Spinal Cord Stimulation - RSD/CRPS

Complex Regional Pain Syndromes (Reflex Sympathetic Dystrophy and Causalgia) and Spinal Cord Stimulation

The complex regional pain syndromes (CRPS I and CRPS II), also known as reflex sympathetic dystrophy and causalgia, have been recognized for the past 2,500 years and believed in for the past 150, but they have yet to be understood. These syndromes can be characterized by discrete sensory, motor, and autonomic findings, but many patients with CRPS continue to suffer for years without a diagnosis. The role of the sympathetic nervous system in maintaining these syndromes and its appropriateness as a target for treatment continue to be subjects of enduring controversy. As might be expected in a group of disorders that we still have trouble naming, much less diagnosing, it has been very difficult to reach a consensus on how to treat people afflicted with the CRPS. Recent insights into how the nervous system responds to injury are beginning to explain some of the "impossible" neurological findings that are characteristic of CRPS. These research findings may soon be translated into specific therapies targeted at the processes of neural inflammation that appear to play an important role in these syndromes. Using currently available techniques of quantitative sensory testing should allow us to improve our approach to diagnosing our patients and monitoring their responses to treatment. Incorporating these diagnostic techniques into clinical studies now promises to improve the utility of clinical research in this field. Case-series studies suggest that spinal cord stimulation is a safe and effective treatment for many people with advanced CRPS who have not obtained adequate relief with other treatments.
Pain Medicine Article

Daniel S. Bennett, MD, DABPM, and Daniel Brookoff, MD, PhD

Anything that can provide relief is to be welcomed

Music can reduce chronic pain

Research has confirmed listening to music can have a significant positive impact on perception of chronic pain.

US researchers tested the effect of music on 60 patients who had endured years of chronic pain.

Those who listened to music reported a cut in pain levels of up to 21%, and in associated depression of up to 25%, compared to those who did not listen.

The Journal of Advanced Nursing study also found music helped people feel less disabled by their condition.

The patients who took part in the study were recruited from pain and chiropractic clinics.

They had been suffering from conditions such osteoarthritis, disc problems and rheumatoid arthritis for an average of six-and-a-half years.

Most said the pain affected more than one part of their body, and was continuous.

Some listened to music on a headset for an hour every day for a week, while the rest did not.

Among those who listened to music, half were able to chose their favourite selections, the rest had to pick from a list of five relaxing tapes provided by the researchers.

Consistent improvements

Researcher Dr Sandra Siedlecki, of the Cleveland Clinic Foundation, said: "Our results show that listening to music had a statistically significant effect on the two experimental groups, reducing pain, depression and disability and increasing feelings of power.

"There were some small differences between the two music groups, but they both showed consistent improvements in each category when compared to the control group.

"Non-malignant pain remains a major health problem and sufferers continue to report high levels of unrelieved pain despite using medication.

"So anything that can provide relief is to be welcomed."

Professor Marion Good, who also worked on the study, said: "Listening to music has already been shown to promote a number of positive benefits and this research adds to the growing body of evidence that it has an important role to play in modern healthcare."

Previous research published in the same journal found listening to 45 minutes of soft music before going to bed can improve sleep by more than a third.

Complex phenomenon

Dr Cathy Stannard, honorary secretary of the British Pain Society, said other studies had shown music could have a positive impact on the perception of pain.

But she said the effects tended to be relatively small, and there was doubt as to whether they were anything other than very short term.

"The perception of pain is very complicated, and is influenced by factors such as emotion, experience and mood," she said.

"If music makes you feel relaxed and chilled out then one might expect it would affect our perception of pain."

Dr Stannard said it was possible that music simply provided a distraction which stopped people concentrating on their pain.

She said it was not surprising that drugs which had a specific action on the body often had a limited effect on a phenomenon as complex as pain.

"We need to start to think outside the box," she said.

Story from BBC NEWS:

Article - Chronic Regional Pain Syndrome, I & II

Complex Regional Pain Syndrome

By Steven A. King, MD, MS, Psychiatric Times

June 2006, Vol. XXIII, No. 7

Of all the common pain syndromes, perhaps none is so misunderstood by both physicians and patients as complex regional pain syndrome (CRPS). Types I and II of CRPS are the current names for what were previously called reflex sympathetic dystrophy (RSD) and causalgia, respectively. Because of limited knowledge about these disorders, patients who suffer what is frequently very severe pain often have their condition misdiagnosed and do not receive appropriate treatment.

Although many physicians are still relatively unfamiliar with these disorders, the first in-depth description was made over 140 years ago by the physician often considered the father of American neurology, S. Weir Mitchell, and his colleagues, based on their observations of soldiers wounded in the Civil War. They noted that some soldiers who were wounded in the hand or foot developed a burning pain that was exacerbated by touching the affected body part. This syndrome was named causalgia, Greek for “burning pain.”

