Complex regional pain syndrome requires aggressive rehabilitation
Saturday, April 30, 2005
Over the last few weeks, this column has featured a variety of chronic pain conditions, including lower back pain, pelvic pain and fibromyalgia. They increasingly are recognized by health-care providers as common disorders that significantly interfere with our ability to function.
An intriguing but less common cause of chronic pain is called "complex regional pain syndrome," previously known as "reflex sympathetic dystrophy" or "causalgia." This condition originally was described during the Civil War, when soldiers experienced continuous, often burning, pain long after their gunshot wounds or stabbing injuries had healed.
Unlike conditions such as arthritis, which affect many parts of the body simultaneously, CRPS usually begins in one limb. It occurs three times as often in women than men and can occur at any age, even in children.
In CPRS, patients generally experience persistent pain in an arm or leg, often with a burning or aching quality. The skin of the affected limb can change color, from white to blue to a mottled reddish color. The skin is extremely sensitive to touch; even a gentle breeze or light brush from clothing will produce intense pain. This excessive sensitivity is called allodynia, and makes even everyday events such as putting on clothing painful.
If untreated, the affected limb may become stiff and swollen. It may sweat more than the limb on the other side. Since moving the limb makes the pain worse, patients protect the arm or leg from movement, which leads to weakness and atrophy of the muscle, which results in even less mobility.
CRPS often occurs after trauma to an extremity. The injury does not have to be severe. Even a seemingly mild event, such as a sprained ankle or a bruised thumb, can result in this chronic, painful condition. Even vaccinations have been reported to produce it. The pain outlasts the injury, persisting long after the original condition has healed. Even when the original site of the trauma is small, the pain can spread to the entire extremity.
There are two types of CRPS: Type I occurs after an injury, illness or surgery that didn't directly damage the nerves of the limb. Type II follows a direct trauma to the nerve itself and is less responsive to treatment than Type I.
Fortunately, the incidence of CRPS is very low. According to a review article in the Archives of Neurology, only 2 percent to 14 percent of nerve injuries to limbs result in this syndrome. However, about 10 percent of patients seen in pain clinics are diagnosed with this disorder.
The main therapy for CRPS is what most patients would rather not do: movement. Moving an affected arm or leg initially worsens the pain, but immobility can lead to permanent bone and joint changes and loss of muscle bulk. At its worst, CRPS can result in a useless limb.
Early treatment is imperative, before muscle wasting and joint stiffness occur. An aggressive physical therapy and rehabilitation program focuses on the return of function to the arm or leg. Therapists use desensitization techniques to "train" the skin to become less sensitive to touch or pressure. They start with a light cotton touch and, gradually, move to more rough materials stroked on the skin.
Medications for CRPS include simple analgesics such as acetaminophen and anti-inflammatory agents. Topical pain relievers such as Aspercreme and Ben-Gay often are well-tolerated. Anti-inflammatory drugs such as corticosteroids are used cautiously, as they may have risky side effects over the long term. Some steroid preparations are available in creams and gels, which are safer than ingesting them orally. Many patients find that the prescription Lidoderm Patch, a local-anesthetic, provides effective relief.
Long-term medicines include those that act directly on the nerves - in the affected limb or in the brain - that carry and receive pain signals. Tricyclic antidepressants, serotonin-active drugs and muscle relaxants help many individuals. Blocking the nerve signals at their source is accomplished with sympathetic nerve blocks, which often can give immediate and long-lasting relief.
In severe cases, narcotics and local anesthetics can be infused directly into the space surrounding the spinal cord and spinal cord stimulators, which are tiny electrodes placed near the nerves of the spine.
Mind-body treatments, therapeutic touch and reiki healing help individuals with chronic pain increase function and diminish the effect pain has on everyday activities. There is also evidence that acupuncture can increase the release of chemicals called endorphins that block the brain's perception of pain. Since many acu-points are near nerves, the stimulation of these nerves from acupuncture needles activates the nerve's muscle, sending a signal to the brain to release these endorphins, which act much like morphine to dull pain.
The most successful treatment for CRPS, much like other chronic pain syndromes, entails a combination approach. Short and long-term medications, nerve blocks or spinal cord stimulators can allow an individual with CRPS to break the cycle of the pain and permit vigorous participation in a supervised exercise program to prevent immobility and ultimate disuse of the affected limb.
Women (or the men who care about them) who have a question about women's health can send their questions to Tucker via e-mail to AskDrTucker@aol.com or mail them to Ask Dr. Tucker, The Plain Dealer Features Department, 1801 Superior Ave., Cleveland, OH 44114. Tucker is a clinical associate professor of neurology at Case Western Reserve University School of Medicine and is directing medical-student education at the American Headache Society.
Â© 2005 The Plain Dealer. Used with permission.
Saturday, April 30, 2005
Monday, April 25, 2005
Neurology Deptartment at Massachusetts General Hospital
Originally uploaded by rsdscrpsnews.
This might be helpful to people that are newer to learning about RSDS/CRPS. It's an archive of a web forum of questions and responses. The forum is a bit old.. but there is a lot of interesting information inside. The forum is a part of the Department of Neurology at Massachusetts General Hospital website.
