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A M E R I C A N A C A D E M Y O F P A I N M A N A G E M E N T<br />
The Pain Practitioner<br />
Volume 16, Number 1 • Spring 2006<br />
CRPS: Grappling with the Mysteries<br />
SPECIAL EDITION<br />
Articles,<br />
Interviews,<br />
Commentary<br />
James Giordano, PhD<br />
James W. Broatch, MSW<br />
Bradley S. Galer, MD<br />
Edward C. Covington, MD<br />
David D. Sherry, MD<br />
Donald C. Manning, MD, PhD<br />
Lynn R. Webster, MD<br />
Keri L. Fakata, PharmD<br />
Joshua P. Prager, MD, MS<br />
Philip Getson, DO<br />
Peter A. Moskovitz, MD<br />
ALLODYNIA<br />
Artist: Stephen Spagnoli
A M E R I C A N A C A D E M Y O F P A I N M A N A G E M E N T<br />
The Pain Practitioner<br />
Volume 16, Number 1 • Spring 2006<br />
CRPS: Grappling with the Mysteries<br />
SPECIAL EDITION<br />
Articles,<br />
Interviews,<br />
Commentary<br />
James Giordano, PhD<br />
James W. Broatch, MSW<br />
Bradley S. Galer, MD<br />
Edward C. Covington, MD<br />
David D. Sherry, MD<br />
Donald C. Manning, MD, PhD<br />
Lynn R. Webster, MD<br />
Keri L. Fakata, PharmD<br />
Joshua P. Prager, MD, MS<br />
Philip Getson, DO<br />
Peter A. Moskovitz, MD<br />
ALLODYNIA<br />
Artist: Stephen Spagnoli
A M E R I C A N A C A D E M Y O F P A I N M A N A G E M E N T<br />
The Pain Practitioner<br />
Volume 16, Number 1 • Spring 2006<br />
CRPS: Grappling with the Mysteries<br />
SPECIAL EDITION<br />
Articles,<br />
Interviews,<br />
Commentary<br />
James Giordano, PhD<br />
James W. Broatch, MSW<br />
Bradley S. Galer, MD<br />
Edward C. Covington, MD<br />
David D. Sherry, MD<br />
Donald C. Manning, MD, PhD<br />
Lynn R. Webster, MD<br />
Keri L. Fakata, PharmD<br />
Joshua P. Prager, MD, MS<br />
Philip Getson, DO<br />
Peter A. Moskovitz, MD<br />
ALLODYNIA<br />
Artist: Stephen Spagnoli
T A B L E O F C O N T E N T S<br />
SPECIAL ISSUE CRPS: GR APPLING WITH THE MYSTERIES<br />
EDITOR-IN-CHIEF: Lennie Duensing<br />
CO-EDITOR OF THIS SPECIAL EDITION: Debra Nelson-Hogan<br />
MEDICINE AND HUMANITIES EDITOR: James Giordano, PhD<br />
6<br />
9<br />
FEATURES<br />
16<br />
22<br />
32<br />
40<br />
50<br />
59<br />
63<br />
68<br />
72<br />
74<br />
82<br />
Editor’s Corner<br />
By Lennie Duensing and Debra Nelson-Hogan<br />
Dolor, Morbus, Patiens: Maldynia, Pain as Illness and Suffering<br />
By James Giordano, PhD<br />
RSDSA: Expanding Research,<br />
Education, and Awareness of CRPS<br />
By James W. Broatch, MSW, RSDSA Executive Director<br />
PEOPLE WITH CRPS: THEIR STORIES AND<br />
ACCOMPLISHMENTS 23 Stephen Spagnoli • 24 Wilson Hulley<br />
25 Barbara Schaffer • 26 Lisa Delia• 27 Sharon Weiner<br />
Complex Regional Pain Syndrome:<br />
New Hope After a Decade of Dispelling Myths<br />
By Bradley S. Galer, MD<br />
Exploring Psychosocial Issues in CRPS<br />
An Interview Edward C. Covington, MD<br />
When Children Hurt Too Much: Diagnosis and<br />
Treatment of Amplified Musculoskeletal Pain<br />
By David D. Sherry, MD<br />
EMERGING TREATMENT AND DIAGNOSIS<br />
Neuroimmunologic Approaches to Emerging<br />
and Potential Therapies for CRPS<br />
By Donald C. Manning, MD, PhD<br />
Ziconotide: Promising New Treatment for<br />
Complex Regional Pain Syndrome (CRPS)<br />
By Lynn R. Webster, MD, and Keri L. Fakata, PharmD<br />
New Rechargeable Spinal Cord Stimulator Systems<br />
Offer Advantages in CRPS Treatment<br />
By Joshua P. Prager, MD, MS<br />
The Use of Thermography in the<br />
Diagnosis of CRPS: A Physicians’ Opinion<br />
By Philip Getson, DO<br />
IN CONCLUSION<br />
A Theory of Suffering<br />
Peter A. Moskovitz, MD<br />
DEPARTMENTS<br />
82 Academy News • 84 Classified Advertisements • 85 Directory<br />
On the Cover: Allodynia by Stephen Spagnoli. This painting in iodine and acrylics is<br />
an actual imprint of the artist’s body.<br />
Academy Board of Directors<br />
President<br />
Paula L. Gilchrist, LPT, DPM<br />
Secretary<br />
Barbara Lum, BS<br />
Treasurer<br />
Carl H. McNeely, APRN, PNP<br />
Co-Chairs, Board of Advisors<br />
Rick Marinelli, ND, MAcOM, LAc<br />
Gerald Q. Greenfield Jr., MD<br />
Director-at-Large<br />
Christopher Brown, DDS, MPS<br />
Academy Staff<br />
Executive Director<br />
Kathryn A. Padgett, PhD<br />
Deputy Executive Director<br />
Marsha Stanton, MS, RN<br />
Director of Education<br />
Terry Finigian<br />
Education Administrator<br />
Lois Baker<br />
Director of Pain Program<br />
Accreditation and Outcomes<br />
Measurement<br />
Alexandra Campbell, PhD<br />
Director of Communications<br />
and Advocacy<br />
Lennie Duensing, MEd<br />
Administrative Assistant<br />
Mari Fairhurst<br />
Director of Publications<br />
Carol Harper, MA<br />
Director of Sales<br />
Jillian Manley<br />
Sales Representative<br />
Rosemary LeMay<br />
General Membership Coordinator<br />
Marcella Mateo<br />
Credentialing, Office Manager<br />
Joy McCurry<br />
Chief Financial Officer<br />
Connie Mulalley<br />
Academy Consultants<br />
Research Consultant<br />
Edward E. Duensing, MLS<br />
Copy Editor<br />
Nan Newell<br />
The Pain Practitioner is published by the American<br />
Academy of Pain Management, 13947 Mono<br />
Way, Ste. A, Sonora, CA 95370, Phone<br />
209-533-9 7 4 4 , F a x 2 0 9 - 5 3 3 - 9 7 5 0 , and<br />
Email: aapm@aapainmanage.org, website:<br />
www. aapainmanage.org. Copyright 2006<br />
American Academy of Pain Management. All<br />
rights reserved. Send correspondance to Lennie<br />
Duensing, MEd, at lduensing@yahoo. com.<br />
Contact Jillian Manley at 209-533-9744<br />
regarding advertising opportunities, media kits,<br />
and prices.<br />
The Pain Practitioner is published by the<br />
American Academy of Pain Management solely<br />
for the purpose of education. All rights are<br />
reserved by the Academy to accept, reject, or<br />
modify any submission for publication. The<br />
opinions stated in the enclosed printed<br />
materials are those of the authors and do not<br />
necessarily represent the opinions of the<br />
Academy or individual members. The Academy<br />
does not give guarantees or any other<br />
representation that the printed material<br />
contained herein is valid, reliable, or accurate.<br />
The American Academy of Pain Management<br />
does not assume any responsibility for injury<br />
arising from any use or misuse of the printed<br />
material contained herein. The printed material<br />
contained herein is assumed to be from reliable<br />
sources, and there is no implication that they<br />
represent the only, or best, methodologies or<br />
procedures for the pain condition discussed. It<br />
is incumbent upon the reader to verify the<br />
accuracy of any diagnosis and drug dosage<br />
information contained herein, and to make<br />
modifications as new information arises.<br />
All rights are reserved by the Academy to<br />
accept, reject, or modify any advertisement<br />
submitted for publication. It is the policy of the<br />
Academy to not endorse products. Any<br />
advertising herein may not be construed as an<br />
endorsement, either expresed or implied, of a<br />
product or service.<br />
4 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
EDITORS’ CORNER | COMPLEX REGIONAL PAIN SYNDROME<br />
LENNIE DUENSING<br />
Editor-in-Chief<br />
CRPS Special Edition<br />
BY LENNIE DUENSING, EDITOR-IN-CHIEF<br />
AND DEBRA NELSON-HOGAN, CO-EDITOR, SPECIAL CRPS EDITION<br />
DEBRA NELSON-HOGAN<br />
Co-Editor<br />
“Complex Regional Pain Syndrome (CRPS) is a perplexing<br />
condition that has been relatively ignored and misunderstood<br />
by the medical community because it is so unusual.”<br />
— BRADLEY S. GALER, MD<br />
THE AMERICAN ACADEMY OF PAIN MANAGEMENT AND<br />
THE REFLEX SYMPATHETIC DYSTROPHY SYNDROME<br />
ASSOCIATION have joined together to produce this<br />
special spring edition of The Pain Practitioner. Entitled,<br />
“CRPS: Grappling with the Mysteries,” the issue explores<br />
the most current thinking about Complex Regional Pain<br />
Syndrome (CRPS) from a variety of perspectives.<br />
Why an Issue on CRPS?<br />
WE TOOK ON THIS JOINT PROJECT because CRPS is a condition<br />
that creates a host of treatment nightmares for clinicians.<br />
Unfortunately, most healthcare professionals lack education<br />
about the condition and often delay diagnosis and treatment.<br />
Worse yet, some healthcare professionals and insurance<br />
providers still don’t believe the syndrome exists. The McGill<br />
Pain Scale, however, ranks CRPS pain higher than cancer pain,<br />
and for many of those living with CRPS, the constant and<br />
burning pain creates nothing short of a living hell. This is well<br />
illustrated in the paintings of CRPS sufferer Stephen Spagnoli,<br />
which appear throughout this issue. (See story on page 22 )<br />
In this Issue<br />
James Giordano, PhD, the publication’s new Medicine and<br />
Humanities Editor, opens the issue with a commentary entitled,<br />
“Dolor, Morbus, Patiens: Maldynia, Pain as Illness and<br />
Suffering.” Giordano addresses the need to comprehend the<br />
complexity of pain and suffering, and says that, “… scientific<br />
and humanistic inquiry is fundamental to the provision of<br />
technically right and morally good care.”<br />
James W. Broatch, MSW, RSDSA Executive Director, in<br />
“RSDSA: Expanding Research, Education, and Awareness of<br />
CRPS,” describes that organization’s work discusses the<br />
particular challenges that people who have CRPS face, and how<br />
the 22-year-old organization meets them. There is also a brief<br />
overview of the new third edition CRPS Clinical Practice<br />
Guidelines.<br />
In his article, “Complex Regional Pain Syndrome: New Hope<br />
After a Decade of Dispelling Myths,” Bradley S. Galer, MD,<br />
addresses many facets of this generally misunderstood and<br />
confusing syndrome. Galer looks at the causes of CRPS and<br />
highlights some of the advances made in recent years that have<br />
led to a better understanding of this syndrome, dispels myths<br />
and misconceptions, and describes treatments.<br />
Edward C. Covington, MD, Director of the Chronic Pain<br />
Rehabilitation Program at the Cleveland Clinic Foundation,<br />
discusses the psycho-social issues in CRPS. Covington addresses<br />
CRPS in relation to personality and cognition, the value of<br />
6 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
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EDITORS’ CORNER | COMPLEX REGIONAL PAIN SYNDROME<br />
exercise and activity, and various psychological treatments.<br />
Covington says, “There are people with CRPS who have<br />
managed to transcend it and have a life. For others, it’s less the<br />
case that they have CRPS than that ‘CRPS has them.’”<br />
Pediatric CRPS can be an entirely different syndrome. In his<br />
article, “When Children Hurt too Much: Diagnosis and<br />
Treatment of Amplified Musculoskeletal Pain.” David D.<br />
Sherry, MD, discusses amplified musculoskeletal pain and<br />
describes the epidemiology, etiology, clinical manifestations,<br />
diagnosis, and treatment, and outcomes of these conditions<br />
based on his experience. He says that with the treatment he<br />
recommends, “Most children do well.”<br />
The magazine also includes a special section with articles<br />
focusing on emerging treatments for CRPS (both<br />
pharmacological and non-pharmacological approaches). An<br />
article by Joshua P. Prager, MD, explores the use of spinal cord<br />
stimulation for people with CRPS. Lynn R. Webster, MD, and<br />
Keri L. Fakata, PharmD, discuss ziconotide, a new, nonnarcotic<br />
treatment delivered via an intrathecal pump that is a<br />
treatment option for CRPS patients. Donald C. Manning,<br />
MD, PhD, describes other emerging treatments, and Philip<br />
Getson, MD, gives a brief summary of thermography in the<br />
diagnosis of CRPS.<br />
The section, People with CRPS: Their Stories and<br />
Accomplishments, presents stories about five people with CRPS,<br />
who in spite of their pain, are working in a variety of ways to<br />
support others with the condition.<br />
The issue concludes with a compelling and thoughtful<br />
commentary by Peter A. Moskovitz, MD, called “A Theory of<br />
Suffering.” Moskowitz puts forth a six-part theory that explores<br />
the nature of suffering. He concludes by saying, “The capacity<br />
for suffering is the precursor to natural morality. I stand at the end<br />
of a long line of scientists and ethicists, some cited here, to repeat<br />
that empathy and the understanding of suffering, however elusive<br />
they may be, are the moral obligation of the pain practitioner.…<br />
The treatment of diseases and injuries includes the treatment of<br />
pain. The treatment of pain is all about suffering.”<br />
Debra Nelson Hogan is a communications consultant for RSDSA.<br />
Adding a New Dimension<br />
to The Pain Practitioner<br />
THE ACADEMY WELCOMES JAMES GIORDANO, PHD,<br />
AS MEDICINE AND HUMANITIES EDITOR<br />
THROUGH THE PAIN PRACTITIONER, the American Academy<br />
of Pain Management has provided clinicians with practical<br />
information about pain management and the latest trends in<br />
the field. Now, we are taking the publication a step further.<br />
Starting with this issue, we will be looking at pain, not only<br />
from scientific and medical perspectives, but from the perspective<br />
of the humanities as well—a perspective that hopefully<br />
will give us a greater understanding of the experience of pain,<br />
and how it expressed by those who suffer with it.<br />
To this end, the Academy is pleased to welcome James<br />
Giordano, PhD, as Medicine and Humanities Editor. In this<br />
role, Dr. Giordano will write provide editorial input and write<br />
commentary related the theme of the issue.<br />
“My hope is that we emerge from this Decade of Pain<br />
Control and Research with knowledge and understanding that<br />
advances our epistemology of pain, and in so doing, reconcile<br />
science, medicine and the humanities.” Dr. Giordano says.<br />
“My goal as Medicine and Humanities Editor of The Pain<br />
Practitioner is to create a forum for the provision and<br />
exchange of these ideas—a<br />
forum in which those who<br />
treat people with pain are<br />
empowered by the knowledge<br />
that can only be provided<br />
through a lens that<br />
brings together the<br />
pragmatic sharpness of biomedicine<br />
and the sentient<br />
focus of the humanities.” JAMES GIORDANO, PhD<br />
Dr. Giordano’s ongoing research focuses on the neuroscience<br />
and neurophilosphy of pain, agent-based virtue ethics<br />
in pain research and practice, and neuroethics. He is currently<br />
a Scholar in Residence at the Center for Clinical Bioethics,<br />
Georgetown University Medical Center; a Visiting Scholar at<br />
the Center for Ethics, Dartmouth Medical School; a Fellow<br />
of the John P. McGovern MD Center for Health, Humanities<br />
and the Human Spirit, University of Texas Health Sciences<br />
Center; and, an invited lecturer of the Roundtable in Arts and<br />
Sciences, Oxford University, UK. He is the author of over 55<br />
peer-reviewed papers and three books addressing the neuroscience<br />
of pain, medical philosophy, and bioethics. He is<br />
the bioethics section editor of the American Journal of Pain<br />
Management, editor of the Journal of Practical Pain Management,<br />
and neuroscience editor of the Pain Physician Journal.<br />
8 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
COMMENTARY | GIORDANO<br />
COMMENTARY:<br />
Dolor, Morbus, Patiens:<br />
Maldynia, Pain as<br />
Illness and Suffering<br />
BY JAMES GIORDANO, PhD, MEDICINE AND HUMANITIES EDITOR<br />
AS THE MEDICINE AND HUMANITIES EDITOR for<br />
The Pain Practitioner, I am grateful for the<br />
opportunity to write a commentary on the<br />
papers appearing in this issue on complex<br />
regional pain syndrome (CRPS).<br />
TOGETHER, THESE ARTICLES address this frequently misunderstood<br />
syndrome, convey how an expanding epistemology has<br />
generated enhanced understanding of the mechanistic basis and<br />
existential impact of pain as a complexity-based systems event,<br />
and present the need to develop diagnostic and therapeutic<br />
approaches that reflect this progressive knowledge.<br />
The basic and clinical sciences, humanities, and the<br />
experiential narratives of patients all contribute essential lenses<br />
through which we can examine and de-mystify the enigma<br />
of persistent pain.<br />
I believe that how we come to know about pain<br />
is equally important as, and provides a pediment for, what<br />
we know about pain. It is only through the combination of<br />
distinct domains of knowledge that we can both comprehend<br />
pain as a dysfunction of the dynamical, nonlinear adaptability<br />
of the nervous system, and at the same time apprehend the<br />
manifestations of these changes within the networked-hierarchy<br />
of interacting systems that is the patient as person. 1 Thus,<br />
the study of pain conjoins neuroscience to the burgeoning<br />
discourse of neurophilosophy and, in so doing, may reconcile<br />
issues in the dialectic surrounding the concepts of disease—<br />
illness, brain-mind, and ethical dimensions of care.<br />
Pain as a Spectral Disorder<br />
I POSIT THAT PAIN CAN BE CONSIDERED TO BE A SPECTRAL<br />
DISORDER—one that ranges from a symptom of organic insult<br />
or trauma, to durable, more global pathologic changes occurring<br />
at multiple levels of the nervous system, ultimately affecting<br />
the substrates that are involved in and/or elicit behavior,<br />
emotion, and cognition of the (internal and external) environment<br />
and, thus, some form of the definable “self.” 2<br />
I maintain that with progression across this spectrum, the<br />
disease process of pain increasingly becomes the phenomenal<br />
illness of pain. Classification and diagnoses must acknowledge<br />
pain as disease and manifest illness, recognizing, too, that the<br />
disease process may be durable and immutable (1).<br />
The arbitrary temporal classifications that rested upon the<br />
acuteness or chronicity of pain did little to define the etiologic<br />
and pathophysiologic processes that may cause or perpetuate<br />
the disorder. Hence, these criteria have been replaced by nosologic<br />
distinctions (e.g., nociceptive vs. neuropathic; Type I, II,<br />
III) that have sought to characterize pain according to the<br />
inherent neurological mechanisms. Woolf, Borsook, and<br />
Koltzenburg (2) have recently expanded this schema into an<br />
elegant algorithmic model that thoroughly accounts for stimulus<br />
dependency and neural basis, enabling both mechanistic<br />
identification of types of pain and proof of concept evidenced<br />
in clinical syndrome(s). Certainly, this algorithm can be considered<br />
to be situated along, and/or be representative of, the pain<br />
spectrum, as I have proposed. Yet, the “meaning” and manifestations<br />
of these types of pain still remain implicit in, if not altogether<br />
absent from, the algorithm of Woolf et al. Almost a<br />
decade ago, Lippe (3) proposed the use of the term eudynia to<br />
represent physiologically “normal” or nociceptive pain, and<br />
maldynia to be “abnormal” pain arising from neuropathic<br />
processes. These terms have become increasingly popular, but I<br />
feel that when used alone, they do little to define what “normality”<br />
and “abnormality” actually mean. Similarly, the sole use<br />
of the categorization scheme of Woolf and colleagues is some-<br />
1 These are concepts that are inherent to, and derived from, complexity theory.<br />
I feel that the use of a complexity-based model of pain is important to fully<br />
reconcile the notions of disease and illness, and to fit these within a more<br />
encompassing framework. For a review of complexity theory and its applicability<br />
to neuroscience and medicine, see: Kelso, JS. Dynamic Patterns: The<br />
Self-Organization of the Brain and Behavior, Cambridge, MIT Press, 1995;<br />
Waldrop MM. Complexity: The Emerging Science at the Edge of Order and<br />
Chaos, NY, Touchstone Books, 1992; Dayan P, Abbott LF. Theoretical Neuroscience:<br />
Computational and Mathematical Modeling of Neural Systems. Cambridge,<br />
MIT Press, 2001; and for a straightforward overview, see: Sarder Z,<br />
Abrams I. Introducing Chaos, Cambridge (UK), Icon Books, 2003.<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 9
COMMENTARY | GIORDANO<br />
Comprehending the complexity of …<br />
suffering involves both scientific and<br />
humanistic inquiry and is fundamental<br />
to the provision of technically right<br />
and morally good care.<br />
what sterile and does not depict the potentiality of effects<br />
elicited by a particular type of pain. However, if framed as<br />
domains within the spectrum of pain, these classifications<br />
impart insight to mechanism(s), manifestation(s), and broader<br />
existential meaning.<br />
Maldynia: The Illness of Pain as Suffering<br />
I PROPOSE THAT MALDYNIA be reconsidered to be the multidimensional<br />
constellation of symptoms and signs that represent the syndrome<br />
of persistent pain as phenomenal illness. Thus, by its nature,<br />
maldynia (irrespective of initiating cause and/or constituent<br />
mechanisms) produces, and results from, functional and perhaps<br />
structurally maladaptive changes in the nervous system that<br />
evoke, and are reciprocally affected by, alterations in cognition,<br />
emotion, and behavior. In this way, maldynia is both the conscious<br />
state of pain and a consciousness of pain as a condition of<br />
the internal domain of the lived body and existential disattunement<br />
of the life world. 3 This definition compels a more thorough<br />
consideration of the philosophical and pragmatic basis of pain<br />
medicine, for if maldynia is the illness of pain experienced as suffering,<br />
then the ethical obligations of the pain practitioner are<br />
soundly-based upon an objective knowledge and subjective affirmation<br />
that a patient’s pain and suffering are genuine. 4<br />
Moskovitz describes CRPS as the quintessential maldynic<br />
syndrome. This is well illustrated by Galer and Covington, who<br />
note how multiple biological and psychosocial factors contribute<br />
to, and are affected by, CRPS. The authors take steps to<br />
reveal CRPS not as an unsolvable mystery or specious myth,<br />
but as a complicated clinical problem that is explicable and<br />
treatable. But complicated problems are rarely resolved through<br />
simple means, and the diagnosis and treatment of CRPS<br />
require an insightful, innovative approach that is wholly focal to<br />
the varying pathologic bases and unique, needs of each patient.<br />
The cornerstone of this approach is accurate diagnosis, (4, 5)<br />
and Sherry addresses the differential diagnosis of persistent<br />
musculoskeletal pain in adolescents as an example of how precise,<br />
timely assessment is essential to establishing and implementing<br />
what should be done to most effectively treat a particular<br />
patient with a specific pain disorder. Diagnosis is built<br />
from generalized and specifically contextual knowledge, and<br />
Getson examines thermography as a novel technology and technique,<br />
that, when utilized within an expanded objective and<br />
subjective diagnostic framework, may afford improved evaluative<br />
acumen, thereby determining the appropriate type and ultimate<br />
trajectory of subsequent care. Manning, Webster, and<br />
Fakata, as well as Prager each discuss this care, and their work<br />
emphasizes the importance and viability of rational pharmacology<br />
and new technologies, in an approach that reflects understanding<br />
of the contributory neuropathic mechanism(s), as well<br />
as the relational importance of how these mechanisms are<br />
expressed in the patient.<br />
I maintain that this latter point is particularly critical to<br />
treatment. While there is considerable similarity in the underlying<br />
neural mechanisms of CRPS, their manifestations can be<br />
widely different, based upon the compound predispositions of<br />
each person. The clinician must take this into account when<br />
considering the prudential question of what should be done to<br />
best meet the medical needs of a given patient at a particular<br />
point in the disease-illness continuum (4, 6, 7). Such “customization”<br />
of care allows for evaluation and therapeutics based<br />
upon multiple levels and domains of evidence and is instrumental<br />
in providing the right treatment(s) for the right reason(s) (8,<br />
9). Instead of being inappropriately wedded to a singularly disease-based,<br />
curative model, this approach embraces a larger,<br />
more integrative paradigm, (10) that I feel acknowledges and<br />
communicates to the patient that while cure may not be possible,<br />
effective, ethical care is both achievable and obligatory.<br />
Toward a Neurophilosophy of Pain<br />
GIVEN THE NOTION THAT:<br />
[1] maldynia induces functional and structural changes in<br />
the neurological axis from periphery to brain;<br />
[2] distinct regions in the brain are responsible for the conditions<br />
and awareness of discriminable consciousness (e.g.,<br />
the cingulate gyrus, parietal, prefrontal, and operculoinsular<br />
cortex); and<br />
[3] maldynia-induced changes in these brain regions are capable<br />
of evoking alteration of the sensed internal state that is consciousness,<br />
it becomes clear that maldynia (i.e., pain as suf-<br />
2 There is considerable discussion in the neural sciences (i.e., neurobiology,<br />
cognitive psychology, [neuro]philosophy) regarding the nature or existence<br />
of the “self.” To gain insight into recent perspectives of some of the leading<br />
scholars in this discourse, see: Blackmore S. Conversations on Consciousness:<br />
What the Best Minds Think About the Brain, Free Will, and What It<br />
Means to Be Human. Cambridge (UK), Oxford University Press, 2005.<br />
3 I base this upon the model of levels of conscious processing, first detailed<br />
in psychological terms by Ray Jackendoff (Consciousness and the Computational<br />
Mind, Cambridge, MIT Press, 1990); and expanded by Jesse Prinz<br />
(Furnishing the Mind: Concepts and Their Perceptual Basis, Cambridge, MIT<br />
Press, 2004) to include neural substrates. I feel that this model fits well<br />
within a complexity-based paradigm, and bridges neural mechanisms with<br />
phenomenal experience(s). For further discussion of the phenomenological<br />
approach to illness and pain, see: Gadamer HG. The Enigma of Health. Stanford,<br />
Stanford University Press, 1996; Husserl E. Ideas: General Introduction<br />
to a Pure Phenomenology. NY, Collier, 1962; Svenaeus F. The Hermeneutics of<br />
Medicine and the Phenomenology of Health. Dordrecht, Kluwer, 2000; and<br />
Zaner R. The Problem of Embodiment: Some Contributions to a Phenomenology<br />
of the Body. The Hague, Nijhoff, 1964.<br />
4 Suffering is an extensive topic of study. One of the leading scholars in this<br />
field is Eric Cassell. For an overview of his work specific to a discussion of<br />
suffering and the ethical obligations in caring for those who suffer, see: Cassell<br />
E. The Healer’s Art, NY, Lippincott, 1976, and, Cassell E. The Nature of<br />
Suffering, Oxford, Oxford University Press, 1991.<br />
10 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
fering) may be a disorder of the brain that directly or indirectly<br />
effects a condition of the expressed “mind.”<br />
In this context, Moskovitz’s work becomes particularly<br />
noteworthy. Based upon his clinical experience and the current<br />
body of experimental and philosophical literature, Moskovitz<br />
has developed a theory that localizes suffering to the cingulate<br />
gyrus and adjacent limbic forebrain. Certainly, there is evidence<br />
from recent neuroimaging studies to support the neuroanatomical<br />
basis of his theory, at least in part (11, 12, 13). An interesting<br />
dimension of Moskovitz’s thesis is its solidification of<br />
suffering as a brain event that is evoked by hierarchical mechanisms<br />
of pain, yet allows (indeed, encourages) a philosophical<br />
interpretation of whether suffering represents a biological effect<br />
of the brain state (i.e., a “physical kind”), or is a distinct property<br />
(i.e., a “mental kind”) that exists as some nonmaterial construct<br />
of consciousness. 5 Regardless it is knowable in its entirety<br />
only to the sufferer: even if there were some way to completely<br />
transpose the pattern of cerebral activation from one person<br />
directly to another (e.g., from patient to clinician), the subjective<br />
experience of that identical brain activation would still differ,<br />
since the connectivities shaped by genotype and the myriad<br />
of life experiences are so widely variant (14).<br />
Thus, while Moskovitz’s theory is attractive because it establishes<br />
a physiological basis and anatomy of pain as suffering, I<br />
think that it also raises the question of whether suffering can or<br />
will be knowable through solely objective means. The authentication<br />
of suffering cannot exclusively rely on technology (4, 6,<br />
15, 16), and it is here that this thesis to instigate somewhat<br />
broader considerations. By validating suffering as a neurobiological<br />
event, Moskovitz makes it resonant with the domain of<br />
applied biology that constitutes much of the epistemological<br />
basis for contemporary medicine. Yet, given that these neurobiological<br />
substrates are in some way foundational to consciousness,<br />
he astutely states that only contextual, intersubjective knowledge<br />
can truly afford the clinician an understanding of the unique<br />
nature of a person’s suffering. I agree, for the focus of the clinical<br />
encounter is upon the patient, literally as “the one who suffers.”<br />
Comprehending the complexity of such suffering involves<br />
both scientific and humanistic inquiry and is fundamental to<br />
the provision of technically right and morally good care. I maintain<br />
that this is incontrovertible, and hope that this issue of The<br />
Pain Practitioner provides a forum to stimulate thought and discussion<br />
about the future possibilities that such care may offer. 6<br />
REFERENCES<br />
1. Giordano J. Bioethics and intractable pain. Practical Pain Management,<br />
2005<br />
2. Woolf CJ, Borsook D, Koltzenburg M. Mechanism-based classifications of<br />
pain and analgesic drug discovery. In: C. Boutra, R. Munglani, WK<br />
Schmidt (eds.) Pain: Current Understanding, Emerging Therapies, and<br />
Novel Approaches to Drug Discovery. NY, Marcel Dekker, 2003, pp. 1-8.<br />
3. Lippe P. An apologia in defense of pain medicine. Clin. J. Pain. 1998, 14<br />
(3): 189-190.<br />
4. Giordano J. Toward a core philosophy and virtue-based ethics of pain<br />
medicine. The Pain Practitioner, 2005, 15(2): 59-66.<br />
5. Sadler JZ. Diagnosis/anti-diagnosis. In: J. Radden (ed.) The Philosophy of<br />
Psychiatry: A Companion. NY, Oxford University Press, 2004, pp. 163-179.<br />
6. Giordano J. Moral agency in pain medicine: Philosophy, practice and<br />
virtue. Pain Physician, 2006, 9: 71-76.<br />
7. Pellegrino ED. For the Patient’s Good: The Restoration of Beneficence in<br />
Health Care. Oxford, Oxford University Press, 1987.<br />
8. Turk DC. Customizing treatment for chronic pain patients: who, what, and<br />
why? Clin. J. Pain, 1990, 6: 255-270.<br />
9. Giordano J. Pain research: Can paradigmatic revision bridge the needs of<br />
medicine, science and ethics? Pain Physician, 2004, 7: 459-463.<br />
10. Bonakdar R. Integrative pain management: A look at a new paradigm.<br />
The Pain Practitioner, 2005, 15 (1): 15-18.<br />
11. Bromm B. Brain images of pain. News Physiol. Sci. 2001, 16: 244-249.<br />
12. Apkarian AV, Thomas PS, Krauss BR, Szeverenyi NM. Prefrontal cortical<br />
hyperactivity in patients with sympathetically mediated chronic pain.<br />
Neurosci. Lett., 2001, 311: 193-197.<br />
13. Bingel U, Quante M, Knab R, Bromm B, Weiller C, Buchel C. Subcortical<br />
structures involved in pain processing: Evidence from single-trial fMRI.<br />
Pain, 2002, 99: 313-321.<br />
14. Coghill RC, McHaffe JG, Yen Y-F. Neural correlates of inter-individual differences<br />
in the subjective experience of pain. Proc. Nat. Acad. Sci., 2003,<br />
100 (14): 8538-8542.<br />
15. Reiser SJ. Medicine and the Reign of Technology. Cambridge, Cambridge<br />
University Press, 1978.<br />
16. Sullivan M. Exaggerated pain behavior: By what standard? Clin. J. Pain,<br />
2004, 20 (6): 433-439.<br />
5 The definitions of “kind” are used here in the philosophical sense to mean<br />
a group of things or occurrences that have inherent qualities in common.<br />
Thus, a “physical kind” refers to those things that are directly arising from,<br />
and belonging to, a set of purely physiological events. In contrast, a “mental<br />
kind” refers to those things that may have arisen from something physical,<br />
but have an inherent and unique set of characteristics that separate<br />
them from those things that are physiological. The latter characterization<br />
formalizes that mental processes are different from physiological ones. This<br />
distinction allows for the fact that consciousness may be emergent from the<br />
physiological processes of neurons, but also gives substance to the idea that<br />
conscious processes are in some way “more” than the result of the physiology<br />
that may have produced them.<br />
This speaks to the major “schools,” or orientations in contemporary science<br />
and philosophy of mind, that range from the viewpoint that any mental<br />
event is wholly reducible to a brain event (e.g., materialism and related<br />
orientations of theoretically reductive physicalism), to some middle-ground<br />
positions that allow that brain events produce mind events, but that mind<br />
events have more expansive characteristics or are greater than the sum of<br />
the events which produced them (e.g., nonreductive physicalism, property<br />
dualism, emergence, complementarity) and at the other extreme, the idea<br />
that there is a discernible mental field that occurs within the brain, but is<br />
irreducible, and perhaps unknowable (e.g., strict dualism). There are several<br />
issues in neuroethics that are related to the implications of these distinctions<br />
(e.g., the nature of the “self,” self-determinism, free will, etc.).<br />
The philosopher Colin McGinn claims that our study of the mind is at a<br />
