Pain Management in EDS - The Ehlers Danlos Society · 2016. 4. 18. · Pradeep,Chopra,,MD, 41...
Transcript of Pain Management in EDS - The Ehlers Danlos Society · 2016. 4. 18. · Pradeep,Chopra,,MD, 41...
Ehlers-‐Danlos Na.onal Founda.on August 2013 Conference
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Pain management in Ehlers Danlos Syndrome
Pradeep Chopra, MD, MHCM Director, Pain Management Center,
Assistant Professor, Brown Medical School, Rhode Island Assistant Professor (Adjunct), Boston University Medical Center
[email protected] [email protected]
Pradeep Chopra, MD 1
Disclosure and disclaimer
• I have no actual or poten.al conflict of interest in rela.on to this presenta.on or program
• This presenta.on will discuss “off-‐label” uses of medica.ons
• Discussions in this presenta.on are for a general informa.on purposes only. Please discuss with your physician your own par.cular treatment. This presenta.on or discussion is NOT meant to take the place of your doctor.
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Introduc.on
• Training and Fellowship, Harvard Medical school
• Pain Medicine specialist
• Assistant Professor – Brown Medical School, Rhode Island
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Pain in EDS by body parts • Head and neck • Shoulders • Jaws • Chest • Abdomen • Hips • Lower back • Legs • Complex Regional Pain Syndrome – CRPS or RSD
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Pain in EDS
• From nerves – neuropathic • From muscles – Myofascial • From Joints – nocicep.ve pain • Headaches
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Muscle pain
Myofascial pain
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Muscle Pain
• Muscles are held together by fascia – ‘saran wrap’ which is made of collagen
• Muscle spasms or muscle knots develop to compensate for unbalanced forces from the joints
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Muscle pain 1
• Most chronic pain condi.ons are associated with muscle spasms
• Oben more painful than the original pain • Muscles may .ghten reflexively, guarding of a painful area, nerve irrita.on or generalized tension
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Muscle pain 2
• Myofascial pain syndrome is a chronic form of muscle pain.
• Myofascial pain syndrome centers around sensi.ve points in your muscles called trigger points
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Treatment of muscle pain
• Treat the cause – joint pain, repe..ve use • Trigger point injec.ons • Stretching • Relaxa.on techniques
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Trigger Points
• When muscles are in chronic spasm they stay taut – ‘knots’.
• They develop trigger points which trigger the muscle in to a constant state of spasm
• The trigger points can be painful when touched.
• The pain can spread throughout the affected muscle and other parts
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Trigger Points 2
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Trigger Point injec.ons
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Trigger Point injec.on
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Dry Needling
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Manual Techniques
• Myofascial release: Gentle techniques to improve the mobility of the muscles by mobilizing the .ssue around the muscle
• Muscle energy technique: U.lizes posi.oning of the body and using ac.ve muscle contrac.on to relax muscles and align joints
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Manual Therapy Techniques
• Strain-‐Counterstrain: A posi.onal technique to help relax .ght muscles
• Craniosacral Therapy: A gentle technique to help balance the nervous system
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Muscle Relaxants
• Cyclobenzaprine (Flexeril) • Carisoprodol (Soma) • Tizanidine (Zanaflex) • Baclofen • Benzodiazipine (Valium)
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Muscle relaxants
• Not true muscle relaxants
• Decrease tone
• Lethargy – good for bed.me dosing to sleep
• Approved for long term use: Baclofen, .zanidine
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Risk Factors
• Muscle injury. Stress on your muscles can cause trigger points to form.. Repe..ve stress also may increase your risk.
• Inac.vity. If you've been unable to use a muscle, such as aber surgery or aber a stroke, you may experience trigger points in your muscle as you start to move it during your recovery.
