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Topics in
PAIN MANAGEMENT
Vol. 30, No. 7
Current Concepts and Treatment Strategies
February 2015
CME ARTICLE
Complex Regional Pain Syndrome: Update and Review of
Management
Mikiko Murakami, DO, Boleslav Kosharskyy, MD, Karina Gritsenko, MD, and Naum Shaparin, MD
Learning Objectives: After participating in this CME activity, the physician should be better able to:
1. Clinically assess patients for complex regional pain syndrome (CRPS) using the Budapest Criteria.
2. Educate the patient and supporting family members about interdisciplinary treatment of CRPS.
3. Implement pharmacologic treatments to aid the patient to progress in therapy.
4. Compare some of the interventions used in psychotherapy.
Key Words: Budapest Criteria, Complex regional pain syndrome, Restoration therapy, Pharmacotherapy
I
n the October 2014 issue of Topics in Pain Management
(vol. 30, no. 3), we presented an update and review of the
mechanisms at work in complex regional pain syndrome
(CRPS). In that article, entitled “Complex Regional Pain
Syndrome: An Update and Review of Mechanisms,” we discussed the diagnosis of CRPS and the data to support several
of the proposed contributing factors of the syndrome. We
reviewed and summarized the literature to demonstrate how
epidemiology, genetics, psychosocial factors, immobilization, central nervous system changes, autonomic dysfunction,
neurogenic inflammation, psychological factors, and autoimmunity may be associated with this condition.
In this article, we review the recommended interdisciplinary
treatment algorithms, along with data to support some of the
Dr. Murakami is Resident Physician, Department of Physical Medicine
and Rehabilitation, Icahn School of Medicine at Mount Sinai, Mount
Sinai Health System, New York, New York; Dr. Kosharskyy is Associate
Director of the Pain Service at Montefiore Pain Center, Montefiore
Medical Center, and Assistant Professor of Anesthesiology and
Assistant Professor of Family and Social Medicine at Albert Einstein
College of Medicine of Yeshiva University, Bronx, New York; Dr.
Gritsenko is Assistant Professor of Anesthesiology and Assistant
Professor of Family and Social Medicine, Albert Einstein College of
Medicine of Yeshiva University, Bronx, New York, and Attending
Physician, Montefiore Pain Center and Montefiore Medical Center,
Bronx, New York; and Dr. Shaparin is Director of the Pain Service,
Montefiore Pain Center, Assistant Professor of Anesthesiology, and
Assistant Professor of Family and Social Medicine at Albert Einstein
College of Medicine of Yeshiva University, Bronx, NY 10461; E-mail:
[email protected].
In This Issue
CME Article: Complex Regional Pain Syndrome:
An Update and Review of Management . . . . . . . . . . . . 1
Woman With Rare Genetic Disorder Elects
Amputation to End Chronic Pain . . . . . . . . . . . . . . . . . 9
CME Quiz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
News in Brief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
All authors and staff in a position to control the content of this CME
activity and their spouses/life partners (if any) have disclosed that they
have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity.
Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide
continuing medical education for physicians.
Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™.
Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME
article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This activity
expires on January 31, 2016.
1
Topics in Pain Management
EDITOR
Clifford Gevirtz, MD, MPH
Medical Director
Metro Pain Management
New Rochelle, NY
Clinical Associate Professor
Department of Anesthesiology
Louisiana State University
New Orleans, LA
ASSOCIATE EDITOR
Anne Haddad
Baltimore, MD
EDITORIAL BOARD
Jennifer Bolen, JD
The Legal Side of Pain, Knoxville, TN
February 2015
pharmacotherapies, interventions, and complementary alternative treatments. We complement the first article with this
second part by updating the practitioner on the management
of this challenging pain syndrome.
At the conclusion of this CME activity, the practitioner will
be prepared to perform clinical assessment for CRPS, educate and support patients and families, prescribe evidencebased drug therapies to manage this painful condition, and
consider referring the patient for other interventions such as
psychotherapy.
CRPS Subtypes
CRPS is a chronic pain condition most often affecting one
of the limbs (arms, legs, hands, or feet), usually after an injury
or trauma to that limb. As noted in our previous article, there
are 3 subtypes of CRPS:
Michael DeRosayro, MD
University of Michigan, Ann Arbor, MI
1. CRPS I: causation by an initiating noxious event, such as
a crush or soft tissue injury, immobilization, tight cast, or
surgery;
James Dexter, MD
University of Missouri, Columbia, MO
2. CRPS II: associated with a major nerve lesion; and
Claudio A. Feler, MD
University of Tennessee, Memphis, TN
Elizabeth A.M. Frost, MD
Icahn School of Medicine at Mount Sinai, New York, NY
Alvin E. Lake III, PhD
Michigan Head Pain and Neurological Institute, Ann Arbor, MI
3. CRPS-NOS (not otherwise specified): symptoms consistent with CRPS in which a specific injury or lesion has not
been isolated as the cause.
CRPS has also been staged chronologically, but it has been
demonstrated that the severity of CRPS does not necessarily
Daniel Laskin, DDS, MS
Medical College of Virginia, Richmond, VA
Vildan Mullin, MD
University of Michigan, Ann Arbor, MI
Alan Rapoport, MD
New England Center for Headache, Stamford, CT
Gary Ruoff, MD
West Side Family Medical Center, Kalamazoo, MI
Frederick Sheftell, MD
New England Center for Headache, Stamford, CT
Stephen Silberstein, MD
Jefferson Headache Center, Philadelphia, PA
Steven Silverman, MD
Michigan Head Pain and Neurological Institute, Ann Arbor, MI
Sahar Swidan, PharmD, BCPS
Pharmacy Solutions, Ann Arbor, MI
P. Sebastian Thomas, MD
Syracuse, NY
Marjorie Winters, BS, RN
Michigan Head Pain and Neurological Institute, Ann Arbor, MI
Steven Yarows, MD
Chelsea Internal Medicine, Chelsea, MI
Lonnie Zeltzer, MD
UCLA School of Medicine, Los Angeles, CA
2
The continuing education activity in Topics in Pain Management is intended for clinical
and academic physicians from the specialties of anesthesiology, neurology, psychiatry,
physical and rehabilitative medicine, and neurosurgery as well as residents in those fields
and other practitioners interested in pain management.