Click here to acess the forum
Compiled by Editor at 4/25/2005 05:50:00 PM
Saturday, April 23, 2005
Complex Regional Pain Syndrome
By Mayo Clinic staff
Complex regional pain syndrome (CRPS) â one type of which was formerly known as reflex sympathetic dystrophy syndrome â is an uncommon, chronic condition that usually affects your arm or leg. Rarely, the disease can affect other parts of your body. You may experience intense burning or aching pain along with swelling, skin discoloration, altered temperature, abnormal sweating and hypersensitivity in the affected area.
The nature of CRPS is puzzling, and the cause isn't clearly understood.
Women are more likely to be affected by CRPS than men are. The condition is most common in people between the ages of 40 and 60, but it can occur at any age. Treatment is most effective when started early in the course of the syndrome.
Signs and symptoms
CRPS occurs in two types, with similar signs and symptoms but different causes:
* Type I. Previously known as reflex sympathetic dystrophy syndrome, this type occurs after an illness or injury that didn't directly damage the nerves in your affected limb.
* Type II. Once referred to as causalgia, this type follows a distinct nerve injury. Signs and symptoms of both types of CRPS vary in severity and duration.
The main symptom of CRPS is intense pain, often described as "burning." Additional signs and symptoms include:
* Skin sensitivity.
* Changes in skin temperature, color and texture. At times your skin may be sweaty; at other times it may be cold. Skin color can range from white and mottled to red or blue. Skin may become tender, thin or shiny in the affected area.
* Changes in hair and nail growth.
* Joint stiffness, swelling and damage.
* Muscle spasms, weakness and loss (atrophy).
* Decreased ability to move the affected body part.
Complex regional pain syndrome may result from disturbances in the sympathetic nervous system, the part of the nervous system that controls blood flow and your sweat glands. This syndrome commonly follows an acute problem.
Many cases of CRPS occur after a forceful trauma to an arm or a leg, such as a gunshot wound or shrapnel blast. Other major and minor traumas â surgery, heart attacks, infections, fractures and even sprained ankles â also can lead to CRPS. It's not well understood why these injuries sometimes trigger CRPS.
The syndrome was first described after the Civil War when soldiers continued to report severe pain after their wounds had healed. It was often referred to as "hot pain" during that period.
When to seek medical advice
If you experience constant, severe pain that affects a single limb and makes touching or movement of the limb seem intolerable, see your doctor to determine the cause. It's important to treat CRPS early.
Screening and diagnosis
Your doctor may base a diagnosis of CRPS on:
* Review of your medical history. The onset of CRPS symptoms can often be traced back to an accident, illness or injury.
* Physical examination. An examination of your skin, muscles and joints may reveal information about the source of your tenderness and pain. There may be changes in the normal texture and color of your skin, and you may have problems with range of motion of one or more of your joints.
* Bone scan. A radioactive substance injected into your veins permits viewing of your bones with a special camera. This procedure may show increased circulation to the joints in the affected area.
* Sympathetic nervous system tests. These tests look for disturbances in your sympathetic nervous system. For example, thermography measures the skin temperature and blood flow of your affected and unaffected limbs. Other tests can measure the amount of sweat on both limbs. Dissimilar results can indicate CRPS.
* X-rays. Loss of minerals from your bones may show up on an X-ray in later stages of the disease.
If CRPS isn't diagnosed and treated at an early stage, the disease may progress to more disabling signs and symptoms. If you avoid moving an arm or a leg because of pain, or if you have trouble moving a limb because of stiffness, your skin and muscles may begin wasting (atrophy). You may also experience tightening of your muscles as they lose their tone. This may lead to a condition in which your hand and fingers or your foot and toes contract into a fixed position.
The illness may also spread from its source to elsewhere in your body in these patterns:
* Continuity type. The symptoms may migrate from the initial site of the pain â for example, from your hand â to your shoulder, trunk and face, affecting a quadrant of your body.
* Mirror-image type. The symptoms may spread from one limb to the opposite limb.
* Independent type. Sometimes, the symptoms may leap to a distant part of your body.
Dramatic improvement and even remission of CRPS is possible if treatment begins within a few months of your first symptoms. Treatment options include:
* Medications. Doctors use many types of medications to treat the symptoms of CRPS. Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve) may ease pain and inflammation. In some cases, doctors may recommend prescription medications. For example, antidepressants, such as duloxetine (Cymbalta), and anticonvulsants, such as gabapentin (Neurontin), are used to treat pain that originates from a damaged nerve (neuropathic pain). Corticosteroids, such as prednisone, may reduce inflammation.
Your doctor may also have you take bone-loss medications, such as risedronate (Actonel) and calcitonin (Miacalcin). Opioid medications may be another option. Taken in appropriate doses, they may provide acceptable control of pain. However, they may not be appropriate for people who have a history of substance abuse or lung disease.
Some pain medications, such as COX-2 inhibitors (Celebrex), may increase your risk of heart attack and stroke. It's wise to discuss your individual risk profile with your doctor.
* Applying heat and cold. Applying cold may relieve swelling and sweating. If the affected area is cool, applying heat may offer relief.
* Physical therapy. Gentle, guided exercising of the affected limbs may improve range of motion and strength. The earlier the disease is diagnosed, the more effective exercises may be.
* Sympathetic nerve-blocking medication. Injection of an anesthetic to block pain fibers in your affected nerves may relieve pain in some people.
* Transcutaneous electrical nerve stimulation (TENS). Chronic pain is sometimes eased by applying electrical impulses to nerve endings.
