WELCOME TO THE
PARC!
As of June 1, 2009, we have added new items throughout
our site. We update frequently.
SYNCHRONICITY
"In each of our lives occur mysterious
coincidences,
sudden unexplained events that,
once interpreted correctly
have the power to guide our actions
and affirm our vision."
from the Celestine Prophecy
"TULIP"
STAINED GLASS ART
CARDS
ONE OF 8 UNIQUE DESIGNS
View
more...
*GET OUR NEW DVD SET
(2 DISCS) AND
STAINED
GLASS ART CARDS
PROCEEDS TO PARC PROGRAMS
FOR 2009-10.
CRPS AND
PAIN NEWS
PARC's
NEW CRPS DVD SET:
NOW AVAILABLE!
The CRPS DVD SET
(of two discs) featuring three excellent pain management doctors
is here!
Thanks to our RIDE
TO CONQUER CRPS sponsors who made this possible:
Levinter and Levinter
Centres for Pain Management
Canadian Pain Coalition
Preszler Injury Lawyers
DISC
1 Bonus Feature:
Dr G. Rhydderch MD FRCPC
Dr. H. Pollett MD FRCPC
DISC 2:
Lisa Cardas RN
Dr. David Shulman MD
CCFP FCFP DAAPM
HOW TO GET
YOUR DVD SET:
OPTION 1. To
print a DVD order form to mail in with your cheque, click below:
PRINT
DVD FORM
OPTION 2.
We are now able to accept online transactions with major credit
cards.
PLEASE READ
CAREFULLY BEFORE DOING TRANSACTION BELOW:
The PARC FORM sends us a ONLY A
RECORD
of the item/amount you require.
The second online form is the actual
transaction form.
Please note that you are
NOT donating twice.
Thanks for your patience!
ORIGINAL
STAINED GLASS ART CARDS!
WATER (Design 2 of
8)
OR DESIGN has utilized breathtaking colors and brilliant
textures of stained glass for the luminous glass art that they create.
These radiant cards are awesome photos of the art glass that Pam
and Oded Ravek have so lovingly created.. This set of 8
original cards are blank and suitable for any occasion.
Help support PARC's programs for 2009-10.
MORE STAINED GLASS
ART CARDS
CHAMSA (Design 3 of
8)
FALL (Design 4 of
8)
Can you find the other 4 designs hidden in the web
site?
TO ORDER: To print an order form
to mail in with your cheque, click below:
PRINT
DVD/CARDS FORM
PARC
PEARL: SPRING 2009
- PARC NEWS 2008: What's
New?
- THE TRIAD: SLEEP, MOOD, PAIN
- ARE YOU
DRUG IMPAIRED?: by Willy Noiles
- Phoenix Conference March 27-28:
New Info
- Medications for Pain:
Chris Harper, Pharmacist
- Pain and Personality: part
4
CLINICAL
TRIAL FOR EXPERIMENTAL NEW TREATMENT
Investigator: Dr Mark Ware
McGill University Health Centre (MUHC)
Clinical Investigation for CRPS
Inclusion Criteria:
- over 18
- diagnosis of CRPS more than 6 months
Exclusion Criteria
- kidney or liver disease
- diabetes
-
Willing to attend 4 visits over a 10 week period.at the Montreal
Pain Centre
-
Length of Trial: 10 weeks maximum
-
Travel and accommodation are at patient's own expense.
-
For further information please contact: Research Nurse: Sylvie
Toupin (or Laura Pallett )
-
Tel: (514) 934 1934 x 44348 or 42215 Montreal
General Hospital Pain Centre
CANADIAN
LAWYER
REFERRAL
LIST
PARC is compiling a list of lawyers who deal with
CRPS/RSD
If you can recommend a Canadian lawyer, please contact
us at PARC.
What's in your wallet?
This card is the size of a credit
card easily stored in a purse, wallet or pocket.
Text in part reads:
DO YOU
HAVE BURNING PAIN?
HAS
IT LASTED LONGER THAN THE EXPECTED HEALING TIME?
WHEN TO
SUSPECT CRPS...(quote)
INSIDE
TEXT: Signs
and symptoms of RSD/CRPS.
________
PROFESSIONALS:
Do you have patients recently
diagnosed? Do you need cards for your patients, nurses, hospital
or clinic staff?
This sleek 4"x 3 3/8"pocket card has
concise RSD/CRPS information.