Topics in Pain Management (ISSN
0882-5646) is published monthly by
Lippincott Williams & Wilkins, 16522
Hunters Green Parkway, Hagerstown, MD
21740-2116. Customer Service: Phone (800) 638-3030, Fax (301) 223-2400, or Email
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Topics in Pain Management is independent and not affiliated with any organization, vendor
or company. Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or
Editorial Board. A mention of products or services does not constitute endorsement. All comments are for general guidance only; professional counsel should be sought for specific situations. Editorial matters should be addressed to Anne Haddad, Associate Editor, Topics in Pain
Management, 204 E. Lake Avenue, Baltimore, MD, 21212; E-mail: [email protected].
Topics in Pain Management is indexed by SIIC (Sociedad Iberoamericana de Información
Científica).
©2015 Wolters Kluwer Health, Inc. All rights reserved.
Topics in Pain Management
follow staging, with some patients experiencing severe symptoms immediately.1 The Budapest Criteria tool takes into consideration sensory, vasomotor, sudomotor, and trophic changes
that are noted by the clinician during the visit and subjectively
noted by the patient.
Clinical Diagnosis
Clinical diagnosis using the Budapest Criteria can be made
when the following 4 criteria are met2:
1. Continuing pain disproportionate to any inciting event.
2. At a minimum, 1 symptom must be reported in at least 3
of the 4 following categories:
• Sensory: hyperesthesia or allodynia;
• Vasomotor: temperature asymmetry, skin color changes,
or skin color asymmetry;
• Sudomotor/edema: edema, sweating changes, or sweating
asymmetry; and
• Motor/trophic: decreased ROM, motor dysfunction (eg,
weakness, tremor, and dystonia), or trophic changes
(eg, hair, nail, and skin).
3. Patients must display at least 1 sign at the time of evaluation in at least 2 of the following categories:
• Sensory: evidence of hyperalgesia (to pinprick) or allodynia (to light touch, temperature sensation, deep somatic
pressure, or joint movement);
• Vasomotor: evidence of temperature asymmetry (>1°C),
skin color changes, or asymmetry
• Sudomotor/edema: evidence of edema, sweating changes,
or sweating asymmetry; and
• Motor/trophic: evidence of decreased ROM, motor
dysfunction (eg, weakness, tremor, and dystonia), or
trophic changes (eg, hair, nail, and skin).
4. No other diagnosis better explains the signs and symptoms.
For research purposes, the diagnostic decision rule should
be the finding of at least 1 symptom in all 4 symptom categories and at least 1 observed sign.
Management
There is no gold standard treatment for CRPS. In the 4th
edition of CRPS: Practical Diagnostic and Treatment
Guidelines,3 the integration of physical therapy focusing on
functional restoration in combination with pharmacotherapy,
psychotherapy, and interventions was proposed. The emphasis
is on prompt diagnosis, early treatment, and avoidance of
implementing drug therapy alone to prevent disuse of the
affected limb and the psychological consequences of living
in pain.4
©2015 Wolters Kluwer Health, Inc. All rights reserved.
February 2015
Functional Restoration Therapy
The therapy algorithm is based on functional restoration of
the presensorimotor cortexes. Gradual desensitization goes
hand in hand with increased functionality: less pain, more
ROM, and increased strength. Medications and interventions
should only be added if patients cannot proceed to the next
step in therapy.3 Four steps have been defined within a functional restoration therapy algorithm3:
1. Mirror visual feedback, graded motor imagery, reactivation, contrast baths, desensitization, exposure, and therapy;
2. Edema control, flexibility (active), isometric strengthening,
postural correction, diagnosis, and treatment of secondary
myofascial pain;
3. Stress loading, isotonic strengthening, ROM (gentle, passive), general aerobic conditioning, postural normalization,
and balanced use; and
4. Ergonomics, movement therapies, normalization of use,
and vocational/functional rehabilitation.
Pharmacotherapy
Pharmacotherapy is most effective used in combination with
functional restoration. Monotherapy is best to minimize side
effects and maximize compliance,3 but comorbidities such as
depression must be considered. Because CRPS differs from
other nociceptive or neuropathic pain conditions and can
affect an individual’s central pathway, motor function, and
autonomic function, no single medication treats all components of the syndrome.
If a patient cannot progress in therapy because of pain,
edema, inflammation, or immobility, medications can be considered on the basis of symptoms3 (Table 1).
Various types of medications used to provide relief of the
CRPS symptoms include:
• Anti-inflammatories. In acute CRPS, pro-inflammatory
cytokines [tumor necrosis factor-α, interleukin-2 (IL-2), IL-1β,
and IL-6] are upregulated; in contrast, anti-inflammatory
cytokines (IL-4 and IL-10) are diminished.5 Although it has
been customary to start patients on anti-inflammatories,
there are conflicting data regarding these agents as treatment
for CRPS. Inflammation in CRPS is largely thought to be
due to neurogenic inflammation initiated by inflammatory
mediators from the terminals of afferent nociceptors, and
nonsteroidal anti-inflammatory drugs have mixed success in
neuropathic pain.3,6,7 Some data demonstrate that oral corticosteroids are beneficial in acute CRPS.8 (Suggested dose:
naproxen 250–500 mg orally 2 times/day.)
• Immune modulators. Dimethyl sulfoxide (DMSO) cream,
a free-radical scavenging agent, has anti-inflammatory,
analgesic, mast-cell inhibition, and muscle-relaxing effects,
and is thought to be beneficial for CRPS-I.7 A study of 29
3
Topics in Pain Management
February 2015
Table 1. Pharmacotherapy for Pain, Edema, Inflammation, or Immobility in Patients Who Cannot
Otherwise Progress in Therapy
Symptom
Medication
Mild to moderate pain
Excruciating, intractable pain
Inflammation, edema
Simple analgesics and/or interventional blocks
Opioids, interventional blocks
Corticosteroids (systemic or targeted, acute), nonsteroidal anti-inflammatory drugs
(chronic), immune modulators
Sedative, analgesic antidepressant/anxiolytics, and/or psychotherapy
Anticonvulsants and/or other sodium channel blockers and/or N-methyl-D-aspartate
antagonists
Calcitonin, bisphosphonates
Depression, anxiety, insomnia
Significant allodynia/hyperalgesia
Significant osteopenia, immobility,
and trophic changes
Profound vasomotor disturbance
Calcium channel blockers, sympatholytics, and/or interventional blocks
patients demonstrated that topical application of DMSO
50% decreased pain intensity according to a visual analog
score with results approaching absence of pain, and it led
to higher scores on the quality-of-life questionnaire. The
authors concluded that topical DMSO 50% is an additional
tool for use in treating CRPS-I, providing an overall sense
of relief and decreased rigidity with few side effects.9
• Capsaicin cream. The mechanism of action of capsaicin was
thought to be related to substance P, but it is now thought to
be due to the decrease of the transient receptor potential cation channel subfamily V member 1 (TRPV1), the capsaicin
receptor. There is good evidence demonstrating that capsaicin treats neuropathic pain.10 (Suggested dose: capsaicin topical 4 times/day over painful regions.)