* Biofeedback. In some cases, learning biofeedback techniques may help. In biofeedback, you learn to become more aware of your body so that you can relax your body and relieve symptoms of pain.
* Spinal cord stimulation. Your doctor inserts tiny electrodes along your spinal cord. A small electrical current delivered to the spinal cord sometimes results in pain relief.
Living with a chronic, painful condition can be challenging, especially when â as is often the case with CRPS â your friends and family don't believe you could be feeling as much pain as you describe. Share information from reliable sources about CRPS with those close to you to help them understand what you're experiencing.
Take care of your physical and mental health by following these suggestions:
* Maintain normal daily activities as best you can.
* Pace yourself and be sure to get the rest that you need.
* Stay connected with friends and family.
* Continue to pursue hobbies that you enjoy and are able to do.
If CRPS makes it difficult for you to do things you enjoy, ask your doctor about ways to get around the obstacles.
Keep in mind that your physical health can directly affect your mental health. Denial, anger and frustration are common with chronic illnesses.
At times, you may need more tools to deal with your emotions. Professionals such as therapists or behavioral psychologists may be able to help you put things in perspective. They can also teach you coping skills that may help you, including relaxation techniques.
Sometimes, joining a support group, where you can share experiences and feelings with other people, is a good approach. Ask your doctor what support groups are available in your community.
Compiled by Editor at 4/23/2005 09:27:00 PM
Friday, April 22, 2005
Early Diagnosis and Appropriate Treatment Key to Any Possibility of Recovery
MILFORD, Conn., April 22 /PRNewswire/ -- Paula Abdul's story about her struggle with Reflex Sympathetic Dystrophy Syndrome (RSD), also known as Complex Regional Pain Syndrome (CRPS) highlights this complex and poorly understood disorder. CRPS/RSD is a neurological syndrome characterized by severe and relentless pain that, according to the McGill Pain Index, is greater than that experienced by cancer patients. A common complication after surgery or minor injury, CRPS/RSD is a major cause of disability-only one in five patients is able fully to resume prior activities. The continuing tragedy is that many physicians are not familiar with its telltale symptoms and do not consider the diagnosis in their examination. Experience has shown that early diagnosis promotes more successful outcomes for people with the syndrome.
Telltale Signs and Symptoms of CRPS 1/ RSD
CRPS/RSD is a diagnostic consideration for patients who have pain
(moderate to severe) that is disproportionate to any inciting event (surgery, sprain, fracture, etc.) and has some of the following characteristics:
* Pain is described as deep, aching, cold, burning, and/or increased skin sensitivity
* The presence of an initiating noxious event (surgery, sprain, fracture, etc.)
* Continuing pain (moderate to severe) associated with allodynia (pain due to stimulus that does not normally provoke pain) or hyperalgesia (excessive sensitivity to pain)
* The pain is disproportionate to any inciting event.
* Abnormal swelling in the affected part
* Abnormal hair or nail growth
* Abnormal skin color changes
* Abnormal skin temperature (greater than 10C asymmetry)
* Abnormal sweating
* Limited range of movement, weakness, or other motor disorders (paralysis, dystonia, etc.)
* CRPS/RSD is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction
Treatment options generally include pain management-nerve blocks and analgesics-plus physical therapy; psychological therapy helps people manage their pain.
RSDSA is a national not-for-profit organization, headquartered in Milford, Connecticut, that promotes greater public and professional awareness of CRPS / RSD and educates those afflicted with the syndrome, their families, friends, insurance and healthcare providers on the disabling pain it causes. For more information, please visit http://www.rsds.org. For interviews with physicians, researchers, or patient, please call toll-free (877)662-7737
SOURCE Reflex Sympathetic Dystrophy Syndrome Association
Web Site: http://www.rsds.org
Compiled by Editor at 4/22/2005 08:22:00 PM
Anti-Epilepsy Drug May Reduce Nerve Pain
Thu Apr 21, 2005 06:43 PM ET
This story originally appeared HERE.
NEW YORK (Reuters Health) - A new study indicates, that the drug Gabitril (tiagabine) is effective in easing a disorder termed complex regional pain syndrome, which involves diffuse pain in the arms or legs, often following a localized injury.
Gabitril is a drug commonly used to treat epilepsy. Studies in animals suggest that it would be effective in treating pain caused by nerve damage as well, Dr. Raymond Sorensen and Michael G. Jenson note in their report, published in the American Journal of Pain Management.
The researchers, based at PETC Research Group in Tulsa, Oklahoma, treated 20 patients with complex regional pain syndrome type -- also commonly called reflex sympathetic dystrophy -- with Gabitril, started at 2 to 4 mg daily and escalating to doses of up to 12 mg.
The patients, who had never been tried on anti-epilepsy drugs or for whom such drugs had been ineffective, took the new drug for 24 weeks.
Sixteen patients reported either excellent or good reduction in their symptoms. The other four reported little improvement (less than 20 percent reduction in symptoms).
Three patients discontinued treatment due to nausea and one because it wasn't helping.
"Placebo-controlled trials are needed to better assess this most promising agent," the authors conclude.
SOURCE: American Journal of Pain Management, April 2005.
Â© Reuters 2005. All Rights Reserved.
Compiled by Editor at 4/22/2005 06:38:00 PM
This story originally appeared at http://seven.com.au/todaytonight/story/?id=20239
REPORTER: Rohan Wenn
BROADCAST DATE: April 21, 2005
Magnets have long been touted as an alternative pain relief. Do they have any healing powers? Today Tonight put magnets to the test.
