Saturday, August 14, 2010

Just Because

Surprised Kitty (original)

Uploaded to YouTube by rozzzafly on October 13, 2009

Re: Surprised Kitty

Uploaded to YouTube by 1Click2Fame on December 02, 2009

Surprised turtle
From -- LOL

Surprised Dog

Uploaded to Youtube by OkGo on January 08, 2010:
"Bunny the dog doing her 'surprised kitten' impression."

Friday, August 13, 2010

2010 Charles Prize for Poetry

This blog risks being overcome by negativity, drowning in The Acerbic (that Northern Sea).

Poetry has saved us before, no doubt it can ably throw a line over the bow (Though would it not make more sense that we'd be now floating, now drowning in the rear, behind, off the stern?.  Who would fall from the bow, how and why?).

If I continue to worry about where I am in relation to my salvation, I'll be lucky if I am even deemed somewhere overboard, and worth rescuing.

Thank goodness for people of clarity, and good humor.  Also, there's an expanse, a general bigness, in these generous people.  There's room enough.

Such is Doctor Charles, Physician Writer, Healer.  I've been reading the entries to a poetry competition he's sponsoring, and enjoying them very much.  They are affirmative and rich, spare and true.

Ah, but there is not, as yet, a villanelle.

Why don't you enter?  Here is what he has to say about the contest -- take a moment and visit his blog, take the measure of the place, and then consider trusting him and his readership with a poetic creation that treats "health, science, or medicine."

Fred and I will stick to what we do best:  Interpretive Dance (As Performed In The Moat).  Good luck and happy reading over at The Examining Room of Dr. Charles.

[I can already feel the snark begin to calm ~ that morsel of marine excrement, Ochoa, sink into watery oblivion ~ that Reuben-oid Scamster ride the swell, only to drift, away.]

Announcing the first annual 2010 Charles Prize for Poetry. Bold and pretentious name aside, the award will be given to the writer who submits for consideration the most outstanding poem within the context of health, science, or medicine.

Open to everyone (patients, doctors, science people, nurses, students, etc.). 1 or 2 entries per person.

Poems should be related to experiencing, practicing, or reflecting upon a medical, scientific, or health-related matter.

The winner will be selected by a panel of three judges, including me. These other judges may or may not be Nobel Laureates, you never know, but all appreciate poetry. I may ask for your permission to post a copy of your poem on this blog as we go, with or without attribution as you wish.

Is such an eponymous contest grandiose? Yes. Does the limited poetry I’ve written carry the gravitas needed to make me an authority on the subject? No way.

But should your poem be selected as the winner, you shall receive a plaque, an award of $500, and a tasty cherry tomato from my garden. Seriously. At least one person has written that winning the cherry tomato is more important to her than all the gold in the world. I’m sorry that my budget is not higher, but I thought I could swing $500 without enlisting sponsorship. Who needs an iPhone anyway?

Update – with so many great poems in so far, I think I’ll award a few surprise prizes for honorable mentions

So have fun, find inspiration, and send your entry to:

drcharles.examining *at*

Contest closes August 31st.

PHOTO CREDIT: NASA, Stormy Weather in the North Sea, with Sweden, Denmark, and Norway, featured.

Stormy weather over the North Sea is not uncommon, and so the powerful winds that swept over the European ocean basin on October 27, 2006, were not extraordinary. Winds gusting to hurricane force raged over the sea for several hours, and by the time that the Moderate Resolution Imaging Spectroradiometer (MODIS) on NASA’s Aqua satellite flew over at 1:00 p.m. local time, the sea had turned a foamy, white-flecked green off the shore of Denmark. Westerly winds were driving waves into shore, creating a fringe of white where waves crashed onto the beach. In the image, glimmers of white glint in the murky waters offshore where waves break over the shallow continental shelf. The violent sea churned up clouds of sediment, giving the water the brown and green color seen here. Clearer, deep water farther north is nearly black, by contrast.

Thursday, August 12, 2010

Grizzly Prospects

I used my vast collection of Thanks-For-Charging-It VISA Points for a gift card to use online at Cabela's.
If that seems an odd choice on my part, you're right!  A Brit might cry out:  "Spot on!"

Hunting, archery, and shooting -- not the favored pasttimes you'll have noted here at elle est belle la seine

What does Cabela's offer for someone as refined as myself?  What might I actually order from an outfitter of camouflaged Bambi assasins? 


Why, Bear Repellent, of course!

Not the wimpy 1.9 ounce spray designed for suburban joggers to bring down some average and unimaginative -- though admittedly fast -- miscreant... Not that fifth-of-a-second's bit of perfumed spray that hangs on a keychain, either.  We are talking over 13 ounces of Predator Defense, enough to erect a Wall of Wicked WhoopAss from 35 feet away.

