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http://www.painphysicianjournal.com/...10;573-578.pdf

A 42 year old female patient undewent a series of 12 ... ECT treatments for ... depression ...

This standard treatment procedure for refractory depression completely resolved the patient's depressive symptoms. In addition, the patient's CRPS symptoms were also REVERSED. ...

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After 4 years of intractable pain and failed treatment attempts, following ECT, the patient made a full physical and social recovery. She no longer requires any pain OR depression medication. She now leads a normal life and has returned to working FULL-TIME as an attorney.
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Therefore, it is possible that ECT may trigger the RECOVERY PROCESS of the brain that has been reorganized by CRPS pain to its original form. Because our patient's symptoms did not immediately completely improve, it can be postulated that ECT may begin the process that restores the brain to its normal functional somatotopic processing capacity, but it may require a prolonged period of time to completely recover.

There is always hope!

Thanks Ada, very very much, for your understanding and friendship.

XOXO Sandy

I must agree I have seen Dr Schwartzman and was going to Germany for Ketamine. I mustr say there is alot of things involved with Ketamine that need to be reviewed. Dr Schwartzman is only interested in Ketamine and no other procedure, and yes i was too told i am depressed. Well lets see, in a wheelchair, 25 years of pain 9 failed surgeries, on disabilty, gained a ton of weight, have discolored feet, burning pain and overall miserabel,,, HELLO!!!!!!!!!!!!! I hope you have a pain free night, i will keep you in my thoughts

I never thought I was "truly" depressed until the day I got relief from RSD when my first SCS was implanted. During the "honeymoon" period with my neurostimulator, people were commenting to me how great I looked! That I had so much life and vibrancy in my eyes; that I looked like my old self. Hearing that, I realized what I must've conveyed "in my eyes" for the past couple of years is someone who was me.

I was lucky to have enjoyed that period, to reconnect and get to be my old self for awhile. When the RSD pain started emerging through after about 6 weeks, it also attacked that new glow I so happily enjoyed.

To suggest that RSD and Depression don't go hand-in-hand is a total contradiction. When a disease is attacking your nervous system, creating excrutiating pain 24/7, and problems with mobility, relationships, employment, sleeping, etc, for any human being NOT to be depressed could only be possible from him/her being high on drugs.

Dr. S should be ashamed of himself for even suggesting the anyone with RSD would not be depressed as well!!!!

I believe certain Drs. jump on a banwagon of certain treatments due to the kickbacks they get from pushing them. I think there should be a law that keeps them from taking kickbacks.

These Drs. end up having a one track mind and therefore anything else offered for something is passed up. This happens with meds, pain pumps, SCS's, VNS's, anything that seems to bring them the most kickback.

My depression got so much worse when I developed RSD and when I look back at what I went through, I can relate to anyone just starting out with the RSD and trying to get the right treatments.

I do believe also that if a person has depression so bad that it overtakes whatever illness they are going through, then the depression needs to be treated with meds and councelling to help get it under control also. It goes back to people accepting the fact that they are dealing with the depression and finding the right help for it. Once the depression is under control then a person can see the other things clearer that they are dealing with.

I think what is bad also is that these Drs. don't try to help give a person ideals of where to get help or acknowledge it openly instead of just putting it in the paperwork for the patient to read after they get their medical papers.

Also, why does a Dr. not say if you get the depression under control then you could come back and see me and then I might be able to help you?

Ada

There are very good reasons for not wanting to give Ketemine to someone that suffers from depression.

Ketamine has very powerful effects on your brain. Everyone here has heard or read about how they have to use other drugs to try to control the hallucinations that patients experience with ketamine. As I understand it this drug can cause long term physiological problems for some.

While I totally understand disappointment with being disqualified from the ketamine treatment for depression, in defence of the doctors involved with the clinical trials using ketamine I believe they are making that decision in your best interest. Some people are disqualified for physical reasons too. That doesn't make the doctors self serving.

These doctors are not saying you that should not have depression along side with your RSD. What they are saying is that patients who have the 2 together are not good candidates for the treatment with Ketamine. I think that is being responsible.