Multiple similar conditions were described over the years and received a variety of names, including post-traumatic injuries, algodystrophy, and Sudeck atrophy. In 1953, John Bonica, one of the pioneers in the study of pain, suggested that these disorders be subsumed under “reflex sympathetic dystrophy.” However, the validity of this term has been questioned frequently. One of the major problems encountered in its use is the uncertainty of the role of the sympathetic nervous system (SNS) in this disorder. The fact that there is a great deal of variability in response to sympathetic blocks suggests that in many patients, the pain is not due to a disorder of the SNS.

Because of this and the general confusion over RSD and causalgia, the International Association for the Study of Pain renamed these syndromes in its classification of chronic pain.1 RSD became CRPS type I and causalgia became CRPS type II. The diagnostic criteria for CRPS are shown in the Table (see June 2006 Psychiatric Times, page 9). The difference between types I and II is that in the latter, there is evidence of a definable nerve lesion.

Two terms used to describe the pain, allodynia and hyperalgesia, are notable in the criteria for both types of CRPS. Allodynia is pain due to a stimulus that is not usually painful and is commonly the most dramatic presenting symptom of these disorders. Patients with this problem may wear loose-fitting clothing to limit the amount of contact between it and the skin in the affected area. In more severe cases, patients may complain that even having bedsheets touching the body part can cause severe pain. In hyperalgesia, a normally painful stimulus causes more discomfort than expected. Both allodynia and hyperalgesia are covered by the more general term “hyperesthesia,” an increased sensitivity to stimulation.

The frequency of occurrence of CRPS is unclear. A recent study of patients with fractures of the distal radius reported that CRPS type I developed in 18%.2 Another study of 162 soldiers wounded in the Iraqi war who were seen in pain clinics reported that 4.3% suffered CRPS type II and 1.9%, CRPS type I.3 Based on reports that patients with CRPS often see a number of physicians before their condition is diagnosed correctly, it appears that many cases are never diagnosed. Type I may especially go unrecognized because of the absence of an identifiable peripheral nerve injury and the usual relationship of the disorder to some form of trauma, ranging from an accident-induced injury to surgery or diseases that can cause pain, including myocardial infarction and post-herpetic neuralgia. Since pain is an expected sequela of these events, the possibility of CRPS may not be considered by health care providers for lengthy periods.

Unfortunately, because many patients with CRPS appear “normal” and because pain such as allodynia seems so bizarre and so foreign to most laypeople and even some health care professionals, patients may be mistakenly thought to be either exaggerating their pain for secondary gain or even malingering. One of the saddest things is that these patients may find their pain discounted by so many others and may be stigmatized as falsifying their discomfort.

The cause of CRPS remains a mystery. A variety of physiologic mechanisms have been proposed. The classic view that the pain is due to hyperactivity of the SNS has been discounted, although the SNS appears to be involved in some of the symptoms, most notably the edema, blood flow, and sudomotor changes. Currently, CRPS is believed to be due to a combination of peripheral and central factors.4 Among the peripheral mechanisms that have been proposed are an inflammatory process, peripheral sensitization, and changes in sodium channels. These processes may result in central changes, including an exaggerated response to the peripheral input and a reduction of descending inhibitory pathways.

Because the severity of the original trauma does not appear to be correlated with these disorders, the significance of psychological factors and the possibility that they may play an important role - if not the major role - in the development of the pain have often been the focus of attention. Despite this speculation, there have never been consistent findings of a correlation between preexisting mental disorders and the development of CRPS. However, it has been proposed that there may be changes in the brain, most notably in the primary sensory cortex, secondary to CRPS, and that these can lead to a distorted body image.5,6 What role these changes may play in the pain and other symptoms of CRPS is still the subject of speculation.

Dr King is clinical professor of psychiatry at the New York University School of Medicine.

References
1. Merskey H, Bogduk N, eds.Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2nd ed. Seattle: IASP Press; 1994.
2. Puchalski P, Zyluk A. Complex regional pain syndrome type 1 after fractures of the distal radius: a prospective study of the role of psychological factors. J Hand Surg (Br). 2005;30:574-580.
3. Cohen SP, Griffith S, Larkin TM, et al. Presentation, diagnoses, mechanisms of injury, and treatment of soldiers injured in Operation Iraqi Freedom: an epidemiological study conducted At two military pain management centers. Anesth Analg. 2005; 101:1098-1103.
4. McBride A, Atkins R. Complex regional pain syndrome. Curr Orthop. 2005;19:155-165.
5. Moseley GL. Distorted body image in complex regional pain syndrome. Neurology. 2005;65:773.
6. Birklein F, Rowbotham MC. Does pain change the brain? Neurology. 2005;65:666-667.

Worker Compensation Resources - CA

VotersInjuredatWork.org is committed to effecting changes in the workers’compensation system that will help those who have been injured on the job in California receive appropriate medical treatment and get back on track with their lives. That includes keeping the social safety net intact while recovery occurs and people adjust to what is now a different life, whether it is due to a permanently disabling condition or an increased understanding of the fine line between good fortune and disaster.

Learn about topics that include:
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If you or someone you know and love was injured at work, this web site is for you.