point of “cognitive closure,” given the inherent limitations of the contemporary<br />
human brain. Instead, I prefer to think, optimistically, that we are on a<br />
path of extended contemplation that allows us to gain ongoing insight from<br />
an ever-increasing knowledge base achieved through widening collaboration<br />
within, and between, multiple disciplines. Again, it is beyond the scope of<br />
this paper to address the nature of consciousness, but one can see how this<br />
discussion would nonetheless be important to the study of pain, suffering,<br />
and the ethics of science and medicine.<br />
6 Obviously, the extent of the topic of CRPS cannot be completely or fully<br />
addressed in a volume such as this. For a thorough summary of mechanistic,<br />
diagnostic, and therapeutic approaches to CRPS, see: Wilson PR, Stanton-<br />
Hicks M, Harden RN (eds.) CRPS: Current Diagnosis and Therapy. Seattle,<br />
IASP Press, 2005.<br />
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FEATURE | BROATCH<br />
RSDSA: Expanding Research,<br />
Education, and Awareness of CRPS<br />
BY JAMES W. BROATCH, MSW, RSDSA EXECUTIVE DIRECTOR<br />
SCIENTISTS AND CLINICIANS ARE STILL BAFFLED by this<br />
little-known, poorly understood collection of signs and<br />
symptoms of CRPS—what causes it, why it develops<br />
in one person and not in another with the same injury,<br />
why it occurs in more females than males, and why<br />
children and teens with this syndrome generally get<br />
better while most adults (80 percent in one prospective<br />
study) cannot resume prior activities (1).<br />
The <strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong> Syndrome Association<br />
(RSDSA) deals with issues like these every day. Founded in<br />
1984 to raise money for research, over the years, our mission<br />
has broadened to include awareness, education, patient support,<br />
legislative issues, and the creation of a CRPS patient<br />
database. Based in Milford, Connecticut, RSDSA has two fulltime<br />
employees and is guided by a talented 10-member board<br />
of directors (four of whom have CRPS). Our Scientific Advisory<br />
Committee is led by R. Norman Harden, MD, and<br />
Srinivasa N. Raja, MD, and is comprised of some of the key<br />
thought leaders on CRPS who serve as consults on medical,<br />
treatment, and research issues. RSDSA has grown into a<br />
national, nonprofit organization with an annual revenue is<br />
over $600,000, 90 percent of which is spent on research and<br />
educational programming.<br />
Research<br />
RSDSA is committed to encouraging research to discover the<br />
cause(s) and cure(s) of CRPS. Why? Because medical professionals<br />
and the public are still largely unaware of this intensely<br />
painful and potentially debilitating syndrome. For example, a<br />
1999 epidemiology study published in PAIN reported that the<br />
mean number of different physicians who evaluated a CRPS<br />
patient prior to being seen at a pain center was 4.8 (2). Then in<br />
2005, an Internet-based survey of 1,362 people with CRPS<br />
(conducted by Johns Hopkins School of Medicine and funded<br />
by RSDSA) found that 56 percent of the respondents saw more<br />
than four physicians prior to being diagnosed with CRPS-not<br />
much of an improvement!<br />
Also, the reality is: you can’t cure what you don’t understand!<br />
Peter Moskowitz, MD, a member of the RSDSA board of<br />
directors, explains, “Science helps us learn new things, and there is<br />
much we want to know about CRPS. The best science not only<br />
helps us know about difficult subjects—and CRPS is a very difficult<br />
subject—it also tells us how we know what we know and<br />
informs our understanding of the disease process and its treatment.”<br />
It is for these reasons that we fund at least two research<br />
grants (up to $50,000 each) every year. Since 1992, RSDSA has<br />
funded $732,665 in fellowships and research grants. Recent<br />
RSDSA-funded grants include:<br />
❥ Treatment of Complex Regional Pain Syndrome Type I by<br />
Nitroglycerine, A Web-Based Epidemiological Survey of CRPS-I;<br />
❥ Identification of CRPS Subtypes and Effective Treatments;<br />
❥ Changes in CSF Cytokine levels in <strong>Reflex</strong> <strong>Sympathetic</strong><br />
<strong>Dystrophy</strong>; Validation of Revised Diagnostic Criteria<br />
for CRPS/RSD; and,<br />
❥ Noninvasive Investigation of Human Brain Mechanisms<br />
Associated with the Development and Treatment of RSD.<br />
An Outcome of RSDSA Research Funding<br />
In 2004, we funded a study called Development of a rat model<br />
of CRPS-I based on partial injury to nociceptive axons. The<br />
results of this study prompted further research, which evolved<br />
into a paper written by Anne Louise Oaklander, MD, PhD,<br />
called Evidence of focal small-fiber axonal degeneration in complex<br />
regional pain syndrome-I (reflex sympathetic dystrophy). This<br />
study will be published in Pain and proves that: “CRPS-I now<br />
has an identified cause takes it out of the realm of so-called<br />
‘psychosomatic illness.’ (3)”<br />
Detailed application guidelines for funding can be<br />
found on our website at: www.rsds.org<br />
Education and Awareness<br />
In order to encourage accurate diagnosis and appropriate treatment,<br />
RSDSA has developed informative educational brochures<br />
with the assistance of our Scientific Advisory Committee. One<br />
of the most widely distributed is a screening tool for medical<br />
professionals—a laminated, two-sided, wallet-sized card that lists<br />
the signs and symptoms of CRPS Type I on one side and provides<br />
a pain rating scale on the other. We mailed the card along<br />
with an informative cover letter to members of the American<br />
16 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
Academy of Family Physicians, the American Academy of Physician<br />
Assistants, and the American Society of Pain Management<br />
Nursing. The letter began with the prescient sentence “A minute<br />
of your time can prevent a lifetime of suffering.” The response<br />
was enthusiastic. Many of the physicians and nurses were on<br />
medical- and nursing-school faculties and requested multiple<br />
copies for their students and fellows. RSDSA members also<br />
asked for individual copies for themselves and other family<br />
members and additional copies to distribute to medical professionals<br />
in their communities.<br />
In addition, RSDSA is publishing its third edition of<br />
evidenced-based Clinical Practice Guidelines (in press) and<br />
the RSDSA Review Digest, a compendium of articles that have<br />
appeared in the RSDSA Review on the diagnosis, treatment,<br />
and management of CRPS. Although the articles are archived<br />
on our website, 42 percent of Americans do not have access to<br />
the Internet and most medical professionals are too busy<br />
to thoroughly search our website. The Digest will be a perfect<br />
companion to the Clinical Practice Guidelines. We expect that<br />
medical professionals will also distribute the compendium to<br />
their patients with CRPS. If you would like to receive any of<br />
our free materials, please call 877-662-7737.<br />
Each year, staff and volunteers exhibit at major medical,<br />
insurance, and school nurse conventions and conferences.<br />
RSDSA believes it is vitally important for its members to attend<br />
new conferences in order to inform the attendees about our<br />
programs and educational materials, our top-notch website,<br />
research funding opportunities, ongoing CRPS clinical trials,<br />
and to discuss with medical professionals how we can work<br />
with them to help their patients and improve their practices.<br />
Shefali Agarwal, MPH, Srinivasa Raja, MD, both from Johns Hopkins School of<br />
Medicine and Bradley Galer, MD, RSDSA board member, discuss the results of an<br />
Internet-based epidemiological study funded by RSDSA.<br />
Patient Support<br />
At RSDSA, we are acutely aware of the devastation caused by<br />
the pain of CRPS. People become disabled and marriages fail.<br />
Families break part and lives are financially ruined. People<br />
become socially isolated and housebound. In our 2005 Internet<br />
Survey, 47 percent of the respondents reported that they had<br />
considered suicide and 15 percent of this group had tried.<br />
Although there is no hard data on the number of CRPS-related<br />
suicides, the donations section of our newsletter includes several<br />
gifts made in memory of individuals who, more often than not,<br />
have taken their own lives. It is chilling.<br />
For this reason, although we do not offer formal patient<br />
services, I do talk to those people who call<br />
or send email, as does my assistant, Gayle<br />
Bonavita, and several of our board members<br />
who have CRPS.<br />
CRPS Education Bills<br />
Through grass-roots initiatives, we have<br />
helped people with CRPS in their efforts<br />
to get CRPS Awareness legislation<br />
passed in Delaware, New York, and Pennsylvania;<br />
similar legislation has been or<br />
will be introduced in New Jersey, Illinois,<br />
Oregon, Michigan, and California. The<br />
legislation mandates that a state’s<br />
Department of Health conduct medical<br />
professional and public education programs<br />
to encourage earlier detection and<br />
appropriate treatment of CRPS.<br />
Jim Broatch talks to attendees at the Academy’s annual meeting in San Diego.<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 17
FEATURE | BROATCH<br />
We are acutely aware of the devastation caused by the pain of CRPS.<br />
People become disabled and marriages fail. Families break part and lives<br />
are financially ruined. People become socially isolated and housebound.<br />
CRPS, Social Security, Workers’<br />
Compensation, and the Insurance Industry<br />
Although it is a challenge for most people who apply for Social<br />
Security Disability benefits, individuals with CRPS are hampered<br />
by the lack of knowledge and understanding of the syndrome<br />
itself. In 1999, RSDSA was instrumental in convincing<br />
the Social Security Administration to issue a special ruling on<br />
how to adjudicate CRPS claims. We continue to receive letters<br />
RSDSA Publications<br />
and email from members<br />
who have used<br />
our information to get<br />
their claims approved.<br />
Injured employees<br />
with CRPS do not fare<br />
well in the Workers’<br />
Compensation (WC)<br />
program. Of the 1,362<br />
people who completed<br />
the web-based survey,<br />
41% reported being<br />
injured at work; however,<br />
only a few of<br />
them obtained workers’<br />
compensation benefits.<br />
Too often, the<br />
relationship between<br />
an injured worker and<br />
the WC insurance carrier<br />
erupts into a war.<br />
Treatment is frequently<br />
delayed and denied.<br />
In 2005, RSDSA<br />
exhibited at the conferences<br />
of two major workers’ compensation groups, the<br />
Risk and Insurance Management Society and Case Management<br />
Society of America. We view these conferences as opportunities<br />
to reach out to case managers and risk managers,<br />
some of whom still view CRPS as a nebulous, expensive,<br />
and frequently fraudulent claim. We launched a special newsletter,<br />
Working Together, Ensuring a Brighter Future, at these conferences.<br />
Our goal is to develop a mutually beneficial<br />
relationship. We will distribute our new Clinical Practice Guidelines<br />
to the insurers to encourage early intervention and appropriate<br />
treatment, enabling individuals with CRPS to recover<br />
and return to work.<br />
RSDSA publishes several free brochures to help people with CRPS/RSD, their families, and their healthcare<br />
providers. Please call RSDSA at 877-662-7737 to order copies.<br />
In Pain, Out of Work, and Can’t Pay the Bills, a resource directory, contains information on government programs, patient<br />
assistance programs, insurance, community and faith-based sources of help, resources for veterans, and much more.<br />
Recognizing, Understanding, and Treating CRPS/RSD is a quick overview of the syndrome, its telltale signs and symptoms,<br />
and treatment ideas. It is particularly valuable for those people who are newly diagnosed and their families.<br />
Helping Children with RSD Succeed in School is a practical guide for parents, teachers, school nurses, and administrators<br />
on accommodating the school environment for children and adolescents who have CRPS/RSD.<br />
Treating Complex Regional Pain Syndrome/<strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong> Syndrome, A Guide for Therapy contains<br />
information on evaluation of CRPS/RSD for functional rehabilitation, treatment protocols, and treatment progression.<br />
CRPS/RSD and Sports Injuries: Prevention is the Name of the Game addresses the risk that athletes have of developing<br />
the syndrome. New research also links the development of CRPS to some of the surgeries that have traditionally helped<br />
sports injuries. This brochure is a must-read for athletes, parents, coaches and athletic trainers, as well as those who<br />
practice sports medicine.<br />
Telltale Signs & Symptoms Handicard is a quick reference for practitioners. The laminated, credit-card size card features<br />
the telltale signs of CRPS on one side and a pain scale on the other. This tidy handout has been a great hit among<br />
healthcare professionals, students, and people who have CRPS/RSD.<br />
Patient Education<br />
Linda Lang, an RSDSA board member and coauthor of Living<br />
with RSDS, described the tremendous losses experienced by an<br />
individual with CRPS.<br />
What to Call It —CRPS or RSD?<br />
IN RECENT YEARS, the medical community has almost universally accepted the term Complex Regional Pain<br />
Syndrome Type I (CRPS) to describe what had been called <strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong> Syndrome (RSD). CRPS is<br />
a more comprehensive term that denotes the syndrome’s regional nature and that it is not always mediated by the<br />
sympathetic nervous system. For this magazine, we used whatever term the author chose (CRPS, RSD/CRPS, or RSD).<br />
18 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
Lisa Delia, Maria Brown, and Jim Broatch at the 2005 Achilles Walk for Hope and Possibility fundraiser.<br />
RSDSA sponsored a team.<br />
“… [I]n publicizing RSD, we generally focus on the pain,<br />
not the disabilities that come with it-the legs and hands that no<br />
longer work, the bones that become osteoporitic, the joints that<br />
become locked, the muscles that become spastic. … There is an<br />
awful lot we leave out—how a productive member of society<br />
can become too disabled to work or take care of her children.<br />
We don’t discuss the tremendous personal losses—families,<br />
friends, jobs—that RSD wreaks … (4)”<br />
We address many of these issues in our publications, such<br />
as the RSDSA Review (a quarterly newsletter), the Support<br />
Group Newsletter (a bi-monthly electronic publication), and<br />
In Pain, Out of Work, Can’t Pay the Bills, a resource directory<br />
that identifies the governmental and private programs that<br />
can help low-income families obtain treatment and needed<br />
medication, pay their bills, and avoid losing their home.<br />
Originally published in 2001, the directory is now in its third<br />
edition. We publish several brochures as well, such as<br />
CRPS/RSD: Prevention is the Name of the Game, which links<br />
CRPS to sports injuries and the surgeries that traditionally<br />
follow them. This brochure is written for coaches and trainers,<br />
and particularly for athletes, a group we believe is at high<br />
risk for developing the syndrome.<br />
Website<br />
Most people with CRPS or persistent pain learn about RSDSA<br />
by visiting our website, www.rsds.org. In 2005, we had an average<br />
of 37,000 visits per month. Our highest traffic, 57,000 in<br />
April, was driven by a People magazine cover story revealing that<br />
Paula Abdul had been diagnosed with RSD.<br />
Our website houses all of our educational<br />
brochures (in <strong>PDF</strong> format); videos<br />
or PowerPoint ® presentations from past<br />
international conferences; scientific articles<br />
on the diagnosis, treatment, and management<br />
of CRPS that have appeared in our<br />
quarterly newsletter or in peer-reviewed<br />
journals; links to other professional and<br />
consumer sites; and much more. We<br />
encourage individuals to sign up to receive<br />
free electronic alerts about new discoveries,<br />
clinical trials, articles in the media, legislative<br />
initiatives, and upcoming events.<br />
Srinivasa N. Raja, MD, Director<br />
of Pain Research at Johns Hopkins University<br />
has created a PowerPoint ® presentation,<br />
Diagnosis and Treatment Options<br />
of RSD/CRPS, which can be downloaded<br />
for use during in-service training or for<br />
personal edification.<br />
Join RSDSA<br />
RSDSA is a vibrant organization that is<br />
sensitive to the needs and concerns of<br />
its 6,000 members and the greater<br />
CRPS community. In the Fall 2005 RSDSA Review, Norman<br />
Harden, MD, said, “Without RSDSA, progress in fighting the<br />
syndrome would likely come to a halt. Even basic and essential<br />
Revised Clinical Practice Guidelines<br />
THE THIRD EDITION of RSDSA’s Clinical Practice Guidelines<br />
will be available in hard copy and on the website by the end<br />
of March. In 2004, RSDSA approved a grant to revise the<br />
evidence-based Clinical Practice Guidelines, which had not been updated<br />
since 2002. RSDSA received a grant from the National Organization<br />
for Rare Diseases, Inc. (NORD) to print and distribute the guidelines.<br />
R. Norman Harden, MD, Director, Center for Pain Studies, Addison Chair,<br />
Rehabilitation Institute of Chicago, Chicago, Illinois, edited the guidelines.<br />
Contributing authors were Stephen Bruehl, PhD, Department of<br />
Anesthesiology, Vanderbilt University Medical Center, and Allen Burton,<br />
MD, Department of Anesthesiology and Pain Medicine. The guidelines<br />
include the following five chapters and a treatment algorithm:<br />
❥ Introduction and Diagnostic Considerations<br />
❥ Interdisciplinary Management<br />
❥ Pharmacotherapy of Complex Regional Pain Syndrome (CRPS)<br />
❥ Psychological Interventions<br />
❥ Interventional Therapies<br />
CRPS can be a difficult syndrome to treat, especially if treatment<br />
is offered piecemeal rather than in an interdisciplinary fashion as<br />
recommended. Jim Broatch, Executive Director, says, “Our goal in<br />
writing these guidelines was to make sure that those individuals<br />
suffering with CRPS receive the proper diagnosis and appropriate<br />
treatment. Through education, we hope to minimize patient<br />
losses as much as we possibly can.”<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 19
FEATURE | BROATCH<br />
information, such as how best to make the diagnosis and what<br />
causes the disease, is lacking, and these are traditional topics<br />
funded for research by RSDSA (5).”<br />
Members include people with CRPS, their families, and<br />
practitioners. We encourage all of you to join RSDSA. Help us<br />
to promote greater awareness of CRPS among your medical<br />
colleagues and to improve the lives of individuals with CRPS<br />
and their families.<br />
Together we can make a huge difference.<br />
REFERENCES<br />
1. Veldman HJM, Reyen HM, Arntz R, Goris JA. Signs and symptoms of<br />
reflex sympathetic dystrophy: Prospective study of 829 patients. The<br />
Lancet 1993; 342; 1012-1015.<br />
2. Oaklander et al., Evidence of focal small-fiber axonal degeneration in<br />
complex regional pain syndrome-I (reflex sympathetic dystrophy). Pain.<br />
2006;120: 235-243.<br />
3. Allen G, Galer BS, Schwartz L. Epidemiology of complex regional pain<br />
syndrome; a retrospective chart review of 134 patients. Pain.<br />
1999;80:539-544.<br />
4. Lang, L. An Army of Six Million, RSDSA Review. Fall 2004.17:9.<br />
5. Broatch JW, Every Dollar for Research Counts. RSDSA Review.<br />
Fall 2005:18:3.<br />
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20 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
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FEATURE | PATIENT PROFILE<br />
PEOPLE<br />
WITH CRPS<br />
THEIR STORIES AND<br />
ACCOMPLISHMENTS<br />
The following are profiles of five remarkable individuals, identified by RSDSA,<br />
who live with CRPS—and on-going pain. Although their stories are different,<br />
all have in common the desire and will to make life better for others with the<br />
condition—and the determination to live full and meaningful lives.<br />
Stephen Spagnoli<br />
STEPHEN SPAGNOLI, 46, A FORMER LANGUAGE ARTS TEACHER, MUSICIAN,<br />
AND COMPOSER FROM QUEENS, NEW YORK, ALWAYS KNEW HE HAD TALENT<br />
AS A VISUAL ARTIST, BUT HIS LIFE AS A PAINTER DIDN’T BEGIN UNTIL HE<br />
STARTED RECOVERING FROM A TERRIBLE THREE-YEAR BOUT WITH RSD. This<br />
experience, he says, was his “wake-up call.”<br />
In1997, Stephen developed a repetitive stress injury in his right arm<br />
caused by doing work around his house. Within three weeks, his left arm<br />
mirrored the same symptoms. Visits to numerous doctors produced no<br />
results. “I explained to the doctors that having pain in the other arm meant<br />
the pain had to be neuropathic, but none agreed.” In 1998, a doctor who<br />
was convinced that Stephen had tennis elbow operated on his right arm. Stephen Spagnoli<br />
“That’s when the disease exploded and I was diagnosed with RSD,”<br />
Stephen says. “The pain spread from my arms to my trunk, then to my legs, my face—everywhere. I had a full-body allodynia. I was<br />
bedridden from 1998 until 2001. I spent 15 hours out of each day in the bathtub. The quality of my life was zero. I was treated<br />
with heavy doses of morphine, but the drugs did nothing to reduce my pain.”<br />
22 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
The turning point came when Stephen found a doctor in<br />
Florida who specializes in RSD. “His protocols were different<br />
from any others I’d heard about. He gave me multiple injections<br />
along the edge of my spinal cord (not epidurals, but trigger-point-like<br />
injections). He got me off the morphine and put<br />
me on Buprenex. That’s when things turned around. I started<br />
moving and having energy again, and getting the pain under<br />
control (as opposed to the pain having control of me). I was<br />
still frail and walking with a cane, and I still had flare-ups, but<br />
I was no longer praying not to wake up in the morning.”<br />
When Stephen recovered enough to resume activities, he<br />
had the rare opportunity to explore “a path not taken” in his<br />
life before RSD. “I’ve always been an artist but never thought<br />
of it as a career. I had sold my illustrations to magazines and<br />
newspapers in the past, but I didn’t start expressing myself<br />
through painting until I had recovered enough from the RSD.<br />
When he began painting, Stephen’s work focused solely on<br />
various aspects of RSD. “Some were visualizations of pain and<br />
some were tactile (what the allodynia felt like). Some were<br />
images of despair and loss—the loss of who I was, my ability to<br />
enjoy being touched, and my sexuality.”<br />
Today, Stephen works in his studio each day. His abstract<br />
paintings no longer deal with pain, and he is working on the<br />
illustrations for a short story that is a metaphor for what he<br />
went through during his illness and recovery, and a book for<br />
adolescents.<br />
“I realized that I had always wanted to be an artist. The<br />
RSD was my ‘wake-up call’—just like it was a wake-up call in<br />
every other facet of my life. The RSD was a gift because it<br />
gave me the space to become what I always should have been.<br />
It also gave me an appreciation of life and my family.”<br />
Stephen says, “In a way, I used my paintings as a ‘revenge<br />
on the disease’ by making it something that could be shown. I<br />
wanted to put it up to the light.” For people who were beginning<br />
to have RSD symptoms, he wanted to encourage them<br />
to seek help immediately. He also wanted to use visual<br />
imagery to show the doctors who denied that he had RSD,<br />
that they were wrong.<br />
Stephen does not know if his condition will continue to<br />
improve, but he is hopeful. “I’m mobile and I can use my<br />
hands. I still can’t play ball with my kids, I’m not well enough<br />
to work out and keep in shape, and I still can’t play my guitar,<br />
although I try sometimes (Stephen had signed a contract with<br />
BMI, a music publishing company, prior to his illness). I just<br />
have to be patient and keep doing what I’m doing.”<br />
LOVERS<br />
Soapstone and mixed media on canvas 10x10<br />
SPASM canvas on canvas 20X18<br />
“The RSD was a gift because it gave me the<br />
space to become what I always should have been”<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 23
PEOPLE WITH CRPS | THEIR STORIES AND ACCOMPLISHMENTS<br />
Wilson H. Hulley<br />
floor, “pawing” light switches on or off, and<br />
retrieving items from counters or even the<br />
WHEN WILSON HULLEY WAS<br />
refrigerator. Most important for someone<br />
DIAGNOSED WITH RSD, he<br />
like Wilson, Star allowed him to be independent-she<br />
acted as a cane when his bal-<br />
figured he had two choices:<br />
cave in and let the syndrome<br />
ance was compromised and, because his<br />
and the ensuing disability<br />
legs are painfully tender to the touch, she<br />
destroy him or continue to fight for the<br />
acted as a buffer between him and other<br />
rights of people with disabilities. Two years<br />
people in a crowd.<br />
before the onset of RSD, Wilson had<br />
Beyond the practical aspects, assistance<br />
joined the President’s Committee on the<br />
dogs also provide emotional support. “Pain<br />
Employment of People with Disabilities.<br />
places both physical and emotional restrictions<br />
on our lives, and although medication<br />
On the Committee, he was Special Assistant<br />
to the Executive Director, Advisor to<br />
and other treatment modalities help, those<br />
the Chairman and to The President, and<br />
of us disabled by CRPS often can use the<br />
Wilson Hulley and his assistance dog, Star<br />
a member of their Executive Staff; Wilson<br />
‘leg up’ provided by a canine companion.<br />
helped develop the language for the Americans<br />
with Disabilities Act, which President George H. Bush can break down the social and physical barriers often imposed<br />
Also, an affectionate, highly trained canine<br />
signed into law.<br />
by a disability,” he says.<br />
A car accident in 1986 left Wilson with a traumatic brain Wilson continues to be dogged in his fight for the rights of<br />
injury and the many months of rehabilitation gave him a special<br />
insight into the challenges that face people with disabilities. CRPS. As a member of the Board of Directors of RSDSA, he<br />
people with disabilities, and specifically for those who have<br />
Having held a number of senior management positions in the communicates with others who have the syndrome and has<br />
private and public sector, Wilson’s resume reads like a “Who’s served as an advocate when necessary. He is particularly interested<br />
in the plight of returning war veterans who suffer chronic<br />
Who” and his experience and contacts gave him a definite edge.<br />
For example, he was working with the Committee when the pain. Beyond the RSD community, Wilson serves on the<br />
memorial for President Franklin Roosevelt was being designed. Northwest Airlines Customer Advisory Board on Disabilities,<br />
There was a lot of discussion about whether to portray him for whom he reviews disability policies for both employees and<br />
in a wheelchair or not. Wilson recalls writing a note to then passengers. Also, having been mugged twice since becoming<br />
President Bill Clinton that said, “Mr. President. Just do it!” The disabled, Wilson recently retired from the board of directors of<br />
wheelchair won.<br />
the National Organization for Victims Assistance. And, he<br />
Wilson’s “Just do it!” attitude has served him well. For serves as the advisor to the International Association of Assistance<br />
Dog Partners; where he and Star were honored in 2004<br />
example, when he realized in 1994 that he needed help getting<br />
around, he applied for an assistance dog from the National with the Unsung Hero Award; just one of many awards and<br />
Education for Assistance Dog Services (NEADS) in Princeton, honors he has received in his lifetime of serving others.<br />
Massachusetts. Star, a British Black Labrador Retriever, helped Like others who suffer from CRPS, the magnitude of Wilson’s<br />
personal loss is huge but unlike so many others, he contin-<br />
Wilson negotiate the world for 10 years (she recently passed<br />
away at the age of 12. He is awaiting his second assistance dog ues to be empowered to make the world a better, safer, and<br />
from NEADS). Although we don’t automatically associate assistance<br />
dogs with people in pain, they can do multiple things<br />
happier place for those who are disabled.<br />
that make life manageable, such as picking things up from the<br />
“ … an affectionate, highly trained canine can break<br />
down the social and physical barriers often<br />
imposed by a disability.” WILSON HULLEY<br />
24 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
Barbara Schaffer<br />
IN 1988, BARBARA SCHAFFER, a 38-year-old vocational rehabilitation<br />
counselor, developed RSD from a minor injury at<br />
work. Although her RSD was diagnosed and treated almost<br />
immediately, the disease progressed rapidly. Exercise exacerbated<br />
her condition, other complications set in, and nothing<br />
relieved her pain. Yet in spite of her worsening physical condition,<br />
Barbara continued working at the job she loved for two<br />
more years (until the program shut down), and began taking<br />
action to help others who were living with RSD.<br />
Shortly after being diagnosed in 1988, Barbara launched an<br />
RSD support group in her area. And in 1992, she published an<br />
RSD newsletter and launched the first RSD website.<br />
Barbara’s group also ran four CME conferences for doctors<br />
and nurses through Geisinger Medical Center, a tertiary-care<br />
teaching hospital in the area.<br />
Two years ago, Barbara worked with others (Rick Ulrich<br />
and Jenny Dye, both of whom have RSD) to get an RSD bill<br />
passed in Pennsylvania. “The bill calls for<br />
educating the public and medical community<br />
about RSD. We were successful because<br />
State Representative Merle Phillips worked<br />
with us. He’d known me and Rick, and he’d<br />
seen what RSD had done to us. Once the<br />
bill was passed, the State Department of<br />
Health held a meeting with providers from<br />
all over the state who treat people with<br />
RSD. The purpose of this meeting was to<br />
find out what the providers wanted done,<br />
and that’s how the outreach program was<br />
developed. New York State put out an RSD<br />
bill the year before, but they’ve didn’t have<br />
Barbara and Paul Schaffer<br />
the money to implement it. In Pennsylvania<br />
the money came out of the Department of Health budget. So<br />
the implementation may not be as good as we would like, but<br />
we do have pamphlets in all the Department of Health sites<br />
and there is RSD information on their website.” Pennsylvania<br />
is one of the three states in the country to have passed RSD<br />
legislation.<br />
Today, at 56, Barbara has had to cut back her activities, but<br />
that hasn’t stopped her from working for others with RSD.<br />
Doctors refer patients to her, and she gives support to them<br />
over the phone. She also contributes her time to RSDSA. Last<br />
year she assisted RSDSA staff in organizing a conference in her<br />
area; she writes articles for their newsletter that focus on RSD<br />
and the arts; and she has worked on the organization’s annual<br />
fundraising dinner.<br />
At home, Barbara spends time with her husband (he takes<br />
care of their three grandchildren while their daughter and<br />
son-in-law are at work). “I’ve been lucky to be involved with<br />
my grandchildren. I’m a big part of their lives, which is very<br />
important to me.”<br />
Barbara is philosophical about the challenges<br />
of living with RSD. “I have lost the<br />
ability to do many of the things that I<br />
loved, and I have mourned their loss. But I<br />
continue to find new things to do and new<br />
ways to do old things. In filling my days<br />
with activities and friends and my grandchildren,<br />
I have learned that there are<br />
many ways I can enjoy life. This is a constant<br />
challenge because RSD is always<br />
changing. But isn’t change one of the constants<br />
of life? I try to remember that life<br />
has made me no promises, that each day is<br />
a gift, and that I get to choose whether I<br />
suffer or enjoy it.”<br />
“ I try to remember that life has made me no promises,<br />
that each day is a gift, and that I get to choose<br />
whether I suffer or enjoy it.” BARBARA SCHAFFER<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 25
PEOPLE WITH CRPS | THEIR STORIES AND ACCOMPLISHMENTS<br />
Lisa Delia<br />
KEEP ON MOVING By Ed Delia<br />
My wife, Lisa, was diagnosed with RSD in May 2003,<br />
approximately five months after she triggered the<br />
syndrome by jumping up to squash a bug on the<br />
ceiling. After being misdiagnosed by two orthopedists,<br />
Lisa was in physical therapy and not making<br />
much progress. On the Internet, Lisa found a condition that<br />
resembled the symptoms she was experiencing. It was RSD.<br />
Dr. Robert Knobler, a neurologist in Fort Washington, Pennsylvania<br />
who has treated a lot of people with RSD, started Lisa on<br />
a regimen of walking and water therapy. Consistent physical<br />
activity combined with (warm) water therapy seems to help her<br />
condition. We have found that moving is a must. Move when<br />
you don’t want to, put the work in every day. Evidence of<br />
progress comes in months and years.<br />
Last spring, “movement” escalated when we were introduced<br />
to the Achilles track club, a worldwide not-for-profit<br />
organization that encourages people with all types of disabilities<br />
Valerie Lacey, Emma Delia, Ed Delia, Albee Delia and Lisa Delia at the<br />
Achilles Walk finish line.<br />
