Dear Dew -
The one thing I have to focus on is when you said:
I was dx 15 months out from initial injury. Too late for blocks, or anything!
I'm pleased to report that there are still good treatment options available. Check out for one, Schwartzman RJ, Alexander GM, Grothusen JR, Paylor T, Reichenberger E, Perreault M, Outpatient intravenous ketamine for the treatment of complex regional pain syndrome: A double-blind placebo controlled study, Pain 2009, in press, free full text at
http://www.rsds.org/2/library/articl...n_Pain2009.pdf :
a b s t r a c t
Complex regional pain syndrome (CRPS) is a severe chronic pain condition that most often develops following trauma. The pathophysiology of CRPS is not known but both clinical and experimental evidence demonstrate the important of the NMDA receptor and glial activation in its induction and maintenance. Ketamine is the most potent clinically available safe NMDA antagonist that has a well established role in the treatment of acute and chronic pain. This randomized double-blind placebo controlled trial was designed to evaluate the effectiveness of intravenous ketamine in the treatment of CRPS. Before treatment, after informed consent was obtained, each subject was randomized into a ketamine or a placebo infusion group. Study subjects were evaluated for at least 2 weeks prior to treatment and for 3 months following treatment. All subjects were infused intravenously with normal saline with or without ketamine for 4 h (25 ml/h) daily for 10 days. The maximum ketamine infusion rate was 0.35 mg/kg/h, not to exceed 25 g/h over a 4 h period. Subjects in both the ketamine and placebo groups were administered clonidine and versed. This study showed that intravenous ketamine administered in an outpatient setting resulted in statistically significant (p < 0.05) reductions in many pain parameters. It also showed that subjects in our placebo group demonstrated no treatment effect in any parameter. The results of this study warrant a larger randomized placebo controlled trial using higher doses of ketamine and a longer follow-up period.
2009 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
And while, in the study's conclusion, the authors note that among its limitations were the "nonstratification of patients either by length of time with the illness or by the temperature of the affected area," it bears noting that not only was the sole inclusion criteria, for any patient with a confirmed a diagnosis of CRPS "whose condition was intractable for a minimum of 6 months and had failed at least three of the following therapies; nerve blocks, opioid analgesics, non-opioid analgesics, non-steroidal anti-inflammatory drugs, anti-seizure medications, antidepressants, muscle relaxants or physical therapy[,']"
but, in conjuntion with another point, they make the following observation:
There were no significant differences between those patients with a shorter duration of CRPS (11 patients with an average length of illness of 2.6 years and a range of 0.8–4.2 years) and longstanding patients (8 patients with an average length of illness of 12.2 years and a range of 6.8–20 years). [Para. 4.2]
In other words, not only did they make no effort whatsoever to cherry-pick their subjects based upon duration of disease, but looking at the spread of patients, someone with only 15 months of the disease looks like a newbie!
And as noted in the earlier thread on this piece,
Ketamine, the article http://neurotalk.psychcentral.com/thread104838.html, it's just this kind of double blind placebo controlled study (or perhaps a larger one with NIH funding behind it, now that this one has crossed the threshold) that is going to make the WC insurance companies of the world finally pay for this treatment!
And even without ketamine, have you considered Methadone or Zometa? Methadone is surely covered by WC and has the unique advantage (in addition to being a powerful analgesic) of being an NDMA-receptor antagonist: which is to say that it goes to the heart of the beast. Just be sure to get something prescribed by your doctor to keep your GI system moving while you're on it.
And there are yet more things out there, for now considered experimental, including the very interesting work Michael Stanton-Hicks, MD is doing with "high dose" Prialt, to say nothing of my old favorite, before I found out that California law restricts its use only to certain defined psychiatric diagnoses: right unilateral electroconvulsive therapy.
Finally, just in terms of learning how to drop your resistance to the pain and accept it as just another sensation for the time being, I cannot begin to tell you what a life altering experience I had - about a year into my diagnosis - when a
really good pain psychologist suggested that I take an MBSR class. (Mindfulness Based Stress Reduction.) The program has been run out of the Univ. of Mass. Med School for over 30 years (started by one Jon Kabot-Zin, PhD. - an interesting Google search). I've heard Jon speak at UCLA (a packed-hall) and it's clear that one of the origional and continuing central thrusts of the program has been assisting people in chronic pain. And it works! It's built around a 2 and 1/2 hour class that meet one day a week for eight weeks, with a strong emphasis on a daily practice of meditation and yoga (wonderful for proprioceptive skills) concluding with a day long retreat/program. For those of us who don't live near its Worcester MA base of operations, where teachers are trained and classes are freely provided to students, the cost is roughly $500, depending on the area. Here's the homepage, along with a search engine that let's anyone find one of its trained teachers in their area. (Full disclosure: my MBSR teacher 7 years ago is one of my best friends today.)
http://www.umassmed.edu/Content.aspx...d&itemid=41254
So hang in there and be of good cheer,
Mike