If I could walk, I'd swagger.

My WhoopAss Bear Repellent was not designed to be used on humans. Nowhere in the sales points or in the WhoopAss Bear Repellent literature is use on humans condoned or advised.

Therefore, I immediately set to work on a moving, yet clearly exculpatory, Penitent Confession to commit to memory -- because I fully intend to release my beast on Mortal Man

(Unless Marlinspike Hall is invaded by grizzlies ineluctably drawn by the abundance of Koi and MoatMonster Fish.  Grizzlies are, il faut le dire, not exactly common in Tête de Hergé [très décédé, d'ailleurs].)

The Former-Inmate-Turned-Security-Advisor consulted by an alarmed -- but notably absent -- Captain Haddock, has directed me to attach the Bear Repellent to the right arm of the wheelchair, within easy reach but sufficiently out of the way that it won't be set off accidentally.  I am also instructed to always have a phone on board -- though if it takes the police an hour to respond, I am not sure that matters.  I get the sense, from the epic number of winks winked my way, that the old Haddock family charm may have reached out to local law enforcement... so, fine, I will give Tante Louise a buzz during or after our next break-in.  (Tante Louise is our area's version of an early response system!)  During or after, but not before I unleash The Beast and deliver my personal brand of WhoopAss upon the Intrepid Interloper!

The spray comes with a handy guide, called "Bear Safety Tips." I set about reading it straight away, of course.

You know those humor segments that feature "the world's dumbest X" -- robbers that choose to enter via the ceiling and get stuck between floors, the thief who leaves his wallet behind, the calculus teacher that can't do basic math?  The common element, what makes us guffaw, is the lack of expertise exhibited by the purported expert -- the trapped robber, the identified thief, the ignorant schoolteacher.

Consider the parents described in my handy "Bear Safety Tips" booklet by UDAP Bear Defense Spray President Mark Matheny:

In the past, bear spray has received some negative press because, when used incorrectly, the odor of the bear pepper spray can actually attract bears.  Some individuals, under the mistaken impression that bear spray acts as a repellant, have sprayed their personal items with it in an attempt to deter bears from getting into their gear.  Parents have even sprayed it on their children and themselves like it is OFF or DEET insect repellent.  DO NOT SPRAY PEPPER POWER BEAR DETERRENT ON PEOPLE!
Can you imagine spraying your child with anything without knowing what it was, without any idea of what it might do?  I mean, if you wish to be an idiot, do it on your own time, and on your own mucous membranes...


Did I notice that last sentence?  "DO NOT SPRAY... ON PEOPLE"?  I've already stated my intentions and not even a phrase in all CAPS is going to make me act any differently.  My Penitent Confession isn't quite ready for use, but in the meantime, should another Intrepid Intruder decide to climb through our glassless Fresh Air Access Modules (preceded by his useless hammer), were I to accidentally confuse him for a rabid grizzly bear, who is going to cry "Foul"?

I promise that during the hour spent waiting for the police to finish their Monks Fudge down at the Cistercians' Place I will gently bathe the eyes of the whimpering behemoth that I mistook for Ursus arctos horribilis... while La Bonne et Belle Bianca Castafiore serenades the savage beast, most likely with a selection from Gounod's Faust.

I wonder what else my Thanks-For-Charging-It Points on my Tête de Hergé VISA might deliver, in terms of protecting The Manor?

photo credit:  Mathieu Belanger/Reuters

Wednesday, August 11, 2010

Rivulets of Pluckiness: My Psychopathology (WITH UPDATE)

In the week since sending off my application for health insurance under the Pre-Existing Condition Insurance Plan * , I am feeling much worse.  In the course of the day, my mind wanders back to my last conversation with one of the world's most talented shoulder surgeons -- and my ludicrous questions to the very patient man.

"How will I know if it gets worse, if I need to come in?" and another 5 permutations of the same inquiry were met with a muttered:  "You'll know." 

Eyes downcast. 
No charge for the office visit.
Orders for joint aspiration under fluoroscopy -- the sixth -- which the hospital refused to schedule due to my lack of insurance.

My Teacherly Self has assured you many times, Faithful Reader, that there are, indeed, stupid questions.  My question'to ShoulderMan, however obtuse it might sound to you, was not stupid. It just didn't have an answer.

Given that fever, pain, sweats, and fatigue are daily occurrences, nothing to write home about, and certainly nothing to call the doctor over, how am I supposed to gauge... change?  That's one version of my question.  The throbbing, throbbing version?  How much can I stand?  How much, in the Name of God, should I stand?  What am I worth?

