treating complex regional pain syndrome ( crps ) is difficult because it still does not have a recommended therapy .
a 29-year - old man was diagnosed with crps after surgery on his 4 and 5 left toes 7 years ago . though he had undergone diverse pain treatment , the symptoms persisted , so he visited dunsan korean medicine hospital of daejeon university .
this case report presents results on the effect of bee venom pharmacopuncture in treating patient with crps .
bee venom pharmacopuncture ( bvp ) , 0.15 to 0.4 ml dosage , was administered at gb43 .
the symptoms were evaluated using a numeric rating scale ( nrs ) and the dosage of pain medicine .
on the first visit , he was taking an anticonvulsant , a trycyclic antidepressant , and an analgesic . on the nrs
he also complained of severe pain and hypersensitivity when the 4 and the 5 toes were touched just slightly .
after treatment , on the nrs , the score for toe pain was 0 , and he no longer needed to take pain medication . during the 4-months follow - up period , he has remained without pain ; neither have additional symptoms appeared nor adverse events occurred .
complex regional pain syndrome ( crps ) is a neuropathic pain disease , which is the name now given to group of conditions previously described as  reflex sympathetic dystrophy ( rsd) , 
algodystrophy ,  sudeck s atrophy. this chronic pain syndrome appears after big and small tissue damage , such as a sprain , a fracture , neurologic damage , spinal cord injury , cerebral infarction and myocardial infarction .
these conditions share a number of clinical features , including spontaneous pain that is mostly on the limbs , associated allodynia , hyperalgesia , autonomic changes , trophic changes , and functional loss .
the diagnosis of crps had been based on the criteria of the international association for the study of pain published in 1994 .
however , due to the lack of specificity and accuracy of diagnosis , the criteria , as revised in 2004 , are used instead .
the primary medications for treating crps are anti - inflammatory drugs , anticonvulsants , antidepressants , and steroids . for additional pain control , nerve blocks , such as regional nerve blocks and sympathecotomies , and interventional
treatment , such as spinal cord stimulation , are used together . though various remedies exist , the therapeutic responses to traditional treatments are relatively poor , and because of the complicated symptoms , a diverse approach is necessary . besides the traditional therapy ,
patients with crps recently treated in china were reported to have been improved by 80% , and that improvement continued for more than 20 months .
also , chronic crps patients treated with acupuncture have been reported to show reduced pain and depression and enhanced quality of life . in additional to international studies on acupuncture , cases using anti - inflammatory pharmacopuncture , harpagophytum radix .
pharmacopuncture , and placental extracts   have been reported in korea . in this research study
, we describe the case of a patient with crps who responded to bee venom pharmacopuncture ( bvp ) with impressive and sustained results .
this patients was a 29-year - old male with a history of congenital polysyndactylia of the 4 and the 5 toes .
he had undergone a polydactyly resection , separation of syndactyly , and split thickness skin - graft on march 14 , 2006 and surgery on the necrosis site on april 20 , 2006 .
after joining the army in 2006 and complaining of difficulty with military life because of the congenital polysyndactylia , he underwent resection , separation of syndactyly , on his 4 and 5 toes . after the surgery he reported pain and paresthesia on those toes and was diagnosed with crps ; however , according to the operation notes , no neurologic damage had occurred .
afterward the diagnosis , he was treated with anti - inflammatory drugs , anticonvulsants and antidepressants and had undergone nerve blocks 10 times before being examined at our clinic . when the pain worsened , he was prescribed a narcotic analgesic , in spite of which he complained of pain of more than 5 on the numeric rating scale ( nrs ) , depression , and anxiety .
although he had received treatments such as medications and nerve blocks , the pain had not decreased under a nrs score of 5 , even reaching a nrs score of 8 on occasion .
also , long - term therapy and medication had led to depression and anxiety . on the first visit
, he was taking an anticonvulsant ( gabapentin ) 2700 mg / day , a trycyclic antidepressant ( amitriptyline hydrochloride ) 10 mg / day , and an analgesic ( tramadol hydrochloride ) 50 mg as required .
at the first examination in our clinic , he complained of severe pain and hypersensitivity when his 4 and 5 toes were touched just slightly and of dyspepsia , rash , and depression . during the treatment period at our clinic , which ran from january 2 , 2014 ,
the patient first visited dunsan korean medicine hospital on december 14 , 2013 , and started receiving injection of sweet bvp from january 2 , 2014 .
the acupuncture point was gb43 , near the tender point , and the dosage of bee venom was gradually increased from 0.15 to 0.4 ml .
the initial plan was once a week for 10 weeks , but as the treatment progressed , we added the treatment period was extended to 14 weeks . at the first treatment , the dosage of the bvp was 0.15 ml , at the second treatment , it was 0.2 ml , and at the third treatment , it was 0.3 ml .
as the dosage of 0.3 ml induced no side effect , the dosage was kept at 0.3 ml until the 8 treatment . for the remaining treatment after the 8 ,
the irritation decreased , but no change in the nrs score was noted . on the 2 day of treatment , the patient reduced gabapentin from 2700 to 900 mg / day , though the nrs score still persisted .
on the 4 day of treatment , the average nrs score declined from 5 to 3 , and the sharpest pain appeared just once or twice a week , with rare sudden pain . on the 5 day of treatment
after that treatment , the patient experienced pain to a regular degree without sudden severe pain .
