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What is RSD?

Posted by Carol D. on 7/17/02 at 16:06 (089890)

I have been tentatively diagnosed with TTS and possible metatarsalgia. I have read on this bulletin board the term 'RSD' and don't know what it is. What is it? Also, are these disorders of the foot often intertwined? Thanks for any help. Carol D.

Re: RSD

wendyn on 7/17/02 at 18:34 (089901)

A Description of RSD/CRPS: View Thread
Posted by Janet C on 4/10/02 at 23:43

Reflex Sympathetic Dystrophy (RSD), also known as Complex Regional Pain Syndrome (CRPS), is a complicated pain problem. It is characterized by severe pain and progressive physical changes that persist long after the original injury has healed. The original injury may have been as severe as a bullet wound or as simple as a sprained ankle. The syndrome can also sometimes occur after routine surgery.

Victims of RSD usually describe the pain as burning or shooting with extreme sensitivity to touch. For example, an article of clothing rubbing the affected area will often cause severe, extraordinary discomfort.

RSD usually occurs in an extremity (leg and foot or arm and hand), but can occur almost anywhere, including the chest, breast or abdomen. It is impossible to predict who will develop RSD. RSD is suspected when pain and other physical changes persist after healing appears complete and other causative factors have been ruled out.

Stages and Physical Changes:

RSD develops slowly, in stages, over several months or years. Initially the area may appear swollen and feel warm to touch due to both inflammation and spasms of the surrounding blood vessels.

In the second stage, the blood supply to the area diminishes and the area becomes cool to touch. The skin becomes shiny and waxy and there is a loss of hair and skin tone. The pain increases and there can be weakening of the underlying bone.

In the third and final stage, there is wasting of the affected muscles and disabling pain. Left untreated, the area can develop contractures from disuse which can become permanent.

Many Doctors classify RSDS into these different stages. It helps to understand the complexity of the disease. But all the stages can combine with one another, and not everyone experiences the same symptoms, or you may never advance to another stage. This is part of what makes RSDS difficult to diagnose.

Treatment:

Because of the complicated and progressive nature of this potentially devastating pain syndrome, treatment must be aggressive and must focus on rehabilitation as well as pain management. The doctor will prescribe treatment for the causative factors as well as the resultant physical, psychological and emotional side effects.

Nerve blocks are used to break the pain cycle and prevent progression of symptoms. These are most effective in the earlier stages and may need to be repeated several days in a row. Hospitalization for continuous nerve block is sometimes necessary.

Narcotic medications will decrease the pain of RSD but do not impact the underlying problem. In the early stages, it is preferable to use pain medicines that are also anti-inflammatories. Steroids may be prescribed short term to relieve symptoms and arrest their progression. Anti-depressants are used to improve sleep and inhibit pain pathways. Anti-convulsants and oral anesthetic agents may also be helpful for this type of pain.

Physical therapy is very important for pain relief and to maintain muscle strength and mobility. Massage, ultrasound and whirlpool may be employed for comfort, while aquatic or land exercise and mobilization prevent muscle wasting and disability.

The intensity of pain and muscle weakness often make compliance with prescribed treatment difficult for the patient. It is extremely important that all medicines be taken as directed and that exercises be performed regularly despite the pain. Education and counseling related to coping with and managing pain are available and may be helpful. In addition, biofeedback can assist individuals in learning to control blood flow and muscle tension to lessen symptoms.

Re: RSD

wendyn on 7/17/02 at 19:42 (089909)

This was an excellent explanation Janet gave a while back (I hope she doesn't mind me pasting it here)

RSD is essentially when someone's sympathetic nervous system goes out of whack following an injury or surgery. From what I understand, there are actual changes to the physical structure of the nerves themselves. They continue to misfire and misbehave long after the initial injury.

RSD can be made worse by surgery.

I seem to be 'stuck' in the first stage. My feet will become red and hot for no obvious reason. Someone asked me other day if they were sunburned (they are not). This is accompanied by intense pain and burning.

One of the strangest symptoms that many of us have, is experiencing actual physical pain when startled. So, rather than just just reacting when someone darts out in front of me while I'm driving - I actually experience a painful 'jolt' throughout all of my nerves. It lasts a fraction of a second but it feels AWFUL. I never had this before I developed RSD.

I never even mentioned it to anyone (including my doctor) until someone else here brought it up (I thought I was losing my mind!!!)

Re: RSD

Janet C on 7/18/02 at 00:14 (089927)

Thanks for pasting, and posting that response, Wendy. Here's another explanation that I think is quite informative:

What is RSD? From Jim O'Donnell's RSD/CRPS Site

Reflex Sympathetic Dystrophy is a chronic pain disorder involving the sympathetic nervous system. It usually is the result of an injury or trauma, but can also be a complication of surgery, infection, casting or splinting and myocardial infraction (heart attack). The trauma sets off the body's mechanism for pain recognition, but then the 'normal system of pain perception' begins to misfire in it neural response, and an abnormal cycle of intractable pain begins. As RSD progresses, the abnormal pain of the sympathetic nervous system has an effect on other areas of the body and can result in total disability as muscles, bones, skin and the autonomic immune system become involved.

The first indication of RSD is prolonged pain usually more severe than the injury. The symptoms are severe burning pain in a localized area, intense sensitivity to temperature and light touch, and a color change to the skin.

There are several stages to RSD, which progress at different rates in different people. Initially, there is swelling and redness in the affected area.

Next, the area becomes blue and cold, with increased pain and stiffness of ligaments and joints, and Osteoporosis may become evident.

Finally, there may be a wasting of affected muscles, contraction of tendons, and a definite withering of the affected limb. In all of the stages, severe chronic pain continues to be a major complaint.

Although RSD can be a progressive disorder, it should not be assumed that all cases will advance and present all clinical symptoms and dysfunction.

CLINICAL SYMPTOMS OF RSD

Pain is the first and primary complaint, described as extremely severe and burning & aching in nature
Swelling and joint tenderness
Loss or diminished motor function
Muscle spasms
Increased sweating
Changes in skin temperature and color
Bone softening - patchy osteoporosis

EFFECTS of RSD:

RSD can be
as painful as CANCER
as costly as AIDS
as crippling as ARTHRITIS

WHAT CAUSES RSD?

Trauma (often minor) such as a bruise, sprain or broken bone
Surgery
Myocardial Infarction (heart attack)
Infections
Repetitive motion disorders such as Carpal Tunnel Syndrome

HOW IS RSD DIAGNOSED?

Clinical Evaluation
Sympathetic Blockade
X-Ray
Thermographic Study
EMG, CAT scan, MRI studies
IV Systemic Blockade

HOW IS RSD TREATED?

Drug Therapy
Nerve Blocks
Physical Therapy
Sympathectomy
Transcutaneous Electrical Stimulator

IMPLANTABLE DEVICES:

Spinal Cord Stimulator or Drug Delivery Infusion Pump

With best wishes, always ~ Janet

Re: Here are some more facts and fiction about RSD:

Janet C on 7/18/02 at 00:58 (089930)

From The Reflex Sympathetic Dystrophy Syndrome Association Of America:

Reflex Sympathetic Dystrophy Syndrome (RSD) is poorly understood by patients, their families, and healthcare professionals. In some cases the condition is mild, in some it is moderate, and in others it is severe. We have compiled a list of some of the common misconceptions about this syndrome followed by the facts.
_______________________________________________________________________
Reflex Sympathetic Dystrophy Syndrome (RSD/CRPS) is rare.

