Lakshmi Vas - Academia.edu (original) (raw)

Papers by Lakshmi Vas

Research paper thumbnail of Chronic Pain

Research paper thumbnail of Unilateral upper limb plexopathy pain caused by cancer

Oxford University Press eBooks, 2022

This chapter explores the concept that although nerve blocks may have a place in the treatment of... more This chapter explores the concept that although nerve blocks may have a place in the treatment of upper limb plexopathy, the interventional pain doctor must assess carefully all factors contributing to a patient’s pain and distress. The chapter covers pain relief options such as stellate ganglion block, pulsed radiofrequency (PRF), and ultrasound guided dry needling (USGDN), and finishes with some key learning points for the reader.

Research paper thumbnail of Treatment of interstitial cystitis/painful bladder syndrome as a neuropathic pain condition

Indian Journal of Urology, 2014

A lady of 52 years with painful bladder syndrome/interstitial cystitis (PBS/IC) presented with ch... more A lady of 52 years with painful bladder syndrome/interstitial cystitis (PBS/IC) presented with chronic pelvic pain, irritative voiding with sphincter dominance on urodynamics. 3 yrs of oral analgesics, antispasmodics and intravesical therapy was ineffective. We surmised her pain, and irritative voiding to be secondary to constant straining against a dysfunctional pelvic floor. We treated PBS/IC as a neuropathic phenomenon with a combination of neuromodulator medications and continuous caudal epidural analgesia to reduce the pain induced peripheral and central sensitisation. Botulinum toxin type A injection into pelvic floor muscles appeared to address their dysfuction. Clinical and urodynamics response was encouraging.

Research paper thumbnail of An unusual way to use an endobronchial blocker

Annals of Cardiac Anaesthesia, 2001

The techniques for lung isolation in infants are, endobronchial intubation and bronchical blockad... more The techniques for lung isolation in infants are, endobronchial intubation and bronchical blockade with Fogarty catheter or a univent tube. Unlike endobronchial intubation, bronchial blockade has the advantage that lung can be segregated at will. Endobronchial blocker is usually placed as a planned procedure just after induction of anaesthesia either under vision with the help of a fibreoptic bronchoscope or alternatively a rigid bronchoscope is used to position it in either bronchus and later the trachea. We report here a rather unusual and desperate way of using a Fogarty catheter halfway through the surgery due to unforeseen bleeding during thoracotomy. The pros and cons of attempting selective segregation and regional ventilation of lung under these circumstances is discussed.

Research paper thumbnail of Multimodal Treatment With Pulsed Radio-Frequency (PRF), Botulinum Toxin (BTX-A), Ultrasound Guided Dry Needling (USGDN) for Multifaceted Cervicogenic Headache - A Neuro-Myopathic Disorder

Neuromodulation, Apr 1, 2023

Research paper thumbnail of Peripheral nerve blocks including neurolytic blocks

Oxford University Press eBooks, 2022

Patients with cancer may suffer from pain due to neuralgia in a nerve distribution that may be di... more Patients with cancer may suffer from pain due to neuralgia in a nerve distribution that may be directly due to the cancer or its treatment. A successful nerve block may give considerable relief in these patients. This chapter covers a variety of different common nerve blocks such as intercostal nerve block, suprascapular nerve block, and femoral nerve block. This chapter also addresses pain service and nerve blocks in hospice settings and includes a list of key learning points.

