WELCOME TO THE
PARC!
As of June 17, 2008, we have added many new
items on this page and throughout our site.
Our 2006-7 articles are archived. Click
here.
We continue to add news frequently so please
bookmark this page.
THOUGHT
FOR THE NEW YEAR
"Healing occurs
in the sacred space
of calmness and confidence,
not amid the turmoil
of fear, anger and pain."
Dharma Singh Halls MD
IMPORTANT
EVENT NOTICES:
1. PARC'S
SPRING EVENT
May 31,
2008
HAS BEEN
MOVED TO NOVEMBER
in conjunction
with
National Pain Awareness
Week across Canada, (Nov 2-8)
the first week
in November.
Details when available.
-----------------
2. IN
CONJUNCTION WITH THE RIDE TO CONQUER CRPS
MUHC PAIN
CENTRE,
MONTREAL
PRESENTS
Complex Regional
Pain Syndrome Type I (RSD):
New data from the
clinic and the laboratory.
A Pain Forum presentation of the MUHC
Pain Center
DATE: Monday, 28 July 2008
TIME: 1:00-4:30 PM
PLACE: Livingston Hall Lounge (Room L6-500)
Montreal General Hospital
SCHEDULE:
1:00-1:05 Welcoming remarks (Gary J. Bennett, PhD; McGill University)
1:05-1:45 CRPS-I: The clinical picture. (David L. Shulman, MD
CCFP FCFP DAAPM; Rothbart Pain Clinic, Toronto) RIDE TO CONQUER
CRPS 2008 STOP
1:45 -2:45 A new theory: Deep tissue microvascular pathology
as the cause of CRPS-I. (Terence J. Coderre, PhD; McGill University)
2:45-3:00 Health break
3:00-3:30 The role of the endothelins in CPIP pathology (Magali.
Millecamps, PhD, McGill University)
3:30-4:00 CRPS-I breakthroughs: New data from Boston and Haifa
(G. Bennett, PhD)
4:00-4:30 Discussion
4:30 Adjourn
For directions and parking information see: http://www.muhc.ca/pfv/mgh/directions/
Other information: gary.bennett@mcgill.ca; tel.: (514) 398-3432;
FAX: (514) 398-8241.
RIDE TO
CONQUER CRPS 2008
July
19, 2008
Please click on the date above for details.
We are now able to accept donations online with
major credit cards.
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.
CRPS/CPAC
SUPPORT GROUP
NEW LOCATION
Please note: Our CPAC/ PARC support group
has moved to a new location as of Nov 2007.
Meetings are the first and third Tuesday
of each month
SUMMER MEETING DATES:
July 8th
Aug. 5th.
SUPPORT GROUP
COMMUNITY
ROOM
412 Louth Street,
St. Catharines.
TIME: 10:30-Noon
If you plan on attending, and travelling from far
away,
please contact our office first
and confirm the meeting date.
------
UPCOMING SUPPORT GROUP
EVENTS:
"Meditation/Yoga
for Chronic Pain"
FIRST: January 29,2008
SECOND: Feb. 12, 2008
THIRD: Feb. 26, 2008.
cancelled
FOURTH: March 25,
2008
APRIL: 1, 2008.
April 29, 2008 cancelled
May 13, 2008.
May 20, 2008.
June 10, 2008.
June 24,2008
------
PLACE: Tangled Yoga,
25 Main Street, Port
Dalhousie
TIME: 10:30-11:45
AM
INSTRUCTOR: Carol
Cowan, Certified Yoga teacher
WEAR: Loose comfortable
clothing and bring a positive attitude.
There is a small fee.
----------
"LOW
INTENSITY LASER THERAPY (LILT)"
with
DR
PATRICK MADDALENA DC DIRECTOR
ACCELERATED
HEALTH AND WELLNESS Centre
St. Catharines
TUESDAY
JUNE 3, 2008
10:30
AM TO NOON
Community Room
412 LOUTH ST.
ST. CATHARINES
Everyone is welcome. Admission is free.
Since seating is limited, please RSVP.
For details or directions, please contact us at
PARC.
.
---------
"NUTRITION
FOR CHRONIC PAIN"
(includes
STRESS MANAGEMENT, ALLERGIES)
Judy
Tucker RNCP EFT_ADV
DATE: Tuesday, April
8
This event was well attended and our speaker had
a great deal of information to share with us.
Should anyone wish to contact Judy please contact
us at PARC.
.
PARC NEWS
PARC
PEARL: SPRING 2008
- PARC NEWS 2008: RIDE
- WHAT IS IT LIKE TO UNDERGO THE
KETAMINE COMA PROCEDURE?
INTERVIEW WITH HEATHER KENNEDY-REDMOND by Willy Noiles
- KETAMINE TREATMENTS
- PAIN AND PERSONALITY PART 2
To order your issue:
CONTACT
US AT PARC.
PARC'S
WISH LIST
Please read this list and if you can help in any
way, we would be very appreciative.
- sponsors for the RIDE TO CONQUER CRPS in 2008
- sponsors for our educational programs for 2008
- office materials
- DVD sponsor
- volunteers to promote awareness across Canada
- support group volunteers
- person(s) with fundraising experience
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.
________
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?
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.
Available
now!
Q: HOW CAN I
GET A FREE CARD?
A: Sign up
as a new member or renew your membership 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/0
PARC PO BOX 21026
ST.
CATHARINES, ONTARIO
CANADA
L2M 7X2
=================
Proceeds go to our Education
Programs for 2008.
