NEUROLOGICAL AND MUSCULOSKELETAL DISORDERS
Summary
The case involves a 43-year-old White male with a chief complaint of pain which began seven years ago. He was referred for psychological assessment as the family physician felt that the pain was ‘in his head’. He has been on hydrocodone but uses it sparingly due to side effects. The patient has a normal mental assessment status. During the interview, he experiences cramping and from the knee downwards turned purple which was witnessed by the attending physician and lasted about two minutes. The patient was diagnosed with complex regional pain disorder (CRPS). CRPS is a chronic pain disorder that often lasting more than six months and affects one’s limbs after an injury caused by damage or malfunction of the peripheral and central nervous systems (Birklein, 2015).
The first decision made beginning Savella 12.5mg OD on day 1: followed by BID on days 2 and 3, and then BID on day 4-7, followed by 50mg afterward. The patient reports on the 4th week without using crutches but limping slightly. Report that pain is manageable with a scale of 4. He complains of increased sweating and his vitals demonstrate elevated blood pressure of 147/92 mmHg and pulse of 110b/min. The second decision I took is continuing with medication but lowering the dose to 25mg twice a day; the patient reports using crutches and increased pain threshold at a scale of seven. the blood pressure levels reduced to 124/85MmHg and pulse of 87. The patient appears to have lost hope due to a recent slip in his pain. The third decision I took is changing the Savella dosage to 25mg orally in the morning and 5omg in the 50mg at bedtime. other therapies include physical and occupational therapy, and psychological therapy as the pain has a huge impact on the psychological and emotional status of the patient.
Support with evidence-based literature
I believe that the decisions made are ported by evidence. Savella is an SNRI used in the treatment of chronic neuropathic pain, fibromyalgia, and depression. An increase in 5HT and NE inhibits pain signals in the brain and spinal cord. The patient is likely to be depressed after being abandoned by her fiancée and his work is affected, therefore, the use of Savella is effective in managing depression and relieving chronic pain. Due to the side effect of nausea, increased sweating, and elevated blood pressure, dose adjustment is recommended. According to Goh, Chidambaram, & Ma (2017), Savella is administered in two dived dosages per day and the dose is adjusted based on the patient’s tolerability. Savella is known to cause elevated blood pressure thus it should be measured before initiating therapy and monitored periodically.
Expectations
By initiating the treatment, I aimed to relieve pain while avoiding side effects. There is no definite treatment of CRPS but pain management is crucial in increasing the quality of life and reducing psychological and emotional burdens (Goh, Chidambaram, & Ma, 2017). Therapy aims to reduce pain and enable the patient to gain the functional ability of the limb. The first decision was aimed at reducing pain and preventing depression. The second decision aimed at improving pain to scale of 3, and reducing blood pressure levels while the third decision was aimed at maintaining blood pressure and elevating the symptoms of CRPS. To reduce side effects, the low and gradual dosage is recommended (Mackey & Feinberg, 2017). Therefore, the decisions made should consider patient symptoms, side effects, and the goals of therapy.
Difference between expected and actual results
Decision #1: I expected to reduce pain and increase the function ability of the limb. The patient has been abandoned by the fiancé and his job affected thus although he denies being depressed, I aimed to reduce depression. I achieved my expectations although the patient presented with side effects such as nausea and elevated blood pressure. In the second decision, I aimed to reduce blood pressure, increase function ability, and pain threshold to scale of 3. However, the results demonstrated a worsened pain threshold &7/10, reduced function ability, and the patient was depressed. Blood pressure reduction was achieved. The third decision, aimed at maintaining low levels of blood pressure and managing pain. Although the was no total pain control, the threshold was manageable. It is recommended that other therapies such as psychotherapy and physical therapy combined with medication can improve outcomes and reduce the burden of the condition. Mackey & Feinberg (2017) stated stopping using medication or changing it will cause withdrawal symptoms thus it is recommended to lower drug dosages slowly.
References
Birklein, F. (2015). Complex regional pain syndrome. Journal of neurology, 252(2), 131-138. Retrieved from: https://link.springer.com/article/10.1007/s00415-005-0737-8
Goh, E. L., Chidambaram, S., & Ma, D. (2017). Complex regional pain syndrome: a recent update. Burns & Trauma, 5(1). doi: 10.1186/s41038-016-0066-4
Mackey, S., & Feinberg, S. (2017). Pharmacologic therapies for complex regional pain syndrome. Current pain and headache reports, 11(1), 38-43. https://dx.doi.org/10.1007%2Fs11916-007-0020-z