thank you! - Reflex Sympathetic Dystrophy Association of America

Volume 20, Issue 3
R e f l e x S y m p a t h e t i c D y s t r o p h y S y n d r o m e A s s o c i a t i o n
in this issue:
1 Thank you! Thank you!
2 News from the Patient
Representative
3 Thanksgiving
4 RSDSA News
6 Mailbag
9 When RSD Hits
a New Phase
10 Cognitive Behavioral
Therapy for CRPS
Participants gather at the Mall of America in Minneapolis to raise awareness of RSD.
Thank you! Thank you!
By James W. Broatch, MSW, Executive Director
12 The Use of Opiods in
CRPS-related Pain
14 Opiods for CRPS?
Think again.
16 How to Avoid Firing
Your Lawyer
18 Donations
This newsletter is not intended
to provide advice on personal
medical matters, or to substitute
for consultation with a physician.
On behalf of the Board of
Directors of the Reflex
Sympathetic Dystrophy
Syndrome Association and staff, I want to
thank everyone who donated to help fund
our educational program for occupational
and physical therapists. Together we
raised more than $50,000! We are in
the process of signing a contract for the
production of the DVD this month.
We asked our membership to consider
making at least a $5 gift: 557
individuals responded (more than 9
percent of our membership). Donations
ranged from $1 to $10,000. Bernie
Ackerman of Bethlehem raised $5,000
by running a ½ Marathon of Hope on
behalf of his 15-year-old daughter Liz,
who developed CRPS while playing
baseball for her high school.
Jeanie Moser from Missouri wrote
“Having had RSD twice now, in
both of my hands, I am so grateful
for my OT therapist. I literally would
not be able to use my left hand if he
had not worked with me. He did his
own research. It was a painful time,
but it worked.”
(Continued on page 3)

Board of Directors
James E. Tyrrell, Jr. Esq.
Chairman of the Board
Paul Charlesworth, CPCU
President
Mary Beth Kenny Ludington
Patient Representative/Secretary
Donald F. McKee
Treasurer
Rebecca C. Amoroso
Bradley S. Galer, MD
Wilson H. Hulley
Disability Advocate
Linda Lang
Pierre LeRoy, MD
Donald C. Manning, MD, PhD
Betty Maul
Peter A. Moskovitz, MD
Idamarie Scimeca Duffy
James W. Broatch, MSW
Executive Director and Newsletter Editor
Tel: (203) 877-3790
Toll free: (877) 662-7737
Email: info@ rsds.org
RSDSA website
www.rsds.org
Newsletter Managing Editor:
Debra Nelson-Hogan
Email: Newsletter@rsds.org
Editorial Assistant:
Katie L. Aker
RSD has been assigned the code
number 337.2. It has been classified
into four categories:
(1) 337.20 – unspecified site
(2) 337.29 – other specified site
(3) 337.21 – upper extremity
(4) 337 – lower extremity
How to give to RSDSA through the United Way
RSDSA is a partner in the combined
Federal campaign. Our designation
number is #11045.
Working to raise awareness of reflex
sympathetic dystrophy syndrome
(RSD) and complex regional pain
syndrome (CRPS) since 1984.
As many of you know, November is
CRPS Awareness month, and this year
has been particularly jam-packed with
events. On November 6, I went to Somerset
Medical Center in New Jersey
to attend a meeting of the wonderful
support group Living with RSDS. Their
president, Sharon Weiner, had arranged
for a special guest speaker to address
the group. The speaker was Mike
Roman, a former surgical assistant,
who at 27 had knee surgery following
a basketball injury. Unfortunately, he
developed MRSA, the devastating staph
infection that has recently been in the
news. Despite multiple surgeries to remove
the infection, Mike was forced to
undergo an above-the-knee amputation.
After surgery, he developed phantom
limb pain, with many of his symptoms
similar to those of CRPS.