Dick Wicks suffers from a condition called Reflex Sympathetic Dystrophy Syndrome (RSDS), also known as Complex Regional Pain Syndrome (CRPS).
"I had eight years of pain and suffering, in and out of hospital 26 times," Mr Wicks said.
Mr Wicks began manufacturing magnetic products he said could be used to relieve pain by acting on iron in the blood.
"They say the iron ions are attracted to the magnets in your haemoglobin and it creates a lovely warm feeling," Mr Wicks said
Grant Stevenson from The Australian Skeptics is sceptical.
"We need some short term studies, more research and longer term studies too," Mr Stevenson said.
Putting magnets to the test
Today Tonight tested the product with the help of six retirees.
Cliff, Tess, Daphne, Gilda, Irene, and Marshall rated their current pain levels on a scale of one to five then wore a knee support for six weeks, noting how their knee felt each week.
Only three knee supports contained magnets.
By week three Cliff was feeling some benefit and believed he had one of the knee supports that contained magnets.
"I am getting a bit less pain, I am getting more movement, and more confidence, I don't have to struggle down there and then struggle up," he said.
Marshall and Tess also felt improvements, although Marshall said it might have as much to do with the brace as any magnets.
"Whether it's the result of the support or the warmth of it, I wouldn't know with any certainty, there is no doubt my knee is feeling better," Marshall said.
After six weeks the retirees were asked how they had been feeling.
Tess felt a substantial reduction in pain. Marshall reported some fluctuation in pain levels, and suspected he had a fake.
"My knee does feel more free and it's comfortable though whether it's the support, or the magnets I don't know who to give credit to," Marshall said.
He did not have magnets in his support. But Cliff did, and he experienced a significant drop in pain.
Irene did not experience any reduction in pain.
"I think I had the fake one I hope I had the fake one," she said.
She did. Daphne was equally disappointed, with no real reduction in pain. Her brace was also a fake.
"It didn't make any difference," Daphne said.
Gilda had the magnets and experienced a big reduction in pain levels.
Mr Wick said the TT test was proof magnets seem to make life a little easier for people in pain.
"We work with chronic pain sufferers and the results have been fantastic over the years," Mr Wicks said.
Dick Wicks' products are available at www.dickwicks.com.au or phone 1800 662 000.
The Australian Skeptics: www.skeptics.com.au
Australian reflex sympathetic dystrophy syndrome support group: www.ozrsd.org/web/main.htm
The information on seven.com.au/todaytonight is made available for information purposes only, and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Also, the accuracy, currency and completeness of the information is not guaranteed. The Seven Network does not accept any liability for any injury, loss or damage incurred by use of or reliance on the information.
Compiled by Editor at 4/22/2005 06:26:00 PM
Thursday, April 21, 2005
By CÃ©sar G. Soriano, USA TODAY
American Idol judge Paula Abdul, responding to questions about her erratic behavior on the hit Fox talent show, says she is suffering from a rare neurological disorder and does not have a drug problem.
"Drugs? I'm not addicted to pills of any kind," Abdul says in the new issue of People magazine (on newsstands Friday).
Abdul, 42, says she has been battling chronic pain that began after a cheerleading accident at age 17 left her with an injured disc in her neck.
The pain got worse after "a couple of car accidents" in the 1980s and a plane crash in 1992, which led to seizures, bulimia and depression, she says. In search of relief, Abdul had 12 operations and used medications she says left her so "loopy" that she chose to live with the pain.
The turning point came last summer, she says, when she began taking Enbrel, an anti-inflammatory drug normally used to treat rheumatoid arthritis and psoriasis.
A spokeswoman for the drug says it does not have psychological side effects.
In November, Abdul says, she was diagnosed with Reflex Sympathetic Dystrophy (aka Complex Regional Pain syndrome), a chronic neurological disorder that causes severe, debilitating pain. It affects 500,000 to 1 million Americans and is more prevalent in women, according to the Reflex Sympathetic Dystrophy Syndrome Association.
The disease is treatable and usually involves physical and sometimes psychological therapy, says Norman Harden, director of the Center for Pain Studies at the Rehabilitation Institute of Chicago. "People can do well and get on with their lives."
Abdul says she kept her condition secret from her fellow Idol judges but decided to go public after reading message boards about her behavior on and off the set.
"Between getting up and dancing at the drop of a hat, and her refusal to let Simon (Cowell) finish a sentence ... she's become both distracting and annoying," says Idol fan Steve Walker of Memphis.
Abdul says she is now pain-free, and her happy-go-lucky demeanor is proof of how good she feels.
"If people only knew what I've gone through with pain and pills. I'm dancing for joy at the fact that not even a year ago I was in so much pain I could barely get up," she tells People.
Last month, she was sentenced to two years' probation after pleading no contest to a misdemeanor count of hit-and-run driving.
Idol producers and her castmates declined to comment on Wednesday.
"It was getting ugly with the lies people were saying," Abdul tells Entertainment Tonight in an interview airing today and Friday. "It was time to set the record straight. I want America to know that I have never been addicted to anything, no chemical dependency, nothing for recreational purposes."
