Friday, August 29, 2008

ACOEM Publishes Chronic Pain Guidelines

ACOEM Publishes Chronic Pain Guidelines

The American College of Occupational and Environmental Medicine has published new medical treatment guidelines for providing care to workers with chronic pain. The guidelines are available online now; in September a print version will be available.

More than 200 recommendations for chronic pain are outlined in the new evidence-based guidelines, which ACOEM says were developed by a multi-disciplinary panel of national experts and reviewed by representatives of leading medical and health organizations. The recommendations focus on diagnostic and other testing and treatments for several chronic pain conditions, including complex regional pain syndrome (CRPS), neuropathic pain, trigger points/myofascial pain, chronic persistent pain, fibromyalgia, and chronic low back pain. An extensive volume of literature was used to develop the recommendations, which feature more than 1,500 references, including 546 randomized controlled trials.

"These guidelines were developed using ACOEM's published methodology, which incorporates the highest scientific standards for reviewing evidence-based literature, ensuring the most rigorous, reproducible, and transparent occupational health guidelines available," said Editor-in-Chief Kurt T. Hegmann, M.D., MPH. "Literally thousands of hours of review of the available scientific literature went into this process, yielding what we consider state-of-the-art medical guidelines."

Other highlights of the guidelines include:

  • An in-depth review of over 20 medications (prescription, over-the-counter, complementary and alternative) used to treat patients with chronic pain, including an extensive appendix on guidance for the use of opioids.
  • Detailed recommendations regarding the use of appliances (e.g., magnets), skilled allied-health provided medical therapies (e.g., acupuncture, manipulation/mobilization, myofascial release), electrical therapies (e.g., PENS, TENS).
  • Uses and limitations of injection therapies (e.g., diagnostic and therapeutic facet joint injections, trigger/tender point injections, botulinum injections, intrathecal drugs).
  • A discussion of spinal cord stimulation for CRPS and other painful conditions.
  • A detailed review of psychological services (e.g., evaluation and behavior therapy) and rehabilitation for delayed recovery, including biofeedback, work conditioning/work hardening/early intervention programs, and interdisciplinary pain rehabilitation programs.
  • A focus on functional restoration, including an active exercise program and behavioral program.

In addition to being available electronically, the guidelines also will be available in a new print edition of the Occupational Medicine Practice Guidelines 2nd Edition, 2008 Revision, which is currently in production. Orders are being accepted now for delivery in September of this volume, which includes guidelines on a variety of musculoskeletal conditions. Individual chapters from the print publication are also available at ACOEM's Web site.

ACOEM's online treatment guidelines are exclusively distributed by Reed Group. For more information, or to order UMK Professional or the ACOEM Guidelines Electronic version, visit or call (866) 889-4449.

Click here for the original article online.


Treatment of Patients With Complex Regional Pain Syndrome Type I With Mannitol: A Prospective, Randomized, Placebo-Controlled, Double-Blinded Study

Abstract - selected

Copyright © 2008 American Pain Society Published by Elsevier Inc.

Original report

Treatment of Patients With Complex Regional Pain Syndrome Type I With Mannitol: A Prospective, Randomized, Placebo-Controlled, Double-Blinded Study

Roberto S. Perezlow asterisk, , , Corresponding Author Contact Information, E-mail The Corresponding Author, Elien Pragt§, José Geurts, short parallel, Wouter W. Zuurmondlow asterisk, , Jaap Patijnshort parallel and Maarten van Kleef, §, short parallel

Research Consortium Trauma RElated Neuronal Dysfunction (TREND), Delft, The Netherlands. Research Institute for Extramural Medicine (EMGO), Amsterdam, The Netherlands. low asteriskVU University Medical Center, Department of Anesthesiology, Amsterdam, The Netherlands. short parallelPain Knowledge Center Maastricht, Maastricht, The Netherlands. §University Hospital Maastricht, Department of Anesthesiology, Maastricht, The Netherlands

Received 27 September 2007;
revised 6 February 2008;
accepted 12 February 2008.
Available online 10 April 2008.