FACT It is not a rare disorder and may affect millions of people in this country. This syndrome occurs after 1 to 2 % of various fractures, after 2 to 5% of peripheral nerve injuries, and 7 to 35% of prospective studies of Colles fracture. The diagnosis is often not made early and some of the very mild cases may resolve with no treatment and others may progress through the stages and become chronic, and often debilitating.
________________________________________________________________________
RSD/CRPS is a recently discovered disease.

FACT It was described during the Civil War and has been in the literature under a variety of names ever since.
________________________________________________________________________
The pain is not as bad as the patient says it is.

FACT The pain is often as bad as claimed and may be even worse.
________________________________________________________________________
RSD/CRPS following surgery means that the physician did something wrong.

FACT RSD/CRPS can occur following surgery as well as a trauma. This does not mean that the surgery was performed incorrectly.
________________________________________________________________________
Minor injuries cannot cause RSD/CRPS.

FACT Minor injuries, such as a sprain or a fall are frequent causes of RSD/CRPS. RSD/CRPS can start immediately after the injury or later. One characteristic of RSD/CRPS is that the pain is more severe than expected for the type of injury that occurred. In 10 to 26% of cases no precipitating factor can be found.
________________________________________________________________________
RSD/CRPS does not spread.

FACT The usual pattern of spread is up the same extremity and then may continue to spread on the same side of the body or to the opposite extremity. RSD/CRPS may spread to a distant site. According to the RSDSA database, the condition spreads in 70% of patients.
________________________________________________________________________
RSD/CRPS will burn itself out in 6 months.

FACT Many patients who are not treated early will experience spread of RSD and this may become a lifelong problem. Even with early treatment this may become a chronic condition.
________________________________________________________________________
Children do not get RSD/CRPS limb pain in children is psychological.

FACT RSD/CRPS can start as young as 3 years of age. This is not a psychological condition. Children may develop psychological problems when physicians, parents, teachers, and other children do not believe their complaints of pain.
________________________________________________________________________
After one or two treatment programs have not helped, there is nothing that can be done. The patient should be told to go home and learn to live with the pain.

FACT There are many forms of treatment for RSD/CRPS. Treatment may include medication, sympathetic nerve blocks, physical therapy, psychological support, and possibly sympathectomy, or dorsal column stimulator. The physician directing the care of the patient should have a treatment plan. In severe or long term cases, a Pain Clinic with a coordinated plan may be helpful.
________________________________________________________________________
Patients continue to complain because of secondary gains. They are looking for sympathy and are gaining satisfaction from this experience.

FACT As with any group of individuals there is a small percentage of RSD/CRPS patients who get satisfaction from a chronic illness. The vast majority of RSD/CRPS patients were active, productive individuals prior to this disease and do not enjoy the pain, the loss of independence, the loss of job or inability to attend school and the loss of income. The most devastating aspect of the illness is that physicians, other health care professionals, employers and especially friends and family members do not understand how much the patient is suffering. They are not looking for sympathy, only understanding.
________________________________________________________________________
Once RSD/CRPS is in remission, it does not come back.

FACT It may subside for years and then recur with a new injury. The reoccurrence should be treated immediately.
________________________________________________________________________
Vigorous and aggressive physical therapy is best.

FACT Physical therapy should be carried out only under a physician's supervision. Osteoporosis occurs with RSD/CRPS and as a result of bone loss, pathological fractures can be caused by overly aggressive therapy. In general, 'To hurt, is not to harm' as long as the patient is self mobilizing. Aquatic therapy at a comfortable water temperature can often facilitate mobilization of extremities, especially if RSD/CRPS is in the lower extremity. However, the cliché 'No pain, no gain' does not apply to RSD/CRPS patients.
________________________________________________________________________
The treatment for all RSD/CRPS patients should be the same.

FACT Each patient needs an individual treatment plan. What helps one patient, may not help another.
________________________________________________________________________
RSD/CRPS is not recognized as a reason for long-term disability or SSI payments.

FACT It is. The physician directing the patient's care should write a letter or report describing the severity of the condition.
________________________________________________________________________
Any physician can treat RSD/CRPS without outside help.

FACT RSD/CRPS is a complex condition with varying degrees of severity and disability. Patients should be cared for by a physician who knows how to treat RSD/CRPS. Often, a team approach (physician, physical therapist, anesthesiologist, mental health provider, and social worker) is most helpful.
________________________________________________________________________
There are no symptoms except pain, swelling, heat or coldness, and color change.

FACT There are many other symptoms including movement disorders (difficulty starting movement, increased tone, increased reflexes, tremor, muscle spasms), weakness, fatigue, skin rashes, frequent infections, migraine headaches, and others may be found as more data is accumulated.
________________________________________________________________________
Family and friends find this condition easy to understand.

FACT RSD/CRPS is difficult for many physicians to understand. It is not surprising that family and friends do not understand the patient's pain and disability.
________________________________________________________________________
Blocks and other treatments only work in the first stage of the disease.

FACT There are treatments that will help in any stage of RSD/CRPS. If RSD/CRPS spreads or if a new injury occurs, blocks may be effective again.
________________________________________________________________________
RSD/CRPS occurs in psychologically unbalanced people.

FACT Persons who get RSD/CRPS are not any different than the rest of the population psychologically. Once they get RSD/CRPS and they are in constant pain, with friends, family and employers not believing them, they may be depressed and suffer other psychological changes. When RSD/CRPS symptoms are relieved these changes disappear.
________________________________________________________________________
Every patient has the same results from a medication or treatment.

FACT There are many forms of treatment and combinations of treatment and medication. What is highly effective for one, may not work in another. Medication dosages may need to be adjusted to get the best results.
________________________________________________________________________
A patient who has no visible sign or positive tests does not have RSD/CRPS.

FACT RSD/CRPS is a clinical diagnosis. This means that the physician makes the diagnosis based on thorough history and physical examination. When seeing a new physician, it is a good idea to have a brief medical history with dates of various treatments and the response to them. Also include a brief summary of any hospitalizations and surgeries. It is helpful for the doctor to have a copy of this information before your appointment. Given the complexity of RSD/CRPS, it is helpful for the patient to keep their own set of relevant medical records.
________________________________________________________________________
There is no hope for patients who have had RSD/CRPS for a long time.

FACT The future of RSD/CRPS treatment is optomistic. Researchers worldwide investigate effective treatments and the cause of RSD/CRPS.
________________________________________________________________________
We hope all physicians will recognize and diagnose RSD/CRPS in the early stages so that the patient can be treated promptly and appropriately. Any physician unfamiliar with the treatment of RSD/CRPS should refer patients immediately to a physician or center that treats RSD/CRPS.

Re: RSD

elliott on 7/18/02 at 11:53 (089963)

Funny, but reading your list, the misconception that people with RSD are psychologically unbalanced reminds me about what a PT I went to recently claimed (you're not gonna like this), namely that just about everyone he saw for RSD was kinda fluky, and he believed there was a connection (he doubted the RSD diagnosis in many of them too). Of course, the fact that they already had it (if they did) before they saw him didn't help their cause, nor the difficulty in getting a definitive diagnosis, although things are getting more rigorous, see, e.g.,

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1620860&dopt=Abstract

The PT was telling me he has patients who, when he asks them on a scale of 1 to 10, with 10 being the most unbearable pain imaginable, what kind of pain they're in now, they sit there calmly and matter of factly say, 'oh, a 10', rigt in the middle of casual conversation, and not the writhing on the floor he'd expect.

