced to edema and alleviated by a shrinker, I'll
bet
his pain will diminish using an off-the-shelf below-knee 18-25mmHg
compression stocking(Jobst, Sigvarus, etc.)
I have cared for one individual that elected transtibial amputation for
RSD--symptoms simply migrated proximally into the residual limb.
Needless
to say prosthetic fitting was-and is-a nightmare. The are number of
similar
cases documented in the literature (which I have note perused in several
years since I managed the above-mentioned individual). These are
extremely
difficult and frustrating cases. Hopefully, your patient has access to
a
comprehensive pain management program where you r orthotic expertise
will be
only one facet of a global approach to his pain management. You might
ask
your local reference librarian to conduct a Medline or Ovid search on
management of RSD to see the latest literature.
Yoiu have to look at this as a long term process and be sure that your
patient and his payer and case manager sign on to the
process and agree to abide by it. First you gradually introduce total
contact to the limb below the knee with any one of the
following modalities (in increasing fashion): a simple sock, then a
tighter sock, a 24 length of compressogrip, a low
compression surgical hose (12mm Hg), a moderate compression hose (20-30
mm Hg), a 30-40 compression hose, a serial
cast with compressogrip or hose as the skin interface. Once the patient
is tolerating the constant buit non-weight bearing
pressure you fabricate an AFO that utilizes a neoprene liner surrounding
the circumference of the limb at the proximal medial
tibial flair and the undercut of the calf muscle. I use TPE because it
is very flexible and lends itself to being manipulated to
circumferencial pressure. With velcro you simply hold the limb up and
gradually increase the pressure on the plantar and
medial aspects of the foot. I have use
d this system very successfully for about six patients. You can also use
different thicknesses of socks to vary the presssure.
Above all, be positive that you can relieve the pain but relentless in
your insistance that the patient be patient and play the
treatment out as his tolerance for pressure allows. Let me know if you
need anymore info.
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list.
Citation
Derek Kozar, “RSD Replies Part 1,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 6, 2024, https://library.drfop.org/items/show/217947.
