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THIRTEEN THINGS YOUR HEALTH INSURER

DOESN'T WANT YOU TO KNOW

Do you ever feel that when it comes to your health plan the deck is stacked against you? That's because there are plenty of things your health insurer doesn't want you to know. Here are just 13 of them.

1. It is sometimes cheaper to let you die rather than to treat you for a serious condition.

Health insurers don't deny care, they deny payment for the care, which usually amounts to the same thing. They deny payment because it saves them money. These denials sometimes cause patients' deaths. Sound outrageous? Consider the statement below. It's an excerpt from the May 30, 1996, testimony given before the United States House of Representatives by Dr. Linda Peeno, a former HMO medical director and medical claims reviewer for Humana and Blue Cross and Blue Shield of Kentucky. Peeno is now a medical-ethics consultant and managed care whistleblower.

"I wish to begin by making a public confession: In the spring of 1987, as a physician, I caused the death of a man. Although this was known to many people, I have not been taken before any court of law or called to account for this in any professional or public forum. In fact, just the opposite occurred: I was "rewarded" for this. It bought me an improved reputation in my job, and contributed to my advancement afterwards. Not only did I demonstrate I could indeed do what was expected of me, I exemplified the "good" company doctor: I saved a half million dollars!

Whether it was nonprofit or for-profit, whether it was a health plan or hospital, I had a common task: using my medical expertise for the financial benefit of the organization, often at great harm and potentially death, to some patients. . . . I am the evidence that managed care is inherently unethical, in the areas of both medicine and business. Had my experiences been the result of merely local aberrations, I would not have had anything to do for the past six years. On the contrary, I discovered that my experiences are standard practice and quite ordinary for the managed care business."

But the Health Insurance Association of America (HIAA) says doctors are "actually more likely to face financial incentives encouraging them to provide high-quality care and high productivity rather than those that might be expected to reduce the amount of care they provide."

2. Health insurers routinely hide benefit exclusions.

Health insurers make their covered benefits as narrow as the market allows and routinely redesign benefits to control their highest costs, according to Peeno. They also use disingenuous policy language to "hide" exclusions in not-very-plain sight.

For example, some dental plans cover accidental injury to your teeth. So if you bite down on a hard candy and your tooth partially crumbles, you believe the insurer will pay to fix it. But you're in for a rude awakening when you submit your claim and it's denied weeks later. That's when you discover the policy's "definition of terms" section states in fine print: "Injury to the teeth while eating is not considered an accidental injury."
The HIAA says that while health plans and insurance regulators make every effort to ensure that insurance contracts are clear, "understanding them does require a significant degree of effort" on the part of the consumer.

3. Health insurers don't really want you to understand how your health plan works.

Health insurers use marketing that enhances the attractive elements of a plan, but they don't disclose potential plan problems. Most group health insurance members have no idea of their exact coverage limits or rules of their plans until after the open enrollment period when they receive their benefit booklets.

Even then, the benefit booklets don't fully reflect the contract between the members' employer and the health insurer. The seeds of some of the most common claims problems are sown when employers purchase health insurance for their employees, according to Maria K. Todd, president and CEO of HealthPro Consulting Consortium Inc., a private managed care consulting firm in Aurora, Colo. Todd says most employers use health insurance brokers to whom they give a list of desired benefits. The broker, in turn, identifies insurers that offer affordable plans with those benefits. Once the employer selects an insurer, the broker hands the employer a contract to review and sign.

According to the HIAA, "all the disclosure in the world won't help if people don't take the time necessary to be careful shoppers." The association urges "health insurance purchasers" (including consumers and insurance brokers for employers) to make sure they know what they are buying before they make any major health insurance purchase.

4. Health insurers employ "phantom networks."

Did you ever try to switch primary care physicians within your plan's provider network only to find out with each phone call that many of the doctors named on the provider list are not accepting new patients? Then you have fallen prey to a health insurer that uses a "phantom network," a directory filled with doctors who are no longer with the plan or who are not taking new patients. Health insurers leave the names on the list to make it look they have more doctors available to health plan members.

The New York Attorney General's Office, for example, is currently investigating health plans that list physicians as participants even when the doctors are not taking any new patients.

HIAA says the problem is that printed booklets that list a plan's participating doctors can quickly become out of date. Instead of relying on printed materials, visit your plan's Web site where there is usually a more up-to-date listing. "Health plans are interested in serving their members in order to keep them — not in antagonizing them," says HIAA.