Briefing on Pain - June 13, 2006

Report on Congressional Briefing on Pain held on June 13, 2006

The Congressional Briefing on Pain held June 13, 2006, on Capitol Hill was attended by over 100 congressional staffers and pain advocates. The room was packed and over-flowing into the hall, as Rep. Mike Rogers, Rep. Charlie Norwood and featured speakers passionately shared the facts about pain, the personal and economic impact of this "silent epidemic," and the critical need for federal pain policy and legislation.

Congressman Rogers welcomed the audience and challenged people to learn about the healthcare crisis of the undertreatment of pain and to join forces in support of H.R. 1020, the National Pain Care Policy Act (introduced by Congressman Rogers). This "silent epidemic" is destroying the lives of over 50 million Americans and costing $100 billion in lost productivity. Congressman Norwood, a co-sponsor of the bill, spoke of his commitment to the millions of people suffering daily, the need for "balanced" pain policy and his concerns about abuse and illegitimate internet sales.

Dr. Howard A. Heit, a physician and person living with chronic pain, dependent on a wheel chair and body brace, shared his personal story and his life's work. Dr. Heit treats both patients with pain and patients with the disease of addiction. Dr. Heit raised the question - "why is pain not treated with medications approved by the FDA and consistent with state and federal regulations?" He discussed the barriers to pain management, such as, the confusion between physical dependence and addiction, inadequate education in pain and addiction, and the fact that the "balance" has been lost between preventing abuse and diversion and ensuring the availability of strong pain medications for medical purposes, "for all patients who need them for the relief of pain."

Dr. Rollin M. Gallagher, the Director of the Center of Pain Medicine, Research and Policy at the University of Pennsylvania School of Medicine and the Director of Pain Management at the Philadelphia Veterans Affairs Medical Center, urged the support of H.R. 1020, the Pain Care Policy Act. He said it will address the "enormous impact of chronic pain on our economy, and the suffering that chronic pain causes people, families and business and yes, taxpayers." He discussed the impact for veterans, trying to restore life, "following blast injuries causing severe tissue and nerve damage that leave them in a state of permanent severe pain" and "it is the pain that prevents them from resuming a reasonable quality of life, a productive life."

Mary Vargas, JD, a disability rights attorney and chronic pain patient who spent the past ten years advocating on behalf of pain patients while struggling to receive care for herself, provided a vivid and moving account of what it really means to be one of the fifty million, whose lives are being ravaged by a pain. She spoke of how statistics are so "sanitized and simplified, and so unimaginable when looking at the impact of untreated or undertreated or inappropriately treated pain in just one of those fifty million." Her journey has included "16 doctors with countless specialties (an average number for pain patients), hospitals in four states, three physical therapy practices, numerous procedures - too many to count," as well as 8 surgeries and thousands of dollars, not covered by health insurance. Vargas spoke of the "fight of her life, just to receive care" and the additional barriers she has encountered, such as a lack of education of healthcare professionals, "their palpable and unabashed fear of enforcement by the DEA," her difficulty in getting prescriptions filled and enduring the stigma of being a pain patient.

All speakers expressed gratitude to Congressman Rogers for introducing the National Pain Care Policy Act and urged all who attended to become active in the fight to assure that healthcare providers are educated and "care is based on solid medicine, not fear", that critically needed research and public awareness are funded, and that everyone of the 50 million Americans with untreated or undertreated pain "deserve to have hope that they will wake up one day to a life that is not dictated by pain".

All attendees received a folder of information with pain facts, statistics, personal stories (from the American Pain Foundation's Voices of People in Pain) and pertinent articles.

Thank you to Congressman Rogers and all individuals and organizations that helped to make this Congressional Briefing on Pain a success. Together we will make a difference!

CRPS/RSD Conference, Chicago

A Comprehensive Review of Complex Regional Pain Syndrome (CRPS):

Dispelling the Myths & Looking at Emergent Treatment

Chicago September 2006

Northwestern University's Feinberg School of Medicine, the Reflex Sympathetic Dystrophy Syndrome Association (RSDSA) and Rehabilitation Institute of Chicago Academy are sponsoring a 2-day course on Complex Regional Pain Syndrome (CRPS) also known as Reflex Sympathetic Dystrophy Syndrome (RSD).

This course will clarify key issues surrounding this chronic pain condition that continues to baffle healthcare practitioners. Experts will discuss the pathophysiology of CRPS, new diagnostic criteria validation, and the recently revised clinical practice guidelines.

Course Chairs:
R Norman Harden, MD is Director for Pain Studies, Addison Chair, Rehabilitation Institute of Chicago; Associate Professor, Physical Medicine & Rehabilitation, Northwestern University, Feinberg School of Medicine, Chicago IL.

Joshua P. Prager, MD, MS is Director, Center for the Rehabilitation of Pain Syndromes (CRPS), Departments of Internal Medicine and Anesthesiology, David Geffen School of Medicine at University of California, Los Angeles, CA.

To register visit: http://www.ric.org/education/