People do have different perceptions of pain. There are some who faint at an injection or the pain from it, or even an MRI, and others who barely need pain killers following surgery. Is it possible that those with a very low tolerance for pain or something else a little off balance make them as group more likely for their nerves to misfire and give them RSD?

-----

Re: Great post -- do you have a link?

Ed Davis, DPM on 7/18/02 at 12:18 (089968)

Great post. Do you have a link?
Ed

Re: here's the link

elliott on 7/18/02 at 12:49 (089970)

http://www.rsds.org/

I just typed in the organization at the top of her post into google, and out it popped. Click on English. Her post is the 'facts and fiction' link appearing in the list.

Re: RSD

wendyn on 7/18/02 at 13:39 (089980)

Who knows if there's a relation to a malfunctioning sympathtetic nervous system, but the low pain tolerance theory doesn't hold much promise in my mind.

I've been told on numerous ocassions (56 hour labor, minor surgery without anesthetic, arterial blood tests etc) that I seem to have an exceptionally high tolerance for pain (both pre and post RSD). The tolerance to pain itself may often be somewhat psychological, but the physiological changes from pain and RSD are not.

Sounds to me like that PT needs to do a little more research on RSD.

Re: RSD

Sharon W on 7/18/02 at 13:52 (089982)

Wendyn, Brian, et al,

I don't have RSD and I'm certainly not an expert on it, although I've been reading the posts. Still, I can't help wondering if it's actually the OTHER way around -- perhaps people who tend to develop RSD are those with a HIGH pain tolerance, the ones who DON'T go yelling and screaming and dramatically demanding that their doctors prescribe painkillers at the first sign of pain. From my readings on the subject of chronic pain, it appears that longstanding, UNTREATED pain sometimes develops into RSD --and that would tend to indicate that people who are really STOIC, the ones who have to be really MISERABLE before they will go to their doctors and complain that they are in pain -- are the ones most at risk for RSD! Certainly, there are several examples of people who post on this board (yourself included, Wendy) who have RSD but certainly DON'T seem to be hysterical about pain or inclined to overreact to in any way.

-- Sharon

Re: RSD

elliott on 7/18/02 at 14:16 (089985)

Well, I'm sure we could find counterexamples to your hypothesis too. And I think many develop RSD very soon after an event, be it trauma, surgery, or whatever. That's not due to stoicism. It's stoicism (if you call it that) that can make them even worse by delaying treatment.

Not everything in that list is so clear either. Take the one about the myth that if you get RSD from surgery, then the surgeon did something wrong. Well, if that's a myth (I'm not so sure about that one, and I believe the wording used does leave open the possibility that he could be at fault), unless you buy the theory that it's totally random, presumably something in that patient made him/her more likely to trigger off a strange nervous reaction. That just doesn't seem like stoicism to me, just the opposite.

I'm not saying my PT was right nor that it applies to everyone, I'm only quoting his observation, and wondering if there's at least some correlation.

---

Re: RSD

Sharon W on 7/18/02 at 14:41 (089987)

Elliott,

I certainly didn't mean to imply that being stoic is the ONLY way to end up with RSD! I know that many people develop RSD after surgery, and that some seem to get it as a 'complication' of some other painful and chronic problem such as fibromyalgia or PN.

But I do strongly suspect that UNTREATED pain can be a major contributing factor. I would be really curious to see someone do a study in which patients with RSD who got it after surgery are interviewed as to whether they believe the pain medications they received immediately after their surgery were adequate or not -- and compare that group with a group of 'controls' who had the same sugery but did NOT develop RSD. Of course, it would be very important to factor in which medications were actually PRESCRIBED for them...

-- Sharon

Just a thought.

-- Sharon

Re: RSD

elliott on 7/18/02 at 14:52 (089992)

Certainly agree that leaving RSD untreated is likely to make it worse; that seems to be well-documented. Not sure if what you say in your last paragraph is true. If so, next time I have surgery, rather than take one or two of those Percocets and then say 'Forget this!', I'll finish the whole bottle--I won't care if I get dizzyness, tiredness, constipation, lack of urination, whatever. :-)

----

Re: RSD

Carole C in NOLA on 7/18/02 at 16:09 (089998)

56 hours of labor? {{{ Wendy! }}}

5 hours of induced labor, plus 45 minutes of delivery seemed like forever to me. Your point is well taken.

Carole C

Re: RSD

wendyn on 7/18/02 at 20:12 (090009)

Carole, I was actually induced over three separate days. They started in on a Friday morning. I was sent home after about 16 hours of labor because I wasn't progressing. Had contractions on and off all weeekend. They induced again Monday morning. Contractions became so intense by late Monday night that I actually went in reverse (swelled instead of dialating). So they stopped inducing, but the contractions hung around.

They started all over again Tuesday morning, my son was born at around dinner time Tuesday night by C-section.

It was nasty.

Re: RSD

wendyn on 7/18/02 at 20:23 (090013)

Sharon, you make some interesting points. I've often wondered if my reluctance to use pain meds may have actually contributed to my RSD.

When I first developed TTS my doctor prescribed me Naproxen. I tried taking it, but it made me very sleepy. I was doing capital budget work (which is a snoozer at the best of times) so there was no way I could take it and function at work.

I'm allergic to codeine, and I was afraid of the side effects of the Voltaren and Elavil they wanted to try me on.

Actually, I guess I have something of a phobia to medicine. My youngest son had a severe reaction to pencillin - and I've been hesistant to take anything since then.

Knowing what I know now, if I had that kind of pain again I WOULD TAKE SOMETHING FOR THE PAIN rather than suffering through it. I don't think my deicsion was wise.

Re: rough time

Carole C in NOLA on 7/18/02 at 20:35 (090014)

Stories like that remind me that women are truly tough.

Carole C

Re: RSD

Sharon W on 7/19/02 at 09:58 (090097)

Wendyn,

As you probably know, Tammie also says that she had always avoided taking painkillers in the past.

I can't quote a reference but I do remember being taught in a seminar that nurses often UNDERmedicate stoic patients for pain, that research has shown patients who (in filling out questionnaires for the research study without knowing exactly WHAT was being studied) reported that they do not like to take painkillers and claim to be able to 'handle' pain without them, and in general could be described as 'stoic,' are less likely to ASK for painkillers than someone else who has had an equivallent procedure done and are ALSO less likely to be OFFERED painkillers by the nurse, or asked about their pain, because they don't cry out or grimace or moan and groan or whatever.

Combine that with the fact that, in all probability when they get home they may not even FILL a prescription for painkillers, or if they do, they'll only take 1 or 2 of them and then after that they'll just 'grit their teeth and bear it' -- and I think it may well help to explain why some patients get RSD after ANY kind of surgery. I know I keep quoting this one (it was Donna SL who shared it with ME) but Daniel Brookhoff describes the process of how chronic pain, and related problems like RSD, can develop from unrelieved 'acute' pain. The link is:

http://www.hosppract.com/issues/2000/07/brook.htm

Sharon

Re: not stupid at all

Carole C in NOLA on 7/19/02 at 11:53 (090114)

From looking at your photos, you have a small frame. I'd guess that you wanted to give regular childbirth your best try, and you did. That's not stupid, even if you had to have a C-section in the end. There was no way to know how things would (or wouldn't) progress.

I'm a large framed, tall person, but even so I was really lucky that delivering a nine and a half pound baby went so easily for me. At the time I would not have said that. Haha! Little did I know.

Carole C

Re: not stupid at all

wendyn on 7/19/02 at 13:08 (090121)

Carole, I did want to give the whole natural childbirth thing a try. Amazingly, I even tried again aftr my first c-section. My second was born by emergency c-section though after a very brief period of labor.

