Finding an RSD Specialist
Office personnel at the RSDSA-CA have identified the most frequently asked
question from an RSD patient being, "Do you know of an ‘RSD Specialist’ in my area?" Understanding
more about the ‘pain management process’ may help patients in selecting a physician or pain clinic and what you
may experience if you begin a pain management therapy program.
Whether you are insured by private insurance like a PPO, or are in an HMO
program or insured under a state program such as Medi-Cal, the process of pain management may ultimately lead to a ‘team
approach’ for patient care.
Basically, a person can begin with a physician in almost any field of medicine
when they are first diagnosed with RSD. Depending on the stage of the illness and other physical or mental conditions that
may be present will determine the next steps in treatment. The patient may be referred to one type of specialist for certain
tests and medication therapy, and then to another specialist for other treatments such as nerve blocks to help confirm the
Most likely, at some point a physician will assume a role as the ‘primary
care doctor’ in pain management therapy to coordinate the procedures and medications in the patient’s care. This
doctor may be an Anesthesiologist, a Neurologist, a Rheumatologist, an Internist, a Neurosurgeon or Orthopedic Surgeon, or
a doctor practicing General Medicine. Also included in a Pain Management Program may be a Physical Therapist and a Psychiatrist
or Psychologist. The primary care doctor will determine what a patient needs and will consult with all of the appropriate
fields of medicine to ensure a thorough pain program is established. This can get very confusing and frustrating
for the patient because it may seem like ‘no one knows what to do or anything about RSD!’
The process of evaluating treatment for RSD is not an easy task.
The severe chronic pain is a major focus for the patient, but the
physician must consider the overall health of the patient and any secondary medical conditions that require treatment. Chronic
pain is understood to be a persistent pain that frequently is not amenable to routine pain control methods. It can develop
when pain lasts longer than is expected for a trauma or injury. Because there are many differences in what is regarded as
chronic pain, management strategies remain flexible and related to specific cases. The American Pain Society has published
an article discussing ‘Adjuvant Agents for Managing Chronic Pain’ (1) (Adjuvant agents are those that assist or aid other medication) The APS article states:
‘Pathophysiologic classification of pain may assist in selecting
appropriate therapies and determining a prognosis for patients. (2) There
are four major categories into which chronic pain can be classified: nociceptive, neuropathic, mixed, or unknown origin. Nociceptive
pain can be either visceral or somatic; it is derived from stimulation of pain receptors. (3) Development of nociceptive
pain may be due to the inflammation, mechanical deformation, ongoing injury, or destruction of tissue. Neuropathic pain involves
a pathophysiological process in either the peripheral or central nervous system (CNS) or both. (4) Examples of
neuropathic pain include trigeminal neuralgia, postherpetic neuralgia, poststroke central or thalamic pain and phantom limb
pain. Chronic pain can have mixed or unknown mechanisms or it can be psychological in nature. (5) These types of pain are unpredictable and difficult to treat.
Because many different neurotransmitters ( e.g., substance
P, serotonin, prostaglandins, bradykinin, leukotrienes, histamine ) and receptors ( e.g., opioid, serotonin, acetylcholine,
dopamine, norepinephrine ) are involved in pain, many potential targets for drug therapy exist. The selection of an appropriate
analgesic medication can be difficult. The World Health Organization (WHO) has developed a three-step approach for selecting
analgesics for the management of chronic pain. (6)
Not all physicians use the WHO three-step approach universally, and this approach may not represent a routine procedure to
be employed for all chronic pain patients.
The first-line agents are acetaminophen and nonsteroidal anti-inflammatory
drugs. If pain relief does not occur with these agents, low-dose opioid combinations such as acetaminophen with codeine (Tylenol
No 3 ®), acetaminophen and hydrocodone (Lortab ®, Vicodin ®) and acetaminophen with oxycodone (Percocet ®) can be used as
second-line agents. If the pain is still not controlled, stronger opioids such as morphine, hydromorphone, and methadone can
be used. For patients who still do not achieve adequate pain control, it may be necessary at this point to consider adjuvant
analgesic therapy. Adjuvant agents are not typically thought of as having analgesic properties. However, they are helpful
in maximizing pain control and lowering the required dosage of opioids and can be used in combination with the above therapies.’
If a physician does not have a conclusive diagnosis of what is causing
the chronic pain or it is unclear if it is nociceptive, neuropathic or a mixed classification of chronic pain, it may take
a trial of several different medications to find those that are helpful in treating each patient. Even if there has been a
diagnosis of RSD, it may still require trying different medications in each patient’s case because not all people with
respond the same to medication.
