" Fly high (pain free) but never loose control ! "

      The relief of pain and suffering is one of the most important tasks a Physician can undertake.

   American Academy of Pain Medicine :

      "Milions of people suffer from chronic or intractable pain. Persistant pain varies in etiology and presentation, In some cases, symptoms and signs may be evident within a few weeks to a few months after occurrence of an injury or the onset of the disease. Inappropriately treated  pain seriously compromises patient's quality of life, causing emotional suffering and increased risk of lost livelihood and social intergration. Severe chronic pain often leads to mood disorders, including depression, and in rear cases, suicide."

      "Each physician bears the responsibility to evaluate and treat persistent pain as serious medical condition. Principal  treatment physician must approach each patient with respect and urgency and provide appropriate and timely referrals to a Pain Medicine specialist .."

  Topic's of the month 

      I.  "Body Perception Disturbances in Complex Regional Pain Syndrom"

People with CRPS (complex regional pain syndrom) often describe altered thoughts, perceptions, and feelings about their limb, known as perception disturbances.These thought and feelings include a repulsionand dyslike of the limb, a sense that somehow it feels alien  and does not belong. In extreem cases, some have a desire to amputate the limb, despite being adviced against it by the doctors.

Many express that what they see when looking at their affected limb is often at odds with how the limb feells.

Typically the affected limb is perceived  by the individual  as being much larger than it acctually is , it feels burnig, hot, yet is cool to touch , and it is havier then in reality.

Individuals commonly report a difficulty in knowingwhere their affected limb is physically positioned despite of heightened awareness due to pain.

They describe holding their limb in what

feels to be normal and more comfortable position but anawere that it is actually abnormal until others draw their attantion to it.

Recent evidence suggests that body perception disturbance is becoming an increasingly recognized characteristic of CRPS, with uo to 84% expressing one or more oof these features. Farthermore, those with body perception disturbances often have greater difficulty in engaging with their affected limb, which can affect rehabilitation outcomes.It is important for health professionals to express a greater understanding of these seemingly bizzare feature which can improve the communicaton between the patient and their practitioner, builds trust and confidence in their clinical team, and allay unnecessary  fears of " going nuts"that patients commonly express when discussing their symptoms.

The most recent research concludes that those cases with longstanding CRPS had greater body perception disturbances, as did thyose in greater pain.Also has been found that these patients had poorer perception of touch. These findings were proportional = congruent also with brain imaging a "fMRI" a functioniing magnetic resonance imaging) in most cases so far.  This exciting reasearch analysis are ongoing at the present time. We will update you when the reports of the studies are completed ...

 A CRPS belong to a very large group of many types of periferal neuropaty:polyneuropathy, mononeuropathy, mononeuritis multiplex, autonomic neuropathy, RSD, and even currently disputed types of Fibromyalgia (Fibromyalgia - Preeliminary  Proposed Diagnosticcriteria- please read at the end of this article)

The most common form is symetrical periferal polyneuropathy, which mainly affects feet and legs.

 A radiculopathy involves spinal nerve roots, but if periferal nerves are also involved the term radiculoneuropathy is used.

II.  Neuropathy is often associated with weakness, authonomic changes and sensory changes.

Los of muscle bulk or fasciculations, a particular fine twitching of muscle can be seen.

Sensory symptoms encompass loss of sensation and "positive" phenomena including pain

Neuropathic pain also called Neuralgia.

Neuropathic pain may result from disorder of the periferal nervous system or the cental nervous system (brain and spinal cord).Thas , neuropathic pain may be devided into central, peripheral and mixed neuropathic pain.Central neuropatic pain is found in the spinal cord injury, multiple sclerosis, and some strokes.

Fibromyalgia, adisorder of chronic widespread pain, is potentially a central pain disorderand is responsive to medications effective in neuropatic pain.Aside of the Diabetes and other metabolic conditions, the common cause of painfull periferal neuropaties is herpes zostr infection, HIV - related neuropaties, nutritional deficiencies, toxins, remote manifestations of the malignancies, genetic and immune mediated disorders. Neuropathic pain is common in cancers as a direct result of cancer on perferal nerves ( compression by the tumor) as thr side effect of some chemotherapy  drugs and a sa resultof the radiation injury,injury.

  Symptoms

Neuropatic pain may result in numbness, abnormal sensation   called dysthesias and allodynias that occur either spontaneously or in reaction to external stimuli, and a charcteristic form of pain, called neuropathic pain or neuralgia, that is qualitatively different from the ordinary nocioceptive pain one might experience from stubbing a toe. 

 ADC Pain Instiute of South Florida

900 NW 13 street, Ste 302

Boca Raton, FL. 33486                                       

Phone: (561) 362-2969

Fax: (561) 362-2970

info@ADCPainInstituteofSoFl.com

 Links:

www.ncbi.nlm.nih.gov/sites/entrez/

www.drsulekha.com/blog/post/2006/06/yoga- and-back-pain.htm 

www.holisticonline.com/yoga/hol_yoga_

www.breathing_importance.htm

www.bocamag.com

www.undas.um.org

MEDNET.MIAMI.med,miami.com

 A.D.Carlson,M.D.

President

Topic of the month- cont.

" CRPS ,NEUROPATHY, PRELIMINARY CRITERIA FOR DX FM.."(cont.)

    Neuropathic pain may have continous or/and paroxysmal (episodic)components.

Common qualities of the pain include burning or coldness,"pins and needles"sensations, numbness and itching.Ordinary pain results from exclusive stimulation of pain fibers, while neuropathic pain often results from the firing of both pain and non-pain (touch,warm,cool) sensory nerve fibers serving the same area. The result is signals that the spinal cord and brain do not normaly receive.

Treatments

Neuropathic pain is very difficult to treat with only 40-60% of patients atchieving partial relief.

For pharmacological therapy favored treatments are using certain antidepressants e.g. tricyclic antidepressants (Elavil) and selective serotonin- norepinephrine re-up take inhibitors (SNRI's), anticonvulasants, especially Lyrica,Neurontin and topical lidocaine.Opioids analgesics and tramadol are useful agents but not recommended as the first and only therapy.Between oipoids, especially methadone  is more effective as its NMDA antagonistic action has been found most effective in treatment of neuralgia type of pain.

Topical agents like local anesthetics have been found useful in neurpopathic pain, especially like in a  post herpetic neuralgias,lidocain patches, repeated topical applications of capsaicin reduce skin sensitivities can provide relief.. Diabethic neuralgia often has been found  benefit from a diatery supplemental tratment in addition to pharmacutical.ALA lipoic acid and benfotiamine, resercheraddition to the regiment therapy. Other modality of therapy, used as adjunctive to the main streem tx provide additional better outcome in pain relief are : massage, cognitive psychotherapy , meditations , accupuncture and prescribed excersises. TENS should be always considered as a valuble adjunct to a treatment of neuropatic pain.  

 FIBROMYALGIA (FM) is a disorder of the central nervous system that is farther sensitised by periferal input.

It may be exacerbated by Hashimoto"s Thyroiditis, metabolic disturbances, and central and periferal disturbance seen in the restless legg syndrom RLS, - Currently , these are specifically omitted in the " PRIELIMINARY PROPOSED DIAGNOSTIC CRITERIAS FOR DIAGNOSING FIBROMYALGIA". 

However, confussingly, some symptoms are listed as primary to FM when they are symptoms of commonly occuring conditions.