5. Health insurers can make you "split" your pills.

You may be surprised one day when you fill your prescription and discover a pill splitter inside the bag along with a bottle of larger-dose pills that you must cut in half. Mandatory pill splitting has been condemned by the American Medical Association (AMA), the American Society of Consultant Pharmacists (ASCP), and the American Pharmaceutical Association (APhA) due to the health risks involved. These include the chance that patients will divide the pills unevenly and wind up taking incorrect doses or, because some suffer from cognitive impairments, they may forget which pills they must split.

Six California Kaiser Permanente patients and one doctor formerly under contract with the HMO are currently suing Kaiser for allegedly forcing its members to split pills. The lawsuit alleges the practice allows Kaiser to profit because smaller-dose versions of some prescription pills cost Kaiser almost as much as larger-dose versions of the same pill.

Kaiser spokesperson Beverly Hayon calls the charges "bogus" and says that pill splitting is purely voluntary and only encouraged for a handful of drugs — and then only for those patients who would not be adversely affected by an imprecise dose. "Kaiser does not have a mandatory pill-splitting policy," says Hayon. "No way. No how."

6. Health insurers will go after your auto insurance settlement.

You're probably not aware that it's perfectly legal in most instances for health insurers to place a lien on any third-party settlement money you get from an auto insurer after an accident. This practice is known as "subrogation," which simply means "substituting one for another."

Health insurers are allowed to recoup the cost of your medical care from the settlement you receive from the person who injured you. For example, if your auto accident medical expenses total $5,000 and you win a $10,000 settlement, your health insurer can take half — but only if its "rights of recovery" are spelled out in your plan agreement or summary of benefits.

7. Health insurers purposefully delay paying claims in order to maximize their profits.

Although 46 states have prompt-pay laws, those laws apply only to "clean claims," or claims submitted to them without any missing or wrong information. The problem is, according to Peeno; health insurers create a maze of payment-submission rules that guarantee there will be many "technical" denials for missing information or failure to follow the convoluted claims-submission procedures.

Why do insurers drag their feet on paying claims? Your premium money is invested in interest-bearing accounts. An insurer delays remittance until the interest in these accounts is sufficient to pay the accumulated claims without cutting into the insurer's profit margin. Medical ethicists such as Peeno say "growing" the money isn't a questionable business practice, but the deliberate denial and/or slow payment of claims is. The problem is widespread. Last year, Texas Insurance Commissioner Jose Montemayor slapped 17 health insurers with fines totaling $9.2 million for violating the state's prompt-pay law and lawsuits have been filed across the country by doctors charging slow payment of claims by health insurers.

The HIAA disputes Peeno's allegations: "Each time a claim has to be handled, the administrative costs for that claim increase, and these increased costs would quickly outweigh any benefit to be realized by 'growing' the money as alleged by Ms. Peeno."

TOP 10 INCOME SOURCES FOR LAYOFF VICTIMS

$25 million a pop.
4. Have rock star and celebrity pals throw you a benefit concert.
3. One word: TUPPERWARE.
2. Harvest own stem cells for sale to scientists.
1. Pass go, collect $200.

8. Your doctor isn't calling the shots.

Do you know whose guidelines your health insurer follows when approving the length of your hospital stay? Your doctor, right? Wrong. Your insurer is most likely using guidelines developed by an actuarial consulting firm such as Milliman & Robertson. The problem is: Many doctors complain that Milliman & Robertson's recommended hospital stays are dangerously brief.

For example, Milliman & Robertson data state that the "target" hospital stay for meningitis (an infection of the covering of the brain and the spinal cord) is three days. Many physicians say this is outrageously short and that the average length of hospital stay for meningitis is a week or more.

The use of Milliman & Robertson data to limit patients' care (and increase revenue) is just one of the allegations brought forth in a lawsuit filed by the state medical associations of California, Georgia, and Texas in U.S. District Court in Miami that accuses a nine health plans (Aetna Inc. and its Prudential unit, CIGNA Corp., Coventry Health Care Inc., Foundation Health Systems, Humana Inc., PacifiCare Health Systems, United Health Group, and WellPoint Health Networks) of violating federal racketeering laws.

The HIAA says that the Milliman & Robertson guidelines are adjusted on a case-by-case basis depending upon the condition of the patient, and when problems arise "it is often the result of doctors not adequately explaining the special circumstances that make a longer stay necessary."

9. You don't have to pay out-of-network charges when they're not your fault.

There are times when you've played by all the HMO rules and you still wind up with a bill for out-of-network charges. But is it your responsibility to pay the doctor's fee for an out-of-network radiologist who read your hospital X-ray because no in-network radiologist was available? No, you most certainly do not. A patient can do nothing more than to select an in-network primary care physician and in-network hospital, according to Dr. Harvey Frey, director of the Health Administration Responsibility Project in California. Other than that, you have no control of who else gets involved with your care within the hospital setting.

