The Nod: Affirming the Legitimacy of Libya's TNC

Excellent move:

ISTANBUL (AP) — U.S. Secretary of State Hillary Rodham Clinton says the Obama administration has decided to formally recognize Libya's main opposition group as the country's legitimate government. The move gives foes of Libyan leader Moammar Gadhafi a major financial and credibility boost.



Clinton announced Friday that Washington accepts the Transitional National Council as the legitimate governing authority of the Libyan people. Diplomatic recognition of the council means that the U.S. will be able to fund the opposition with some of the more than $30 billion in Gahdafi-regime assets that are frozen in American banks.

Just perusing the initial reports from various news outlets, it looks like most of the other 32 nation members of the "Contact Group on Libya" have also recognized the legitimacy of the TNC. 
 

Excellent decision...

Stasis

Well, it looks like I may keep blogging after all.  Your spontaneous cheers of approval warm the cockles of my heart.  Thank you so much (my best Brenda Leigh Johnson impression).

It was an afternoon of misadventures, my favorite kind of afternoon.  I do feel awful, though, for dragging others through these fun times, and by "others," I usually mean Fred.

I had not been to my pain management doctor's office since March -- at which time two things happened:  the PA I had been seeing there quit, and I began the Great Subanesthetic Ketamine Adventure over at the Hospital for Catastrophes.  Each one of these two things engendered other things until I was practically tripping over all that accumulated quiddity.

The PA leaving caused me to question the quality of care I'd been receiving.  It sounds odd, I am sure, but Allison the PA was light years ahead of the doctor of record, in terms of staying abreast of CRPS research and treatment opportunities.  He had begun to depress me.  I would show up every month with questions from what I'd been reading and about what others had told me.  I swear that I was not obnoxious about it, and never dominated his time.  Fred used to time him from the moment of entry to the second he grabbed the door knob in retreat -- and this doctor rarely stayed in the exam room longer than 3 minutes. 

At some point, Dr. PainDood decided that I did not understand my situation.  He began taking my gesticulating hands in his big old dry ones, looking me soulfully in the eye, and saying:  "Prof-de-Rien, there are no more treatments to try... There is nothing that is going to help... We can only manage the pain to the best of our ability."

He's a very handsome man, and he would pause, head held at a flattering angle, long arms and finely tapered fingers extended -- Dr. PainDood loves handshakes, handholding, all things hand.

[I suppose that is preferable to, say, the kisses I used to field from a certain rheumatologist, and it's definitely superior to the tears that always flow from the sweet, sensitive eyes of my neurologist, The Rock.]

I got the same speech, month after month, fighting it, hating it for the first several iterations... then caving, imploding, believing it.  And so it was that nothing ever changed, except for a worsening of CRPS, then the onset of infected prostheses and osteomyelitis, all accompanied by the collapsing joints of avascular necrosis.  Life may not have been anywhere near good, but there was a measure of orderliness to my degradation.  Woo-hoo!  I got worse but my pain management stayed the course;  I got the same medications, at the same strength, month after month, year after year, and it was consistently ineffective.  If I dared raise the specter of change, I got The Speech -- and the Handholding.

There came a visit, about 3 years ago, I think, when the last remnant of rebellion in me reared its faltering head.  What about x, what about y?  Couldn't we give z a go?  And then, poof, Dr. PainDood took back both his hand and his spiel, declared me to be on permanent pharmacological pain management, and turned me over to his Physician's Assistant, Allison.

I thought she was punking me, for sure, the first few times she began the appointment with news from a conference on neuropathic pain, with an update on the research into the inflammatory response, or with the suggestion that we give an old drug a new try at a radically different dose.  Sure, sometimes she pitched ideas that were clearly birthed in left field, but always, always, I knew that she believed that improvement was possible, that improvement was necessary.

Plus, she totally understood that my hands HURT, and so she left them the hell alone!  (You've no idea how much I dreaded Dr. PainDood's obsession with the shaking and holding of hands.  I figured it to be some sort of bizarre challenge to my integrity, a nonverbal inquiry into whether my continuing ed credits from the Emily Post Institute were up-to-date.)