Please contact PARC
for more details.
ONTARIO
DOCTOR FACTS
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
PARC's
NEW June 2 DVD: RELEASE DATE SOON!
A set of two (2)
DVDs of our June 2 seminar will be out soon.
DVD 1: Lisa Cardas RN, Dr.
Shulman (part 1)
DVD 2: Dr. Shulman (part
2), Gerry Hruby
When we have
the release date we will post it here.
Sorry
our DVD release date is delayed.
If you want to reserve
advance copies, click below.
Make sure to fill
in your entire information on our contact form: e.g. name/address/e-mail
etc. Thanks!
Contact us at PARC.
QX314
and Capsaicin
A combination of two drugs can selectively block pain-
sensing neurons in rats without impairing movement or other sensations
such as touch, according to a new study by National Institutes
of Health (NIH)-supported investigators. The finding suggests
an improved way to treat pain from childbirth and surgical procedures.
“It may also lead to new treatments
to help the millions of Americans who suffer from chronic pain.
“
The study used a combination of capsaicin -- the substance
that makes chili peppers hot -- and a drug called QX-314. This
combination exploits a characteristic unique to pain-sensing neurons,
also called nociceptors, in order to block their activity without
impairing signals from other cells. In contrast, most pain relievers
used for surgical procedures block activity in all types of neurons.
This can cause numbness, paralysis and other nervous system disturbances.
"The Holy Grail in pain science is to eliminate pathologic
pain without impairing thinking, alertness, coordination, or other
vital functions of the nervous system.
This finding shows that a specific combination of two molecules
can block only pain- related neurons. It holds the promise of
major future breakthroughs for the millions of persons who suffer
with disabling pain,"
says Story C. Landis, Ph.D., director of the National
Institute of Neurological Disorders and Strokes at NIH.
Lidocaine, the most commonly used local anesthetic,
relieves pain by blocking electric currents in all nerve cells.
Although it is a lidocaine derivative, QX-314 alone cannot get
through cell membranes to block their electrical activity. That's
where capsaicin comes in. It opens large pores called TRPV1 channels
-- found only within the cell membrane of pain-sensing neurons.
With these channels propped open by capsaicin, QX-314 can pass
through and selectively block the cells' activity.
The research team, led by Clifford J. Woolf, M.D., Ph.D., (MGH)
and Bruce Bean, Ph.D. (Harvard), tested the combination of capsaicin
and QX-314 in neurons isolated in Petri dishes and found that
:
it blocked pain-sensing neurons without affecting other nerve
cells. This study showed that the drugs could block pain without
impairing motor neurons that control movement.
The drug combination took half an hour to fully block
pain in the rats. However, once it began, the pain relief lasted
for several hours. "Current nerve blocks cause paralysis
and total numbness," Dr. Woolf says. "This new strategy
could profoundly change pain treatment in the perioperative setting."
The treatment tested in this study is unique in that it uses a
type of ion channel (TRPV1 channels) as an avenue to deliver medication.
Ion channels are pores in the cell membrane that control the flow
of electrically charged ions in and out of cells. "I'm not
aware of any other strategy that uses a channel within cells to
deliver a drug to a select set of cells," Dr. Woolf says.
"This project is a nice illustration of how research
trying to understand very basic biological principles can have
practical applications," says Dr. Bean. "Surgical pain
is the obvious first application "
Dr. Woolf says. However, similar therapies might eventually be
useful for treating chronic pain, he adds. Chronic pain continues
for weeks, months, or even years and can cause severe problems,
and is often resistant to standard medical treatments.
Bnshtok AM, Bean BP, Woolf CJ. "Inhibition
of nociceptors by TRPV1-mediated entry of impermeant sodium channel
blockers." Nature Oct.2007
EVIDENCE
OF NERVE DAMAGE IN CRPS1
For immediate release: January 30, 2006
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 the 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.
ARTICLES
January 3, 2008.
Heather Kennedy is being interviewed by London A Channel today
about her ketamine coma treatment in Mexico. She is the third person
to take part in this experimental treatment and the first known
case from Canada.
_______________________________________________________
PARC regrets that this treatment is not yet available in Canada
however, it brings us hope that even the most severe cases can be
treated.
PLEASE NOTE: Heather's interview
with PARC, written by Willy Noiles, will appear in PARC's MARCH
2008 issue.
To get your March issue, contact us at PARC.
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.
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 Ortho-McNeil-Janssen Pharmaceuticals,
Inc.
=================================================
PARC NOTE: Please contact the drug company in question for details
.
CRPS STUDY
Autonomic Dysfunction and Spinal Cord Stimulation in
Complex Regional Pain Syndrome
*CURRENTLY RECRUITING*
Patients diagnosed with Complex Regional Pain Syndrome or Reflex
Sympathetic Dystrophy Syndrome are Needed
For a study investigating how the autonomous nervous system works
before Spinal Cord Stimulator Implant and after
· Participants must be Male or Female
· Between ages 18-65 years old
· Affected in one leg or arm
If interested please contact:
Laura Diedrich, MD
Vanderbilt University
(615) 936-0041
Or email: laura.diedrich@vanderbilt.edu
Please label the email: CRPS study
---------------
NOTE: PARC has inquired about Canadian patients.
They may be accepted into the study with certain conditions. If
interested, inquire to the above e-mail address.
THE
RSDCANADA SURVEY
As of January 9, 2004, RSD CANADA
officially launched its online CRPS/RSD survey!
Please support the first RSD survey in Canada!
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