I worked with a girl who was my size, she delivered a baby just over 11 pounds last year. Naturally.

I asked her what she did that made her doctor so mad at her (I'm amazed she did it and lived to talk about it!!!!)

In my case, I was only 16 when I had my first, so I was very tiny. I also was not nearly as assertive as I am now. I think that if this were to happen to me now I would say NO THANKS to the third day of inducing. 2 full days was ENOUGH!!!!!

Re: Pain meds

wendyn on 7/19/02 at 13:13 (090123)

Sharon, this pretty much describes what I've done in the past. I would not do this again in the future. I've had some bad side effects from meds, I'm allergic to codiene and morphine. I can't take toradol, and Laratine (sp?) made me violently ill. Most of this was discovred following bunion surgery.

As a result, I had demerol for 48 hrs after my C-section, then I went straight to plain old tylenol. That's a big jump in pain relief.

Now that I know that pain itself is actually bad for you, I would make more of an effort to not let it get out of control.

Unfortunately, other then tylenol for little stuff and demerol for big stuff - my pain relief options seem to be limited.

Re: Pain meds

Sharon W on 7/19/02 at 13:42 (090125)

Ugh. The pain relief from Demerol never really seems to last from one dose to the next.

What meds do you use NOW -- just Tylenol?

Sharon

Re: Pain meds

wendyn on 7/19/02 at 13:50 (090126)

Sharon, If I really need something I usually take tylenol. I prefer Motrin or Advil but I can usually only tolerate 1 pill (or a kids sized dose) without side effects.

I experienced absoultely NO pain relief from Morphine. I guess maybe because I was allergic to it (?). Actually, I'd had so much right after my surgery that the nurse asked me if I was perhaps a recreational user.

Shortly afterwards I started to get purple and itchy. I actually think I got more pain relief from the Tylenol than I did the morphine. Since demerol is the 'best' I've ever had, it seems pretty good to me!!!!!!!

The problem with the meds was the worst part of the recovery.

Re: Pain meds

Sharon W on 7/19/02 at 15:39 (090144)

Wendyn,

I'm sure you know that people with RSD (or any other type of chronic pain, for that matter) suffer from a REDUCED sensitivity to opiates, which is really adding insult to injury!

Sharon

Re: here's the link ---thank you

Ed Davis, DPM on 7/19/02 at 18:58 (090155)

Gracias.
Ed

Re: Pain meds

wendyn on 7/19/02 at 19:36 (090165)

Sharon, I did not know that about RSD and pain meds. But this experience was pre-RSD so I don't know if that could factor in.

Apparently the itchy wasn't what convinced them (that went on all day). It was the purple color and the itchy nose that seemed to change things. Apparently an itchy nose means something.

Re: Pain meds

BrianG on 7/19/02 at 22:33 (090186)

Hi Wendy,

There are actually a couple more good pain meds you may want to try. The first is Methadone. Because it's not a time release med, you can break each pill in halves, and quarters. By starting at such a small dose, you may be able to tolerate it better. I've read that it's THE best med for nerve type pain.

The other is the Fentanyl patch, (or lolipop) which is also different than codeine, and morphine. Good luck if you decide to look into pain meds again.

BrianG

BRAND NAME: DURAGESIC PATCHES
AVAILABLE IN
25 microgram, 
50 microgram, 
75 microgram &
100 microgram 
PATCHES     
USES OF THIS MEDICATION
The primary use of the fentanyl patch is to provide a continuous delivery of pain reliever to a patient with on-going pain. These patches are especially useful after a surgical procedure but are also helpful in the management of cancer pain, or after injury.  In the past, pain relievers were given as shots or pills on an “as needed” basis. Since it is difficult to determine when an animal is in pain, the basic guideline is to consider the pain that human patients report after similar surgeries or injuries.  If a human would be expected to experience pain in a similar circumstance, then it can be assumed that an animal would feel pain as well. 
Research into the human experience of pain and its relief has yielded some important information:
Recovery from illness is faster if pain is alleviated
 
It is more effective to prevent pain than to alleviate existing pain (i.e. using pain medications in anticipation of pain is more effective than waiting until the pain already exists)
 
Continuous delivery of pain relief is more effective than periodic administration of pain relief
The “transdermal” delivery systems have been very popular for continuous delivery of estrogens, nicotine, and anti-nausea medication (scopolamine).  It appears that they also provide an excellent  means of pain relief delivery.
HOW THIS MEDICATION WORKS
Fentanyl is a narcotic, a member of the same group of drugs to which opium and morphine belong.  The following is a simplification of how these drugs affect the body:
The opiate drugs bind to different types of opiate receptors throughout the nervous system. Different types of opiates tend to bind to different types of receptors thus creating differences in effect between the different opiates.  The “mu” receptor is responsible for the narcotic effects of euphoria, addiction, and respiratory depression.  There are also “kappa” and “sigma” receptors with other effects.
Fentanyl binds only the mu receptor approximately 75 to 100 times stronger than morphine.  It reaches its peak blood level in 3-6 hours in the cat but may require a full 12 hours in the dog to reach its full effect. After removal, fentanyl blood levels drop to zero within 24 hours. Patches last at least 4 days in pets.
SIDE EFFECTS
The most serious potential side effect is respiratory depression (i.e. not breathing adequately). This is a rare problem but if unusual weakness is observed, the patch may be removed.  This effect could become a significant risk if the patch is exposed to heating (electric blankets, sitting near a heater vent, heated water bed etc.)  The patch may be toxic if swallowed.
Occasionally, a pet reacts to the adhesive on the back of the patch. Such skin reactions should resolve with patch removal and application of a topical coritsone product.
The euphoria effect can lead to an excessive appetite though in some animals, nausea results from the fentanyl leading to a reduced appetite.
Fentanyl is not felt to be a sedative in the cat but  in the dog some sedation may be observed. A wobbly gait may be a sign of sedation.
There is some variability in the blood levels achieved by different individuals. Some individuals require additional medication for “breakthrough” pain.
INTERACTIONS WITH OTHER MEDICATIONS
Fentanyl should be used with caution in combination with medications that have sedating properties. 
Narcotics, including fentanyl, should not be used in patients using Anipryl/L-Deprenyl for either the treatment of Cushing's disease or for senility/cognitive dysfunction.
CONCERNS AND CAUTIONS
Fentanyl is a 'controlled' drug meaning that special government paperwork is required to order it and stock it.  Your veterinarian may require you to return any used patches for documentation of proper disposal.
THE APPLICATION OF HEAT
TO A FENTANYL PATCH
CAN LEAD TO SUDDEN DELIVERY
OF A LARGE AMOUNT OF FENTANYL.
Human deaths have been reported in patients
with patches sleeping on heated water beds.
If your pet has a fentanyl patch,
be sure to avoid situations where
the patch could be excessively heated.
 
Fentanyl patches may be toxic if swallowed by small children.  Be conscious of any children curious about the patch or attempting to manipulate it
.

Re: Pain meds

wendyn on 7/19/02 at 23:29 (090188)

Thanks Brian!! Fortunately, I don't have a whole lot of pain that needs medication anymore. The flare ups from RSD seem to go away on their own, and a lot of the heat and discomfort is not really always 'pain' in the true sense of the word.

My mom mentioned the fentanyl after she had back surgery. It seems to be one of the few things she can take (she has more problems with meds than I do). And, she said it was very effective for pain.

Should I ever need it though - it's nice to know it's out there.