Mike spoke quite movingly about his
long journey of debilitating pain, depression,
financial difficulties and withdrawal
from family and friends. Feeling that
he had become a burden to his family,
he briefly considered suicide. His wife’s
support remained constant, and he fortunately
ended up at a pain specialist who
urged him to try a new type of spinal
cord stimulator. This decision proved to
be the turning point for him. A devoted
husband and father, he is now pursuing
his dream of professional racecar driving,
and is aiming for the Indy 500. His
courage and indomitable spirit were an
inspiration to all of us, and you can read
his story at raceagainstpain.com.
News From
the Patient
Representative
By Mary Beth Kenny Ludington
The next big event was the Bounty of
Hope on November 14. Always a fun
evening, it is also an important one, as
it raises both money and awareness.
Proceeds from the dinner and silent
auction fund many of RSDSA’s awareness
projects. This year’s honoree was
Dr. Joshua Prager, who utilized a PowerPoint
® presentation to graphically
depict the symptoms of CRPS to the
audience. He also described the success
of the comprehensive multidisciplinary
treatment program he directs at the
Center for the Rehabilitation of Pain
Syndromes at UCLA.
The month ended with Jim Broatch
and board member Dr. Peter Moskovitz
accepting an invitation from the Korean
Pain Society and the Korean CRPS
Association to speak at their conference.
They also visited with some of
the foremost CRPS experts in Europe
at the Neuropathic Pain Consortium
in the Netherlands. Their visit enabled
them to examine the state of emerging
research across the globe, to explore the
possibility of collaboration on a study
of the long-term effects of CRPS and to
forge important relationships with leaders
in the field in other countries. I was
tremendously impressed by the fact that
they accepted the invitation knowing
that they would have to miss Thanksgiving
with their families. That level of
dedication and commitment gives us
ALL something to be grateful for this
holiday season! n
2 RSDSA Review: Vol. 20, Issue 3

(Continued from page 1)
The Puerto Rico Occupational Therapy
Association sent $50. Your kind notes
and words of encouragement were very
heart warming. Together, we are making
a difference.
In October, the MN RSDS/CRPS Coalition
sponsored its second walk-a-thon to raise
money for CRPS research. More than 40
individuals from Minnesota, Wisconsin, and
as far away as Connecticut, participated and
thus far, we have raised more than $10,000!
I want to thank Bonnie Scherer, Linda
Loudermill, Barbara VanKeuren, and the
MN RSDS/CRPS Coalition for their hard
work and dedication.
In three major walks (two of the walks
were cosponsored with the Achilles Track
Club), RSDSA raised $40,000, a little
more than in 2006. We know that the CRPS
community has the potential for promoting
much greater public awareness and research
dollars. In 2008, we hope to raise more than
$100,000 for CRPS research. With your
help, we will succeed. n
Thanksgiving
By Paul R. Charlesworth
President, RSDSA Board of Directors
During this season of Thanksgiving and joy it is easy
to forget those who suffer in silence from CRPS. So
many go undiagnosed, untreated, undertreated,
can’t afford treatment, can’t resolve conflicts, don’t
get understanding or support from friends or family,
don’t get insurance reimbursement, get despondent
and try suicide. I want you to know how much Jim
Broatch ,our executive director, Gayle Bonavita our
administrative assistant, our entire board, and our
many volunteers around the country want to help.
Call us if you need help or if you know someone
else who does…help us with that first step of
communication.
We are a small organization, but we have grown and
we are very determined to continue with our mission
of support, information, and search for effective
treatments and a cure as soon as possible. Most
who interact with RSDSA have little sense of the
board of directors or our two wonderful full-time
employees. Their thanks is in what they accomplish
for you and the organization. During this season, I
would like to thank them and urge all of you who read
this to thank them in any way you find appropriate
as well. All of our Board members serve as day-today
workers for RSDSA, not just members of the
governing body. Most of all I would like you to know
how very motivated they are to succeed and help find
a cure. Take hope in their work and the work of the
many researchers who now work in the field of CRPS.
