Product Progress Assessment

Purpose:

I hope to send my work to Dr. Maxey and make some corrections along the way. I also hope to
tailor my case study to a scientific audience. This work should allow me to get real world
experience with scientific translation, while allowing me to go into the complexities of science.

Introduction:

Complex Regional Pain Syndrome is a rare disease that still puzzles scientists. Complex
Regional Pain Syndrome, or CRPS, has only about 74 cases of CRPS. Such a low number of
cases translates to a prevalence of about 5.46 people per 100,000 people1. CRPS is a chronic
pain that normally occurs around a joint or arm/leg. Typically the pain is noticed by shingles,
sensitivity, swelling in the painful area, temperature changes in the skin, and joint stiffness.
Normally, these symptoms occur after an injury, surgery, or a heart attack. However, CRPS can
occur even without any of these previous issues. Due to the rarity, there have not been enough
cases to determine what causes CRPS. Doctors think that CRPS could be caused by an injury to a
nerve or an abnormality in the central nervous system.

CRPS often occurs in two types: type 1 and type 2. Type 1 CRPS, or Reflex Sympathetic
Dystrophy Syndrome, is the most common type of CRPS. This type of CRPS often occurs after a
serious injury that did not damage the peripheral nerve. It is unclear how these injuries can
trigger CRPS, but some scientists speculate that it might be due to a dysfunctional interaction
between the central and peripheral nervous system2.

Treatments for CRPS vary greatly. Often patients begin with steroid injections (corticosteroid)
in which the steroid reduces inflammation of a nerve. The corticosteroid works by mimicking the
actions of hormones. Hormones keep the body intact and help maintain homeostasis. The steroid
acts as these hormones by reducing inflammation and keeping the body in balance3.

Other treatments can include a simple medial branch block. A medial branch block is blocking
the nerve branches, where the patient only loses sense for a certain part of a limb. Often the
patient is given local anesthetic which works by inhibiting channels in the cell membrane called
the sodium pump. By inhibiting the pump, the anesthesia stops sodium from centering the pump.
This stops action potentials, which are the signals sent from neuron to neuron. After numbing the
branch of the nerve, some pain doctors use a treatment called radiofrequency ablation. This
treatment heats up a needle to about 80 degrees Celsius, and kills of the branch of the nerve.
However, for CRPS this would not be feasible, as often the entire limb is affected, so burning the
entire nerve would lose complete motor function.

A popular treatment for CRPS patients is the use of stimulators. The first type is known as a
classic spine stimulator. Generally people get the spine stimulator after a failed back surgery or
after amounting tremendous pain. The spinal stimulator sends mild electrical shocks along the
spine, so pain signals are not found. Essentially, the spine stimulator is tricking the brain to
where the pain signals cannot be found. A small battery powers the spine stimulator and
generates the electrical signal. Unlike most implants, however, the spine stimulator has a trial, so
if the patient does not feel any remediation, then the patient can decide not to use it4.

A second type of implant is known as the dorsal root ganglion, or DRG stimulator. The DRG
stimulator is best noted to work on patients with CRPS. The DRG is an implant that generates
pulses and has four leads. This pulse generator is then attached to the leads near wherever the
pain is located. This stimulator also blocks pain signals with frequencies. Unlike the traditional
spine stimulator, the DRG specifically targets an area in the spine, particularly the nerve bundles.
The main role of the dorsal ganglions is to transmit information regarding senses. The dorsal
ganglion carries sensory messages from the peripheral nervous system to the central nervous
system. The stimulator sends electrical signals to the dorsal ganglion and interrupts the pain
signals, so it is never sent to the brain. This is the reason that DRG is so successful in CRPS
patients. The DRG targets specific parts to block the pain, whereas other methods block generic
pain5.

Materials:

To do a case study, one must get approved by the doctor and patient. Normally it is necessary to
get the case study approved by the hospital as well, but in this study, the patient is associated
with a different hospital. Dr. Maxey is the doctor who is helping with this case study and the
patient in which Dr. Maxey has taken approval from, is Tyler Burr. Tyler Burr is diagnosed with
CRPS and he had visited many doctors to get the problem resolved. Finally, he came to Dr.
Maxey. With Dr. Maxey he tried different treatments, and Dr. Maxey tried a new treatment. This
new treatment worked well for him.

Procedures:

1. Begin by emailing Dr. Maxey about a patient to interview for a case study.
2. After the patient has been found, email Dr. Maxey and the patient (Tyler in this case)
about coordinating a time to speak.
3. Schedule a date for the interview with both Dr. Maxey and Tyler Burr.
4. Note the details of the case and record the conversation in case, I miss anything.
5. Make an outline of the case study writing and analysis.
6. Get the outline approved by Dr. Maxey and begin working on the rough draft.
7. Edit it at a minimum of 3 times, then show it do Dr. Maxey and get it approved.
8. Call other pain management doctors to get any more suggestions.

Conclusions:

Tyler has had a variety of treatments and had suffered from CRPS for about five years. Suffering
with CRPS really affected his daily activities, as he could enjoy doing them. Only pain medicine
worked for Tyler, as other methods have proven to be ineffective. His pain began with shingles
and small pain from the belly to the right side of the back. Shingles is essentially a minimal
version of smallpox and has an antibiotic. For Tyler, however, the antibiotic did not work and
stressed him out. Tyler’s right leg continued to hurt with redness and swelling. Over time, the
pain became worse with effects such as burning becoming prominent. After consulting an
internal medicine doctor, Tyler was sent to go see a neurologist. They tried to do a branch block
on Tyler’s nerve, so he could possible not feel the pain in the leg. Not only did the branch block
fail to help the pain, but shortly after the injection, Tyler actually began to get muscle spasms.
Soon after the muscle spasms, the pain spread to the left leg and became red. This redness would
hurt a lot and begin to create the shingle feeling. Another type of treatment that Tyler underwent
is known as a typical epidural steroid injection. Doctors were hopeful that this would alleviate
Tyler’s pain, but once again this did not work.