PHOTO: LORRY MULHERN/CHRIS HERDER, LOTUSPHOTOGR APHERS.COM<br />
to participate in mainstream athletics. It promotes personal<br />
achievement and enhanced self-esteem. The founder, Dick<br />
Traum, was the first amputee to run and finish the New York<br />
marathon. Achilles was founded in 1983 and now has 110<br />
chapters worldwide and 40 in the U.S.<br />
Once a year Achilles sponsors “Hope and Possibility: 5<br />
miler Run, Walk or Roll.” The participants all have some level<br />
of disability—blind runners pair with sighted ones, quadriplegics<br />
compete in wheelchairs, wounded Veterans walk or run. In<br />
April of 2005, Lisa and I met with Mary Bryant from Achilles.<br />
She instantly adopted our cause to promote awareness of RSD<br />
and invited people with RSD to participate. We had less than<br />
two months to pull this off.<br />
Lisa called Jim Broatch, the Executive Director of RSDSA<br />
to see if the organization could help spread the word. RSDSA,<br />
with Celgene’s financial support, supplied T-shirts and paid the<br />
entry fee for participants. Lisa sent email to support groups<br />
across the country, inviting them to come. Her niece, Maria<br />
Brown, a graphic arts student, created a logo for the poster that<br />
graced the RSD tent. On June 26, in 82-degree-heat, 25 people<br />
with RSD, their friends and family, joined thousands of others<br />
who gathered in Central Park for the event. Our family,<br />
including my 87-year-old mother and our three children,<br />
Albee, Daniel, and Emma, joined Lisa and me on<br />
the track. Some with RSD did the race in wheelchairs,<br />
and others, like Lisa, used crutches.<br />
It was not easy; at the four-mile point Lisa was tired<br />
and hurting, but the people on the sidelines, including<br />
New York firefighters, were cheering. “You can’t imagine<br />
the camaraderie you feel you get from support of people,<br />
like the firefighters and others egging you on,” Lisa said.<br />
The walk took its toll. For about three weeks afterwards,<br />
Lisa’s pain flared. Nevertheless, we will be back<br />
in Central Park this August for the 2006 Achilles Walk.<br />
In spite of the short notice, Lisa and the group of supporters<br />
helped raise more than $26,000 for awareness<br />
last June. We have to keep moving forward. We are<br />
committed to raising awareness of RSD and the horrible<br />
pain involved.<br />
“ You can’t imagine the camaraderie you feel you get<br />
from support of people, like the firefighters and<br />
others egging you on.” LISA DELIA<br />
26 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
Sharon Weiner<br />
SHARON WEINER WAS THE ULTIMATE<br />
“SUPER MOM.” A full-time career<br />
woman, a wife, and mother of a son and<br />
daughter, she always made time to be<br />
involved with Scouts, PTA, and school<br />
plays. But when Sharon was diagnosed with<br />
RSD/CRPS in 1996 at the age of 38, she knew<br />
her life would have to change. Slowed down,<br />
but unstoppable, Sharon not only learned to do<br />
Sharon Weiner<br />
things in new ways, but she launched a support<br />
group to help others with the syndrome.<br />
“When I was first diagnosed with RSD, I was happy to<br />
know that there was a reason for all this pain, but when I<br />
started realizing the impact it was going to have on my life, I<br />
knew I needed to learn more. I found a support group about an<br />
hour from home and it was the most uninformative, depressing<br />
thing I had ever gone to. It was a complete ‘woe is me’ meeting.<br />
The people just wanted to complain and tell their stories.<br />
When I walked out, I thought, ‘I might as well give up now.’”<br />
Determined to get a local group started, Sharon went to a<br />
<strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong> Syndrome Association (RSDSA)<br />
meeting in Atlantic City and found people from her area who<br />
were interested in joining. As soon as she returned home, she<br />
arranged for a regular meeting room at a medical center, printed<br />
flyers, and sent them to all pain centers in the region. The first<br />
meeting of the group convened in November 1997 and continues<br />
to meet monthy.<br />
“We call the group ‘Living with RSD.’ We know there’s no<br />
cure, so we offer information on how to deal with it. The first<br />
half-hour of each two-hour meeting is devoted to open discussion.<br />
The second part of the meeting focuses on a particular<br />
topic. We’ve offered presentations on self-defense, cooking, legal<br />
issues, social security, and clothing. Often we address psychosocial<br />
issues. I don’t always agree the speakers, but I’m committed<br />
to making information available to people.”<br />
“Living with RSD” meetings are not limited to people with<br />
the syndrome; they are also open to family members and<br />
friends. Most members, however, are women ranging in age<br />
from their late twenties to early fifties. “At one point we even<br />
had a fourteen-year-old girl, but many of the issues we address<br />
are those she didn’t need to deal with yet, such as marital or<br />
financial problems, how to deal with Workers’ Comp, or how<br />
to get Social Security.”<br />
The group also has family sessions in<br />
which those with RSD/CRPS leave the room<br />
and family members have the opportunity to<br />
speak with a psychologist. “This is important<br />
because CRPS causes rifts in families—the<br />
dynamics change,” Sharon says. “Family members<br />
need to understand the limitations of the<br />
condition, know when to be helpful, and when<br />
not to be enabling. Getting RSD is particularly<br />
hard for husbands who were the family breadwinners.<br />
It’s a huge loss of self-esteem and it’s<br />
often hard to ask for help. All of us with RSD<br />
need to understand that we’ve lost part of our<br />
lives, and we need to go through a grieving process for that.”<br />
Newcomers to the group receive a packet that contains<br />
basic RSD information as well as a host of resources and a<br />
schedule of meetings. Sharon has found that people with<br />
RSD/CRPS not only find this packet instructive, but they can<br />
also show it to their families and doctors—because a lot of people<br />
don’t believe this disease exists.<br />
In 19????, the support group became a nonprofit organization<br />
with the help of an accountant with RSD/CRPS. Now, a<br />
significant part of Sharon’s work is devoted to fundraising.<br />
“There are no dues, because a lot of people have financial<br />
problems when they have a long-term syndrome like this. I’m<br />
not afraid to ask for money or services from other sources, and<br />
I’m always trying to figure out how we can get jobs done for<br />
the organization. We’re listed with United Way, and many of<br />
my friends and family donate through their jobs. We’ve sold<br />
T-shirts, flower bowls, and lately we’ve been doing flea markets.<br />
Right now we need money for a mass mailing to healthcare<br />
professionals and a revamping of our website.”<br />
“My mother says this work is my ‘calling.’ When I need<br />
something done, I figure it out. I got that from my father,”<br />
Sharon says. When he wanted to build something, he got a<br />
book and built it. Having RSD can be overwhelming, but<br />
you can’t give up hope. You just have to look for new ways of<br />
doing things.”<br />
Although Sharon no longer goes to a regular job, her life is<br />
full and active—and for her kids, she has never stopped being<br />
a very super mom.<br />
“ All of us with RSD need to understand that we’ve<br />
lost part of our lives, and we need to go through<br />
a grieving process for that.” SHARON WEINER<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 27
FEATURE | GALER<br />
32 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
COMPLEX REGIONAL<br />
PAIN SYNDROME:<br />
New Hope After a<br />
Decade of Dispelling Myths<br />
BY BRADLEY S. GALER, MD<br />
Stephen Spagnoli<br />
C Fibers Backfiring<br />
Mixed Media on Canvas 30x60<br />
Complex Regional Pain Syndrome (CRPS)<br />
is a perplexing condition that has been<br />
relatively ignored and misunderstood by the<br />
medical community because it is so unusual.<br />
Perhaps the confusion that is invoked by this<br />
condition is precisely due to its atypical clinical<br />
presentation: the pain in CRPS patients<br />
does not follow a pattern expected in painful<br />
neurologic conditions, the affected body part<br />
changes color and temperature quite dramat -<br />
ically, and patients often display protective<br />
behavior that looks odd to a practitioner.<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 33
FEATURE | GALER<br />
TABLE 1 | IASP Diagnostic Criteria (2)<br />
COMPLEX REGIONAL<br />
PAIN SYNDROME TYPE I (RSD)<br />
❥ The presence of an initiating noxious event,<br />
or a cause of immobilization<br />
❥ Continuing pain, allodynia, or hyperalgesia with<br />
which the pain is disproportionate to any inciting event<br />
❥ Evidence at some time of edema, changes in skin blood<br />
flow (skin color changes, skin temperature changes more<br />
than 1.1°C difference from the homologous body part),<br />
or abnormal sudomotor activity in the region of the pain<br />
❥ This diagnosis is excluded by the existence of conditions<br />
that would otherwise account for the degree of pain<br />
and dysfunction<br />
COMPLEX REGIONAL<br />
PAIN SYNDROME TYPE II (CAUSALGIA)<br />
❥ The presence of continuing pain, allodynia, or hyperalgesia<br />
after a nerve injury, not necessarily limited to the<br />
distribution of the injured nerve<br />
❥ Evidence at some time of edema, changes in skin blood<br />
flow (skin color changes, skin temperature changes more<br />
than 1.1°C difference from the homologous body part),<br />
or abnormal sudomotor activity in the region of pain<br />
❥ This diagnosis is excluded by the existence of conditions<br />
that would otherwise account for the degree of pain<br />
and dysfunction<br />
FURTHERMORE, CRPS OFTEN MAY RESULT from a work-related<br />
injury and thus may carry suspicion of an ulterior financial<br />
motive-although this is rarely, if ever, the case. And lastly, often<br />
the CRPS patient has a comorbid psychiatric condition. The<br />
net result has been a tendency among many in the medical<br />
community to keep CRPS patients at arm’s length, ultimately<br />
making it even more difficult for these patients to receive<br />
appropriate therapy.<br />
Fortunately, over the past decade an international group of<br />
research scientists and clinicians, who are dedicated to advancing<br />
our understanding and treatment of this difficult condition,<br />
have made great strides. Although there is still no cure or complete<br />
understanding of the pathophysiology underlying CRPS,<br />
most patients can be helped by educated pain practitioners who<br />
are able to alleviate their CRPS patients’ pain and improve function<br />
and quality of life with the proper care. This short review<br />
article will attempt to dispel old myths, summarize advances in<br />
our understanding of CRPS, and describe promising new<br />
approaches to therapy.<br />
What Is CRPS?<br />
OVER THE PAST DECADE, a great deal has been published in<br />
medical scientific peer-reviewed journals regarding CRPS (“reflex<br />
sympathetic dystrophy” and “causalgia”), documenting it as a<br />
true biomedical clinical disorder with underlying neurological<br />
pathology in both the peripheral and central nervous systems.<br />
Numerous attempts have been made to identify common causes<br />
and features to serve as a basis for effective treatment. International<br />
pain experts have questioned many of the previously<br />
long-held medical assumptions regarding this condition by performing<br />
research to test old hypotheses. Their healthy skepticism<br />
has resulted in exposing most of these old medical “tenets” as<br />
myths or half-truths. CRPS is at last being viewed from a datadriven<br />
scientific and clinical perspective (1, 2).<br />
A crucial part of this effort has been the attempt by the<br />
International Association for the Study of Pain (IASP) to more<br />
accurately define this medical condition, now called “Complex<br />
Regional Pain Syndrome” (CRPS), and especially to differentiate<br />
it from other conditions involving nerve pain (2). The new<br />
IASP diagnostic criteria recognize two syndromes: CRPS I<br />
and CRPS II [Table 1]. Both are conditions in which pain is<br />
most often severe and the area affected is characterized by skin<br />
sensitivity, abnormal color changes, temperature changes, and<br />
sweating. Not all patients have all these symptoms continuously,<br />
but they must always have more than just pain and skin<br />
sensitivity (allodynia and/or hyperalgesia), which are common<br />
among many neuropathic pain conditions. CRPS II (previously<br />
called causalgia) differs from CRPS I (or RSD) in being the<br />
result of identifiable nerve injury; otherwise, they are the same<br />
symptomatically. By accurately defining CRPS, there is a much<br />
better chance of finding effective treatments and defining the<br />
underlying etiology.<br />
Myth 1<br />
ONE OF THE MAJOR MYTHS regarding treatment of CRPS is<br />
that nerve blocks are the key to diagnosis and therapy. Even<br />
today, physicians commonly confuse the term “sympathetically<br />
A mistaken notion that heightens undue fear and anxiety in CRPS patients<br />
is the belief that all CRPS patients will progress through a series of increasingly<br />
debilitating stages and that CRPS will spread to other parts of the body.<br />
34 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
To date, there is no known predisposing risk factor for developing CRPS. No<br />
psychological profile has been identified that predisposes one to developing<br />
CRPS, nor have any data been published that have found a genetic link.<br />
maintained pain” (SMP) with CRPS. SMP, by definition,<br />
means only that a patient reports pain relief following a sympathetic<br />
block; thus, patients with a variety of clinical conditions,<br />
such as diabetic neuropathy, can also have SMP. Furthermore,<br />
although nerve blocks may be curative for some patients with<br />
CRPS, this is not true in all, and probably most, patients.<br />
For many patients, the majority of their pain is thought to<br />
be caused by mechanisms independent of the sympathetic<br />
nervous system (so-called “sympathetic independent pain”<br />
—SIP), and therefore sympathetic nerve blocks are not<br />
effective. The authorities have come to acknowledge that the<br />
cornerstone of CRPS treatment is physical and rehabilitation<br />
therapy, and not nerve blocks (1, 2). It is crucial to remember<br />
that the diagnosis of CRPS is a clinical one, based on history<br />
and examination findings [Table 1], without regard to response<br />
to sympathetic blocks.<br />
Myth 2<br />
A MISTAKEN NOTION that heightens undue fear and anxiety in<br />
CRPS patients is the belief that all CRPS patients will progress<br />
through a series of increasingly debilitating stages and that<br />
CRPS will spread to other parts of the body. A recent study has<br />
shown that there is no one set of stages that every patient goes<br />
through, and that the intensity and severity of symptoms/signs<br />
do not correlate with duration of CRPS (3). This study also<br />
made the important discovery that there appear to be three distinct<br />
subgroups of CRPS patients who differ in their grouping<br />
of CRPS signs/symptoms:<br />
[1] a relatively minor syndrome with vasomotor<br />
signs predominating,<br />
[2] a relatively limited syndrome with neuropathic<br />
pain/sensory abnormalities<br />
predominating, and<br />
MYTH<br />
[3] a florid CRPS. Although CRPS may indeed<br />
spread, this does not occur in every patient.<br />
Moreover, “spreading” of symptoms is often misdiagnosed<br />
as progressing CRPS. Instead, what<br />
often happens is that disuse or misuse of the<br />
affected limb leads to secondary myofascial<br />
problems, which then can become another independent<br />
source and site of symptoms.<br />
Myth 3<br />
RELATED TO MYTH 2 is the erroneous belief that<br />
therapy will be unsuccessful unless started early in<br />
the course of CRPS. Although it is definitely<br />
important to receive treatment as early as possible,<br />
patients should not be viewed as hopeless if their CRPS has<br />
remained undiagnosed or poorly treated for 5 or even 10 years.<br />
Based on authorities’ experience, patients with CRPS can and<br />
do respond to a variety of therapies even when they have had<br />
the condition for many years (1).<br />
Myth 4<br />
PERHAPS THE MOST PERVASIVE, DISTURBING, AND DAMAGING<br />
MYTH is that CRPS is a psychological disorder and is “all in the<br />
patient’s head.” Unfortunately, this tall tale had been perpetuated<br />
by many prominent neurologists up until the past few<br />
years, causing undue pain and suffering, as well as assisting the<br />
medical-legal-workers compensation systems in denying CRPS<br />
patients’ right to appropriate (paid-for) healthcare and insurance<br />
benefits. To some extent, this misguided belief probably<br />
reflects the unusual nature of CRPS as mentioned earlier. Also,<br />
like many chronic pain patients, CRPS patients do often<br />
develop secondary psychological conditions, including depression,<br />
anxiety, or post-traumatic stress disorder (PTSD), as a<br />
result of the effect severe pain has on their lives, but not as a<br />
cause of the condition (1, 2, 4). It is confirmed by scientific<br />
data that CRPS is not a psychiatric condition.<br />
What Causes CRPS?<br />
CRPS IS AN UNDERLYING PAIN CONDITION that is caused by<br />
abnormality in the nervous system, although standard neurological<br />
tests are frequently normal (except in CRPS II). Recent<br />
TABLE 2 | Common Myths<br />
FACT<br />
Nerve blocks are the key to therapy. Nerve blocks are effective in only a small<br />
percentage of CRPS patients. The key<br />
to therapy is multidisciplinary care<br />
focused on active rehabilitation of the<br />
involved body part.<br />
CRPS progresses through a series of CRPS does not progress through welldebilitating<br />
stages and will spread. defined stages. There are different subgroups<br />
of patients with various symptoms.<br />
CRPS does not spread in every patient.<br />
Therapy will be unsuccessful CRPS patients may respond to appropriate<br />
unless started early.<br />
therapies regardless of when they are started.<br />
It’s all in your head—CRPS is a CRPS is a chronic neurological condition<br />
psychiatric condition.<br />
resulting from a dysfunction in the<br />
peripheral and central nervous system.<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 35
FEATURE | GALER<br />
Although there is still no cure or complete understanding of the pathophysiology<br />
underlying CRPS, most patients can be helped by educated pain practitioners<br />
who are able to alleviate their CRPS patients’ pain and improve function<br />
and quality of life with the proper care.<br />
animal models for nerve pain have shown that animals suffering<br />
a nerve injury can display characteristics similar to humans with<br />
CRPS, including sensitivity to touch and changes in temperature<br />
and color, as well as “mirror” symptoms, all of which have<br />
been found to have an underlying neuropathological cause.<br />
Following injury, the body undergoes a series of physiologic<br />
responses designed to heal the damage, including an inflammatory<br />
response that results in changes in the area, such as redness,<br />
warmth, and swelling. This response is accompanied by changes<br />
in the nervous system, which registers pain sensations in the surrounding<br />
area, and results in skin sensitivity, allodynia, and<br />
hyperalgesia. In effect, many of the signs and symptoms that<br />
patients with CRPS experience are part of the normal healing<br />
process These responses usually cease after a short period of time<br />
but in CRPS they may continue indefinitely. Thus, one hypothesis<br />
is that CRPS represents a disruption of the healing process<br />
(1), although it is not known how pain and other CRPS symptoms<br />
are maintained over months and even years.<br />
Over the past few years, scientific studies performed with<br />
CRPS patients have strongly suggested that brain pathologic<br />
changes may be underlying some patients’ symptoms, which<br />
are likely reversible. A recent study demonstrated that CRPS<br />
patients had shrinkage of their somatosensory cortex contra -<br />
lateral to the affected limb, which was reversed with treatment<br />
that improved their symptoms (5).<br />
Is There a Predisposition to Getting CRPS?<br />
TO DATE, THERE IS NO KNOWN PREDISPOSING RISK FACTOR for<br />
developing CRPS. No psychological profile has been identified<br />
that predisposes one to developing CRPS, nor have any data<br />
been published that have found a genetic link (1, 6, 7). However,<br />
there is evidence suggesting that increased stress at the<br />
time of the inciting injury may be a risk factor (1, 6, 7).<br />
Approach to Treatment<br />
UNFORTUNATELY, THERE IS NO “MAGIC BULLET” for patients<br />
with CRPS. When a CRPS patient presents for treatment, most<br />
authorities generally still recommend a sympathetic nerve block<br />
to assess whether the patient has SMP (or SIP). If the patient is<br />
found to have SMP, there is a possibility that a series of these<br />
blocks may bring significant relief and for a minority of<br />
patients may be curative. However, patients and physicians<br />
should be warned not to be disappointed if a trial of one or two<br />
nerve blocks indicates that this therapy does not work for them.<br />
Each patient is different in terms of response to nerve blocks<br />
and medications. Although no treatment has been shown to<br />
help all patients with CRPS, the good news is that there is a<br />
long list of treatments that have been shown to ameliorate the<br />
pain and improve the quality of life for many patients.<br />
It is the responsibility of each pain provider to become<br />
familiar with the wide range of treatments reported to help<br />
patients with CRPS, not just perform invasive procedures,<br />
which will benefit few patients. Also critical in successfully treating<br />
CRPS is regular contact among all of the patient’s treating<br />
healthcare providers so that their efforts can be coordinated.<br />
Physiotherapy<br />
A CENTRAL, IF NOT THE KEY, GOAL OF THERAPY is to get the<br />
painful limb moving to restore normative function (1, 2, 7).<br />
Methods for accomplishing this goal consist of everything from<br />
restoring range of motion, slowly increasing tolerance for daily<br />
activities such as walking and sitting, and reducing sensitivity to<br />
clothing and other objects in the environment. Defined PT and<br />
OT techniques that have been used successfully include desensitization,<br />
stress loading, and a slowly progressive program of<br />
active exercise.<br />
Unquestionably, there will be times when patients will not<br />
want to move, and other times when they will want to move<br />
too much. The key is to have the patient maintain a systematic,<br />
long-term, structured program where slow and gradual gains are<br />
made on a weekly basis, both in the gym and at home.<br />
Psychotherapy<br />
PSYCHOLOGICAL ASSESSMENT AND COUNSELING is important,<br />
not because psychological factors cause CRPS, but because, like<br />
all chronic pain conditions, CRPS often has profound psychological<br />
effects on patients and their families. CRPS patients may<br />
suffer from major depression, anxiety, or post-traumatic stress<br />
disorder, all of which tend to heighten the perception of pain<br />
and make rehabilitation efforts more difficult (1, 2, 7). Patients<br />
who are not optimally treated for these psychological conditions<br />
simultaneously with their pain will not obtain optimal benefit<br />
from the overall treatment plan.<br />
Pharmacotherapy<br />
BECAUSE THERE IS NO KNOWN CURE FOR CRPS, pharmacotherapy<br />
is aimed at relieving painful symptoms in order to facilitate<br />
patient participation in rehabilitation therapy and, over time, a<br />
return to as much normal activity as possible. Medications<br />
should be tried one at a time, slowly but aggressively, making<br />
changes (increasing or decreasing doses, or changing medication)<br />
over the course of a few days or a week, if necessary, until<br />
the right agent or combination of agents is found that provides<br />
the optimal degree of pain relief with the most tolerable side<br />
36 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
effects. It is crucial to perform one medication change at a time<br />
so that the provider can ascribe improvement or side effects to<br />
the correct drug. As in treating any chronic pain condition, no<br />
one drug is effective in every patient, and each patient differs in<br />
terms of response and dosage required. However, with a persistent,<br />
systematic approach, most CRPS patients can eventually<br />
find a medication or group of medicines that provides meaningful<br />
pain relief (1, 2, 7).<br />
Athough randomized trials are scarce in CRPS (according<br />
to published reports and expert opinion), it is recommended<br />
that medication management be based on 3 classes of drugs<br />
[Table 3]; (these recommendations also generally comply with<br />
the recent clinical recommendations published for the treatment<br />
of neuropathic pain conditions (8)):<br />
[1] TOPICAL DRUGS (targeted peripheral analgesics), by definition,<br />
do not deliver meaningful amounts of medication to<br />
the bloodstream, but act locally on the painful nerves, skin,<br />
and muscles. Therefore, this class of drugs rarely, if ever,<br />
produces any systemic side effects. Currently, the only<br />
FDA-approved topical analgesic is the lidocaine patch 5%<br />
(Lidoderm ® ), which is indicated for another neuropathic<br />
pain condition, postherpetic neuralgia. Several publications<br />
have shown it to be potentially efficacious in other painful<br />
nerve conditions, including CRPS and diabetic neuropathy,<br />
as well as inflammatory conditions, such as osteoarthritis<br />
(9). A case series has shown a compounded form of the<br />
NDMA-antagonist, ketamine, to be of potential effectiveness<br />
(10), although caution should always be used when<br />
using non-FDA formulations.<br />
[2] ANTICONVULSANT SEIZURE MEDICATIONS are now first-line<br />
therapies to treat a variety of neuropathic pain conditions.<br />
Although many of these agents tend to have intolerable side<br />
effects, gabapentin (Neurontin ® ) and pregabalin (Lyrica ® )<br />
are among those that may be better tolerated.<br />
[3] OPIOID THERAPY has also become a mainstay in the treatment<br />
of a variety of chronic pain conditions, including neuropathic<br />
pain states. Drugs in this class include oxycodone<br />
ER, oxymorphone ER, morphine ER, and the transdermal<br />
fentanyl patch. Although addiction is believed to be rare in<br />
properly treated chronic pain patients, practitioners should<br />
be aware of the behaviors that may reflect misuse and the<br />
tools that may assist in such evaluation (11).<br />
Drugs in Development<br />
ALTHOUGH DEFINITIVE DATA have not been published, several<br />
possible exciting new therapies may be available over the next<br />
few years. Thalidomide is currently being studied, based on the<br />
positive experience of some patients (12). Also, recent reports<br />
have shown promise for controlled intravenous infusions of<br />
ketamine (13).<br />
Conclusion<br />
RESEARCH PERFORMED OVER THE PAST DECADE has brought<br />
much enlightenment to our understanding of CRPS and has<br />
helped to dispel many myths that had resulted in further pain<br />
and suffering among CRPS patients. As such, the next decade<br />
promises more progress, thanks to the many dedicated<br />
researchers and clinicians worldwide. A new, revised CRPS Treatment<br />
Guidelines is currently being written by CRPS experts, led<br />
by Dr. Norman Harden, and should be read by all pain practitioners<br />
when published. In addition, the pharmaceutical industry<br />
is very much involved in searching for new therapies to treat<br />
CRPS and other chronic neuropathic pain conditions.<br />
REFERENCES<br />
1. Galer BS, Schwartz L, Allen RJ. Complex regional pain syndromes type I:<br />
reflex sympathetic dystrophy, and type II causalgia. In: Loeser JD, Butler<br />
SH, Chapman CR, Turk CDC, eds. Bonica’s Management of Pain. 3rd ed.<br />
Lippincott Williams & Wilkins; Philadelphia, Penn;2000.<br />
2. Stanton-Hicks M, Baron R, Boas R, et al. Complex regional pain syndromes:<br />
guidelines for therapy. Clin J Pain. 1998;14:155-166.<br />
3. Bruehl S, Harden RN, Galer BS, Saltz S, Backonja M, Stanton-Hicks M.<br />
Complex regional pain syndrome: are these distinct subtypes and sequential<br />
stages of the syndrome? Pain. 2002;95:119-124.<br />
4. Bruehl S, Husfeldt B, Lubenow TR, Nath H, Ivankovich AD. Psychological<br />
differences between reflex sympathetic dystrophy and non-RSD chronic<br />
pain patients. Pain. 1996 Sep;67:107-14.<br />
5. Pleger B, Tegenthoff M, Ragert P, Förster AF, Dinse HR, Schwenkreis P,<br />
Nicolas V, Maier C. Sensorimotor retuning in complex regional pain syndrome<br />
parallels pain reduction. Ann Neurol. 2005;57:425-9.<br />
6. Geertzen JH, de Bruijn-Kofman AT, de Bruijn HP, van de Wiel HB, Dijkstra<br />
PU. Stressful life events and psychological dysfunction in Complex<br />
Regional Pain Syndrome type I. Clin J Pain. 1998;14:143-7.<br />
7. Harden RN. A clinical approach to complex regional pain syndrome. Clin<br />
J Pain. 2000;16(2 Suppl):S26-32.<br />
8. Dworkin RH, Backonja M, Rowbotham MC, Allen RR, Argoff CR, Bennett<br />
GJ, Bushnell MC, Farrar JT, Galer BS, Haythornthwaite JA, Hewitt DJ,<br />
Loeser JD, Max MB, Saltarelli M, Schmader KE, Stein C, Thompson D, Turk<br />
DC, Wallace MS, Watkins LR, Weinstein SM. Advances in neuropathic<br />
pain: diagnosis, mechanisms, and treatment recommendations. Arch Neurol.<br />
2003;60:1524-34.<br />
9. Argoff C. Topical treatments for pain. Curr Pain Headache Rep.<br />
2004;8(4):261-7.<br />
TABLE 3 | Medications (1, 2, 7, 8)<br />
DRUG CLASS<br />
EXAMPLES<br />
Topical Drugs Lidocaine patch 5%<br />
(Targeted peripheral analgesics) (Lidoderm®)<br />
Anticonvulsants<br />
Opioids<br />
Gabapentin (Neurontin®)<br />
Pregabalin (Lyrica®)<br />
Morphine ER<br />
Oxycodone ER<br />
Oxymorphone ER<br />
Transdermal fentanyl patch<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 37
FEATURE | GALER<br />
10. Gammaitoni A, Gallagher RM, Welz-Bosna M. Topical ketamine gel: possible<br />
role in treating neuropathic pain. Pain Med. 2000;1(1):97-100.<br />
11. Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener<br />
and opioid assessment measure for patients with chronic pain. Pain.<br />
2004;112:65-75.<br />
12. Rajkumar SV; Rafael Fonseca R; Thomas E. Witzig TE. Complete Resolution<br />
of <strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong> With Thalidomide Treatment. Arch<br />
Intern Med. 2001;161:2502-2503.<br />
13. Correll GE, Maleki J, Gracely EJ, Muir JJ, Harbut RE. Subanesthetic ketamine<br />
infusion therapy: a retrospective analysis of a novel therapeutic<br />
approach to complex regional pain syndrome. Pain Med. 2004;5:263-75.<br />
Outcomes<br />
Measurement<br />
The Pain Outcomes Profile<br />
BRADLEY S. GALER, MD,<br />
is CEO and President of<br />
Topiceutical, Inc., a<br />
company that develops<br />
topical treatments for<br />
pain and headache.<br />
Are you Credentialed in Pain Management?<br />
The Academy offers 3 levels of interdiscliplinary<br />
pain management credentialing:<br />
• Diplomate<br />
• Fellow<br />
• Clinical Associate<br />
To receive a copy of the Credentialing Booklet, call the Academy at<br />
209-533-9744, or download it from the website at www.aapainmanage.org<br />
E X A M S I T E S<br />
2006<br />
Exam date<br />
Saturday<br />
June 3, 2006<br />
Saturday<br />
June 3, 2006<br />
Sunday<br />
Sept. 10, 2006<br />
Saturday<br />
Dec 2, 2006<br />
Saturday<br />
Dec 2, 2006<br />
Exam Location<br />
Los Angeles, CA<br />
Chicago, IL<br />
Orlando, FL<br />
(Annual Conference)<br />
San Diego, CA<br />
Orlando, FL<br />
Application<br />
Deadline<br />
April 19, 2006<br />
April 19, 2006<br />
August 16, 2006<br />
October 18, 2006<br />
October 18, 2006<br />
A useful measurement tool<br />
that tracks patients' progress<br />
throughout treatment for:<br />
-Pain Intensity-<br />
-Mobility-<br />
-Activities of Daily Living-<br />
-Vitality-<br />
-Negative Affect-<br />
-Fear-<br />
Order forms for the POP Starter Kit<br />
can be downloaded from the Academy's website at<br />
www.aapainmanage.org.<br />
If you are interested in participating in research<br />
regarding the the Pain Outcomes Profile,<br />
call Alexandra Campbell, PhD,<br />
at 209-533-9744, or<br />
send an email to her at<br />
alex@aapainmanage.org.<br />
American Academy of Pain Management • 13947 Mono Way #A • Sonora, CA 95370<br />
Phone: 209-533-9744• Fax: 209-533-9750 • www.aapainmanage.org<br />
38 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
Concerned About Passing the<br />
Credentialing Exam?<br />
Then Take the Pre-exam Track at the<br />
17th Annual Clinical Meeting<br />
Who and What: For the first time, the American Academy of Pain Management is offering a<br />
full-day pre-exam track designed to help members prepare for the Credentialing test. The track<br />
will be staffed by many of the exam item writers and experts from various disciplines. Participants<br />
will have an opportunity to listen, ask questions, and understand many of the tenets,<br />
philosophies, and treatment approaches covered on the Credentialing test.<br />
When: Pre-exam Track: Thursday, September 7, from 7:30 am to 4:30 pm<br />
Exam: Sunday, September 10<br />
Where: Walt Disneyworld Swan and Dolphin, Orlando, Florida<br />
Cost and Registration: $185 for members and $225 for non-members (includes lunch).<br />
Registration may be completed in advance through the website or in person the day of<br />
the pre-conference activity.<br />
Recommended Reading: Weiner’s Pain Management: A Practical Guide for Clinicians, Seventh Edition<br />
Take the track, take the test, and become<br />
a credentialed (Diplomate, Fellow, or<br />
Clinical Associate) member of the<br />
American Academy of Pain Management!
