Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
c arachnoiditis education project SUPPORTIVE THERAPIES FOR ARACHNOIDITIS A HANDBOOK FOR PATIENTS & FAMILIES By Forest Tennant M.D., Dr. P.H. 338 S. Glendora Ave. West Covina, CA 91790 626-919-0064 Fax: 626-919-0065 E-mail: [email protected] Websites: www.foresttennant.com www.hormonesandpaincare.com January, 2016 Arachnoiditis is a rare disease that requires rare care. This handbook accompanies a medical protocol for physicians, nurse practitioners, and other health professionals. This document is provided as a public service by the Tennant Foundation. 0 c TABLE OF CONTENTS arachnoiditis education project No. 1 Preface Document Page 2 2 ArachnoiditisHow It Develops And Progresses 3 4 Finding Medication That Works For You Three Legs Of Arachnoiditis Treatment 5 6 5 Do You Have Enough Pain Relief? 7 6 Sleep 8 7 Spinal Cord Exercise 9 8 Improving Your Spinal Fluid Flow 10 9 Dietary Supplements For Arachnoiditis And Cauda Equina Inflammation 11 10 Diet For Centralized Pain Patients 12 11 Electricity Elimination 13 12 Catecholamine Drugs For Severe, Intractable Pain 14 13 Pain Relief Drugs For Centralized Pain Patients With Constant Pain 15 14 How An Arachnoiditis Patient With Constant Pain Must Take Their Pain Medication 15 Neuroinflammation: The Missing Link 18 16 The Importance Of Spine Bracing 19 17 18 Control Of Neuroinflammation: The Arachnoiditis Patient’s Major Challenge How And Why To Use Ketamine? 19 Your Life-Lines: Walking and Stretching 3-4 16-17 20-21 22 23 1 PREFACE This handbook contains supportive therapies that have been found helpful over several years by our cauda equina inflammation (CEI) and adhesive arachnoiditis (AA) patients Many of the recommendations here are century-old remedies that are time-eternal but still useful. Also, many of the recommendations here are not generally known or accepted by the scientific establishment Information here may be shared with any CEI or AA patient and family as these conditions may be rapidly progressive and have disastrous disabling consequences This handbook is dedicated to my early, instructive and afflicted patients who persevered: Gary, Michael, Marjorie, Melody, Joe, Kimberly, Radine, James, Leslie. The medical protocol that accompanies this handbook has been developed by treating arachnoiditis patients over several years. It, like other medical protocols, is to provide a standard regimen that is safe and effective for the majority of patients. There are several components to the protocol. Not all will be effective for every patient as the purpose of a protocol is to attempt enough different treatments to provide some relief and recovery to all patients. The protocol and this handbook are constantly being updated as new therapies are being investigated. 2 c arachnoiditis education project ARACHNOIDITISHOW IT DEVELOPS AND PROGRESSES Arachnoiditis simply means inflammation of the arachnoid lining of the thecal sac. Adhesive arachnoiditis means that the arachnoid layer has adhered or glued itself to nerve roots or the spinal cord. The above definitions do not describe the usual pathologic process that precedes the tragic development of adhesive arachnoiditis. The actual disease process begins with nerve root or “cauda equina” inflammation. Only when inflamed nerve roots stick or adhere (forming an adhesion) to the arachnoid lining does “arachnoiditis” occur. Some patients who are diagnosed as arachnoiditis or have the symptoms of this condition only have nerve root inflammation and have not progressed to the point that the nerve roots have adhered to the arachnoid lining. This does not necessarily mean that symptoms and impairments are less or that aggressive treatment is not needed. MRI INTERPRETATION Magnetic resonance imaging (MRI) studies are often not interpreted by radiologists as showing the presence of arachnoiditis even