She and I both thought that Ketamine might be my Big Chance, and it was Allison who discovered that there were treatment opportunities right here in Tête de Hergé.

You've probably heard about "contracts" between doctors and patients when it comes to the serious matter of narcotic pain management.  I probably signed one but I don't remember.  The guidelines make sense and I always followed them -- if I get my pain medications from this doctor, then I don't seek pain medication from any other doctor.  I take my meds as prescribed, and I don't sell them or give them to anyone else. 

The only deviant behavior I exhibit is a tendency to not take as much as I am told to take.  That's it.

Since my last appointment with Allison and my first appointment today with her replacement, Maria, I have tapered off of methadone and Percocet, and lived on ibuprofen.  I have been in more pain than I knew was possible.  I did it so that the ketamine infusions would have the best chance possible to work -- you gotta let that stuff antagonize the heck out of those NMDA glial cells, hoo-baby, uh-huh!

Of course, I've pretty much been bed-ridden from pain and sometimes I devolve into Pure Twitch.  Ibuprofen was dissolving my stomach lining, and beginning to mess with my kidneys. 

The only option offered after ketamine failed was to have an intrathecal pump "installed" so as to receive the very toxic, very potent, crazy-making drug Prialt, a synthetic model of a certain sea snail's venom.  Being too close to crazy already, and since my spine is riddled with thousands of micro-fractures already... I declined.

So the catastrophic hospital politely returned me to the care of Dr. PainDood, although they cordially invited me to check in every few months to see what might be blowing in the wind...

It's not like I've been hanging on the street corner these last few months, making drug deals -- at night, traipsing off to raves, clubbing -- life a sudden party.  Still, my welcome back into the bosom of narcotic pain management this afternoon was fraught with suspicion.

Between March and July, where had I been getting my medication?
Did the doctor at the catastrophic hospital prescribe me any pain killers?
Was I sure?
Did I understand the question?
Was I sure?
Did the doctor at the catastrophic hospital prescribe *anything*?
Was I sure?
Did I understand the question?

The idea that a patient would stop taking narcotics on their own just did not compute.  To cheer them up, I told them that I was filled with excitement at the thought of taking opiates again.  "I can hardly wait," I crowed.  "Please, please, return me to the stagnant status quo!"

Okay, so I may have left out that when we showed up this afternoon, they had no record of the appointment.  Did I fail to mention that the new PA, Maria, kindly worked me in, so that we didn't have to make another trip across the wilds of The Lone Alp?  She sorted through a complicated history in an organized way, applauded my reduction of methadone dosage from 40 mg to 10 mg, and...

suggested acupuncture.

Things are back to normal. 

the monks are deep in GOOG

Thank you, Larry Page.     

Thank you, GOOGLE.

It may just be a fleeting thing, this 12.49% after hours hike... But it will keep Marlinspike Manor's Feline Remnant in kibble for another month.

The monks are deep in GOOG, so we're getting ready to jump the orchard wall so as to get to the Cistercian's Celebratory Mass in time for the Second Quarter Earnings Processional -- the best incense wafting is right there at the beginning.    Abbot Truffatore left a garbled message, saying something about "good times" and breaking open the 2010 beaujolais nouveau... 

I'll probably hang out at the monastery after the party, for Compline. I love that haunting lullaby but hate having to make the return trek to The Manor afterward, all alone.  (I don't want to be caught in the back orchard after dark.  Who would?!) Thank God for air-conditioned tunnels and quiet-loving Postulants as escorts.

"May the almighty Lord grant us a quiet night and a perfect end...

and not let today's gain be sucked up by tomorrow's losses."  AMEN

Wednesday Night Suppers

I spent several hot hours this afternoon in a state that seemed simultaneously a part of waking, a part of sleeping, definitely involved in sweating, highly aware of felines, and disgusted by the telephone and its attendant messages.

Having hoofed it to the bathroom upon shaking off all of the above, that was where I screamed a tender "Bye-ay-ay!  Have-ah-ah gooo-oo-d thai-aye-aye-am!" to Fred, who was off to consort with the Militant Lesbian Existential Feminists at their regular Wednesday Night Supper. (I always wonder what Fred actually hears me screaming, since my phrases are sucked up by Marlinspike Hall's intramural echo effects -- It's all those Garderobe Chutes, remember?)