For instance, what am I to do or think when the pain begins to have that unmistakable infected ::twinge:: again, when using my left arm to do anything beyond putting a masterful grip on a paperback (currently The Cider House Rules by John Irving) causes an increase in fever and pain, even brings on The Febrile Shivers, when my hair is plastered to my head by what can only be called RIVULETS of salty sweat?  I confess that I cannot squelch the feeling that something ought to be done, that there ought to be some sort of response.  Hello?  Hello?

If you would like to make a call, please hang up, and try again.

Hey... I just noticed something:  It's a sign of my innate PLUCKINESS that I came up with RIVULETS.
[Possibly from Italian rivoletto, diminutive of rivolo, small stream, from Latin rvulus, diminutive of rvus, stream; see rei- in Indo-European roots.]

So, Friend.  What kind of psychological disorder is this, then?  Are my mind and my body in collusion? Are psyche and soma permitting a worsening of things now that addressing this bone infection won't q:u:i:t:e ruin me financially?  Or is it that now I am allowed, by a hyper-protective subconscious, to perceive just how bad things really are, and have been?  Whatever the underlying psychology, psychopathology -- I don't want to go down this road.  I don't want things to get harder. 

Yes, I hear that annoying high-pitched whine, too. 

I cannot go on like this -- this daily descent into Hell.  Have I garnered no new skills?  Why can't I look the other way, play the Polyanna Glad Game

I haven't phoned in my distress, nor emailed my Go-To-Guy Internist, because the one detail that never quite leaves me is the one where both ShoulderMan and Go-To-Guy cough-and-blurt that there is nothing more to do, except to remove my prostheses.  Permanently.

I can see how that would prevent the hardware from serving as petri dishes for further bonzo-bacteria... but it doesn't address the little buggers already in the humerus... Y'know? 

Impending Implosion Warning.  Impending Implosion Warning.  Impending Implosion Warning.

Thanks for the space and time to vent. 

{you know i want to apologize.  you know i do.  and so i ask myself:  whose blog is it anyway?  hmmm?}

AUGUST 12, 2010: If you happen to be sporting your Dancing Shoes, prepare to do the Happy Dance! 

Today's mail included a slender envelope from the Pre-Existing Condition Insurance Plan, Administered by GEHA. 

 I admit that Fred was asked to pray before I opened it -- not some wimpy WASP-y mumblejumble, no!  Fred incorporates kippah, tallit, and tefillin -- and he looks quite fetching in his spiritual armor -- while he performs an impeccable High Mass in medieval Latin.  To cover all bases, we set out large baguette-shaped baskets full of French Existential classics, a sort of tired homage to Christ as the Bread of Life, and a nod-with-a-wink to actual bread to keep the actually living... alive. 

La Bonne et Belle Bianca felt it imperative that she don a long, white linen tunic, à la Isadora Duncan, and run on her tippy-toes -- in a weird crisscross pattern abbreviated by what might have been S.O.S. signals -- while waving smoking fronds of sage.

Marmy Fluffy Butt, after her great swath of tail was sufficiently poofed, led Dobby and Uncle Kitty Big Balls in a decorous purred rendition of Hymn of Hope, the famed devotional commissioned for the 150th anniversary of the First Baptist Church of Lapeer, Missouri.  Marmy is particularly keen on the musical notation for the piece that dictates it be done "reverently with quiet strength."

Thus fortified, I carefully slit open the envelope, hands trembling.  It was a flashback to the long ago days of college acceptances, with the significant improvement that the word approved was greatly bolded.

 As in:  approved approved approved !

When the sage ash settled, and the sacramental music faded into a bit of impressive jazzy scat, a few inconsistencies between the promised item and the item delivered were noted -- the monthly premium that was only to change when one shifted from one age bracket to another now may possibly change due to "market" forces; the deductible paid between now and the end of the year does not appear to be applied to next year's due, and a few other odd notes.  Each problem may be resolved by the more complete language of the full policy, which I haven't yet received.

Anyway, Dear Reader -- dance!  Dance with abandon, dance with joy -- I am insured! 

President Obama?  Thank you!

Monday, August 9, 2010

Special Issue! Get Your Special Issue, Right Here!

Oh, the excitement.  Hold me back. 

The current issue of everyone's bedtime reading, Pain Medicine -- The Official Journal of the American Academy of Pain Medicine and of the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists and of the International Spine Intervention Society?

None other than the long awaited Volume 11, Issue 8?

Dated August 1, 2010?

Okay, so it is the "Introduction to CRPS" Special Issue!

No, I am NOT kidding!  Life CAN be unexpectedly exciting and off-the-chart, unimaginably AWESOME!  When you least expect it, just when you thought it would never happen:  A CRPS SPECIAL ISSUE!