Research paper thumbnail of How to set up a pain clinic and practice as a pain management specialist

Indian Journal of Anaesthesia, 2006

Research paper thumbnail of Reversal of Quadriplegia with Ultrasound-guided Dry Needling of Muscles Affected by Critical Illness Polyneuromyopathy/Neuropathy

Indian Journal of Critical Care Case Report, Nov 4, 2022

CASE REPORT the bronchospasm. The patient perceptibly improved, and the ventilation improved stea... more CASE REPORT the bronchospasm. The patient perceptibly improved, and the ventilation improved steadily over 48 hours. His C-reactive protein (CRP) at ICU admission was 36, and his white blood cell (WBC) count was 20,000. Later CRP varied between 399 and 145 and 120 and finally 7.5 and WBC count from 31,000 to 12,000. A transfusion of packed cells was administered to treat hemoglobin of 7 gm/dL. The patient was uneventfully weaned off the ventilator at 21 days, the tracheostomy closed, and oral feeds resumed. His glycosylated hemoglobin was 7.6 gm/dL; total protein was 5.10 gm/dL, and albumin was 2.20 gm/dL with albumin:globulin ratio of 0.76. Creatine kinase was 40 U/L, procalcitonin was 1.5, and vitamin B12 levels were normal. Then he was found to have profound quadriplegia and extensive anasarca over the extremities. The neurologist diagnosed critical illness neuromyopathy based on electromyography findings (Table 1) and started coenzyme Q. He was discharged after 26 days in the hospital and 23 days in ICU.

Research paper thumbnail of Ultrasound guided dry needling: Relevance in chronic pain

Research paper thumbnail of Multimodal Treatment for Postherpetic Neuralgia With Novel Perspective of Neuralgia as Neuromyalgia

Neuromodulation, Apr 1, 2023

Research paper thumbnail of Post-herniorrhaphy Pain and Its Management

Research paper thumbnail of Unusual hyperkalemia in neuroblastoma

Journal of Indian Association of Pediatric Surgeons, Apr 1, 1997

ABSTRACT: A 3 year old girl with neuroblastoma with preoperative diarrhoea and hypokalemia develo... more ABSTRACT: A 3 year old girl with neuroblastoma with preoperative diarrhoea and hypokalemia developed sudden intra operative hyperkalemia. The possible etiology and treatment are discussed.

Research paper thumbnail of Ultrasound Appearance of Forearm Muscles in 18 Patients With Complex Regional Pain Syndrome 1 of the Upper Extremity

Pain Practice, Apr 11, 2012

Objective: To explore the potential diagnostic utility of musculoskeletal ultrasonography (USG) c... more Objective: To explore the potential diagnostic utility of musculoskeletal ultrasonography (USG) changes in complex regional pain syndrome type 1 (CRPS-1) of the upper extremity. Methods: With informed consent, 18 consecutive patients referred to our institution with CRPS-1 of the upper limb were examined with ultrasound scanning of both upper limbs. Qualitative comparison of the scan of the forearm muscles of the affected side with the unaffected side was made. Results: The muscles affected by CRPS-1 demonstrated increased echogenecity. The outlines of the muscles were either indistinct or completely obliterated. A group of several muscles appeared like one homogenous, hyperechoic mass, with loss of normal architecture. Compared with the unaffected side, the muscle thickness on the CRPS-1 side measured by calipers on ultrasound was reduced irrespective of the duration of disability or disuse of the hand. The flexors and extensor muscles of the forearm were maximally affected. Conclusion: Ultrasonography provides useful anatomical information, regarding structure, kinesiology, and gross pathological changes of muscle, that may prove useful in understanding the motor impairment associated with CRPS-1. USG shows promise as a cost-effective bedside tool for the diagnosis of CRPS-1 and in guiding physical therapy. n

Research paper thumbnail of Interventions for head and neck cancer pain

Oxford University Press eBooks, 2022

Head and neck cancers (HNC) are the sixth most common cancer and include oral, pharynx, larynx, n... more Head and neck cancers (HNC) are the sixth most common cancer and include oral, pharynx, larynx, nasal cavity and sinus malignancies. Pain may be caused by the cancer invading nerve, muscle and bone, tumour pressure or mucositis. This chapter discusses the role of interventional procedures that target TGN, GPN, stellate ganglion, sphenopalatine ganglion and myofascial pain sources.