• Vitamin C. The exaggerated inflammatory response in CRPS
generates excess free radicals. One literature review concluded that routine, daily administration of vitamin C may
be beneficial after foot and ankle surgery or injury to avoid
CRPS.11 A review of vitamin C prophylaxis in 40 patients
with stage II or III trapeziometacarpal arthritis requiring
joint replacement revealed that no CRPS-I occurred, compared with 13% cases of CRPS-I after the same implant
without vitamin C prophylaxis.12 (Suggested dose: vitamin
C 500 mg orally for 50 days.11)
• Antidepressants. The psychogenic association of depression to CRPS continues to be debated, with no data proving that depression causes pain. Antidepressants can treat
the consequential depression of the patient, which can
lower the pain threshold. Serotonin-norepinephrine reuptake inhibitors are FDA-approved for various chronic pain
conditions, but they have not been trialed for CRPS.
Tricyclic antidepressants (TCAs) such as nortriptyline and
amitriptyline can be used for neuropathic pain; nortriptyline has fewer adverse effects.
4
• Calcitonin. Despite conflicting evidence, calcitonin is often
prescribed.13-15 Intramuscular calcitonin was researched for
poststroke patients and demonstrated to suppress the onset
of CRPS when started immediately after the stroke.16
(Suggested dose: nasal calcitonin 200 units 2 times/day.)
• Bisphosphonates. These agents relieve spontaneous and
stimulus-evoked pain and improve functional status in
patients with early disease (<6 months). (Suggested dose:
neridronate IV 100 mg 4 times over 10 days or pamidronate
IV 90 mg 4 times over 10 days.)17
• Dystonia treatment. Dystonia and contractures can occur in
severe CRPS, leading to pain, decreased ROM, and disability. The mechanism differs from dystonia seen in patients
who have central nervous system pathologies. Baclofen is
generally a first-line agent. Trihexyphenidyl and Botox can
also be considered. (Suggested dose: Botox 40 sites or 200
units.)
• Opioids. This class should be used as second- or third-line
agents. Opioids can be used for neuropathic pain, with methadone having advantages because of N-methyl-D-aspartate
(NMDA) antagonism. The practitioner must be vigilant about
managing tolerance, and the risks of opioid-induced hyperalgesia or overdose. The practitioner should be beware that using
short-acting opioids for rescue dosing remains controversial.3
• NMDA antagonist, ketamine infusion. NMDA antagonists
have promising results, but there are toxic side effects and it
is a drug with potential for abuse.18 Optimum dose, route,
and timing of administration remain to be determined.18-20
• IV magnesium. In a pilot study of 8 patients, IV magnesium significantly improved pain, impairment, and quality
of life. It was also well-tolerated.21
• IV immunoglobulin. The autoimmune theory for CRPS
hypothesizes that injury facilitates the binding of preexisting
©2015 Wolters Kluwer Health, Inc. All rights reserved.
Topics in Pain Management
autoantibodies to target structures, enhancing central sensitization. (Suggested dose: IV immunoglobulin 0.5 g/kg over
10 days.)22
• Mannitol + corticosteroid + gabapentin. A recent study
compared the clinical results of 4 treatment modalities for
CRPS-I associated with various types of upper extremity
fractures. In comparing the groups (NSAID, gabapentin,
IV mannitol with corticosteroid, or IV mannitol with corticosteroid and gabapentin), the authors concluded that a
protocol including a combination of IV 20% mannitol and
corticosteroid with oral gabapentin is an acceptable and
effective treatment for CRPS-I.23
Pain Interventions
Interventional management of CRPS can be categorized into
3 main approaches24:
1. Minimally invasive approaches, which include sympathetic nerve blocks, IV regional nerve blocks, and somatic
nerve blocks;
2. More invasive approaches, which include epidural and plexus
catheter blocks, neurostimulation, and intrathecal drug
infusion; and
3. Surgical and experimental interventions, which include
sympathectomy and motor cortex stimulation.24
Minimally Invasive Approaches
Sympathetic block of the stellate ganglion or the lumbar
sympathetic chain has demonstrated pain relief that outlasts
the local anesthetic effects.25 One study reviewed a treatment
that included IV regional anaesthetic block with lidocaine and
methylprednisolone. In this study, 168 patients with CRPS-I
of the upper extremity were treated in a 5-year period. At the
end of treatment, 88% of the patients reported minimal or no
pain. After a mean follow-up of 5 years (range, 28 months to
7 years), complete absence of pain was reported by 92% of
the patients in the study.26
A 2013 analysis that summarized Cochrane and nonCochrane reviews revealed moderate evidence that sympathetic
nerve blocks with anesthetics and IV regional blocks with guanethidine are not effective.27 Despite conflicting research outcomes, sympathetic blocks continue to be widely used
internationally to treat CRPS. In a study of 14 patients who had
joint stiffness caused by CRPS-I, the authors concluded that the
nerve block is a valuable diagnostic and therapeutic option for
the management of joint stiffness caused by CRPS-I.28
More Invasive Approaches
Neurostimulation can be considered if a patient has had no
response to conventional treatment (eg, pharmacotherapy)
within 12 to 16 weeks.
Spinal cord stimulation (SCS) has been demonstrated to be
highly effective in the treatment of CRPS-I, resulting in sig©2015 Wolters Kluwer Health, Inc. All rights reserved.