Oh, drat, I didn't quite get that right, did I?  I meant to say: the Militant Lesbian Existential Feminists and The Mousse, she of the indeterminate persuasions.  The Mousse was tagged as The Mousse due to her fondness for the chocolate version of this dessert, the only food [besides a garlic pizza] to ever strike me low with food poisoning.
As it would happen, The Mousse participated in the previously mentioned "several hot hours," horning in on my rest by leaving a long, idiotic, breathless message for Fred, complete with ingratiating references to my various past contributions to these weekly culinary adventures.  In fact, I was planning to get up and cook something fascinating for My Clueless Darling to take... but something, something, something seemed to push me back into my steamy lethargy, lolling about the bed, smushing one incubating hairy feline after another. 

[And when I use "loll," I mean lax, lazy, AND indolent.  Take that, you verbmeisters.]

In an effort to eat cake and ice cream at every possible opportunity, The Mousse strives to celebrate any birthday, inoculation, anniversary, voter registration, first or last drunk, momentous sexual indiscretion, substantial retail discount, and whatever.  It turns out that tonight is Elaine's birthday and Llewellyn-Femme's Fifth Anniversary of Her First Swim With Sharks.  Tiger shark diving season is getting ready to kick off down in the Bahamas, so The Wednesday Supper Gang is also going to lay hands on Llewellyn-Femme -- in a non-Christian (yet inclusive) kind of pseudo-ecumenical militant lesbian existentialist feminist way -- in order to bless and protect her from sharp white teeth and iron jaws during her stints in the cage.

Anyway, so The Mousse opines during her extended whine on my voice mail service that Fred should probably help out by bringing ice cream, which would go nicely with her shark-themed birthday gateau.
I know that everything she says is in code, and when I break it down, I toss and turn and incorporate her ball-breaking bullcrap into a fresh, restless dream.

I was hoping to sort of pull myself back together while Fred is partying down at E-Cong, a vast repast before him on the long folding table, surrounded by women who don't share his spiritual beliefs, and one who wants to jump his bones.

He's not the only guy.  The Church Secretary is a guy.  And sometimes our old friend Sven shows up. 

I am hoping, though, that Sven didn't decide to attend this evening's supper -- because Fred recently decided to take Sven's inventory -- a very rare thing for even-keeled, sweet-hearted Fred.  With a little time, he'll remember that Sven's a friend, even if we've all been pretty weak in the Friend Maintenance category.

It has to do more with Sven's wife, Hazelnut.  She's an honest-to-goodness Minister, having trained in Existentialism at the knobby knees of Rev. R. Lanier Clance, Founder and Minister Emeritus of the First Existentialist Congregation.  Somehow, she learned very little, and over time, has forgotten that.

Anyway, this is not a critique of her sermonizing... but of her vast talent for taking hostages. 

Oh, okay, it's all about her every-sixth Sunday delivery of the same message:  How Christianity Hurted Me (pout::pout::pout).  Her father, damn the man, was a missionary who inflicted the habit of prayer on his children while tending to a lost flock of Native Americans who had the gall to claim pre-existent spirit-oriented lives. 

At some point in her childhood, Hazelnut suffered a severe injury, lost a leg -- She lives in pain.

I think that she has pain as her core.  I think pain is what is going on. 

So Fred is hot under the collar, almost continually, about the feminist inroads being made at E-Cong.  He's at the point where he responds to any challenge by demanding that you ("you" standing in for one Militant Lesbian Existential Feminist) "define your terms." Unfortunately, some internet genius cobbled together a list of 74 different "types" of feminism, a list which Fred declared authoritative and inviolate, and which he promptly committed to memory.

Should you defy authority and, undaunted, offer up a 75th version, Fred will stomp his feet, sputter, and craftily reply: "Yeah?  Well, spell it!"

Sven is blind. 

I am not trying to elicit any particular response by informing you that Sven is blind.  I am simply trying to advance what may appear to be a stalled narrative.  I wish the story could be told without mentioning either Hazelnut's missing leg or Sven's missing eyesight. 