If this happens to you, raise a ruckus. Appeal the insurer's payment decision. File an official complaint with your state insurance department. You can find the contact information for your department by selecting the state in which you live from the pull-down menu at the top of this page. Ask the department to investigate the insurer's tactics.

10. Health insurers make a fine distinction between "emergency" and "urgent" care.

Your health insurance policy most likely contains a clause that states you will not be billed for emergency room services if those services are eligible under "The Prudent Layperson Standard" for emergency room visits. These visits have been defined as medical, maternity, or psychiatric emergencies that would lead a "prudent layperson" (an average person) to believe that a serious medical condition exists or the absence of immediate medical attention would result in a threat to the person's life, limb, or sight. This includes situations where an individual is in severe pain.

But in some health plans, conditions such as a broken hip are not classified as conditions that require emergency care. They are classified as "urgent" conditions and you must call your primary care physician to get authorization to visit the emergency room.

11. Health insurers don't want you to know how they come up with their prices.

Would you shop at a grocery store where none of the merchandise had price labels? Of course not, but many health insurers use a pricing practice known as "UCR," which stands for "usual, customary, and reasonable," to determine how much of a claim they will pay. As the name says, these charges are supposedly the "going rate" that health care providers in your area charge.

But you can't get their UCR prices to dispute your claim or compare plans. They're secret. Even court orders have done little to force insurers to supply the formulas that they say they use to devise UCR rates, claiming it's "proprietary" business information.
"Publishing this type of information would lead to providers gaming the system to raise fees, thus eliminating any competitive market forces that may influence providers' fees," according to the HIAA. "This would result in even higher costs for health care services."

According to the HIAA, the insurance industry voluntarily developed the external review process (subjecting claims determinations made by a health plan to review by external experts) in an effort to address the concerns of health plans, consumers, and doctors regarding the appropriateness of experimental and investigational procedures.

13. Health insurers don't want you to know that some of their practices violate laws.

Although 46 states have prompt-pay laws, insurers still violate them flagrantly enough to set off lawsuits and insurance department investigations that often lead to fines. The majority of these are settled quietly. And then the cycle begins again.

Insiders say what health insurers really fear are the massive class action lawsuits that ask the courts to force the insurers to repay all the money they have gained from these practices. One of these lawsuits is currently being played out in a Miami courtroom where 600,000 doctors are taking a stand against nine of the nation's top health insurers.

On May 9, 2001, Judge Federico Moreno ordered full discovery in the lawsuit, a ruling that requires each party to request information and documents from the other side in an attempt to "discover" facts relevant to the case. At the time of Moreno's discovery ruling, Rocky Wilcox, the general counsel for the Texas Medical Association, promised the order "will rip back the curtain and expose to the American public all the dirty tricks these HMOs play every day."

HIAA says lawsuits threaten access to health care. "Lawsuits only serve to drive up the cost of health insurance by channeling scarce health care dollars into the pockets of trial lawyers and away from patient care."

GREAT ARTICLE!

"When my grandmother got arthritis, she couldn't bend over and paint her toenails anymore. So my grandfather does it for her all the time, even when his hands got arthritis too. That's love." Rebecca - age 8

"When someone loves you, the way they say your name is different.
You know that your name is safe in their mouth." Billy - age 4

"Love is when a girl puts on perfume and a boy puts on shaving cologne
and they go out and smell each other." Karl - age 5

"Love is when you go out to eat and give somebody most of your French
fries without making them give you any of theirs." Chrissy - age 6

"Love is what makes you smile when you're tired." Terri - age 4

"Love is when my mommy makes coffee for my daddy and she takes a
sip before giving it to him, to make sure the taste is OK." Danny - age 7

"Love is what's in the room with you at Christmas if you stop opening
presents and listen." Bobby - age 5

"Love is when you tell a guy you like his shirt, then he wears
it everyday." Noelle - age 7

"Love is when mommy sees daddy smelly and sweaty and still says
he is handsomer than Robert Redford." Chris - age 8

Love is when your puppy licks your face even after you left
him alone all day." Mary Ann - age 4

"I know my older sister loves me because she gives me all her
old clothes and has to go out and buy new ones." Lauren - age 4

"I let my big sister pick on me because my Mom says she only picks
on me because she loves me. So I pick on my baby sister because I love
her." Bethany - age 4

You really shouldn't say 'I love you' unless you mean it. But if you mean it,
you should say it a lot. People forget," Jessica - age 8

"There are two kinds of love. Our love. God's love.
But God makes both kinds of them." Jenny - age 4

Equally important, those who help the needy whether in government or non-profits will be able to identify more easily if a Veteran is better served by the Veterans Affairs Department or some other program," said Associate Director for Information Technology and E-Government Mark Forman.