PATIENTS:
Are you tired of
explaining what RSD/CRPS is? Do your family and friends understand?
Does your doctor know about it? Does the ER staff, specialist,
local hospital, nurse, or physiotherapist know?
Now there is no
need to explain--let the Pocket Card do it for you.
Why not keep one in your wallet and carry extras
to educate your doctors?
Q: HOW CAN I GET
A FREE CARD?
A: Sign up
as a new member with PARC. Please send your mailing address and
membership fee ($35 CDN for deluxe or $25 CDN for newsletter only
) to the address below. (Please note: US and International rates
available on request.)
Q: WHAT IF I ONLY
WANT CARDS ?
To receive a quantity
of cards, please tell us how many you wish and include a donation
($2 per card) inside a self-addressed envelope
sent to our mailing address:
PARC
POCKET CARD
c/o
PARC PO BOX 21026
ST.
CATHARINES, ONTARIO
CANADA
L2M 7X2
=============
Proceeds go to our Education
Programs for 2009.
Please contact PARC
for more details.
CPAC
/PARC
SUPPORT
GROUP
MEETS FIRST TUESDAY
OF THE MONTH
DAY/TIME: Tuesdays
10:30-Noon
COMMUNITY
ROOM
412 Louth Street,
St. Catharines.
_____
MEETINGS: January 7, 2009.
February 3, 2009
March 3, 2009*
April 7, 2009
April 14, 2009 (**
event )
May 5. 2009
June 2, 2009
We discuss current issues in pain e.g. coping,
medical treatment. We also have local speakers, help attendees
find local resources and the group runs local events.
____
COMING TUESDAY APRIL 14,
2009
11-11:45 AM
"CHI KUNG FOR
CHRONIC PAIN"
with Sensei Joe
Desharnais
Xinarts Studio
Cancelled.
_______________
TUESDAY, MARCH
3
11 AM
"Drugs for
Pain"
Question and Answer
Session
with Chris Harper
B.Pharm
Shoppper's Drug
Mart
Thanks to Chris Harper
for an excellent discussion on medications. Chris has been a pharmacist
for over 20 years and serves the people of north St. Catharines.Please
see the PARC spring newsletter for an article on Chris.
-----
PLEASE NOTE: We welcome out of town visitors
however if you plan on travelling any distance, please contact
our office first and confirm the next meeting date.
CONTACT
US AT PARC.
PARC'S
WISH LIST 2009
Please read this list and if you can help in any way,
we would be very appreciative.
- sponsors for our educational programs for 2009-10
- office materials
- volunteers to promote awareness across Canada
- volunteers to start support groups
- person(s) with fundraising experience, publicity, board experience
CONTACT
US AT PARC.
IMPORTANT
NEWS BULLETIN:
New research has
found markers for CRPS. this means that CRPS can now be diagnosed.
From Boston, a skin biopsy (3mm punch
biopsy) can detect distal nerve damage (distal portion of axons).
From Haifa Israel, a simple saliva test can
measure high levels of LDH (lactate dehyrogenase), the same substance
found in heart attack victims. High levels of albumin are also found.
These tests are not
yet available in Canada, however we hope they will be soon. Further
details as they become available.
Brain is rewired in
patients with chronic pain syndrome
CBC News
The brains of people with a chronic pain condition
look like an inept cable worker rewired areas related to emotion,
pain perception and skin temperature, a brain imaging study suggests.
In Wednesday's issue of the journal Neuron, researchers reported
using magnetic resonance imaging (MRI) to look for the differences
in the brains of 22 normal subjects and 22 subjects with a chronic
pain condition called complex regional pain syndrome.
The brains of chronic pain patients showed changes
in the brain's white matter, the cable-like network of fibres that
deliver messages between neurons.
"This is the first evidence of brain abnormality
in these patients," said the study's lead investigator, Vania
Apkarian, a professor of physiology at Northwestern University's
Feinberg School of Medicine in Chicago.
"People didn't believe these patients. This
is the first proof that there is a biological underpinning for the
condition."
The syndrome often begins with significant damage
to a hand or foot. In five per cent of patients, the pain continues
to rage long after the injury has healed. The cause is unknown.
Typical features include:
- Pain that radiates from the injury site, such as the hand,
to the rest of the arm or even the whole body.
- Skin colour changing to blue or red, and skin temperatures
that feel hotter at first and then colder as the condition becomes
chronic.