I'd much rather do a commercial for their jazz music -- Sven tickles the ivories, Hazelnut croons;  They're wonderfully good.  Neither is disabled, both are achievers, maybe even overachievers.  That Hazelnut manages to be a full time teacher, pursue her musical ambitions, and serve as a Minister, is downright inspirational.  Sven is equally busy, also holding down a challenging job while serving as the driving force in their jazz career.
I mention their achievements to the Fredster, adding the raising of two fine sons to the list.  I'm hoping that he'll remember that Hazelnut has a right to her opinions, that he really does like and appreciate her, and that Sven is quite capable of critical thought and is no one's captive minion.  

"Yeah?  Well, spell it!"

Fred is so angry at Hazelnut he could just spit.  He tells me that she trashes Christianity, and with glee.  He tells me she is rewriting the history of E-Cong (a large part of which is his own history) and inserting feminism into a perfectly fine stand-alone existential foundation.  The beginnings of this Existential Fellowship were solidly grounded in philosophy and psychology, in personal responsibility, and in caring for one another -- never a simple task.  "No one used the F-word back then!"

I never thought that I would be a sounding board for attacks on feminism, and in my own home, too.  Okay, so, technically, we are just caretakers here, squatters in this vast manor until such time as Captain Haddock and Company resume their  occupancy -- but it feels like home.  I don't think I've ever been so close to an Indentured Domestic Staff before coming to Marlinspike Hall. 

Just the other day, hands on his hips, standing in the middle of the Fragonard Hobby Room, lost in its thinly veiled erotic frills, Fred had something of a hissy fit, and dared to define fair feminism as stuff women do.  So very frustrated with E-Cong and its revisionist historians, he now mistakes gender as the driving force behind feminist thought... an easy mistake to make, but tiresome, too.  The pink tits and ass of Fragonard did not help matters any.  [I'm just sayin'.] 

Yes, yes.  We have waltzed around "what's-wrong-with-calling-it-humanism?" and there's been fervent fomentation of Søren Kierkegaard and philosophical approaches to Christian theologies.  Unfortunately, Hazelnut could be heard, in the background, improvising melody and turning "phallocentrism" and "don't-it-just-beg-the-question-baby?" into pure rhythmic scat.

As a result of  these highminded debates and other equally muddled communications, Fred resigned from the E-Cong Board of Directors, and Sven promptly signed on.  Fred thinks that Hazelnut forced Sven to put himself up for nomination and that his presence signals the beginning of Militant Lesbian Existential Feminism's heyday.

"Yeah, well..."

My patient and compassionate Fred recently decided that Sven would be an Excellent Guy were he just free of Hazelnut.  His reasoning is that Sven doesn't know or have the capacity to navigate this world (being blind from birth and all) and has come to so depend on his wife that he is "clearly" suffering from... Stockholm Syndrome.  That's right, Sven has been held hostage and has come to sympathize with his tormentor, his wife, his partner in song -- Hazelnut the Haggling Hun.

I don't mind listening to most anything Fred has on his mind.  Like everyone, he works things out sometimes by talking things out.  He's very procedural.  He's an incredible writer, very clear, his words pristine in concert with his thought.  His humor will surprise you.  His elegant persuasions sway, his logic is rarely fallacious.

But he isn't budging on this one.  The Fredster fails to progress, his labor stalled. Which would also be fine, even kind of fun to debate, to examine -- but for one unanticipated twist:  Sven needs to be enlightened. That's right, Fred plans to inform his friend that he is being manipulated and hijacked in the worst way.  He plans to soften the blow by reminding Sven that he certainly doesn't deserve this fate, and shouldn't be judged for having subverted his good judgment to Hazelnut's ill-conceived opinions and attitudes.  What with Sven being so handicapped 'n all, no one will judge him harshly for his singular lack of backbone and his inability to agree with Fred over Hazelnut.

I heard a peculiarly soft voice issuing from my gaping maw, and thought:  Uh-oh.  My superior tone was dripping with condescension, equally at ease when among the people as when mingling with my equals.

I was enunciating, in the manner elicited back in my school days by a demonic French prof who would mark cadence by fierce taps on my curly head with a wooden ruler.  Always a bad sign, this patient, sneering enunciation.