GovBenefits is the new government web site that will serve as a single, online source for information on government benefits. It will help users access eligibility information through an easy-to-use online screening tool that asks basic questions about items such as income, marital or employment status, and family size. Based on user responses, information is then provided about the programs for which users may be eligible. The site also provides general descriptions and contact information for federal benefit programs.

The site currently offers information on about 55 programs. More programs will be added to the site in the future.

E-government is an integral part of the President 's Management Agenda to make it easier for citizens and businesses to interact with the government, save taxpayer dollars and streamline citizen-to-government transactions

It was late one Tuesday evening,

Before a mother could sit down,

To tell her only child about

The terror that hit downtown.

She looked into the eyes of her son

God, she loved him so,

She felt her heart begin to break

And the hurt begin to show.

She gathered all her strength and courage,

as her story she began to tell.

"Baby don't cry, but I'm afraid daddy

Might be under a building that fell."

The boy looked back at his mother,

His eyes made not one blink.

And the mother's tears began to fall.

What would her baby think?

You see, his dad is a firefighter,

And his hero from the day of his birth.

He loved his dad more than anything else

That could ever inherit this earth.

The mother's head began to drop,

Her forehead resting on palm.

She thought her son would be upset.

Instead, he was very calm.

The boy leaned over towards his mom,

And put his hand upon her head.

In her ear he began to whisper,

And this is what he said:

"Mommy please don't cry,

I knew daddy wasn't coming home.

I talked to him just a while ago,

But it wasn't on the phone.

He told me that he loved me,

And he promised we'd meet again.

He told of his new home,

And the job he was to begin."

"God is building an army,

And there are many angels needed.

That, is where daddy and the others went.

They weren't all defeated."

It was then, the mother lifted her head.

The tears streamed down her face.

And she could feel her husband's presence,

As it filled her heart with grace.

It was then she knew her son was right.

He was in God's great army now.

She also knew her son was safe,

That he'd be kept from harm somehow.

So, evil-doers of the world beware.

An army is on the way.

Bolstered by new angels,

Who left the towers that day.

Their commander has never been beaten.

His power has never been matched,

And if evil thinks He was almighty before…

Well, the surface has just been scratched!

Dear Son,

The other day I went up to a local Christian bookstore and saw a "honk if you love Jesus" bumper sticker. I was feeling particularly sassy that day because I had just come from a thrilling choir performance, followed by a thunderous prayer meeting, so I bought the sticker and put it on my bumper. Boy, I'm glad I did! What an uplifting experience followed!

I was stopped at a red light at a busy intersection, just lost in thought about the Lord and how good He is... and I didn't notice that the light had changed. It is a good thing someone else loves Jesus because if he hadn't honked, I'd never have noticed!

I found that LOTS of people love Jesus! While I was sitting there, the guy behind started honking like crazy, and then he leaned out of his window and screamed, "For the love of GOD! GO! GO! Jesus Christ, GO!"

What an exuberant cheerleader he was for Jesus! Everyone started honking! I just leaned out of my window and started waving and smiling at all these loving people. I even honked my horn a few times to share in the love!

There must have been a man from Florida back there because I heard him yelling something about a "sunny beach"... I saw another guy waving in a funny way with only his middle finger stuck up in the air. I asked my teenage grandson in the back seat what that meant, he said that it was probably a Hawaiian good luck sign or something. Well, I've never met anyone from Hawaii, so I leaned out the window and gave him the good luck sign back. My grandson burst out laughing ... he was enjoying this religious experience, too!

A couple of the people were so caught up in the joy of the moment that they got out of their cars and started walking towards me. I bet they wanted to pray or ask what church I attended, but this is when I noticed the light had changed.

So, I waved to all my sisters and brothers grinning, and drove on through the intersection. I noticed I was the only car that got through the intersection before the light changed again and I felt kind of sad that had to leave them after all the love we had shared. So I slowed the car down, leaned out of the window and gave them all the Hawaiian good luck sign one last time as I drove away.

Praise the Lord for such wonderful folks!

Love, Grandma

Toshimitsu Kitajima. Kyoko Saito*, Shinsuke Hamaguchi*, Masa-hiro Omoto*, Mutsuo Mishio*, Yasuhisa Okuda, First Dept of Anesthesiology, Dokkyo Univ School of Medicine, Mibu, Tochigi 321-0293,Japan

Aim of Investigation: Complex Regional Pain Syndrome (CRPS) often occurs after a trauma, but CRPS type 1 following traffic accidents is rare. We report four patients who developed CRPS type 1 following car collisions.