February 2015
nificant, long-term reduction in pain and improvement in
quality of life.24 SCS, because of costs and invasiveness, has
been used as a last resort when treating CRPS. Authors of a
2013 literature review, which considered safety, efficacy, costefficacy, and cost neutrality, concluded that SCS should not
be considered a therapy of the last resort for CRPS but rather
should be applied earlier (eg, 3 months) as soon as more conservative therapies have failed.29,30
A case series of 5 patients demonstrated that combined SCS
and intrathecal baclofen neuromodulation decreased pain
Starting Treatment of CRPS:
A Proposed Guide
F
or the primary care provider, the multitude of CRPS
treatment options can be overwhelming, especially with
no gold standard for treatment. Functional restoration therapy is the main treatment, with pharmacologic treatments to
support progression of therapy. We propose the following
scheme.
Acute CRPS: Treatments That Can Be
Started by the Primary Care Provider
1. Over-the-counter supplements:
• Vitamin C (reduce free radicals): Suggested dose
500 mg by mouth once daily;
• Fish oil (reduce inflammation and enhance immune
system): 1 to 2 g by mouth once daily;
• Vitamin B complex (for nerve health): If supplement
includes vitamin B1 100 mg, vitamin B6 100 mg, vitamin B12 100 mcg, suggested dose: vitamin B complex by mouth 1 to 2 tablets by mouth once daily; and
• Acetyl-L-carnitine (reduce free radicals and block
T-type calcium channel): Suggested dose: acetyl-Lcarnitine 500 to 1000 mg by mouth 3 times/day.
2. Treat pain and inflammation: naproxen 500 mg by
mouth 2 times/day.
3. Reduce free-radical scavengers and inflammation:
DMSO cream.
4. Neuropathic pain: anticonvulsants, TCAs (eg, nortriptyline as it has less side effects than amitriptyline).
5. Chronic CRPS—referral to a specialist to evaluate the
necessity of:
• IV magnesium;
• Ketamine infusion;
• IV mannitol + corticosteroid + gabapentin; and
• Pain interventions.
5
Topics in Pain Management
intensity in refractory CRPS cases or improved associated
abnormal dystonic posture and movement disorders and
reduced pain fluctuations.31
Dorsal root ganglia (DRG) may be more effective as a physiological target for electrical modulation compared with spinal
cord stimulators because of the confluence of sensory fibers in
the DRG. In a study of 8 subjects, 1 month after implantation
of the neurostimulator, participants reported an average of 62%
pain reduction in both intensity and surface area, with pain
relief persisting through 1 year in most subjects. Improvements
in edema, trophic skin, and functionality were also noted.32
Surgical and Experimental Approaches
Sympathectomies are thought to be effective CRPS treatments. No randomized controlled trials have been carried out to
study sympathectomy in patients with CRPS, but a military
study in 2000 included 1564 patients with nerve injuries. The
data from this study demonstrated that 89% of patients experienced pain relief from a sympathetic block. Of these patients,
100% had complete relief of symptoms in the immediate postoperative period and for follow-up from 1 to 6 years.33 In a
2003 meta-analysis, 94% of the patients undergoing sympathectomy were cured of CRPS symptoms.34
Animal studies have demonstrated that the pathophysiology of
CRPS involves coupling between nociceptive fibers and sympathetic fibers.35 In a study of 16 patients with CRPS-II who
had ineffective pain treatment for more than 6 months, subcutaneous venous sympathectomy was performed, and 75% of the
patients achieved significant improvement in limb function.36
Amputation for long-standing, therapy-resistant CRPS-I
continues to remain controversial. A 2011 literature review
demonstrated that recurrence of CRPS-I in the stump
occurred in 31 of 65 patients, and 15 patients had phantom
pain. Patient satisfaction was reported in 8 studies, although
the definition of “satisfaction” was not clear.37
Psychotherapy
A 2012 systematic review analyzed psychosocial factors
associated with CRPS and concluded that research does not
reveal evidence to support any specific personality or psychopathology predictors of the condition.38 However, depression
and anxiety can be consequences of becoming disabled or
experiencing chronic pain, and secondary gain must also be
recognized.
Psychological interventions for CRPS are theorized to be palliative and possibly have a pathophysiologic impact on the disease.39 CRPS affects adrenergic mechanisms and inflammatory
mediators, both of which can be affected by the psyche.
Although the sample sizes have been small, the research
behind adding psychotherapy to physical therapy and pharmacotherapy in the efficacy of treating CRPS has been promising,
demonstrating improvements in skin temperature, pain, ROM,
and edema. A literature review reveals the positive efficacy of
6
February 2015
behavioral interventions for CRPS, demonstrating that modalities
such as thermal biofeedback, hypnotic imagery, physical therapy, and relaxation training can reduce pain and, in some cases,
completely resolve symptoms.3 Other modalities, such as eyemovement desensitization and reprocessing, hypnosis, and
meditation, have also been used.3
Harden et al3 used the following psychological interventional
step-by-step algorithm to help address issues such as painrelated fears, incorrect beliefs, expectations, and family education:
1. Patient and family education about CRPS.
• Pathophysiology in lay language;
• Disuse issues;
• Reactivation;
• Self-management focus; and
• Possible psychophysiological interactions.
2. Psychological evaluation (core issues).
• Comorbid axis I psychiatric disorders;
• Cognitive, behavioral, emotional response to CRPS;
• Ongoing life stressors; and
• Responses of significant others to CRPS.
3. Psychological pain management intervention.
• Relaxation training with biofeedback;
• Cognitive intervention;
• Behavioral intervention; and
• Family intervention.
4. If axis I psychiatric disorders or major life stressors are
identified, the practitioner should conduct focused cognitive behavioral therapy targeting these issues.
Integrative Medicine
Very little research has been done in the field of complementary alternative medicine for CRPS. However, we know
that specific treatments and remedies relieve pain with a good
side-effect profile. Modalities such as acupuncture,40,41 craniosacral therapy, and osteopathic manipulations have been
demonstrated to decrease perceived pain, reduce inflammation, and relax the stressed mind.
In addition, food and supplements have been demonstrated
to affect pain in the following ways:
• Consuming the ideal ratio of omega-3 to omega-6 polyunsaturated fatty acids. Omega-6s are important for the body’s
immune system. They have a proinflammatory effect that
may contribute to chronic inflammation. Omega-3s reduce
©2015 Wolters Kluwer Health, Inc. All rights reserved.
Topics in Pain Management
these proinflammatory responses and have been demonstrated to decrease inflammation in rheumatoid arthritis42
and reduce progression of osteoarthritis.43 (Suggested dose:
fish oil 1–2 g by mouth daily.)