Re: Brian

wendyn on 7/19/02 at 23:55 (090189)

Brian, do you realize you posted something related to veterinary use of this drug?

Are you trying to tell me something?!?!?

;)

Re: RSD

wendyn on 7/17/02 at 18:34 (089901)

A Description of RSD/CRPS: View Thread
Posted by Janet C on 4/10/02 at 23:43

Reflex Sympathetic Dystrophy (RSD), also known as Complex Regional Pain Syndrome (CRPS), is a complicated pain problem. It is characterized by severe pain and progressive physical changes that persist long after the original injury has healed. The original injury may have been as severe as a bullet wound or as simple as a sprained ankle. The syndrome can also sometimes occur after routine surgery.

Victims of RSD usually describe the pain as burning or shooting with extreme sensitivity to touch. For example, an article of clothing rubbing the affected area will often cause severe, extraordinary discomfort.

RSD usually occurs in an extremity (leg and foot or arm and hand), but can occur almost anywhere, including the chest, breast or abdomen. It is impossible to predict who will develop RSD. RSD is suspected when pain and other physical changes persist after healing appears complete and other causative factors have been ruled out.

Stages and Physical Changes:

RSD develops slowly, in stages, over several months or years. Initially the area may appear swollen and feel warm to touch due to both inflammation and spasms of the surrounding blood vessels.

In the second stage, the blood supply to the area diminishes and the area becomes cool to touch. The skin becomes shiny and waxy and there is a loss of hair and skin tone. The pain increases and there can be weakening of the underlying bone.

In the third and final stage, there is wasting of the affected muscles and disabling pain. Left untreated, the area can develop contractures from disuse which can become permanent.

Many Doctors classify RSDS into these different stages. It helps to understand the complexity of the disease. But all the stages can combine with one another, and not everyone experiences the same symptoms, or you may never advance to another stage. This is part of what makes RSDS difficult to diagnose.

Treatment:

Because of the complicated and progressive nature of this potentially devastating pain syndrome, treatment must be aggressive and must focus on rehabilitation as well as pain management. The doctor will prescribe treatment for the causative factors as well as the resultant physical, psychological and emotional side effects.

Nerve blocks are used to break the pain cycle and prevent progression of symptoms. These are most effective in the earlier stages and may need to be repeated several days in a row. Hospitalization for continuous nerve block is sometimes necessary.

Narcotic medications will decrease the pain of RSD but do not impact the underlying problem. In the early stages, it is preferable to use pain medicines that are also anti-inflammatories. Steroids may be prescribed short term to relieve symptoms and arrest their progression. Anti-depressants are used to improve sleep and inhibit pain pathways. Anti-convulsants and oral anesthetic agents may also be helpful for this type of pain.

Physical therapy is very important for pain relief and to maintain muscle strength and mobility. Massage, ultrasound and whirlpool may be employed for comfort, while aquatic or land exercise and mobilization prevent muscle wasting and disability.

The intensity of pain and muscle weakness often make compliance with prescribed treatment difficult for the patient. It is extremely important that all medicines be taken as directed and that exercises be performed regularly despite the pain. Education and counseling related to coping with and managing pain are available and may be helpful. In addition, biofeedback can assist individuals in learning to control blood flow and muscle tension to lessen symptoms.

Re: RSD

wendyn on 7/17/02 at 19:42 (089909)

This was an excellent explanation Janet gave a while back (I hope she doesn't mind me pasting it here)

RSD is essentially when someone's sympathetic nervous system goes out of whack following an injury or surgery. From what I understand, there are actual changes to the physical structure of the nerves themselves. They continue to misfire and misbehave long after the initial injury.

RSD can be made worse by surgery.

I seem to be 'stuck' in the first stage. My feet will become red and hot for no obvious reason. Someone asked me other day if they were sunburned (they are not). This is accompanied by intense pain and burning.

One of the strangest symptoms that many of us have, is experiencing actual physical pain when startled. So, rather than just just reacting when someone darts out in front of me while I'm driving - I actually experience a painful 'jolt' throughout all of my nerves. It lasts a fraction of a second but it feels AWFUL. I never had this before I developed RSD.

I never even mentioned it to anyone (including my doctor) until someone else here brought it up (I thought I was losing my mind!!!)

Re: RSD

Janet C on 7/18/02 at 00:14 (089927)

Thanks for pasting, and posting that response, Wendy. Here's another explanation that I think is quite informative:

What is RSD? From Jim O'Donnell's RSD/CRPS Site

Reflex Sympathetic Dystrophy is a chronic pain disorder involving the sympathetic nervous system. It usually is the result of an injury or trauma, but can also be a complication of surgery, infection, casting or splinting and myocardial infraction (heart attack). The trauma sets off the body's mechanism for pain recognition, but then the 'normal system of pain perception' begins to misfire in it neural response, and an abnormal cycle of intractable pain begins. As RSD progresses, the abnormal pain of the sympathetic nervous system has an effect on other areas of the body and can result in total disability as muscles, bones, skin and the autonomic immune system become involved.

The first indication of RSD is prolonged pain usually more severe than the injury. The symptoms are severe burning pain in a localized area, intense sensitivity to temperature and light touch, and a color change to the skin.

There are several stages to RSD, which progress at different rates in different people. Initially, there is swelling and redness in the affected area.

Next, the area becomes blue and cold, with increased pain and stiffness of ligaments and joints, and Osteoporosis may become evident.

Finally, there may be a wasting of affected muscles, contraction of tendons, and a definite withering of the affected limb. In all of the stages, severe chronic pain continues to be a major complaint.

Although RSD can be a progressive disorder, it should not be assumed that all cases will advance and present all clinical symptoms and dysfunction.

CLINICAL SYMPTOMS OF RSD

Pain is the first and primary complaint, described as extremely severe and burning & aching in nature
Swelling and joint tenderness
Loss or diminished motor function
Muscle spasms
Increased sweating
Changes in skin temperature and color
Bone softening - patchy osteoporosis

EFFECTS of RSD:

RSD can be
as painful as CANCER
as costly as AIDS
as crippling as ARTHRITIS

WHAT CAUSES RSD?

Trauma (often minor) such as a bruise, sprain or broken bone
Surgery
Myocardial Infarction (heart attack)
Infections
Repetitive motion disorders such as Carpal Tunnel Syndrome

HOW IS RSD DIAGNOSED?

Clinical Evaluation
Sympathetic Blockade
X-Ray
Thermographic Study
EMG, CAT scan, MRI studies
IV Systemic Blockade

HOW IS RSD TREATED?

Drug Therapy
Nerve Blocks
Physical Therapy
Sympathectomy
Transcutaneous Electrical Stimulator

IMPLANTABLE DEVICES:

Spinal Cord Stimulator or Drug Delivery Infusion Pump

With best wishes, always ~ Janet

Re: Here are some more facts and fiction about RSD:

Janet C on 7/18/02 at 00:58 (089930)

From The Reflex Sympathetic Dystrophy Syndrome Association Of America:

Reflex Sympathetic Dystrophy Syndrome (RSD) is poorly understood by patients, their families, and healthcare professionals. In some cases the condition is mild, in some it is moderate, and in others it is severe. We have compiled a list of some of the common misconceptions about this syndrome followed by the facts.
_______________________________________________________________________
Reflex Sympathetic Dystrophy Syndrome (RSD/CRPS) is rare.