To assess the effects of intravenous administration of the free radical scavenger mannitol 10% on complaints associated with complex regional pain syndrome Type I (CRPS I), a randomized, placebo-controlled, double-blinded trial was performed. Forty-one CRPS I patients according to the Bruehl et al diagnostic criteria, were included in 2 outpatient pain clinics of 2 university medical centers and randomly assigned to receive either 10% mannitol iv in 1 L 0.9% NaCL in 4 hours for 5 consecutive days or equal volumes of 0.9% NaCL (placebo). Patients in both groups received physical therapy according to protocol and rescue pain medication if required. Complaints on impairment and disability level and quality of life were assessed up to 9 weeks after baseline, with primary measurement points at 2, 6, and 9 weeks. Monitoring of pain using the visual analogue scale took place continuously during the course of the trial. Except for a significant improvement on a subscale of the Jebsen-Taylor hand function test, no significant differences were found between mannitol and placebo treatment. Changes in both groups in the course of the trial were small and clinically irrelevant on all measurement indices. We conclude that intravenous administration of 10% mannitol is not more effective than placebo in reducing complaints for CRPS I patients and provides no addition to already-established interventions for CRPS I. Whether 10% mannitol can provide beneficial effects for subgroups of CRPS I patients with a pathophysiological profile more closely fitting the presumed mode of action for this intervention remains to be established.


This article addresses the efficacy of the intravenous administration of the free radical scavenger mannitol for treatment of CRPS type 1. This intervention is not more effective than placebo in reducing complaints for CRPS I patients and provides no addition to already-established interventions for CRPS I.

Key words: Complex regional pain syndrome; mannitol; scavengers

Article Outline

Sample and Data Collection
Measurement of Effects
Analysis of Data
Outcomes and Estimation
Impairment and Function Level
Quality of Life
Adverse Events and Side Effects
Success of Blinding

The Journal of Pain
Volume 9, Issue 8, August 2008, Pages 678-686

Click here for the original article online.


Efficacy of Ketamine in Anesthetic Dosage for the Treatment of Refractory Complex Regional Pain Syndrome:

Efficacy of Ketamine in Anesthetic Dosage for the Treatment of Refractory Complex Regional Pain Syndrome: An Open-Label Phase II Study
Ralph-Thomas Kiefer, MD,* Peter Rohr, MD, Annette Ploppa, MD,* Hans-Jürgen Dieterich, MD,* John Grothusen, PhD, § Sandra Koffler, PhD, Karl-Heinz Altemeyer, MD, Klaus Unertl, MD,* and Robert J. Schwartzman, MD §
*Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany; Department of Anesthesiology, Intensive Care and Emergency Medicine and Pain Therapy, Klinikum Saarbrücken, Teaching Hospital University of the Saarland, Saarbrücken, Germany; Departments of §Neurology, Psychiatry, Drexel University College of Medicine, Hahneman University Hospital, Philadelphia, PA, USA
Correspondence to Robert J. Schwartzman, MD, Department of Neurology, Drexel Universtity, College of Medicine, Hahneman University Hospital, Broad and Vine Streets, Mail Stop 423, Philadelphia, PA 19102-1192, USA. Tel: 215-762-7090; Fax: 215-762-3161; E-mail:

Financial Disclosure: The study was financed by departmental resources.

Copyright American Academy of Pain Medicine
Complex Regional Pain Syndrome • Ketamine • NMDA-Receptor • Reflex Sympathetic Dystrophy • Pain Therapy • Quality of Life


Objective. Advanced complex regional pain syndrome (CRPS) remains very difficult to treat. While subanesthetic low-dose ketamine has shown promise in early localized CRPS, its use in advanced CRPS has not been as effective. Since ketamine's analgesic potency and duration of effect in neuropathic pain are directly dose-dependant, we investigated the efficacy of ketamine in anesthetic dosage in refractory CRPS patients that had failed available standard therapies.

Methods. Twenty ASA I-III patients suffering from refractory CRPS received ketamine in anesthetic dosage over 5 days. Outcome criteria were pain relief, effect on the movement disorder, quality of life, and ability to work at baseline and up to 6 months following treatment.

Results. Significant pain relief was observed at 1, 3, and 6 months following treatment (93.5 ± 11.1%, 89.4 ± 17.0%, 79.3 ± 25.3%; P < class="i">P < class="i">P <>

Conclusions. This open-label trial suggests benefit in pain reduction, associated CRPS symptoms, improved quality of life and ability to work following anesthetic ketamine in previously refractory CRPS patients. However, a randomized controlled trial will be necessary to prove its efficacy.

10.1111/j.1526-4637.2007.00402.x About DOI

Click Here For The Original Article Online.


Humans are more important than animals

Tuesday 26 August 2008

Stuart Derbyshire

Humans are more important than animals

When it comes to using animals in research, the only moral judgement should be: does it benefit humankind?

Last week, the scientific journal NeuroImage published an article arguing that ‘by and large animal models offer very limited insights into the complex clinical picture of pain’ (1). The authors claimed that new procedures with humans, especially functional neuroimaging, should be more broadly adopted instead of animal-based studies into the nature and causes of pain.