Methods: Four patients, one male and three females, felt persistent pain in the neck, shoulder and upper extremity after car collisions. They were treated by orthopedists but their pain was not relieved. They experienced coldness, cyanosis, hyperalgesia, edema, sudo-motor disturbance, or allodynia in the unilateral upper extremity one week to two months after the accidents. They continued treating with medication and rehabilitation therapy, but their symptoms did not improve. They were referred to us 5 months to 2 years after the accidents.

Results: They were diagnosed as having CRPS type 1 in accordance with the diagnostic criteria. MR imaging revealed that three patients had cervical disc herniation. One patient was normal on cervical X-ray and MR images. Consecutive stellate ganglion blocks (SGBs) with local anesthetics were performed to improve their symptoms.

Conclusions: Minor injury around the cervical region after a traffic accident may induce increased sympathetic tone, followed by CRPS type 1. SGBs gradually decrease the symptoms.

Heinz Konrad. Physician of the Pain Therapy and Palliative Care Service of the Central Hospital of the Santa Casa de Sao Paulo. Sandra M.C.M. Coeli, Chief of the Pain Therapy and Palliative Care Service of the Central Hospital of the Santa Casa de Sao Paulo Largo Como 330, Sao Paulo, 04922-130, BRAZIL

Aim of Investigation: 1) verify the efficacy of the therapy programs employed; 2) see if there is any correlation between the studied parameters and the obtained pain reduction; 3) critically evaluate the therapy applied.

Methods: We studied 30 randomly selected patients suffering from RSD, who have been treated and followed in our Service over a period of 15 years (Jan. 1982 to Jan. 1997). Results: We found that, regarding RSD, our Service has results similar to those of other pain services in the world who deal with this pathology. We could not detect any correlation between the several parameters studied and the result of pain reduction.

Conclusions: We conclude that regarding the exact knowledge of the physiopathology of RSD, and its resulting rational therapeutic approach, we are still almost totally in the dark.

You only own four spices: salt, pepper, ketchup, and mustard

You design your kid's Halloween costumes to fit over a snowsuit.
The mosquitoes have landing lights

You have more miles on your snowblower than on your car.
You have 10 favorite recipes for moose meat.
You thought "Grumpy Old Men" was a documentary
The hardware store on any Saturday is busier than the toy stores at Christmas.
You live in a house that has no front steps, yet the door is three feet above the ground.
You've taken your kids trick-or-treating in a blizzard.
Driving is better in the winter because the potholes get filled with snow.

You think everyone from the city has an accent. .
You think sexy lingerie is fleece socks and a flannel nightie with only 8 buttons.
You owe more money on your snowmobile than on your car.
The local paper covers national and international headlines on one page,

but requires 6 pages for sports.
At least twice a year, the kitchen doubles as a meat processing plant.
The most effective mosquito repellent is a shotgun.
Your snowblower gets stuck on the roof.
You think the start of moose season is a national holiday.
You head south to go to your cottage.
You frequently clean grease off your barbecue so the bears won't prowl on your deck.
You know which leaves make good toilet paper. .
The mayor greets you on the street by your first name.
There is only one shopping plaza in town.
The municipality buys a Zamboni before a bus.
You find -60 a might chilly.
The trunk of your car doubles as a deep freeze. .
You attended a formal event in your best clothes, your finest jewels and your Sorels.
You can play road hockey on skates.
You can tell the difference between a chipmunk and a squirrel from 300 yards away.
Shoveling the driveway constitutes a great upper body workout.
You know the 4 seasons: Winter, Still Winter, Almost Winter, and Construction.
Submitted by Lynda!

Kann Meyer*'. Ann Kvamstrom'², Lars-OlofNordfors³, Erik Kinnman', Torsten Gordh², Ann Kristofferson', 'Astra Pain Control AB, S-151 85 Sodertalje, Dept of Anaesthesiology and Intensive Care, Univ Hospital, Akademiska Sjukhuset, S-751 05 Uppsala, 'Dept of Anaesthesiology and Intensive Care, Danderyd Hospital, S-182 88 Stockholm, Sweden.

Aim of Investigation: To investigate the interference of chronic peripheral neuropathic pain (PNP) on quality of life (QoL).