FACT It is not a rare disorder and may affect millions of people in this country. This syndrome occurs after 1 to 2 % of various fractures, after 2 to 5% of peripheral nerve injuries, and 7 to 35% of prospective studies of Colles fracture. The diagnosis is often not made early and some of the very mild cases may resolve with no treatment and others may progress through the stages and become chronic, and often debilitating.
________________________________________________________________________
RSD/CRPS is a recently discovered disease.

FACT It was described during the Civil War and has been in the literature under a variety of names ever since.
________________________________________________________________________
The pain is not as bad as the patient says it is.

FACT The pain is often as bad as claimed and may be even worse.
________________________________________________________________________
RSD/CRPS following surgery means that the physician did something wrong.

FACT RSD/CRPS can occur following surgery as well as a trauma. This does not mean that the surgery was performed incorrectly.
________________________________________________________________________
Minor injuries cannot cause RSD/CRPS.

FACT Minor injuries, such as a sprain or a fall are frequent causes of RSD/CRPS. RSD/CRPS can start immediately after the injury or later. One characteristic of RSD/CRPS is that the pain is more severe than expected for the type of injury that occurred. In 10 to 26% of cases no precipitating factor can be found.
________________________________________________________________________
RSD/CRPS does not spread.

FACT The usual pattern of spread is up the same extremity and then may continue to spread on the same side of the body or to the opposite extremity. RSD/CRPS may spread to a distant site. According to the RSDSA database, the condition spreads in 70% of patients.
________________________________________________________________________
RSD/CRPS will burn itself out in 6 months.

FACT Many patients who are not treated early will experience spread of RSD and this may become a lifelong problem. Even with early treatment this may become a chronic condition.
________________________________________________________________________
Children do not get RSD/CRPS limb pain in children is psychological.

FACT RSD/CRPS can start as young as 3 years of age. This is not a psychological condition. Children may develop psychological problems when physicians, parents, teachers, and other children do not believe their complaints of pain.
________________________________________________________________________
After one or two treatment programs have not helped, there is nothing that can be done. The patient should be told to go home and learn to live with the pain.

FACT There are many forms of treatment for RSD/CRPS. Treatment may include medication, sympathetic nerve blocks, physical therapy, psychological support, and possibly sympathectomy, or dorsal column stimulator. The physician directing the care of the patient should have a treatment plan. In severe or long term cases, a Pain Clinic with a coordinated plan may be helpful.
________________________________________________________________________
Patients continue to complain because of secondary gains. They are looking for sympathy and are gaining satisfaction from this experience.

FACT As with any group of individuals there is a small percentage of RSD/CRPS patients who get satisfaction from a chronic illness. The vast majority of RSD/CRPS patients were active, productive individuals prior to this disease and do not enjoy the pain, the loss of independence, the loss of job or inability to attend school and the loss of income. The most devastating aspect of the illness is that physicians, other health care professionals, employers and especially friends and family members do not understand how much the patient is suffering. They are not looking for sympathy, only understanding.
________________________________________________________________________
Once RSD/CRPS is in remission, it does not come back.

FACT It may subside for years and then recur with a new injury. The reoccurrence should be treated immediately.
________________________________________________________________________
Vigorous and aggressive physical therapy is best.

FACT Physical therapy should be carried out only under a physician's supervision. Osteoporosis occurs with RSD/CRPS and as a result of bone loss, pathological fractures can be caused by overly aggressive therapy. In general, 'To hurt, is not to harm' as long as the patient is self mobilizing. Aquatic therapy at a comfortable water temperature can often facilitate mobilization of extremities, especially if RSD/CRPS is in the lower extremity. However, the cliché 'No pain, no gain' does not apply to RSD/CRPS patients.
________________________________________________________________________
The treatment for all RSD/CRPS patients should be the same.

FACT Each patient needs an individual treatment plan. What helps one patient, may not help another.
________________________________________________________________________
RSD/CRPS is not recognized as a reason for long-term disability or SSI payments.

FACT It is. The physician directing the patient's care should write a letter or report describing the severity of the condition.
________________________________________________________________________
Any physician can treat RSD/CRPS without outside help.

FACT RSD/CRPS is a complex condition with varying degrees of severity and disability. Patients should be cared for by a physician who knows how to treat RSD/CRPS. Often, a team approach (physician, physical therapist, anesthesiologist, mental health provider, and social worker) is most helpful.
________________________________________________________________________
There are no symptoms except pain, swelling, heat or coldness, and color change.

FACT There are many other symptoms including movement disorders (difficulty starting movement, increased tone, increased reflexes, tremor, muscle spasms), weakness, fatigue, skin rashes, frequent infections, migraine headaches, and others may be found as more data is accumulated.
________________________________________________________________________
Family and friends find this condition easy to understand.

FACT RSD/CRPS is difficult for many physicians to understand. It is not surprising that family and friends do not understand the patient's pain and disability.
________________________________________________________________________
Blocks and other treatments only work in the first stage of the disease.

FACT There are treatments that will help in any stage of RSD/CRPS. If RSD/CRPS spreads or if a new injury occurs, blocks may be effective again.
________________________________________________________________________
RSD/CRPS occurs in psychologically unbalanced people.

FACT Persons who get RSD/CRPS are not any different than the rest of the population psychologically. Once they get RSD/CRPS and they are in constant pain, with friends, family and employers not believing them, they may be depressed and suffer other psychological changes. When RSD/CRPS symptoms are relieved these changes disappear.
________________________________________________________________________
Every patient has the same results from a medication or treatment.

FACT There are many forms of treatment and combinations of treatment and medication. What is highly effective for one, may not work in another. Medication dosages may need to be adjusted to get the best results.
________________________________________________________________________
A patient who has no visible sign or positive tests does not have RSD/CRPS.

FACT RSD/CRPS is a clinical diagnosis. This means that the physician makes the diagnosis based on thorough history and physical examination. When seeing a new physician, it is a good idea to have a brief medical history with dates of various treatments and the response to them. Also include a brief summary of any hospitalizations and surgeries. It is helpful for the doctor to have a copy of this information before your appointment. Given the complexity of RSD/CRPS, it is helpful for the patient to keep their own set of relevant medical records.
________________________________________________________________________
There is no hope for patients who have had RSD/CRPS for a long time.

FACT The future of RSD/CRPS treatment is optomistic. Researchers worldwide investigate effective treatments and the cause of RSD/CRPS.
________________________________________________________________________
We hope all physicians will recognize and diagnose RSD/CRPS in the early stages so that the patient can be treated promptly and appropriately. Any physician unfamiliar with the treatment of RSD/CRPS should refer patients immediately to a physician or center that treats RSD/CRPS.

Re: RSD

elliott on 7/18/02 at 11:53 (089963)

Funny, but reading your list, the misconception that people with RSD are psychologically unbalanced reminds me about what a PT I went to recently claimed (you're not gonna like this), namely that just about everyone he saw for RSD was kinda fluky, and he believed there was a connection (he doubted the RSD diagnosis in many of them too). Of course, the fact that they already had it (if they did) before they saw him didn't help their cause, nor the difficulty in getting a definitive diagnosis, although things are getting more rigorous, see, e.g.,

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1620860&dopt=Abstract

The PT was telling me he has patients who, when he asks them on a scale of 1 to 10, with 10 being the most unbearable pain imaginable, what kind of pain they're in now, they sit there calmly and matter of factly say, 'oh, a 10', rigt in the middle of casual conversation, and not the writhing on the floor he'd expect.

People do have different perceptions of pain. There are some who faint at an injection or the pain from it, or even an MRI, and others who barely need pain killers following surgery. Is it possible that those with a very low tolerance for pain or something else a little off balance make them as group more likely for their nerves to misfire and give them RSD?