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Nerve pain
Neuropathic pain
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Nerve pain in Connec.ve .ssue disorder / EDS
• Nerve connec.ve .ssue is more fragile • Fragile nerves get over stretched when crossing or associated with hypermobile joints
• Small Fiber neuropathy • Neuropathic pain, Complex Regional Pain Syndrome (CRPS) or Reflex Sympathe.c Dystrophy (RSD)
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Nerve pain in EDS -‐ Mitochondria
• Is it Mitochondrial disorder ? • Mitochondria found in cells of the human body
• They produce energy • Suspect, if the pain is widespread and involves nerves
• Exercise intolerance, muscle weakness, seizures, developmental delays etc.
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Neuropathic pain medica.ons
• Gabapen.n (Neuron.n®) • Pregabalin (Lyrica®)
• Duloxe.ne (Cymbalta®) • Milnacipran (Savella®)
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Gabapen.n and pregabalin • Promising results have been shown. • Gabapen.n – go up to 900mg, then 1800mg. Slow ac.ng drug.
• Pregabalin – 150mg to 300mg. Faster ac.ng drug.
• The difference may not be obvious at first but when they come off it, they no.ce an increase in pain
• Chance of increased dizziness in POTS -‐ usually stops aber being on the drug for some.me.
• Start low, go slow
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SNRI (selec.ve nor-‐epinephrine release inhibitors)
• Duloxe.ne (Cymbalta®) • Milnacipran (Savella®)
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SNRI (selec.ve nor-‐epinephrine release inhibitors)
• Increase nor -‐ epinephrine levels in the central nervous system
• Increased nor-‐epinephrine levels help in modula.ng pain signals
• Milnacipran increases nor-‐epinephrine by 3 .mes as compared to duloxetne
• May increase blood pressure and heart rate
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An.depressants
• Tricyclic an.depressants (TCA) well studied in neuropathic pain
• Reuptake blockers of serotonin and noradrenaline (Amitrityline, nortriptyline) – work well
• SSRI (Prozac, Zolob) – do not work well for pain
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Reflex Sympathe.c Dystrophy (RSD)
Complex Regional Pain Syndrome (CRPS)
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Common clinical features of RSD
• Con.nuous burning pain • Pain dispropor.onate in intensity to the inci.ng event
• Pain to touch – Allodynia • Pain not in any specific nerve distribu.on or even to the site of injury
• Swelling • Increased / decreased swea.ng
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Symptoms of CRPS / RSD • Pain – severe, constant • Temperature difference • Hypersensi.vity • Tremor, Involuntary movements, muscle spasms, atrophy (weakening of the muscle)
• Increased swea.ng • Color difference • Bone thinning • Swelling • Hair and nail changes
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Headaches and Neck pain
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Headaches
• Mostly unknown cause • Cerebrovascular reac.vity • Prone to migraines and Tension Type Headaches
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Headaches and neck pain
• Headaches may be caused by neck pain • Headaches may be from – inside the head (Migraines) or – outside (chronic daily headaches or tension type headaches)
• Treatment for both is different
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Headaches and Neck pain
• C1-‐C2 instability • Kyphosis (Bent backwards) of neck spine • Degenera.on of neck disks (especially C4-‐C5, C5-‐C6)
• Cranio-‐cervical instability (junc.on between head and neck not stable)
• Chiari malforma.on
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Symptoms of neck (C1-‐C2) instability
• Neck pain • Headaches in the back of the head (occipital headaches)
• Fain.ng sensa.on with rota.ng head to the side
• Choking sensa.on • Treatment – surgical fusion, strengthening of neck muscles, try bracing for flare ups
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Migraines • Treatment depends on the frequency – if they are occasional, do not treat
• Abor.ves for infrequent migraines • Prophylac.c for frequent migraines • Triptans (Rizatriptan -‐ Maxalt®, Sumatriptan -‐ Imitrex®, etc – very effec.ve as abor.ve, not prophylac.c)
• Triptans not approved for children under 12 years • Prophylac.c in children – Cyprohetadine -‐ Periac.n® Improves appe.te also
• Other prophylac.cs – amitriptyline, nortriptyline, topiramate
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Red Flags
• Acute (sudden) abdominal or flank pain may be due to a ruptured uterine, intes.ne or twisted intes.ne
• Bleeding in the head may present with sharp pain in head, change in mental status or seizure
• Emergency
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TMJ Pain
Temporo Mandibular Joint Dysfunc.on
