Expert interdisciplinary care can allow patients with chronic pain to live an improved quality of life. The model of integrated physical therapy with behavioral health and medical support works when patients are able to invest themselves fully in their treatment. The model breaks down when patients are in too much pain to consider rehabilitation as a treatment option, as is often the case with CRPS.
A recipient of the APS Clinical Centers of Excellence Award, Pacific Rehabilitation offers an interdisciplinary program that can include interventional treatment for injured workers. The goal is to move patients from a chronic cycle of pain associated with activity towards an active lifestyle and even return to work. The program combines managing pain aggressively, specialized treatment using functional restoration (including targeted stretching and strengthening, correcting postural abnormalities, treating the muscle pain present with the disorder), CRPS specific treatment (including desensitization, graded motor imagery, mirrorbox therapy and edema management) and providing psychological support to help patients reach their goals. The program has seen patients make gratifying improvements in the ability to function.
Some patients, who have already undergone numerous procedures, including sympathetic ganglion blocks and related surgeries prior to seeking out pain center treatment, choose to focus only on physical rehabilitation. Others seek pain relief before they can begin the process of recovery. For these patients, an anesthesiology team at a local hospital places a temporary epidural catheter infusing anesthetic continuously for one to two weeks. Typically, patients experience significant pain relief, are then able to begin weight-bearing or to move their upper extremity, enabling them to start therapy. After the catheter is removed, the intensity of rehabilitation increases over 2- 8 weeks until patients show maximum recovery.
While the combined interventional and interdisciplinary rehabilitation approach isn’t a cure, it reduces the patient’s burden of pain so that they can envision returning to their former activities. Two case examples:
Ruth of Sumas, Washington said: “The whole process wasn’t as intimidating as it sounds. The doctors have been so nice and everyone’s involvement was helpful. I received information about touch therapy and meditation which has been useful, in addition to rehab. The catheter made a difference to my pain levels. I no longer have pain as high as 8-10/10. I mostly have pain at 3/10, at most it will go up to 5/10. It helped to do rehab with the catheter in place. The treatment has allowed me to keep my glove off. Instead of wearing it 24/7 now, I now wear it 2 hours a day. It’s good to be able to do things you haven’t in a while because of the pain.” Ruth completed the program with the goal of returning to work as a cashier.
Another graduate opted not to use the interventional approach but focused on rehabilitation and discontinuing use of opioids while in the program. He had initially sustained a crush injury to the lower extremity and compartment syndrome, requiring multiple surgeries to stabilize ankle and leg fractures. Initially on high dose opioids, he was tapered off during the course of rehabilitation. Prior to Pain Program treatment, he had already had more than a hundred visits of physical therapy but was still dependent on a cane and falling a few times a month. After the program, he had a near-normal gait pattern without a cane, had tapered off all opioids, improved his standing ability from 15 minutes to 60 minutes, improved body mechanics from 64% to 100% and demonstrated ability to lift 50 lbs (improved from 20 lbs). This was sufficient to allow him to proceed towards vocational retraining in Engineering.
Although CRPS can be a devastating condition, a balanced approach is imperative for the most severe cases, and can be a starting point towards recovery.
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Niriksha Malladi, MD
Dr. Niriksha Malladi is the Medical Director of Pacific Rehabilitation Centers and responsible for overseeing quality and safety of medical care in the Center’s programs. In addition to her medical director responsibilities, Dr. Malladi serves on the Physician Advisor Panel for the Center of Occupational Health & Education (COHE) of Western Washington, and is on the American Pain Society Selection Committee for the Centers of Excellence Awards.
Dr. Malladi is a board-certified Physiatrist who specializes in the non-operative treatment of musculoskeletal, pain and spine disorders and has expertise in the multidisciplinary treatment of chronic pain. She sees patients with musculoskeletal disorders, nerve pain, myofascial pain syndromes, chronic pain, spinal disorders and work-related injuries. She has researched and published on interdisciplinary pain management, interventional approaches to pain, and electrodiagnostics.
Dr. Malladi’s treatment philosophy involves treating the whole person, not just the pain. By identifying the contributors to persistent pain, targeted therapy is applied to improving the person’s well-being. With this approach, patients are frequently able to taper off medications, integrate safe and healthy approaches to pain management and improve their ability to function at work and home.
Dr. Malladi is an active member of the American Pain Society and American Academy of Physical Medicine and Rehabilitation.