Compiled by Editor at 4/21/2005 02:20:00 PM
Wednesday, April 20, 2005
April 12, 2005
Device with Most Powerful, Longest Lasting Battery Now Available to Help Patients with Difficult-to-Treat Chronic Pain
Medtronic, Inc. (NYSE:MDT) today announced that its Restore(TM) Rechargeable Neurostimulation System is now available, following approval granted by the United States Food and Drug Administration (FDA). The Restore System offers the most powerful and longest-lasting rechargeable battery available. It is a new treatment option for people suffering from complex, difficult-to-treat chronic pain, and those requiring high-power stimulation for pain relief.
The Restore battery can last for up to nine years, exceeding that of any other rechargeable spinal cord stimulator on the market. And like a cell phone battery, the Restore System's battery can be recharged. When battery levels are low, an alarm sounds and an icon appears on the system's programmer screen, alerting patients of the need to recharge. Recharging can occur without interrupting delivery of the stimulation.
The System's high-power battery offers Restore patients the convenience and flexibility of the longest time between recharge periods. Patients will typically need to recharge the Restore battery approximately once per month, whereas other devices on the market may require recharges as frequently as once per week.
Another feature of the Restore System is the hand-held programmer that is similar to a remote control. Patients use it to manually choose from an unmatched number of program options - as set by a physician - to meet his or her individual treatment needs.
The launch of Restore marks a significant step forward in the treatment of chronic pain, according to David Caraway, MD, PhD, medical director of the Tri-State Regional Pain Management Service at St. Mary's Hospital, Huntington, WV. "Medtronic's newest spinal cord stimulator should help us treat some of the most complex forms of chronic pain better than we have in the past," says Caraway. "This is welcome news for patients who haven't had much success with other chronic pain treatments. By delivering a high level of sustainable power, this new rechargeable device will provide relief to many who suffer greatly and may be functionally impaired by pain. With this device, the patient controls the pain - the pain doesn't control the patient."
About the Restore(TM) Rechargeable Neurostimulation System
The Restore System is indicated to manage chronic, difficult-to-treat pain in the trunk and/or multiple limbs that is associated with failed back syndrome, post laminectomy pain, unsuccessful disc surgery or degenerative disc disease, among others.
The device, about the size of a stopwatch, is implanted under the skin. Up to two leads - with eight electrodes each - deliver electrical pulses to the spine. Based on individual patient need, doctors can customize the positioning of the electrodes to deliver stimulation directly to the target area on the spine, and in doing so, block pain signals from reaching the brain. "Restore is the most advanced neurostimulation system on the market today," said Jon Tremmel, president, Medtronic Neurological. "With the Restore System, Medtronic now provides the broadest range of chronic pain management therapies and devices to best address patient needs."
For more information on the Restore(TM) Rechargeable Neurostimulation System, visit www.medtronicrestore.com, or call 800-510-6735.
About Chronic Pain
Defined as pain that persists or recurs for more than six months, chronic pain can be caused by a variety of injuries and diseases, and most commonly affects the lower back and legs. Left untreated or under-treated, chronic pain can destroy a person's life. Beyond the physical disability that often results, it can lead to difficulty holding a job, low self-esteem, strained relationships, depression, and suicide.
It is estimated that chronic pain affects approximately 25 percent of the U.S. population. Chronic pain accounts for an estimated $100 billion per year in medical costs, including 515 million lost workdays and 40 million physician visits.
For more information on chronic pain, visit the American Pain Foundation web site at www.painfoundation.org.
About Medtronic Neurological Therapies
The Restore System is the latest advancement to join the Medtronic portfolio of neurostimulation and pump pain therapies. Along with Restore, a number of Medtronic pain therapies are currently available to clinicians specializing in the management and treatment of chronic pain.
Medtronic's neurostimulation therapy already has achieved worldwide medical acceptance for the management of chronic, intractable, unilateral or bilateral pain associated with many pain-related conditions. Patients can obtain information on Medtronic neurostimulation at www.medtronicpaintherapies.com.
About Medtronic, Inc.
Medtronic, Inc., headquartered in Minneapolis, is the world's leading medical technology company, providing lifelong solutions for people with chronic disease.
Any forward-looking statements are subject to risks and uncertainties such as those described in Medtronic's Annual Report on Form 10-K for the year ended April 30, 2004. Actual results may differ materially from anticipated results.
Compiled by Editor at 4/20/2005 11:17:00 AM
Tuesday, April 19, 2005
Article reprinted here is orginally from MedScape (WebMD)
Link is http://www.medscape.com/viewarticle/502018
You may be requied to register on their site to read the full article.
Interventional Approaches to Pain Management
Daniel S. Bennett, MD, DABPM
The treatment of pain encompasses the use of both drug and nondrug therapies. At the 21st Annual Meeting of the of the American Academy of Pain Medicine (AAPM), both topics were given free reign. Because the efficacy of pharmacologic therapies is estimated to be less than 40%, neuromodulation in both chemical and electrical modes is emerging as a leading technology in the treatment of neuropathic pain. Numerous exceptional sessions at this year's meeting addressed both chemical and electrical approaches to pain management.
This discussion focuses on the various symposia, clinical and scientific presentations, and research poster submissions related to the use of nonopioid therapies for the management of pain.