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TM Joint pain
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Temporo-‐mandibular joint dysfunc.on (TMJ)
• Present in 70% • Clicking sound • Grinding at night or clenching teeth • Joint pain, chewing muscle pain • Treatment: avoid excessive mouth opening, cau.on when yawning, orthodon.st specializing in TMJ
• Avoid over the counter mouth guards
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Arm and leg pain
• Brachial plexus neuropathy • Lumbosacral neuropathy • Mechanical pressure due to disloca.ons and subluxa.ons
• Nerve disorders in EDS make them prone to damage
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Spine pain
• Facet joint instability • Sacroiliac joint pain • Muscles around the spine • Degenera.ve disc disease
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Spine pain
• Steroid injec.ons • Core strengthening exercises • Temporary brace if flare up
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Tendons and Ligaments
• Ligaments and tendons are made of connec.ve .ssue
• Ligaments connect bone to bone • Tendons connect muscle to bone • Tendons are an extension of the strong connec.ve .ssue that surrounds all muscles – the fascia
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Tendon and ligament pain
• Bracing or spica • Topicals • Preven.ve measures – Avoid overstretching or hyperextending joints – Avoid high impact ac.vi.es
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Preven.on
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Preven.ng pain
• Do not stand on one hip or sway at hips
• Do not stand on the outside of your feet
• Do not sleep on your stomach, head turned to one side for a prolonged period
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Preven.ng pain
• Do not sit with legs outstretched, or with legs tucked under the butocks ‘W’ posi.on
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Preven.ng pain
• Do not hyperextend knees when standing
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Preven.ng pain
• Do not sit kneeling with butocks res.ng on ankles
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Preven.ng Pain – working at home
• Avoid repe..ve ac.vi.es – vacuuming, raking, filling dish washer, s.rring. Change ac.vity frequently.
• Work surface (kitchen counter, sink etc.) should be at appropriate height. Use blocks to raise your work surface
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Preven.ng pain -‐ sleeping
• EDS pa.ents wake up with pain and s.ffness • Use a sob matress • Prefer using separate matresses for partner and yourself
• Feather pillow or memory foam pillows
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Preven.ng pain -‐ shopping
• Do not carry a heavy or light bag hanging from a shoulder
• Do not carry grocery bags in hand, especially heavy one. Keep them light.
• Use shopping trolley. Use wheels wherever you can
• Keep handbags light
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Preven.ng pain – clothes
• Keep clothes loose and light • Women – bra with wide straps and possibly cross-‐over straps
• Wear light and sob shoes. Use well balanced ortho.cs
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Preven.ng pain – going to the den.st
• EDS’ers wind up making more trips to the den.st
• Talk to den.st about EDS • Numbing medicine may not work or you maybe too sensi.ve to them
• TMJ – not to keep mouth open too long • Posi.on of neck – prefer being in a more flat posi.on with neck supported
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Medica.ons
• Opioid or narco.cs • NSAID’s (non steroidal an.-‐inflammatory drugs)
• Acetaminophen / paracetamol • An.-‐depressants • An.convulsants • Other
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LDN
Low Dose Naltrexone
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Low Dose Naltrexone (LDN)
• Naltrexone blocks the effect of opioids. • Approved 30 years ago by the FDA for opioid and alcohol addic.on
• In the late 1980’s it was discovered that at low doses it helped pa.ents with immune disorders.
• Since then, LDN has been used extensively by pa.ents with immune disorders like Mul.ple sclerosis, Crohn’s disease, Rheumatoid arthri.s
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Low Dose Naltrexone (LDN)
• There are several theories as to how LDN may work
• Low side effect profile • Inexpensive • Useful for chronic pain • Useful for symptoms of EDS
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Low Dose Naltrexone (LDN)
• Good experience with using in EDS and chronic pain
• Unsure as to how it helps EDS. • Most pa.ents with EDS report improvement in func.on
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Acetaminophen / Paracetamol
• One of the safest analgesics • By itself is good for mild to moderate pain • Poten.ated effect when combined with other analgesics such as NSAIDS (Naproxen, Ibuprofen) or opioids (Codeine, Oxycodone).