- A hike in immune markers in the blood showing the immune system
has shifted into overdrive.
- The white matter changes are related to the duration and intensity
of pain and anxiety that patients feel, Apkarian said.
Dramatic improvements or remission are possible if
treatment such as anti-inflammatories, physical therapy, sympathetic
nerve blockers, electrical impulses applied to nerve endings, biofeedback
and spinal cord simulation are used early, according to the Mayo
Clinic.
The new anatomical findings could provide targets for potential
drug treatments, the researchers said.
Aside from the white matter changes, the brains of people with CRPS
also showed an atrophy of the neurons or grey matter that has been
found in other types of chronic pain.
HE SUFFERED
FOR 12 YEARS
Burlington
man celebrates the end of pain shooting up his right leg to his
groin.
Toronto Sun
November 23, 2008
Chris Todman went
in for foot surgery--and came out with terrible pain in his testicles.
It lasted 12 years. Like a vise in the worst place. Day and night.
An awful burning broken only by bolts of agony six or seven times
an hour.....
... Later he was
diagnosed with Reflex Sympathetic Dystrophy (RSD)
a fancy name for chronic pain......
Page 6 by Mike Strobel,
Toronto Sun.
mike.strobel@sunmedia.ca
Tel: 416 947 2265
To read the rest
of the article go to: www.torontosun.com
Therapist uses brain
to help ease people's pain
The Bath Chronicle
An expert from Bath is pioneering a new treatment for people with
agonising pain.
Occupational therapist Jenny Lewis believes she can revolutionize
treatment of a condition that leaves patients in so much pain they
would rather cut off their arm or leg than endure the constant agony.
One in every 4,000 people in the UK suffers from Complex Regional
Pain Syndrome (CRPS), which can be triggered after a small injury
and often leaves patients in significant physical torment.
Dr Lewis, who is based at the Royal National Hospital for Rheumatic
Diseases (RNHD) in Bath, has secured a fellowship at a leading international
centre. She will work at McGill University in Canada, using brain
imaging to investigate the phenomenon known as body perception disturbance.
The RNHD, also known as The Min, is the only UK hospital that offers
an inpatient rehabilitation service, and sees about 100 new patients
with CRPS each year.
During her clinical work Dr Lewis noticed how patients behaved
in an unusual way towards their painful limb.
"While treating patients with CRPS I noticed that rather than
protect and look after their painful limb as you might expect, patients
often ignored it," she said.
"They had a distorted perception of their limb and when asked
to close their eyes and describe it, they would leave out whole
anatomical sections.
"They would express feelings of loathing towards it, often
behaving as if it was not part of their body. Some even had a desperate
desire to amputate it."
Body perception disturbance sees patients often unable to engage
with the painful limb, which can be detrimental to their rehabilitation.
Dr Lewis will use magnetic resonance imaging to explore possible
changes in the region of the brain responsible for touch sensation.
She hopes to use this as evidence of changes in the way that the
brain represents the limb where chronic pain is felt, and will compare
this brain activity to how patients describe their body perception
disturbance to establish whether there is a relationship between
the two.
"A better understanding of this relationship will inform treatment
and contribute to improving rehabilitation outcomes for patients
with CRPS and other chronic pain conditions," she added.
CANADIAN
PAIN SOCIETY SURVEY 2007
- 33% (about 1/3) of Canadians live with moderate
to severe pain
- 1 in 6 have constant pain
- 1 in 5 experience pain daily
- 33% are depressed or anxious
- 30% have relationships which are affected
"1 in 4 Canadians suffer from chronic pain yet access
to effective treatment for chronic pain is poor"
VETS AVERAGE THREE TIMES THE PAIN TRAINING
THAN DOCTORS
Pain education varies in Canada. A CPS survey of 41 programs
at 10 major universities found that:
- Doctors receive an average of 19
hours in pain training
- Nurses averaged 31 hours
- Vets averaged 98 hours
"This poor level of education in pain just compounds
the crisis of underrated pain in Canada" says Barry
Sessle, CPS President.