INTERVIEW | COVINGTON<br />
LIFEBOAT mixed media on canvas 36x40<br />
Stephen Spagnoli<br />
40 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
EXPLORING<br />
PSYCHOSOCIAL<br />
ISSUES IN CRPS<br />
An Interview with Edward C. Covington, MD, Director of the<br />
Chronic Pain Rehabilitation Program at the Cleveland Clinic Foundation<br />
Q. What is the current thinking about the relationship<br />
between the psyche and the soma in CRPS?<br />
DR. COVINGTON A recent search for articles on CRPS, which<br />
are being published at the rate of about 100 per year, showed<br />
that there is still tremendous controversy about the nature<br />
of this disease, and whether it is a psychiatric rather than a<br />
medical condition.<br />
Authors have proposed several theories about how the<br />
psyche might be related to the soma in this syndrome, and<br />
each has varying support. Some believe that CRPS is a psychiatric<br />
illness—a con<strong>version</strong> disorder—that there is something<br />
‘in the head’ that makes it come about. Others see CRPS as a<br />
result of a psychiatric illness or personality disorder that makes<br />
some more likely to get it than others. Some contend that CRPS<br />
causes psychological symptoms or psychiatric illness, while others<br />
think that psychological factors modify the course of CRPS—<br />
making it better or worse. Others think that adjustment and<br />
function in CRPS are determined by psychological factors.<br />
CRPS AND PERSONALITY<br />
Q. Are people with particular personalities<br />
prone to certain diseases?<br />
DR. COVINGTON There was a very old theory that held that different<br />
personality types were vulnerable to different illnesses.<br />
For example, that particular personality types had Crohn’s disease,<br />
others had migraine headaches, and that other types had<br />
CRPS. These ideas were widely taught, but never substantiated,<br />
and had been essentially discredited by the time I was in training<br />
25 years ago. Few people now believe this theory, although<br />
occasionally you’ll hear someone refer, for example, to<br />
migraineurs as compulsive, but this is essentially just folklore.<br />
Q. What about the relationship between personality<br />
and CRPS?<br />
DR. COVINGTON People often mistakenly equate correlation<br />
with causation. Personalities change when people are miserable<br />
and unable to function. So CRPS patients may be irritable,<br />
complaining, or demanding, leading others to conclude that<br />
these traits led to the disease. Another reason people have<br />
thought that personality disorders predisposed to CRPS is<br />
because there are often extreme behavioral changes following a<br />
trivial injury. Thus the inclination is to think, ‘Oh, c’mon, that<br />
couldn’t hurt that bad.’ Psychogenic theories also flourished<br />
because, despite the last twenty years of research, the condition<br />
remains ill-defined. Its pathophysiology is obscure. We don’t<br />
have a good understanding of exactly what CRPS is and why<br />
some people get it and others don’t.<br />
It is common to assume that when no explanation for a<br />
condition can be found, then it must be psychogenic. If doctors<br />
can’t figure it out, perhaps ‘it’s all in the head.’ People with<br />
fibromyalgia and irritable bowel syndrome have been subjected<br />
to the same sort of ideas, and I’m convinced that both are<br />
absolutely organic diseases, as is CRPS.<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 41
INTERVIEW | COVINGTON<br />
Q. Have any studies demonstrated the relationship<br />
between CRPS and personality abnormalities?<br />
DR. COVINGTON Cross-sectional, correlational studies demonstrate<br />
that there is an association between personality abnormalities<br />
and chronic pain. If you go to any chronic pain unit, you<br />
will see considerable evidence of personality disorder. By the<br />
same token, an association can also be shown between obesity<br />
and diet cola. That does not mean that diet cola causes obesity.<br />
A common error in medical discussions is to assume that when<br />
two things are associated, one must cause the other. Obviously,<br />
this is not the case.<br />
In a 1993 study of tertiary pain patients, researchers compared<br />
CRPS patients with patients who had back pain or neuropathic<br />
pain (1). Findings showed that the CRPS patients were<br />
just like the neuropathy patients, which is not surprising, since<br />
CRPS is a neuropathic pain syndrome. Their similarities<br />
included their symptom reporting, illness behavior, and psychological<br />
distress. The incidence of disability was a little higher in<br />
CRPS. When CRPS patients were compared to back pain<br />
patients, actually the back pain patients tended to have more<br />
diffuse, ill-explained complaining, and more non-specific symptoms<br />
than the CRPS patients. Sexual abuse, physical abuse,<br />
emotional abuse—traumas that we think contribute to the formation<br />
of physical symptoms in the absence of physical disease,<br />
were no more prevalent in people with CRPS than in those<br />
with back ache or neuropathic pain. This is pretty strong evidence<br />
that old ideas about special sorts of psychiatric profiles of<br />
CRPS patients were specious.<br />
Q. How does personality affect the way an individual<br />
copes with CRPS, or any other disease?<br />
DR. COVINGTON There’s an old story about a little boy who was<br />
whistling when he had to shovel manure on Christmas morning.<br />
When his companion asked how he could be so happy, the<br />
boy replied, ‘With all this manure, I figure there has to be a<br />
pony someplace.’ So with all the manure that people have written<br />
about CRPS, we must wonder, ‘Is there a pony someplace?’<br />
That is, is there a kernel of truth here? I think the truth lies in<br />
the fact that the mind plays a role in all suffering and in all<br />
function. It’s the mind that copes or fails to do so, whether the<br />
stress is a stock market crash, the death of a spouse, or a painful<br />
disease. Among intractable cases, failures of coping and adaptation<br />
will be disproportionately represented. There are people<br />
with CRPS who have managed to transcend it and have a life.<br />
For others, it’s less the case that they have CRPS than that<br />
‘CRPS has them.’ CRPS has taken over their lives. People who<br />
have problems with coping and those who have personality<br />
disorders are the ones most likely to have difficulty dealing<br />
with a disaster or catastrophe of any kind, including CRPS.<br />
The problem, of course, is to know whether the person failed<br />
to cope because of poor coping skills, or whether it was<br />
because of an unusually severe case of CRPS.<br />
If we define personality as a bias towards certain ways of<br />
thinking, behaving, and feeling, then it would stand to reason<br />
that personality has to affect coping strategies, stress tolerance,<br />
and even what sorts of things a person finds stressful. Perso -<br />
nality affects autonomic responses, which contribute to<br />
sympathetically-maintained pain, and influences a person’s<br />
needs to escape demands, stress, and responsibility. It determines<br />
whether a person has healthier ways of dealing with<br />
stress as well as perseverance in recovery efforts. Thus,<br />
personality will affect how a person deals with disease,<br />
and perhaps, his motivation for wellness.<br />
Q. Does CRPS cause emotional problems?<br />
DR. COVINGTON There are studies of CRPS in which most<br />
CRPS patients were contemplating suicide and there are<br />
contrasting studies in which researchers were surprised to find<br />
that most CRPS patients were indifferent and happy. Such<br />
extreme differences in reports are hard to interpret. We do<br />
know that some people with CRPS are depressed, irritable,<br />
tense, and anxious, some will abuse substances, some will get in<br />
trouble with analgesics, some will feel suicidal, some will<br />
become withdrawn—and some won’t.<br />
Q. Is there an association between CRPS and<br />
depression?<br />
DR. COVINGTON Yes. In a 1988 study, Rudy, Kerns, and Turk<br />
confirmed that chronic pain is associated with depression (2). It<br />
was also associated with interference with life; i.e., many people<br />
with chronic pain had ceased such activities as socializing, going<br />
to films, having sex, playing with their kids—the things in life<br />
that gave them joy. These losses were associated with depression.<br />
Also it was common for people with chronic pain to come<br />
to see themselves as helpless and trapped and to feel unable to<br />
do anything about their lives. Those feelings are all associated<br />
(Continued on page 47)<br />
We do know that some people with CRPS are depressed,<br />
irritable, tense, and anxious, some will abuse substances,<br />
some will get in trouble with analgesics, some will feel<br />
suicidal, some will become withdrawn—and some won’t.<br />
42 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
CENTER SPREAD
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with depression. However, they found that when they controlled<br />
for interference and ‘self-control,’ pain was no longer<br />
associated with depression.<br />
This was an epiphany for me because in years of working in<br />
a chronic pain rehabilitation program, I had often been surprised<br />
that some of the most grateful patients were ones who<br />
had little or no pain relief. When I’d seek an explanation for<br />
why they were satisfied with a treatment that seemed to have<br />
failed, they’d reply with such statements as, ‘Yes, but now I have<br />
my life back!’<br />
What this tell us is that if we can help people with pain to<br />
regain the things in life that bring them joy, and can help them<br />
regain a sense of empowerment and control over their lives,<br />
then it may be possible for them to have a good quality of<br />
life—a life with pleasure and freedom from depression, despite<br />
persistent pain. This is an especially critical issue because of the<br />
fact that chronic pain, while often helped, is rarely cured.<br />
Q. If a person with CRPS is extremely upset, can that<br />
affect the disease?<br />
DR. COVINGTON It is clear that psychic factors can modulate<br />
the disease. There are several studies that show that people had<br />
marked stress at the time they developed CRPS. And we know<br />
that autonomic arousal stimulates catecholamine release, so if a<br />
person with CRPS becomes frightened, angry, has an orgasm—<br />
anything that causes emotional arousal—it can cause a pain<br />
discharge at the same time.<br />
Q. What is the relationship between pain and activity<br />
in people with CRPS?<br />
DR. COVINGTON In a 1969 study, a researcher found that many<br />
of the trophic sequelae (i.e., claw hand, ridge fingers, and skin<br />
changes) were due to prolonged disuse occasioned by pain.<br />
He claimed that these changes developed in people who were<br />
poorly motivated to get well—who were unwilling to overcome<br />
the stiffness that follows immobilization after trauma. So basically,<br />
he said that people get CRPS because they’re not exercising<br />
enough—that getting the disease was their own fault.<br />
While I dispute the idea that getting the disease was their<br />
fault, we do know that responses to pain range from normal<br />
function to invalidism. And we do know from a number of<br />
studies that simple disuse, overprotection, and immobilization<br />
will create many characteristics that resemble CRPS (including<br />
bony demineralization, vasomotor changes, and swelling). A<br />
very old study of 142 patients found that exercise alone caused<br />
reversal of edema, trophic changes, and vasomotor signs (3).<br />
This was a study of young people, and young people do get<br />
well much more often than adults do.<br />
So the fact that disuse and immobilization produce signs<br />
similar to CRPS, together with the fact that use and exercise<br />
can eliminate some of the signs of CRPS, suggests that behaviors<br />
are likely to play a major role in the extent to which this<br />
We don’t have a good<br />
understanding of exactly<br />
what CRPS is and why<br />
some people get it<br />
and others don’t.<br />
disease progresses or improves. I doubt that it’s the only factor,<br />
but it strongly suggests that what patients do in response to the<br />
disease may strongly impact outcome.<br />
COGNITION<br />
Q. Wh at affect does cognition (what a person thinks)<br />
have on the disease?<br />
DR. COVINGTON What patients think can disable them. Misunderstandings<br />
and misinformation can lead to inactivity. A person<br />
may fear spinal range of motion because the associated pain<br />
could presage paraplegia or incontinence. The cognition thus<br />
leads to inactivity which leads to deconditioning. A cycle of<br />
escalating pain and disability ensues. Fitness and education can<br />
be curative. And with CRPS, you often see people who seem to<br />
be more disabled than they ought to be. This disability may<br />
appear psychiatric when actually it’s a lack of information or<br />
misinformation—a knowledge deficit. When people are<br />
informed about what they can do safely, they will sometimes<br />
get well, at times with no help from health care providers.<br />
Q. What are some beliefs that can make a person sick?<br />
DR. COVINGTON Several studies have shown that a belief that<br />
pain is mysterious and unexplained, or that it connotes body<br />
damage will increase suffering and dysfunction, even when the<br />
beliefs are false. If a person sees himself as helpless and fragile, of<br />
if he sees the world as indifferent, hostile, and without opportunity—such<br />
beliefs can increase the person’s level of disability.<br />
The concept of ‘locus of control’ is an important focus of<br />
work with people in pain. An internal locus of control is characteristic<br />
of those who see themselves as ‘the captains of their<br />
ships.’ They tend to be ‘take charge’ or executive types. A<br />
patient with this attitude is much more likely to do well than<br />
one who attributes events to fate or to powerful other people.<br />
Those with an external locus of control are likely to take a<br />
passive (and therefore ineffective) approach to dealing with<br />
pain, since they think their efforts are futile. In our rehabilitation<br />
program we even go to the point of encouraging certain<br />
patients to wear sweatshirts that say ‘CEO’ to remind them that<br />
they are the CEOs of their lives as they learn to manage pain.<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 47
INTERVIEW | COVINGTON<br />
The sine qua non of good<br />
pain treatment is reconditioning.<br />
I can’t say enough<br />
good things about helping<br />
people to get fit.<br />
The concept of learned helplessness builds on the same<br />
theme. Those taught by bitter experience that they are powerless<br />
to change their plight are likely to give up and risk becoming<br />
depressed, resigned, and passive. The bottom line is that<br />
those who see themselves as capable are likely to do a lot to try<br />
to cope with pain.<br />
Q. In terms of getting better, how do people with an<br />
external locus of control fare compared to those with<br />
an internal locus of control?<br />
DR. COVINGTON ‘Fault and blame’ are potentially very toxic to<br />
patients in pain. Doug DeGood reported a nice study of this<br />
subject (4). Patients were asked to respond to a number of questions<br />
about their pain, several of which dealt with the issue of<br />
who was to blame for the pain. It was found that patients who<br />
blamed their pain on others were more likely to be depressed,<br />
more behaviorally aberrant, more likely to have failed treatment,<br />
and more pessimistic about the benefit of future treatment.<br />
Those who did not blame others, who said ‘things happen,’<br />
seemed to do better.<br />
This concept suggests a slogan from Alcoholics Anonymous:<br />
‘Holding onto resentments is like drinking poison and<br />
waiting for your enemy to get sick.’ Clinically, we see people<br />
who are absolutely stuck and destroyed by the grudges they’re<br />
holding. Although doing so is a challenge, at some point, they<br />
must relinquish the focus on the person who ‘did them dirty,’<br />
and start focusing on the question, ‘How can I have a good life?’<br />
OPERANT CONDITIONING<br />
Q. What role does operant conditioning play in people<br />
with CRPS?<br />
DR. COVINGTON All animals tend to repeat behaviors that are<br />
rewarded, and to reduce behaviors that are not. Imagine a world<br />
in which that was not true. Animals would fail to return to the<br />
place where they found water and food, and would fail to avoid<br />
the place where they’d been attacked. Survival is contingent on<br />
being programmed to repeat behaviors that are rewarded.<br />
Unfortunately, behavior is often influenced more powerfully<br />
by what is immediate than by what is important. Thus, we<br />
are all at risk of behaving self-destructively in response to<br />
reinforcers. This is why ‘buy now, pay later’ is so seductive.<br />
Many behaviors that would promote recovery are unpleasant at<br />
first. Conversely, many things that are very pleasant at first can<br />
make you sick. For example, almost every back patient would<br />
feel better if he simply went to bed. But after a few weeks of<br />
this, some ‘strenuous’ activity such as tying shoelaces will cause<br />
pain and send the person back to bed. Thus the rest, which<br />
causes initial relief, leads ultimately to more pain and less function.<br />
Therefore it is essential for people in chronic pain to<br />
consider the long term effects of their choices, as opposed to<br />
focusing only on what helps immediately.<br />
Q. For people with CRPS and other chronic diseases<br />
there are sometimes secondary gains. Would you talk<br />
about these?<br />
DR. COVINGTON ‘Secondary gains’ are the good things that<br />
happen when one is sick—security, increased attention, nurture,<br />
medications that relieve pain. But there are tremendous<br />
‘secondary losses’ associated with chronic pain as well. You can<br />
lose the pride of being the bread winner, the camaraderie of<br />
co-workers, and a sense of identity. Financial compensation is<br />
often thought of when the term secondary gain is used, and in<br />
fact, many chronic pain patients do receive money as a result of<br />
becoming disabled; however, most remain poor. They have a<br />
steady but meager source of income, and little hope of more in<br />
the future, because there won’t be any raises. Nevertheless, the<br />
‘gains’ of illness can certainly reduce patients’ efforts to recover,<br />
especially if there are few gains to be had for being well.<br />
PSYCHOLOGICAL TREATMENTS<br />
Q. What are some proven psychological treatments<br />
for CRPS?<br />
DR. COVINGTON There are several. Probably the most important<br />
“psychological treatment” is physical therapy. I list it as a<br />
“psychological” treatment because it not only helps patients<br />
become strong enough to resume activities that used to give<br />
them pleasure, it also changes the way they see themselves. It<br />
helps them feel powerful and less fragile, and it reduces depression<br />
and anxiety. The sine qua non of good pain treatment is<br />
reconditioning. I can’t say enough good things about helping<br />
people to get fit.<br />
Cognitive therapies, helping people reinterpret their situations<br />
and their pain in ways that facilitate coping, have been<br />
shown to improve pain and function in a number of painful<br />
conditions.<br />
Another treatment is psychophysiologic training. Often<br />
this involves biofeedback equipment, which measures muscle<br />
tension, hand temperature, palmar sweating, and so on. It<br />
teaches people to relax muscles and reduce sympathetic arousal.<br />
It helps people feel they have some power over their bodies,<br />
instead of their bodies having power over them, and it helps<br />
them understand the effects of emotions on pain.<br />
48 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
It is common for patients in pain initially to reject psychological<br />
therapies with a retort such as, ‘What does my boss have<br />
to do with my back ache?’ I may not have an answer to that;<br />
however, when we hook a patient up in the biofeedback lab,<br />
and he talks about his boss, and the equipment shows various<br />
indicators of autonomic arousal and muscle tension, he very<br />
quickly understands that stress is affecting his body functions.<br />
This often ‘snares’ a person into the work of examining the role<br />
of life stresses in their pain, emotional distress, and function. It<br />
also helps patients learn to calm themselves without a pill.<br />
Hypnosis is another useful treatment. It helps people learn<br />
to control body functions they normally can’t control. In<br />
CRPS, hypnosis changes pain and circulation. It reduces autonomic<br />
arousal, which reduces sympathetically maintained pain.<br />
Patients must learn—and practice—self hypnosis for continued<br />
benefit. Functional brain imaging has demonstrated that hypnosis<br />
can reduce both physical and emotional pain responses in<br />
the brain cortex, so that the effects of this psychological treatment<br />
are clearly physical.<br />
Psychotherapy is indicated when people are psychologically<br />
troubled, when it is needed to facilitate behavioral changes,<br />
and to help ‘jump start’ people when there is a psychogenic<br />
component to their disability. The most common type with<br />
pain patients is cognitive behavioral therapy—a cognitive<br />
restructuring.<br />
In other instances, support groups can be helpful. Pain<br />
patients can be remarkably helpful to each other, and often help<br />
each other find ways out of dilemmas that seemed insoluble.<br />
People can help each other if there is a caring, trusting environment<br />
established, and sometimes this can happen without a lot<br />
of professional input.<br />
At our clinic we insist on family education and therapy. In<br />
part this is because an entire family can be adversely affected by<br />
an illness, and in part it is to teach the family how to maintain an<br />
environment that promotes wellness rather than regression. This<br />
often means teaching them when not to provide care and sympathy.<br />
Families often have pent-up anger because of the effects of<br />
another’s chronic pain on their lives, and this can poison the<br />
Many behaviors that<br />
would promote recovery<br />
are unpleasant at first.<br />
Conversely, many things<br />
that are very pleasant at<br />
first can make you sick.<br />
relationship and the patient’s attempt at recovery. It is important<br />
to address this in order for everyone in the family to feel better.<br />
Behavior Modification (contingency management) improves<br />
function, helps people be distracted from pain, normalizes<br />
mood, and improves quality of life. It is important to consistently<br />
reinforce well behaviors and not illness behaviors. People<br />
often mistakenly think that behavior modification means ignoring<br />
a person with pain, which is clearly counterproductive. You<br />
don’t ignore the person, you ignore the maladaptive behavior.<br />
You spend more time and pay more attention, but you try to be<br />
a friend, a companion, a playmate, or a lover—not a nurse.<br />
Q. You run a multidisciplinary pain management clinic.<br />
What is the value of a multidisciplinary approach?<br />
DR. COVINGTON This is a mystery in some ways. Programs of<br />
this sort typically treat patients who have failed to receive lasting<br />
benefit from medications, physical therapy, psychological<br />
therapies, and a plethora of other interventions. Yet, when they<br />
are treated in a holistic manner that combines behavioral, medical,<br />
and rehabilitation approaches, they may ‘blossom’ and feel<br />
that they have truly recovered their lost selves. They begin to<br />
play, to laugh, to function sexually, and often to earn an<br />
income. I suspect that it is the simultaneous use of these disciplines<br />
in an appropriate environment that helps get patients<br />
started on a path to recovery that was not achieved with many<br />
of these techniques in isolation.<br />
REFERENCES<br />
1. Ciccone DS, et al. Psychological dysfunction in patients with reflex<br />
sympathetic dystrophy. Pain. 1997 Jul;71(3):33-33.<br />
2. Rudy TE, Kerns RD, Turk DC. Chronic pain and depression: toward a<br />
cognitive-behavioral mediation model. Pain. 1988 Nov;35(2):129-40.<br />
3. Shumacker HB, Abramson DI, Posttraumatic vasomotor disorders, Surg<br />
Gynecol Obstet 88 (1949):417-434.<br />
4. DeGood DE, Kiernan B: Perception of fault in patients with chronic pain.<br />
Pain. 1996;64(1):153-9.<br />
EDWARD COVINGTON, MD<br />
is Director of the Chronic Pain<br />
Rehabilitation Program at the<br />
Cleveland Clinic Foundation<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 49
FEATURE | SHERRY<br />
WHENCHILDREN<br />
HURTTOOMUCH<br />
Diagnosis and Treatment of Amplified Musculoskeletal Pain<br />
BY DAVID D. SHERRY, MD<br />
50 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
There are multiple forms of amplified musculoskeletal<br />
pain (chronic musculoskeletal pain out of proportion<br />
to the known stimulus) in children, ranging from<br />
Complex Regional Pain Syndrome (CRPS) in one limb<br />
to total body pain. The cause is unknown but may be<br />
related to trauma, illness, or psychological stress, and<br />
the incidence seems to be increasing.<br />
THERE IS A TYPICAL PRESENTATION, mostly among adolescent<br />
girls with allodynia, marked pain and dysfunction<br />
disproportionate to the known stimulus, and an<br />
incongruent affect. Con<strong>version</strong> symptoms are not<br />
uncommon. The treatment is intense exercise therapy<br />
focused on function, desensitization, and attention to<br />
concurrent conditions (psychological, mechanical,<br />
inflammatory). The outcomes are very good, with virtually<br />
all patients regaining full function and between 80 - 90%<br />
resolving all pain. These conditions present some of the greatest<br />
challenges in pediatrics but are also the most rewarding to treat<br />
because the child goes from being highly disabled to normal.<br />
Case Presentation<br />
BETTY WAS AN ATTRACTIVE, bright, athletic 14-year-old girl<br />
who stepped on a rock at the bottom of a swimming pool and<br />
hurt her right foot. The skin was not broken, but over the next<br />
two days her foot became progressively more painful, swollen,<br />
blue, and cool to the touch. In the emergency department a<br />
radiograph was normal and a splint was applied. Betty required<br />
crutches and developed marked tenderness to touch. She was<br />
put in a cast, but the cast caused so much pain that it had to be<br />
removed the next day. The pain spread to include her entire<br />
right leg and also the left foot (although she could bear weight<br />
on that side), and to both hands (presumably from using<br />
crutches). She was unable to move her right foot, or her toes,<br />
which occasionally went numb (although they still hurt). Today,<br />
she hurts too much to wash or shave her right leg. She cannot<br />
attend school, because she is fearful that the leg might get<br />
bumped, and she is unable to concentrate because of the intensity<br />
of her pain. She cannot sleep well and when she does sleep,<br />
she wakes frequently with pain. The pain in her right foot is<br />
greater than 10 out of 10, and her hands and left foot hurt 10<br />
out of 10. The pain has taken over her life and the life of her<br />
family. She has seen multiple healthcare practitioners, has had<br />
numerous tests (all of which are normal), and has either failed<br />
to respond or has developed unacceptable side effects from a<br />