The Cutting Edge
Dr. Robert Levy discussed the use of supraorbital stimulation for neuropathic facial pain, in an Update Session on innovative surgical strategies for pain management. This type of pain has been recalcitrant to pharmacotherapeutics, and outcomes following ablative and decompressive surgery have been suboptimal. Levy demonstrated the percutaneous surgical implantation techniques of positioning linear electrode "strings," which have shown high success rates (> 75%) in treating pain syndromes involving the peripheral distributions of V1. The small energy requirements inherent in the electrode configurations allow the use of an implanted pulse generator that will have a life expectancy for many years.
Next, Dr. Oren Sagher then discussed the physiological effects of spinal neuromodulation and the implications for treatment. He reminded the audience of the animal work showing a spinal cord/brainstem loop through the thalamic structures, and later work that found the loop extending to structures as deep as the prefrontal cortex/cingulate gyrus and somatosensory cortex. He compared these humble beginnings of the studies of the electric organ fish to the state of electrotherapy for the treatment of the vascular and sensory systems in the United States. Our colleagues in Europe are using spinal cord stimulation to treat angina and promote ulcer healing/limb salvage (via increasing transcutaneous pressure of CO2 [TpCO2]) to a great degree. In the United States, we are limited with regard to these approaches because of US Food and Drug Administration (FDA) constraints and insurance reimbursement issues. Dr. Sagher presented compelling data showing the cerebrovascular effects of spinal cord stimulation and the use of this modality for treating spasticity via corticomotor pathways.
Occipital neuralgia, hyperextension cervicogenic headaches, and transformed migraine have been extremely difficult to treat. In the same session, Richard Weiner, MD, described a highly effective technique of occipital nerve stimulation. This form of peripheral nerve stimulation is thought to work through a "backdoor approach" -- retrograde conduction via C1, C2, and C3 interneuronal connections to the cell body of cranial nerve V, which lies in the tissues near the fourth ventricle. This path forms the "migraine" circuit, and its electrical neuromodulation can quiet the phenomena of migraine common in these conditions. Although this method of neural stimulator placement is "off-label" (as is peripheral nerve stimulation, in general), its outcome has been consistently excellent. Dr. Weiner advocates this in patients who have failed traditional medication regimens.
Peripheral Nerve Stimulation for Facial Neuralgias
Hayek and colleagues reported 3 cases of refractory chronic postsurgical trigeminal neuropathic pain successfully treated with peripheral nerve stimulation with percutaneously implanted leads. One patient suffered from supraorbital neuralgia and 2 had infraorbital neuralgia that were refractory to pharmacologic therapies. All 3 patients experienced more than 50% reduction in visual analog scale (VAS) scores after stimulation; all 3 had responded to diagnostic nerve blockade prior to implantation.
Spinal Cord Stimulation for Visceral Pelvic Pain
Kapural and Mekhail presented the results of spinal cord stimulation for 5 women with visceral pelvic pain that had been poorly responsive to pharmacotherapeutics, therapeutic injections, and other conservative therapies. Diagnoses included endometriosus, multiple surgical explorations with adhesions, and dyspareunia. All 5 patients had received hypogastic blocks with 1-4 weeks of complete relief. A trial of stimulation preceded implantation. Average follow-up was 33.6 months. The mean VAS score dropped from 8 to 3. The pain disability index changed from an average of 58 to 19.7. Opioid use decreased from an average of 26 mg to 5 mg morphine sulfate equivalent per day.
At another Update Session, Dr. Aaron Calodney and Dr. Curtis Shipman, brought an evidence-based focus to the rationale for interventional techniques in the diagnosis and treatment of lumbar radicular pain. Dr. Calodney began by discussing the anatomy of the lumbar space and the anterior/posterior compartments, stressing that an inflammatory cascade begins when disc herniation occurs: These effects can be mitigated by steroids. Because studies strongly support inflammation as the cause of radicular pain in the absence of spinal nerve compression, early application of steroids is advocated; no evidence exists, however, supporting an alteration in the rate of disc resorption. In general, nerve pain, not somatic-referred pain, is the indication for lumbar injections.
Furthermore, these authorities emphasized that there is no role for a "series" of injections without regard to the response to a previous injection (provided the injection was performed properly and the injectate went into the right space). Thus, the old adage of "a series of 3 injections" is simply an "old wives' tale." The use of fluoroscopy is the standard of care, and Calodney and Shipman stressed the importance of fluoroscopically guided injections.
They also differentiated translaminar injections from transforaminal injections. A translaminar injection is not selective or specific and is typically used when multiple nerve rootlets are being targeted. Studies by Stanley and colleagues and Van Akkerveeken showed that selective nerve root injections (transforaminal epidural injections) correlated with positive surgical outcomes as high as 95%. Thus, in patients with radicular pain patterns, Calodney and Shipman recommend transforaminal injections for both diagnostic and therapeutic benefit because these correlate with optimal surgical outcomes, should the patient eventually undergo surgical therapy. (The surgeon can correlate the nerve rootlet to the images, thereby honing in on the level in question.)
Although further along the continuum of care, intrathecal therapies offer a method of treatment for complex conditions that are unresponsive to other neuromodulation techniques or in situations in which technically electrical means are riskier or impossible. As expressed by Dr. Krames during the introductory comments for a session devoted to this topic, intrathecal therapy is "the end of the pain treatment continuum" and is an expensive delivery system for analgesic medications and an alternative to systemic means, to be used after more conservative approaches have failed.
