Treating Complex Regional Pain Syndrome Using Counterstrain: A Novel Approach

Participants

• Number: 1

• Description: a 23-year-old woman with pain and numbness in her right foot and leg, following right plantar sesamoidectomy due to non-healing fractures. The pain had then progressively intensified over the past year. It was evaluated as 6 out of 10 at rest and 10 out of 10 in its worst occurrences; worsened by prolonged physical activity or by sitting for a long time, and relieved by light physical activity or compression stockings. Initially sharp, the pain then increased, becoming muscle cramp-like with a sensation of intense localized pressure and muscle fatigue. Later, a neuropathy developed in her right foot and leg, with associated alterations in temperature perception. Episodes of paresthesia would occur both when she was at rest and following contact with clothing or bedding (in which case she would occasionally wake up). After 9 months, severe pain and contractures began in the flexor tendons of the plantar aspect of her right foot, which would also wake her from sleep.

She tried physiotherapy (2 times a week for 4 months), medications (gabapentin 100mg 3 times a day) and braces (4 months) but without relief: the medications were then discontinued because they actually worsened the symptoms. Following a diagnosis of complex regional pain syndrome, the patient started transcutaneous nerve stimulation (TENS) 3 times a day, which brought some relief for a few hours.
At the time of the visit, the patient could not discriminate between hot and cold, and the leg alternated its color between red and purple and its tactile character between hot and cold, with episodes of swelling. The paresthesia, which began in the big toe and extended to the entire leg up to the buttock, involving the sciatic nerve, resulted in proprioceptive deficits that made it difficult for her to drive. She reported that her leg “felt like lead” and her foot “like a brick”, and movements had become limited. The severely painful areas also had tactile discrimination deficits.

On physical examination, the right leg was edematous, poorly colored, and cold to the touch. The calf and quadriceps were atrophic with restricted range of motion (ROM). Her gait was unbalanced toward the right leg, which worsened the pain. Sitting induced radicular pain radiating from the gluteus to the surgical incision made in the foot, and this pain was reproduced by deep pressure of the piriformis.
Therefore, the diagnosis of complex regional pain syndrome with secondary piriformis syndrome was confirmed.

Interventions and evaluations

• Evaluation of the symptoms
• 6 sessions of OMT
• OMT: various techniques to first establish a balance of the autonomic nervous system and then to treat the symptoms.
  • Inhibition of the orthosympathetic nervous system through rib raising with subsequent parasympathetic stimulation through suboccipital release; assessment of tissue quality from the foot to the popliteal cord to identify the presence of tender points to be treated by counterstrain; treatment of the piriformis by counterstrain; combination of continuous deep pressure and counterstrain, adjusting for patient feedback, for complex regional pain syndrome allodynia.

Results

The piriformis treatment induced immediate and lasting resolution of the following symptoms: buttock pain, paresthesia, and difficulty sitting. The combined treatment between deep pressure and counterstrain induced a series of muscle contractions/clonics that subsided once the technique was performed. With each session, the symptoms improved. From the second session, particularly painful points related to both muscular and neurological changes were treated.
After the third session there was improvement in edema, leg coloring, temperature discrimination, and proprioception.
At the end of the six sessions, temperature discrimination was fully recovered except for a small area around the surgical incision, and the patient was able to safely resume driving, as well as sitting for long periods or jogging for more than 45 minutes.

Discussion

An approach based on countestrain techniques has been shown to resolve symptoms of pain and paresthesia related to a complex regional pain syndrome.

Most likely, following the original trauma and surgery, postoperative inflammation and reduced circulation induced increased nociceptive stimulation, leading to the patient’s allodynia and hyperesthesia as well as an imbalance in the autonomic nervous system.

Accordingly, the osteopathic intervention first aimed at improving symptoms by treating hypertonic myofascial restrictions, a fact that may have induced an improvement in blood and lymphatic circulation. As a result, waste metabolites, inflammatory substances, and nociceptive neurotransmitters were removed and new nutrients arrived to the hypoxic tissues, thus improving pain, edema, and ROM. Improved movement in turn improved venous return and lymphatic flow, thus creating a virtuous circle that promoted healing throughout the course of the treatment.

In this regard, it must be remembered that myofascial restrictions with the presence of myofibroblasts not only may contribute to hypoxia but also to nerve entrapment, thus promoting nociception and inflammation. Consequently, manipulation directed at relaxing these restricted areas may promote a decrease in nociceptive electrical discharge.

Since there is not much data on the treatment of such complex syndromes with osteopathy in the literature, it should be emphasized that the processes reported above are hypotheses of the author, who hopes for an increase in scientific research in these areas in order to both improve knowledge of the pathophysiology of certain syndromes and expand the therapeutic potential.