I remember the whispers, the muttering, the animalistic vocalizations, the underground rumor that such a thing might happen, one day.

I used to dream of making the cover -- of winning out over the hundreds of other beautiful people with icy, purple extremities and twisted appendages because I, Me, Moi -- I had the iciest, the purplest, the most twisted stuff of them all.  Mwa ha ha!

What?  What?  Did I write that out loud?

In addition to my covergirl fantasy, I confess to a couple of snickers and a near snort -- it just strikes mine ear as funny -- Introduction to CRPS

Introduction to CRPS -- Doesn't it sound like one of the evening offerings for the local university extension?

Introduction to Container Gardening! Haiku in a Jiffy!  Cardio Salsa!  Introduction to CRPS!  Intermediate Creative Non-Fiction! Hip Hop for Beginners!

The university closest to Marlinspike Hall puts out a colorful brochure with "What are you waiting for? Begin Your Personal Renaissance today!"  slashed in italic red across the top.

As if that weren't enough to depress me, those Academic Stuffed Shirts (but Marketing Djinni) go on to congratulate themselves for offering "seriously unstuffy adult education... since 1951."  Seriously unstuffy.  Those wackadoodles!  Excuse me while I slap my knee and die laughing.

Okay, I confess.  My breath is bated in anaerobic anticipation for their Personal Renaissance BOGO sale, when, I imagine, the Au Pair Enrichment Program (no, I am not kidding) will kick off with "What to Say When You Talk to Yourself."  It seems that the State Department of Tête de Hergé (très décédé, d'ailleurs) aims to educate the many imported exotic babysitters that litter our domestic landscapes.  In order to successfully obtain a pre-framed Certificate of Completion, our Au Pairs must complete 13 semester hours at an accredited university extension program -- plus $14.95 for the frame, $3.95 extra for matting (hanging hardware included).

Once the Au Pair establishes fluency in the languages and cultures of Tête de Hergé (très décédé, d'ailleurs), s/he is free to use the rest of his or her 13 semester hours to take Personal Enrichment electives.

I checked the credentials for the instructor of this Self Talk course, and she is, indeed, a  "Licensed and Certified Self-Talk Instructor," having attended the famed Self-Talk Institute -- brainchild of Dr. Shad Helmstetter, Ph.D. -- yes, of Scottsdale, Arizona.  That Doctor Helmstetter.

I was pleasantly surprised to find that the good doctor maintains a website where one can purchase CDs of his life-changing Self Talk scripts -- in case you, like me, can't think of a thing to say to yourself and don't have Monday evenings free to audit the Personal Renaissance Au Pair Enrichment Program.  The hallmark of any good webpage -- with just a glance, several pressing questions were answered:  How often do I need to talk to myself?  Are Helmstetter's Self-Talk Scripts the absolute best out there? Are these the last Self-Talk Scripts I will ever have to buy?

He calls them a Lifetime Library -- No more obsessive shushing, no more reading material merely on loan, like at your average library, all those annoying renewals and returns, dealing with snarky middle-aged women sporting pince-nez, going on and on about late fees, and blocking your access to computer porn.

[Not to go off on a tangent, but I wanted to address the wearing of the Pince-Nez, which, as you likely know, is undergoing a revitalization.  You can find the answer to any of your pince-nez related concerns at this useful blog:  Pince-Nez Renaissance,  whose stated purpose is:
To assist those who are interested in wearing pince-nez and promote awareness of this antique eyeglass style. There is very little information available on wearing pince-nez and it is easy to become discouraged. This site, the work of two full-time pince-nez wearers, provides the advice necessary for wearing this distinguished style of eyeglasses.

So it's true -- you can find anything on the internet.  I guess the corollary must work, as well, huh? The internet has room for everyone.  Thank goodness.]

This is the set of Self-Talk CDs that is personally recommended by Dr. Shad Helmstetter — the best Self-Talk ever produced.

Each album includes four complete Self-Talk Sessions — 1 Morning Session, 1 Nighttime Session, and 2 Daytime Sessions — so you’ll have exactly the right Self-Talk morning, daytime, and night.

The best-selling Self-Talk CD program of all time!

Dr. Shad Helmstetter wrote this state-of-the-art set of Self-Talk CDs to be the ultimate self-improvement CDs -- exactly the right Self-Talk that would cover everything - Self-Talk that anyone could use at any time for every situation.

The Lifetime Library is a set of CDs that covers:Self-Esteem; Financial Success; Personal Relationships; Personal Organization; Job and Career; Health and Fitness; Personal Growth; and Quality of Life.

No home should be without this incredible, life-changing library of professionally recorded Self-Talk CDs.

