Pain Medical Musing

POT’s is a syndrome where one is unable to maintain blood pressure standing and so often faint –  and is often associated with attacks of tachycardia.

Finding this situation in a chronic pain patient, greatly complicates the situation, and makes pain recovery less likely. I find myself scratching my head about where to go.

• Association of POTS with autonomic neuropathy brings up issue that certain Fibromyalgia cases have small fiber neuropathy. Autoimmune mechanisms are involved and question lies, which ones would respond to IV gamma globulins or Plasmaphoresis – certainly the ones with frank Chronic Demyelinating Inflammatory Polyneuropathy (CIDP) but what about milder forms? Prednisone steroid pulses work in early CRPS and could help some autonomic neuropathy (certainly in CIDP) – but when to try? Measuring certain antibodies might help but in some situations testing is rare or unavailable.
• Association of a case of POTS with chairi malformation brings up association of certain FM cases with treatable chairi syndrome cases. Our MRI testing is either unavailable or untrustworthy.
• Large association of POTS with Ehlers-Danlos hypermobility syndrome makes pain issues much more likely. Saw one case of CRPS caused by superficial radial nerve injury from unstable distal radius. Does one dare try prolotherapy to an already painful site?
• Body- wide serotonin in POTS is low  and POTS is associated with  high suicide risk, adding a deeply troubling challenge to pain in POTS cases.
• Treatment of associated sleep apnea with CPAP may be complicated. Ordinary CPAP might not work and BIPAP might need to be tried. The anxiety that is associated might limit mask use and in one case, clonazepam 1 mg hs had to be used to reduce nightmares and  ensure CPAP use.
• Cases are found of CRPS and POTS helped by treatment of bacterial overgrowth. Is this why Cefadroxil antibiotic cured one CRPS case?
• Using Naltreoxone dual opioid blocker /mild stimulator could help CRPS and POTS but how does one get subjects off opioids first?
• Rare POTS cases found deficient in thiamine, B12 and Vitamin D offer rare cures. These deficiencies also flare Fibromylagia. Treatment of the POTS with local measures and Flourinef and or Midodrine can help.

Continue reading →