Research paper thumbnail of Flexion test for confirmation of tracheal tube placement in paediatrics

Pediatric Anesthesia, Jul 1, 2002

volume rather than incidence. While exposure to large volumes of blood increases the risk of tran... more volume rather than incidence. While exposure to large volumes of blood increases the risk of transfusion, the number of patients not being transfused is more important. As concluded in the recent Editorial (3), the sitting position is not yet obsolete!

Research paper thumbnail of Complex Regional Pain Syndrome-Type 1 Presenting as deQuervain’s Stenosing Tenosynovitis

Pain Physician, Jan 14, 2016

To report the presentation of complex regional pain syndrome-1 (CRPS-1) as deQuervain's stenosing... more To report the presentation of complex regional pain syndrome-1 (CRPS-1) as deQuervain's stenosing tenosynovitis (DQST). Case report: A 24-year-old woman presented with 3-year history of clinical diagnostic criteria (CDC) of CRPS-1. Conservative and surgical treatment for this as DQST had failed to relieve her. We diagnosed the problem as CRPS-1with CDC as inflammatory manifestations of a mechanical tendinoses of all her 5 digital tendons caused by movement of the fingers and hand tethered by agonist (flexor)/ antagonist (extensor) muscles in co-contraction. Ultrasound guided dry needling (USGDN) relaxed the muscles, replacing the abnormal agonist/antagonist co-contraction with normal agonist/antagonist coordination. Resolution of tendinoses reversed the inflammation causing the CDC. Six months later she leads normal personal and professional life, with reduction of scores of painDetect (from 21 to 5), Patient Health Questionnaire (from 13 to 4), Disability of arm, shoulder and hand from 70.8 to 25 and reversal of muscle abnormality characteristic of CRPS-1 on Musculoskeletal Ultrasonography (MSKUSG). Conclusion: We believe the primary pathology of CRPS-1 to be co-contraction of agonist (flexor)/antagonist(extensor) muscles of digits resulting in tendinoses akin to DQST. CDC of CRPS are actually inflammatory manifestations of tendinoses amenable to reversal by USGDN which also addresses the disability, a hallmark of CRPS.

Research paper thumbnail of Musculoskeletal Ultrasonography in CRPS: Assessment of Muscles Before and After Motor Function Recovery with Dry Needling as the Sole Treatment

Pain Physician, Jan 14, 2016

Background: Motor impairment is an important criterion in the Clinical Diagnostic Criteria (CDC) ... more Background: Motor impairment is an important criterion in the Clinical Diagnostic Criteria (CDC) of Complex Regional Pain Syndrome type-1 (CRPS-1) as defined by International Association for Study of Pain (IASP). Objective: To describe the changes in musculoskeletal ultrasonography (MSKUSG) in CRPS-1 before and after treatment with ultrasound-guided dry needling (USGDN) in retrospective data from 44 patients. Study Design: Patients irrespective of age, gender, or cause of CRPS were included in this retrospective data analysis; the Budapest criteria for the diagnosis of CRPS were stringently adhered to. Setting: The analysis was done at Ashirvad Institute for Pain Management and Research with the database of CRPS patients who were treated between December 2005 and December 2014. Methods: The CDC, range of motion at upper extremity joints, dynamometry, Disability of arm, shoulder and hand score (DASH) and ultrasonography were documented on days one, 15, and 45. MSKUSG demonstrated loss of myoarchitecture and reduced bulk. Results: All 44 patients received USGDN as the sole intervention with medications and physiotherapy. MSKUSG at 15 and 45 days after starting USGDN showed a return of normalcy to the myoarchitecture and muscle bulk increase that coincided with the disappearance of CDC and a progressive and predictable improvement of the DASH scores in all the 44 patients. Limitation: The analysis focuses on only 2 parameters: the musculoskeletal changes of the forearm flexors and extensors on ultrasound guidance and the efficacy of the dry needling treatment. It is not a comparative study with another accepted form of treatment or intervention. We have not looked into the age and gender predilection of the condition owing to the small sample size of the study. Analysis of long term maintenance of relief and rehabilitation of the disability were limited to one year. Conclusion: Myofascial pathology of co-contraction appears to cause CDC of CRPS and probable ischemic loss of myoarchitecture. Relief of co-contraction with USGDN allowed resolution of tenosynovitis causing the CDC and return of normal myoarchitecture.