BBC News, and several anti-vivisectionists who were invited to comment on the report on various radio stations, interpreted this as a call to end animal pain-research (2). The publication of the article came in a week (17 to 22 August) when the World Congress on Pain was taking place in Glasgow (3). I was there, along with several of the authors of the NeuroImage paper and hundreds of students, clinicians and academics who treat patients with pain or who research the causes and effects of pain.

‘Animal models’ try to recreate disease in an animal in order to study the progress and treatment of the disease in a highly controlled fashion. There are, without doubt, many problems with this approach to disease (4). Even the best animal models cannot hope to mimic all the facets of human disease. How, for example, can we model frustration at no longer being able to play football by using rats in a laboratory? We can’t, and the same is true for almost all psychological reactions to disease.

This is a particularly acute problem for pain researchers because some of the most troublesome chronic pain disorders - such as fibromyalgia, non-specific low back pain, irritable bowel syndrome and so on - do not have an obvious physical cause and psychological factors loom large. And animal models tell us little about these factors.

These problems are not, however, insurmountable. Anyone who has missed a night or two of sleep will likely be familiar with fatigue and feeling somewhat bruised with aches and pains in their joints and muscles. This feeling is not unlike what fibromyalgia patients report, and sleep-deprived rats can provide a model to explore the causes of at least some of the symptoms of fibromyalgia. There were 37 presentations at the World Congress on Pain that describe animal pain models, including models of complex regional pain syndrome, bone fracture pain, osteoarthritis, neuropathic pain and visceral pain. Almost 200 presentations included ‘animal’ in their title and almost all of the talks on neurobiology included a reference to animal research to establish the basic knowledge.

So why, then, has NeuroImage thrown in the towel and run an article calling on these researchers to consider doing something else? In part, this has come about because of several new pain drugs that have failed the transition from animal to human. A class of drugs known as the NK antagonists, for example, works well in animals but has been largely ineffective in human trials. This is disappointing, but perhaps not that surprising. The most successful drugs for pain are opioids (poppy juice) and aspirin (willow bark), which were both discovered hundreds of years ago. Treating pain is difficult and there is a long history of failure. It seems unlikely that any one approach - animal models, brain imaging, microdosing or whatever - will suddenly yield success.

At the Congress I was able to meet with some of the authors and ask them about their article in NeuroImage (5). Those I spoke to agreed that animal research has played an important role in developing our understanding of the basic physiology of pain and that the BBC News headline overstated the case against animal pain-research. There was general agreement that animal research will continue to play an important part in advancing our understanding of pain biology. Opinions differed about the future role of animal research in drug discovery.

I think this is a necessary and sensible argument for pain researchers to have, and there is a strong case to be made for de-emphasising the role of animal models in developing pain therapy. Personally I am not convinced that any technique is likely to take us closer to curing the most troublesome pain disorders and so I believe we should continue with a broad approach and see what we get. But I understand that others see a way to success by redirecting resources from animal models towards neuroimaging, clinical trials, human tissue banks and other techniques of human study. I welcome the debate and the effort to put our money where our collective mouth is.

However, a major problem with the NeuroImage article is that the debate was posed not just as a scientific issue but also as an ethical one. The article followed a meeting organised by Focus on Alternatives, a group which brings together representatives from British non-profit organisations that advocate methods to replace the use of laboratory animals in research, education and testing (6). Members of Focus on Alternatives include the Hadwen Trust, which funds exclusively non-animal techniques in an effort to eradicate animal research (7). The Hadwen Trust does not believe that animal experiments are ethically supportable.

Gill Langley works for the science department of the Hadwen Trust - and she and her husband Chris Langley were both authors on the NeuroImage paper. Chris Langley was the lead author and is probably responsible for the tone of the paper being negative about the prospects for animal research. There is a very big problem when ethical concerns latch on to scientific discussion in this manner.

The ethical case for moving away from animal models of disease is based on a principled objection to animal research. That objection is based on the belief that using animals instrumentally to benefit humans is morally wrong and so animal research, and all instrumental use of animals, should stop. I have documented my many objections to this stance elsewhere (8). If we were to accept that using animals for research is morally wrong, then such research should logically come to an end, with no ifs or buts. That would be a potential disaster for medical research and experimentation.

Realising that this is likely to be a tough sell, moderate anti-vivisectionist groups, like Focus on Alternatives and the Hadwen Trust, have tried to sneak an ethical argument into scientific discussion by suggesting that animal procedures are not desirable and in an ideal world we would do something else. These arguments are spurious and should fail. Without a thoroughgoing principled objection to animal research, the only grounds for proceeding, or doing something else, are the needs of human beings. If we consider chronic pain an important issue for human beings, and animal models provide a way towards a cure, then we should do more - lots more - animal research. Under these circumstances, the more animal research we do, the more moral we are being.