Method: A cross sectional observational study in 126 PNP patients treated at pain clinics in Sweden. Efficacy of current treatment and reasons for discontinuation of previous treatments were recorded. The intensity of pain at rest as well as movement, touch and cold evoked pain was assessed using a visual analogue scale (VAS, 0-100). A 7-graded verbal scale was used to study 25 pain and side effect related symptoms. Health related QoL was evaluated using SF-36, Nottingham Health Profile and a Health Rating Scale (VAS, 0-100).

Result: Only 40% of previous treatments provided pain relief. For these patients, the reason for discontinuation was insufficient effect in 41%, severe side effects in 39% or both in 19%. A majority of patients had tried several treatments. The efficacy of current treatment was also poor. The median VAS score for pain at rest was 40, movement 53, touch 34 and cold 41. The type of pain that was most intense varied between patients. Difficulty to sleep, lack of energy, drowsiness, difficulty to concentrate and dry mouth were the most bothersome symptoms. All dimensions of SF-36 and NHP were significantly impaired. Employment status was reduced due to pain in 52% of the patients.

Conclusions: Limited clinical efficacy and tolerability of neuropathic pain treatment causes a substantial impairment of QoL. In evaluation of treatment efficacy, the impact on QoL should be assessed in addition to pain intensity measures.

T. Nagaro. S. Abe*, S. Kimura and T. Arai, Dept. ofAnesthesiol-ogy and Resuscitology, Ehime Univ., Ehime, 791-0295, Japan

Aim of Investigation: We investigated to find which neuropathic pains and patients respond well to intravenous lidocaine.

Methods: After obtaining informed consent, 115 patients with neuropathic pain were enrolled in this study. The pain severity (PS, range 0-10) was measured 1 min., 5 min., 15 min. and 35 min. after 1.5 mg/kg of lidocaine was administered intravenously over 1 min. The percentage of pain relief was calculated from the lowest PS. "Good" was defined when pain reduction was over 50 % and "poor" when it was below 50%. We investigated differences in pain relief accounting for differences in age and sex, site of the nerve disease, and pain characteristics (severity, duration and nature).

Results: Eighty-one of 115 (70.4%) patients experienced "good" pain relief. For peripheral nerve disease, 70 of 90 (77.8%) patients experienced "good" pain relief, which was higher than that from central nerve diseases (44.0%). Forty-seven of 58 (81.0%) patients with pains of PS below 5 experienced "good" pain relief, compared to 58.2% who had pains of PS above 5. Seventy-three of 95 (76.8 %) patients over 50 years old experienced "good" pain relief, compared to only 40 % of those below 50 years old. There were no differences for other characteristics.

Conclusions: This study suggests that the patients with the peripheral nerve diseases and mild or moderate pain and older patients benefit the most from IV lidocaine.

Setsuro Ogawa. Jitsu Kato, Shigeru Saeki, Takashi Nakamura, Takahiro Suzuki, Miho Kashiwazaki, Surugadai Nihon Univ Hospital Dept. ofAnesthesiology, Tokyo, Japan

Aim of Investigation: To investigate the mechanisms ofneuro-pathic pain syndromes by pharmacological test, drug challenge test (DCT), in application of treatments.

Methods: Physiological saline (as a placebo) was followed by a test drug (phentolamine, thiamylal, lidocaine, morphine or ketamine) after 5 minutes from administration of physiological saline and VAS was observed every 1 and 5 minutes. If VAS did not become zero, supplemental administration was performed in every 5 minutes up to 2 times (maximum 3 times).

Results: The results were summarized as follows; 1) Phentolamine positive in 32 out of 92 patients. 2) Thiamylal positive in 39 of 86 patients. 3) Lidocaine positive in 28 of 65. 4) morphine positive in 26 of 32. 5) Ketamine positive in 40 of 65. Relationship between the results of test and the efficacy of treatment used according to the results of DCT showed that there were a vourious responses to the subsequent treatments.

Conclusion: Mechanisms of neuropathic pain should be considered when adequate treatments are intended to apply because the mechanisms are thought to be different in each patient with neuropathic pain. DCT is one of the useful procedures for assessment of the mechanisms of pain.

5) It gets late early out there. Yogi Berra (on Yankee Stadium in the fall)

Renato Verdugo. Jose Ochoa, Univ. de Chile and Good Samaritan Hospital, Portland, OR 97210

Aim of Investigation: Delineate nature and mechanisms of movement disorders in Reflex Sympathetic Dystrophy (Complex Regional Pain Syndrome I, CRPS I) and Causalgia (CRPS II).

Methods: Patients (58) fulfilling diagnostic criteria for CRPS and displaying abnormal movements underwent comprehensive clinical and neurophysiological evaluation of central and peripheral motor, sensory and autonomic systems and investigation of their symptoms through placebo controlled diagnostic blocks.