For more info go to: www.painexplained.ca
EVIDENCE
OF NERVE DAMAGE IN CRPS1**
Study finds nerve damage in previously
mysterious chronic pain syndrome Reduction in small-fiber nerves
may underlie complex regional pain syndrome-I (reflex sympathetic
dystrophy)
BOSTON – Researchers at Massachusetts General Hospital (MGH)
have found the first evidence of a physical abnormality underlying
the chronic pain condition called reflex sympathetic dystrophy or
complex regional pain syndrome-I (CRPS-I). In the February issue
of the journal Pain, they describe finding that skin affected by
CRPS-I pain appears to have lost some small-fiber nerve endings,
a change characteristic of other neuropathic pain syndromes
“This sort of small-fiber degeneration has been found in every
nerve pain condition ever studied, including postherpetic neuralgia
and neuropathies associated with diabetes and HIV infection,” says
Anne Louise Oaklander, MD, PhD, director of the MGH Nerve Injury
Unit, who led the study. “The nerve damage in those conditions has
been much more severe,
Complex regional pain syndrome is the current name for a baffling
condition first described in he 19th century in which some patients
are left with severe chronic pain and other symptoms – swelling,
excess sweating, change in skin color and temperature – after what
may be a fairly minor injury. The fact that patients’ pain severity
is out of proportion to the original injury is a hallmark of the
syndrome, and has led many to doubt whether patients’ symptoms are
caused by physical damage or by a psychological disorder. Pain not
associated with a known nerve injury has been called CRPS-I, while
symptoms following damage to a major nerve has been called CRPS-II.
Because small-fiber nerve endings transmit pain messages and
control skin color and temperature and because damage to those fibers
is associated with other painful disorders, the MGH research team
hypothesized that those fibers might also be involved with CRPS-I.
To investigate their theory they studied 18 CRPS-I patients and
7 control patients with similar chronic symptoms known to be caused
by arthritis. Small skin biopsies were taken under anesthesia from
the most painful area, from a pain-free area on the same limb and
from a corresponding unaffected area on the other side of the body.
The skin biopsies showed that, the density of small-fiber nerve
endings in CRPS-I patients was reduced from 25 to 30 percent in
the affected areas compared with unaffected areas. No nerve losses
were seen in samples from the control participants, suggesting that
the damage was specific to CRPS-I, not to pain in general. Tests
of sensory function performed in the same areas found that a light
touch or slight heat was more likely to be perceived as painful
in the affected Areas of CRPS-I patients than in the unaffected
areas, also indicating abnormal neural function. “The
fact that CRPS-I now has an identified cause takes it out of the
realm of so-called ‘psychosomatic illness.’
One of the great frustrations facing CRPS-I patients has been
the lack of an explanation for their symptoms. Many people are skeptical
of their motivations, and some physicians are reluctant to prescribe
pain medications when the cause of pain is unknown,” says Oaklander.
“Our results suggest that CRPS-I patients should be evaluated by
neurologists who specialize in nerve injury and be treated with
medications or procedures that have proven effective for other nerve-injury
pain syndromes.”
She adds that the next research steps should investigate why
some people are left with CRPS after injuries that do not cause
long-term problems for most patients, determine the best way of
diagnosing the syndrome and evaluate potential treatments. “Investigations
that identify the causes of disease are only possible if patients
are willing to come to the lab and allow researchers to study them,”
she adds. “We are tremendously grateful to these CRPS patients,
whose willingness to let us study them – despite their chronic pain
– allowed us to make an important step in helping those who suffer
from this condition.” Oaklander is an assistant professor of Anesthesia
and Neurology at Harvard Medical School.
The study was supported by grants from The Mayday
Fund, the National Institute for Neurological Disorders and Stroke,
and the American Federation for Aging Research. Coauthors are Julia
Rissmiller, Lisa Gelman, Li Zheng, D, PhD; Yuchiao Chang, PhD; and
Ralph Gott, all of the MGH. Massachusetts General Hospital, established
in 1811, is the original and largest teaching hospital of Harvard
Medical School. Contact: Sue McGreevey
(617) 724-2764
* PARC NOTE: This paper is the
most significant study about CRPS/RSD since it takes us out of the
realm of psychosomatic or "all in your head" illnesses
to proof that CRPS/RSD is a real, organic illness. (Of course, we
all knew that anyway!)
If you are a patient reading this, please print it out for
your doctor to read. We thank you.
*2009
UPDATE: Dr. Oaklander
will update everyone on this important discovery on March 28th in
Phoenix at the RSDSA Conference. See our CONFERENCES page.