We can argue that we should not waste our time and resources on rubbish animal models, which is what at least some of the authors of the NeuroImage article were hoping to get at, but not that animal models are immoral, which is what the Langleys believe.

Focus on Alternatives has successfully played a trick. It called a meeting of some excellent scientists for a creative discussion on how to advance human models of pain and better address the problem of pain. Its members then wrote an article ostensibly addressing the scientific problem of using animals but with an ethical objection to animal research layered on top.

This is a trick that campaigners have pulled off successfully before with a workshop on sepsis to address the limited value of animal sepsis models (9). Previously, however, this trick has not led to publication in a major specialist science journal such as NeuroImage. The publication in NeuroImage represents a propaganda coup for those who oppose animal research in principle and is to be very much regretted.

Stuart Derbyshire is a senior lecturer in psychology at the University of Birmingham.

Previously on spiked

Stuart Derbyshire suggested we need to have the hard arguments in favour of animal research. Helene Guldberg made the ethical case for vivisection and was told by Professor John Martin why animal research is justified. James Panton reviewed Adam Wishart’s documentary Monkeys, Rats and Me: Animal Testing. Or read more at spiked issue: Animals.

(1) ‘Volunteer studies in pain research - Opportunities and challenges to replace animal experiments: The report and recommendations of a Focus on Alternatives workshop’, C.K. Langley, Q. Aziz, C. Bountra, N. Gordon, P. Hawkins, A. Jones, G. Langley, T. Nurmikko, I. Tracey.,
NeuroImage, Volume 42, Issue 2, 15 August 2008, Pages 467-473

Call to end animal pain-research, BBC News, 14 August 2008

World Congress on Pain, International Association for the Study of Pain

The trouble with animal models, The Scientist, 21(7), p. 44

(5) I spoke with Anthony Jones, who was my Ph.D. supervisor, Turo Nurmikko and Irene Tracey. I also spoke with several other colleagues and friends at the congress who work with animal models of pain. The general consensus was that we are suffering from some overblown expectations of what animal models can deliver, but that animal models remain an important component of research into pain. The opinions and comments expressed in this article reflect that consensus but the reflection is being done by the author and the opinions should be attributed to the author alone. I make no claim to be speaking on behalf of the World Congress on Pain or anyone else except myself.

Focus on Alternatives

Hadwen Trust

Time to abandon the three Rs, by Stuart Derbyshire, The Scientist, February 2006

(9) ‘Opportunities to Replace the Use of Animals in Sepsis Research. The Report and Recommendations of a Focus on Alternatives Workshop’, Chris Langley, Chris Brock, Gerard Brouwer, Alun Brown, Lucie Clapp, Jon Cohen, Tom Evans, Carol Newman, Samantha Orr, Barry Phillips, Andy Rhodes, Nigel Webster & Karl Wooldridge, Alternatives to Laboratory Animals 33, 641–648, 2005

Click Here For The Original Article Online.


Biennial Meeting of the Scandinavian Hand Society in Helsinki, Finland

27. elokuuta 2008

Biennial Meeting of the Scandinavian Hand Society in Helsinki, Finland

Welcome - Congreszon: "Welcome. The organizing committee has a pleasure to invite you to the Biennial Meeting of the Scandinavian Hand Society in Helsinki, Finland. The meeting is organized by the Finnish Society for Surgery of the Hand and the Finnish Society of Hand Therapists.

The congress venue is located at a comfortable seaside congress hotel just five kilometres from the city centre. The guest speakers represent the most innovative hand surgeons, scientists and hand therapists of recent years in Europe.

The main topics are selected from the themes that have shown the most advancement and innovations or controversy. Instructional courses will be prepared with special reference to our resident members.

A special afternoon for the workshops will be arranged on Wednesday afternoon before the get together party. We are sure that you will bring home lots of new ideas and warm memories from Helsinki."