I wish I were equipped with what is necessary for such shameless promotion.  Imagine me in the middle of your telecommunication highway, stopping traffic, wearing a sandwich board advertising Special Issue!  Get Your Special Issue, Today!  CRPS, The Down and Dirty!  Get Your Special CRPS Issue, Today!

What did you expect:  The End is Near?

The Introduction to CRPS Special Issue -- and by this, I mean the introduction, as in the piece doing the introducing, was written by Peter R. Wilson MB, BS, PhD.

What follows is an embarrassment of riches, at least as far as CRPS research is concerned -- solid work by known names in the field -- pioneers, even.   Maybe the best part of all?  There is no evidence of the existence, much less the thought, of that TURD José Ochoa!

Objectification of the Diagnostic Criteria for CRPS - August 1, 2010 (Pain Medicine -- Journal of the American Academy of Pain Medicine)
Author Information:  R. Norman Harden, MD, Rehabilitation Institute of Chicago, 446 E Ontario Street, Suite 1011, Chicago, IL 60611, USA. Tel: 312-238-5654; Fax: 312-238-7624; E-mail:

Abstract:  The current diagnostic criteria for complex regional pain syndrome (CRPS), codified by the International Association for the Study of Pain's taxonomy committee, and newer statistically derived criteria (the “Budapest” criteria), are both deliberately based on bedside testing. Designing criteria that are accessible to any clinician, not requiring any special equipment or training, is very important for clinical diagnosis. However, that approach, albeit pragmatic, forces a very heavy reliance on the subjective (not only the subjective response of the patient, but the subjective impression of the clinician). This is very problematic scientifically and statistically. Fortunately, with some new technologies and new approaches to old technologies, significant improvements can be made not only in terms of quantification, but also in allowing significant objectification of the diagnostic data. We will initiate a discussion of some of these potentially useful approaches.
Plasticity of Complex Regional Pain Syndrome (CRPS) in Children - August 1, 2010 (Pain Medicine)
Author Information:  Michael Stanton-Hicks, MB, BS, Dr. Med, FRCA, ABPM, Pain Management Department, Center for Neurological Restoration, Consulting Staff, Children's Hospital CCF Shaker Campus, Pediatric Pain Rehabilitation Program, Cleveland Clinic, Cleveland, OH 44195 USA. Tel: 261-445-9559; Fax: 216-444-9890; E-mail:
Abstract:  Complex regional pain syndrome I (CRPS I) is defined by the International Association for the Study of Pain (IASP) criteria to include pain that is disproportionate to the inciting event, sensory disturbances such as allodynia/ hyperalgesia, autonomic dysfunction, and motor dysfunction that usually occurs after trauma that is frequently trivial and generally expressed in an extremity. These symptoms are well described in the adult population, but there are relatively few data or reports of its prevalence in the pediatric population. Recent studies have demonstrated that unlike the adult population, about 90% of the cases reported are females in a range of 8 to 16 years, the youngest being 3 years old. There tends to be delay in recognizing the diagnosis, which may be as long as 4 months. In contrast to adults, the response to treatment, particularly exercise therapy with behavioral management will achieve almost 97% remission. While the pathophysiology is poorly understood, many features, particularly the neurologic abnormalities, suggest both peripheral and central nervous system involvement. Peripheral small fiber neuropathy as an etiology and inflammation involving small nerve fibers (neurogenic inflammatory pain) has been suggested. A tissue inflammatory etiology has been investigated over the past 25 years. However, these inflammatory aspects differ from those seen in other conditions involving tissue inflammation. The suggestion that CRPS in children is a different clinical entity than that seen in the adult, is probably incorrect, as recent evidence would suggest that the pathophysiology is most likely identical involving endocrine, behavioral, developmental, and environmental factors that distinguish clinical presentation in children from the adult. Behavioral management is a mandatory accompaniment of any program of exercise therapy and the sometimes extreme sensory disturbances and parental enmeshment do distinguish the clinical presentation from that in the adult. Interventional procedures may be required in the face of extreme allodynia preventing exercise therapy, and in occasional cases interruption of the sympathetic nerves may reverse this symptom in a few children. Occasionally, continuous analgesia techniques such as that which can be delivered by tunneled epidural catheter or an externalized neurostimulator (spinal cord stimulation) for short periods of time are effective.
A Hypothesis for the Cause of Complex Regional Pain Syndrome-Type I (Reflex Sympathetic Dystrophy): Pain Due to Deep-Tissue Microvascular Pathology
Author Information: Terence J. Coderre, PhD, Anesthesia Research Unit, McGill University, Room 1203, McIntyre Bldg., 3655 Promenade Sir William Osler, Montreal, Quebec, Canada H3G 1Y6. Tel: 514-398-5773; Fax: 514-398-8241; E-mail:

Abstract:  Complex regional pain syndrome-type I (CRPS-I; reflex sympathetic dystrophy) is a chronic pain condition that usually follows a deep-tissue injury such as fracture or sprain. The cause of the pain is unknown. We have developed an animal model (chronic post-ischemia pain) that creates CRPS-I-like symptomatology. The model is produced by occluding the blood flow to one hind paw for 3 hours under general anesthesia. Following reperfusion, the treated hind paw exhibits an initial phase of hyperemia and edema. This is followed by mechano-hyperalgesia, mechano-allodynia, and cold-allodynia that lasted for at least 1 month. Light microscopic analyses and electron microscopic analyses of the nerves at the site of the tourniquet show that the majority of these animals have no sign of injury to myelinated or unmyelinated axons. However, electron microscopy shows that the ischemia-reperfusion injury produces a microvascular injury, slow-flow/no-reflow, in the capillaries of the hind paw muscle and digital nerves. We propose that the slow-flow/no-reflow phenomenon initiates and maintains deep-tissue ischemia and inflammation, leading to the activation of muscle nociceptors, and the ectopic activation of sensory afferent axons due to endoneurial ischemia and inflammation.

These data, and a large body of clinical evidence, suggest that in at least a subset of CRPS-I patients, the fundamental cause of the abnormal pain sensations is ischemia and inflammation due to microvascular pathology in deep tissues, leading to a combination of inflammatory and neuropathic pain processes. Moreover, we suggest a unifying idea that relates the pathogenesis of CRPS-I to that of CRPS-II. Lastly, our hypothesis suggests that the role of the sympathetic nervous system in CRPS-I is a factor that is not fundamentally causative, but may have an important contributory role in early-stage disease.

Role of Neuropeptide, Cytokine, and Growth Factor Signaling in Complex Regional Pain Syndrome
Author Information: Wade S. Kingery, MD, Physical Medicine and Rehabilitation Service (117), Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave., Palo Alto, CA 94304, USA. Tel: 650-493-5000 ext 64768; Fax: 650-852-3470; E-mail:

Objective.  Complex regional pain syndrome (CRPS) patients exhibit multiorgan pathology and inflammatory changes after limb trauma. The objective of this study was to identify how neuro-cutaneous signaling is facilitated after fracture and examine how this altered signaling contributes to the development of CRPS-like changes in the injured limb.

Design and Methods.  These studies used a rat tibia fracture model that reliably generates hindpaw warmth, edema, increased spontaneous protein extravasation, allodynia, unweighting, and periarticular bone loss, a symptom complex resembling the vascular, nociceptive, and bone sequelae observed in early CRPS. Substance P (SP)-evoked extravasation responses, EIA and PCR assays, and immunohistochemical techniques were used to evaluate post-fracture up-regulation of neuro-cutaneous inflammatory signaling. A SP NK1 receptor antagonist was used to inhibit CRPS-like changes in the fracture model.

Results.  In the rat fracture model the SP-evoked extravasation and edema responses were enhanced. SP NK1 receptor expression also increased in the microvascular endothelial cells in the fracture hindpaw skin, leading us to postulate that NK1 receptor up-regulation mediates the facilitated extravasation and edema responses observed after SP injection. The NK1 receptor antagonist LY303870 reversed hindpaw warmth, edema, increased vascular permeability, allodynia, and unweighting observed after tibia fracture in rats. There was also increased keratinocyte proliferation and NK1 receptor expression in the fracture hindpaw. Similar to the rat fracture model, we have observed increased epidermal thickness and keratinocyte NK1 expression in skin biopsies from CRPS patients. There was an up-regulation of inflammatory cytokine expression in the rat hindpaw skin and in keratinocytes at 4 weeks post-fracture. These inflammatory mediators appear to play a crucial role in the development of pain behavior after fracture, as we have repeatedly demonstrated that inhibition of cytokine, and NGF signaling prevents the allodynia and attenuates unweighting at 4 weeks post-fracture. LY303870 treatment also reversed post-fracture keratinocyte proliferation, suggesting that SP might be acting as an intermediate mediator in the inflammatory cascade by causing the up-regulation of inflammatory proteins that can directly sensitize nociceptors in the skin and joints.