Research paper thumbnail of Ultrasound-Guided Intra-articular Injection of the Radio-ulnar and Radio-humeral Joints and Ultrasound-Guided Dry Needling of the Affected Limb Muscles to Relieve Fixed Pronation Deformity and Myofascial Issues around the Shoulder, in a Case of Complex Re

Pain Practice, Jun 14, 2017

Complex Regional Pain Syndrome (CRPS) occurs due to different pathophysiological mechanisms. Pres... more Complex Regional Pain Syndrome (CRPS) occurs due to different pathophysiological mechanisms. Presently there is no description of definitive treatment that can resolve the especially recalcitrant motor issues of disability in CRPS-1. We have herein described the successful management of motor disability with a multi-modal approach in a patient with CRPS-1 that occurred as a result of a fracture sustained in the lower end of the radius. Sensory/sudomotor/vasomotor symptoms were relieved completely by medications and stellate ganglion block, in two weeks. Ultrasound guided dry needling secured near-complete improvement of shoulder and hand movements in 45 days. Ultrasound guided intra-articular (radio-ulnar and radio-humeral joint) injections with steroid, reduced residual pain and improved forearm movements by 50% initially. The patient continued to receive regular sessions of dry needling, physiotherapy and cognitive behavioral therapy. By the end of one year, the functions of the limb improved remarkably as did the functional outcome scores. In this patient with CRPS-1, intra-articular injections with steroid reduced nociception in the affected local structures and sensitization in the nervous system; dry needling resolved the myofascial issues; sustained physiotherapy maintained the motor recovery and behavioral therapy techniques addressed the cognitive and life-stress issues. It was concluded that the presenting symptoms in this case were a consequence of interactions between humoral, nervous and myofascial systems. This article is protected by copyright. All rights reserved.

Research paper thumbnail of Reversal of Complex Regional Pain Syndrome Type 2 and the Subsequent Management of Complex Regional Pain Syndrome Type 1 Occurring after Corrective Surgery for Residual Ulnar Claw

Pain Medicine, Jun 1, 2014

quent, followed by cocaine use, where over half (N = 8) with a positive UDT had a prior UDT showi... more quent, followed by cocaine use, where over half (N = 8) with a positive UDT had a prior UDT showing cocaine. Twenty-three of the 55 patients (42%) prescribed with opioids had negative UDT. Six of the 23 patients (26%) prescribed with opioids were unable to be located in the LA Board of Pharmacy database, possibly either because they never filled the prescription or they filled the prescription in another state. The remaining 17 of the 49 patients (35%) prescribed opioids who were located in the LA Board of Pharmacy were categorized as having inappropriate UDT as their UDT was negative for opioids. Six of 28 patients (21%) prescribed benzodiazepines had negative UDT. However, 5 of the 6 (83%) were prescribed benzodiazepines only for insomnia to take as needed. The remaining one patient was categorized as having an inappropriate UDT, as this medication was not prescribed to be taken as needed. Prior research findings have shown that HIV clinicians seldom follow recommended guidelines for opioid prescribing and often do not recognize opioid analgesic abuse [3]. Similar to the findings of Sekhon et al., this study highlights the problem of inappropriate UDT, suggesting the importance of integrated care for HIV patients with chronic pain. Current guideline recommendation to systematically perform UDT among all patients prescribed opioids and/or other controlled substances should be considered.