Patients
Spend Five Days in Coma to Manage Pain
Desperate Patients Undergo Risky Procedure as Last Resort
Defile's pain was a result of something called RSD, or Reflex Sympathetic
Dystrophy, a chronic neurological syndrome characterized by severe
burning pain, pathological changes in bone and skin, excessive sweating,
tissue swelling, and extreme sensitivity to touch. An injury Defile
suffered during the accident brought on RSD, which sent his nervous
system out of control and triggered pain signals that were out of
proportion to reality.
Dr. Robert Schwartzman, professor and chairman of neurology at the
MCP Hahnemann School of Medicine in Philadelphia, has researched
RSD for more than 30 years. He says it's important to understand
that this is not a psychological condition.
"That injury changes the genetics of the spinal cord,"
Schwartzman said. "It happens in children and it can happen
to anybody. And it is absolutely not psychological."
In DeFilippo's case, he says the pain was paralyzing — often
sending him into blackouts.
Lindsay Wurtenberg, 14, says her life was turned upside down by
RSD after she was bitten by a spider. She ended up with such crippling
pain that she needed a wheelchair.
"It just kept getting worse and worse and worse every week,"
Wurtenberg said.
DeFilippo, of Langhorne, Pa., and Wurtenberg, of Mickletown, N.J.,
turned to a new treatment, only being offered outside of the United
States, when they figured there were no other options left.
Both patients traveled to Germany, where doctors used huge amounts
of the anesthetic ketamine to put them into a coma for five days.
The procedure is not performed in the United States because the
Food and Drug Administration does not approve of coma inducement
for longer than two days.
Schwartzman, the only American doctor working with the German team,
says the anesthetic — when administered for five days —
works wonders on RSD patients.
What we're doing is changing your spinal cord back to normal. The
downside is, yes, it's very risky," Schwartzman said.
Risks related to the procedure include blood clots in the lungs
and infections from catheters. But Wurtenberg's mother says the
risky process gave her daughter her life back.
Schwartzman says that while the procedure has helped Wurtenberg
and DeFilippo, it hasn't helped every patient with RSD.
He says the process only blocks the extreme pain patients experience,
but doesn't fix the underlying problem. As a result, the pain associated
with RSD can return.
DeFilippo says the procedure has completely changed his life.
"Luckily enough, I was given the opportunity to be able to
undergo the treatment and it virtually has changed my life,"
DeFilippo said. "I was in such a state of agony. My life —
quality of life — was nonexistent. Now I have everything looking
up for me."
ABC News affiliate WPVI in Philadelphia
contributed to the "Good Morning America" report.
PLEASE NOTE: This procedure
is not yet available in Canada. PARC is monitoring this situation
closely.
More on our STUDIES page under
Studies 2008.
NOTE: This treatment is now available
in Mexico through the RSD Foundation: www.rsdfoundation.org
Low doses
of a common intravenous anesthetic
may relieve
debilitating pain syndrome
Limited, low-dose infusions of a widely used anesthetic drug may
relieve the often intolerable and debilitating pain of Complex Regional
Pain Syndrome (CRPS), a Penn State Milton S. Hershey Medical Center
researcher found.
"This pain disorder is very difficult to treat. Currently-available
therapies, at best, oftentimes only make the pain bearable for many
CRPS sufferers," said Ronald E. Harbut, M.D., Ph.D., assistant
professor of anesthesiology, Penn State Hershey Medical Center.
"In our retrospective study, some patients who underwent a
low-dose infusion of ketamine experienced complete relief from their
pain, suggesting that this therapy may be an option for some patients
with intolerable CRPS."
The study, titled "Subanesthetic Ketamine Infusion Therapy:
A Retrospective Analysis of a Novel Therapeutic Approach to Complex
Regional Pain Syndrome," was published in the September 2004
issue of Pain Medicine, the official journal of the American Academy
of Pain Medicine.
CRPS (type I), also known as Reflex Sympathetic Dystrophy Syndrome
(RSD), affects between 1.5 million and 7 million people in the United
States and is oftentimes marked by a severe, burning pain that can
be very resistant to conventional therapies. The pain frequently
begins after a fall or sprain, a fracture, infections, surgery,
or trauma. Often present in the limbs with possible later spreading
to other parts of the body, patients also may experience skin color
changes, sweating abnormalities, tissue swelling, and an extreme
sensitivity to light touch or vibrations. The McGill Pain Index
rates CRPS as 42 on the scale of 50, with 50 being most severe.