Lordwood we haven't heard from you in a long time. I truly hope you have found some alternatives for your treatment and that things are getting better for you.

MsL

Lordwood -

I second MsL's concern. Please be advised, however, that because you are depressed you may be a candidate for ECT, preferrably "non-dominant unilateral electorconvulsive therapy" (more commonly known as "right-unilateral ECT" or just RUL-ECT) which has substantially fewer effects on long-term memory than does the treatment of long standing ("bi-lateral ECT" or BL-ECT.)

Praise God (PG for short?) apparently makes reference to a casenote by Wolanin MW, Gulevski V, and Schwartzman RJ, Treatment of CRPS With ECT, Pain Physician 2007, 10:573-578 free full text available at http://www.rsds.org/2/library/articl...chwartzman.pdf What makes this case so significant, is that the authors were simply following the patient for her pain, it was her psychiatrist who ordered the ECT for the pain induced depression (DSM IV code 293.83: mood disorder due to medical condition) whereupon she was cured of both!

The RSDSA Medical Archieves Page does a good job of posting full text copies of many of the most important medical articles on CRPS at http://www.rsds.org/2/library/articl...html#Treatment where they are listed first by broad category, and then alphabetically by the last name of the first author. NOTE TO ALL: Before putting up a link just to an abstract, please check the RSDSA page to see if free full text copies are already avialable and then link to that page.

And Lordwood, please note the great irony that it is far easier to get ECT for depression than chronic pain/CRPS! In fact, in California, I learned about a year ago that, following a well-meaning voter initiative passed in 1976, it's illegal to give ECT for anything other that certain defined psychiatrict conditions, outside of a formal human study approved by a medical center's Institutional Review Board (IRB), a process I'm told takes about a year of a physician's life.

Finally, you can also check out a review article I wrote a year and a half ago at the request of the RSDSA, Michaels F Jr., Right Unilateral Electroconvulsive Therapy Treatment for CRPS, Practical Pain Management 2008, March; 68-75 free full text at http://www.rsds.org/2/library/articl...haels_CRPS.pdf There's a lot of stuff in there, including reports of quite detailed safety studies.

Good luck!

Mike

ps It was also my upclose and personal understanding that the blanket "no psychiatric condtions" for the use of ketamine came not from Dr. Schwartzman but his IRB. Effective as of late 2004.

Ada -

Just one point of clarification, since this is a thread on Ketamine. Where the drug went generic many years ago, by definition there is no manufacturer holding patent rights in whose interest it would be to push favorable academic studies. (And I wish I could say the same of the great weight of the professional literature in general, but you and I know better.) Ditto kickbacks, which only work if tje mnaufacter has a pool of "monopoly rents" out of which to make the payments in the first place.

And if you do a PubMed search for RS Schwartzman going back over the last 20+ years, you'll find a great many RSD articles having nothing to do with ketamine: witness the ECT article referred to above. It just so happens that he believes, as do many, that NDMA receptor antagonists provide the best shot in the long run of curing otherwise untreatable cases of CRPS and that it makes the most sense to start with ketamine where it's the most powerful of those drugs.

Finally, he's largely a one man shop right now, and except for those long term patients from SE PA who he has followed for many years, can only be doing so many research studies, which is where his out of town patients fit in, after all of them have received a comprehensive evaluation, whether or not they will qualify for the treatment protocal at issue. Mayo Clinic Rochester is much the same way, it will offer a comprehensive evaluation to anyone who can get an appointment, but will only treat those patients who live in the immediate area, for purposes of follow up, etc. (The fact that my parents live in a condo 3 blocks away didn't cut it.) At least Dr. Schwartzman doesn't draw that line when it comes to people who can participate in his current studies. And trust me from personal experience, his letter to my referring phyician carried for more weight with my disability carrier than anything they saw from any other physician, including those at the Mayo Clinic, or their own IME report for that matter.