Research paper thumbnail of Successful Reversal of Complex Regional Pain Syndrome Type 1 of Both Upper Extremities in Five Patients

Pain Medicine, Sep 1, 2012

Research paper thumbnail of Chronic Pain

Research paper thumbnail of Unilateral upper limb plexopathy pain caused by cancer

Oxford University Press eBooks, 2022

This chapter explores the concept that although nerve blocks may have a place in the treatment of... more This chapter explores the concept that although nerve blocks may have a place in the treatment of upper limb plexopathy, the interventional pain doctor must assess carefully all factors contributing to a patient’s pain and distress. The chapter covers pain relief options such as stellate ganglion block, pulsed radiofrequency (PRF), and ultrasound guided dry needling (USGDN), and finishes with some key learning points for the reader.

Research paper thumbnail of Treatment of interstitial cystitis/painful bladder syndrome as a neuropathic pain condition

Indian Journal of Urology, 2014

A lady of 52 years with painful bladder syndrome/interstitial cystitis (PBS/IC) presented with ch... more A lady of 52 years with painful bladder syndrome/interstitial cystitis (PBS/IC) presented with chronic pelvic pain, irritative voiding with sphincter dominance on urodynamics. 3 yrs of oral analgesics, antispasmodics and intravesical therapy was ineffective. We surmised her pain, and irritative voiding to be secondary to constant straining against a dysfunctional pelvic floor. We treated PBS/IC as a neuropathic phenomenon with a combination of neuromodulator medications and continuous caudal epidural analgesia to reduce the pain induced peripheral and central sensitisation. Botulinum toxin type A injection into pelvic floor muscles appeared to address their dysfuction. Clinical and urodynamics response was encouraging.

Research paper thumbnail of An unusual way to use an endobronchial blocker

Annals of Cardiac Anaesthesia, 2001

The techniques for lung isolation in infants are, endobronchial intubation and bronchical blockad... more The techniques for lung isolation in infants are, endobronchial intubation and bronchical blockade with Fogarty catheter or a univent tube. Unlike endobronchial intubation, bronchial blockade has the advantage that lung can be segregated at will. Endobronchial blocker is usually placed as a planned procedure just after induction of anaesthesia either under vision with the help of a fibreoptic bronchoscope or alternatively a rigid bronchoscope is used to position it in either bronchus and later the trachea. We report here a rather unusual and desperate way of using a Fogarty catheter halfway through the surgery due to unforeseen bleeding during thoracotomy. The pros and cons of attempting selective segregation and regional ventilation of lung under these circumstances is discussed.

Research paper thumbnail of Multimodal Treatment With Pulsed Radio-Frequency (PRF), Botulinum Toxin (BTX-A), Ultrasound Guided Dry Needling (USGDN) for Multifaceted Cervicogenic Headache - A Neuro-Myopathic Disorder

Neuromodulation, Apr 1, 2023

Research paper thumbnail of Peripheral nerve blocks including neurolytic blocks

Oxford University Press eBooks, 2022

Patients with cancer may suffer from pain due to neuralgia in a nerve distribution that may be di... more Patients with cancer may suffer from pain due to neuralgia in a nerve distribution that may be directly due to the cancer or its treatment. A successful nerve block may give considerable relief in these patients. This chapter covers a variety of different common nerve blocks such as intercostal nerve block, suprascapular nerve block, and femoral nerve block. This chapter also addresses pain service and nerve blocks in hospice settings and includes a list of key learning points.