after the 7 day of treatment , he reduced the dosage of gabapentin from 900 to 600 mg / day for 2 weeks , but upon feeling discomfort , increased it to 900 mg / day again . on the 10 day of treatment
, he reduced the dosage to 300 mg / day and experienced no increase in pain after that .
while insomnia and anxiety arose without the trycyclic antidepressant , he took additional herbal medicine , ondam - tanggami ( wendan - tangjiawei ) . on the 13 day of treatment , he stopped taking all western medicines .
after the 14 treatment , the last injection , the average nrs score was 1 to 2 .
on the nrs , the patient rated his pain as 0 after the 2-months and the 4-months follow - ups ( may 30 and of july 31 , 2014 ) .
no additional symptoms have occurred ( table 1 ) , ( fig 2 ) . during the 14 treatments , no side effects due to bee venom
especially , at the 11 treatment , the patient noted insomnia and anxiety after discontinuing amitriptyline hydrochloride .
he took herbal medicine for 2 weeks , after which those symptoms were relieved , with no further occurrence .
after the 14 treatments , the pain had disappeared at the surgical site , and the sensation in the 4 and the 5 left toes was 80% that in the 4 and the 5 right toes ( table 1 ) .
we administered 0.15 ml of sweet bvp initially , but because the duration of the disease had been long and the pain control had been difficult , the dosage was increased gradually to 0.4 ml ( fig 1 ) we checked for any side effects while increasing the dosage . although the patient felt stiffness at the injection point on the foot , a dosage under 0.3 ml was considered to be appropriate .
the initial plan was for one injection to be given each week for 10 weeks , which was based on the experience of the therapist .
after 10 treatments and 2 weeks of observation , although his pain level on the nrs was 2 and he felt no inconvenience in daily living , we decided to perform four additional injections until the symptoms disappeared . on the 10 day of treatment ,
the pain had decreased to an average nrs score of 2 , and on the 13 day of treatment , the patient noted pain relief without any medication .
especially , on the 14 day of treatment , of the last treatment , pain had disappeared , and just a little paresthesia was noted .
we could relieve the symptoms with 10 treatments , but they had completely disappeared after the four additional treatments .
thus , we recommend that the treatment plan be based on 10 treatments , with the possibility of about 5 additional treatments , depending on the state of the patient
. the patient additionally complained of insomnia and anxiety during the course of treatment , the 11day .
he had undergone depression because of persistent pain and failure to control the pain associated with crps . as the insomnia and anxiety
were thought to be symptoms caused by discontinuing the nervous system drugs which he had taken for the last 7 years , we administered herbal medicine .
he reported that it irritated him , but not strongly , and the insomnia and anxiety disappeared after 2 weeks .
a period for discontinuing medication that has been taken for a long time , rather herbal medicine , seems to be needed .
no new systemic symptoms appeared following the treatment , and no additional medication was prescribed , except for the herbal medicine ondam - tanggami ( wendan - tangjiawei ) used for insomnia and anxiety and the intermittent herbal medicine sojukgunbihuan ( xiaojijianpiwan ) used for dyspepsia .
due to the fact that there are few distinct treatments for crps , many studies on anti - inflammatory drugs , nerve blocks , vitamin therapy , and acupuncture for treating patients with crps [ 11 , 12 ] . among those ,
a study on bee venom therapy is now ongoing , and it has been proven with rodents that bee venom alleviates thermal hyperalgesia .
also , a chemotherapy - induced peripheral neuropathic pain model   and clinical research [ 15 , 16 ] have already established the effect of bee venom therapy .
although these studies are not related to crps , they do show the effectiveness of using bee venom to treat neuropathic disease .
thus , using bee venom therapy to treat patients with crps should hold promise . in the present case , bee venom therapy administered to a patient who had been suffering from crps with failure to control its pain for almost 7 years proved to be effective . however , the exact mechanism and therapy methods are beyond the limits of this case report .
we particularly suggest further studies on the required length of the treatment and the dosage for bee venom therapy , clinical observations of bee venom therapy , and studies on the mechanisms of bee venom therapy applied to neuropathy .
 objectives : treating complex regional pain syndrome ( crps ) is difficult because it still does not have a recommended therapy . a 29-year - old man was diagnosed with crps after surgery on his 4th and 5th left toes 7 years ago . though he had undergone diverse pain treatment , the symptoms persisted , so he visited dunsan korean medicine hospital of daejeon university . 
 this case report presents results on the effect of bee venom pharmacopuncture in treating patient with crps.methods:bee venom pharmacopuncture ( bvp ) , 0.15 to 0.4 ml dosage , was administered at gb43 . 
 the treatment was applied each week for a total 14 times . 
 the symptoms were evaluated using a numeric rating scale ( nrs ) and the dosage of pain medicine.results:on the first visit , he was taking an anticonvulsant , a trycyclic antidepressant , and an analgesic . on the nrs 
 the worst pain in the toes received a score of 8 . 
 he also complained of severe pain and hypersensitivity when the 4th and the 5th toes were touched just slightly . 
 other complaint included dyspepsia , rash , and depression . 
 after treatment , on the nrs , the score for toe pain was 0 , and he no longer needed to take pain medication . during the 4-months follow - up period , he has remained without pain ; neither have additional symptoms appeared nor adverse events occurred.conclusion:bvp may have potential benefits for treating patients with crps . 
Objectives:
Methods:
Results:
Conclusion:
1. Introduction
2. Case report
3. Discussion