Dear Folks-

First, my apologies for being away for so long. I understand that a number of my old friend no longer drop by, but that there are new faces here as well. And to them, hello.

Until last fall I was a frequent contributor, often posting stuff on recent articles, etc, many of which I could get through graduate student friends. Then last October or so I forwarded to Jim Broatch of the RSDSA an intriguing case report from Dr. Schwartzman’s group concerning a woman – a disabled judge – with long-term "refractory" full body RSD who had eventually developed a deep depression, for which she was treated by her psychiatrists with conventional “bi-lateral electroconvulsive therapy” (BL ECT), whereupon her RSD suddenly went into complete remission and had, as of the date of the 2007 article, remained that way four years later. Wolanin MW, Gulevski V, and Schwartzman RJ. Treatment of CRPS With ECT. Pain Physician. 2007. 10:573-578. Jim then put it up on the RSDSA Medical Articles Archive page under the heading “Treatments,” where it is indexed alphabetically by author and can be found at http://www.rsds.org/2/library/articl...ive/index.html.

I then suggested to Jim that it might make a nice topic for an article in the RSDSA Review, to which he asked me if I had any suggestions for an author, whereupon I volunteered. Long story short, as I dug into this, it got more and more interesting, and when I reported some of my preliminary findings – namely that an alternative form of ECT associated with far fewer cognitive side effect than BL had been wrongly ascribed 15 years ago as being ineffectual in the treatment of chronic pain – I was told to refocus my efforts instead on an informal medical journal Jim was beginning to develop of relationship with, the Journal of Practical Pain Management. Now, the last time I took any science class was 30 years ago in college, so the idea of writing for a medical publication was daunting to say the least. But with a few particularly helpful hints from my doctors and after pouring through over a hundred journal articles and a few books later, to the exclusion of virtually everything else in my life, things started to gel. And fortunately, a couple of my doctors stayed there to critique me all along the way.

Basically, so-called “right unilateral ECT” (RUL ECT) is associated with no significant long term retrograde amnesia – the principle side-effect of BL – and works about as well as BL in reported cases in the treatment of RSD, putting roughly 2 out 3 cases into long term remission. But what was fascinating was that with modern brain imaging techniques, scientists could see an increase in blood flow to on part of the brain – the thalamus – during the moment of the ECT seizure! This was exciting because the thalamus was known to experience reduced blood flow in RSD/CRPS-1 patients and would be restored to normal upon successful treatment, e.g., with ketamine, but it had been thought that the change was an “adaptive” response to the reduction of pain over time. Now here was evidence that it was happening in the instant of the ECT treatment. What’s also interesting is that not only does ECT have an almost identical regional cerebral blood flow (rCBF) “profile” to ketamine administration, but when ketamine is used as the general anesthetic in ECT treatments (a general anesthetic is always required) there is virtually no short-term memory loss beyond the time it takes to clear the anesthetic from the system, when short-term memory losses lasting perhaps 4-6 weeks after ECT treatments were always deemed a cost of the treatment.

Plus ECT is relatively safe overall, and is associated with no more than 2 deaths per 100,000 in a large demographic study, as opposed to the “normal” death rate of 7.7 per 100,000 associated with general anesthesia in the United States. Finally, among all of the chronic pain conditions treated with ECT, RSD has actually been suggested to have among the highest success rates.

Having said this, I should caution all that while these reports go back many, many years, there have never been any large double blind studies done of this treatment: which would be almost impossible to do because one apparently can tell waking up whether you’ve been zapped or not. As such, the issue of insurance coverage may be somewhat problematic for the time being.

In any event, after months of frustratingly slow effort, I barely finished the article in time to meet my deadline, which now appears in the March 2008 issue of the Journal of Practical Pain Management under the title “Right Unilateral Electroconvulsive Therapy Treatment for CRPS.” A copy of my article can be linked to on the JPPM site at http://www.ppmjournal.com/pdfs/PPM_M...haels_CRPS.pdf and I’m pleased to see it on the RSDSA Medical Articles Archive page as well. I would encourage anyone who’s interested to take a look.

And no, I haven’t had the treatment yet myself (anywhere from 8 to 12 separate applications appear to be required) but hope to do so when it can be arranged.

Please excuse the length of the post, but there was much I wanted to share.

Mike