Research paper thumbnail of How to set up a pain clinic and practice as a pain management specialist

Indian Journal of Anaesthesia, 2006

Research paper thumbnail of Reversal of Quadriplegia with Ultrasound-guided Dry Needling of Muscles Affected by Critical Illness Polyneuromyopathy/Neuropathy

Indian Journal of Critical Care Case Report, Nov 4, 2022

CASE REPORT the bronchospasm. The patient perceptibly improved, and the ventilation improved stea... more CASE REPORT the bronchospasm. The patient perceptibly improved, and the ventilation improved steadily over 48 hours. His C-reactive protein (CRP) at ICU admission was 36, and his white blood cell (WBC) count was 20,000. Later CRP varied between 399 and 145 and 120 and finally 7.5 and WBC count from 31,000 to 12,000. A transfusion of packed cells was administered to treat hemoglobin of 7 gm/dL. The patient was uneventfully weaned off the ventilator at 21 days, the tracheostomy closed, and oral feeds resumed. His glycosylated hemoglobin was 7.6 gm/dL; total protein was 5.10 gm/dL, and albumin was 2.20 gm/dL with albumin:globulin ratio of 0.76. Creatine kinase was 40 U/L, procalcitonin was 1.5, and vitamin B12 levels were normal. Then he was found to have profound quadriplegia and extensive anasarca over the extremities. The neurologist diagnosed critical illness neuromyopathy based on electromyography findings (Table 1) and started coenzyme Q. He was discharged after 26 days in the hospital and 23 days in ICU.

Research paper thumbnail of Ultrasound guided dry needling: Relevance in chronic pain

Research paper thumbnail of Multimodal Treatment for Postherpetic Neuralgia With Novel Perspective of Neuralgia as Neuromyalgia

Neuromodulation, Apr 1, 2023

Research paper thumbnail of Post-herniorrhaphy Pain and Its Management

Research paper thumbnail of Unusual hyperkalemia in neuroblastoma

Journal of Indian Association of Pediatric Surgeons, Apr 1, 1997

ABSTRACT: A 3 year old girl with neuroblastoma with preoperative diarrhoea and hypokalemia develo... more ABSTRACT: A 3 year old girl with neuroblastoma with preoperative diarrhoea and hypokalemia developed sudden intra operative hyperkalemia. The possible etiology and treatment are discussed.

Research paper thumbnail of Ultrasound Appearance of Forearm Muscles in 18 Patients With Complex Regional Pain Syndrome 1 of the Upper Extremity

Pain Practice, Apr 11, 2012

Objective: To explore the potential diagnostic utility of musculoskeletal ultrasonography (USG) c... more Objective: To explore the potential diagnostic utility of musculoskeletal ultrasonography (USG) changes in complex regional pain syndrome type 1 (CRPS-1) of the upper extremity. Methods: With informed consent, 18 consecutive patients referred to our institution with CRPS-1 of the upper limb were examined with ultrasound scanning of both upper limbs. Qualitative comparison of the scan of the forearm muscles of the affected side with the unaffected side was made. Results: The muscles affected by CRPS-1 demonstrated increased echogenecity. The outlines of the muscles were either indistinct or completely obliterated. A group of several muscles appeared like one homogenous, hyperechoic mass, with loss of normal architecture. Compared with the unaffected side, the muscle thickness on the CRPS-1 side measured by calipers on ultrasound was reduced irrespective of the duration of disability or disuse of the hand. The flexors and extensor muscles of the forearm were maximally affected. Conclusion: Ultrasonography provides useful anatomical information, regarding structure, kinesiology, and gross pathological changes of muscle, that may prove useful in understanding the motor impairment associated with CRPS-1. USG shows promise as a cost-effective bedside tool for the diagnosis of CRPS-1 and in guiding physical therapy. n

Research paper thumbnail of Interventions for head and neck cancer pain

Oxford University Press eBooks, 2022

Head and neck cancers (HNC) are the sixth most common cancer and include oral, pharynx, larynx, n... more Head and neck cancers (HNC) are the sixth most common cancer and include oral, pharynx, larynx, nasal cavity and sinus malignancies. Pain may be caused by the cancer invading nerve, muscle and bone, tumour pressure or mucositis. This chapter discusses the role of interventional procedures that target TGN, GPN, stellate ganglion, sphenopalatine ganglion and myofascial pain sources.