Last, I would like you to know that we are going in
some new directions to help. Rather than simply
reviewing research proposals submitted to us, we are
now funding a long-term research proposal with the
help of a very generous benefactor family and we are
raising money to fund conferences to help establish
the best data about incidents of CRPS and best
treatment approaches. As we expand our mission
we need your financial support and your volunteer
support more than ever. Please help us provide more
help and research…talk it up with people you know,
especially friends and family. Please accept our best
wishes for a joyous holiday season. n
Join RSDSA
People who join RSDSA are not content
to be victims, but take an active role in our goals of
education, awareness, and research. Our members
are people like you-patients, family and friends,
healthcare professionals, attorneys, and business
people who understand the devastating effects of
CRPS and want to make a difference. Your RSDSA
membership is important. There is power in numbers
and we would like to see our membership, currently
more than 7,000, double so that when we talk to
the legislature, the pharmaceutical companies,
and medical associations, our voice is strong and
our message is clear.
As a member, you have a forum to communicate your
concerns, share your experiences, and learn about
the most recent advances in treatment and research.
Fill our the membership application and join today!
Yes! I would like to be a member
and support RSDSA
❑ Patient (US) $15 ❑ Patient (outside US) $25
❑ Can’t afford membership
Name
Address
❑ Additional donation
City State Zip
Phone
email
❑ Please send me information on starting a support group.
For credit card orders, please complete:
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exp. Date
Signature
Please make check or money order in $US payable to
RSDSA. Mail your check with this form to:
RSDSA, 99 Cherry Street, PO Box 502, Milford, CT, 06460
3

RSDSANEWSRSDSANEWSRSDSANEWS
Minneapolis Walk for
a Cure
On October 29th, approximately 50
people met at 7:00 am in the Macy’s
Court at the famous Mall of America in
Minneapolis for the 2007 RSD Awareness
Walk for a Cure. Linda Loudermill,
Barbara Van Keuren, and Bonnie Scherer
organized the walk, which raised more
than $10,000.
Brian Hicks with his wife Teresa and his sons Joel (on the left), and Justin during the New York Marathon
in November.
RSDer Member of the
New York Marathon
Freedom Team
Brian Hicks, who has suffered with
CRPS for nearly 10 years, was invited
to be a member of the Freedom Team of
Wounded Veterans and participate using
a hand cycle in the New York Marathon
on November 4th. Veterans were flown
to New York from all over the country
to participate in the marathon with the
Freedom Team. Brian finished the
marathon in 2 hours and 26 minutes.
The Freedom Team is a part of Achilles,
an organization that supports athletes with
disabilities. Brian learned about the Freedom
Team through the RSDSA website’s
information on the Achilles Walks. In fact,
he was a medalist at the Achilles Walk in
Atlanta last June.
The Freedom Team consists of veterans
who range from those who were injured
in Iraq just a few months ago to those
wounded in Vietnam.
Brian was diagnosed with CRPS several
years ago, but it had gone into remission.
It returned with a vengeance after he was
involved in a HumVee accident in Iraq.
He was ultimately discharged and is
currently on disability.
Brian said the New York event was wonderful
and as an added bonus, Achilles
gave him the hand cycle he used for “as
long as he wants it.” He plans to participate
in the Miami Marathon at the end of
January and will surely be taking part in
the Atlanta Achilles Run in 2008.
Dr. Peter Moskovitz presents Chan Kim, MD, PhD,
President of the Korean Pain Society with a copy
of “Living With RSDS”, which he co-authored
with Linda Lang.
People who participated in the Minneapolis Walk
for a Cure and Awareness raised more than
$10,000 for research.
RSDSA Honored by Korean
CRPS Patients Association
In late November, Jim Broatch, RSDSA
executive director and Peter Moskovitz,
MD, a member of the RSDSA Board
of Directors, were the guests of the
Korean CRPS Patients Association at
the annual meeting of the Korean Pain
Society in Seoul. Both gentlemen gave
presentations to the Pain Society. In
addition, they met with a group of pain
practitioners and principal organizers
of the Pain Society as well as representatives
of various pharmaceutical and
medical device companies.