• Magnesium. Overactivation of the NMDA receptor systems plays a role in central sensitization.44 NMDA receptor antagonists have undesirable side effects; an alternative
strategy to reducing the effect of NMDA is to reduce dietary polyamine intakes. Polyamines originate from diet
and gut bacterial metabolism.45 Magnesium is an NMDA
receptor blocker that has been suggested for brain function, including the reduction of pain paroxysms in patients
with neuropathic pain.46
• Vitamin C. Vitamin C reduces free radicals and can prevent
the onset or worsening of nerve injury in neuropathic pain.
(Suggested dose: vitamin C 500 mg by mouth per day.)
• Vitamin B complex. Vitamins B6 and B12 are necessary for
nerve function. Several studies indicate that the use of
vitamin B may help neuropathic pain. (Suggested dose:
vitamin B complex 1–2 tablets by mouth daily, with a typical B-complex formula containing vitamin B1 100 mg,
vitamin B6 100 mg, and vitamin B12 100 mcg.)
• Alpha-lipoic acid. Alpha-lipoic acid has been studied
extensively for neuropathic pain, especially in Australia
and Europe. Its mechanisms include free-radical scavenging, and recent studies show it may also be a T-type calcium channel blocker.47 One systematic literature review
demonstrated that when alpha-lipoic acid IV 600 mg over
3 weeks is administered, a significant and clinically relevant reduction in neuropathic pain is noted (grade of recommendation: A). 48 It can also be taken orally and
purchased over the counter. (Suggested dose: alpha-lipoic
acid 100 mg by mouth daily.)
• Acetyl-L-carnitine (ALC). ALC is a molecule derived from
acetylation of carnitine in the mitochondria. ALC represents
a consistent therapeutic option for peripheral neuropathies,
and its complex effects, neurotrophic and analgesic, on the
basis of epigenetic mechanism, open new pathways in the
study of peripheral nerve disease management.49 It is also
being used in early dementia and Alzheimer disease.
(Suggested dose: ALC 500–1000 mg by mouth 3 times/
day.)49
Conclusion
There have been many advances in CRPS research, with literature demonstrating evidence to support the integration of
functional restoration therapy, pharmacotherapy, and psychotherapy. Despite all of the modalities available, a significant
number of patients with CRPS experience long-lasting symptoms.50 Early detection and treatment is key, and prevention of
disease worsening should be considered. ■
©2015 Wolters Kluwer Health, Inc. All rights reserved.
February 2015
Acknowledgment. This article was reviewed and edited by
Elizabeth A.M. Frost, MD, Professor, Department of
Anesthesiology, Icahn Medical Center at Mount Sinai, New
York, New York.
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2007;8(4):326-331.
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Harden RN, Oaklander AL, Burton AW, et al. Complex regional
pain syndrome: practical diagnostic and treatment guidelines. 4th ed.
Pain Med. 2013;14(2):180-229.
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Turner-Stokes L, Goebel A. Complex regional pain syndrome in
adults: concise guidance. Clin Med. 2011;11(6):596-600.
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Schlereth T, Drummond PD, Birklein F. Inflammation in CRPS:
role of the sympathetic supply. Auton Neurosci. 2014;182:102-107.
6.
Borchers AT, Gershwin ME. Complex regional pain syndrome: a
comprehensive and critical review. Autoimmun Rev. 2014;13(3):242265.
7.
Birklein F, Schlereth T. Current aspects of the therapy of complex
regional pain syndrome. Nervenarzt. 2013;84(12):1436-1444.
8.
Christensen K, Jensen EM, Noer I. The reflex dystrophy syndrome
response to treatment with systemic corticosteroids. Acta Chir
Scand. 1982;148(8):653-655.
9.
Gaspar M, Bovaira M, Carrera-Hueso FJ, et al. Efficacy of a topical treatment protocol with dimethyl sulfoxide 50% in type 1 complex regional pain syndrome. Farm Hosp. 2012;36(5):385-391.
10. Carroll I, Curtin CM. Management of chronic pain following
nerve injuries/CRPS type II. Hand Clin. 2013;29(3):401-408.
11. Shibuya N, Humphers JM, Agarwal MR, et al. Efficacy and safety of
high-dose vitamin C on complex regional pain syndrome in extremity trauma and surgery—systematic review and meta-analysis. J Foot
Ankle Surg. 2013;52(1):62-66.
12. Zollinger PE, Unal H, Ellis ML, et al. Clinical results of 40 consecutive basal thumb prostheses and no CRPS type I after vitamin C
prophylaxis. Open Orthop J. 2010;4:62-66.
13. Maihofner C Seifert F, Markovic K. Complex regional pain syndromes: new pathophysiological concepts and therapies. Eur J
Neurol. 2010;17(5):649-660.
14. Sahin F, Yilmaz F, Kotevoglu N, et al. Efficacy of salmon calcitonin in complex regional pain syndrome (type 1) in addition to
physical therapy. Clin Rheumatol. 2006;25(2):143-148.
15. Schurmann M, Vogel T, Gärtner A, et al. Experiences with calcitonin treatment of patients with type I complex regional pain syndrome (CRPS I–Sudeck disease). Z Orthop Ihre Grenzgeb.
2001;139(5):452-457.
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16. Matayoshi S, Shimodozono M, Hirata Y, et al. Use of calcitonin
to prevent complex regional pain syndrome type I in severe hemiplegic patients after stroke. Disabil Rehabil. 2009;31(21):
1773-1779.
17. Varenna M, Adami S, Rossini M, et al. Treatment of complex
regional pain syndrome type I with neridronate: a randomized,
double-blind, placebo-controlled study. Rheumatology (Oxford).
2013;52(3):534-542.
18. Azari P, Lindsay DR, Briones D, et al. Efficacy and safety of ketamine in patients with complex regional pain syndrome: a systematic
review. CNS Drugs. 2012;26(3):215-228.
19. Pickering AE, McCabe CS. Prolonged ketamine infusion as a therapy
for complex regional pain syndrome: synergism with antagonism?
Br J Clin Pharmacol. 2014;77(2):233-238.
February 2015
30. Dworkin RH, O’Connor AB, Kent J, et al. Interventional management of neuropathic pain: NeuPSIG recommendations. Pain.
2013;154(11):2249-2261.
31. Goto S, Taira T, Horisawa S, et al. Spinal cord stimulation and
intrathecal baclofen therapy: combined neuromodulation for treatment of advanced complex regional pain syndrome. Stereotact
Funct Neurosurg. 2013;91(6):386-391.