though the patient has all the symptoms. This is usually because the nerve roots are in the inflammation and clumping stage but have not yet adhered themselves to the arachnoid lining. Nerve root or cauda equina inflammation can often be, however, observed on an MRI since inflammation causes edema (swelling), displacement, and the adherence or clumping of nerve roots to each other. DANGER OF NEUROINFLAMMATION Make no mistake about nerve root inflammation. It is extremely painful, debilitating, and progressive. A major reason for this short education piece is to broaden the understanding of nerve root inflammation, expand MRI interpretation, and, most of all, call for more aggressive treatment of nerve root inflammation. Simply put, if nerve root inflammation is not stopped, the nerve roots will clump together in a mass (tumorlike) and cause severe pain and dysfunction of the nerves that connect to the stomach, intestine, sexual THE ANATOMICAL SETTING FOR CAUDA EQUINA INFLAMMATION The pathologic process that leads to arachnoiditis can occur due to the anatomic make-up of the spinal cord and nerve roots. The spinal cord itself goes from the brain down the vertebral canal to about the first lumbar vertebra. The end is cone-shaped known as the “conus medullaris”. About 2 dozen string-type nerves known as nerve roots or collectively as the “cauda equina” (in Latin this means horses tail due to the visual similarity) originates from the conus and trail downward to the sacrum. These nerve roots are encased in a protective sac known as the thecal sac. Its lining is called the dura mater, and the inner-most layer is the arachnoid. Within the thecal sac is the cerebrospinal fluid which is there to nourish the nerve roots and wash away toxic materials such as tissue particles that may result from inflammation. The small nerve roots are always in fluid and protected by a covering. Any contaminant or irritant that enters this protected area may set-up an on-going inflammatory process. 3 organs, pelvis, legs, and feet. The clump retains electricity, interferes with nerve conduction, interferes with flow of spinal fluid, and produces toxic, inflammatory by-products that create a systemic (“all-over”) autoimmune condition. The retained electricity and impairment of nerve conduction leads to such symptoms as sweating, hot flashes, jerking legs, and burning feet. The mass of clumped nerves may also cause some blockage of cerebrospinal fluid flow that can produce headaches, blurred vision, and pain behind the eyes. All these symptoms may occur without the arachnoid layer actually being adhered to inflamed nerve roots. NECESSITY OF EARLY DIAGNOSIS Patients tend to respond much better to treatment if they only have inflamed nerve roots and have not yet progressed to adhesion formation with the arachnoid lining. Cauda equina nerve root inflammation is analogous to the inflammation of rheumatoid arthritis in a joint. If it is not controlled by aggressive medical management, the joint will progressively be more painful, deformed, and destroyed. The same process occurs with the nerve roots in the spinal canal. INCREASING HOPE FOR THE FUTURE The term “arachnoiditis” will continue to be used to encompass both patients who show nerve root adhesion to the arachnoid layer as well as those patients whose nerve roots are inflamed and pathologically clumped together. Arachnoiditis is still listed as a rare disease on the “Rare Disease Registry”, and it is recognized enough to have its own “International Classification of Disease” code number (ICD-10, G 03.9). In the past it has been thought to be a “hopeless” disease for which only symptomatic treatment could be done. Our new understanding of nerve root inflammation, autoimmunity, centralized pain, electromagnetism, and the neurohormones have given us the tools to greatly control arachnoiditis and nerve root inflammation just as we do with rheumatoid arthritis. A medical protocol to treat arachnoiditis has been developed for outpatient, medical practitioners and it will be made available on request. Every patient with arachnoiditis can and should now get enough relief and recovery to have a meaningful, quality of life without suffering. “Our mission is to bring ARACHNOIDITIS EDUCATION PROJECT THE TENNANT FOUNDATION 334 S. GLENDORA AVE. WEST COVINA, CA 91790 Ph: 626-919-7476 Fax: 626-919-7497 E-mail: [email protected] arachnoiditis treatment to every community”. 