4 RSDSA Review: Vol. 20, Issue 3

RSDSANEWSRSDSANEWSRSDSANEWS
Rock Out To Knock Out RSD
“Imagine a day, an hour, or even a minute
without pain; that is what we are fighting
so hard for...”
This statement is true for CRPS sufferers
everywhere, but Ashley Goodall has taken
her fight into another direction. In 2006,
Ashley founded ‘Rock Out To Knock Out
RSDS, Inc.,’ a non-profit organization
meant to raise awareness and money for
CRPS research through concerts with
local bands, drawings, and donations.
Dr. Joshua Prager receives the Clinical Excellence Award from Jim Broatch.
2007 Bounty of Hope
On November 14th, a little more than
200 people gathered at the Union League
Club in New York City for the 9th Annual
Bounty of Hope Silent Auction and
Fundraising Dinner. Joshua Prager,
MD, MS, the director of the Center for
Rehabilitation of Pain Syndromes (CRPS)
at UCLA Medical Plaza, was the keynote
speaker and recipient of a Clinical
Excellence Award. Next year’s dinner is
scheduled for November 12, 2008.
Guests at the 2007 Bounty of Hope check out the silent auction items. Daria and Paul Charlesworth
chat with Barbara Schaffer during the auction.
The 16-year-old high school student from
Bakersfield, California was diagnosed
with CRPS when she was 8. Before
Ashley was diagnosed, she spent 7 years
visiting over 10 doctors, and almost had
her arm amputated due to a misdiagnosis.
At one point, the pain was so excruciating
that she stopped going to school. Some
people even started to think she was
making up her syndrome, increasing the
frustration of Ashley’s loved ones.
Although the idea had been several years in
the making, Ashley raised $5000 at the first
Rock Out concert last October. This year
she raised $3000 even before the concert
in San Luis Obispo, from people who just
wanted to help Ashley and her cause. Half
of the proceeds go towards future concerts,
such as the next one in Los Angeles.
Money raised by Rock Out in the past has
gone towards a RSDSA walk, medical
equipment for a CRPS patient, research
for the Pediatric Pain Program at the
University of California Los Angeles
Mattel Children’s Hospital, and raising
awareness. For more information on
Rock Out To Knock Out RSDS, Inc.,
visit www.tkorsds.org. n
5

Mailbag
October 14, 2007
I am an RSD patient who, after failing all
protocols that I tried in the United States,
sought treatment through Traditional
Chinese Medicine in China in March
of 2007. By July 2007, I was pain free.
The enclosed story tells of my journey
to China and my amazing recovery from
the pain of RSD. I am currently pain free
and working full-time in the hospital
where I was treated. I am currently
working and living in China, but travel
to the United States several times a year
to visit my family. I will be in North
Carolina again this spring. The dates for
my spring trip are not yet set.
I am interested in working with U.S.
and international RSD patients, RSD
associations, and other organizations that
want to know of the profound changes
resulting from my treatment. I believe this
treatment will work for others who suffer
from the agonizing pain of this disease.
I have included my story with this letter.
Thank you for your consideration.
Sincerely,
John Lauritzen
JOHN’S STORY
My RSD developed after a lisfranc fracture
of the left foot. Foot surgery was
required and I had no problems postsurgery.
Three weeks following surgery
I developed severe, unrelenting pain and
was sent to the Arnold Pain Management
Center at Beth Israel Hospital in Boston.
Doctors there diagnosed me with RSD and
were hopeful, since the disease was in the
early stages, that the pain management
team could relieve my pain. Over the next
six months I had sympathetic blocks, epidural
steroid injections, epidural infusions,
a spinal cord stimulation trial, narcotic
trials. None of the procedures gave me
permanent pain relief. Relief from some
of these procedures lasted hours, others,
days. Before I developed RSD, I lived independently
in an apartment in the Boston
area. The apartment was just a three-block
walk from the train. Now that I had RSD,
I could see the train from my apartment
window, hear it, but was no longer able to
use it. I went from being an independent
adult to wheelchair-bound. Shopping for
groceries, getting a haircut, even doing
laundry, required assistance.