32. Van Buyten JP, Smet I, Liem L, et al. Stimulation of dorsal root
ganglia for the management of complex regional pain syndrome: a
prospective case series. Pain Pract. 2014 [Epub ahead of print].
33. Hassantash SA, Maier RV. Sympathectomy for causalgia: experience with military injuries. J Trauma. 2000;49(2):266-271.
34. Hassantash SA, Afrakhteh M, Maier RV. Causalgia: a meta-analysis of the literature. Arch Surg. 2003;138(11):1226-1231.
20. Harbut RE, Correll GE. Successful treatment of a nine-year case
of complex regional pain syndrome type-I (reflex sympathetic dystrophy) with intravenous ketamine-infusion therapy in a warfarinanticoagulated adult female patient. Pain Med. 2002;3(2):
147-155.
35. Baron R, Levine JD, Fields HL. Causalgia and reflex sympathetic
dystrophy: does the sympathetic nervous system contribute to the
generation of pain? Muscle Nerve. 1999;22(6):678-695.
21. Collins S, Zuurmond WW, de Lange JJ, et al. Intravenous magnesium for complex regional pain syndrome type 1 (CRPS 1) patients:
a pilot study. Pain Med. 2009;10(5):930-940.
36. Happak W, Sator-Katzenschlager S, Kriechbaumer LK. Surgical
treatment of complex regional pain syndrome type II with regional
subcutaneous venous sympathectomy. J Trauma Acute Care Surg.
2012;72(6):1647-1653.
22. Goebel A, Baranowski A, Maurer K, et al. Intravenous immunoglobulin treatment of the complex regional pain syndrome: a randomized trial. Ann Intern Med. 2010;152(3):152-158.
37. Bodde MI, Dijkstra PU, den Dunnen WF, et al. Therapy-resistant
complex regional pain syndrome type I: to amputate or not?
J Bone Joint Surg Am. 2011;93(19):1799-1805.
23. Lee SK, Yang DS, Lee JW, et al. Four treatment strategies for complex
regional pain syndrome type 1. Orthopedics. 2012;35(6):e834-e842.
38. Lohnberg JA, Altmaier EM. A review of psychosocial factors in
complex regional pain syndrome. J Clin Psychol Med Settings.
2013;20(2):247-254.
24. Stanton-Hicks M. Complex regional pain syndrome: manifestations and the role of neurostimulation in its management. J Pain
Symptom Manage. 2006;31(4 suppl):S20-S24.
25. Price DD, Long S, Wilsey B, et al. Analysis of peak magnitude and
duration of analgesia produced by local anesthetics injected into
sympathetic ganglia of complex regional pain syndrome patients.
Clin J Pain. 1998;14(3):216-226.
39. Harden RN. Complex regional pain syndrome. Br J Anaesth.
2001;87(1):99-106.
40. Wilder RT. Management of pediatric patients with complex
regional pain syndrome. Clin J Pain. 2006;22(5):443-448.
41. Vickers AJ, Linde K. Acupuncture for chronic pain. JAMA.
2014;311(9):955-956.
26. Varitimidis SE, Papatheodorou LK, Dailiana ZH, et al. Complex
regional pain syndrome type I as a consequence of trauma or surgery to upper extremity: management with intravenous regional
anaesthesia, using lidocaine and methyloprednisolone. J Hand
Surg Eur. 2011;36(9):771-777.
42. Calder PC. Marine omega-3 fatty acids and inflammatory processes: Effects, mechanisms and clinical relevance. Biochim
Biophys Acta. 2014 [Epub ahead of print].
27. O’Connell NE, Wand BM, McAuley J, et al. Interventions for
treating pain and disability in adults with complex regional pain
syndrome. Cochrane Database Syst Rev. 2013;4:CD009416.
43. Lopez HL. Nutritional interventions to prevent and treat osteoarthritis. Part I: focus on fatty acids and macronutrients. PM R. 2012;
4(5 suppl):S145-S154.
28. Muhl C, Isner-Horobeti ME, Laalou FZ. et al. The value of nerve blocks
in the diagnoses and treatment of complex regional pain syndrome type
1: a series of 14 cases. Ann Phys Rehabil Med. 2014;57(6-7):
381-393.
44. Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in
pain. Science. 2000;288(5472):1765-1769.
29. Poree L, Krames E, Pope J, et al. Spinal cord stimulation as treatment for complex regional pain syndrome should be considered
earlier than last resort therapy. Neuromodulation. 2013;16(2):
125-141.
8
45. Bell RF, Borzan J, Kalso E, et al. Food, pain, and drugs: does it
matter what pain patients eat? Pain. 2012;153(10):1993-1996.
46. Pickering G, Morel V, Simen E, et al. Oral magnesium treatment in
patients with neuropathic pain: a randomized clinical trial. Magnes
Res. 2011;24(2):28-35.
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February 2015
47. Lee WY, Orestes P, Latham J, et al. Molecular mechanisms of
lipoic acid modulation of T-type calcium channels in pain pathway.
J Neurosci. 2009;29(30):9500-9509.
49. Onofrj M, Ciccocioppo F, Varanese S, et al. Acetyl-L-carnitine:
from a biological curiosity to a drug for the peripheral nervous system and beyond. Expert Rev Neurother. 2013;13(8):925-936.
48. Mijnhout GS, Alkhalaf A, Kleefstra N, et al. Alpha lipoic acid: a
new treatment for neuropathic pain in patients with diabetes? Neth
J Med. 2010;68(4):158-162.
50. Bean DJ, Johnson MH, Kydd RR. The outcome of complex regional
pain syndrome type 1: a systematic review. J Pain. 2014;15(7):
677-690.
Woman With Rare Genetic Disorder Elects Amputation to
End Chronic Pain
T
he Portland Press Herald (Portland, Maine) published a
That hyperflexibility and tissue fragility, combined with her
3-part article about a local woman who elected to amputate
running, had worn out the ligaments of her feet, causing her
her left foot after 11 years of refractory chronic pain in both
to feel knife-like pain.
feet, caused by the genetic disorder Ehlers-Danlos syndrome.1
Before physicians finally reached the EDS diagnosis, they
Her decision had been controversial, with many surgeons
prescribed several strategies and performed several surgeries:
she contacted unwilling to consider amputation. After having
Morgan was first told she needed to stretch more, which she
the surgery and completing rehabilitation with a prosthetic
did. She underwent cortisone injections and nerve blocks in
foot, the patient is happy with her decision and more active,
her spine. She received shockwave therapy, being told it would
finding that the solution of amputating one foot allows her to
break up the tissue in her feet and promote healing. Surgeons
put less stress on her other foot, leading to manageable pain
cut ligaments in her feet and tendons of her calves to make
and a decision not to pursue amputating her right foot.2,3
them longer and stronger, they said.