I'll write more about this event. Mediracer is participating. Detailed information about Mediracer Ltd's role and participation is available through:

Seppo Nevalainen
Sales Director
Mediracer Ltd.
Teknologiabulevardi 3-5
01530 Vantaa
Mobile: +358 40 5018875

Organizing committee

  • Jarkko Vasenius, chairman (
  • Jouni Havulinna
  • Taneli Haapaniemi
  • Yrjänä Nietosvaara
  • Heidi Miettinen
  • Pasi Paavilainen
  • Tove Palmgren
  • Irmeli Parjo
  • Jorma Ryhänen
  • Hanna Uusitalo
  • Eero Waris
  • Anna Viinikainen

Scientific committee

  • Jouni Havulinna
  • Yrjänä Nietosvaara
  • Timo Raatikainen
  • Jarkko Vasenius
  • Martti Vastamäki
  • Simo Vilkki

Scientific committee (Therapists)

  • Kirsi Karjalainen
  • Riitta Keponen
  • Marisa Nikkonen
  • Pirjo Peurala
  • Tarja Rantala
  • Sanna Rautakorpi

Main Topics

Distal radius fractures

  • CMC I problems
  • CRPS
  • Microsurgery
  • Rheumatoid arthritis
  • Spastic hand
  • Surgery of the growing hand
  • Wrist instability

Guest speakers

  • Tim Davis, MD, UK

  • Jan Fridén, MD, Sweden

  • Marc Garcia-Elias, MD, Spain,

  • Maarit Gockel, MD, Finland

  • Lise-Lotte Hermansson, OT Sweden

  • Karin Holzer, OT, Austria

  • Rolf Habenicht, MD, Germany

  • Heli Lagus, MD, Finland

  • Marisa Nikkonen, OT, Finland

  • Tage Orenius, Psychologist, Finland

  • Margareta Persson, OT, Sweden

  • Francisco de Pinal, MD, Spain

  • John Stanley, MD, UK

  • Oili Tomminen, OT, Finland

  • Griet van Veldhoven, OT, OE, Norge

  • Simo Vilkki, MD, Finland

Thursday, August 28, 2008

More kids need help in coping with pain

More kids need help in coping with pain

Posted by Brie Zeltner August 25, 2008 16:27PM

Despite big advances in the understanding and treatment of pain in children, chronic pain in kids remains an undertreated problem.

The myth that children don't feel the same amount of pain adults do persists, despite diagnoses of "adult" conditions such as fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome and intractable headaches.

At the Pain Center at Akron Children's Hospital, a team of pediatric pain specialists, massage therapist, acupuncturist, nurses, physical therapists and other experts come together to care for kids much like in an adult pain center. The main difference is that treatment of pediatric pain patients always is more conservative, said director Dr. Ibrahim Farid.

"Anytime I give a kid a medicine, I still think of it as a conservative treatment, but I try to save that as a last resort," he said.

His plan for most kids relies heavily on physical therapy, coping techniques, massage therapy and acupuncture, which all are available in the same office.

"I do believe in the biology and the physiology of the patients [to heal] themselves," he said.

After three years of pain, frustration and bouncing from doctor to doctor, 17-year-old Jacqui Reese was tired of trying to convince everyone that the pain in her legs wasn't from shin splints. Her toes were so stiff they wouldn't bend, her legs would swell up and turn blotchy, and her shins felt like they were being repeatedly stuck with knives.

Reese, of Doylestown, finally found relief at the Akron pain center after Cleveland Clinic doctors diagnosed her with fibromyalgia and complex regional pain syndrome, a little-understood disorder that can strike after an injury has healed and causes continued pain and swelling.

She has been pain- and medication-free since completing six months of therapy in February.

"In the first month, it was really amazing how much of a difference there was," Reese said. A dedicated soccer player, she recovered even faster when she stopped occasionally jumping in at practices and decided to just work on getting better.

"I want to play in college, so I want to focus on that and not risk going through what I did before."

Click Here For The Original Article Online.


Never too late to learn

Never too late to learn

9:40am Friday 22nd August 2008

A 37-YEAR-OLD Netherton man is proving it is never too late to learn after scooping a top grade in an AS Level exam.

Father-of-three Jason Collins, of Spring Road, Netherton is a mature student at Dudley College and scored an A grade in English Literature.

He already has four A grade A-Levels under his belt in history, psychology, sociology and law and was even placed in the top five highest achieving law students in the country last year.

The impressive succession of results is a far cry from his school days, which Jason admits he “wasn’t bothered” about.

Jason has also managed to defy illness after being struck down with Complex Regional Pain Syndrome, which left him confined to a wheelchair six years ago.

But undeterred by his illness, Jason decided he wanted to get back into work and is aiming towards a career in law, possibly in the probation service.

He added: “I find law fascinating, you could say it floats my boat and I am going to Walsall to do a one year law course from September.

“It used to do my head in being stuck at home, unable to work, I needed to be doing something, so I decided to get my grades.

“I would encourage everyone to just go and do it, the benefits are enormous.”

Jason was joined at the nerve wracking result opening moment by two of his daughters, who went to support their clever dad.

He said: “I want to make sure they all do well at school, I now realise how important education is. I will always encourage them to get good grades. I just wish I had done it years ago.”

Click Here For The Original Article Online.