Results: There was no patient whose chronic pain and movements could be attributed to overt nerve injury (CRPS II). All were diagnosed as CRPS I. They presented spasms (35 patients), coarse tremor (9), irregular jerks (5), choreiform movements (1) or combinations of the above (8). Abnormal movements were characteristically bizarre.

Remarkably, in addition to lack of evidence of nerve injury, the patient's central motor and sensory pathways also responded normally to rigorous neurophysiological testing. Additionally, all patients displayed one or more signs of psychogenic dysfunction in relation to their painful neurological display, including:

1. muscle weakness due to interrupted willful drive (Emg)

2) disappearance of abnormal movement with distraction,

2. extreme fluctuations in the distribution and character of movements,
3. abolition of the movements with placebo,
4. relief of muscle weakness by placebo,

6) non-anatomical cutaneous hypoesthesia,

7) reversal of hypoesthesia through inert or active placebo effect,

8) normal two point discrimination threshold in spite of profound tactile hypoesthesia,

9) cure with psychotherapy in three patients and

10) documentation of malingering in two.

Conclusions: Prior etiologic hypotheses pointing at psychogenesis behind these abnormal movements are supported by the present study which, in addition, highlights the pseudo-neurological character of the sensory and motor symptomatology in these patients.

We asked 809 RSD patients this question. Here are some more of their answers. I am sure some of you will see yourself in many of them J

1) There are many people that have RSD. Each individual has a different area of involvement, level of pain, and different meds/treatments may be needed for each case. We are not crazy and are not hypochondriacs. Our pain is very real! The more the public knows about RSD the better chance of research for a cure and early diagnosis which is imperative. Also, RSD patients are looking for empathy not sympathy. We want support and understanding not attention

He’s rail thin, and he walks—carefully and slowly—with the aid of a wooden cane. He’s 42, but he looks frail. He looks as though he’s in pain.

Stephen Spagnoli has Reflex Sympathetic Dystrophy Syndrome, or RSD, an incurable, chronic illness. "It’s like having sciatica in all your extremities," he said, "and on top of that, having a full-body sunburn, plus pneumonia."

He can tell you how there were times that he couldn’t dial a telephone, he couldn’t light a match, he couldn’t bear to wear clothes, how he soaked in the bathtub for three days at a stretch, not even getting out to sleep.

But you’ll understand it better if you can see his pain. Look at the picture he’s painted. It’s called "Thermosystemic,’ and it’s his personal ode to RSD, the disease that won’t let him go. Against the black background rise razor-sharp spikes, representing nerve endings on fire emitting blood-curdling screams. It hurts to look at it. It hurts to look at Spagnoli.

"It’s almost like you’re terminal," he said, "like you’re dying, but unlike death, it is never ending." It is through paintings such as "Thermosystemic," which alludes to a test that RSD patients undergo, that Spagnoli hopes to make the world aware of the disease that has so changed his world. Although his mixed-media paintings, some of which incorporate medications and medical paraphernalia, are specifically about his own fight with the disease, they are meant, he said, to chronicle the pain experienced by all RSD sufferers.

Spagnoli’s own story starts in 1996. He was a community service facilitator at a Brooklyn high school, coordinating teenage volunteers. Right after he moved into his Flushing home, he came down with a mysterious ailment that would finally be diagnosed as RSD, the poorly understood and often unrecognized multi-symptom, multi-system syndrome that usually affects one or more extremities or even the entire body. According to the Reflex Sympathetic Dystrophy Syndrome Association of America, the disorder is common, affecting about 5 percent of those who suffer physical injuries, and dates back to Civil War times.

"I had ripped out all the carpets in the house, and I had gotten repetitive stress injury in my elbow,’ he says. "Then one day I threw a newspaper into the car—it was the Sunday New York Times, so it was heavy—and my right arm burned from my shoulders to my fingers. Then my left arm did the same."

Before he knew what he had, the pain had started to spread and had become unmanageable. His weight went from 145 to 112. "It’s like my nervous system was being hijacked," he said, adding that he became super-sensitive to everything in his environment.

Through the years, he went to several doctors and tried several treatments, everything from steroids to self-hypnosis. Now, he takes injections of Buprenex—sometimes two or three a day—to ease the pain. "The drug is my only pain relief," he said. "I have to be very careful about everything. A twisted ankle could set it off. Moving my paintbrush, sometimes I have to stop after a couple of hours. I’m susceptible to colds."