After the pain continued to persistent, Tyler got more pain medication, like opioids. The pain
would still continue without much more help. To find the problem, Tyler received an EEG scan,
which uses electrical signals to sense brain activity. After doing this, the neurologist did not find
one specific thing that led to the pain of Tyler. At this time, the doctors still did not believe
CRPS was the problem. Going on with pain procedures, Tyler received a spine stimulator trial,
which seemed to be terrible for him. It made his pain unbearably worse, so doctors decided to
not use spinal stimulators any longer. The spinal stimulator has created more pain in several
other areas, so this was not too unusual. Looking at the procedures, so far, it is evident that
couple procedures would just not work.

Further, Tyler got an X-Ray to see any possible abnormalities, so doctors could understand the
state of Tyler’s pain. The X-Ray shows that Tyler’s bones were dematerialized and seemed much
weaker than a normal bone. Looking at the images, it became evident that Tyler had been
suffering from CRPS. From this point, doctors were sure that Tyler suffered from CRPS, so they
began to shift their treatment plans and only to focus specifically on CRPS. One downside to all
these procedures is that all the medicines and anesthesia has caused the shingles to come back. It
is unclear why this has caused shingles, but this intact led the doctors toward different trials. One
trial was an epidural placement, which places a machine to displace steroid into the epidural
space. While doing this, the doctors also decided to freeze a nerve, so they could monitor the
pain levels. However, this did not help reduce the pain as doctors thought it would. After this
procedure had failed, doctors tried to use a pain pump on Tyler. The pain pump is supposed to
release fluids into the body as medicines. This procedure did not change the pain for Tyler.

Soon after, Tyler stopped using opioids, as he did not want to deal with the long term effects.
The long term affects of opioids is still unknown, so Tyler decided to try another type of
stimulator called the DRG, or the dorsal root ganglion. The first trial did not work at all, but
research shows that the DRG is effective in CRPS patients, so Tyler received a second trial. The
second trial worked greatly, and Tyler’s pain went down from an 8/9 to a 2/3. Tyler could not
wear jeans previous to using the DRG because of them being too tight, but the DRG allowed him
to do so. Thus, he was able to go back to doing daily activities. While doing daily activities,
Tyler also underwent physical therapy and desensitizing activities. The desensitizing activities
are meant to help CRPS patients feel the areas of pain, without being overly reactive. Slowly, but
surely, Tyler was returning back to daily life. Many of his symptoms are gone with the DRG, and
he has recommended the DRG to anyone with CRPS, as it helped him greatly.

1. Paola, Sandroni, and Benrud Larson. “Complex Regional Pain Syndrome Type I: Incidence and... : PAIN.” LWW,
journals.lww.com/pain/Abstract/2003/05000/Complex_regional_pain_syndrome_type_I__incidence.23.aspx.
2. “Complex Regional Pain Syndrome.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 15 Feb. 2018,
www.mayoclinic.org/diseases-conditions/complex-regional-pain-syndrome/symptoms-causes/syc-20371151.
3. “Prednisone and Other Corticosteroids: Balance the Risks and Benefits.” Mayo Clinic, Mayo Foundation for Medical Education and
Research, 26 Nov. 2015, www.mayoclinic.org/steroids/art-20045692.
4. Mehta, Neel. “Spinal Cord Stimulation for Chronic Back and Neck Pain.” Spine-Health, 23 Sept. 2016, www.spine-
health.com/treatment/back-surgery/spinal-cord-stimulation-chronic-back-and-neck-pain.
5. “What Is DRG Stimulation, And Can It Help My Pain?” Pain Doctor, paindoctor.com/treatments/dorsal-root-ganglion-stimulation-
drg-stimulation/.

Summary of Work:

Thus far, I have finished my rough draft for the case study. I have also sent the rough draft to Dr.
Maxey, so he can check up on it and give me some suggestions. My work has been productive,
but additional improvements should be made. My rough draft consists of the introduction above,
which has to be looked at further in depth. Additionally, I went over my steps toward finishing
my case study. Lastly, I showed the conclusions that have been made thus far, based off the
patient used in this case study.

Reflections:

Thus far, this has been my work. This is my most basic/ rough draft of the case study. It is
evident that I have much more work to do, as I am not ready to show this to professional
audiences. Of course, I have not tailored it that far. I am finding it difficult, however, to use a
high level of vocabulary, as I am not a strong writer. I also lack the knowledge of a pain
management doctor to make this work, of such eloquence. Even through all the downsides, I am
very happy with my work thus far. I have put in a lot of effort, and am confident in my abilities
to move forward. Further steps would include fixing up my writing and tailoring it to a more
scientific audience.

Dates:
2/20/2018- Finalization of product proposal and steps to take toward the success of product

More Dates TBD

Future Work:

In the coming weeks, I will wait to see the suggestions of Dr. Maxey. After doing this, I will ask
Dr. Maxey for help in making my piece much more novel and scientific. After this, I will make
the final touches before visiting other pain management doctors for their suggestions.