Focus on… Dr. Robert J. Schwartzman
By Debra Nelson-Hogan
Robert J. Schwartzman, MD, Professor and Chairman of Neurology at the Drexel University College of Medicine in Philadelphia has researched CRPS for more than 30 years and his clinical and research programs have treated more than 4,000 people with CRPS. One of the pioneers in CRPS 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 CRPS, "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 CRPS." They are:
- Pain, allodynia, hyperalgesia, hyperpathia
- 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."
The more we learn, the more evident it becomes that we need new and more effective therapeutic options to treat CRPS. Currently Dr. Schwartzman 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 CRPS 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 CRPS 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 CRPS 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 CRPS 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 CRPS. 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."