Post Stroke Joint Pain/ CRPS/ EDS/ Misc

POST STROKE JOINT PAIN/ COMPLEX REGIONAL PAIN SYNDROME (CRPS)

Post Stroke Joint Pain is a condition which may accompany an injury or stroke and may cause peripheral chronic pain in the shoulder joints, arm or leg. The condition develops continuous throbbing pain and is sensitive to touch, changes in skin temperature, color and texture with joint stiffness, swelling and damage affecting the movement ability of the affected part.

The main causes for post stroke joint pain is either central or peripheral in origin. Conventional treatment methods take in a combination of therapies including medications, therapies and nerve stimulations to strengthen the range of motion of the affected body parts ad joints.

Complex regional pain syndrome (CRPS) is a complex neurological syndrome that causes intense pain after a trauma or injury to the peripheral nerve in any part of the body. The condition occurs in any part where there is a peripheral nerve running from the spine to the body extremities including arms, hands, legs and feet. The doctor diagnoses the symptoms and tailor treatment plan to reduce pain and inflammation. This includes medications, nerve stimulations and physical therapy to improve range of motion of the affected body part.

HYPERMOBILITY/ EHLERS-DANLOS SYNDROME WITH ARTHRALGIA/ RECURRENT DISLOCATION OF PATELLA

It is a condition affecting the connective tissues present in joints and blood vessel walls. They are inherited disorders that damages or alters the strength and elasticity to the underlying connective tissues in the body resulting in stretchy, fragile skin and overly flexible joints. The exact cause of the condition is unknown and is inherited from the parents. The doctor checks for extremely loose joints, ability to hyperextend elbows and knees, touch floor with palm of hands, fragile skin, and a family history of EDS syndrome to diagnosis the condition.

Comprehensive Dextrose Prolotherapy for Hypermobility/ Ehlers-Danlos syndrome with Arthralgia/ Recurrent Dislocation of Patella  
Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to loose and damaged ligaments, tendon and muscle attachments around the involved joint. Prolotherapy  works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament regeneration, tightening and repair. Prolotherapy is an effective non surgical treatment method used successfully in many joint conditions, and in Dr Tejaz John’s experience it can prove to be helpful in patients with recurrent dislocation of patella/ EDS. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous structures in the joint and near the knee cap.

Patient Benefits of Comprehensive Dextrose Prolotherapy

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who wish to avoid if not delay Surgery
• Significantly reduces the symptoms of Recurrent dislocation of Patella and Arthralgias in Ehler Danlos Syndrome.Repairs and tightens
• ligaments improving joint stability and ease of standing, sitting & walking
• Safe and effective treatment method, reduced risk of adverse events.
• Faster healing and recovery.

To know more about Prolotherapy for Hypermobility/ Ehlers-Danlos syndrome with Arthralgia/ Recurrent Dislocation of Patella book an appointment now.                           

ALTERNATE TREATMENTS FOR POST STROKE JOINT PAIN (PERIPHERAL)/ CRPS AT BETH YEHUWDAH ARTHRITIS CENTRE, PULLAD AND DAYSTAR CLINIC , ALAPPUZHA

Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Significantly reduces the symptoms associated with CRPS and peripheral causes of Post Stroke Pain.
• Reduced risk of adverse events compared to oral steroid tablets which are taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• Reduces joint stiffness.
• Effective treatment method in neural symptoms like numbness, tingling and weakness caused due to inflammatory conditions.
• Faster recovery.
• NESTIT treatment usually results in significant, effective, progressive improvement of pain, numbness, and function if given in series.

At Beth Yehuwdah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha we provide a variety of options for patients suffering from Post Stroke Joint Pain/ CRPS. To know more about treatment plans and treatment cost, book an appointment now from one of the best joint pain treatment center in Kerala.