4 FINDING MEDICATION THAT WORKS FOR YOU You are being treated with a “medical protocol” which means you are prescribed or issued 4 to 8 medications at one time. Not all are expected to help and some may cause side-effects. CRITICAL ACTIONS TO TAKE 1. Stop any medication that has side-effects, agitates you, or causes increased pain. 2. Stop any medication after 1 month if you are not getting any positive benefit from it. 3. Continue medications you believe are helping you. 4. Report all positive and negative experiences to the clinic. GOAL: FIND 2 OR 3 EFFECTIVE MEDICATIONS OUT OF EVERY 5 YOU TRY. BACKGROUND: Non-standard medications and medical measures are only administered when the standard ones fail to achieve pain relief and control the inflammation of CEI and AA. No guarantee can be made as to the safety and effectiveness of non-standard medications. 5 c arachnoiditis education project THE THREE LEGS OF ARACHNOIDITIS TREATMENT PAIN RELIEF NEUROINFLAMMATION CONTROL NEUROGENESIS The 3 “legs” must be simultaneously administered to be optimally effective. 6 c arachnoiditis education project DO YOU HAVE ENOUGH PAIN RELIEF? Without enough pain relief, you can’t expect the anti-inflammation and neurohormone regeneration elements of the medical protocol to help much. Excess pain eliminates the ability of nerve roots to regenerate. Here is how to know you have enough pain relief: 1. You must have enough pain relief to get out of bed between 6:00 and 7:00 am. Keep your pain medication next to your bed and take it immediately when you awake each morning. Your first dosage should be before 7:00 AM. 2. You must be out of bed and doing normal activities of daily living before 8:00 am. The natural hormones of the body are at their highest peak between 6:00 and 10:00 am. It is critical that you are active at this time every day because these are the hours that the body does most of its healing and regeneration. 3. Take your last dosage of pain medication within 1 hour of going to bed. If you awake with pain during the night, take a dose of pain medication. KET POINT: IF YOU DON’T HAVE ENOUGH PAIN RELIEF TO GET OUT OF BED BETWEEN 6:00 AND 7:00 AM EACH DAY, YOU NEED MORE OR BETTER PAIN MEDICATION. 7 c arachnoiditis education SLEEP project A regular sleep pattern enhances the hormone and immunologic systems that are necessary for neurogenesis. Be in bed between 10:00 and 11:30 PM. Do your last stretches and medication dosage 30 to 60 minutes before bedtime. Keep your pain medications beside your bed. Take additional dosages during the night, if necessary. Take your first morning pain relief medications to be out of bed between 6:00 and 7:00 AM. Goal is 4 to 8 sleeping hours. Do not expect more than four hours of consecutive sleep. Most popular sleep aids are zolpidem (Ambien®) and temazepam (Restoril®). Take melatonin 5 to 10 mg with your sleep aid to assist sleep and help regulate your hormone and immune systems. 