Although much is unknown about CRPS, the pain experienced by patients
appears to be caused by over-stimulation of a nerve receptor complex
involved in the process of feeling pain. Therefore, efforts have
been made to treat CRPS by blocking these receptors. Whereas most
pain medications do not effectively block these receptor complexes
(often referred to as NMDA-receptors), ketamine does.
The study was initiated by Graeme E. Correll, B.E., M.B.B.S., and
involved reviewing the medical records of 33 patients with CRPS
treated by Correll. The patients, some of whom had failed to obtain
pain relief from conventional therapies, were treated with low-dose
inpatient intravenous infusions of ketamine between 1996 and 2002
in Mackay, Queensland, Australia. Ketamine infusions were started
at very low rates and were slowly increased in small increments
as tolerated by selected patients. The therapy was then continued
as long as the patient tolerated the drug and continued to benefit
from it. Treatment cycles generally continued until the patient
experienced complete pain relief; until initially-obtained relief
would not improve any further; or for no more than 48 hours if there
was no improvement in pain severity.
Pain was completely relieved for 25 (76 percent) patients, partially
relieved for six (18 percent) patients, and not relieved for two
(6 percent) patients. Although the relief obtained did not last
indefinitely, 54 percent remained completely pain-free for three
months or more and 31 percent for six months or more. For 12 patients
who received a second treatment, 58 percent experienced relief for
one year or more with 33 percent remaining pain-free for more than
three years.
The most frequent side effect reported was a feeling of inebriation.
Hallucinations occurred in six patients with less frequent side
effects including complaints of light-headedness, dizziness and
nausea. Liver enzymes were altered in four patients but resolved
after therapy.
The exact mechanism of sustained pain relief is unknown, but is
currently under study at Penn State Hershey Medical Center. Harbut
likened the ketamine treatment to the healing of a broken bone.
"If someone breaks a bone and you simply put the two pieces
back together, they won't immediately heal. However, if you add
a splint and hold the bones steady for a period of time, and then
later take away the splint the bone is healed. I believe that the
ketamine treatment does something similar that lends support and
allows the nerve cells to heal themselves, so that when you take
away the ketamine, the pain is reduced or gone."
Harbut began studying CRPS with Correll during a work assignment
Harbut volunteered to take in far northern Queensland, Australia,
in the late 1990s. Correll was developing a therapy for CRPS but
wanted a collaborator to formally research the effectiveness of
the therapy. Harbut brought Correll's method back to the U.S. where
he developed an FDA-approved study protocol (used at the Mayo Clinic
Scottsdale) using this method to attempt to treat post herpetic
neuralgia, another pain disorder with symptoms somewhat similar
to CRPS. At the same time, Harbut met a patient who had suffered
with intolerable CRPS for nine years who wanted to try this new
therapy. That patient became the first successful treatment of intractable
CRPS in the U.S. (A Case Report of this treatment appeared in the
June 2002 issue of Pain Medicine.)
"Ultimately, we want to find a way to improve the quality
of life for those who suffer with intolerable CRPS, some of whom
at times contemplate suicide because of their endless pain,"
Harbut said. "Although optimistic about these early findings,
certainly more study is needed to further establish the safety and
efficacy of this novel approach." (A large clinical study is
currently planned and under development at Penn State Hershey Medical
Center.)
In addition to Harbut and Correll, the team involved in this study
included: Jahangir Maleki, M.D., Ph.D., and Edward J. Gracely, Ph.D.,
Drexel University College of Medicine; and Jesse J. Muir, M.D.,
Mayo Clinic Scottsdale.
Various treatment centers in USA offer this treatment.
Further reading:
Koffler et al The Neurocognitive effects of 5 day anesthetic
ketamine for the treatment of CRPS Archives of Clinical Neuropsychology
2007; 22: 719-729
Needlestick Distal Nerve Injury in Rats
Models Symptoms
of Complex Regional Pain Syndrome
Sandra M. Siegel, PhD
Jeung W. Lee, PhD
Anne Louise Oaklander, MD, PhD
Pain Mechanisms
Section Editor: Tony L. Yaksh
BACKGROUND: Complex Regional Pain Syndrome (CRPS)-I
consists of chronic limb
pain and dysautonomia triggered by traumas that sometime seem too
trivial to be
causative. Several pathological studies have identified minor distal
nerve injuries
(DNIs) in CRPS-I patients, but retrospective studies cannot establish
causality.
Therefore, we, prospectively investigated whether DNIs are sufficient
to cause
CRPS-like abnormalities in animals. We used needlestick, a cause
of human CRPS,
to evaluate lesion-size effects.