Research paper thumbnail of Flexion test for confirmation of tracheal tube placement in paediatrics

Pediatric Anesthesia, Jul 1, 2002

volume rather than incidence. While exposure to large volumes of blood increases the risk of tran... more volume rather than incidence. While exposure to large volumes of blood increases the risk of transfusion, the number of patients not being transfused is more important. As concluded in the recent Editorial (3), the sitting position is not yet obsolete!

Research paper thumbnail of Complex Regional Pain Syndrome-Type 1 Presenting as deQuervain’s Stenosing Tenosynovitis

Pain Physician, Jan 14, 2016

To report the presentation of complex regional pain syndrome-1 (CRPS-1) as deQuervain's stenosing... more To report the presentation of complex regional pain syndrome-1 (CRPS-1) as deQuervain's stenosing tenosynovitis (DQST). Case report: A 24-year-old woman presented with 3-year history of clinical diagnostic criteria (CDC) of CRPS-1. Conservative and surgical treatment for this as DQST had failed to relieve her. We diagnosed the problem as CRPS-1with CDC as inflammatory manifestations of a mechanical tendinoses of all her 5 digital tendons caused by movement of the fingers and hand tethered by agonist (flexor)/ antagonist (extensor) muscles in co-contraction. Ultrasound guided dry needling (USGDN) relaxed the muscles, replacing the abnormal agonist/antagonist co-contraction with normal agonist/antagonist coordination. Resolution of tendinoses reversed the inflammation causing the CDC. Six months later she leads normal personal and professional life, with reduction of scores of painDetect (from 21 to 5), Patient Health Questionnaire (from 13 to 4), Disability of arm, shoulder and hand from 70.8 to 25 and reversal of muscle abnormality characteristic of CRPS-1 on Musculoskeletal Ultrasonography (MSKUSG). Conclusion: We believe the primary pathology of CRPS-1 to be co-contraction of agonist (flexor)/antagonist(extensor) muscles of digits resulting in tendinoses akin to DQST. CDC of CRPS are actually inflammatory manifestations of tendinoses amenable to reversal by USGDN which also addresses the disability, a hallmark of CRPS.

Research paper thumbnail of Musculoskeletal Ultrasonography in CRPS: Assessment of Muscles Before and After Motor Function Recovery with Dry Needling as the Sole Treatment

Pain Physician, Jan 14, 2016

Background: Motor impairment is an important criterion in the Clinical Diagnostic Criteria (CDC) ... more Background: Motor impairment is an important criterion in the Clinical Diagnostic Criteria (CDC) of Complex Regional Pain Syndrome type-1 (CRPS-1) as defined by International Association for Study of Pain (IASP). Objective: To describe the changes in musculoskeletal ultrasonography (MSKUSG) in CRPS-1 before and after treatment with ultrasound-guided dry needling (USGDN) in retrospective data from 44 patients. Study Design: Patients irrespective of age, gender, or cause of CRPS were included in this retrospective data analysis; the Budapest criteria for the diagnosis of CRPS were stringently adhered to. Setting: The analysis was done at Ashirvad Institute for Pain Management and Research with the database of CRPS patients who were treated between December 2005 and December 2014. Methods: The CDC, range of motion at upper extremity joints, dynamometry, Disability of arm, shoulder and hand score (DASH) and ultrasonography were documented on days one, 15, and 45. MSKUSG demonstrated loss of myoarchitecture and reduced bulk. Results: All 44 patients received USGDN as the sole intervention with medications and physiotherapy. MSKUSG at 15 and 45 days after starting USGDN showed a return of normalcy to the myoarchitecture and muscle bulk increase that coincided with the disappearance of CDC and a progressive and predictable improvement of the DASH scores in all the 44 patients. Limitation: The analysis focuses on only 2 parameters: the musculoskeletal changes of the forearm flexors and extensors on ultrasound guidance and the efficacy of the dry needling treatment. It is not a comparative study with another accepted form of treatment or intervention. We have not looked into the age and gender predilection of the condition owing to the small sample size of the study. Analysis of long term maintenance of relief and rehabilitation of the disability were limited to one year. Conclusion: Myofascial pathology of co-contraction appears to cause CDC of CRPS and probable ischemic loss of myoarchitecture. Relief of co-contraction with USGDN allowed resolution of tenosynovitis causing the CDC and return of normal myoarchitecture.