Fred promptly made me define my terms.  Feeling kind of antithetical (also nauseated), I proceeded to draw a distinction between being correct and being right.  As in, he may be correct, but I am clearly right.  Miss Marmy Fluffy Butt, my Debate Coach, nodded her approbation.

And so I cling to my rightness.  He has no business saying anything of the sort to Sven.  "Sven, my friend, your whole life is but a regurgitation of your wife's bullshit... It's called the Stockholm Syndrome... It's a psychological paradox and I just thought you oughta know that you haven't had an idea to call your own in over 20 years... But I wanna reiterate that you couldn't help it, you're blind as a freaking bat!"

I don't think Fred heard any of my reasons to shut-the-hell-up-about-the-silly-stockholm-syndrome but I think I saw a flicker of something in his eyes when I said:  "Well, at least promise me that if you say this awful thing to him, that you will stand by him as a friend after it is said.  You have a responsibility to do so..."  It was probably a trick of lighting.

Who would have thought that these Wednesday night "church" suppers had so much at stake?  Jealousies of all sorts, machinations worthy of Machiavelli, insincerity as an art form, suffering bodies, suffering minds, troubled souls. 

I guess I can decide not to give a crap about The Mousse.  Given the Sven, Fred, and Hazelnut Triad, she just doesn't measure up as a worry or concern.  She's a simple annoyance. Just try and jump his bones, you dessert-driven nagging harpy, I don't care.  Whose Manor does he come home to, hmmm?

I'm up in the Computer Turret at the moment (obviously, huh?!) and it looks like Ruby the Honda CRV is coming down the road, throwing up dust and scaring our herd of Square Island Buffalo. Yep, that's her, weaving and dodging those giant hooves.  Unfortunately, La Bonne et Belle Bianca Castafiore pulled up the drawbridge when she came home from rehersals earlier --  he's gonna have to leave Ruby to crank it back down...

What the... ?

Even from here, it's clear that Fred has the mother of all black eyes and two (maybe three) fingers in a splint.  And I am not sure, but I think he is GURGLING.

Bless his heart.

I think I'll just sleep up here tonight.

Recent CRPS Research

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I'm not feeling much like blogging these days, being about as busy as a body can be hosting Tête de Hergé's most anticipated Pity Party of the 2011 season.  Nonetheless, having run across some interesting newly published research, I did some wicked-fast copying and pasting, cogitating and perusing, and hope that you will find some of this CRPS work helpful and interesting.  I confess to having focused on aspects of this Sucky Disorder that are posing a challenge and raising questions in my life at present:  sensory dysfunction, disorder of body schema, hemilateral sensory disturbances, dystonia, and -- what the heck! -- ketamine induced liver injury!

There is some comfort in noting the many articles and topics being published and discussed -- just not enough comfort to warrant ending the Pity Party.  Maybe come August.  (Actually, ManorFest is about a week away, at which time my rabid navel-gazing will no longer be tolerated around here.  Already, people are strumming their fingers and rolling their eyes at my wailing and cultivated introspection.  I saw a preliminary ManorFest schedule in which I am relegated to working night shifts, exclusively, far from the public eye.  Harrumph.)

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Title
Comparable disorder of the body schema in patients with complex regional pain syndrome (CRPS) and phantom pain.

Author(s)
Reinersmann A, Haarmeyer GS, Blankenburg M, Frettlöh J, Krumova EK, Ocklenburg S, Maier C

Institution
Abteilung für Schmerztherapie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH Bochum, Ruhr-Universität Bochum, Bochum, Deutschland, annika.reinersmann@rub.de.

Source
Schmerz 2011 Jul 9.

Abstract
In patients with complex regional pain syndrome (CRPS) a disruption of the body schema has been shown in an altered cortical representation of the hand and in delayed reaction times (RT) in the hand laterality recognition task. However, the role of attentional processes or the effect of isolated limb laterality training has not yet been clarified.The performance of healthy subjects (n=38), CRPS patients (n=12) and phantom limb pain (PLP) patients (n=12) in a test battery of attentional performance (TAP) and in a limb laterality recognition task was compared and the effect of limb laterality training in CRPS patients and healthy subjects evaluated.The RTs of both CRPS and PLP patients were significantly slower than those of healthy subjects despite normal TAP values. The CRPS and PLP patients showed bilaterally delayed RTs. Through training RTs improved significantly but the RTs of CRPS patients remained slower than those of healthy subjects. In this study an equal disruption of the body schema was found in both CRPS and PLP patients which cannot be accounted for by attentional processes. For CRPS patients this disorder cannot be fully reversed by isolated limb laterality recognition training.