Conclusions.  Collectively, these data suggest that neuro-cutaneous signaling is up-regulated and can mediate inflammatory changes observed in the hindpaw skin of the fracture rat model and in human CRPS skin. Future translational and clinical studies mapping these inflammatory changes may identify novel therapeutic targets for preventing post-traumatic pain from transitioning into chronic CRPS.
Role of Minimal Distal Nerve Injury in Complex Regional Pain Syndrome-I
Author Information: Anne Louise Oaklander, MD, PhD, Massachusetts General Hospital, 275 Charles St./Warren Bldg. 310, Boston, MA 02114, USA. Tel: 617-726-2000; Fax: 617-726-0473; E-mail:

Abstract: Unavailable/ See first page of article online

Sensory Disturbances in Complex Regional Pain Syndrome: Clinical Observations, Autonomic Interactions, and Possible Mechanisms
Author Information: Peter D. Drummond, PhD, School of Psychology, Murdoch University, Perth, Western Australia 6150, Australia. Tel: 61-8-9360-2415; Fax: 61-8-9360-6492; E-mail:


Objective.  To review mechanisms that might contribute to sensory disturbances and sympathetically-maintained pain in complex regional pain syndrome (CRPS).

Background.  CRPS is associated with a range of sensory and autonomic abnormalities. In a subpopulation of patients, sympathetic nervous system arousal and intradermal injection of adrenergic agonists intensify pain.

Results.  Mechanisms responsible for sensory abnormalities in CRPS include sensitization of primary afferent nociceptors and spinothalamic tract neurons, disinhibition of central nociceptive neurons, and reorganization of thalamo-cortical somatosensory maps. Proposed mechanisms of sympathetically-maintained pain include adrenergic excitation of sensitized nociceptors in the CRPS-affected limb, and interaction between processes within the central nervous system that modulate nociception and emotional responses. Central mechanisms could involve adrenergic facilitation of nociceptive transmission in the dorsal horn or thalamus, and/or depletion of bulbo-spinal opioids or tolerance to their effects.

Conclusions.  Sympathetic neural activity might contribute to pain and sensory disturbances in CRPS by feeding into nociceptive circuits at the site of injury or elsewhere in the CRPS-affected limb, within the dorsal horn, or via thalamo-cortical projections.
Vasomotor Disturbances in Complex Regional Pain Syndrome—A Review
Author Information: Gunnar Wasner, Prof Dr Med, Department of Neurology, and Division of Neurological Pain Research and Therapy, University Clinic of Schleswig-Holstein, Campus Kiel, Schittenhelmstraße 10, 24105 Kiel, Germany. Tel: 49-431-597-8815; Fax: 49-431-597-8530; E-mail:

Abstract: Complex regional pain syndromes (CRPS) are characterized by vascular disturbances primary affecting the microcirculation in the distal part of the involved extremity. In the acute stage inhibited sympathetic vasoconstriction and exaggerated neurogenic inflammation driven by central and peripheral mechanisms, respectively, seem to be the major pathophysiological mechanisms inducing vasodilation. During the chronic course of the disease as well as early in some patients vasoconstriction dominates the clinical picture induced by changes in the microcirculation itself such as endothelial dysfunction or vascular hyperreactivity, whereas sympathetic vasoconstrictor activity returns and neurogenic inflammation is less severe. It can be suggested that the interaction between different mechanisms underlying vasomotor disturbances as well as the severity of each single mechanism in the individual patient have a great impact on the variety of the overall clinical picture in CRPS. Irrespective of the underlying pathophysiology, measurements of skin temperature differences between the affected and the contralateral extremity can serve as a diagnostic tool in CRPS, in particular when sensitivity and specificity is increased by considering dynamic alterations in skin temperature asymmetries.

Movement Disorders in Complex Regional Pain Syndrome
Author Information:  Jacobus J. van Hilten, Department of Neurology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, the Netherlands. Tel: 31-71-5262895; Fax: 31-71-5248253; E-mail:

Abstract: About 25% of the patients with complex regional pain syndrome (CRPS) suffer movement disorders, including loss of voluntary control, bradykinesia, dystonia, myoclonus, and tremor. These movement disorders are generally difficult to manage and add considerably to the disease burden. Over the last years, interesting findings have emerged that show how tissue or nerve injury may induce spinal plasticity (central sensitization), which alters sensory transmission and sensorimotor processing in the spinal cord and is associated with disinhibition. These changes, in turn, set the stage for the development of movement disorders seen in CRPS. There are no randomized control studies on the treatment of movement disorders in CRPS but findings from fundamental and clinical research suggest that strategies that enhance the central inhibitory state may benefit these patients.