According to the Ehlers-Danlos
National Foundation (EDNF)
website,4 people with EhersThe pain affected her marriage, social life, work, and other aspects
Danlos syndrome (EDS) have a
of her life. After being told there was no cure, she considered
genetic defect in their connective
tissue, resulting in fragile skin and
amputation. Her biggest obstacle turned out to be finding a surgeon.
unstable joints due to faulty or
reduced amounts of collagen.
There are 6 major subtypes classified under this syndrome. The
Meanwhile, Morgan went from easy athlete to someone who
most common type—classical—has been estimated to occur in
carefully planned to spend as little time as possible on her
fewer than 1 of every 10,000 individuals, though other estifeet. The pain affected her marriage, social life, work, and
mates indicate the occurrence could be as low as 1 in 40,000
other aspects of her life. After being told there was no cure,
individuals.4
she considered amputation and read the blog of a 61-year-old
runner who elected amputation and prosthetics. She decided
The EDNF website contains several resource guides for
to have her left foot amputated.
medical professionals, in addition to several pages with information for patients.
Willing to Risk Phantom Limb Pain
Gymnastics, Cheerleading, and Running
The woman profiled by the Portland Press Herald, Elisha
Morgan, 35, was a gymnast as a child and a cheerleader in high
school. By college, she had become a runner who logged 30
miles a week. Her pain became noticeably bad during her last
year in college, but it wasn’t correctly diagnosed until years
later.1
Once the EDS diagnosis was made, Morgan told the newspaper, she was still a bit skeptical, as her physicians had been
wrong so many other times. But after she read about EDS, it
made sense—she had always been particularly flexible as a
gymnast and was able to perform a “snake-like” trick with her
hands pressed together. The syndrome is marked by hyperflexibility in the joints.
©2015 Wolters Kluwer Health, Inc. All rights reserved.
Morgan’s biggest fear with this choice had been phantom
limb pain, but she felt it was a risk worth taking. Her biggest
obstacle turned out to be finding a surgeon who would perform the amputation. None of the Maine surgeons she contacted approved of her decision.1,2
She ultimately went to the Lahey Hospital and Medical
Center in Boston, where Margaret Lobo, MD, director of foot
and ankle surgery, agreed amputation was a valid option but
recommended she find a surgeon with more experience.
Morgan ultimately turned to Blake Ohlson, MD, in South
Carolina, the same surgeon who had amputated the feet of the
runner, Richard Blalock, whose blog Morgan had followed.
According to the second of the 3-part series, Ohlson performs about 3 or 4 elective amputations a year. He told the
9
Topics in Pain Management
February 2015
newspaper that Morgan wasn’t a typical candidate for the procedure—she didn’t even limp. Morgan explained the reason
for this to the newspaper, saying she could not favor one foot
over the other when both burned in pain.2
limb pain did not develop. She has decided not to amputate
her right foot, however. With the prosthetic on her left leg, she
is able to favor that leg, leading to less stress and therefore
less pain in the right foot.
The article also describes the
larger problem of chronic pain
in the United States, quoting
She has decided not to amputate her right foot. With the
figures from the 2011 Institute
of Medicine report for the monprosthetic on her left leg, she is able to favor that leg, leading
etary cost of such pain: $560
to less stress and therefore less pain in the right foot.
billion to $635 billion annually
in health care costs and lost productivity. In the microcosm of
Ohlson required Morgan obtain a second opinion and a psyone medical center, the article says, chronic pain accounts for
chiatric evaluation, which she did. Although Morgan had
300 referrals a month at the Mercy Pain Center in Portland.1
wanted both feet amputated, Ohlson told her he would ampuReferences
tate one. He performed an Ertl procedure, using part of the
1. Bridgers L. Chronic pain, drastic decision: Elisha’s choice; first of
amputated bone to create a bridge between the ends of the tibia
three parts. Portland Press Herald, December 21, 2014.
and fibula, holding them with a long screw until they grew and
2. Bridgers L. After foot amputated, relief and high hopes; second of
fused together. Morgan underwent a long recovery and rehabilthree parts. Portland Press Herald, December 22, 2014.
itation visits over several months back home in Maine.
Prosthetic Left Foot Alleviates Stress on
Right Foot
Morgan told the newspaper in the third article of the series
that she is happy, active, and glad of her choice. Phantom
3.
Bridgers L. Pain relief after amputation gives gift of mobility to
Gorham woman; third of three parts. Portland Press Herald,
December 23, 2014.
4.
Ehlers Danlos National Foundation website. http://www.ednf.org.
Dear Topics in Pain Management subscribers,
For those of you who access the CME tests online, the test for this issue of Topics in Pain Management will be available
through Lippincott CME Connection at http://cme.lww.com.
To access Topics in Pain Management tests on the new Lippincott CME Connection, follow the “Subscriber Activation
Instructions” provided on the primary website: www.topicsinpainmanagement.com.
Thank you for your continued support of Topics in Pain Management.
Publisher
Wolters Kluwer
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©2015 Wolters Kluwer Health, Inc. All rights reserved.
Topics in Pain Management
February 2015
Topics in Pain Management CME Quiz
To earn CME credit, you must read the CME article and
complete the quiz and evaluation assessment survey on the
enclosed form, answering at least 70% of the quiz questions
correctly. Select the best answer and use a blue or black pen
to completely fill in the corresponding box on the enclosed
answer form. Please indicate any name and address changes
directly on the answer form. If your name and address do not
appear on the answer form, please print that information in
the blank space at the top left of the page. Make a photocopy
of the completed answer form for your own files and mail the
original answer form in the enclosed postage-paid business
reply envelope. Your answer form must be received by
Lippincott CME Institute by January 31, 2016. Only two
entries will be considered for credit.
Online quiz instructions: To take the quiz online, log on to
your account at www.topicsinpainmanagement.com, and
click on the “CME” tab at the top of the page. Then click on
“Access the CME activity for this newsletter,” which will
take you to the log-in page for http://cme.lww.com. Enter
your username and password. Follow the instructions on the
site. You may print your official certificate immediately.