Language
GER

PubMed ID
21739258

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Title
Impaired Hand Size Estimation in CRPS.

Author(s)
Peltz E, Seifert F, Lanz S, Müller R, Maihöfner C

Institution
Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.

Source
J Pain 2011 Jul 7.

Abstract
A triad of clinical symptoms, ie, autonomic, motor and sensory dysfunctions, characterizes complex regional pain syndromes (CRPS). Sensory dysfunction comprises sensory loss or spontaneous and stimulus-evoked pain. Furthermore, a disturbance in the body schema may occur. In the present study, patients with CRPS of the upper extremity and healthy controls estimated their hand sizes on the basis of expanded or compressed schematic drawings of hands. In patients with CRPS we found an impairment in accurate hand size estimation; patients estimated their own CRPS-affected hand to be larger than it actually was when measured objectively. Moreover, overestimation correlated significantly with disease duration, neglect score, and increase of two-point-discrimination-thresholds (TPDT) compared to the unaffected hand and to control subjects' estimations. In line with previous functional imaging studies in CRPS patients demonstrating changes in central somatotopic maps, we suggest an involvement of the central nervous system in this disruption of the body schema. Potential cortical areas may be the primary somatosensory and posterior parietal cortices, which have been proposed to play a critical role in integrating visuospatial information. PERSPECTIVE: CRPS patients perceive their affected hand to be bigger than it is. The magnitude of this overestimation correlates with disease duration, decreased tactile thresholds, and neglect-score. Suggesting a disrupted body schema as the source of this impairment, our findings corroborate the current assumption of a CNS involvement in CRPS.

PubMed ID
21741321

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Title
The Specificity and Mechanisms of Hemilateral Sensory Disturbances in Complex Regional Pain Syndrome.

Author(s)
Knudsen L, Finch PM, Drummond PD

Institution
School of Psychology, Murdoch University, Perth, Western Australia.

Source
J Pain 2011 Jun 22.

Abstract
Hyperalgesia often extends from the affected limb to the ipsilateral forehead in patients with complex regional pain syndrome (CRPS). To investigate whether this is more common in CRPS than other chronic pain conditions, pressure-pain thresholds and sharpness to a firm bristle were assessed on each side of the forehead, at the pain site, and at an equivalent site on the contralateral side in 32 patients with chronic pain other than CRPS (neuropathic or nociceptive limb pain, radicular pain with referral to a lower limb or postherpetic neuralgia), and in 34 patients with CRPS. Ipsilateral forehead hyperalgesia to pressure pain was detected in 59% of CRPS patients compared with only 13% of patients with other forms of chronic pain. Immersion of the CRPS-affected limb in painfully cold water increased forehead sensitivity to pressure, especially ipsilaterally, whereas painful stimulation of the healthy limb reduced forehead sensitivity to pressure pain (albeit less efficiently than in healthy controls). In addition, auditory discomfort and increases in pain in the CRPS-affected limb were greater after acoustic startle to the ear on the affected than unaffected side. These findings indicate that generalized and hemilateral pain control mechanisms are disrupted in CRPS, and that multisensory integrative processes may be compromised. PERSPECTIVE: The findings suggest that hemilateral hyperalgesia is specific to CRPS, which could be diagnostically important. Disruptions in pain-control mechanisms were associated with the development of hyperalgesia at sites remote from the CRPS limb. Addressing these mechanisms could potentially deter widespread hyperalgesia in CRPS.

PubMed ID
21703937

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Title
Fixed Dystonia in Complex Regional Pain Syndrome: a Descriptive and Computational Modeling Approach.

Author(s)
Munts AG, Mugge W, Meurs TS, Schouten AC, Marinus J, Moseley GL, van der Helm FC, van Hilten JJ

Source
BMC Neurol 2011 May 24; 11(1):53.