Friday, August 15, 2008

(August 14, 2008 - Insidermedicine) On a recent trip to Palo Alto, we met up with Dr. Elliot Krane, MD, who is the Director of Pain Management Services at Lucile Packard Children’s Hospital. Dr. Krane focuses on complex regional pain syndrome, and is also a Professor of Anesthesia and Pediatrics at the Stanford University School of Medicine.

If you believe there is someone conducting world class medical research in your area, and would like them to be featured on Insidermedicine's In the Spotlight, please contact us at



Imaging Study Of Pain Sheds Light On Mystery Condition

Imaging Study Of Pain Sheds Light On Mystery Condition

The first-ever functional brain imaging study of chronic pain conducted in children, done by researchers at Harvard-affiliated McLean Hospital and Children's Hospital Boston, has shed new light on a mysterious condition known as complex regional pain syndrome (CRPS) and offers hope for a better understanding of the disorder in both children and adults. The study, supported by the Mayday Fund of New York, is the result of a joint effort between researchers at Children's who treated the patients in the study and the P.A.I.N. (Pain & Analgesia Imaging and Neuroscience) group at McLean, who conducted the imaging tests.

"Studying pain in children offers us insights into how the brain may cure itself because the young brain is so adaptable relative to the adult brain," says David Borsook, MD, PhD, director of the P.A.I.N. group at McLean, and senior author of the study published in the current issue of Brain (abstract). "This may offer very important insights into the development of new therapeutic approaches to chronic pain-a condition that more than 50 million Americans suffer from with relatively little in terms of highly effective therapies."

CPRS is a disorder of the peripheral nervous system characterized by severe pain, hypersensitivity to stimuli, poor circulation, abnormal sweating, muscle atrophy, joint problems, movement disorders and cognitive changes, among other symptoms.

"This is a significant pain problem that often leaves individuals incapacitated, wheel chair-bound and limited in their physical abilities," notes Borsook, who added that in the pediatric population, girls are affected more frequently than boys. "It can be difficult to diagnose and without proper treatment children and adults living with CPRS live in absolute agony."

Typically, the condition stems from an initial injury, usually the hands or feet, and spreads sometimes to the opposite limb or side of the body, even to the entire body. It is more common in women and is now being seen in some girls after they have suffered sports injuries.

"CRPS is a frightening illness because it can develop as a result of a seemingly trivial injury," says Borsook. "For example, a 14-year-old girl can sprain an ankle during a basketball game, but what seems like a common and easily treatable injury can develop in to CRPS, causing extreme pain throughout her body."

In their novel study, the McLean and Children's researchers developed the first model of the illness that allows them to examine the efficacy of interventional treatments."

"The central nervous system imaging of pain in pediatric patients is a nascent development within the increasingly productive field of functional MRI (fMRI)," explains Alyssa Lebel, MD, senior associate in Pain Medicine and Neurology at Children's and first author on the paper. "This non-invasive technique provides a unique window into regions of the brain actively engaged in pain transmission and modulation. Contrast to adult, pediatric patients are still developing these regions, along with their connections, and may show fMRI patterns of activation in response to pain that differ from adults. Additionally, children often recover symptomatically from painful disorders, such as CRPS."

Lebel notes that the research team's data provides early information about provocative changes in central nervous system (CNS) circuitry in symptomatic and recovered patients with CRPS, as well as demonstrates that the technique is tolerable and acceptable to children with neuropathic pain.

"We will continue to study pediatric patients with CRPS and with other painful disorders, such as headache, to begin to define the pediatric CNS circuitry of acute and chronic pain," says Lebel. "Such information may eventually allow current and novel therapeutic interventions to target the CNS processes ultimately responsible for the complex sensory and emotional experience of pediatric pain."

In children, the symptoms often appear to resolve in time, while in adults resolution is less common. Treatment is generally limited to pain medications and physical therapy. Because the symptoms in children frequently reverse, the researchers decided to image the brains of children with the condition both while symptoms were present and then after the symptoms had gone away-a comparison that cannot be done in adults.

"Our team took advantage of the opportunity to look at children in the pain state and the non-pain state," said Borsook, who is co-director of the P.A.I.N. Group of the Department of Radiology at Children's with Lino Becerra, PhD. "We were trying to define what happens to a changing brain as it adapts over time in those afflicted with this syndrome." A key advantage of imaging children is that they do not usually have other illnesses and are not typically on other medications that might influence the findings, he adds.

"This paper is not just a first for kids, but also has implications for understanding the adult condition," he said.

The imaging studies revealed some unexpected findings. Most importantly, the images taken in the non-pain state showed that brain recovery was not complete.