It is only through his painting and the support of his wife, Karen, and daughters Dana, 10, and Maya, 7 that he has come to grips with RSD. "Art was always my refuge. I began it as therapy, and it became a narrative, it became a story," he said, adding that he turned his basement into his studio/therapeutic center. "I wanted to convey the experience as much as possible, but I didn’t want to scare people away."

The artwork, which he describes as "lyrically abstract" and which looks like Damien Hirst on tranquilizers, incorporates RDS-related items. Some are collages that include syringes, iodine—which is used to clean the side of the injections—and Epsom salts.

It is his hope that the works will be publicly displayed for educational purposes. "RSD is curable, reversible in the first 60 days," he said, adding that he also is writing an autobiographical book about the disease titled "The Third Fire." "But doctors are not trained to recognize it until it is clinically observable, and by then, it is too late."

Although he is working on other non-RSD projects, including a comic strip that he hopes to syndicate, his RSD art is his priority. He doesn’t want to sell the paintings; he simply want to exhibit them to send a message. Again, he studied the searing "Thermosystemic," noting that at the very tips of those nerve endings, he has painted a pleasant blue sky. "That cool area, I guess, symbolized hope," he said as he picked up his wooden cane again.

For more information on Stephen Spagnoli’s RSD artwork, call 718-460-6818,

Source: Queens Neighborhoods section of New York Newsday, May 8, 2002.

If you have a poem to share on our website, a Medical Article, some humor for our humor page, events coming up for your group, etc., send it to the same place J

If you are interested in a little excursion on Sunday morning to visit the Lighthouses in and around Portland via shuttle bus please let us know. Right now we do not know the cost but expect it to be around $20 per person. If we have enough interest by August, we will set it up!

We now have two brand new awareness items available. One is the

This beautiful patch is 2 1/2 inches by 4 1/2 inches and is designed to compliment the RSD Awareness Pin. In small gold letters across the top it says REFLEX SYMPATHETIC DYSTROPHY and across the bottom it has the web site and on a white background, in the center of the pin, a large red flame, the same logo as the Awareness Pins, and can either be pressed on or sewn on hats, jackets, back packs etc.

We anticipate that they will generate questions about RSD from the people who see it, and at the same time provide the place to get answers www.RSDHope.org As with the pins, ALL PROFIT from the sale of these patches will go to the "Hope For Tomorrow" Research Fund.

the other new item is the

The shirt has a small logo (3 1/2 by 4 inches) on the front just below the left shoulder it has the logo "Burning For A Cure" in red. It is the same as the white short sleeve T-shirt only much smaller logo. They are really sharp and should stimulate questions about RSDS.

The Long sleeve T-Shirts are available in Small, Medium, and Large ______________ @ $20 each And 2X Large ____________ @$22 each

This is a one-inch oval pin. It is red, white, and gold. We hope it will become the National Symbol for RSD much the same way other diseases use ribbons. It is beautifully done.

In small gold letters across the top it says REFLEX SYMPATHETIC DYSTROPHY and across the bottom it has the web site and on a white background, in the center of the pin, a large red flame.

The cost is $5.00 per pin including shipping. ALL PROFITS from the sale of these RSD Pins will go into the "Hope for Tomorrow" Research Fund

Number of pins ___________ @ $5.00 each _____________

KEY CHAINS $4.00 EACH _____________Quantities Limited

BROCHURES ___ 10 Brochures for $4.00 ___ 20 Brochures for $7.50 ___ 50 Brochures for $18.00

"Burning for a Cure" Color - WHITE - Quantity; Medium ___ Large ___ Extra Large ___2X____

" Help Put Out the Flame" Color - RED Quantity: Medium ___ Large ___ Extra Large ___2X____

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"Burning for a Cure" Logo, Color – WHITE Quantity: Medium _____ Large ___ Extra Large ___ 2X ___

"Help Put Out the Flame" Logo, Color - RED Quantity: Medium ___ __Large ___ Extra Large ___ 2X ___

DRAGON FULL COLOR SWEATSHIRTS Quantity: Medium ___ Large ___

Extra Large ___ 2X ___

RSDS SURVEY PACKET __________ $15 each Packet, includes Survey and all three Supplements.

RSDHope SEMINAR 2001 VIDEO SET ______ ($50 each) Video Set delivered Priority mail.

RSDHope PENS_____ $2 each Large Barrel, rubber grip, logo and website printed on side. Very Kewl.

TOTE BAG _____ $12 each, with RSDHope Logo & "Burning for a Cure"

*DONATIONS are accepted in any amount

$____________________________

____________ Total number of items ordered

$____________ Total cost of ORDER

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Volume 7 * Issue 2 * SUMMER 2002 © 2002