-----

Re: Great post -- do you have a link?

Ed Davis, DPM on 7/18/02 at 12:18 (089968)

Great post. Do you have a link?
Ed

Re: here's the link

elliott on 7/18/02 at 12:49 (089970)

http://www.rsds.org/

I just typed in the organization at the top of her post into google, and out it popped. Click on English. Her post is the 'facts and fiction' link appearing in the list.

Re: RSD

wendyn on 7/18/02 at 13:39 (089980)

Who knows if there's a relation to a malfunctioning sympathtetic nervous system, but the low pain tolerance theory doesn't hold much promise in my mind.

I've been told on numerous ocassions (56 hour labor, minor surgery without anesthetic, arterial blood tests etc) that I seem to have an exceptionally high tolerance for pain (both pre and post RSD). The tolerance to pain itself may often be somewhat psychological, but the physiological changes from pain and RSD are not.

Sounds to me like that PT needs to do a little more research on RSD.

Re: RSD

Sharon W on 7/18/02 at 13:52 (089982)

Wendyn, Brian, et al,

I don't have RSD and I'm certainly not an expert on it, although I've been reading the posts. Still, I can't help wondering if it's actually the OTHER way around -- perhaps people who tend to develop RSD are those with a HIGH pain tolerance, the ones who DON'T go yelling and screaming and dramatically demanding that their doctors prescribe painkillers at the first sign of pain. From my readings on the subject of chronic pain, it appears that longstanding, UNTREATED pain sometimes develops into RSD --and that would tend to indicate that people who are really STOIC, the ones who have to be really MISERABLE before they will go to their doctors and complain that they are in pain -- are the ones most at risk for RSD! Certainly, there are several examples of people who post on this board (yourself included, Wendy) who have RSD but certainly DON'T seem to be hysterical about pain or inclined to overreact to in any way.

-- Sharon

Re: RSD

elliott on 7/18/02 at 14:16 (089985)

Well, I'm sure we could find counterexamples to your hypothesis too. And I think many develop RSD very soon after an event, be it trauma, surgery, or whatever. That's not due to stoicism. It's stoicism (if you call it that) that can make them even worse by delaying treatment.

Not everything in that list is so clear either. Take the one about the myth that if you get RSD from surgery, then the surgeon did something wrong. Well, if that's a myth (I'm not so sure about that one, and I believe the wording used does leave open the possibility that he could be at fault), unless you buy the theory that it's totally random, presumably something in that patient made him/her more likely to trigger off a strange nervous reaction. That just doesn't seem like stoicism to me, just the opposite.

I'm not saying my PT was right nor that it applies to everyone, I'm only quoting his observation, and wondering if there's at least some correlation.

---

Re: RSD

Sharon W on 7/18/02 at 14:41 (089987)

Elliott,

I certainly didn't mean to imply that being stoic is the ONLY way to end up with RSD! I know that many people develop RSD after surgery, and that some seem to get it as a 'complication' of some other painful and chronic problem such as fibromyalgia or PN.

But I do strongly suspect that UNTREATED pain can be a major contributing factor. I would be really curious to see someone do a study in which patients with RSD who got it after surgery are interviewed as to whether they believe the pain medications they received immediately after their surgery were adequate or not -- and compare that group with a group of 'controls' who had the same sugery but did NOT develop RSD. Of course, it would be very important to factor in which medications were actually PRESCRIBED for them...

-- Sharon

Just a thought.

-- Sharon

Re: RSD

elliott on 7/18/02 at 14:52 (089992)

Certainly agree that leaving RSD untreated is likely to make it worse; that seems to be well-documented. Not sure if what you say in your last paragraph is true. If so, next time I have surgery, rather than take one or two of those Percocets and then say 'Forget this!', I'll finish the whole bottle--I won't care if I get dizzyness, tiredness, constipation, lack of urination, whatever. :-)

----

Re: RSD

Carole C in NOLA on 7/18/02 at 16:09 (089998)

56 hours of labor? {{{ Wendy! }}}

5 hours of induced labor, plus 45 minutes of delivery seemed like forever to me. Your point is well taken.

Carole C

Re: RSD

wendyn on 7/18/02 at 20:12 (090009)

Carole, I was actually induced over three separate days. They started in on a Friday morning. I was sent home after about 16 hours of labor because I wasn't progressing. Had contractions on and off all weeekend. They induced again Monday morning. Contractions became so intense by late Monday night that I actually went in reverse (swelled instead of dialating). So they stopped inducing, but the contractions hung around.

They started all over again Tuesday morning, my son was born at around dinner time Tuesday night by C-section.

It was nasty.

Re: RSD

wendyn on 7/18/02 at 20:23 (090013)

Sharon, you make some interesting points. I've often wondered if my reluctance to use pain meds may have actually contributed to my RSD.

When I first developed TTS my doctor prescribed me Naproxen. I tried taking it, but it made me very sleepy. I was doing capital budget work (which is a snoozer at the best of times) so there was no way I could take it and function at work.

I'm allergic to codeine, and I was afraid of the side effects of the Voltaren and Elavil they wanted to try me on.

Actually, I guess I have something of a phobia to medicine. My youngest son had a severe reaction to pencillin - and I've been hesistant to take anything since then.

Knowing what I know now, if I had that kind of pain again I WOULD TAKE SOMETHING FOR THE PAIN rather than suffering through it. I don't think my deicsion was wise.

Re: rough time

Carole C in NOLA on 7/18/02 at 20:35 (090014)

Stories like that remind me that women are truly tough.

Carole C

Re: RSD

Sharon W on 7/19/02 at 09:58 (090097)

Wendyn,

As you probably know, Tammie also says that she had always avoided taking painkillers in the past.

I can't quote a reference but I do remember being taught in a seminar that nurses often UNDERmedicate stoic patients for pain, that research has shown patients who (in filling out questionnaires for the research study without knowing exactly WHAT was being studied) reported that they do not like to take painkillers and claim to be able to 'handle' pain without them, and in general could be described as 'stoic,' are less likely to ASK for painkillers than someone else who has had an equivallent procedure done and are ALSO less likely to be OFFERED painkillers by the nurse, or asked about their pain, because they don't cry out or grimace or moan and groan or whatever.

Combine that with the fact that, in all probability when they get home they may not even FILL a prescription for painkillers, or if they do, they'll only take 1 or 2 of them and then after that they'll just 'grit their teeth and bear it' -- and I think it may well help to explain why some patients get RSD after ANY kind of surgery. I know I keep quoting this one (it was Donna SL who shared it with ME) but Daniel Brookhoff describes the process of how chronic pain, and related problems like RSD, can develop from unrelieved 'acute' pain. The link is:

http://www.hosppract.com/issues/2000/07/brook.htm

Sharon

Re: not stupid at all

Carole C in NOLA on 7/19/02 at 11:53 (090114)

From looking at your photos, you have a small frame. I'd guess that you wanted to give regular childbirth your best try, and you did. That's not stupid, even if you had to have a C-section in the end. There was no way to know how things would (or wouldn't) progress.

I'm a large framed, tall person, but even so I was really lucky that delivering a nine and a half pound baby went so easily for me. At the time I would not have said that. Haha! Little did I know.

Carole C

Re: not stupid at all

wendyn on 7/19/02 at 13:08 (090121)

Carole, I did want to give the whole natural childbirth thing a try. Amazingly, I even tried again aftr my first c-section. My second was born by emergency c-section though after a very brief period of labor.

I worked with a girl who was my size, she delivered a baby just over 11 pounds last year. Naturally.