Mike

I just want to point out briefly that ECT is a brutal, brutal treatment that has long term consequences. It is NOT used often to treat depression- it is a treatment of last resort for severely suicidal and psychotic patients who keep trying to hurt themselves. There is very very little research to suggest that this is effective for treatment of pain- they are mostly case studies of a few individuals, and no large cohort studies. It is also important to note that the ECT in these case studies was administered due to suicidal tendencies, not for pain as the primary purpose. It makes me wonder if the pain reduced because the depression reduced. And, in these cases where pain relief resulted, it was from bilateral ECT, which can have devastating effects on memory and even one's ability to function.

I was hospitalized for a while due to severe depression and PTSD. I watched people go through ECT who were in inpatient with me and decided that I would do everything possible to avoid going through that. I am fortunate that I found an antidepressant that works, and that inpatient and outpatient treatment helped my depression. ECT is not pleasant at all, and I was happy that I did not have to resort to it.

Lynns

Dear Lynn -

I am very sorry for what you went through.

However, please note that the disabled former judge who recieved BL for her depression secondary to RSD got her life back and was in an apparent permenant remission 4 years later, working as an attorney. Wolanin MW, Gulevski V, Schwartzman R, Treatment of CRPS with ECT, Pain Phys. 2007;10:573-578 at , full text at http://www.rsds.org/2/library/articl...chwartzman.pdf And note, this is the same Robert Schwartzman who was later to observe in Schwartzman RJ, Erwin KL, Alexander GM, The Natural History of Complex Regional Pain Syndrome, Clin J Pain. 2009;25:273-280, 273, full text at http://www.rsds.org/2/library/articl...lexanderGM.pdf that in a study of 656 patients with CRPS of at least 1-year duration, "None of the patients in this study demonstrated spontaneous remission of their symptoms."

You say in your post that "in these cases where pain relief resulted, it was from bilateral ECT." this is simply not the case. As I attempted to point out in Right Unilateral Electroconvulsive Therapy Treatment for CRPS, Pract Pain Manage. 2008 March;68-75, 69, that conclusion was reached in err by King and Nuss in Reflex Sympathetic Dystrophy Treated by Electroconvulsive Therapy: Intractable Pain, Depression, and Bilateral Electrode ECT, Pain,1993, 55:393-396, when they misread one of two studies they relied upon, Mandel MR. Electroconvulsive Therapy for Chronic Pain Associated with Depression, Am. J. Psychiatry, 1975 132:632-636, which had found that RUL was effective for chronic pain — providing persistent relief for four of six patients, where at least one of the four (and quite possibly two) had RSD. (And the other case relied upon by King and Nuss dealt with patients suffering from poststroke thalamic pain!)

Unfortunately, it was not until the publication of McDaniel WW, Electroconvulsive Therapy In Complex Regional Pain Syndromes, The Journal of ECT 2003, 19:226-229 (in three cases of depressed patients with RSD, RUL ECT relieved the RSD although not the concomittant fibromyalgia in one of the patients), that the misstatement of King and Nuss was first questioned.

Now, you also say:

It is also important to note that the ECT in these case studies was administered due to suicidal tendencies, not for pain as the primary purpose. It makes me wonder if the pain reduced because the depression reduced.

First of all, I know of nothing in the record that indicates that these people all had "suicidal tendancies." You can't make that jump from just the use of the term depression. Certainly not in 1957 when other treatment options were few and far between, and not today, where as I understand it, the prevailing standard for the treatment of depression by ECT is that it be "refractory" meaning not susceptable to treatment by other means, and imposing a substantial burden on the ability of the patient to function. And while it's true that all of the patients referred to in the literature had co-morbid RSD and depression, that is certainly the position Lordword finds himself in today. So for purposes of providing Lordwood guidance, the studies are precisely on point.