• Poten.a.ng effect helps lower the need to take NSAIDs and Opioids.
• Keep an eye on maximum dose – 3000gms/ day ( 9 regular Tylenols®)
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NSAID (Non steroidal an.-‐inflammatory drugs)
• Naproxen, Ibuprofen etc
• Good analgesics. Beter if combined with acetaminophen/paracetamol • Significant side effects – gastric irrita.on, kidneys • Avoid in Irritable Bowel Syndrome, Ulcera.ve Coli.s
• Not useful in neuropathic pain
• May be used in joint pain
• Beter off using it as a topical for superficial joints (Shoulder, knee, ankles, hands)
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Topicals
• NSAID’s are commonly effec.ve
• Avoids the side effects of oral medicines
• Far more effec.ve locally at the site of pain
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Topicals – ointment, lo.ons, patches
• Compounding pharmacies can make a compound with NSAID’s
• DMSO and Ac.ve Max® – use as addi.ve to help beter penera.on
• Diclofenic acid with DMSO (Pennsaid®) • Diclofenac acid (Voltaren® gel) • Flector® patch helpful • Lidocaine patch not helpful
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Opioids
• Counterproduc.ve for chronic pain • Mild doses for a short term are good for acute pain
• Safer than using NSAID’s (ibuprofen, naproxen)
• Maybe combined with NSAID’s or acetaminophen for beter effect and lower dose
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71 Webster LR, Webster RM. Pain Med. 2005;6(6):432-442. "
Prevalence of Addic.on
Total PainPopulation"
Addiction: 2% to 5%"
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Gluten free diet • Gluten is a protein found in wheat, rye, barley and other grains
• One can develop an intolerance at any age. • Gluten as a protein can cause an inflammatory response in the body.
• Migraines, chronic body ache, abdominal pain, Fibromyalgia, hypermobility syndromes (EDS), mul.ple joint pains
• Hold off on gluten foods for 8 weeks to see if it makes a difference.
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Star.ng treatment -‐ medicines and exercise
Start low, go slow
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Service Dogs • Trained to each person’s physical impairments • help with func.oning and independence • Constant companion, will oben sense its owners pain and will comfort them both physically and emo.onally
• Can sense distress and call for help • Service dogs give pa.ents a feeling of security allowing them to be more ac.ve physically and socially
• Provide stability while walking, open and close doors, switch on and off lights
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Service Dogs
• POTS – they can sense when their owner is having an episode of dizziness or seizure
• EDS and pain -‐ they protect the limb from being injured or touched
• Helps boost confidence in their owners.
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Watson and Usher
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Exercise and Physical Therapy
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EDS – Exercise and Physical Therapy Goals
• Restore func.on
• Learn how to properly adjust limb movements
• Muscle strengthening
• Aqua therapy
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Physical Therapy -‐ two types
• Pa.ents who have recently developed pain – PT should focus more on pain
• Pa.ents who have had for a while (Chronic) – PT should be more .me based
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Physical Therapy – Pain focused
• The level and progression of exercise is determined by the intensity of the pain.
• The intensity of the exercise should be low in cases of (or days of) highly intense pain.
• Similarly, the intensity of exercise should be high if the pain is rela.vely low.
• Its not harmful if there is an increase in pain for a short dura.on (approx. 1 to 2 hours) aber exercise
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Physical Therapy – Pain Focused
• A program is designed based on the pa.ents limita.ons
• Pa.ent exercise within those limits. • It builds confidence and increases confidence in using their limbs
• Pain focused PT has been shown to decrease considerably symptoms of recent onset RSD
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Physical Therapy – Time focused
• The level of exercise is built over .me unrelated to intensity of pain
• Preferred approach in cases of long standing
• Pain focused PT can give way to Time Focused PT and vice versa
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