host of medications, treatments, and blocks.<br />
Betty’s symptoms are not unusual for a child with amplified<br />
musculoskeletal pain. There are multiple forms, usually defined<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 51
FEATURE | SHERRY<br />
TABLE 1 | The Yunus & Masi Criteria<br />
for Fibromyalgia in Children (4)<br />
Major:<br />
___________________________________<br />
❥ Generalized musculoskeletal<br />
aching at 3 or more sites<br />
for 3 or more months<br />
❥ Absence of underlying<br />
condition or cause<br />
❥ Normal laboratory tests<br />
❥ Five or more typical<br />
tender points<br />
Minor:<br />
____________________________________________________________________<br />
❥ Chronic anxiety<br />
❥ Numbness<br />
or tension<br />
❥ Fatigue<br />
❥ Poor sleep<br />
❥ Chronic headaches<br />
❥ Irritable bowel syndrome<br />
❥ Subjective soft tissue<br />
swelling<br />
Fibromyalgia defined as present if the subject has:<br />
_______________________________________________________________________________________________________________<br />
❥ All 4 major criteria and 3 minor criteria OR<br />
❥ First 3 major criteria, 4 tender points, and 5 minor criteria.<br />
by the location or presence of autonomic dysfunction. Children<br />
with amplified musculoskeletal pain fall into two broad categories:<br />
those with localized pain and those with diffuse pain (1).<br />
The most easily recognized type of localized pain is CRPS.<br />
Children with CRPS have overt autonomic dysfunction that is<br />
manifested by coolness or cyanosis of the limb and, occasionally,<br />
increased perspiration or edema. Additionally, many, if not<br />
most, of these children have localized pain amplification without<br />
autonomic signs (e.g., cold, blue). In studies of children<br />
with diffuse pain, fibromyalgia receives the most attention<br />
(although this term is not often used in conjunction with children<br />
since it may differ from adult fibromyalgia). Two sets of<br />
criteria for childhood fibromyalgia have been established. The<br />
American College of Rheumatology criteria require 11 of 18<br />
trigger points on the body to be painful along with three<br />
months of widespread pain (3). The criteria of Yunus and Masi<br />
require either four or five painful trigger points and multiple<br />
related symptoms (see Table 1) (4). Determining whether trigger<br />
points are painful or not is highly subjective. Most children<br />
will identify these points as tender or sore, and not painful as<br />
required by the definition. Not all children with diffuse pain<br />
have painful trigger points, so some do not satisfy the criteria<br />
for fibromyalgia. Additionally, there are children with intermittent<br />
localized or diffuse pains, or overlapping features of the<br />
above, e.g., a cool, blue foot and total body pain.<br />
Children with amplified musculoskeletal pain are more disabled<br />
than those with arthritis or with mechanical joint problems,<br />
and they and their families suffer intensely. In addition to<br />
their pain, these children often experience isolation from peers<br />
and are commonly told by medical professionals that they are<br />
“faking it” or that “it shouldn’t hurt all that much.” This does<br />
a great disservice to these children and their families.<br />
Epidemiology<br />
THERE ARE NO SPECIFIC STUDIES of the<br />
incidence of childhood amplified musculoskeletal<br />
pain. Studies of normal schoolchildren<br />
have found that 1.2% to 6%<br />
fulfill criteria for fibromyalgia and up to<br />
7.5% report widespread musculoskeletal<br />
pain. Children with amplified musculoskeletal<br />
pain comprise approximately<br />
10% of children in pediatric rheumatic<br />
disease clinics, and it is the impression of<br />
many clinicians that the incidence is<br />
increasing (5 - 7).<br />
The average age of onset of amplified<br />
musculoskeletal pain is preteen to early<br />
teen. Amplified musculoskeletal pain is<br />
rare below the age of six years, so diagnosing<br />
it in young children needs to be done<br />
with much circumspection; however, children<br />
as young as two years old have developed it. The majority<br />
of these children are female (80% in most series), perhaps<br />
because females have lower pain thresholds and report pain<br />
more frequently than males.<br />
Most children with amplified musculo skeletal pain are<br />
Caucasian. There is a suspicion that the majority are from<br />
upper socioeconomic levels; however, no race or economic<br />
level is spared.<br />
❥ Pain modulation by<br />
physical activities<br />
❥ Pain modulation<br />
by weather factors<br />
❥ Pain modulation<br />
by anxiety/stress<br />
Etiology<br />
THE ETIOLOGY OF AMPLIFIED MUSCULOSKELETAL PAIN is<br />
unknown, but it usually can be related to trauma, illness, or<br />
psychological distress. Most pediatric rheumatologists think the<br />
latter plays a significant role in most, but not all, children.<br />
Whether cause or effect, the pain and dysfunction experienced<br />
by most of these children is such that it inflicts psychological<br />
havoc on both child and family. Genetic factors have been<br />
implicated in fibromyalgia and CRPS, and a very weak association<br />
has been made between fibromyalgia and increased flexibility.<br />
It is likely that there is a combination of both intrinsic<br />
factors (such as individual pain threshold, gender, and coping<br />
strategies) and extrinsic factors (such as previous pain experiences,<br />
social stresses, modeling of chronic pain behaviors, and<br />
central and peripheral pain mechanisms) that work together to<br />
give rise to amplified musculoskeletal pain (8).<br />
Clinical Manifestations and Diagnosis<br />
ALTHOUGH EACH CHILD IS UNIQUE, there are enough significant<br />
similarities in the history and physical examination to<br />
establish the pattern for most. The typical patient is a mature<br />
and accomplished adolescent girl who suffers a minor injury or<br />
illness and then has increasing pain and dysfunction over several<br />
days to months. The pain may be localized, with or without<br />
signs of autonomic dysfunction, or it may be diffuse.<br />
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FEATURE | SHERRY<br />
Not uncommonly it begins as a localized pain and spreads.<br />
Allodynia (tenderness to a normally nonpainful stimulus) is<br />
common. Clothing, bumps while riding in the car, and even<br />
the wind against bare skin will cause pain. Some children, usually<br />
those with diffuse pain, will have multiple bodily complaints,<br />
which help define fibromyalgia by the Yunus and Masi<br />
criteria (see Table 1). These children typically report very high<br />
levels of pain (10 out of 10) with an incongruently cheerful<br />
affect, and severe dysfunction. They present themselves as<br />
mature and accomplished teens who are perfectionistic, and<br />
who meet the emotional needs of their peers and others rather<br />
than their own. They are severely incapacitated, much more<br />
than children with arthritis or mechanical limb pain, and multiple<br />
physician visits and therapeutic failures are common.<br />
Autonomic signs seen in CRPS usually consist of coolness<br />
and cyanosis. These signs may not be apparent at rest but may<br />
develop after exercising the limb. Occasionally there is increased<br />
perspiration or dystrophic skin.<br />
Allodynia is tested by either light touch or gentle pinching<br />
of a fold of skin. The area of allodynia may vary in location on<br />
repeated testing.<br />
Painful trigger points can be found in those with fibromyalgia.<br />
These points are reported as painful, not tender or sore,<br />
with 3-4 kilograms of digital pressure. These points are: base of<br />
occiput, lateral transverse process of C6, mid superior border of<br />
the trapezius muscle, medial border of the scapula, just superior<br />
to the spine of the scapula, superior anterior border of the<br />
medial 2nd rib, 1 cm distal to the lateral epicondyle, mid gluteal<br />
fold, 1 cm posterior to the greater trochanter, and 1 cm proximal<br />
to the medical knee mortise (3). Control points should also<br />
be tested, such as the forehead, thumbnail, shaft of the tibia, and<br />
outer third of the clavicle (9). Those with painful control points<br />
are, perhaps, better described as having total body pain.<br />
Con<strong>version</strong> symptoms are fairly common and include<br />
numbness, bizarre gait, paralysis, or abnormal shaking or<br />
tremors. Dizziness is a common complaint, but vestibular function<br />
tests are normal (10).<br />
Laboratory Tests<br />
ALL LABORATORY BLOOD AND URINE TESTS ARE NORMAL.<br />
Radiographs may show osteoporosis, and a bone scan is usually<br />
normal although it can show decreased uptake, especially in<br />
CRPS (or spotty increased uptake characteristic of adult CRPS)<br />
(11). Magnetic resonance images can show edema, but the<br />
anatomy is otherwise normal.<br />
Diagnostic Pitfalls<br />
CHILDREN THOUGHT TO HAVE AMPLIFIED MUSCULOSKELETAL<br />
PAIN should have a careful evaluation for other causes. The<br />
most common diagnosis I make in these children is spondyloarthropathy,<br />
since enthesitis (inflammation at the insertion<br />
of tendon and ligament into bone) is not a feature most<br />
These conditions present<br />
some of the greatest<br />
challenges in pediatrics<br />
but are also the most<br />
rewarding to treat<br />
because the child goes<br />
from being highly<br />
disabled to normal.<br />
practitioners check for. Malignancies, usually spinal cord<br />
tumors, are the most serious condition one can miss, so a<br />
detailed neurological examination is mandatory. Arthritis has<br />
been mistaken rarely for amplified musculoskeletal pain, but<br />
it is usually obvious on examination. Rarely will undetected<br />
thyroid disease in children be manifest as diffuse pain.<br />
Disease Activity<br />
INITIALLY AND DURING FOLLOW-UP there needs to be ongoing<br />
assessment of pain and dysfunction. Self-report, such as a mark<br />
on a visual analog scale or a rating of 0 - 10 on a verbal scale, is<br />
adequate to measure pain. Functional measures can be elaborate<br />
(such as standardized age-appropriate questionnaires) but, in<br />
practice, asking about school attendance, walking endurance,<br />
chores, and participation in recreational activities is sufficient.<br />
Treatment<br />
INITIALLY, IT IS PARAMOUNT to establish a trusting relationship<br />
with the child and family. You have to believe that the child is<br />
in pain since that child has been given both verbal and nonverbal<br />
messages that the pain is all in his or her head or that he or<br />
she is malingering. I have found it extremely useful to explain<br />
the pain in terms of sympathetically mediated pain amplification;<br />
this approach reinforces the reality of the pain, gives an<br />
understandable reason for the pain, and is a mechanism with<br />
which to introduce the treatment strategy (12).<br />
“Further medical investigation is unnecessary, even if the<br />
family is convinced that an insidious diagnosis has been overlooked<br />
or that a test (even if done previously and was normal)<br />
will establish a diagnosis.<br />
All medications for pain need to be discontinued. Children<br />
who are on medications for depression or anxiety disorders may<br />
need to continue their use, but those treated with antidepressants<br />
for pain reduction alone should stop taking the drugs.<br />
Several of the medications used for pain will need to be tapered,<br />
54 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
especially opioids. Opioids should be tapered about 10% per<br />
day and, depending on the dose, gabapentin should be tapered<br />
over two to three weeks. Tramadol binds to opioid receptors;<br />
therefore, those children on a high dose of this medication<br />
should have it tapered.<br />
There are no controlled studies of the vast number of treatments<br />
reported in the literature for the various forms of amplified<br />
musculoskeletal pain. Treatments are legion and include<br />
pain medications, antidepressants, gabapentin, transcutaneous<br />
nerve stimulation, nerve blocks and sympathectomy (for<br />
CRPS), epidural catheters for continuous drug infusion, pain<br />
pumps, lidocaine and opioid patches, acupuncture, massage,<br />
cognitive-behavior therapy, psychotherapy, and exercise therapy.<br />
Most authors agree that exercise therapy is helpful in<br />
achieving the best long-term outcomes in all forms of amplified<br />
musculoskeletal pain. I have found it to be the most helpful<br />
with the longest-lasting results (13, 14). The nature of the exercise<br />
therapy, however, is different from what physical and occupational<br />
therapists are accustomed to (15). The primary goal of<br />
the program we use is to restore function, so the exercise program<br />
is very intense and directed at doing normal and aerobic<br />
activities (such as jumping, climbing stairs, building walking<br />
speed and endurance, performing sports drills, and carrying<br />
loads). Pain is not directly treated and is ignored as much as<br />
possible during the exercise sessions. The vast majority will<br />
gradually resolve all pain once full function has been restored.<br />
Allodynia is treated by desensitization with rubbing, vibration,<br />
and applying textures to the skin.<br />
Some children can and do carry on this exercise program on<br />
their own at home once they realize that even though exercising<br />
hurts, it is not damaging and is, in fact, going to make them<br />
better. For most children, however, the pain is too great for<br />
them to exercise at home, so they need to come into the office<br />
to participate in our program. We give them five hours of exercise<br />
therapy daily for an average of three weeks. Most children<br />
will also have improvement in their mood, sleep, and energy<br />
level, and relief from other somatic complaints once they start<br />
this intensive exercise program.<br />
In addition to exercise therapy, the psychodynamics of<br />
the child and family should be evaluated, since most families<br />
and children will have significant psychological difficulties.<br />
These may require individual, family, or marital therapy (or a<br />
combination of these therapies) (16, 17).<br />
Good sleep hygiene is helpful and should be mentioned<br />
even though fixing the sleep problems does not resolve the<br />
somatic symptoms. Frequently children with amplified musculoskeletal<br />
pain have a sleep complaint (not a true sleep disorder)<br />
and having a good night sleep is helpful. This includes going to<br />
bed only when one is sleepy, not reading or watching television<br />
while in bed, eliminating caffeine, practicing relaxation techniques,<br />
eliminating napping, and having a routine for sleeping<br />
and waking on weekdays and weekends.<br />
Complementary treatments are frequently sought, but there<br />
are no data regarding benefit. These treatments include herbal<br />
therapy, massage, magnet therapy, homeopathy, reflexology,<br />
aromatherapy, to name a few, but only rarely is any sustained<br />
benefit reported. We cannot recommend any of these treatments<br />
and, as with allopathic medications, we discontinue<br />
them once the diagnosis is made.<br />
Outcomes<br />
MOST CHILDREN DO WELL with the described treatment<br />
approach. The outcome may vary, depending on the form of<br />
amplified musculoskeletal pain; however, long-term studies in<br />
children are rare. Most children with CRPS (92% of 103 children<br />
studied) who were treated with an intense exercise program<br />
resolved all signs and symptoms and 88% were well after<br />
five years (14). Less than half of 70 children with CRPS who<br />
were treated with drugs, blocks, and moderate exercise resolved<br />
all symptoms; no long-term outcomes were reported (18).<br />
TABLE 2 | Key Points in the Recognition<br />
and Treatment of Amplified<br />
Musculoskeletal Pain in Children<br />
1<br />
There is a high index of suspicion<br />
for the presence of amplified<br />
musculoskeletal pain in patients<br />
with these characteristics or<br />
manifestations:<br />
❥ Adolescent female<br />
❥ Mature beyond years<br />
❥ Accomplished<br />
❥ Perfectionistic<br />
❥ Anxious to please<br />
❥ Prolonged school absence due to<br />
pain<br />
❥ Marked dysfunction<br />
❥ Worsening of pain over time<br />
❥ Normal examination except pain<br />
❥ No enthesitis or arthritis<br />
❥ Normal neurological exam<br />
❥ Localized pain on examination<br />
❥ Allodynia<br />
❥ Autonomic signs<br />
❥ Incongruent affect<br />
❥ La belle indifference<br />
❥ Widespread pain on examination<br />
❥ Multiple painful points<br />
❥ Normal laboratory studies<br />
❥ Failure of all prior therapies<br />
2<br />
Once an amplified musculoskeletal<br />
pain is recognized:<br />
❥ Acknowledge the pain<br />
❥ Explain that it is amplified,<br />
and not indicative of<br />
underlying damage or disease<br />
❥ Stop further medical investigations<br />
❥ Stop medications as appropriate<br />
❥ Restore function<br />
❥ Prescribe aerobic exercise, up to<br />
5 hours daily of intense therapy<br />
focused on functional activities<br />
and continuing for 2-4 weeks<br />
❥ If allodynia is present, desensitize<br />
with tactile stimulation<br />
❥ Advise child to resume full-time<br />
school attendance<br />
❥ Advise child to resume social<br />
and recreational activities<br />
❥ Evaluate the psychological<br />
dynamics and treat if appropriate<br />
❥ Anticipate total resolution<br />
of symptoms<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 55
FEATURE | SHERRY<br />
Children with diffuse pain or fibromyalgia may have more<br />
long-term pain, depending on the treatment and study (17,<br />
19). However, 11 of 15 school children identified on screening<br />
to have fibromyalgia resolved their fibromyalgia after 30<br />
months (20). It is important to realize that these children were<br />
not seeking medical help when diagnosed. Cognitive-behavior<br />
therapy alone was employed in five girls with fibromyalgia, and<br />
four reported no pain 10 months later (21).<br />
Children with amplified musculoskeletal pain may develop<br />
other bodily pains such as headache and abdominal pain (8). In<br />
the children we have followed, unresolved psychological issues<br />
contributed to nonpainful poor outcomes such as con<strong>version</strong><br />
reactions, eating disorders, school avoidance, suicide attempts,<br />
and acting out behaviors.<br />
Summary<br />
AMPLIFIED MUSCULOSKELETAL PAIN IN CHILDREN may vary<br />
from localized CRPS to widespread, total body pain. Children<br />
with amplified musculoskeletal pain all suffer significant pain<br />
and disability and need compassionate care that should include<br />
a timely and accurate diagnosis, explanation of the possible<br />
causes of pain, and an effective therapeutic approach (see Table<br />
2). The diagnosis involves excluding conditions that can cause<br />
pain and by the typical pattern manifest in most with amplified<br />
musculoskeletal pain. The psychological aspects involved should<br />
be formally assessed in all children. Intense exercise therapy<br />
along with desensitization is the treatment of choice and of<br />
great benefit to most. Normal function, at a minimum, should<br />
be restored, and reflected in school attendance and social and<br />
sports activities. In those in whom the pain continues, cognitive-behavior<br />
therapy or more formal psychotherapy should be<br />
pursued. Pharmacological agents should be limited to specific<br />
indications, not pain. Children with amplified musculoskeletal<br />
pain and their families challenge one’s diagnostic and therapeutic<br />
skills, but the outcome is rewarding. Rarely can we so significantly<br />
alter the course of a condition that renders children<br />
completely debilitated as we can in those who suffer with<br />
amplified musculoskeletal pain.<br />
6. Malleson, P.N., M.Y. Fung, and A.M. Rosenberg, The incidence of pediatric<br />
rheumatic diseases: results from the Canadian Pediatric Rheumatology Association<br />
Disease Registry. Journal of Rheumatology, 1996. 23(11): p. 1981-7.<br />
7. Manners, P.J., Epidemiology of the rheumatic diseases of childhood. Current<br />
Rheumatology Reports, 2003. 5(6): p. 453-7.<br />
8. Sherry, D.D., Pain Syndromes, in Adolescent Rheumatology, D.A. Isenberg<br />
and J.J.I. Miller, Editors. 1998, Martin Dunitz Ltd: London. p. 197-227.<br />
9. Okifuji, A., et al., A standardized manual tender point survey. I. Development<br />
and determination of a threshold point for the identification of positive<br />
tender points in fibromyalgia syndrome. Journal of Rheumatology,<br />
1997. 24(2): p. 377-83.<br />
10. Rusy, L.M., S.A. Harvey, and D.J. Beste, Pediatric fibromyalgia and dizziness:<br />
evaluation of vestibular function. Journal of Developmental &<br />
Behavioral Pediatrics, 1999. 20(4): p. 211-5.<br />
11. Laxer, R.M., et al., Technetium 99m-methylene diphosphonate bone scans<br />
in children with reflex neurovascular dystrophy. Journal of Pediatrics,<br />
1985. 106(3): p. 437-40.<br />
12. Sherry, D.D., An overview of amplified musculoskeletal pain syndromes.<br />
Journal of Rheumatology Supplement, 2000. 58: p. 44-8.<br />
13. Sherry, D.D., et al., Psychosomatic musculoskeletal pain in childhood: clinical<br />
and psychological analyses of 100 children. Pediatrics, 1991. 88(6):<br />
p. 1093-9.<br />
14. Sherry, D.D., et al., Short- and long-term outcomes of children with complex<br />
regional pain syndrome type I treated with exercise therapy. Clinical<br />
Journal of Pain, 1999. 15(3): p. 218-23.<br />
15. Sherry DD, executive producer. Amplified Musculoskeletal Pain in Childhood.<br />
Diagnosis and Treatment. A Guide for Physical and Occupational<br />
Therapists. (Videotape, DVD) MMII, www.childhoodrnd.org<br />
16. Sherry, D.D. and R. Weisman, Psychologic aspects of childhood reflex neurovascular<br />
dystrophy. Pediatrics, 1988. 81(4): p. 572-8.<br />
17. Sherry, D.D. and P.N. Malleson, The idiopathic musculoskeletal pain syndromes<br />
in childhood. Rheumatic Diseases Clinics of North America, 2002.<br />
28(3): p. 669-85.<br />
18. Wilder, R.T., et al., <strong>Reflex</strong> sympathetic dystrophy in children. Clinical characteristics<br />
and follow-up of seventy patients. Journal of Bone & Joint Surgery<br />
American, 1992. 74(6): p. 910-9.<br />
19. Siegel, D.M., D. Janeway, and J. Baum, Fibromyalgia syndrome in children<br />
and adolescents: clinical features at presentation and status at follow-up.<br />
Pediatrics, 1998. 101(3 Pt 1): p. 377-82.<br />
20. Buskila, D., et al., Fibromyalgia syndrome in children—an outcome study.<br />
Journal of Rheumatology, 1995. 22(3): p. 525-8.<br />
21. Walco, G.A. and N.T. Ilowite, Cognitive-behavioral intervention for juvenile<br />
primary fibromyalgia syndrome. Journal of Rheumatology, 1992.<br />
19(10): p. 1617-9.<br />
REFERENCES<br />
1. Malleson, P.N., M. al-Matar, and R.E. Petty, Idiopathic musculoskeletal<br />
pain syndromes in children. Journal of Rheumatology, 1992. 19(11): p.<br />
1786-9.<br />
2. Merskey, D.M. and N. Bogduk, Classification of Chronic Pain. Descriptions<br />
of Chronic Pain Syndromes and Definitions of Pain Terms. 1994, Seattle:<br />
IASP Press.<br />
3. Wolfe, F., et al., The American College of Rheumatology 1990 Criteria for<br />
the Classification of Fibromyalgia. Report of the Multicenter Criteria<br />
Committee. Arthritis & Rheumatism, 1990. 33(2): p. 160-72.<br />
4. Yunus, M.B. and A.T. Masi, Juvenile primary fibromyalgia syndrome. A<br />
clinical study of thirty-three patients and matched normal controls.<br />
Arthritis & Rheumatism, 1985. 28(2): p. 138-45.<br />
5. Bowyer, S. and P. Roettcher, Pediatric rheumatology clinic populations in<br />
the United States: results of a 3-year survey. Pediatric Rheumatology Database<br />
Research Group. Journal of Rheumatology, 1996. 23(11): p. 1968-74.<br />
DAVID D. SHERRY, MD<br />
Director, Clinical Rheumatology,<br />
Attending, Pain Management,<br />
Professor of<br />
Pediatrics at The Children's<br />
Hospital of Philadelphia<br />
University of Pennsylvania<br />
56 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
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EMERGING TREATMENT AND DIAGNOSIS<br />
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58 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
FEATURE | COMPLEX REGIONAL PAIN SYNDROME<br />
Neuroimmunologic Approaches to<br />
Emerging and Potential Therapies<br />
for Complex Regional Pain<br />
Syndrome (CRPS)<br />
BY DONALD C. MANNING, MD, PhD<br />
Despite a great deal of progress in defining<br />
Complex Regional Pain Syndrome (CRPS),<br />
there is still controversy regarding the<br />
mechanisms involved.<br />
THEORIES HAVE INCLUDED INFLAMMATION, neuropathic mechanisms,<br />
ischemic injury and abnormal sympathetic nervous system<br />
function. To date there is no approved treatment for<br />
CRPS, and therapies for neuropathic or inflammatory pain<br />
have given disappointing results, affording many patients only<br />
partial relief at best (1). Therefore, it is time for a reevaluation<br />
of CRPS mechanisms to enable new therapeutic opportunities.<br />
The high female predominance (75%) and the combination of<br />
inflammatory and neuropathic pain components could be consistent<br />
with an autoimmune mechanism. Targeting therapies<br />
toward immune activation involving cytokines, glia, or the<br />
infiltration of immune cells is a new approach for pain therapy,<br />
although it has already been employed with some success in<br />
oncology and rheumatology.<br />
Neuroimmune activation involves a bidirectional stimulation<br />
of neurons and immune cells in response to trauma or<br />
inflammation (2). Immune cells release inflammatory [e.g.,<br />
cytokines tumor necrosis factor (TNF), interleukin (IL)-1<br />
and IL-6] and anti-inflammatory (e.g., cytokine IL-10)<br />
molecules and they, in turn, are modulated by neurotransmitters,<br />
especially the sympathetic nervous system transmitter norepinephrine<br />
(3,4). Cytokines are polypeptides that can act<br />
locally, within tissues, or at a distance similar to hormones.<br />
They regulate replication, development and activation of cells<br />
in the immune, nervous and hematopoetic systems. The biology<br />
of the cytokines is complicated in that different cells can<br />
produce the same cytokine that can in turn have different<br />
effects or different cytokines can have similar effects or antagonize<br />
each other depending upon the local environment.<br />
Cytokines as Chronic Pain Mediators<br />
TNF, IL-1 AND IL-6 are the cytokines with the best-documented<br />
pathological roles in neuropathic pain. In healthy animals,<br />
the administration of IL-1 or TNF alone can produce<br />
symptoms of neuropathic pain. Spinal neuron activation by<br />
these cytokines can produce long-term alterations in neuronal<br />
excitability. Activation of non-neuronal glial cells with extensive<br />
interconnections within the spinal cord could account for central<br />
cytokine release (5) as well as the spread of excitation<br />
beyond traditional neuroanatomical boundaries and reactivation<br />
of the pain system after new injuries (6). Infusion of IL-1 or<br />
TNF for adjuvant cancer chemotherapy has been associated<br />
with an incidence of nearly 50% of pain syndromes or complaints<br />
of pain and tenderness at the injection site (7-9).<br />
Whereas TNF and IL-1 play important roles in the<br />
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EMERGING TREATMENT AND DIAGNOSIS | MANNING<br />
initiation of persistent neuropathic pain, delayed IL-6 production<br />
is a factor in the maintenance of such pain (10). Another<br />
set of cytokines such as IL-10 serves to inhibit inflammation<br />
and immune activation (11). Malfunction of this inflammatory/anti-inflammatory<br />