"The brain changes seen during the pain state don?t disappear during the early non-pain state. As a result, subsequent injuries could rekindle the condition or other problems could occur later," Borsook warns.

Further studies will seek to evaluate how long it takes brains to recover fully and determine the efficacy of treatments.

"Our results suggest significant changes in CNS circuitry in pediatric patients with CRPS may outlast the signs and symptoms," report the authors. They conclude that even with a more rapid resolution of pain in children, the effect of the nerve damage and other changes that occur in CRPS at a time of development of brain connections may have prolonged effects upon brain circuitry. This could impact upon pain processing in these individuals later in life.

This initial research has been pivotal in establishing a newly formed program P.A.I.N. Group at Children's using fMRI to evaluate pediatric pain disorders; the program has been supported by the hospital and the Departments of Radiology and Anesthesiology.

"It brings new research to understanding acute and chronic pain disorders in childhood," says Borsook. "Furthermore, it integrates programs that are already at the forefront of pediatric pain treatment (such as the newly established Mayo Pediatric Pain Rehabilitation Program at Children's) with modern neuroimaging facilities recently established at Children's Waltham."

By: Harvard School of Public Health - Fri, 08/01/2008 - 15:25

Click Here For The Original Article Online.


Hope is out there for patients suffering intolerable pain

Hope is out there for patients suffering intolerable pain

Published: Friday, August 1, 2008 7:28 AM EDT
Editors note: This is the second in a two-part series on Reflex Sympathetic Dystrophy, also known as complex regional pain syndrome. Part I appeared in last week’s issue.

Chronic pain disease is a life-altering condition. But reflex sympathetic dystrophy (RSD) is chronic pain squared, according to American RSDHope, an online non-profit awareness and support group.

As several local families know all too well, RSD or complex regional pain syndrome, is considered the most painful form of chronic pain that exists. The simple touch of a loved one or a gentle breeze across the skin can cause unbearable pain. Even noise and vibrations can hurt.

The constant pain is described as a burning pain like having a hot poker thrust into the affected area which is usually hot or cold to the touch. The pain often spreads from the original site to many other parts of the body. It can also result in tremors, insomnia and emotional disturbances. Some patients report short-term memory loss or depression.

There are two types of CRPS. Type I, also referred to as RSD, are cases in which the nerve injury cannot be immediately identified

Type II, also referred to as Causalgia, are cases in which a distinct “major” nerve injury has occurred

Among the local families dealing with this devastating condition are the Horvaths, Lees and Savinos of Essex Fells and the Summervilles of Caldwell. Last week’s edition included a story describing the ordeal the Savino and Lee families have endured.

Michelle Horvath, 42, has suffered with the condition for about three years. It began with a tumor in her wrist. When she had surgery to remove the tumor the doctors also cut the median nerve and, she said, she had a reaction to that with a few weeks.

Never having had surgery before, she said her first response was, “Wow, this is a very painful thing.”

Like most people, she had no familiarity with RSD.

But that’s exactly what she was diagnosed with.

Her initial treatment after surgery was physical therapy and drugs including Percoset. But it was not helping much, she said.

Like many in the area she consulted Dr. Daniel Richman, head of pain management and an anesthesiologist at Hospital for Special Surgery in New York City, one of the top doctors for RSD. It was he who diagnosed her RSD.

By now she was having tremors and the pain was so severe she could not endure a physical exam.

“I went to touch my hair and it felt like there was something in it like Brillo or something,” Horvath said. But when she used her other hand she realized it was quite normal and it was the RSD that created the sensation of something rough and painful.

Next morning she had a stellate ganglion block. This procedure is an injection of a local anesthetic into the sympathetic nerve tissue on the either side of the voice box, in the neck. The injection blocks the sympathetic nerves and can help relieve pain.

Her pain medications were also increased and added to. At various times she has been on the painkillers Neurontin, Percoset and Vicodin. She has taken Amitryptolene to help her sleep and Ativan and others to control the tremors. She takes Methadone and has recently gone on Mexiletine. In all she takes 17 pills a day, all in an effort to relief the pain.

Dr. Richman told her she was very fortunate in getting an early diagnosis.

“This can really be a horror,” he said.

When Horvath found she was losing movement in her right arm she went on a regimen of physical therapy twice a week to get the movement back.

“The whole thing was very overwhelming,” she said.

Within three weeks it had spread down into her legs forcing her to crawl up the back stairs of her Essex Fells home.

One of her symptoms, which vary from patient to patient, is that she is always very cold. Some patients are always very hot.

Horvath said she did everything the doctors said to do, because she was terrified.

“I realized how fast and aggressive this is,” she said.