I asked her what she did that made her doctor so mad at her (I'm amazed she did it and lived to talk about it!!!!)

In my case, I was only 16 when I had my first, so I was very tiny. I also was not nearly as assertive as I am now. I think that if this were to happen to me now I would say NO THANKS to the third day of inducing. 2 full days was ENOUGH!!!!!

Re: Pain meds

wendyn on 7/19/02 at 13:13 (090123)

Sharon, this pretty much describes what I've done in the past. I would not do this again in the future. I've had some bad side effects from meds, I'm allergic to codiene and morphine. I can't take toradol, and Laratine (sp?) made me violently ill. Most of this was discovred following bunion surgery.

As a result, I had demerol for 48 hrs after my C-section, then I went straight to plain old tylenol. That's a big jump in pain relief.

Now that I know that pain itself is actually bad for you, I would make more of an effort to not let it get out of control.

Unfortunately, other then tylenol for little stuff and demerol for big stuff - my pain relief options seem to be limited.

Re: Pain meds

Sharon W on 7/19/02 at 13:42 (090125)

Ugh. The pain relief from Demerol never really seems to last from one dose to the next.

What meds do you use NOW -- just Tylenol?

Sharon

Re: Pain meds

wendyn on 7/19/02 at 13:50 (090126)

Sharon, If I really need something I usually take tylenol. I prefer Motrin or Advil but I can usually only tolerate 1 pill (or a kids sized dose) without side effects.

I experienced absoultely NO pain relief from Morphine. I guess maybe because I was allergic to it (?). Actually, I'd had so much right after my surgery that the nurse asked me if I was perhaps a recreational user.

Shortly afterwards I started to get purple and itchy. I actually think I got more pain relief from the Tylenol than I did the morphine. Since demerol is the 'best' I've ever had, it seems pretty good to me!!!!!!!

The problem with the meds was the worst part of the recovery.

Re: Pain meds

Sharon W on 7/19/02 at 15:39 (090144)

Wendyn,

I'm sure you know that people with RSD (or any other type of chronic pain, for that matter) suffer from a REDUCED sensitivity to opiates, which is really adding insult to injury!

Sharon

Re: here's the link ---thank you

Ed Davis, DPM on 7/19/02 at 18:58 (090155)

Gracias.
Ed

Re: Pain meds

wendyn on 7/19/02 at 19:36 (090165)

Sharon, I did not know that about RSD and pain meds. But this experience was pre-RSD so I don't know if that could factor in.

Apparently the itchy wasn't what convinced them (that went on all day). It was the purple color and the itchy nose that seemed to change things. Apparently an itchy nose means something.

Re: Pain meds

BrianG on 7/19/02 at 22:33 (090186)

Hi Wendy,

There are actually a couple more good pain meds you may want to try. The first is Methadone. Because it's not a time release med, you can break each pill in halves, and quarters. By starting at such a small dose, you may be able to tolerate it better. I've read that it's THE best med for nerve type pain.

The other is the Fentanyl patch, (or lolipop) which is also different than codeine, and morphine. Good luck if you decide to look into pain meds again.

BrianG

BRAND NAME: DURAGESIC PATCHES
AVAILABLE IN
25 microgram, 
50 microgram, 
75 microgram &
100 microgram 
PATCHES     
USES OF THIS MEDICATION
The primary use of the fentanyl patch is to provide a continuous delivery of pain reliever to a patient with on-going pain. These patches are especially useful after a surgical procedure but are also helpful in the management of cancer pain, or after injury.  In the past, pain relievers were given as shots or pills on an “as needed” basis. Since it is difficult to determine when an animal is in pain, the basic guideline is to consider the pain that human patients report after similar surgeries or injuries.  If a human would be expected to experience pain in a similar circumstance, then it can be assumed that an animal would feel pain as well. 
Research into the human experience of pain and its relief has yielded some important information:
Recovery from illness is faster if pain is alleviated
 
It is more effective to prevent pain than to alleviate existing pain (i.e. using pain medications in anticipation of pain is more effective than waiting until the pain already exists)
 
Continuous delivery of pain relief is more effective than periodic administration of pain relief
The “transdermal” delivery systems have been very popular for continuous delivery of estrogens, nicotine, and anti-nausea medication (scopolamine).  It appears that they also provide an excellent  means of pain relief delivery.
HOW THIS MEDICATION WORKS
Fentanyl is a narcotic, a member of the same group of drugs to which opium and morphine belong.  The following is a simplification of how these drugs affect the body:
The opiate drugs bind to different types of opiate receptors throughout the nervous system. Different types of opiates tend to bind to different types of receptors thus creating differences in effect between the different opiates.  The “mu” receptor is responsible for the narcotic effects of euphoria, addiction, and respiratory depression.  There are also “kappa” and “sigma” receptors with other effects.
Fentanyl binds only the mu receptor approximately 75 to 100 times stronger than morphine.  It reaches its peak blood level in 3-6 hours in the cat but may require a full 12 hours in the dog to reach its full effect. After removal, fentanyl blood levels drop to zero within 24 hours. Patches last at least 4 days in pets.
SIDE EFFECTS
The most serious potential side effect is respiratory depression (i.e. not breathing adequately). This is a rare problem but if unusual weakness is observed, the patch may be removed.  This effect could become a significant risk if the patch is exposed to heating (electric blankets, sitting near a heater vent, heated water bed etc.)  The patch may be toxic if swallowed.
Occasionally, a pet reacts to the adhesive on the back of the patch. Such skin reactions should resolve with patch removal and application of a topical coritsone product.
The euphoria effect can lead to an excessive appetite though in some animals, nausea results from the fentanyl leading to a reduced appetite.
Fentanyl is not felt to be a sedative in the cat but  in the dog some sedation may be observed. A wobbly gait may be a sign of sedation.
There is some variability in the blood levels achieved by different individuals. Some individuals require additional medication for “breakthrough” pain.
INTERACTIONS WITH OTHER MEDICATIONS
Fentanyl should be used with caution in combination with medications that have sedating properties. 
Narcotics, including fentanyl, should not be used in patients using Anipryl/L-Deprenyl for either the treatment of Cushing's disease or for senility/cognitive dysfunction.
CONCERNS AND CAUTIONS
Fentanyl is a 'controlled' drug meaning that special government paperwork is required to order it and stock it.  Your veterinarian may require you to return any used patches for documentation of proper disposal.
THE APPLICATION OF HEAT
TO A FENTANYL PATCH
CAN LEAD TO SUDDEN DELIVERY
OF A LARGE AMOUNT OF FENTANYL.
Human deaths have been reported in patients
with patches sleeping on heated water beds.
If your pet has a fentanyl patch,
be sure to avoid situations where
the patch could be excessively heated.
 
Fentanyl patches may be toxic if swallowed by small children.  Be conscious of any children curious about the patch or attempting to manipulate it
.

Re: Pain meds

wendyn on 7/19/02 at 23:29 (090188)

Thanks Brian!! Fortunately, I don't have a whole lot of pain that needs medication anymore. The flare ups from RSD seem to go away on their own, and a lot of the heat and discomfort is not really always 'pain' in the true sense of the word.

My mom mentioned the fentanyl after she had back surgery. It seems to be one of the few things she can take (she has more problems with meds than I do). And, she said it was very effective for pain.

Should I ever need it though - it's nice to know it's out there.

Re: Brian

wendyn on 7/19/02 at 23:55 (090189)

Brian, do you realize you posted something related to veterinary use of this drug?

Are you trying to tell me something?!?!?

;)