The APS article continues to say, ‘The largest body of literature
on adjuvant agents focuses on the use of antidepressants, specifically tricyclic antidepressants (TCAs) and their role in
nociceptive and neuropathic pain. (7) TCAs such as amitryptyline (Elavil ® ), desipramine (Norpramin ® ) doxepin (Sinequan
® ) imipramine (Tofranil ®) and nortriptyline (Pamelor ® have been studied for their role in treating neuropathic pain. Amitriptyline
has also been shown to be beneficial in nociceptive pain, especially somatic pain. Newer antidepressants such as selective
serotonin reuptake inhibitors (SSRIs) have also been studied for their role in chronic pain management. Fluoxetine (Prozac
® ) has been shown to be effective in reducing pain and improving global wellness scores in patients with Fibromyalgia, especially
when used in combination with amitriptyline. In evaluating the use of SSRIs in diabetic neuropathy, paroxetine (Paxil ® )
has been demonstrated to produce an improvement in patients’ pain.
Anticonvulsants have been beneficial in treating spontaneous shooting pain
that manifest from neural damage. Neuroleptic drugs such as carbamazepine (Tegretol ® ) & phenytoin (Dilantin ® ) have
shown improvement in pain intensity. A newer antiepileptic agent, Gabapentin (Neurontin ® ) has fewer side effects than the
older anticonvulsants and analysis demonstrated a response rate of 50% in patients with polyneuropathy and trigeminal neuralgia.
N-methyl-D-aspartate (NMDA) receptor antagonists are used to manage neuropathic
pain. Dextromethorphan and Ketamine are two NMDA receptor antagonists currently available. A hypothesis as to the difference
in response ( in a clinical study of Dextromethorphan by Nelson et al ) is that NMDA receptor antagonists are particularly
beneficial in patients with ongoing peripheral neuron damage, as seen in diabetic neuropathy, but not in patients with fixed
lesions, which are common in postherpetic neuralgia. Chronic pain will remain an issue for many patients who have failed traditional
analgesic therapy administered in accordance with treatment guidelines. Practitioners must not only recognize chronic pain
but also aggressively treat the condition. Whenever possible, treatment should be proactive rather then reactive. Adjuvant
agents are not considered first-line therapy in pain management. Instead, they optimize pain control and provide relief to
patients who suffer from intractable pain.
Management of chronic pain is a complex process requiring appropriate medication
management as well as treatment of the whole person. A management strategy must be tailored to individual patient needs and
situation, and must be constantly reviewed to ensure optimal patient outcome.’ In reviewing the ‘three-step
approach for selecting analgesics for pain management’ that was established by the World Health Organization, RSD patients
may recognize many of the medications mentioned in the article as those that they have been given in their own pain management
So, rather then focusing on trying to find a doctor that
is an ‘RSD specialist’ ... the patient should actually be seeking is a physician that has certification in Pain
Medicine or Pain Management - Anesthesiology. . While many organizations, clinics
and institutes offer continued medical education units (CME units) for ‘pain treatment courses’
or ‘pain related lectures or seminars’, this is not to be confused with the actual Certification achieved in Pain
Medicine or Pain Management – Anesthesiology.<O:P></O:P>
The American Board of Pain Medicine (ABPM) was founded in 1991 as
the American College of Pain Medicine. In 1994 the name was changed to the American Board of Pain Medicine to
reflect the nomenclature of other medical specialty boards. This not-for-profit corporation operates as an autonomous
entity, independent of any other association, society, or academy. ‘Pain Medicine has emerged as a separate and
distinguishable specialty that is characterized by a distinct body of knowledge and a well-defined scope of practice, which
is based on an infrastructure of scientific research and education. Competence in the practice of Pain Medicine requires advanced
training, experience, and knowledge.’
After an examination and certification by the ABPM, a pain physician ‘serves
as a consultant to other physicians but is often the principal treating physician and may provide care at various levels,
such as direct treatment, prescribing medication, prescribing rehabilitation services, performing pain relieving procedures,
counseling patients and families, directing a multidisciplinary team, coordinating care with other health care providers and
providing consultative services to public and private agencies pursuant to optimal health care delivery to the patient suffering
from pain. The pain physician may work in a variety of settings and is competent to treat the entire range of pain encountered
in the delivery of quality health care.’
