The New Treatment Protocol Offers Hope For CRPS Patients, Reduces Allodynia

Summary: Complex regional pain syndrome (CRPS) is among the most difficult-to-treat conditions causing chronic pain and increased sensitivity to various stimuli. Even slight exposure to some irritants may cause severe pain. Thus, the condition is debilitating. In 2018, Johnathan H. Goree, MD, proposed the treatment protocol for the condition. In the new study, researchers validated the protocol and found it quite effective in Complex Regional Pain Syndrome treatment and in reducing allodynia.

Some pains are quite challenging to treat, causing allodynia, a condition when even some common irritants that generally do not cause pain may cause severe pain in such individuals. One such example of a chronic and painful condition with a reduced pain threshold is complex regional pain syndrome (CRPS).

CRPS remains quite a poorly understood condition, as its pathogenesis is unclear. Nonetheless, there has been much progress in new treatments for CRPS over the years. Moreover, many doctors and pain specialists now realize it as a distinct pathological condition requiring a specific treatment approach.

In 2018, Johnathan H. Goree, MD, develope`d a treatment protocol for CRPS. This treatment protocol recommends using gabapentin, bisphosphonates, ketamine, stellate ganglion blocks, and neuromodulation through occupational therapy, and it also recommends quitting smoking. Although this protocol was produced after years of research, in medicine, any protocol can only be widely accepted if it has been validated in multiple studies and in different population groups2.

After all, any treatment recommendation is of little value if its results cannot be repeated in different clinical settings. Furthermore, there is always a risk that the person who created the protocol missed something. However, now, a new study shows that this treatment protocol works.

The protocol was validated in an independent study by Mi Mi Kim, M.D., M.P.H., Loren Guzman, M.D., and Johnathan Goree, M.D. from the Department of Anesthesiology, University of Arkansas Medical Sciences, Little Rock, AR. They shared the findings of their study at a 19th Annual Pain Medicine Meeting.

The treatment protocol consists of four primary areas of focus; pain management, sympathetic nerve block, occupational therapy, and smoking cessation. In the study, patients received 300 mg gabapentin thrice daily, 35 mg alendronate daily, 10% topical ketamine, and some other painkillers like tramadol. For nerve blockers, they mainly used bupivacaine plus epinephrine.

After one month of treatment, most patients reported significant benefits in treating CRPS symptoms. Those who reported significant benefits continued with home-based therapy and occupational therapy. The therapy was repeated in the patients who responded to treatment in the early stages but stopped responding later. The study involved 25 patients, and all reported significant benefits. In addition, the benefit was proportional to therapy adherence.

40% of the participants in the study reported significantly improved range of motion. However, this improvement was close to 85% in patients with better adherence to the therapy. Similarly, 60% of patients reported reduced allodynia. Again, this improvement was barely 11% in those with poor treatment adherence but above 80% in those with more or less good treatment adherence.

The researchers found that bisphosphonate use and stellate ganglion blocks highly correlated to reported benefits. They also noted that issues like depression, anxiety, and opioid use in the initial presentation did not make a difference in the final outcomes. This means that this treatment protocol is good for different kinds of patients.

In short, the study could validate the proposed treatment protocol for CRPS. It found that benefit from the treatment protocol was significant only if patients adhered to the prescribed treatment. Moreover, the study also found that even those with moderate adherence benefited significantly. Only those with very poor adherence did not report any benefit.

CRPS is among the most challenging-to-treat conditions causing chronic pain and reduced pain threshold. The pain is debilitating in most cases, and patients do not respond to the most commonly used pain treatments. Thus, this new treatment protocol offers hope.

By Gurpreet Singh Padda, MD, MBA