ABSTRACT:
BACKGROUND: Complex regional pain syndrome (CRPS) may occur after trauma, usually to one limb, and is characterized by pain and disturbed blood flow, temperature regulation and motor control. Approximately 25% of cases develop fixed dystonia. Involvement of dysfunctional GABAergic interneurons has been suggested, however the mechanisms that underpin fixed dystonia are still unknown. We hypothesized that dystonia could be the result of aberrant proprioceptive reflex strengths of position, velocity or force feedback.
METHODS: We systematically characterized the pattern of dystonia in 85 CRPS-patients with dystonia according to the posture held at each joint of the affected limb. We compared the patterns with a neuromuscular computer model simulating aberrations of proprioceptive reflexes. The computer model consists of an antagonistic muscle pair with explicit contributions of the musculotendinous system and reflex pathways originating from muscle spindles and Golgi tendon organs, with time delays reflective of neural latencies. Three scenarios were simulated with the model: (i) increased reflex sensitivity (increased sensitivity of the agonistic and antagonistic reflex loops); (ii) imbalanced reflex sensitivity (increased sensitivity of the agonistic reflex loop); (iii) imbalanced reflex offset (an offset to the reflex output of the agonistic proprioceptors).
RESULTS: For the arm, fixed postures were present in 123 arms of 77 patients. The dominant pattern involved flexion of the fingers (116/123), the wrists (41/123) and elbows (38/123). For the leg, fixed postures were present in 114 legs of 77 patients. The dominant pattern was plantar flexion of the toes (55/114 legs), plantar flexion and inversion of the ankle (73/114) and flexion of the knee (55/114). Only the computer simulations of imbalanced reflex sensitivity to muscle force from Golgi tendon organs caused patterns that closely resembled the observed patient characteristics. In parallel experiments using robot manipulators we have shown that patients with dystonia were less able to adapt their force feedback strength.
CONCLUSIONS: Findings derived from a neuromuscular model suggest that aberrant force feedback regulation from Golgi tendon organs involving an inhibitory interneuron may underpin the typical fixed flexion postures in CRPS patients with dystonia.

PubMed ID
21609429

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Title
Drug-induced liver injury following a repeated course of ketamine treatment for chronic pain in CRPS type 1 patients: A report of 3 cases.

Author(s)
Noppers IM, Niesters M, Aarts LP, Bauer MC, Drewes AM, Dahan A, Sarton EY

Institution
Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands.

Source
Pain 2011 May 3.

Abstract
Studies on the efficacy of ketamine in the treatment of chronic pain indicate that prolonged or repetitive infusions are required to ensure prolonged pain relief. Few studies address ketamine-induced toxicity. Here we present data on the occurrence of ketamine-induced liver injury during repeated administrations of S(+)-ketamine for treatment of chronic pain in patients with complex regional pain syndrome type 1 as part of a larger study exploring possible time frames for ketamine re-administration. Six patients were scheduled to receive 2 continuous intravenous 100-hour S(+)-ketamine infusions (infusion rate 10-20mg/h) separated by 16days. Three of these patients developed hepatotoxicity. Patient A, a 65-year-old woman, developed an itching rash and fever during her second exposure. Blood tests revealed elevated liver enzymes (alanine transaminase, alkaline phosphatase, aspartate transaminase, and γ-glutamyl transferase, all⩾3 times the upper limit of normal) and modestly increased eosinophilic leukocytes. Patient E, a 48-year-old woman, developed elevated liver enzymes of similar pattern as Patient A during her second ketamine administration and a weakly positive response to antinuclear antibodies. In a third patient, Patient F, a 46-year-old man, elevated liver enzymes (alanine transaminase and γ-glutamyl transferase) were detected on the first day of his second exposure. In all patients, the ketamine infusion was promptly terminated and the liver enzymes slowly returned to reference values within 2months. Our data suggest an increased risk for development of ketamine-induced liver injury when the infusion is prolonged and/or repeated within a short time frame. Regular measurements of liver function are therefore required during such treatments. During repeated ketamine infusion for treatment of CRPS1, three patients developed liver injury probably allergic in nature.

PubMed ID
21546160