The American Medical Association (AMA) strategic agenda remains rooted
in commitment to standards, ethics, excellence in medical education and practice, and advocacy on behalf of the medical profession
and the patients it serves. The Accreditation Council for Graduate Medical Education (ACGME) oversees residency
training programs and training institutions in the United States. The ACGME sets requirements that institutions must
meet in order to sponsor graduate medical education (GME). According to the institutional requirements, the purpose
of GME is to 'provide an organized educational program with guidance and supervision of the resident, facilitating the resident's
professional and personal development while ensuring safe and appropriate care for patients.' The institutional requirements,
along with each specialty's program requirements, guide institutions and residency programs in the process of providing an
ethical and professional environment in which the educational curricular requirements can be met.'
Understanding these new subspecialties of Pain Management - Anesthesiology
and Pain Medicine will help people find a physician with knowledge, experience and commitment to diagnosing and treating chronic
pain such as RSD/CRPS.
Detailed Specialty for Pain Management - Anesthesiology:
The anesthesiologist who specializes in pain management is a physician who must receive additional training in pain
management after the completion of anesthesiology training. Certification in pain management will recognize those
physician anesthesiologists who, through special examination in pain management, have documented competence to provide a high
level of care either as a primary physician or consultant for patients experiencing problems with acute or chronic pain in
both hospital and ambulatory settings and coordinate a multidisciplinary approach toward pain management. The additional
training in pain management prepares the anesthesiologist to treat patients within the entire range of painful disorders with
mastery of an additional body of knowledge required for the diagnosis and management of patients with pain.
The American Board of Anesthesiology offers additional certification of
Added Qualifications in Pain Management. The ACGME Program Requirements for Pain Management - Anesthesiology is 1 year
in Pain Management after completion of a core residency program related to Pain Management accredited by the ACGME.
Detailed Specialty for Pain Medicine:
Pain Medicine physicians limit their practice to the evaluation and management of individuals with acute, cancer and chronic
pain. The Pain Medicine physician has background in the neurophysiology and neurochemisty of pain. Physicians
in diverse fields of medicine are active in pain medicine. These diverse fields include Anesthesiology, Oncology, Neurosurgery,
Neurology, Physical Medicine and Rehabilitation, Psychiarty, Internal Medicine, Family Practice and other subspecialties.
Two-year Pain research fellowships are available from the National Institutes
of Health (NIH). One-year Pain fellowships are offered on an ACGME accredited basis by many anesthesiology programs.
Physicians in specialties other than anesthesiology or anesthesiologists
who do not meet the criteria for Pain Management - Anesthesiology can apply to become Fellows of the American College of Pain
Medicine (ABPM) if they meet the following requirements: (1) currently certified by one of the member Boards of the
American Board of Medical Specialties (ABMS), (2) two years in the practice of Pain Medicine, (3) an unrestricted license
to practice medicine in one of the 50 states.
1. Adjuvant Agents for Managing Chronic Pain, Amy L. Whitaker, PharmD; Daniel T Kennedy, PharmD BCPS; Ralph E Small,
PharmD PCCP PASHP PAPhA, American Pain Society BULLETIN, March/April 1999- Vol 9, #2.
2. Foley, KM, (1994), Pain management
in the elderly. In WR Hazzard, EL Bierman, JP Blass, WH Ettinger & JB Halter (Eds.), Principles of geriatric medicine
and gerontology ( 3rd ed., pp. 317-331) New York: McGraw Hill.
3. Meyer, RA; Campbell, JN; & Raja, SN;
(1994) Peripheral and neural mechanisms of nociception. In PD Wall & R Melzack (Eds) Textbook of pain ( 3rd
ed., pp 13-44) New York: Churchill Livingstone.
4. Bennett, GF (1994) Neuropathic pain. In PD Wall & R Melzack (Eds.),
Textbook of pain (3rd ed., pp 201-224) New York: Churchill Livingstone.
5. Craig, KD (1994) Emotional
aspects of pain. In PD Wall & R Melzack ( Eds.), Textbook of pain (3rd ed., pp 261-274) New York: Churchill
6. Montauk, SL; and Martin J; (1997) Treating chronic pain, American Family Physician, 55(4), 451-460.
Onghena, P; & Van Houdenhove B; (1992). Antidepressant induced analgesia in chronic nonmalignant pain: A meta-analysis
of 39 placebo-controlled studies. Pain, 49-, 205-219.