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Focus on… Dr. Robert J. Schwartzman
By Debra Nelson-Hogan
Robert J. Schwartzman, MD, Professor and Chairman of Neurology
at the MCP Hahnemann School of Medicine in Philadelphia has
researched RSD/CRPS for more than 30 years and his clinical
and research programs have treated more than 4,000 people
with RSD. One of the pioneers in RSD research and treatment,
Dr. Schwartzman was a guiding force behind the founding of
RSDSA in 1984 and he has remained a trusted advisor ever since.
Over the years he has seen a number of changes in diagnosis
and treatment of the disorder. He is excited about some of
the new developments in research and treatment and explained
that since he began studying RSD, "We have learned more about
some basic mechanisms; we now know a lot of clinical things
we didn't know before," he explains, "such as identifying
the 5 major components of RSD." They are:
- Pain, allodynia, hyperalgesia, hyperpathia
- Swelling
- Autonomic dysregulation
- Motor dysfunction
- Atrophy and dystrophy
Dr. Schwartzman explains that mechanisms for each component
are being sought by the use of animal and transgenic models.
"We know that vasoactive neuropeptides seem to be important
for the swelling. NMDA receptors and glutamate release from
pain fibers are important in sensitization of central pain
projecting neurons. Once these receptors are open and not
functioning properly, enzymatic and metabolic cascades occur
in pain cells and then they are different. The gain of pain
is increased, or simply put, a small amount of pain is magnified."
Ketamine Research
The more we learn, the more evident it becomes that we need
new and more effective therapeutic options to treat RSD. Currently
Dr. Schwartman is involved in studying the use of high doses
of ketamine, an anesthetic, to block abnormal pain NMDA receptors.
"I'm involved in trials in Germany for RSD patients," he explains.
"We give patients very high doses of ketamine to make them
comatose for five days, and they wake up with no pain. To
date, there have been no complications in 10 patients." An
abstract of the research presented at the recent annual meeting
of the American Academy of Neurology noted that one patient
has remained pain-free for three years, and two others have
suffered little pain. Needless to say, this has created a
lot of excitement in the RSD community. Dr. Schwartzman stresses
the need for further studies to find a better way to achieve
these results because the process is extreme and dangerous.
"It is a very complicated problem. Pain causes changes in
the brain itself. After you've had RSD your brain has changed.
Once you stop the pain, you can retrain the brain and many
of these changes reverse. If you have enough pain long enough
it may cause structural changes in the spinal cord. This has
never been shown in patients but is apparent in experimental
animals."
Another new possible treatment for RSD is thalidomide, a sedative
remembered for its tragic side effects on children in the
1960s. It was not marketed in the United States until recently,
and is currently being tested in two clinical trials. Dr.
Schwartzman notes that in one patient the results were spectacular.
Despite better information and research, "A great deal of
information hasn't gotten down to the physician level." Patients
still are not being diagnosed early enough for appropriate
treatment. There is still a tremendous amount of misinformation.
"The good news is that most physicians now realize that this
is not a psychiatric illness. Everyone with this much pain
is depressed. There is no basic personality type that gets
RSD. Anybody can get it."
He advises patients to keep active, keep functioning as much
as they possibly can. Many patients in pain don't move, then
they gain weight and their joints have problems. Patients
have to fight to be active, bear weight, use extremities the
best they can. "Try to keep into life. Don't give up. Keep
in your life. It is destructive to give up."
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