8 c arachnoiditis SPINAL CORD EXERCISE education project FULL-BODY STRETCH LAYING DOWN Lay down on the floor and do a full-body stretch. Count up to 10. FULL-BODY STRETCH STANDING Spread hands and reach “to sky” until you feel pressure and tugging in your back. Count up to 10. SIT AND STRETCH ARMS Stretch your arms and spread your fingers. Count up to 10. Can do while sitting in a car or plane. LEG RAISE WHILE LAYING DOWN Raise leg until you feel tugging in your back. Count up to 10. LEG RAISE WHILE STANDING Stabilize yourself next to a table or wall. Raise your leg and flex your foot. KNEE PULL WHILE LAYING DOWN Pull knee back until you feel tugging in your back. Count up to 10. INVERSION TABLE If able, a short episode on an inversion Table may assist in pulling adhesions and cauda equina nerves apart to preventing scarring and allow electricity to pass. 9 c arachnoiditis education project IMPROVING YOUR SPINAL FLUID FLOW Arachnoiditis and cauda equina inflammation commonly cause spinal fluid flow obstruction. When spinal fluid is obstructed you may get these symptoms among others: Headache Blurred vision Inability to think or read Weak legs More pain Bladder and bowel function worsens Even worsethe spinal fluid cannot carry away inflammatory particles generated by the inflamed nerve roots. This retards healing. Another function of spinal fluid is to bring nutrients from your food to the nerve roots in the cauda equina. This function may also be impaired. You must do some of the following each day: Rock in a rocking chair Walk on a trampoline Use vibrator or massager over spine (Back scratchers and scrubbers are terrific) Soak or wade in water Walk and swing your arms (“Power Walking”) Rock back and forth on your feet Rub your spine with copper and a magnet Nod your head up and down Scrub you back with a brush 10 c arachnoiditis education project DIETARY SUPPLEMENTS FOR ARACHNOIDITIS AND CAUDA EQUINA INFLAMMATION Our experience has shown that few dietary supplements are effective in our patients. We highly recommend these 3. Vitamin B12 Once or twice weekly. Can be sub-lingual (under tongue) or injectable. Taurine 1000 to 2000 mg a day or L-glutamine 1000 to 2000 mg a day Take taurine and glutamine on an empty stomach with any fluids. Below are listed dietary supplements that have been reported to sometimes be effective in some patients. If you attempt any of these, do so for only a month and stop them unless you believe they really help you. Vitamin D Folic acid Magnesium Tyrosine Carnitine Curcumin Vitamin C Taurine and glutamine make gamma amino butyric acid (GABA) which is the natural electricity conductor in nerves. If you lack GABA you will have more pain. 11 DIET FOR CENTRALIZED PAIN PATIENTS PROTEIN It provides the amino acid building blocks that are necessary for the production of neurotransmitters and tissue healing. YOU MUST EAT SOME OF THE FOLLOWING EACH DAY FISH PORK CHICKEN EGGS TURKEY COTTAGE CHEESE BEEF If you can’t or won’t eat any of the above you must obtain protein powder drinks and/or protein bars from the health food store. VEGETABLES AND FRUITS Some vegetables and fruits have anti-inflammatory activity. Eat some of these each day. CARROT BROCCOLI RADISH BLUEBERRY APPLE CELERY BRUSSEL SPROUTS ONION BLACKBERRY BEETS SPINACH LETTUCE RASPBERRY TOMATOES CUCUMBERS WATERMELON STRAWBERRY DRINKS (Only use dietary sugars if weight is a problem) COFFEE TEA DIETARY SODAS WATER Low dose, occasional alcoholic drinks are acceptable. BANNED TO CONTROL WEIGHT MILK REGULAR SODAS FRUIT JUICE BREAD, ROLLS, BUNS HIGHLY RESTRICTED TO CONTROL WEIGHT (Eat these very sparingly) POTATOES including FRENCH FRIES CAKES/PIES CORN PASTA/PIZZA 12 c arachnoiditis ELECTRICITY ELIMINATION education project A major problem with clumped or trapped nerve roots is that electricity does not pass as it normally should. It builds up – causes increased inflammation – and then it may suddenly release itself in dysfunctional bursts. This is why patients get: Shooting and burning episodes of pain Legs jerk and tremor Feet burn Temperature rises with sweating When you daily do measures to control and eliminate your retained or trapped electricity, you not only suppress painful and troublesome symptoms, you reduce inflammation and promote healing and nerve