What Does the Mechanism of Spinal Cord Stimulation Tell Us about Complex Regional Pain Syndrome?
Author Information:  Joshua P. Prager, MD, MS, Center for the Rehabilitation of Pain syndromes (CRPS) at UCLA, Internal Medicine and Anesthesiology, 100 UCLA Medical Plaza, Suite 760, Los Angeles, CA 90095, USA. Tel: 310-264-7246; Fax: 310-882-7005; E-mail:

Abstract: Spinal cord stimulation (SCS) can have dramatic effects on painful, vascular, and motor symptoms of complex regional pain syndrome (CRPS), but its precise mechanism of action is unclear. Better understanding of the physiologic effects of SCS may improve understanding not only of this treatment modality but also of CRPS pathophysiology.

Effects of SCS on pain perception are likely to occur through activation of inhibitory GABA-ergic and cholinergic spinal interneurons. Increased release of both neurotransmitters has been demonstrated following SCS in animal models of neuropathic pain, with accompanying reductions in pain behaviors. Effects of SCS on vascular symptoms of CRPS are thought to occur through two main mechanisms: antidromic activation of spinal afferent neurons and inhibition of sympathetic efferents. Cutaneous vasodilation following SCS in animal models has been shown to involve antidromic release of calcitonin gene-related peptide and possibly nitric oxide, from small-diameter sensory neurons expressing the transient receptor potential V1 (TRPV1) receptor. The involvement of sympathetic efferents in the effects of SCS has not been studied in animal models of neuropathic pain, but has been demonstrated in models of angina pectoris.

In conclusion, SCS is of clinical benefit in CRPS, and although its mechanism of action merits further elucidation, what little we do know is informative and can partially explain some of the pathophysiology of CRPS.

Free Downloads and More On CRPS Diagnostic Criteria (Woo Hoo!)

In the course of writing one blog post, here I am authoring another.

I just ran across a good article in the newly launched Wiley Online Library -- then discovered the offer of free downloads of most read and most cited articles from the journal Pain Medicine (The Official Journal of the American Academy of Pain Medicine and of the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists and of the International Spine Intervention Society).

Okay, it amounts to just a handful of articles, but some of them are quite good, especially those of the sort I often malign (but always read!) -- the dread review article.

So let us rejoice.
Amen, and amen!

From Volume 8, Number 4, 2007 -- more on diagnostic criteria in CRPS, just in case you haven't realized the importance of this issue by the fact that I have been droning on and on about it at every opportunity.  Anyway, this is a great foundational article about the discussion and helps to put the IASP criteria and the Budapest group's proposals in context.

Proposed New Diagnostic Criteria for Complex Regional Pain Syndrome

R. Norman Harden, MD, Stephen Bruehl, PhD, Michael Stanton-Hicks, MB, BS, DMSc, FRCA, ABPM, and Peter R. Wilson, MB, BS

Rehabilitation Institute of Chicago, Northwestern University, Chicago, Illinois;  Vanderbilt University School of Medicine, Nashville, Tennessee; Cleveland Clinic, Cleveland, Ohio; Mayo Clinic, Rochester, Minnesota, USA

ABSTRACT:  This topical update reports recent progress in the international effort to develop a more accurate and valid diagnostic criteria for complex regional pain syndrome (CRPS). The diagnostic entity of CRPS (published in the International Association for the Study of Pain’s Taxonomy monograph in 1994; International Association for the Study of Pain [IASP]) was intended to be descriptive, general, and not imply etiopathology, and had the potential to lead to improved clinical communication and greater generalizability across research samples. Unfortunately, realization of this potential has been limited by the fact that these criteria were based solely on consensus and utilization of the criteria in the literature has been sporadic at best. As a consequence, the full potential benefits of the IASP criteria have not been realized. Consensus-derived criteria that are not subsequently validated may lead to over- or underdiagnosis, and will reduce the ability to provide timely and optimal treatment. Results of validation studies to date suggest that the IASP/CRPS diagnostic criteria are adequately sensitive; however, both internal and external validation research suggests that utilization of these criteria causes problems of overdiagnosis due to poor specificity. This update summarizes the latest international consensus group’s action in Budapest, Hungary to approve and codify empirically validated, statistically derived revisions of the IASP criteria for CRPS.

Formerly Wiley Interscience, the Wiley Online Library just launched  -- as in *yesterday* -- and it's got some great new features plus a few things in The Realm of The Free (my favorite realm!):

Free access and access information.

Free abstracts and chapter summaries:  All journal abstracts and chapter summaries in books and reference works are free to all users of Wiley Online Library.

Free sample issues:
Each journal has a free sample issue that you can find from the left menu of any journal page.

Free supporting information:
Some articles include extra supporting information and this is available free to all users of the website. You can find supporting information in an extra tab from the abstract or article page.

Access icons:
Shows users in libraries what is free, what you or your institution has subscribed to and you can access.

Access information:
Clearly see why you might not be able to access an article, book, chapter or whole product and find out your options. [Booo!]