And as to the suggestion that alieviating the depression may have had a role in resolving pain, that position was definitive disproved in a study out of Johns Hopkins, that ECT in fact relieved pain independently of its effect on depression. Wasan AD, Artin A, and Clark A, Pain Medicine 2004 5:50-58, which I attempted to address at page 73 of my article. Here's the abstract for the Wasan article:

OBJECTIVE: Chronic pain improves with electroconvulsive therapy (ECT), yet few case reports account for treatment of comorbid major depression, a significant confounder of the analgesia of ECT. This study reports on the analgesia of ECT, controlling for treatment of depression. METHODS: This is a case-matching study comparing outcomes of inpatients with chronic pain and major depression in a multidisciplinary pain treatment unit treated with ECT and medications (cases) with those of inpatients treated with medications only (controls). Both groups received the same behavioral and pharmacological treatments for depression and chronic pain. Outcome measures included 0-10 pain rating scales and the Montgomery-Asberg Depression Inventory. Patients were matched on sex, age within 5 years, admission date within 6 months, psychiatric diagnoses, and, as much as possible, on race and pain syndrome diagnosis. Percentage changes in depression scores and pain scores were calculated from the beginning to the end of admission. RESULTS: There were nonsignificant differences in demographics, except in the proportion married. Twenty-five of 28 ECT patients were matched. Depression improvements were similar between cases and controls (55.9% vs 40.5%). Despite higher initial pain (8.1 vs 6.9 on a 10-point scale), the ECT group had less final pain (3.4 vs 5.5). The ECT group had a 59.8% drop in pain versus a 15.8% drop in the control group, P > 0.01. CONCLUSIONS: ECT has analgesic properties independent of its improvement of depression in patients with chronic pain and major depression. Improvements in depression were similar, while there was a significantly greater improvement in pain with ECT. The lower post-ECT treatment pain scores suggest a specific analgesic effect of ECT. Copyright American Academy of Pain Medicine

PMID: 14996237 [PubMed - indexed for MEDLINE]

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

Finally, although not involving CRPS, we now have a study of the effect of ECT on chronic pain, indepedent of underlying depression. Usui C, Doi N, Nishioka M, Komatsu H, Yamamoto R, Ohkubo T, Ishizuka T, Shibata N, Hatta K, Miyazaki H, Nishioka K, Arai H, Electroconvulsive therapy improves severe pain associated with fibromyalgia, Pain 2006 Apr;121(3):276-80:

Abstract
The pathophysiology of fibromyalgia remains unknown. Several reports have recently suggested the novel concept that fibromyalgia is due to the central nervous system becoming hyper-responsive to a peripheral stimulus. The effect of electroconvulsive therapy (ECT) as pain remedication in cases of fibromyalgia without major depressive disorder was studied in a prospective trial lasting three months. All of the patients taking part in the study fulfilled the American College of Rheumatology diagnostic criteria for fibromyalgia. Technetium-99m ethyl cysteinate dimer single photon emission computed tomography was used to assess regional cerebral blood flow (rCBF) before and after a course of ECT. Pain assessment in the patients was undertaken by use of the visual analog scale (VAS) and by evaluation of tender points (TPs). Beck's depression inventory (BDI) was further used to assess depressive mood change in the patients. Our study clearly demonstrated that pain was significantly less severe after ECT, as indicated by the VAS scale for pain and the evaluation of TPs. A further notable observation was that thalamic blood flow was also improved. We conclude that a course of ECT produced notable improvements in both intractable severe pain associated with fibromyalgia and also in terms of thalamic blood flow.

PMID: 16495009 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/1...m&ordinalpos=7

What I find exciting in this study, is the reference to the modification of rCBF as the mechanism of action in ECT, as first demonstrated in Fukui S, Shigemori S, Yoshimura A, Nosaka S, Chronic Pain with Beneficial Response to Electroconvulsive Therapy and Regional Cerebral Blood Flow Changes Assesed by Single Photon Emission Computed Tomography Reg Anesth Pain Med. 2002; 27(2):211-213, full text at http://www.rsds.org/2/library/articl..._Yoshimura.pdf

Seriously, we now know that inflammatory processes are not responsible for the maintainance of chronic CRPS. And if one if it's hallmarks is abnormal rCBF in the brain, and that can re harmlessly reversed with RUL ECT, in roughly 2 out of 3 patients, then why not?

Mike