Research paper thumbnail of Ultrasound-Guided Intra-articular Injection of the Radio-ulnar and Radio-humeral Joints and Ultrasound-Guided Dry Needling of the Affected Limb Muscles to Relieve Fixed Pronation Deformity and Myofascial Issues around the Shoulder, in a Case of Complex Re

Pain Practice, Jun 14, 2017

Complex Regional Pain Syndrome (CRPS) occurs due to different pathophysiological mechanisms. Pres... more Complex Regional Pain Syndrome (CRPS) occurs due to different pathophysiological mechanisms. Presently there is no description of definitive treatment that can resolve the especially recalcitrant motor issues of disability in CRPS-1. We have herein described the successful management of motor disability with a multi-modal approach in a patient with CRPS-1 that occurred as a result of a fracture sustained in the lower end of the radius. Sensory/sudomotor/vasomotor symptoms were relieved completely by medications and stellate ganglion block, in two weeks. Ultrasound guided dry needling secured near-complete improvement of shoulder and hand movements in 45 days. Ultrasound guided intra-articular (radio-ulnar and radio-humeral joint) injections with steroid, reduced residual pain and improved forearm movements by 50% initially. The patient continued to receive regular sessions of dry needling, physiotherapy and cognitive behavioral therapy. By the end of one year, the functions of the limb improved remarkably as did the functional outcome scores. In this patient with CRPS-1, intra-articular injections with steroid reduced nociception in the affected local structures and sensitization in the nervous system; dry needling resolved the myofascial issues; sustained physiotherapy maintained the motor recovery and behavioral therapy techniques addressed the cognitive and life-stress issues. It was concluded that the presenting symptoms in this case were a consequence of interactions between humoral, nervous and myofascial systems. This article is protected by copyright. All rights reserved.

Research paper thumbnail of Reversal of Complex Regional Pain Syndrome Type 2 and the Subsequent Management of Complex Regional Pain Syndrome Type 1 Occurring after Corrective Surgery for Residual Ulnar Claw

Pain Medicine, Jun 1, 2014

quent, followed by cocaine use, where over half (N = 8) with a positive UDT had a prior UDT showi... more quent, followed by cocaine use, where over half (N = 8) with a positive UDT had a prior UDT showing cocaine. Twenty-three of the 55 patients (42%) prescribed with opioids had negative UDT. Six of the 23 patients (26%) prescribed with opioids were unable to be located in the LA Board of Pharmacy database, possibly either because they never filled the prescription or they filled the prescription in another state. The remaining 17 of the 49 patients (35%) prescribed opioids who were located in the LA Board of Pharmacy were categorized as having inappropriate UDT as their UDT was negative for opioids. Six of 28 patients (21%) prescribed benzodiazepines had negative UDT. However, 5 of the 6 (83%) were prescribed benzodiazepines only for insomnia to take as needed. The remaining one patient was categorized as having an inappropriate UDT, as this medication was not prescribed to be taken as needed. Prior research findings have shown that HIV clinicians seldom follow recommended guidelines for opioid prescribing and often do not recognize opioid analgesic abuse [3]. Similar to the findings of Sekhon et al., this study highlights the problem of inappropriate UDT, suggesting the importance of integrated care for HIV patients with chronic pain. Current guideline recommendation to systematically perform UDT among all patients prescribed opioids and/or other controlled substances should be considered.

Research paper thumbnail of Successful Reversal of Complex Regional Pain Syndrome Type 1 of Both Upper Extremities in Five Patients

Pain Medicine, Sep 1, 2012