Ketamine Treatment

Through “doing her homework” she discovered Dr. Robert Schwartzman and the work he is doing with ketamine in Philadelphia. But at the time there was a two-year waiting list just to get in to see him. Fortunately for her, a family member knew someone who was able to pull some strings and she was able to get in to see the doctor in two weeks taking along her file from Dr. Richman in New York.

She has had ketamine treatments with both Richman and Schwartzman.

The purpose of the ketamine, which is also used as an anesthetic in surgery for large animals, is to quiet the brain.

“With RSD the pain message is constant,” Horvath explained.

The drug is administered to RSD patients through a continuous intravenous infusion of ketamine over a five-day hospital stay.

“It quiets the brain so it can remap itself and allow the pain messages to be turned off,” Horvath said.

Since the procedure is still considered experimental it is not covered by insurance and is costly, ranging from $10,000 to $50,000, according to RSDHope.

The five-day in-patient treatment is maintained by outpatient care every two weeks.

Horvath had been on a waiting list to go to Germany for even more intensive ketamine treatment. Here patients are put in a coma for 10 days while undergoing infusions. According to Horvath, although her husband, Wayne, was worried about the treatment, there have been no fatalities. Three patients developed diabetes as a result of a bad batch of the drug, according to Horvath.

This month she did get the opportunity to go to either Germany or Mexico to receive the treatment but had a change of heart.

“I found out a lot of patients are relapsing after a couple of months,” she said in a phone call Monday, July 28.

So she has decided to hold off on that for now and was scheduled to go for a new ketamine treatment under general anesthesia on Tuesday, July 29. The goal is to give her as high a dose as possible to get it into here system, Horvath said.

A former freelance photo stylist, Horvath said she is unable to work now. She suffers from constant insomnia.

“It’s been horrible,” she says.

Caldwell Resident Seeks Treatment

Corrine Feidt Summerville, 47, who lives on Westville Avenue in Caldwell, is another local resident who has sought treatment from Dr. Richman in New York City, although she had suffered from symptoms for six months to a year before his diagnosis.

She, too, has received a slew of therapies including epidural injections, dozens of trial and continuing prescription medications, physical therapy, hyperbaric oxygen therapy and surgical installation of a spinal cord stimulator.

Her latest treatment earlier this month was ketamine with Dr. Michael Goldberg at Cooper Hospital Camden. After getting some pain relief from the drug Namenda, she underwent the ketamine with disappointing results.

“It worked for the first couple of days,” her husband, Gary, said. But over all Dr. Goldberg determined it was not successful for her. She has now returned to the Namenda and is scheduled to see Dr. Schwartzman in August.

A former medical office assistant, Summerville is now classified as federally disabled and can no longer work.

Her husband works full time as a sales consultant. They have three daughters, all in their 20s, who live at home.

“All family members try to help with regular cleaning, cooking and other jobs around the house, but busy schedules make it difficult,” Mr. Summerville says.

Reduced income because of his wife’s disability also makes life stressful for all, not to mention the emotional upset relating to her condition and pain, he says. In addition, she has to spend many hours alone, he said.

Mrs. Summerville’s condition seems to stem back to an accidedent four or five years when she slipped on the steps while carrying a box of books. This results in a disk injury and a discectomy about a year later. The RSD was diagnosed shortly after that.

RSD has affected her vital functions including vision, arms, legs, hands and feet. She is in constant pain ranging from tolerable to severe. She also suffers from depression.

Like others her symptoms also include sensitivity to touch and swelling in the heat. The affected areas turn blue when cold and she suffers from shaking of her arms, hands, legs and feet, similar to the symptoms of Parkinson’s disease, her husband says.

RSD patients are quick to point out that the symptoms are wide-ranging and different for different people. The condition often leads to feelings of helplessness and depression.

But Dr. Schwartzman says it’s important to understand that this is not a psychological condition. The injury that leads to RSD changes the genetics of the spinal cord, he said.

“It is very important to stay as proactive as possible as pain is unavoidable, whether inactive or active, so not giving in to depression and desperation are very important,” Mr. Summerville stressed.

Having each other in the community seems to be of help to the patients we talked to you. It is helpful to have others who have experienced similar problems to relate to you. Perhaps only they can truly understand what they are going through.

Another source of support for people with RSD/CRPS and their families is the Milford, Conn.-based group Reflex Sympathetic Dystrophy Syndrome Association which also has a small office in New York City and a Web site chockfull of information. The group has slightly more than 7,000 members and, since 1992 has funded more than $1 million in research.

More information on reflex sympathetic dystrophy/ complex regional pain syndrome can be found at

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