regeneration. Here are routine measures. Do some daily. Rub your spine with copper or magnet Wear copper anklet or bracelet Use magnets in your shoes or mattress Wear lots of jewelry Hold door knobs or other metal a second longer Soak in water (Epsom salts help) Pet your dog or cat (Any fur will do) Walk barefoot on carpet or outside on your lawn 13 c arachnoiditis education CATECHOLAMINE DRUGS (StimulantType) FOR SEVERE, INTRACTABLE PAIN project The adrenal gland produces a set of hormones called catecholamines. They include adrenalin, norepinephrine, and dopamine among others. These hormones control the “descending pain pathways”. EXAMPLES OF ADRENERGIC DRUGS 1. Methylphenidate (Ritalin®) – 5, 10, 20 mg 2. Dextroamphetamine – 5, 10 mg 3. Amphetamine Salts (Adderal®) – 5, 7.5, 10, 20, 30 mg 4. Phentermine – 37.5 mg If you have severe, centralized pain from Arachnoiditis, RSD/CRPS, PostViral Syndrome, Traumatic Brain Injury, or other cause, you will almost always need a catecholamine drug for adequate pain relief. 14 c arachnoiditis education project PAIN RELIEF DRUGS FOR CENTRALIZED PAIN PATIENTS WITH CONSTANT PAIN For decent, pain relief you will likely have to take a drug in each category. OPIOIDS TRAMADOL HYDROCODONE OXYMORPHONE MORPHINE CODEINE LEVORPHANOL TAPENTADOL METHADONE HYDROMORPHONE OXYCODONE N-METHYL-D-ASPARATE RECEPTOR STABILIZER KETAMINE NEUROPATHIC AGENTS (Blocks Pain Signals) TOPRIMATE GABAPENTIN CARISOPRODOL DIAZEPAM/CLONAZEPAM/ALPRAZOLAM PREGABALIN ADRENERGIC AGENTS (Replaces adrenalin, dopamine, norepinephrine) METHYPHENIDATE DEXTROAMPHETAMINE AMPHETAMINE SALTS PHENTERMINE MODAFANIL TIME TABLE FOR REGULAR ADMINISTRATION 1st Dose 2nd Dose 3rd Dose 4th Dose 6:00-8:00 AM 10:00-NOON 4:00-6:00 PM 8:00-10:00 PM 15 c arachnoiditis education project HOW AN ARACHNOIDITIS PATIENT WITH CONSTANT PAIN MUST TAKE THEIR PAIN MEDICATION 1. POTENTIATION: All pain relief medication including opioids (e.g. oxycodone, hydromorphone, tramadol, etc.) and non-opioids (e.g. gabapentin, ketamine, dextroamphetamine) should be taken together, at the same time. 2. STOMACH PROTECTION: Pain medications should be taken with a liquid antacid (e.g. Pepto-Bismol or other) to prevent stomach upset. 3. DOSAGE TIMES: The time to take medication must be 4 times a day, every 4 to 6 hours while awake. Here is your dosing schedule. 1st Dose 6:00-8:00 AM 2nd Dose 10:00-NOON 3rd Dose 4:00-6:00 PM 4th Dose 8:00-10:00 PM 4. LONG-ACTING OPIOIDS: If one of your medications is a long-acting opioid (e.g. Nucynta®, Oxycontin®, methadone) they should only be taken with your 1 st dose (6 to 8:00 AM) and last dose (8-10:00 PM). If you currently take a patch opioid, continue it but work to stop it, unless you can’t take oral opioids. 5. MEDICATION BETWEEN DOSAGES: It is acceptable to take a non-pain relief medication such as an anxiety, dietary supplement, hormone, or anti-nausea medication in-between pain medication dosages. 6. EMERGENCY OPIOID DOSAGES: It is acceptable to take an opioid in between your regular pain medication dosage times, but this should only be for emergency use. If you are having breakthrough pain between your regular dosages, you need to increase the potency of your 4 regular dosages. Topical (skin rub) pain relievers including patches can be taken between regular dosages. Also, use your magnet between dosages. 7. SLEEP ISSUES: Your last pain medication dosage is to be taken between 8:00 and 10:00 PM which should be within 1 hour of your bedtime. Take any sleep 16 medication you need 30 to 60 minutes before you lay down to sleep. If pain awakens you during the night, you can take a full or partial dose of your pain medication. Keep your pain medication at your beside and take your first pain medication when you awake in the morning. DO NOT take medication when lying down. Only take it when sitting, or best when standing. Your first medication dosage is best taken before 7:00 AM and NEVER later than 8:00 AM. 8. SIDE EFFECTS: If one of your pain medications makes you sedated, itchy, nauseated, or has other side-effects, you must simply stop it and find another. 