cytokine balance could lead to chronic<br />
pain and inflammatory syndromes. The widespread presence of<br />
receptors for the cytokines in the sensory nervous system suggests<br />
that these nerves serve as immunosensors (12) and form a<br />
link between immune activation and neurobehavioral aspects of<br />
chronic illness (13). Immune activation and cytokine release<br />
have also been associated with decreased mood (14) and inhibition<br />
of certain types of learning and memory (15). Evidence<br />
from animal studies suggests that the action of tricyclic antidepressants<br />
on pain and mood may derive from cytokine interactions<br />
in the brain (16, 17).<br />
Proinflammatory cytokines TNF and IL-6 are specifically<br />
elevated in tissue fluid in CRPS-affected regions but not in<br />
nonaffected regions (18). Cerebrospinal fluid levels of IL-6 and<br />
IL-1 are elevated in patients with CRPS but not in patients<br />
without pain or with chronic non-CRPS-related pain (19).<br />
These findings suggest a specific association between cytokines<br />
and CRPS.<br />
Immunomodulation as a Strategy for Treating CRPS<br />
IN IMMUNE-MEDIATED DISEASES, it is important to suppress<br />
the pathologic elevations of cytokines rather than completely<br />
blocking them. This approach, known as immunomodulation,<br />
serves to restore the normal balance in immune function.<br />
Immunosuppressive agents such as methotrexate (20) and<br />
leflunomide (21) attenuate tactile hypersensitivity in rodent<br />
radiculopathy and neuropathy models. Leflunomide is approved<br />
for clinical use in rheumatoid arthritis and has several antiinflammatory<br />
actions, including inhibition of IL-1, TNF,<br />
and the expression of nitric oxide and COX-2 genes. However,<br />
no clinical studies in chronic neuropathic pain conditions have<br />
been reported. Caution is advised, because general immunosuppressants<br />
can increase the risk and reduce the resolution of certain<br />
types of infection.<br />
A somewhat unexpected drug class for immunomodulation<br />
is comprised of the statins or 3-hydroxy-3-methylglutaryl coenzyme<br />
A (HMGCoA) reductase inhibitors. Reports that statin<br />
treatment could produce improvement in a model of multiple<br />
sclerosis (22) have sparked great interest in this class of drugs.<br />
(23) Treatment with atorvastatin induced the secretion of antiinflammatory<br />
cytokines (IL-4, IL-5, and IL-10) and inhibited<br />
the secretion of Th-1 pro-inflammatory cytokines (IL-2, IL-12,<br />
IFN, and TNF). Another statin, lovastatin, inhibited the<br />
expression of TNF, IL-1, and IL-6 in rat astrocytes,<br />
microglia, and macrophages (24). Statins decreased the expression<br />
of inflammatory mediators in the CNS, including TNF<br />
(25). The potential clinical benefit of using statins to treat neuropathic<br />
pain is unexplored, but these agents may be effective<br />
in preemptive use. How many postoperative or traumatic<br />
neuropathic pain states have been avoided by concomitant use<br />
of statins? Future studies may provide some guidance for the<br />
use of these agents.<br />
In addition, Shir et al. have reported that dietary fat can<br />
reduce the neuropathic pain-related behaviors resulting from<br />
partial sciatic nerve ligation (26). The consumption of unsaturated<br />
corn or soy oils suppressed tactile allodynia and heat<br />
hyperalgesia, an effect that was accentuated by dietary protein<br />
from multiple sources (26). Dietary fats can modulate both<br />
innate and adaptive immune responses through toll-like receptor-4<br />
(TLR-4) receptors. TLR-4 functions in the innate<br />
immune system as a pattern-recognition receptor for pathogens.<br />
In the rat CNS TLR-4 occurs exclusively on microglia (27).<br />
TLR-4 can be activated by bacterial wall molecules such as<br />
endotoxins or lipopolysaccharides and by endogenous ligands<br />
such as heat shock proteins, proteoglycans, and saturated fatty<br />
acids released after neural injury and degeneration (28, 29). Saturated<br />
fatty acids activate TLR-4, but omega-3 polyunsaturated<br />
fatty acids inhibit agonist-induced TLR-4 activation (30). Partial<br />
but significant reduction in hyperalgesia and allodynia<br />
behavior can be accomplished by interfering with the function<br />
of TLR-4 in microglia (31). This mechanism raises intriguing<br />
therapeutic possibilities; however, much work remains.<br />
Inhibitors of Cytokine Production and Function<br />
GLUCOCORTICOIDS HAVE BEEN USED FOR MANY YEARS<br />
to treat CRPS and inflammatory diseases. They can modulate<br />
the immune system and inhibit the production of a wide range<br />
of inflammatory mediators as well as stimulate the production<br />
of anti-inflammatory agents. Glucocorticoid utility for chronic<br />
diseases is severely compromised by a wide range of adverse<br />
effects, including diabetes, impaired wound healing, and susceptibility<br />
to infections, metabolic problems, and bone demineralization<br />
(32). The search for safer and more effective<br />
inhibitors of inflammatory mediators has yielded several new<br />
therapeutic agents. Successful use of TNF monoclonal antibodies<br />
(infliximab) or TNF-receptor fusion protein (etanercept)<br />
has changed the therapy for rheumatoid arthritis and<br />
several other chronic inflammatory diseases. Open-label clinical<br />
reports have claimed rapid resolution of acute sciatica (involving<br />
spinal root irritation) using TNF inhibitors infliximab<br />
(33) or entanercept (34). These findings, however, were not<br />
supported by a larger controlled study of acute radiculopathy<br />
pain using infliximab (35). There are no reports of these agents<br />
being used in trials of CRPS therapy. In one small experimental<br />
report, elevated interstitial cytokine levels from CRPS-affected<br />
regions are markedly reduced by infliximab treatment coincident<br />
with a reduction in clinical symptoms (36). Anakinra is a<br />
recombinant human IL-1-receptor antagonist approved for use<br />
in rheumatoid arthritis (37), but no studies have looked at its<br />
60 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
FEATURE | COMPLEX REGIONAL PAIN SYNDROME<br />
By changing our perspective and looking beyond traditional neuroanatomy<br />
and neurophysiology to understand the body’s response to injury, we may<br />
uncover new therapeutic strategies.<br />
ability to alter the development or maintenance of other<br />
chronic pain states.<br />
Thalidomide was developed as a sedative and antinausea<br />
drug, but its teratogenic effects and propensity to cause peripheral<br />
neuropathy with prolonged use have limited its use. It is<br />
orally active and functions as an immunomodulator by inhibiting<br />
the production of a broad range of pro-inflammatory mediators,<br />
including TNF, IL-1, and IL-6 and by increasing the<br />
level of IL-10, IL-2, and IFN. It also inhibits the production<br />
of TNF from human microglial cells (39). Clinically, thalidomide<br />
has been reported to reduce pain and hyperalgesia in<br />
Complex Regional Pain Syndrome (CRPS) Type I (40-43).<br />
Medicinal chemistry efforts have produced several<br />
generations of immunomodulatory agents derived from thalidomide<br />
that have decreased toxicity. Lenalidomide, a novel<br />
immunomodulatory drug with anti-inflammatory properties,<br />
potently inhibits the secretion of pro-inflammatory cytokines<br />
(e.g., TNF, IL-1 and IL-6) and stimulates the secretion of<br />
anti-inflammatory cytokines (e.g., Il-10). Lenalidomide is currently<br />
approved in the U.S. for the treatment of patients with<br />
transfusion-dependent anemia due to low- or intermediate-1-<br />
risk myelodysplastic syndromes with a deletion 5q cytogenetic<br />
abnormality with or without additional cytogenetic abnormalities.<br />
Based upon reports of symptomatic improvement of CRPS<br />
in response to treatment with thalidomide, as well as upon the<br />
pharmacological properties of lenalidomide, a pilot study was<br />
undertaken to assess the safety and preliminary efficacy of<br />
lenalidomide in subjects with unilateral CRPS Type I (44).<br />
Lenalidomide was used in an open-label study of 40<br />
patients with unilateral CRPS of at least 1-year duration, optimal<br />
conventional therapy, and with entry pain levels registering<br />
at least 4 on a 0-10 pain scale (44). The patients had high levels<br />
of pain, on average, at baseline (7.1 out of 10) and were taking,<br />
on average, more than 4 concomitant CRPS pain medications.<br />
Despite this high degree of prior and current treatment, over<br />
one third of subjects reported at least 30% improvement and<br />
one half reported a 20% improvement in pain levels as well as<br />
broad and significant reductions in CRPS symptoms and sleep<br />
disturbance. Of the original 40 subjects, 28 continued into an<br />
extension phase and 14 are still in the study, with continued<br />
benefit after more than 2 years on the study drug. Data from<br />
this study demonstrated a good overall safety profile; however,<br />
as the study was uncontrolled, it is difficult to interpret the precise<br />
relationship of adverse events to study treatment. Most<br />
adverse events were mild to moderate in severity and many were<br />
attributed to the disease rather than to a reaction to the study<br />
drug. Few subjects required dose reductions or discontinuation<br />
due to adverse events. The results of this study demonstrate a<br />
level of safety and efficacy justifying additional study for the<br />
treatment of CRPS. Controlled studies are currently underway<br />
in subjects with CRPS.<br />
Summary<br />
WE NEED TO FIND NEW APPROACHES to the treatment of<br />
chronic neuropathic pain and CRPS. By changing our perspective<br />
and looking beyond traditional neuroanatomy and neurophysiology<br />
to understand the body’s response to injury, we may<br />
uncover new therapeutic strategies. This short article cannot<br />
possibly provide adequate coverage of the extensive literature<br />
supporting immune- and nervous system interaction, especially<br />
in pain states. An appreciation of the role played by the<br />
immune system in injury-induced pain states, as summarized in<br />
this article, represents a new opportunity. Currently available<br />
immunomodulators and immunosuppressive agents need to be<br />
cautiously evaluated for their pain-modulating ability. The<br />
results of these initial studies will certainly foster more extensive<br />
therapeutic development efforts.<br />
REFERENCES<br />
1. Kingery, WS. A critical review of controlled clinical trials for peripheral<br />
neuropathic pain and complex regional pain syndromes. Pain. 1997;<br />
73:123-139.<br />
2. DeLeo JA, Yezierski RP. The role of neuroinflammation and neuroimmune<br />
activation in persistent pain. Pain. 2001; 90:1-6.<br />
3. Straub, R. Bottom-up and top-down signaling of IL-6 with and without<br />
habituation? Brain, Behavior and Immunity. 2006 January; 20: 1; 37-39.<br />
4. Spengler RN, Allen RM, Remick DG, Strieter RM, Kunkel SL. Stimulation of<br />
alpha-adrenergic receptor augments the production of macrophagederived<br />
tumor necrosis factor. J Immunol. 1990; 145:1430-1434.<br />
5. Aloisi F. Immune function of microglia. Glia. 2001; 36:165-179.<br />
6. Carmignoto G. Reciprocal communication systems between astrocytes<br />
and neurones. Prog Neurobiol. 2000; 62:561-581.<br />
7. Kemeny N, Childs B, Larchian W, Rosado K, Kelsen D. A phase II trial of<br />
recombinant tumor necrosis factor in patients with advanced colorectal<br />
carcinoma. Cancer. 1990; 66:659-663.<br />
8. Del Mastro L, et al. Intraperitoneal infusion of recombinant human tumor<br />
necrosis factor and mitoxantrone in neoplastic ascites: a feasibility study.<br />
Anticancer Res. 1995; 15:2207-2212.<br />
9. Elkordy M, et al. A phase I trial of recombinant human interleukin-1 beta<br />
(OCT-43) following high-dose chemotherapy and autologous bone marrow<br />
transplantation. Bone Marrow Transplant. 1997; 19:315-322.<br />
10. Murphy PG, Grondin J, Altares M, Richardson PM. Induction of interleukin-6<br />
in axotomized sensory neurons. J Neurosci. 1995; 15:5130-5138.<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 61
EMERGING TREATMENT AND DIAGNOSIS | MANNING<br />
11. Watkins LR, Maier SF. Glia: a novel drug discovery target for clinical pain.<br />
Nat Rev Drug Discov. 2003; 2:973-985.<br />
12. Weihe E, et al. Molecular anatomy of the neuroimmune connection. Int J<br />
Neurosci. 1991; 59:1-23.<br />
13. Maier SF, Watkins LR. Cytokines for psychologists: implications of bidirectional<br />
immune-to-brain communication for understanding behavior,<br />
mood, and cognition. Psychol Rev. 1998; 105:83-107.<br />
14. Meyers C. Mood and cognitive disorders in cancer patients receiving<br />
cytokine therapy. In: Dantzer R1 (Ed). Cytokines, Stress and Depression.<br />
New York: Plenum. 1999, pp 75-82.<br />
15. Balschun D, et al. Interleukin-6: a cytokine to forget. FASEB J. 2004;<br />
18:1788-1790.<br />
16. Ignatowski TA, et al. Brain-derived TNF-alpha mediates neuropathic pain.<br />
Brain Res. 1999; 841:70-77.<br />
17. Ignatowski TA, et al. Neuronal-associated tumor necrosis factor (TNF<br />
alpha): its role in noradrenergic functioning and modification of its<br />
expression following antidepressant drug administration. J Neuroimmunol.<br />
1997; 79:84-90.<br />
18. Huygen, FJ, et al. Mast cells are involved in inflammatory reactions during<br />
complex regional pain syndrome type 1. Immunological Letters.<br />
2004; 91:147-154.<br />
19. Alexander, GM., et al. Changes in cerebrospinal fluid levels of pro-inflammatory<br />
cytokines in CRPS. Pain; 116(3):213-219, 2005.<br />
20. Hashizume H, Rutkowski MD, Weinstein JN, DeLeo JA. Central administration<br />
of methotrexate reduces mechanical allodynia in an animal model<br />
of radiculopathy/sciatica. Pain. 2000b; 87:159-169.<br />
21. Sweitzer SM, DeLeo JA. The active metabolite of leflunomide, an<br />
immunosuppressive agent, reduces mechanical sensitivity in a rat<br />
mononeuropathy model. J Pain. 2002; 3:360-368.<br />
22. Youssef S, et al. The HMG-CoA reductase inhibitor, atorvastatin, promotes<br />
a Th2 bias and reverses paralysis in central nervous system autoimmune<br />
disease. Nature. 2002; 420:78-84.<br />
23. Menge T, Hartung HP, Stuve O. Statins-a cure-all for the brain? Nat Rev<br />
Neurosci 2005; 6:325-331.<br />
24. Pahan K, Sheikh FG, Namboodiri AM, Singh I. Lovastatin and phenylacetate<br />
inhibit the induction of nitric oxide synthase and cytokines in rat<br />
primary astrocytes, microglia, and macrophages. J Clin Invest. 1997;<br />
100:2671-2679.<br />
25. Stuve O, Youssef S, Steinman L, Zamvil SS. Statins as potential therapeutic<br />
agents in neuroinflammatory disorders. Curr Opin Neurol. 2003;<br />
16:393-401.<br />
26. Perez J, et al. Dietary fat and protein interact in suppressing neuropathic<br />
pain-related disorders following a partial sciatic ligation injury in rats.<br />
Pain. 2004; 111:297-305.<br />
27. Lehnardt S, et al. Activation of innate immunity in the CNS triggers nedegeneration<br />
through a toll-like receptor 4-dependent pathway. Proc Natl<br />
Acad Sci USA. 2003; 100:8514-8519.<br />
28. Hwang D. Modulation of the expression of cyclo-oxygenase-2 by fatty<br />
acids mediated through toll-like receptor 4-derived signaling pathways.<br />
FASEB J. 2001; 15:2556-2564.<br />
29. Lee JY, Sohn KH, Rhee SH, Hwang D. Saturated fatty acids, but not<br />
unsaturated fatty acids, induce the expression of cyclooxygenase-2 mediated<br />
through toll-like receptor 4. J Biol Chem. 2001; 276:16683-16689.<br />
30. Weatherill AR, et al. Saturated and polyunsaturated fatty acids reciprocally<br />
modulate dendritic cell functions mediated through TLR4. J<br />
Immunol. 2005; 174:5390-5397.<br />
31. Tanga FY, Nutile-McMenemy N, DeLeo JA. The CNS role of toll-like receptor<br />
4 in innate neuroimmunity and painful neuropathy. Proc Natl Acad<br />
Sci USA. 2005; 102:5856-5861.<br />
32. Schacke H, Docke WD, Asadullah K. Mechanisms involved in the side<br />
effects of glucocorticoids. Pharmacol Ther. 2002; 96:23-43.<br />
33. Karppinen J,et al. Tumor necrosis factor-alpha monoclonal antibody,<br />
infliximab, used to manage severe sciatica. Spine. 2003; 28:750-753.<br />
34. Genevay S, Stingelin S, Gabay C. Efficacy of etanercept in the<br />
treatment of acute, severe sciatica: a pilot study. Ann Rheum<br />
Dis. 2004; 63:1120-1123.<br />
35. Korhonen T, et.al. The treatment of disc herniation-induced sciatica with<br />
infliximab: Results of a randomized, controlled, 3-month follow-up study.<br />
Spine. 2005; 30: 2724-2728.<br />
36. Huygen FJ, et.al. Successful treatment of CRPS-1 with anti-TNF. J Pain<br />
Symptom Manage. 2004; 27:101-103.<br />
37. Hallegua DS, Weisman MH. Potential therapeutic uses of interleukin 1<br />
receptor antagonists in human diseases. Ann Rheum Dis. 2002; 61:960-<br />
967.<br />
38. Corral LG, et al. Differential cytokine modulation and T-cell activation by<br />
two distinct classes of thalidomide analogues that are potent inhibitors<br />
of TNF-alpha. J Immunol. 1999; 163:380-386.<br />
39. Peterson PK, et al. Thalidomide inhibits tumor necrosis factor-alpha production<br />
by lipopolysaccharide- and lipoarabinomannan-stimulated<br />
human microglial cells. J Infect Dis. 1995; 172:1137-1140.<br />
40. Rajikumar, SV, et al. Complete resolution of reflex sympathetic dystrophy<br />
with thalidomide treatment. Archives of Internal Medicine; 20:2502-<br />
2503, 2001.<br />
41. Prager J, et al. Open-label clinical experience of thalidomide in the treatment<br />
of complex regional pain syndrome type I. The Journal of Pain;<br />
4(2):68, 2003.<br />
42. Schwartzman, R, et al. Open-label trial of thalidomide in the treatment of<br />
complex regional pain syndrome type I. The Journal of Pain; 4(2):76,<br />
2003.<br />
43. Bengston K, et al. A phase II study of thalidomide in the treatment of<br />
chronic complex region pain syndrome (CRPS). The Journal of Pain;<br />
4(2):85, 2003.<br />
44. Schwartzman R, et al. A multicenter, open-label, 12-week study with<br />
extension to evaluate the safety and efficacy of lenalidomide (CC-5013)<br />
in the treatment of complex regional pain syndrome type-1. pg 580 in:<br />
Abstracts: 11th World Congress on Pain. IASP Press, Seattle. 2005.<br />
DONALD C. MANNING,<br />
MD, PhD, Executive Director,<br />
Neurosciences Clinical<br />
Research and Development<br />
Celgene Corporation,<br />
Summit, New Jersey<br />
Clinical Associate Professor<br />
of Anesthesiology and Pain<br />
Management, University of<br />
Virginia, Health Sciences<br />
Center, Charlottesville, Virginia<br />
62 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
ZICONOTIDE:<br />
Promising New Treatment for Complex<br />
Regional Pain Syndrome (CRPS)<br />
BY LYNN R. WEBSTER, MD AND<br />
KERI L. FAKATA, PHARMD<br />
Ziconotide is a<br />
synthetic neuroactive peptide that<br />
was isolated from a neurotoxin utilized<br />
by the cone shell snail, Conus Magnus,<br />
to capture its prey. It is one of 50,000<br />
peptides isolated from this venom<br />
that has proven to safely and<br />
effectively treat chronic severe<br />
pain in refractory pain patients<br />
who in most cases failed<br />
intrathecal (IT) opioid therapy.<br />
THE FDA APPROVED ZICONOTIDE after a decade of research and<br />
clinical experience in 1,254 patients. Out of this population, 17<br />
were reported to have the diagnosis of CRPS. Eleven of these<br />
patients received ziconotide, and six patients received placebo.<br />
The reported efficacy for this subset of patients was a mean<br />
change in the Visual Analog Scale of Pain Intensity (VASPI) of<br />
25.2 % for patients who received ziconotide, compared to 2.8%<br />
for patients who received placebo (1). One published case report<br />
documented complete resolution of nonambulatory bilateral<br />
lower-extremity CRPS. The patient resumed normal gait after 7<br />
months of treatment and achieved complete resolution with<br />
ongoing of therapy (2). As more experience is gained with the<br />
use of ziconotide, more clinicians are sharing their positive experiences<br />
in treating CRPS at workshops and clinical meetings.<br />
Underlying Mechanisms of Pain in CRPS<br />
IT HAS BEEN PROPOSED that pain in CPRS is neuropathic in<br />
origin, resulting from both peripheral and central sensitization<br />
of somatosensory afferent neurons (3,4). Multiple underlying<br />
mechanisms are responsible for the pain associated with CRPS,<br />
including regional inflammatory reactions, sympathetic maintained<br />
pain, stimulus-independent pain, stimulus-evoked pain,<br />
and peripheral and central sensitization.<br />
Central sensitization may be the mechanism in which<br />
ziconotide is effective for relieving pain and symptoms associated<br />
with CRPS. Transmission of pain from noxious stimuli<br />
results when the stimulated peripheral afferent neurons that<br />
contain A and C fibers transmit nociceptive signals by releasing<br />
chemical signals such as glutamate, aspartate substance P, and<br />
calcitonin gene-related peptide at the spinal cord. These chemical<br />
signals are released at the presynaptic end of the peripheral<br />
neuron in response to an influx of Ca++ into the N-type voltage-sensitive<br />
calcium channel (N-VSCC). These neurotransmitters<br />
activate the dorsal horn neurons in lamina II of the spinal<br />
cord to continue ascending transmission of pain (3,4).<br />
In central sensitization the peripheral afferents spontaneously<br />
fire, resulting in the increased sensitivity of the dorsal<br />
root neuron to input of all forms. In response to inflammation,<br />
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EMERGING TREATMENT AND DIAGNOSIS | WEBSTER & FAKATA<br />
reorganization of peripheral afferent neurons may occur. Fibers<br />
that do not normally transmit pain start expressing the pain<br />
transmitters, so that nonnoxious stimuli that normally activate<br />
these fibers would transit pain.<br />
Ziconotide represents a new class of potent analgesics called<br />
neuronal calcium channel blockers (NCCBs). Its exact mechanism<br />
of action has not been established in humans; however,<br />
animal studies confirm its specificity for N-VSCCs found<br />
throughout the nervous system and concentrated in the spine<br />
on the presynaptic terminals of peripheral nociceptors.<br />
Ziconotide blocks the N-VSCC and prevents release of excitatory<br />
amino acids from the presynaptic terminal, thereby reducing<br />
the amount of stimulation at the dorsal horn neurons. It is<br />
proposed that ziconotide may unwind central sensitization over<br />
time through this mechanism (5).<br />
Clinical Use of Ziconotide<br />
ZICONOTIDE IS CURRENTLY FDA-APPROVED for monotherapy in<br />
patients with chronic severe pain where IT therapy is warranted.<br />
Currently there are no published clinical data on the<br />
efficacy of ziconotide in combination with other IT medications.<br />
The Polyanalgesic Consensus Committee has not made<br />
any formal recommendations regarding the use of ziconotide as<br />
monotherapy or in combination with IT therapies at this time<br />
(6). There is little information on other IT medications in combination,<br />
yet combination IT therapy has been an accepted<br />
standard of practice. The rationale for ziconotide in combination<br />
with other common IT medications is combining different<br />
mechanisms of action for possible additive or synergistic analgesia.<br />
Preclinical studies in animals demonstrated additive or synergistic<br />
effects with opioids, clonidine, and bupivacaine when<br />
utilized in combination with ziconotide (5). Clinicians who<br />
wish to use ziconotide in combination with other IT medications<br />
should first obtain consent.<br />
Some stability data have been published regarding<br />
ziconotide in combination with other common IT medications.<br />
It is important to note that the data represented stability<br />
with 25 mcg/ml formulation of ziconotide with fixed concentrations<br />
of other IT meds. Ziconotide was found to have<br />
relatively good stability with hydromorphone, bupivacaine,<br />
and baclofen. It was completely stable with clonidine (7-10).<br />
Formulated IT products such as Infumorph ® (IT morphine)<br />
and Sublimaze ® (fentanyl) should be avoided because of low<br />
stability. Ziconotide stability is pH dependent and is most<br />
stable at pH of 4.5.<br />
In choosing to use ziconotide in combination with other IT<br />
meds, a clinician should be aware of some inherent stability<br />
considerations because ziconotide is a peptide. On the initial<br />
fill, ziconotide adheres to the titanium in the pump. The initial<br />
concentration may also be altered by the residual volume in the<br />
pump. Ziconotide degrades due to exposure to high temperature<br />
(body temperature), and it is susceptible to oxidation.<br />
Ziconotide may be most effective<br />
in reducing pain and preventing<br />
central sensitization by its<br />
mechanism of action.<br />
The authors of this article recommend keeping ziconotide<br />
at or above a working concentration of 10mcg/ml. This also<br />
allows for the convenience and practicality of utilizing the100<br />
mcg/ml (1ml) vial formulation, taking cost of medication into<br />
consideration. The rinses in the prescribing information can be<br />
conducted through the following steps:<br />
[1] dilute 0.5 ml of the 100 mcg/ml formulation to 6 ml (8.33<br />
mcg/ml);<br />
[2] rinse the pump three times utilizing 2 ml aliquots of step 1<br />
above; and,<br />
[3] utilize the remaining 0.5 ml to dilute to a working concentration<br />
of 10 mcg/ml in 5 ml, or 5 mcg/ml in 10 ml if<br />
lower concentration is necessary for first pump fill with<br />
ziconotide.<br />
Subsequent refills should occur monthly due to stability<br />
concerns; however, further rinses are not required. The entire<br />
vial of 100 mcg/ml 1 ml vial can be used for the refill. The<br />
same concepts are utilized for monotherapy or compounding<br />
ziconotide with other IT medications (11).<br />
Ziconotide is associated with adverse events such as nausea/vomiting,<br />
dizziness, abnormal gait, abnormal vision, and<br />
confusion. These adverse events may present themselves within<br />
the first few days of therapy if treatment is initiated with too<br />
high of a dose. Experienced clinical investigators realize that<br />
ziconotide should be started at 1 mcg/day and titrated by 0.5<br />
mcg/day no more than once a week. This dose is significantly<br />
lower than the maximum recommended starting dose in the<br />
prescribing information. Cognitive effects such as memory loss,<br />
confusion, and psychosis tend to have a later onset of approximately<br />
three weeks. Therefore, to be safe and to not overshoot<br />
the therapeutic window, it is advisable to titrate no more often<br />
than weekly—once a month may be preferable. If adverse<br />
events do occur, they usually resolve after a dose reduction.<br />
Early onset adverse events usually resolve in a few days, whereas<br />
it may take up to three additional weeks to resolve late onset<br />
adverse events. If patients cannot tolerate adverse events,<br />
ziconotide may be abruptly removed from the pump without<br />
any withdrawal sequelae.<br />
Monitoring Considerations<br />
PATIENTS SHOULD BE CONTINUALLY ASSESSED for adverse<br />
events related to ziconotide. They should be instructed to<br />
immediately notify clinic personnel or to seek emergency<br />
medical attention if any serious adverse events should occur.<br />
In clinical studies with ziconotide, a significantly elevated<br />
serum, Creatinine Kinase isoenzyme MM (CK-MM) found in<br />
(Continued on page 66)<br />
64 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
UNRIVALED INDEPENDENCE<br />
COMING SOON…<br />
©Medtronic, Inc., 2006. All Rights Reserved. Printed in USA.