METHODS: Left tibial nerves of male Sprague–Dawley
rats were transfixed once by
30G, 22G, or 18G needles. Unoperated and sham-operated rats provided
controls.
Hindpaw sensory function, edema, and posture were measured.
RESULTS: At Day-7 postoperatively, thresholds for
ipsilateral-hindpaw withdrawal
from Semmes–Weinstein monofilaments were reduced by 51% in
0% of sham-operated
controls; 67% of rats that received 18G-DNI, 88% that received 22G-DNI,
and 89% that received 30G-DNI. Fifty-seven percent of all DNI rats
had contralateral
hindpaw “mirror” changes. The prevalence and severity
of allodynia appeared
independent of lesion size. Hyperalgesic responses to cold and pinprick
applied to
the plantar hindpaw were less common and were ipsilesional only,
as was
neurogenic hindpaw edema. Ipsilesional-only, tonic, dystonic-like
hindpaw postures
were evident in 42% of 18G-DNI, 6% of 22G-DNI, and no 30G-DNI or
sham-operated control rats. The prevalence of postural abnormalities
correlated
with needle diameter (P 0.001). Counting protein gene product
9.5-
immunolabeled axons in skin biopsies from rats’ ipsilesional
hindpaws demonstrated
mean reductions of 0% after 30G-needlestick, 15% after 22G-needlestick,
and 26% after 18G-needlestick, which closely reproduces the 29%
mean epidermal
neurite losses of CRPS-I patients.
CONCLUSIONS: Needlestick DNI models several clinical
and pathological features of
human CRPS and provides direct prospective evidence that even minor
DNI can
cause CRPS-like abnormalities in rats.
(Anesth Analg 2007;105:1820 –9)
Complex regional pain syndrome (CRPS) consists of chronic limb pain
and vascular dysregulation
(edema, color, and/or temperature abnormalities). CRPS symptoms
are defined as disproportionately
severe relative to the causative or remaining tissue injury. For
the majority of patients who lack identified
nerve injuries (currently defined as CRPS-I and also known as reflex
sympathetic dystrophy) these unexplained symptoms contribute to
concerns about malingering
or psychiatric causality, and can complicate treatment of an already
difficult condition.
We suggest that both subtypes of CRPS involve chronic, partial,
injuries to the small-diameter axons
that mediate painful sensations and autonomic function (small fibers).
Axonopathy has been identified in
most neuropathological studies of CPRS-I tissues (1–3). The
other pathological abnormalities present:
blood vessel dilation and hypertrophy, muscle atrophy, osteopenia,
and synovial abnormalities (4) are
also consistent with, and explicable by, axonopathy. Quantitative
analyses suggest that small fiber loss is
often less severe in CRPS-I than in other neuralgias studied (5,6).
Pathological examination of nerves from amputated legs of eight
CRPS-I patients has identified subtle axonal degeneration, predominantly
affecting small fibers (1). Skin biopsies from 18 CRPS-I subjects
(including one needlestick patient) have revealed 29% 15% fewer
protein gene product (PGP) 9.5-immunoreactive neurites in biopsies
from painful CRPS-I-affected skin than in biopsies from unaffected,
same-subject control
From the Departments of Neurology, Anesthesiology,
and Pathology,
Massachusetts General Hospital, Harvard Medical School, Boston,
Massachusetts.
Accepted for publication September 12, 2007.
Supported by Public Health Service grant NINDS R01NS42866,
Address correspondence and reprint requests to Anne Louise
Oaklander, MD, PhD, Massachusetts General Hospital Department
of Neurology, 275 Charles St./Warren 310, Boston, MA 02114.
Copyright © 2007 International Anesthesia Research
Society
DOI: 10.1213/01.ane.0000295234.21892.bc
Vol. 105, No. 6, December 2007 1820
Perioperative Pregabalin Reduces Neuropathic
Pain at 3 Months after Total Knee Arthroplasty (TKA)
Asokumar Buvanendran, M.D., *Scott S. Reuben, MD,
Maruti Kari, MD, Jeffrey S. Kroin, PhD, Craig Della Valle, MD, Rush
University Medical Center, *Baystate Medical Center.