Please note: Lippincott CME Institute, Inc., will not mail certificates to online participants. Online quizzes expire on the
due date.
1. Which one of the following is clinically assessed by the
physician when making a clinical diagnosis of CRPS using
the Budapest Criteria?
A. Sensory, hyperalgesia, skin changes
B. Sensory, proprioceptive, decreased hair, shiny skin
C. Sensory, vasomotor, sudomotor/edema, motor/trophic
D. Sensory, sudomotor/edema, motor/trophic, mood
5. Which one of the following describes the medication with
the appropriate mechanism of action for CRPS?
A. DMSO cream: immune modulator, a free-radical scavenging agent that has anti-inflammatory, analgesic,
mast cell inhibition, and muscle relaxing effects
B. Capsaicin: increase of TRPV1 receptor (capsaicin
receptor)
C. Ketamine infusion: NMDA agonist
D. Vitamin C: NMDA antagonist
2. Which one of the following is the gold standard in treatment
of CRPS?
A. Neuropathic agents
B. Physical therapy
C. There is no gold standard treatment
D. Psychiatric treatment
3. Which one of the following describes the appropriate steps
and exercises in the functional restoration therapy algorithm?
A. Step 1, mirror visual feedback; step 2, ergonomics;
step 3, edema control; step 4, vocational rehabilitation
B. Step 1, reactivation; step 2, isometric strengthening; step
3, ROM (gentle, passive); step 4, movement therapies
C. Step 1, edema control; step 2, flexibility; step 3, aerobic conditioning; step 4, mirror visual feedback
D. Step 1, reactivation; step 2, isometric strengthening; step
3, ROM (gentle, passive); step 4, vocational rehabilitation
4. How does pharmacotherapy work best for patients with CRPS?
A. When it is used as a first-line agent to make the patient
more comfortable
B. When used in combination with functional restoration
C. When used in combination with pain interventions
D. When 2 to 3 medications are combined to maximize
synergistic effects
©2015 Wolters Kluwer Health, Inc. All rights reserved.
6. Despite wide use internationally for CRPS, research outcomes with use of sympathetic blocks have been varied.
A. True
B. False
7. A recent systematic review revealed strong correlation
between depression and anxiety before onset of CRPS and
predictors for improvement.
A. True
B. False
8. There is no evidence that dorsal root ganglia stimulators
are effective in treating CRPS.
A. True
B. False
9. Which one of the following groups of over-the-counter
supplements may decrease pain in patients with CRPS?
A. Magnesium, vitamin C, vitamin B complex, ACL
B. Milk, magnesium, vitamin C, vitamin B complex
C. Milk, magnesium, vitamin C, vitamin D
D. Fish oil, vitamin B complex, vitamin C, aspirin 80 mg
10. A 2011 literature review demonstrated that amputation for
long-standing CRPS-I has great results with high patient
satisfaction.
A. True
B. False
11
Topics in Pain Management
February 2015
NEWS IN BRIEF
Website Intends to Promote
Collaboration Among Pain
Researchers
T
he Interagency Pain Research Portfolio is a federal database launched in May 2014 that lists the federally
funded pain-related research projects and training activities.
The database encourages the dissemination of information
regarding details on current federally supported research
and promotes collaboration among investigators with the
hopes of reducing duplication of effort.
“This database will provide the public and the research
community with an important tool to learn more about the
breadth and details of pain research supported across the federal government,” said Linda Porter, PhD, in a press release.
Porter is a pain policy advisor at the National Institute of
Neurological Disorders and Stroke Office of Pain Policy,
which manages the database.
“[The database] also can be helpful in identifying potential
collaborators by searching for topic areas of interest or for
investigators,” Porter said.
The Pain Research Portfolio has collected information
regarding more than 1200 projects funded by the Agency for
Healthcare Research and Quality, the Centers for Disease
Control and Prevention, the Department of Defense, the
Food and Drug Administration, the National Institutes of
Health, and the Department of Veterans Affairs.
The information is organized into 2 “tiers” of topic areas:
• Tier 1 contains basic, translational, and clinical research; and
• Tier 2 contains 29 specific scientific pain topics and
research themes, including analgesic development, pain
mechanisms, risk factors and causes, and training and
education, among others.
Under the stipulations of the Patient Protection and
Affordable Care Act that specified advancing pain care,
education, and research, the Department of Health and
Human Services created the Interagency Pain Research
Coordinating Committee—an advisory committee of 19
federal and nonfederal members.
The committee aims to help support the advancement of
pain research by coordinating the pain research efforts
among the federal agencies. In its analysis of the federal
research, the committee also identified critical gaps in
research in a 2011 report. These tasks are designed to
encourage collaboration among scientists and reduce redundancy of effort with the ultimate goal of furthering understanding of pain and improving treatment of pain.
The database can be found online at http://paindatabase.
nih.gov.
Epidural Steroid Injections,
Anticoagulants, and Safe
Opioid Prescribing Among
Leading Pain Topics at
Post-Graduate Assembly
I
n future issues, Topics in Pain Management will explore
some of the issues raised at the New York State Society of
Anesthesiologists 68th Annual Post-Graduate Assembly,
December 12–16, 2014.
At many of the pain-related panel discussions and workshops, the hot topics included epidural steroid injections
(both the medications injected and how and whether to
inject patients who are taking anticoagulants) as well as the
continually evolving issue of safe opioid prescribing.
Experts weighing in on these topics included Terese
Horlocker, MD; Subhash Jain, MD; Oscar De Leon-Casasola,
MD; and David Wlody, MD, who also was co-chair of this
year’s PGA, along with Richard A. Beers, MD.
Wlody has been a consultant to the FDA Center for Drug
Evaluation and Research, which has been investigating the
safety of medications for epidural steroid injections. Wlody is
Professor of Clinical Anesthesiology and Vice Chair for Clinical
Affairs at State University of New York and Chair of the
Department of Anesthesiology at Long Island College Hospital.
To follow this topic on the FDA website and view transcripts,
see http://www.fda.gov/AdvisoryCommittees/Calendar/
ucm417300.htm.
Coming Soon:
• Compression Syndromes of the Lower Extremities, Part 2
12
©2015 Wolters Kluwer Health, Inc. All rights reserved.