EMERGING TREATMENT AND DIAGNOSIS | WEBSTER & FAKATA<br />
skeletal muscle, was common in 40% of patients participating<br />
mostly in open-label studies. Elevated CK-MM usually<br />
occurred within the first 2 months of therapy. Other isoenzymes<br />
were rarely affected. Of all patients studied in clinical<br />
trials, there was one case of symptomatic myopathy and two<br />
acute renal failures associated with rhabdomyolysis and<br />
extreme CK elevation (17, 000-27,000 IU/L) (12).<br />
A baseline CK should be obtained with another CK at<br />
2 months, and every 6 months thereafter. CKs should be<br />
obtained if the patient is exhibiting any new neuromuscular<br />
symptoms.<br />
Conclusion<br />
ZICONOTIDE MAY BE MOST EFFECTIVE in reducing pain and<br />
preventing central sensitization by its mechanism of action.<br />
As a result, it may be useful in many patients with CRPS.<br />
Ziconotide will likely not be first-line therapy for CRPS<br />
but will have a role when less invasive therapies have been<br />
exhausted and the pain becomes chronic and severe enough to<br />
warrant an IT pump. Some clinicians are discussing their success<br />
treating CRPS through an earlier utilization of ziconotide<br />
by external catheter. However, prolonged use of external<br />
catheters increases the risk of meningitis. Immediate pain relief<br />
should not be expected with the recommended slow titration.<br />
Treatment with ziconotide will need to be based on the<br />
individual’s response. Ziconotide has the potential of becoming<br />
an important analgesic in our armamentarium to treat CRPS.<br />
REFERENCES<br />
1. Ziconotide: Use in <strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong>, PRI031_<br />
Use_in_<strong>Reflex</strong>_<strong>Sympathetic</strong> <strong>Dystrophy</strong> 03 Ref Number:1-6462160, Elan<br />
Pharmaceutical Inc.<br />
2. Miljanich GP. Ziconotide: Neuronal Calcium Channel Blocker for Treating<br />
Severe Chronic Pain. Current Medicinal Chemistry, 2004. 11: 3029-3040.<br />
3. Ribbers, GM, Geurts AC, Stam HJ, Mulder T. Pharmacologic Treatment of<br />
Complex Regional Pain Syndrome I: A Conceptual Framework. Archives of<br />
Physical Medicine and Rehabilitation 2003; 84: 141-146.<br />
4. Harden RN. Chronic Neuropathic Pain. The Neurologist 2005 11(2): 111-<br />
122.<br />
5. Miljanich GP. Ziconotide: Neuronal Calcium Channel Blocker for Treating<br />
Severe Chronic Pain. Current Medicinal Chemistry, 2004. 11: 3029-3040.<br />
6. Hassenbusch SJ , Portenoy RK, Cousins M et al. Polyanalgesic Consensus<br />
Conference 2003: An Update on the Management of Pain by Intraspinal<br />
Drug Delivery-Report of an Expert Panel. Journal of Pain and Symptom<br />
Management. 2004, 27(6):540-563.<br />
7. Shields D, Montenegro R . The Chemical Stability of Admixtures Combining<br />
Ziconotide and Hydromorphone during Simulated Intrathecal Administration.<br />
(Abstract) Neuromodulation 2005 Vol 8(in press).<br />
8. Shields D, Montenegro R, Ragusa M. The Chemical Stability of Admixtures<br />
Combining Ziconotide and Morphine Sulfate during Simulated<br />
Intrathecal Administration. (Abstract) Neuromodulation 2005. Vol 8(in<br />
press).<br />
9. Shields D, Montenegro R, The Chemical Stability of Admixtures Combining<br />
Ziconotide and Clonidine during Simulated Intrathecal Administration.<br />
(Abstract) Neuromodulation 2005. Vol 8(in press).<br />
10. Shields D, Montenegro R, Ragusa M . The Chemical Stability of Admixtures<br />
Combining Ziconotide and Bupivacaine during Simulated Intrathecal<br />
Administration. (Abstract). Neuromodulation 2005 Vol 8(in press).<br />
11. Webster LR, Fakata KL, Ziconotide for Severe Chronic Pain. Practical Pain<br />
Management May 2005.<br />
12. Prialt (ziconotide intrathecal infusion) prescribing information. Elan<br />
Pharmceutical Inc. 2/2005.<br />
LYNN R. WEBSTER, MD,<br />
is Medical Director, CEO,<br />
Lifetree Pain Clinic,<br />
Salt Lake City, Utah<br />
KERI L. FAKATA, PHARMD,<br />
Lifetree Research and Pain<br />
Clinic, Clinical/Research<br />
Pain Management Pharmacist,<br />
Salt Lake City, UT<br />
66 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
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EMERGING TREATMENT AND DIAGNOSIS | PRAGER<br />
NEW RECHARGEABLE SPINAL CORD<br />
STIMULATOR SYSTEMS OFFER<br />
ADVANTAGES IN CRPS TREATMENT<br />
BY JOSHUA P. PRAGER, MD, MS<br />
n April, 2004, the Food and Drug Administration<br />
(FDA) approved the first rechargeable spinal cord<br />
stimulator (SCS) system. This system, called Precision,<br />
TM produced by Advanced Bionics, is the first<br />
in a new generation of SCS systems that offers a<br />
significant improvement in stimulation to people<br />
with CRPS. In early 2005, Advanced Neuromodulation<br />
Systems received approval for its rechargeable<br />
system, the Eon Ț M and shortly thereafter Medtronic,<br />
the largest producer of neurostimulator systems,<br />
received FDA approval for its Restore TM System.<br />
This article will briefly review the use of SCS for<br />
treatment of CRPS and then describe the potential<br />
of the new systems in improving care and outcomes.<br />
Reprinted from The RSDSA Review, Fall 2005<br />
68 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
SCS as Part of the CRPS Treatment Algorithm<br />
IN 1995, the International Association for the Study of Pain<br />
(IASP) brought together a group of international experts to<br />
address treatment of CRPS. This was one of four meetings the<br />
IASP has held in the last two decades regarding various aspects<br />
of CRPS. Stanton-Hicks published results of the 1995 meeting<br />
as a treatment algorithm, which indicates that the mainstay of<br />
CRPS/RSD treatment is physical therapy, and that nerve blocks<br />
or SCS as adjuvant treatment are important for patients who<br />
are not adequately progressing with physical therapy alone (1).<br />
The important point of this article is that SCS can significantly<br />
enhance CRPS treatment by facilitating physical therapy as part<br />
of the entire rehabilitation process.<br />
Stanton-Hicks suggested that the beneficial effect of SCS<br />
relates not only to pain relief, but it also inhibits or modulates<br />
the sympathetic outflow to the region where the tingling produced<br />
by the stimulation is experienced (2).<br />
SCS and CRPS<br />
THERE HAVE BEEN NUMEROUS STUDIES of SCS for the treatment<br />
of CRPS. These studies have been both retrospective and<br />
prospective randomized. In 1982, Broseta reported the use of<br />
SCS for CRPS-2 patients with 72 percent having experienced<br />
excellent results (3). Barolat (4) reported a 73 percent success<br />
rate of pain in 18 patients with CRPS-1. Kumar (5) discussed<br />
12 patients treated with SCS for CRPS. Robaina (6) compared<br />
SCS with TENS in 35 patients with late-stage CRPS-1; 66 percent<br />
of patients reported good results with SCS, experiencing<br />
rapid relief of pain and reduction in swelling. Bennett (7)<br />
examined not only the effect of SCS on CRPS, but also looked<br />
at the effect of different lead arrays. He found that patient satisfaction<br />
was markedly improved with dual octapolar leads as<br />
opposed to traditional quadripolar leads.<br />
There have been four prospective studies published of<br />
spinal cord stimulation in CRPS. The first, Calvillo (8) in<br />
1998, examined 31 patients with CRPS affecting the upper<br />
extremity with a significant reduction in pain scores compared<br />
to baseline. Oakley and Weiner (9) observed statistically significant<br />
reduction in pain and an 80 percent success rate with SCS<br />
for CRPS. The largest prospective study in CRPS was that of<br />
Kemler (10), in the New England Journal of Medicine in 2000;<br />
54 patients with CRPS-1 of one extremity were randomized to<br />
SCS plus physical therapy or physical therapy alone. A significantly<br />
greater number of patients with SCS plus physical therapy<br />
had a much improved global perceived effect than the<br />
physical therapy group alone. Most recently, Kemler (11) published<br />
a two-year follow up of the randomized trial. The mean<br />
pain score in the 24 implanted SCS patients was significantly<br />
reduced compared to those receiving physical therapy alone;<br />
63 of the SCS patients reported improvement in their global<br />
perceived effect.<br />
Thus, there is significant literature demonstrating the<br />
success with SCS in treating CRPS. This brief discussion<br />
above was not meant to thoroughly review or evaluate this<br />
literature, but merely to call attention to its presence and<br />
provide a reference list where one can review this information<br />
in greater detail.<br />
Rechargeability and its Implication Toward the<br />
Treatment of CRPS with SCS<br />
THE ADVENT OF RECHARGEABILITY, being able to recharge the<br />
SCS battery, creates new opportunities. Previously, when a<br />
battery failed, the entire pulse generator needed to be replaced,<br />
which required expensive surgery and was uncomfortable for<br />
the patient. Rechargeability may significantly reduce the need<br />
to replace internal pulse generators.<br />
Many CRPS patients with SCS systems have needed to<br />
use a lot of power to achieve the pain relief necessary to<br />
function. In order to reduce the need to replace the internal<br />
pulse generator, patients have often rationed the amount of<br />
stimulation by either reducing the power or turning the unit<br />
off some of the time. Thus, both patient and physician have<br />
attempted to manage the battery while compromising treatment.<br />
Rechargeability offers the opportunity to manage the<br />
patient instead of managing the battery.<br />
Bennett (12) notes that large arrays produce greater satisfaction<br />
than traditional quadripolar leads. Rechargeability offers<br />
the opportunity to use many contacts simultaneously, which<br />
uses a significantly greater amount of energy. Previously, this<br />
increased power consumption would have been prohibitive<br />
in some patients. Rechargeability allows the use of a greater<br />
number of electrodes at a given time to provide better coverage<br />
with stimulation.<br />
There are some reports that increased frequency improves<br />
stimulation in patients with CRPS. Although this not been well<br />
documented, it is important to note that higher frequency produces<br />
higher energy consumption. Higher frequency potentially<br />
compromises battery life. Thus, rechargeability provides an<br />
opportunity to fully utilize the potential of any system without<br />
needing to worry about battery failure.<br />
Conventional SCS four- and eight-contact leads were<br />
placed relatively far apart. Oakley and Prager (13) in their<br />
discussion of SCS, indicate that when SCS leads are placed<br />
closer together the result is deeper penetration of the spinal<br />
Rechargeability offers the opportunity to manage the<br />
patient instead of managing the battery.<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 69
EMERGING TREATMENTS | PRAGER<br />
cord, which provides a stronger effect. New lead configurations<br />
have been and will be designed specifically for rechargeable<br />
systems because the more-effective configurations will use more<br />
energy. Thus, once again, rechargeability provides a platform to<br />
allow for a more effective form of stimulation that conventional<br />
primary cell internal pulse generator source would not support.<br />
Cost-Effectiveness of SCS<br />
TAYLOR ET AL (14) recently reviewed the cost effectiveness of<br />
SCS for treating chronic pain. They conclude that in the<br />
medium to long term, SCS is economically favorable compared<br />
to other therapies for people with CRPS. Taylor indicates that<br />
pay back ranged from 15 months to five years after the SCS<br />
was implanted. The pay back period was sensitive to the efficiency<br />
level of the battery/electrode life and the amount of<br />
patient usage. However, this review was performed before<br />
rechargeable batteries. Considering the advantages of rechargeability,<br />
it is possible that pay back will be shortened and that<br />
the costs of SCS plus physical therapy will be lower than the<br />
cost of physical therapy alone. SCS initial costs are offset by a<br />
reduction in healthcare expenditures after the implant.<br />
The Future with Rechargeability<br />
THE RELEASE OF RECHARGEABLE SYSTEMS has prompted the<br />
development of many new lead configurations that will<br />
enhance the effectiveness of SCS for the CRPS patient. New<br />
leads and extensions are currently in development. In particular,<br />
one product that will be available in the near future will allow<br />
four limbs to be treated simultaneously from a single-pulse generator.<br />
For patients with advanced four-limb CRPS, this eliminates<br />
the need for multiple systems; four limbs can be treated<br />
with a rechargeable single-pulse generator that, despite high<br />
energy consumption, will not require frequent replacement.<br />
Summary<br />
SPINAL CORD STIMULATION has a demonstrated efficacy in<br />
treating patients with CRPS when it is used in conjunction<br />
with a comprehensive rehabilitation program. Rechargeability<br />
enhances the ability to perform stimulation without requiring<br />
as frequent internal pulse generator battery replacements.<br />
SCS is cost effective in CRPS and future developments will<br />
enhance its effectiveness.<br />
REFERENCES<br />
1. Stanton Hicks, M. et.al. An updated interdisciplinary clinical pathway for<br />
CRPS: Report of an expert panel. Pain Practice 2002; 2(1):1-16.<br />
2. Stanton-Hicks M., Spinal cord stimulation for the management of complex<br />
regional pain syndromes. Neuromodulation 1999; 2(3):193-201.<br />
3. Broseta J, et.al. Chronic epidural dorsal column stimulation in the treatment<br />
of causalgia pain. Appl Neurophys 1982;45: 190-194.<br />
4. Barolat G. Schwartzman R., et.al., Epidural spinal cord stimulation management<br />
of reflex sympathetic dystrophy. Stereotact Funct Neurosurg<br />
1999; 53:29-39.<br />
5. Kumar K., et.al., Spinal cord stimulation is effective in the management<br />
of reflex sympathetic dystrophy. Neurosurgery 1997; 40:503-508.<br />
6. Robaina F. J., et.al., Transcutaneous electrical nerve stimulation and<br />
spinal cord stimulation for pain relief in reflex sympathetic dystrophy.<br />
Stereotact Funct Neurosurg 1989; 52(1): 53-62.<br />
7. Bennett D. S., et.al., Spinal cord stimulation for complex regional pain<br />
syndrome (RSD): A retrospective multicenter experience from 1995-1998<br />
of 100 patients. Neuromodulation 1999;2:202-210.<br />
8. Calvillo O, et.al., Neuroaugmentation in treatment of complex regional<br />
pain syndrome of the upper extremity. Acta Orthop Belg 1998; 64: 57-<br />
62.<br />
9. Oakley, J. and Weiner, R. L., Spinal cord stimulation for complex regional<br />
pain syndrome: A prospective study of 19 patients at two centers. Neuromodulation<br />
1999; 2:47-50.<br />
10. Kemler, M.A., et.al., Spinal cord stimulation in patients with chronic reflex<br />
dystrophy. N Engl J Med 2000; 43:618-24.<br />
11. Kemler, M.A., The effect of spinal cord stimulation in patients with<br />
chronic reflex sympathetic dystrophy: Two years followup of the randomized<br />
control trial. Ann Neurol 2004; 55:13-18.<br />
12. Bennett, D.S., ibid.<br />
13. Oakley, J., Prager, J., Mechanism of spinal cord stimulation. Spine. 27<br />
(22):2574-2583.<br />
14. Taylor, R. S., The cost effectiveness of spinal cord stimulation:<br />
A systematic review of the literature. J Pain Symptom Manage 2004;<br />
27 (4): 370-8.<br />
JOSHUA P. PRAGER, MD,<br />
MS, is Director, Center for<br />
the Rehabilitation of Pain<br />
Syndromes (CRPS), Departments<br />
of Internal Medicine<br />
and Anesthesiology, David<br />
Geffen School of Medicine<br />
at UCLA, Los Angeles,<br />
California.<br />
70 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
OPINION | GETSON<br />
The Use of Thermography in the<br />
Diagnosis of CRPS: A Physician’s Opinion<br />
BY PHILIP GETSON, DO<br />
EXPERTS WHO EVALUATE PATIENTS WITH CRPS make the diagnosis<br />
based upon history and physical examination. However,<br />
because of the wide variation in symptom complexes, not every<br />
individual presents with the “classic” symptoms that are frequently<br />
associated with CRPS (e.g., temperature change, color<br />
change, and hair growth change).<br />
In the past, attempts have been made to diagnosis CRPS<br />
with triple phase bone scans. Some literature suggests that these<br />
are about 40% accurate, but I believe that in reality the number<br />
is closer to 15%. This test is frequently non-specific in its representation,<br />
and rarely do radiologists offer a diagnosis of CRPS<br />
when they have not been provided with that historical information.<br />
Electrodiagnostic testing (EMGs), CAT Scans, MRIs, etc.,<br />
have no appreciable value in assisting in the diagnosis of CRPS.<br />
Thermography has been utilized in medical application<br />
since the 1950s. Prior to that it had, and still does have, industrial<br />
applications. The use of infrared imaging for neuromuscular<br />
purposes dates back to the 1960’s and has continued despite<br />
lack of widespread acceptance. Numerous articles have been<br />
written regarding the value of thermography in the diagnosis<br />
of sympathetically mediated pain syndromes and work in this<br />
area continues. The July 2002 United States Department of<br />
Health and Human Services document on reflex sympathetic<br />
dystrophy, suggests thermography as the diagnostic tool for the<br />
evaluation of CRPS.<br />
In the 24 years since I began using neuromuscular thermography<br />
in my practice, we have examined thousands of patients<br />
with neuromuscular disorders. Using electronic thermographic<br />
apparatus, the cameras (which were initially driven by liquid<br />
nitrogen) are now hi-tech computer-generated images that<br />
allow us to view the nervous system by measuring changes in<br />
skin temperature. These changes are controlled by the sympathetic<br />
nervous system and alterations in the sympathetics cause<br />
alterations in thermal (infrared) imaging which do not conform<br />
to dermatomal patterns.<br />
While electrodiagnostic testing may show a radiculopathic<br />
pattern, such testing often errs because EMGs measure motor<br />
function as opposed to sensory function, which is the fundamental<br />
basis for CRPS. The mechanism of thermal imaging<br />
allows for perception of altered skin temperature to one-tenth<br />
of one degree centigrade. The lack of symmetry which is out of<br />
conformation to dermatomal distribution patterns goes a long<br />
way to confirming the clinical diagnosis of CRPS.<br />
Measurements taken on an individual within approximately<br />
the first six months of the onset of the pathology will show the<br />
affected side to be warmer than the contra lateral side by temperature<br />
gradient in excess of 0.9 degrees centigrade (considered<br />
by this observer to be the standard for sympathetically mediated<br />
thermal asymmetry). Frequently this asymmetry exceeds 1.5 or<br />
2 degrees and is clearly not the result of vascular pathology per<br />
se. After approximately six months the pattern changes with the<br />
affected side being the “cold side.” It is therefore imperative<br />
that a history of the traumatic event which precipitated CRPS<br />
be afforded the thermographic expert.<br />
As can be seen from the images (included with this article),<br />
the temperature differential is often dramatic. While the human<br />
hand is capable of perceiving significant temperature differential<br />
between two sides, the thermal imaging camera is hundreds of<br />
times more sensitive and the temperature scale (unlike the<br />
human hand) and can be adjusted to incorporate variations<br />
in room and human body temperature, which varies from<br />
individual to individual. Additionally, this author is currently<br />
72 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
collecting data that clearly indicates that the migratory pattern<br />
of CRPS can be documented as much as six to nine months<br />
prior to the occurrence of symptomatology in a limb that has<br />
been affected with sympathetically-mediated dysfunction, but<br />
has not yet become symptomatic at the time the images were<br />
performed. It is fascinating to see patients who offer verbal<br />
complaints (in completed schematic diagram) about one limb,<br />
yet manifest thermal abnormalities in an entirely separate area.<br />
(See attached images).<br />
In addition to the benefits in diagnosing sympathetically<br />
mediated pain syndromes, new thermographic cameras have the<br />
potential to offer real-time imaging capabilities that could allow<br />
monitoring of an affected limb during the surgical implantation<br />
of a spinal cord stimulator. By stimulating the affected nerve<br />
(thereby causing a “warming” of the damaged limb), the surgeon<br />
could place the leads accurately and “know” they were in<br />
the exact place to afford the individual the maximum benefit<br />
to be derived from such implantation. This would reduce the<br />
randomization factor currently in place by allowing for an<br />
electronic “road map” which otherwise does not exist. Similar<br />
use of thermal imaging for surgical or chemical ablations of<br />
sympathetic nerve dysfunction is possible.<br />
In conclusion, thermographic (infrared) imaging appears to<br />
be the best, if not only diagnostic tool, that should be utilized<br />
by the clinician for objectification of a<br />
clinical diagnosis of sympathetically<br />
mediated pain syndromes. The overused<br />
adage, “A picture is worth 1000<br />
words” is particularly applicable here,<br />
not only to assist the clinician in making<br />
the diagnosis, but to add verification<br />
to the patients’ symptoms,<br />
particularly in instances where they have<br />
been led to believe they are “crazy”<br />
because conventional diagnostic testing<br />
does not offer objective evidence of<br />
their symptom complex.<br />
Research on thermographic imaging<br />
is on-going, but as a diagnostic tool,<br />
much of its potential remains untapped.<br />
The number of people who have benefited<br />
from the conclusive diagnosis of<br />
CRPS by thermographic means continues<br />
to grow, thereby allowing clinicians<br />
an opportunity for earlier intervention<br />
of treatment to an affected body part.<br />
PHILIP GETSON, DO, has<br />
been certified by the American<br />
Academy of Thermology,<br />
the American Herschel<br />
Society, the Academy of<br />
Neuromuscular Thermology<br />
and is a Diplomate of the<br />
American Medical Infrared<br />
Association. He has lectured<br />
extensively in the field of<br />
Thermography especially as<br />
to its usage in the diagnosis<br />
of R.S.D. He is currently<br />
working on three separate<br />
papers on the subject.<br />
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T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 73
IN CONCLUSION | MOSKOVITZ<br />
A Theory of<br />
Suffering<br />
BY PETER A. MOSKOVITZ, MD<br />
I present here a personal theory of suffering. It differs from previous efforts to<br />
understand suffering by proposing that the nature of suffering is evolutionary<br />
and neurobiological, rather than metaphysical, phenomenological, or linguistic.<br />
In this theory I argue six interrelated premises:<br />
1. Persistent grief or fear evokes distinct bodily disturbances (somatic markers) that are experienced as suffering;<br />
2. When pain evokes fear and grief, it has the same effect on the maps in the brain’s body-sensing regions as do fear and grief alone;<br />
3. Suffering is not an emotion, but it is an “emotionally competent stimulus,” capable of evoking emotions;<br />
4. The neural substrate for the experience of suffering requires, in part, the anterior cingulate cortex;<br />
5. The evolution of suffering is essential to the com munication of emotion and to mammalian nurturing; and<br />
6. The capacity for suffering is the experiential precursor of empathy and altruism, which are the components of natural morality.<br />
CRPS as the Quintessential Maldynic Pain Disorder<br />
James Giordano used the term maldynia to address and describe the trajectory of chronic pain and stated that maldynia “… evokes<br />
considerable suffering, but the (direct) cause of this is pain qua [as] illness (1).” “Pain” and “suffering” are distinct experiences; suffering<br />
has causes other than pain. The suffering of grief, for example, is often severe and some<br />
At Right 30”x40” oil on board.<br />
Matt Sesow is an independent<br />
American artist residing in<br />
Washington, DC. Visit his<br />
website at www.sesow.com<br />
74 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6<br />
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T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 75
IN CONCLUSION | MOSKOVITZ<br />
even think it can be mortal. Fear, particularly in association<br />
with an event or object that is only vaguely in awareness (as<br />
with anxiety), causes terrible suffering. Who has not used the<br />
expression “I was frightened to death”? Our attitudes toward<br />
suffering, and therefore toward pain, come, in part, from the<br />
observation that pain is often associated with grief and fear,<br />
which are not “objective” physical impairments.<br />
Complex Regional Pain Syndrome (CRPS) is characterized<br />
by pain that is out of proportion to the inciting injury or tissue<br />
damage and thus represents the quintessential maldynic (1, 2)<br />
pain disorder. CRPS commonly begins with a physical impairment,<br />
and although the injury sometimes appears to be trivial,<br />
the subsequent pain and disability of CRPS are severe.<br />
Although often confused, “disability” and “physical impairment”<br />
are independent, and this confusion has harmful effects.<br />
For example, both doctor and patient may wrongly assume that<br />
when the physical impairment (disease) is treated, the disability<br />
(illness) will cease. Furthermore, many physicians harbor a<br />
judgmental disdain (only thinly veiled) for “non-organic” pain<br />
and illness behavior, and nowhere is this failing more evident<br />
than in the care of patients with CRPS. In addition, and in<br />
spite of advancing science, a segment of the medical profession<br />
still thinks that CRPS does not exist at all, that there is a “dystrophic<br />
personality,” or that patients with CRPS are emotionally<br />
disturbed or malingering. The suffering of people with<br />
CRPS is further compounded when the legal system, compensation<br />
agencies, and the medical profession treat the experience<br />
of suffering itself with both passive and active disregard.<br />
There Is No Suffering Without Fear or Grief<br />
Our understanding of suffering has traditionally been more<br />
metaphysical than neurobiological. Eric Cassell described in<br />
detail how pain and disease threaten the integrity of the “facets<br />
of personhood,” a composite of qualities that Antonio Damasio<br />
referred to as “the autobiographical self” (3, 4). In my own<br />
practice, I have seen patients who descend relentlessly from an<br />
acute lumbar injury into chronic pain and disability under such<br />
a threat. The most memorable have been laborers whose identity<br />
as strong providers for their families, in part a culturally<br />
defined role, was threatened by physical impairment. “Independent”<br />
evaluators saw the increased disability as a vaguely inauthentic<br />
secondary gain. The disc impairment was authentic;<br />
however, the pain was suspect because the suffering that<br />
increased the perception of pain—the loss of self-regard and<br />
self-respect, loss of income, loss of customary role behavior, loss<br />
of sexual capacity and identity, the stress of the medico-legal<br />
conflict—was not “legitimate.”<br />
Cassell defined and illustrated over a dozen “existential<br />
domains of the person,” as reframed within a phenomenological<br />
context by Giordano (1). For each of the facets of personhood,<br />
as discussed by Cassell, the threat to the integrity of the individual<br />
resulted in fear, loss, and the fear of loss of any of the<br />
“facets of personhood.” When lost, these facets—cultural background,<br />
habitual and accustomed behaviors, life experiences,<br />
expectations, attachments to family and friends, secret relationships,<br />
thoughts, aspirations, and bodily function—become<br />
objects of grief. The fear of losing them is painful. Such is the<br />
suffering of chronic pain and illness (5). Suffering increases the<br />
noxious perception of disease and recalls associations between<br />
suffering and diverse antecedents and causes of injury, disease,<br />
and suffering long past. Suffering is not simply the affective<br />
experience of pain, for suffering does not exist without the<br />
emotions of fear and grief.<br />
PREMISE 1<br />
Fear and grief evoke bodily disturbances,<br />
the experience of which is suffering.<br />
I PROPOSE THAT PERSISTENT GRIEF AND FEAR evoke distinct<br />
bodily disturbances that are experienced as suffering. The<br />
somatic and visceral effects of grief and fear on the body proper<br />
produce a characteristic perception of the maps in the brain’s<br />
body-sensing regions. I propose that the feelings of fear and<br />
grief are experienced as suffering. A definition of suffering, like<br />
this one, that invokes the “somatic marker” hypothesis of neurologist<br />
and humanist Antonio Damasio, implies a neural substrate<br />
for the experience of suffering (4, 6, 7). And that is what<br />
I intend to propose. Damasio’s language and theories of consciousness<br />
inform much of my thinking.<br />
A Classification of Emotions<br />
SUFFERING IS NOT AN EMOTION; it is the awareness or feeling<br />
of the bodily effects of the emotions of fear and grief. Fear and<br />
grief are two of the six primary emotions, which also include,<br />
according to Paul Ekman’s classification, joy, surprise, disgust,<br />
and anger (8). The fact that Damasio, in his recent work,<br />
accepts this classification gives it greater cogency (9). Each of<br />
the primary emotions has unique facial expressions and, to a<br />
lesser degree, vocal tone and body posture or movement. The<br />
facial expressions of primary emotions are recognizable across<br />
cultural boundaries (where display rules differ) (10), and are, to<br />
some extent, recognizable across species. 1<br />
I am persuaded to think, with arguable economy, that social<br />
and other secondary emotions are combinations of primary<br />
emotions that are superimposed on appetites or drive states, 2<br />
1 Primatologists and dog lovers need no convincing from me.<br />
2 I am not aware of a comprehensive, biologically based classification of<br />
appetites and drives. For the sake of argument, here are ten: thirst, hunger,<br />
oxygenation, elimination, thermal regulation, rest, lust, curiosity,<br />
mastery/dominance, and attachment.<br />
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and experienced in three time frames (past, present, and future). 3<br />
Consider some examples: guilt and shame are varieties of disgust<br />
in differing social contexts. When disgust is directed outward, it<br />
may take the form of disdain; when combined with anger, it<br />
may turn to recrimination and vengeance. The experience of primary<br />
emotions is modified by the virtually infinite variety of<br />
states of mind, particularly considering that the associations of<br />
long-term memory are unique representations of objects and<br />
events. One potential criticism of this taxonomy is that it is<br />
reductive or deterministic. I refute such criticism by calculating 4<br />
the unlimited variety of the precursors of suffering, values, and<br />
behavior. The present discussion is about suffering; but I cannot<br />
ignore the fact that creativity cannot be predicted by a reduction<br />
to finite elements. Our appetites for curiosity and mastery will<br />
sometimes motivate us to think and do outrageous and wonderful<br />
things. When considering the variety of experiences that<br />
result in suffering, most observers recall the opening of Tolstoy’s<br />
Anna Karenina: “All happy families resemble one another; every<br />
unhappy family is unhappy in its own fashion.”<br />
PREMISE 2<br />
When pain evokes fear and grief, the effect on the<br />
maps in the brain’s body-sensing regions is the<br />
same as for fear and grief alone.<br />
I PROPOSE THAT CHRONIC PAIN, OR SEVERE ACUTE PAIN,<br />
evokes fear and grief and that the pain-evoked fear and grief<br />
have the same effect on the maps in the body-sensing regions of<br />
the brain as do fear and grief alone. When pain evokes fear or<br />
grief by threatening the existential domains of the individual, as<br />
in Cassell’s formulation, the suffering that results is qualitatively<br />
no different from any other form of suffering. The differences<br />
in the varieties of the experience of suffering, I propose, arise<br />
from its context—what Cassell referred to as “the meaning” of<br />
suffering. The current technology of neuroscience does not have<br />
the resolution to address, no less to validate, this theoretical<br />
postulate. I have no doubt that it will.<br />
PREMISE 3<br />
Suffering is not an emotion, but is an “emotionally<br />
competent stimulus” capable of evoking emotions.<br />
FEAR AND GRIEF, THE PROPOSED ANTECEDENTS OF SUFFERING,<br />
ARE EMOTIONS. I propose that suffering is not. Emotions evoke<br />
action, somatic and visceral motor activity, and aversive behavior<br />
in the face of fear and disgust. I propose that if fear and<br />
grief do not evoke suffering, they do motivate corrective or<br />
aversive action in the face of danger or loss. 5<br />
I am persuaded to think that suffering does not evoke aversive<br />
or corrective behavior by itself. Suffering is involutional,<br />
resulting in withdrawal, stasis, and inaction. Suffering is interior<br />
and isolating. Suffering is experienced as distress, misery, agony,<br />
anguish, torment, wretchedness, despair, hopelessness, excruciation,<br />
and woe. When we are lonely, we seek companionship.<br />
When we “suffer” the death of a loved one, we shut ourselves<br />
off and rely on the cultural rituals of the funeral, wake, or<br />
receiving of friends and family to provide resilience and connection<br />
to others. We recognize and admire the resilience of those<br />
who console others around them, even though everyone has<br />
experienced the same loss or, in the case of danger, the same<br />
jeopardy and fear.<br />
I have portrayed suffering as leading to inaction and stasis.<br />
I propose that with the evolution of suffering, the emotions of<br />
disgust and anger took on the role of decreasing the intensity of<br />
suffering by motivating action. Such actions often appear to be<br />
maladaptive when they are resentful or hostile. The ancient role<br />
of disgust was to protect against injury from contamination by<br />
waste, decay, and contagion. To experience disgust at the perception<br />
of an abstract stimulus or of a benign object is a recent<br />
response. Rage once served for aggressive display and dominance<br />
in reproductive and survival conflicts. Now, exploitation<br />
and dominance, as expressed in revenge, are more common. 6<br />
Although Elisabeth Kubler-Ross’s work has been criticized after<br />
her death, her well-known monograph on loss and grief<br />
demonstrates how suffering evokes disgust and rage (11).<br />
3 Time frames include the “past” from long-term memory, both declarative<br />
and non-declarative; the “present” from short-term memory (the answer to<br />
Emily Webb’s question [from Thornton Wilder’s Our Town] is: no, we do<br />
not experience life as we live it, we experience it after it happens); and the<br />
“future” as representations of anticipated objects and events (5).<br />
4 The calculation of possible states of mind multiplies six primary emotions,<br />
10 drive states, three time frames, and an arbitrary ordinal scale of intensity<br />
for the contribution of each of the other three dimensions. Even if many of<br />
the cells of such a matrix are empty, the product is a number beyond<br />
comprehension.<br />
5 For example, if I am afraid of a bull moose, I wait until he leaves and do<br />
not cross the valley to fish where he is feeding. But I do not suffer for it,<br />
unless he is feeding at the edge of the best pool in the river.<br />
6 We easily intuit the ancient survival value of fear, surprise, disgust, and anger;<br />
however, we might consider the role of disgust and anger in meliorating suffering<br />
when we recall the media frenzy that accompanies any human tragedy.<br />
Accusation, scapegoating, recrimination, and revenge follow hard upon fear<br />