Introduction: Pregabalin (Lyrica) has been shown
to be effective for the treatment of chronic neuropathic pain (Pain
Res Manag 2006; 11:16A-29A). Pregabalin administered before and
after surgery reduced opioid use following spinal fusion surgery
(Anesth Analg 2006;103:1271). This study examines the hypothesis
that pregabalin administered perioperatively for patients’
undergoing total knee arthroplasty (TKA) can reduce chronic long-term
pain syndromes.
Methods: Following IRB approval, a total of 146
patients having primary TKA were enrolled in this randomized, placebo-controlled,
double-blind study. Patients were randomly assigned to 2 drug groups.
Half of the patients received pregabalin 300 mg orally 2 hours prior
to surgery, and the other half received matching placebo, at the
same time point. In the operating room, patients were sedated with
midazolam and a combined spinal-epidural procedure performed. At
completion of surgery, epidural infusion of fentanyl/bupivacaine
was initiated using continuous basal infusion with superimposed
patient-controlled bolus. Patients subsequently received repeated
doses of pregabalin 150 mg b.i.d. or placebo starting the day after
surgery, with drug dosing continued up until day 14 post-surgery.
The incidence of neuropathic pain was assessed 3 months post-surgery
using the S-LANSS score, a valid diagnostic tool to assess neuropathic
pain, with patients scoring ³12 considered to have neuropathic
pain (J Pain 2005;6:149). The incidence of mechanical allodynia
(stroking) or hyperalgesia (pressure) was also recorded. Comparison
between the 2 groups was by chi-squared test.
Results: There was no difference in demographics
(age, weight, etc.) between the 2 groups. At 3 months post-TKA,
the incidence of patients with neuropathic pain post-TKA was lower
in the pregabalin (1.49%) group compared to the placebo (11.39%)
(P=0.018). The incidence of allodynia in the operated leg (fig)
was also lower (P=0.0337) at 3 months for the pregabalin group (14%)
than the placebo group (37%). The incidence of hyperalgesia in the
operated leg was lower (P=0.0346) for the pregabalin group (20%)
than the placebo group (34%). Patients who received pregabalin also
had lower VAS pain scores in the operated leg at 3 months post-TKA
compared to placebo (P=0.047).
Discussion: Perioperative administration of pregabalin
decreased the incidence of neuropathic pain from 11.39% to 1.49%
at 3 months after TKA. This suggests that pregabalin may be a useful
perioperative medication for decreasing the incidence of chronic
pain for patients undergoing this surgical procedure.
Copyright © 2005 RSDSA
Fentanyl Painkiller Patches
Recalled
Patches Containing the Prescription Painkiller Fentanyl Recalled
Because of Flaw
By Natasha T. Metzler
Associated Press
WASHINGTON---Patches containing the prescription painkiller fentanyl
were recalled Tuesday, because of a flaw that could cause patients
or caregivers to overdose on the potent drug inside.
Sold in the United States under the brand name Duragesic by PriCara
and generically by Sandoz Inc., the recall includes all 25-microgram-per-hour
patches with expiration dates on or before December 2009.
Some of the patches may have a cut in the lining of the internal
reservoir where the drug is stored in gel form. If the fentanyl
gel leaks into the drug's packaging, it could cause a patient
or caregiver to come into direct contact with this powerful "opioid"
drug. This could result in difficulty breathing and a potentially
fatal overdose.
If this reservoir is cut, it can be seen when the foil pouch
containing an individual patch is opened. Damaged patches should
be flushed down the toilet and not handled. Skin that has been
exposed to the gel should be thoroughly rinsed with water, but
not washed with soap.
In December, the FDA put out its second warning in two years
about the dangers of misusing the powerful drug.The drug is intended
for chronic pain in people used to narcotics, such as cancer patients,
and can cause trouble breathing in people not used to this family
of painkillers. Yet the FDA found cases where doctors prescribed
it for headaches or post-surgical pain.
PriCara estimates that two patches out of every million included
in the recall have the defect that causes the leak.
FURTHER INFORMATION: For details on Duragesic
patches sold by PriCara, call 800-547-6446. For details on generic
fentanyl patches sold by Sandoz, call 800-901-7236.
CANADIANS: The recalled patches were also
sold in Canada under the Duragesic brand by Janssen-Ortho Inc.
and generically by Ranbaxy Laboratories Ltd.
All of the patches were manufactured by PriCara affiliate ALZA
Corp. PriCara is a division of rtho-McNeil-Janssen Pharmaceuticals,
Inc.
NOTE: Please contact the drug company in question for details
.
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