9. KEYS TO UNDERSTAND: Pain relief drugs taken together “potentiate” or make their potency more effective than when taken alone. For example, tramadol taken with Percocet® or Norco® makes as potent pain reliever as there is. You must keep your total daily opioid dosage at a level that your local, communitybased, primary care physician or nurse practitioner will prescribe, a local pharmacy will fill, and your insurance plans will cover. You cannot rely on pain specialists, neurologists, or other specialists to prescribe high dose opioids, for pharmacies to stock them, or insurance to pay for them. Due to regulatory restrictions, cost, and lack of medical pain specialists you cannot rely on high dose opioid drugs. 17 c arachnoiditis education project NEUROINFLAMMATION THE MISSING LINK The reason that arachnoiditis sufferers have not been able to get much help is because medical science did not realize that the central nervous system creates an inflammation that has unique characteristics compared to that in joints and muscles. It is formed by the microglial cell, and it does not respond or suppress much, if at all, to standard anti-inflammatory drugs or hydrocortisone. SPINAL CORD INFLAMMATION: Arachnoiditis is basically inflammation of the lining of the spinal covering. Adhesive arachnoiditis is when some of the spinal nerve roots in the cauda equina or the spinal cord adheres or attaches to the lining because of inflammation. Nerve roots of the cauda equina which become inflamed show swelling, enlargement, clumping, and displacement on MRI. SYMPTOMS AND CHARACTERISTICS OF SPINAL CORD INFLAMMATION: PAIN FATIGUE SWEATING/TEMPERATURE SUDDEN FLARES SCARRING PROGRESSIVE CLUMPING/PARALYSIS INFLAMMATION ACCUMULATES: Neuroinflammation constantly builds up and then may suddenly “strike” with a severe pain flare or more paralysis. Worse, it continues to create clumping and scarring. REASON FOR FAILURE: Arachnoiditis patients naturally want to focus on relief of pain, fatigue, and paralysis. We now realize that any medication for pain or even hormonal treatment is only marginally effective UNLESS spinal cord inflammation is first controlled. DIFFICULT TO CONTROL SPINAL CORD INFLAMMATION: We have identified only 2 drugs which we believe reliably control spinal cord inflammation. We believe that diet, magnet-copper application, and certain spinal cord exercises may help, but they are insufficient to fully control spinal cord and arachnoid inflammation. PREVENTION OF BUILD UP: Every arachnoid patient must have a daily regimen to keep neuroinflammation from accumulating. This has been the missing link to relief and recovery. 18 c arachnoiditis education project THE IMPORTANCE OF SPINE BRACING Shockingly, few arachnoid or spinal cord inflammation patients are told they need to periodically wear a brace to protect their damaged area. WORST SITUATION: Riding in a car on plane that has bucket seats. DANGER SITUATION: Walking in unfamiliar areas such as a shopping center, grocery store, or social event. Always wear a back brace to protect yourself in the above situations. MOST IMPORTANT TIME TO WEAR A BACK BRACE: PAIN FLARE 19 c arachnoiditis education project CONTROL OF NEUROINFLAMMATION: The Arachnoiditis Patient’s Major Challenge THE PROBLEM It is now clear that the microglial cell in the nervous system may create chronic neuroinflammation that can destroy cellular tissue, produce scar formation, adhesions, and be progressive. As cellular tissue is destroyed, waste products are formed which may get into the general circulation and cause autoimmune manifestations such as muscle aches and joint pains. When neuroinflammation accumulates or new cellular