and grief. A good example is the Sago Mine explosion in January 2006. After<br />
days of intense rescue efforts, a rumor spread that 1 miner was dead and that<br />
12 survived. The opposite was true and the truth was not transmitted to the<br />
community for 3 hours. The disgust and rage that followed were severe,<br />
arguably out of proportion to the offence. For many, rage and disgust were<br />
easily turned against the media for exploiting the suffering of the lost miners’<br />
families. Perhaps we cleave to the suffering of others to validate our own<br />
resilience, but our reactions only reveal our vulnerability.<br />
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IN CONCLUSION | MOSKOVITZ<br />
Comorbidities Decrease Resilience and<br />
Increase Suffering<br />
EVERY CLINICIAN KNOWS that patients are more likely to lack<br />
resilience in the face of pain if they “suffer” from other emotions<br />
or drive states. Pre-existing depression or any of the<br />
hyper-arousal syndromes—obsessive compulsive disorder, generalized<br />
anxiety, panic disorder, focal phobias, post-traumatic<br />
stress disorder—will exacerbate the experience of pain, and any<br />
of these impairments can be caused by the suffering of chronic<br />
pain (12). Distinguishing cause from effect is difficult. When a<br />
drive state alone causes suffering, it might be sufficient to<br />
address the physiologic need: for example, rehydrate a person<br />
suffering from thirst. This is seldom the case in medical practice,<br />
least of all in pain management. Treating the disease<br />
without addressing the suffering that it causes will not suffice.<br />
A complete discussion of ethics and morality as they apply to<br />
the role of the practitioner is not possible here. It is well presented<br />
by Giordano in his work, cited earlier.<br />
Suffering as Disequilibrium of<br />
Frustrated Appetites and Emotions<br />
ANOTHER WAY TO VIEW THE VARIETY of the precursors of suffering<br />
is in terms of equilibrium and disequilibrium. I propose<br />
that suffering is the result of disequilibrium in any form: dehydration<br />
from thirst, starvation from hunger, shortness of breath,<br />
the ennui of confinement, prolonged separation from a friend<br />
or loved one. Although it is possible that each of these drive<br />
states, alone, is sufficient to cause suffering, I propose that suffering<br />
is mediated by fear and grief when the drive state is prolonged<br />
or severe, not unlike the suffering when chronic pain<br />
evokes fear or grief. We do not suffer from mild thirst; we simply<br />
get a glass of water. Thirst that evokes bodily pain, exhaustion,<br />
and fear of injury or death is another matter and thus a<br />
cause of suffering.<br />
PREMISE 4<br />
The neural substrate for the experience of suffering<br />
requires, in part, the anterior cingulate cortex.<br />
A NUMBER OF OBSERVATIONS persuade me to think that the<br />
anterior cingulate cortex (ACC) and its connectivities to the<br />
posterior cingulate cortex, the ventromedial prefrontal cortex,<br />
the amygdala, the hippocampus and the anterior insula, play an<br />
important, if not central, role in the experience of suffering.<br />
The central nervous system is not merely computational; yet, I<br />
choose a useful, if not precise, analogy of the ACC as the<br />
“CPU” that processes internal and external information that<br />
results in the experience of suffering. The physiologic process<br />
by which these structures, circuits, networks, and systems operate<br />
to produce suffering is unknown. Neuroscientists use such<br />
concepts as synergy, resonance, reverberation, synchrony, and<br />
synchronous oscillation when trying to explain the hypothetical<br />
mechanisms underlying suffering or certainty.<br />
As a medical student, I was fascinated by a patient whose<br />
midline brain tumor involving the ACC 7 produced a curious<br />
insensitivity to pain. The young man felt pain after his surgery,<br />
and reacted protectively to it, but it didn’t “bother” him. What<br />
was thought to be a type of “insensitivity to pain” was, I now<br />
propose, the elimination of the experience of suffering that<br />
would be caused by pain in the presence of an intact ACC. I<br />
propose that the patient’s experience was more than an inability<br />
to “interpret” pain, as in “asymbolia” (13).<br />
Anterior cingulotomy or prefrontal leucotomy relieves the<br />
suffering of chronic pain without eliminating the pain itself.<br />
Such neurosurgical procedures decrease pain behavior and disability<br />
without eliminating nociception (14). Damasio reports<br />
the experience of a man with intractable, totally disabling<br />
trigeminal neuralgia and quotes his response the next day after<br />
undergoing anterior, prefrontal leucotomy: “...the pains are the<br />
same, but I feel fine now (4).”<br />
Neuroimaging has validated the neural basis of semantic<br />
and sensory parameters of pain that are assessed through the<br />
McGill Pain Questionnaire (MPQ), almost 30 years after its<br />
development by Ronald Melzack and Warren S. Torgerson (15,<br />
16 ). Such findings further suggest the role of the ACC in the<br />
experience of suffering. Scoring of the MPQ divides the list of<br />
descriptive words for pain into distinct “sensory” and “affective”<br />
pain rating indices. Neuroimaging of subjects with chronic<br />
pain, when challenged with words from the sensory word list,<br />
revealed activation of areas associated with processing of<br />
somato-sensory nociception. When subjects heard words from<br />
the affective word list, there was increased activity in the insula<br />
and ACC (16, 17, 18). Melzack did not use the word “suffering”<br />
in his extensive, statistical validation of the MPQ,<br />
although I think that the word applies to the affective list. One<br />
observation by Melzack illustrates how the prejudices of clinicians<br />
affected pain assessment, then as now: “… patients are<br />
pleased to see (or hear) words which they use to describe their<br />
pain to family and friends but which they would not tell the<br />
physician because he may consider them psychologically<br />
unsound; the administrator thus often senses the patient’s relief<br />
at seeing such words in a list, implying that they are acceptable<br />
and sound descriptors” (19). Those “taboo” words were ones<br />
that describe suffering (splitting, exhausting, cruel, frightful,<br />
excruciating, etc.), as opposed to the sensory words (burning,<br />
stabbing, throbbing, pressing, stinging, etc.).<br />
7 The famous neurologist Houston Merritt made the diagnosis—<br />
without CT or MRI.<br />
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Functional (f)MRIs of subjects in a state of mind characterized<br />
by grief reveal activation of the posterior cingulate cortex<br />
(20). Recent observations suggest that a predisposition to<br />
depression is related to abnormal (and variably asymmetrical)<br />
feedback circuits that link the ACC and the amygdala, which is<br />
responsible for the experience of fear (21).<br />
Activation of the ACC is observed in experiments in conflict<br />
resolution (22). In fMRI studies by Joshua Greene and colleagues,<br />
subjects who elect a rational solution to a moral<br />
dilemma also show activation of the ACC as a marker of “conflict,”<br />
along with activation of areas of the brain associated with<br />
cognitive processing (23, 24). My response to Greene’s summary<br />
of data and interpretations from the “crying baby” 8 experiments<br />
supports my theory (25). After reading the “crying baby<br />
dilemma,” I concluded, with difficulty, that I would select the<br />
rational solution: I would smother my own crying baby rather<br />
than expose the hiding place of my fellow villagers to a nearby,<br />
wartime enemy that would surely kill us all. The emotional resolution<br />
to the dilemma (do not smother the baby regardless of<br />
the consequences) is “easier” (Greene observed shorter reaction<br />
times). After reading Greene’s article (25), I was unable to sleep,<br />
distressed by thoughts of my own children and six-month-old<br />
granddaughter and by images of William Styron’s Sophie 9 , mortally<br />
suffering for the choice she had made. I speculated that<br />
the rational resolution to the crying baby dilemma requires<br />
more time and produced my own reaction, in part, because the<br />
somatic markers for decision-making in the crying baby<br />
dilemma include those of suffering. My painful obsessions and<br />
insomnia resulted from fear and grief—the emotional cost of<br />
my rational choice—even though the stimulus was fictional,<br />
just like the one in Styron’s novel and the subsequent movie. To<br />
quote Goethe, “To act is easy, to think is hard, to act according<br />
to our thought is troublesome.” 10 PREMISE 5<br />
The evolution of suffering is essential to the<br />
communication of emotion and to mammalian<br />
nurturing.<br />
THE QUALITIES OF SUFFERING that result in withdrawal, isolation,<br />
and stasis—misery, hopelessness, despair, torment,<br />
anguish, etc.—are grievous and fearsome indeed. In the evolution<br />
of species, such qualities and their resulting inaction would<br />
appear to impart a serious survival and reproductive disadvantage.<br />
It would follow, then, that a capacity for suffering should<br />
be extinguished by natural selection. Why, then, does suffering<br />
exist with such negative effects on the human condition? 11 I<br />
propose that suffering evolved, paradoxically, to impart survival<br />
and reproductive advantage.<br />
The increasing size of the brain relative to body mass (a<br />
development that paleontologists and physical anthropologists<br />
call “encephalization” 12 ) imparts survival and reproductive<br />
advantage (26). Increasing encephalization required that offspring<br />
are born neurologically immature, which is a serious survival<br />
disadvantage. 13 I propose that the resolution to the<br />
apparent paradox is the evolution of nurturing: an altruistic<br />
behavior that permits an individual to cooperate with another<br />
and relinquish its independence for the survival of the offspring.<br />
According to Paul MacLean, the transition from fish,<br />
amphibians, and reptiles—many, but not all, of which abandon<br />
their young—to mammals that protect them, play with them,<br />
have distinctive cries of separation and grieve for their loss,<br />
requires the paleopallium, the midbrain, the limbic system,<br />
specifically the circuit of Papez and the ACC (27). I propose<br />
that the full complement of primary emotions, mediated by the<br />
paleopallium, is the currency of mammalian nurturing and its<br />
invariable sequence: attachment, individuation, and separation.<br />
Suffering and empathy are the means of receipt and distribution<br />
of that currency. 14 I conclude, therefore, that suffering and<br />
8 “It is wartime, and you and some of your fellow villagers are hiding from<br />
enemy soldiers in a basement. Your baby starts to cry, and you cover your<br />
baby’s mouth to block the sound. If you remove your hand, your baby will<br />
cry loudly, the soldiers will hear, and they will find you and the others and<br />
kill everyone they find, including your baby. If you do not remove your<br />
hand, your baby will smother to death. Is it okay to smother your baby to<br />
death in order to save yourself and the other villagers?” (25)<br />
9 Meryl Streep played Sophie in the film adaptation of William Styron’s<br />
novel Sophie’s Choice. Sophie, upon arriving at a Nazi concentration camp,<br />
must choose between her two children. One will be taken from her and,<br />
she assumes, killed. She is allowed to keep the other child with her. Neither<br />
child survives. Sophie, years later, in the United States, commits suicide.<br />
10 From Wilhelm Meister’s Apprenticeship, Book VII, chapter 9.<br />
11 Twentieth-century existentialism simply gave up on rationalizing the role of<br />
suffering in the human condition and concluded that suffering is the human<br />
condition. The question of how suffering survives evolution is the same as<br />
the one that philosophers and scientists ask about altruism in its conflict<br />
with exploitation: how can it resist extinction?<br />
12 The rank order of the “encephalization quotient” (EQ) of mammals (humans<br />
7.4, dolphins 5.3, nonhuman primates 2.1-2.5, elephants 1.9, whales 1.8,<br />
canines 1.2, felines 1.0, equines 0.9, ungulates 0.8, rodents 0.4-0.5) well<br />
approximates the prevalence of animal behaviors that imply empathy,<br />
as we know it.<br />
13 Another troublesome paradox of the human condition is that we are capable<br />
of reproduction at the age of about 13 years, but the parts of the brain that<br />
are responsible for the control of impulsive behavior do not mature until<br />
the age of 21, if ever.<br />
14 A corollary to the hypothesis that a capacity for suffering requires the paleopallium<br />
or limbic system is the proposition that, birds not withstanding,<br />
most pre-mammalian species do not suffer, since they lack the neurological<br />
machinery to do so. The obverse proposition is that all mammals, to one<br />
degree or another, possess the capacity for suffering. It is, therefore, ethically<br />
safe to be very careful in the manner in which we conduct animal research.<br />
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IN CONCLUSION | MOSKOVITZ<br />
empathy evolved together, in their primal forms, as essential for<br />
mammalian nurturing. The capacity for empathy requires the<br />
capacity for suffering.<br />
PREMISE 6<br />
The capacity for suffering is the experiential<br />
precursor of empathy and altruism, which are<br />
the components of values and natural morality.<br />
MOST OBSERVERS AGREE that empathy is the antecedent of<br />
altruism (29). Explanations of altruism that rely on self-interest,<br />
enlightened self-interest, kin or group advantage, or strategic<br />
decision-making are either irrational or fail empirical validation.<br />
I propose that the survival and reproductive advantages of suffering,<br />
empathy, and altruism are inextricably related.<br />
Suffering, Empathy, and Mirror Neurons<br />
THE THEORY OF EMPATHY—and, arguably, a theory of suffering—took<br />
an important turn with the discovery by Giacomo<br />
Rizzolatti and colleagues (29) of “mirror neurons” in primates.<br />
The current understanding of mirror neurons was recently summarized<br />
by Rizzolatti and Craighero (30). Mirror neurons are<br />
specialized nerve cells that form systems in several areas of the<br />
brain that are involved in motor functions. According to the<br />
theory, when a person observes the face of another, mirror neurons<br />
appear to evoke in the observer the sensation that the<br />
observed facial muscle activity would evoke. They do not stimulate<br />
the observer to duplicate the activity, only to feel as<br />
though it had. We know that the feeling of the facial muscle<br />
activity that is characteristic of an emotion evokes the feeling of<br />
the emotion. Ekman demonstrated that a person who naively<br />
“makes the face” of sadness by practicing specific facial muscle<br />
activity in a pattern that is characteristic of grief, will feel sad<br />
(31). It follows that when a person observes another in grief,<br />
mirror neurons evoke the feeling of the observed facial expression.<br />
According to Damasio’s somatic marker theory, and<br />
Ekman’s observations, the feeling of sensations from the body<br />
proper (even if the body is observing at rest) that are concordant<br />
with a grieving face is an “emotionally competent stimulus”:<br />
the feelings evoke the experience of grief. 15 The operation<br />
of mirror neurons in humans has been well demonstrated for<br />
simple motor activity. The theory linking mirror neurons to<br />
suffering, empathy, and values is well on the way to validation,<br />
and, validation not withstanding, it makes wonderful sense.<br />
Thus far I have proposed that there is a relationship<br />
between suffering, the capacity for empathy and altruism, and<br />
that the relationship establishes a neural basis for natural morality.<br />
When I refer to altruism, I mean that which consists of fairness,<br />
generosity and regard for others—social emotions and<br />
values. 16 I use the term natural morality to distinguish it from<br />
imposed morality, which is commonly associated with belief<br />
systems and mythology. 17 I believe that altruism is fragile while<br />
exploitation is robust. Cooperation between evolving individuals<br />
did not come easily. The longest period of evolution, as<br />
much as 2.9 billion years, 18 passed while avaricious, self-protective,<br />
single-celled organisms “learned” how to tolerate each<br />
other and cooperate in order to form more efficient and adaptable<br />
multi-celled creatures. 19<br />
Conclusions<br />
IN THIS PAPER I proposed that suffering is the feeling of bodily<br />
disturbance that is evoked by fear or grief primarily, or as a<br />
response to (a) unresolved drives (thirst, hunger, oxygenation,<br />
lust, attachment, etc.) or (b) the experience of pain as it threatens<br />
the integrity of the existential domains of the autobiographical<br />
self. The disability of illness (as opposed to the impairment<br />
of disease) is the effect of suffering as an awareness of the bodily<br />
effects of grief and fear, particularly (but not exclusively) when<br />
evoked by pain.<br />
I offer this theory of suffering in an effort to make suffering<br />
more than just “the story of pain,” the “language of pain,”<br />
or the “emotional aspects of pain.” I have proposed that the<br />
neural substrate of suffering is as real as that of nociception or<br />
fear. Similarly, the burden of suffering is real, even though our<br />
patients use words to describe the experience that are variable<br />
to the point of idiosyncrasy. It is a fatuous conceit to say, “I<br />
feel your pain (or suffering).” No one, neither practitioner<br />
nor patient, can experience the pain or suffering of the other.<br />
That is the interior nature of consciousness and the inherent<br />
15 One aspect of the science of mirror neurons is important for the pain<br />
practitioner who is trying to comprehend the suffering of a patient who<br />
sits with a stooped posture, rocking aimlessly, protecting a withdrawn,<br />
deformed extremity, with the facial expression of fear and grief. Mirror<br />
neurons do not appear to evoke mimicry, only the feeling of mimicry.<br />
Mirror neurons, therefore, do not put practitioners at risk of identification,<br />
a state of mind in which the observer is motivated to behave like the<br />
patient. This is, no doubt, extending limited knowledge too far, but the<br />
ethical distinction between empathy and identification in clinical practice<br />
cannot be overstated. Some practitioners may fear empathy, lest they identify<br />
with the patient and lose clinical perspective in formulating a cogent<br />
diagnosis and appropriate plan of care. The advancing science of mirror<br />
neurons does not eliminate the risk of identification, but it doesn’t<br />
make it inevitable either.<br />
16 This is often referred to by the outmoded term psychological altruism, to distinguish<br />
it from biological altruism, cooperation that promotes survival of the<br />
species but not the individual. Biological altruism is observed in organisms<br />
lacking a central nervous system.<br />
17 In this context I define natural morality as the predisposition to good (as<br />
opposed to right) behavior that does not require, or is independent of, the<br />
existence of a supernatural power or intelligence. For a discussion of natural<br />
law and morality, I refer the reader to Alfonso Gomez-Lobo (32).<br />
18 For those who are interested, a representative evolutionary time-line includes:<br />
Earth cools, water and atmosphere form, 4.1 BYA (billion years ago); singlecelled<br />
organisms appear, 3.9 BYA; sexual reproduction appears, 1.2 BYA;<br />
multi-celled organisms appear, 1.0 BYA; the Cambrian explosion occurs,<br />
0.55 BYA.<br />
19 We share half of our genome with the common yeast whose cooperative skills<br />
go no further than forming colonies. The rest of evolution seems easy in<br />
comparison.<br />
80 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
separation between the observer and the observed. Empathy is<br />
the best we can manage, and if we can muster it to action, that<br />
is good enough.<br />
I believe that the capacity for suffering is the precursor of<br />
natural morality. I stand with numerous scientists and ethicists,<br />
some cited here, to declare that empathy and the understanding<br />
of suffering, however elusive they may be, are the moral obligation<br />
of the pain practitioner. The pain patient has a reciprocal<br />
obligation. Honesty and trust go both ways. Patients deceive<br />
their physicians for a host of reasons, some intentional, some<br />
not. Mistrust at the outset of the relationship thwarts communication.<br />
Mistrust is prejudicial and ethically corrosive. The<br />
moral role of the pain practitioner is to trust the patient’s<br />
reports and expressions of suffering. We cannot measure suffering,<br />
nor can we even be certain of its presence. But we can<br />
explore with the patient the habits, goals, desires, expectations,<br />
roles, attachments—in short, any and every facet of the<br />
patient’s life, some hidden from awareness, that are threatened<br />
by the experience of pain. The treatment of diseases and<br />
injuries includes the treatment of pain. The treatment of pain<br />
is all about suffering.<br />
The author acknowledges the help of Linda Sutton in the preparing<br />
the manuscript and of Russell Stevenson and James Giordano in<br />
formulating and organizing the ideas in it.<br />
REFERENCES<br />
1. Giordano J. Toward a core philosophy and virtue-based ethic of pain<br />
medicine. Pain Practitioner. 2005 Summer; 15 (2): 59-66.<br />
2. Giordano J. The neurobiology of nociceptive and anti-nociceptive systems.<br />
Pain Physician. 2005; 8: 277-291<br />
3. Cassell EJ. The nature of suffering and the goals of medicine. II. Oxford:<br />
Oxford University Press, 1991, 2004.<br />
4. Damasio AR. Descartes’ error: Emotion, reason and the human brain. New<br />
York: Grosset/Putnam Book, 1994.<br />
5. Leder D. Toward a phenomenology of pain. Rev Existential Psychology<br />
and Psychiatry, 1984; 9: 29-43.<br />
6. Damasio AR. The feeling of what happens: Body and emotion in the making<br />
of consciousness. New York: Harcourt-Brace, 1999.<br />
7. Damasio AR. Looking for Spinoza: Joy, sorrow, and the feeling brain. New<br />
York: Harcourt-Brace, 2003.<br />
8. Ekman P. Emotions Revealed: Recognizing Faces and Feelings to Improve<br />
Communication and Emotional Life. New York: Times Books, 2003.<br />
9. Damasio AR. The neurobiological grounding of human values. Changeux<br />
J-P, et al (ed) Neurobiology of human values. Berlin: Springer-Verlag,<br />
2005.<br />
10. Ekman P. Emotions inside out. 130 Years after Darwin’s “The Expression of<br />
the Emotions in Man and Animal.” Ann N Y Acad Sci. 2003; Dec;1000:1-<br />
6.<br />
11. Kubler-Ross E. On death and dying. New York: Simon-Schuster/Touchstone,<br />
1969.<br />
12. Gatchel RJ, Turk DC. Psychosocial factors in pain: Clinical perspectives.<br />
New York: Guilford Press, 1999.<br />
13. Grahek, N. Objective and subjective aspects of pain. Philosophical Psychology.<br />
1991; 4:249-66.<br />
14. White JC, Sweet WH. Textbook of Stereotactic and Functional Neurosurgery.<br />
New York: McGraw-Hill; 1998.<br />
15. Melzack R, Torgerson WS. On the language of pain. Anesthesiology. 1971<br />
Jan; 34(1):50-9.<br />
16. Peyron R, Garcia-Larrea L, Gregoire MC, et al. Functional imaging of brain<br />
responses to pain. A review and meta-analysis. Neurophysiol Clin. 2000;<br />
30: 263-288.<br />
17. Ploghaus A, Narain C, Beckmann CF, et al. Exacerbation of pain by anxiety<br />
is associated with activity in a hippocampal network. J Neuroscience.<br />
2001; 21(24): 9896-9903.<br />
18. Koyama T, McHaffie JG, Laurienti PJ, Coghill RC. The subjective experience<br />
of pain: Where expectations become reality. Proc Natl Acad Sci.<br />
2005 Sep 6; 102(36):12950-5.<br />
19. Melzack R. The McGill pain questionnaire: Major properties and scoring<br />
methods. Pain. 1975; 1: 277-299.<br />
20. Grundel H, O’Connor MF, Lindsey L, et al. Functional neuroanatomy of<br />
grief: An fMRI study. Am J Psychiatry. 2003; 160: 1946-1953.<br />
21. Pezawas L, Meyer-Lindenberg A, Drabant EM, et al. 5-HTTLPR polymorphism<br />
impacts human cingulate-amygdala interactions: a genetic susceptibility<br />
mechanism for depression. Nature Neuroscience. 2005; 8:<br />
828-834.<br />
22. Bitvinick MM, Braver TT, Barch DM, et al. Conflict monitoring and cognitive<br />
control. Psychol Rev. 2001; 108: 624-652.<br />
23. Greene JD, Sommerville R, Nystrom LE, et al. An fMRI investigation of<br />
emotional engagement in moral judgment. Science. 2001; 293:<br />
2105-2108.<br />
24. Greene JD, Nystrom LE, Engell AD, et al. The neural bases of cognitive<br />
conflict and control in moral judgment. Neuron. 2004; 44: 389-400.<br />
25. Greene JD. Emotion and cognition in moral judgment: Evidence from<br />
neuroimaging. Changeux J-P, et al (ed) Neurobiology of human values.<br />
Berlin: Springer-Verlag, 2005.<br />
26. Macphail EM. Brain and Intelligence in Vertebrates. Clarendon Press,<br />
Oxford, 1982.<br />
27. MacLean PD. Cerebral evolution of emotion. Lewis M, Haviland JM (ed)<br />
Handbook of emotions. New York: Guilford Press, 1993.<br />
28. Toi M, Batson CD. More evidence that empathy is a source of altruisticmotivation.<br />
Journal of Personality and Social Psychology. 1972; 43,<br />
281-292.<br />
29. Rizzolatti G, Scandolara C, Matelli M, et al. Afferent properties of<br />
peri-arcuate neurons in macaque monkeys. I. Somatosensory responses.<br />
Behav Brain Res. 1981; 2:125-146.<br />
30. Rizzolatti G, Craighero L. Mirror neuron: A neurological approach to<br />
empathy. Changeux J-P, et al (ed) Neurobiology of human values. Berlin:<br />
Springer-Verlag, 2005.<br />
31. Ekman P. Facial expression. Dalgleish T,<br />
Power M. (ed) Handbook of cognition and<br />
emotion. New York: John Wiley & Sons, 1999.<br />
32. Gomez-Lobo A. Morality and the human<br />
goods: An introduction to natural law ethics.<br />
Washington, DC: GTU Press, 2002.<br />
PETER A.<br />
MOSKOVITZ, MD<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 81
AC ADEMY NEWS | AMERICAN ACADEMY OF PAIN MANAGEMENT<br />
ACADEMY NEWS<br />
The Academy Welcomes<br />
New Credentialing<br />
Coordinator, Christine Wright<br />
CHRISTINE WRIGHT joined the American<br />
Academy of Pain Management in December<br />
2005 as the Credentialing Coordinator.<br />
Christine is responsible for tracking/coordinating<br />
credentialed member and CHRISTINE WRIGHT,<br />
Credentialing<br />
credential eligible applicant processes. She<br />
Coordinator<br />
will also<br />
be involved in the coordination of exhibitor<br />
booths for the 17th Annual Clinical<br />
Meeting in Orlando.<br />
Christine recently moved to California from Boise, Idaho,<br />
where she worked the State of Idaho for the last 25 years.<br />
There she provided direct and indirect services for consumers<br />
and employees and met many interesting challenges including:<br />
developing and coordinating a volunteer program in an institutional<br />
setting, identifying appropriate and cost effective medical<br />
transportation resources for consumers, participating with multiple<br />
agencies in the restructuring of human resources, and<br />
developing a new employee orientation program.<br />
Newly Credentialed<br />
DIPLOMATE<br />
Kenneth J. Allan, MD<br />
Rafael F. Aviles, MD<br />
Alyn LaMar Benezette, DO<br />
Anjum Bux, MD<br />
Robert J. Byrnes, DO<br />
Jacqueline Chanlatte, MD<br />
Jeffrey M. Cox, MD<br />
Sydney H. Crackower, MD<br />
Jay Finke, MD<br />
Kenneth W. Gibson, DO<br />
Allison W. Hanley, MD<br />
James M. Hawk, MD, PA<br />
Jonathan M. Hirsch, MD, PC<br />
Michael S. Lazzopina, MD<br />
Edmund K.T. Liem, DDS<br />
Bettina T. Limjoco, MD<br />
Manoj Maggan, DDS<br />
Don C. McLarey II, MD<br />
Enrico A. Melson, MD<br />
Sunil Shanker Naik, MD<br />
Sardha M. Perera, MD<br />
Aida Suarez Phelan, MD<br />
Kathryn A. Powell-Francis, MD<br />
Chikka M. Raju, MD, MAGD<br />
Challa V. Reddy, MD<br />
Keric J. Shiepis, DC<br />
Louis Greene Stanfield, CRNA, PhD<br />
Robert M. Stein, DVM<br />
Lloyd Stolworthy, MD<br />
Mark R. Stover, DMD<br />
Susan M. Thibault, DPM<br />
Robert N. Ulseth, MD<br />
Shailesh P. Upadhyay, MD<br />
Bradley W. Wargo, DO<br />
Norman H. Wasserman, MD<br />
Igor Wilderma, MD<br />
FELLOW<br />
Jayne D.Andrews, CRNA<br />
Cindy Cornell, BSN, RN<br />
Dennis C. McCraney, PA-C<br />
CLINICAL ASSOCIATE<br />
Paul C. Pollachek, RN, BS<br />
Thank You<br />
The Academy Thanks the Following People for<br />
Their Generous Donations<br />
Davis Bregman, MD<br />
Victoria I. Brightman, DPM<br />
Jose A. Cumba, DMD<br />
Albert C. Cura, MD<br />
Andrew Davy, MD<br />
Leonard B. Goldstein, DDS, PhD<br />
Heusent A. James, MD<br />
IN MEMORY<br />
Valerie Gerard Dillon, MD<br />
Kathleen A. Presutto-Nelson, MD<br />
John E. Freeman<br />
Juan F. Legarreta-Lopez, MD<br />
Andres Vega, MD<br />
C Samuel Verghese, MD, PhD<br />
Oops! In the last issue of The Pain Practitioner, we forgot<br />
to acknowledge two of our photographers (pages 80-81):<br />
Dr. Hal Blatman and Nancy Holland.<br />
82 |T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
N O W A V A I L A B L E !<br />
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CL ASSIFIED ADS & DIRECTORY | AMERICAN ACADEMY OF PAIN MANAGEMENT<br />
CLASSIFIED ADS<br />
To place a classified advertisement in the directory,<br />
call Jillian Manley at the Academy at (209)533-9744<br />
or send an email to jillian@aapainmanage.org.<br />
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Pain Management with Premier Group<br />
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THE GUTHRIE CLINIC is seeking a BE/BC fellowship<br />
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84 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
DIRECTORY<br />
To place an advertisement in the directory, call Jillian Manley at<br />
(209)533-9744 or send an email to jillian@aapainmanage.org.<br />
R ATES<br />
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T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 85
RESOURCES | CRPS<br />
RESOURCES FOR CRPS<br />
Organizations<br />
<strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong> Syndrome Association of America (RSDSA)<br />
RSDSA provides comprehensive information on education, treatment, and research for practitioners and lay people. Information is available as print<br />
pieces or on their website, www.rsds.org. RSDSA publishes a quarterly newsletter, a bi-monthly electronic newsletter and several brochures and<br />
booklets. One of its landmark publications, In Pain, Out of Work, Can’t Pay the Bills, is a resource directory for people who are financially devastated by<br />
CRPS. The organization’s web-housed article archive has more than 80 peer-reviewed articles on various aspects of CRPS.<br />
Address: 99 Cherry St. • Milford, CT 06460<br />
Telephone: 877-662-7737<br />
Email: info@rsds.org<br />
Website: www.rsds.org<br />
International Research Foundation for RSD/CRPS<br />
This is a nonprofit organization dedicated to education and research on <strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong> and Complex Regional Pain Syndrome. The primary<br />
mission of the Foundation is to establish an international research network which will help educate medical professionals and support research worldwide.<br />
Address: USF Medical Clinics c/o Dr. A. Kirkpatrick<br />
12901 Bruce Downs Blvd., MDC59 • Tampa, FL 33612<br />
Telephone: 813-907-2312<br />
Email: info@rsdfoundation.org<br />
Website: www.rsdfoundation.org<br />
National Institute of Neurological Disorders and Stroke (NINDS)<br />
The mission of NINDS is to reduce the burden of neurological disease. NINDS has a listing of clinical trials for neuropathic pain. The information page<br />
that has been condensed from its former fact sheet. It also has a list of clinical trials recruiting people with CRPS.<br />
Address: NIH Neurological Institute<br />
P.O. Box 5801 • Bethesda, MD 20824<br />
Telephone: 800-352-9424 or (301) 496-5751<br />
Website: www.ninds.nih.gov/<br />
National Organization for Rare Disorders (NORD)<br />
NORD is a clearinghouse for information concerning disorders affecting fewer than 200,000 individuals worldwide and features valuable information<br />
on CRPS.<br />
Address: National Organization for Rare Disorders<br />
55 Kenosia Avenue • PO Box 1968 • Danbury, CT 06813-1968<br />
Telephone: 203-744-0100<br />
Tollfree: 800-999-6673 (voicemail only)<br />
Email: orphan@rarediseases.org<br />
Website: www.rarediseases.org<br />
For Grace<br />
For Grace is a nonprofit organization devoted to raising awareness of <strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong> in the medical community and general public.<br />
Address: For Grace<br />
PO Box 1724 • Studio City, CA 91614<br />
Telephone: 818-760-7635<br />
Email: rsdaware@forgrace.org<br />
Website: www.forgrace.org<br />
American RSDHope<br />
This nonprofit group is made up of patients, parents and friends whose mission is to spread information to anyone and everyone who asks or will listen.<br />
Address: American RSDHope<br />
PO Box 875 • Harrison, ME 04040<br />
Email: rsdhope@mail.org<br />
Website: www.rsdhope.org<br />
Promoting Awareness of RSD and CRPS in Canada<br />
Website: www.rsdcanada.org/parc/english/index.html<br />
Books<br />
Living With RSDS, A guide to coping with <strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong> Syndrome, by Linda Lang and Peter Moskovitz, MD. This book is available<br />
from the RSDSA home office for $15 or from Amazon.com.<br />
Positive Options for <strong>Reflex</strong> <strong>Sympathetic</strong> <strong>Dystrophy</strong> (RSD): Self Help and Treatment, by Elena Juris. This book is available from Amazon.com.<br />
Medifocus Guide—contains over 90 pages of information including a clear description of the condition, treatment options, the latest research and a<br />
worldwide directory of RSDS professionals. It is available from the RSDSA website, www.rsds.org.<br />
86 | T H E PA I N P R A C T I T I O N E R | S P R I N G 2 0 0 6
Or register online at www.aapainmanage.org<br />
Register now for the Academy’s 2006 Clinical Meeting in Orlando:<br />
Beyond Boundaries: Forging New Alliances in Pain Management.<br />
Name<br />
Profession<br />
Address<br />
City State Zip<br />
Daytime Phone/Email (required) /<br />
Pre-meeting, Meeting Registration (Thursday) Amount Amount Paid<br />
Member* $ 185<br />
Non-Member $ 225<br />
*Employees of Pain Program Accredited Facilities may register at Member rate<br />
Clinical Meeting Registration (Fri., Sat., Sun.) Early Bird After 7/1 On-Site Amount Paid<br />
Member* $ 375 $ 420 $ 475<br />
Non-Member $ 550 $ 585 $ 640<br />
Full-Time Student Member ** $ 50 $ 60 $ 70<br />
Full-Time Student Non-Member ** $ 85 $ 95 $ 125<br />
One Day $ 250 $ 260 $ 280<br />
Awards Luncheon (Saturday 12:35 - 2:00 pm) $ 35 $ 35 $ 35<br />
You must register and pay for luncheon prior to conference, cannot sign up on-site<br />
*Employees of Pain Program Accredited Facilities may register at Member rate<br />
Membership<br />
Individual Membership $ 195 $195 $195<br />
Amount Paid<br />
Student Membership** $ 50 $ 50 $ 50<br />
**Must provide proof of student status<br />
Total Payment $<br />
Method of payment Visa Mastercard Discover Check Enclosed (US Funds Only)<br />
Credit Card #<br />
Expiration Date Verification Number Signature<br />
Please mail or fax completed Registration Form to:<br />
For AAPM Office Use Only<br />
American Academy of Pain Management<br />
13947 Mono Way #A<br />
Sonora, CA 95370<br />
Phone 209-533-9744<br />
Fax 209-533-9750<br />
Bring<br />
a guest!<br />
The Academy is offering complimentary guest badges for the Exhibit Hall on Friday and Saturday. Badges will be<br />
available at the registration desk.<br />
T H E PA I N P R A C T I T I O N E R | V O L U M E 16 , N U M B E R 1 | 87
A m e r i c a n A c a d e m y o f P a i n M a n a g e m e n t<br />
Beyond Boundaries<br />
Orlando<br />
September 7–10, 2006<br />
FORGING NEW ALLIANCES IN PAIN MANAGEMENT<br />
17th<br />
ANNUAL CLINICAL MEETING<br />
Walt Disney World<br />
Swan and Dolphin<br />
1500 Epcot Resorts Boulevard<br />
Lake Buena Bista, FL 32830<br />
407-934-4888<br />
A m e r i c a n A c a d e m y o f P a i n M a n a g e m e n t<br />
13947 Mono Way #A • Sonora, California 95370<br />
NONPROFIT ORG.<br />
U.S. POSTAGE<br />
PAID<br />
CERES, CA<br />
PERMIT NO. 86