Next, Peter Staats reviewed common agents and newer agents with a special emphasis on ziconotide, an agent that was recently approved for marketing by the FDA. Ziconotide is an omega-conopeptide, which is a synthetic pharmaceutical version of a substance derived from the conus magus (a piscivorous marine snail discovered off the coast of the Philippines). It is an N-type voltage-sensitive calcium channel modulator (NVSCaM). In the human, the predominance of the NVSCaM is found on the dorsal horn where it blocks Ca++ channels, leading to diminution in excitatory neurotransmitter release associated with A-delta and C-nociceptors. Unfortunately, side effects, such as psychosis, can be seen in susceptible individuals, likely because of crossover to hippocampus receptors for the drug.
Samuel Hassenbusch, MD, then reviewed the polyanalgesic guidelines (similar to those covered at the 20th Annual Meeting of the AAPM held in Orlando, Florida, in 2004). Finally, Alexander Krakovsky, MD, closed the session by reviewing the complications associated with intrathecal therapies. Although precise numbers are lacking, the incidence of inflammatory masses involving the implanted catheter tips is estimated to be as high as 2% to 3%. Dr. Krakovsky stated that opioids, predominately morphine, are a leading factor in causing inflammatory masses. Left untreated, these masses grow exponentially and can cause spinal cord compromise leading to neurologic deficits and eventually paralysis. MRI with gadolinium must be performed with careful imaging at the known area of the catheter tip; suspicion should be raised if the patient reports an increase in pain unresponsive to typical dosing, a change in the neurologic baseline, muscle weakness, or bowel/bladder changes. (He recommends neurologic examination each time the medication reservoir is filled.) Aside from technical complications surrounding implantation and perioperative factors, medication errors (compounding) and dosing errors (programming) are the next highest area for concern, and constant vigilance in computation checking is crucial to avoid potentially fatal errors. Last, using manufacturer specified refill kits minimizes the chances of inadvertent filling of side ports (which provide a direct entry into the cerebrospinal fluid) rather than the intended reservoir and should be used where possible.
Studies of Intrathecal Ziconotide and Chronic Pain
Fisher and Lokey presented a case of a 16-year-old boy with reflex sympathetic dystrophy in the bilateral lower extremities with chronic burning pain, partial loss of proprioception in the feet, photophobia, sensitivity to touch/temperature changes, and antalgic gait. He was prescribed intrathecal ziconotide 5 mcg daily. Titration schedules fluctuated with stabilization at 4.5 mcg daily at year 2. The patient established normal activities, graduated from high school, is employed full time, and has discontinued all oral medications. His VAS range has dropped from 70-100 mm, before intrathecal therapy, to 0-10 mm.
Dr. Lynn Webster presented a study that followed 220 patients who were weaned from all intrathecal medications, stabilized on intrathecal saline for 1 week, and then randomized to either receive intrathecal ziconotide (112 patients) or saline (108 patients). In all, 92% of participants completed the study. Mean baseline VAS of pain intensity was 80.7 mm for both groups. After 3 weeks, patients who received ziconotide achieved a mean 14.7% reduction in VAS pain intensity score compared with a 7.2% reduction for patients who received saline (P = .036). On the Clinical Global Impressions scales, a significantly higher percentage of ziconotide (28.4%) than placebo patients (12.1%) reported "a lot" or "complete" satisfaction with treatment (P = .0027) and "very good" or "excellent" pain control (11.9% and 0.9%, respectively; P = .0004). The majority (84%) of adverse events were mild to moderate in severity; 5.4% of the ziconotide group withdrew because of adverse events, as compared with 4.6% of placebo patients. The most frequently reported ziconotide-related adverse effects were dizziness (34.8%), nausea (19.6%), and confusion (14.3%).
A rousing, well-attended session on interventional pain management brought together 10 experts to present evidence on controversial topics in interventional pain medicine. An expert was asked to take either a pro or contra position and then make his/her case regarding the proposed technology; this was followed by an audience computerized question and answer session. The use of this interactive session with computerized audience feedback was excellent. The lecturers and audience were able to view the predebate opinion vote compared with the percentage change following the debate. The topics that were debated included the following.
The use of non-FDA-approved drugs in the intrathecal space: The audience was quite interested in this topic and was of the opinion that it is the physicians' decision as to what to use to alleviate pain for any given patient. Off-label use is accepted and was of little issue in this discussion.
Permanent implantation of surgical leads in the spine -- surgical or percutaneous: Although each presenter made excellent points, Jaime Henderson, MD, from Stanford University, Stanford, California, swayed the audience by a slight margin to the side of paddle electrodes in the final vote. (These are inserted via laminectomy.) In the final discussion, however, he did admit that the percutaneous lead(s) caused less trauma.
The use of high-frequency (spinal cord) stimulation when treating complex regional pain syndrome: The pro speaker Claudio Feler, MD, overwhelmed the audience with his vast experience in this area. David Caraway, MD, PhD, the contra speaker, admitted during the discussion that he too would utilize this modality when treating complex regional pain syndrome because it is a highly effective method.
High cervical spinal cord stimulation leads for 4-extremity neuropathic pain vs intrathecal pump: This debate leaned in favor of an intrathecal pump primarily because this kind of electrical neuromodulation requires 2 implants -- 1 in the cervical region for the arms and 1 in the thoracic region for the legs. Nonetheless, this outcome is puzzling because high cervical spinal cord stimulation is less invasive than a spinal catheter with medications.