tissue is destroyed, a severe pain flare will occur. THE SCIENTIFIC NAME The term “arachnoiditis” literally means inflammation of the arachnoid lining of the spinal cord covering (thecal sac). This is too simplistic. The scientific name should be “cauda equina inflammation” to indicate that not only is the lining of the covering inflamed but so are some of the nerve roots in the cauda equina. It is inflammation of the nerve roots that may spread to form adhesions, scars, and impairment of nerves that lead to the bladder, bowel, stomach, sex organs, and legs. Always assume that a severe pain flare means active neuroinflammation TREATMENT STRATEGY that is destroying additional tissue. An arachnoiditis patient must have 2 basic strategies to control neuroinflammation: (1) daily and chronic suppression of neuroinflammation; and (2) aggressive control of severe pain flares. SPECIFIC TREATMENT To date we have identified only 2 pharmacologic agents to predictably help control the neuroinflammation of arachnoiditis: (1) Ketorolac (Toradol); and (2) Synthetic corticosteroid (methylprednisolone, prednisone, or dexamethasone). While we have observed that some other agents may sometimes suppress the neuroinflammation of arachnoiditis, but these 2 have been the only ones that have been consistently effective. OUR BASIC RECOMMENDATION 1. Ketorolac (Toradol), an injection of 30 to 60 mg, 1 time a week SPECIAL NOTES: Must not be taken daily. Oral ketorolac in our patients has caused too much gastric upset and bleeding episodes. Patients who use ketorolac must have a kidney test every 90 days to detect any adverse effect on the kidney. 20 2. Corticosteroid: a. methylprednisolone 2 to 4 mg b. prednisone 5 - 10 mg Take at 3:00 to 4:00 PM each day. May take it with DHEA (25 to 50 mg) for extra effectiveness and protection against any possible side-effects. Limit the corticosteroid to 5 days a week to protect against side-effects. TREATMENT OF SEVERE PAIN FLARES This usually requires a combination of these drugs: 1. Methylprednisolone 2. Hydromorphone 3. Ketorolac PREVENTION OF SIDE-EFFECTS The measures recommended here have not, to this date, shown any irreversible side-effects. At this time the benefits of neuroinflammation control appear to far outweigh the risks of the measures outlined here. The neuroinflammation associated with arachnoiditis leads to so much disabling pain and serious complications that some risks are warranted. 21 c arachnoiditis education HOW AND WHY TO USE KETAMINE project WHY? Ketamine acts at a special receptor in the central nervous system which is critical for pain control. This receptor is not acted upon by opioids and neuropathic drugs. This receptor is known as the N-methyl-D-aspartate receptor commonly abbreviated NMDA. Good pain control in centralized pain requires: (1) opioid; (2) neuropathic agent, and (3) an NMDA agent and sometimes a (4) catecholamine agent. FORMULATION We initially use a sublingual preparation although oral capsules can later be used. First issue is 60 ml of 40 to 60 mg/ml. DOSAGE AND FREQUENCY We initially start at a very low dosage to avoid side-effects. The dosage is raised over a 2 to 6 week period. INITIAL DOSING 1. 10-15 mg sublingual at 7:00 AM, Noon, 5:00 PM, and 10:00 PM 2. After 1 week raise the dosage to 15 or 20 mg at the times listed above 3. In the 3rd week raise the dosage to 25 mg at the times listed above MAINTENANCE DOSAGE 1. 25 mg, 4 times a day by sublingual route 2. Oral capsules will require 30 to 50 mg a day We now view ketamine as an essential agent in treatment of arachnoiditis. 22 YOUR LIFE-LINE WALKING AND STRETCHING To keep the inflamed nerve roots from forming adhesions and scars, you must walk and stretch every day. When you walk, swing your arms (“power walk”) at times. But don’t overdo! Stop walking when you feel tired or if pain is starting. Never stretch and cause pain. 23