Percutaneous disc treatment vs surgical treatment for lumbar radiculopathy: Surgical disc treatment won overwhelmingly when it was shown how simply this modality is performed. The audience expressed a misconception regarding the simple discectomy vs a more radical approach. Dr. Levy did an outstanding job of explaining both approaches.
This program was supported by an independent educational grant from Cephalon.
1. Levy R, Sagher O, Weiner R, et al. On the cutting edge: innovative surgical treatment for central and neuropathic pain (204). Program and abstracts of the 21st Annual Meeting of the American Academy of Pain Medicine; February 23-27, 2005; Palm Springs, California.
2. Hayek S, Henderson J, Boulis N, Kapural L, Stanton-Hicks M, Nagy M. Peripheral nerve stimulation for post surgical facial neuralgias. Program and abstracts of the 21st Annual Meeting of the American Academy of Pain Medicine; February 23-27, 2005; Palm Springs, California. Abstract 105.
3. Kapural L, Mekhail N. Spinal cord stimulation may be an effective treatment for severe visceral pelvic pain. Program and abstracts of the 21st Annual Meeting of the American Academy of Pain Medicine; February 23-27, 2005; Palm Springs, California. Abstract 114.
4. Calodney A, Shipman C. Spinal injections for lumbar radicular pain. Update session 207. Program and abstracts of the 21st Annual Meeting of the American Academy of Pain Medicine; February 23-27, 2005; Palm Springs, California.
5. Stanley D, McLaren MI, Euinton HA, Getty CJ. A prospective study of nerve root infiltration in the diagnosis of sciatica. A comparison with radiculography, computed tomography, and operative findings. Spine. 1990;15:540-543.
6. Van Akkerveeken PF. The diagnostic value of nerve root sheath infiltration. Acta Orthop Scand Suppl. 1993;251:61-63.
7. Krames E, Staats P, Hassenbusch SJ, Krakovsky AA. Intrathecal therapies. Update session 301. Program and abstracts of the 21st Annual Meeting of the American Academy of Pain Medicine; February 23-27, 2005; Palm Springs, California.
8. Fisher R, Lokey K. Intrathecal ziconotide for chronic, severe pain: a case study. Program and abstracts of the 21st Annual Meeting of the American Academy of Pain Medicine; February 23-27, 2005; Palm Springs, California. Abstract 111.
9. Webster L. Efficacy of intrathecal ziconotide for the treatment of severe chronic pain in adults. Program and abstracts of the 21st Annual Meeting of the American Academy of Pain Medicine; February 23-27, 2005; Palm Springs, California. Abstract 160.
10. Follett K, Hassenbusch SJ, Henderson J, et al. Controversies in interventional pain medicine. Update session 401. Program and abstracts of the 21st Annual Meeting of the American Academy of Pain Medicine; February 23-27, 2005; Palm Springs, California.
Compiled by Editor at 4/19/2005 01:31:00 PM
Monday, April 18, 2005
Reflex Sympathetic Dystrophy
From Mary Kugler,
Your Guide to Rare / Orphan Diseases.
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Complex disorder of pain, altered sensation, and reduced motion
Reflex sympathetic dystrophy (RSD), also known as complex regional pain syndrome (CRPS), is a complex disorder that may develop as a result of injury (most common), surgery, or disease. It consists of unexplained intense pain in a part of the body which has been injured, and includes altered sensation and reduced motion in the body part affected. Once thought to be a rare disorder, reflex sympathetic dystrophy occurs in people of all ethnic backgrounds, with women affected twice as often as men. RSD/CRPS most commonly occurs in adults ages 40-49, but may occur at any age.
Symptoms of reflex sympathetic dystrophy often begin days or weeks after an injury, usually in an arm or leg which has been injured. The symptoms may include:
* unexplained intense pain
* altered skin temperature, either warm or cold
* altered skin color
* reduced motion of the affected part, and movement makes the symptoms worse
* reduced sensitivity to touch and/or pain when touched
* abnormal sweating
Diagnosis of reflex sympathetic dystrophy is mainly based on the symptoms present.
There is no specific blood test for RSD, but blood tests can exclude other disorders. Some specialized diagnostic tests may be helpful in confirming the diagnosis of RSD in some individuals.
Early diagnosis and treatment of reflex sympathetic dystrophy is recommended. Steroid medications such as prednisone or methylprednisolone can provide good pain relief. Opioid pain medications such as morphine are also effective. Studies have examined the use of calcitonin intranasal spray, antiepileptic drugs, antidepressants, and creams applied to the skin for treatment of the pain. A pain specialist should be part of the treament team for an individual affected by RSD. Some individuals may have pain relief with injection of local anesthetic around nerves to the affected area (nerve block).
Physical and occupational therapy are also important in the treatment of RSD to improve the movement of the affected part of the body.
When treated early, many individuals with RSD have relief of symptoms within 18 months. Others individuals, unfortunately, develop chronic pain and disability. Researchers do not know why some people improve while others do not. It is also not known exactly what causes reflex sympathetic dystrophy. Future research will no doubt discover how and why RSD begins, how it develops, and identify those individuals at risk for chronic disease.
Information for this article was taken from:
Hord, E.D. (2004). Reflex sympathetic dystrophy. eMedicine, accessed at http://www.emedicine.com/neuro/topic627.htm.
Compiled by Editor at 4/18/2005 06:00:00 AM