Following one last procedure, my doctors
advised me to return to live near my family
where I could receive assistance and
seek help from Duke Medical Center in
Raleigh, North Carolina.
I returned to Asheville to live with my
mother and stepfather, and began seeing
doctors at Duke and several pain centers
in Asheville. By now I was using narcotics
to manage my pain. Nothing else gave
me relief. I took pain pills all day long and
kept increasing the amount of medication
just to get the same effect. Along with pain
meds, sleep meds were prescribed so that
I could sleep three hours at a stretch each
night. My foot became so sensitive that I
couldn’t tolerate the weight of a sheet on
it. I took pain meds in order to tolerate the
discomfort of putting on my shoes.
All these medications had side effects.
They made me unsteady on my feet the
days I wasn’t in a wheelchair or using
a cane. I fell repeatedly. The falls led to
further anxiety about reinjuring my foot.
I was deconditioned from being in a
wheelchair and tired easily. Doctors’ appointments
filled my life. I saw a neurologist,
internist, psychotherapist, psychiatrist,
physical therapist and pain management
doctor. Riding in a car, albeit one
with excellent suspension, felt as if road
vibrations drove stabbing pain through
my foot. My mother and stepfather put
8,000 miles on their cars from November
until March driving me to and from medical
appointments. Occasionally, I could
work in alternative medicine appointment
in between other medical appointments.
I tried acupuncture, Reikki and meditation.
I went to a local acupuncturist and
the treatments he gave helped at first, and
then failed to touch my pain.
The following spring, I made a desperate
attempt to live on my own again. I hated
being dependent and wanted have my own
life. I moved into an apartment one halfhour
away from my family and attempted
to use the city disability van services to
transport me to my appointments. I signed
up for online for college courses, hoping to
get back to school. Several months later, I
was back at my mother’s house. I couldn’t
manage on my own. I met with the pain
management team at Duke and a pain
management neurosurgeon. Duke doctors
told me that they could not help me as my
other neurological conditions could inter-
6 RSDSA Review: Vol. 20, Issue 3

fere with any further treatments. No one
seemed to know what to do for RSD.
It was all I could do now to dress myself
or focus long enough to listen to a book on
tape. I no longer had the ability to concentrate
well enough to read. My foot became
frozen in place. I had limited mobility, despite
physical therapy from skilled therapists
with knowledge of RSD. My doctors
told me I’d gotten back all the function I
was going to get. My weight skyrocketed
from multiple medications and lack of
mobility. I felt isolated with RSD. I spent
more and more time in my bedroom when
I wasn’t seeing doctors or going to physical
therapy, feeling hopeless and stuck.
My depression increased.
The acupuncturist who had treated me
called me and told me about an article he’d
read in Stroke Survivor Magazine. It was
about a program called China Connection
and he urged me to try it. I was afraid to
leave what was familiar: my doctors who,
even though they weren’t finding solutions
for me, were compassionate. I’d never
been so far away tram everything familiar.
I was fearful of what of what the cabin
pressure in an airplane would do to increase
my foot pain. Traveling by air from
Boston to Asheville, a two and a half hour
trip, had been horribly painful. How would
I manage a thirteen hour plane trip?
My family encouraged me to consider
trying Traditional Chinese Medicine that
was offered at Tianjin Regional Medical
Center in China. Even though I’d been to
the best pain management centers in the
country it was clear I wasn’t improving.
My doctors didn’t say no to my going,
but they were concerned about whether
I could receive a guarantee of recovery;
I could not. When I was accepted in the
program the doctors told me they would
do all they could to help me. Faced with
the last option in the US, placement of a
morphine pump in my body, I decided to
go to China. I was willing to try anything
to get rid of the agonizing pain. If the
doctors had told me to jump five feet in
the air I think I would have tried.
I traveled to China in March 2007. At
first the staff at Tianjin Medical Center
was perplexed. They’d never seen RSD before,
but had great success with movement
disorders from stroke and other neurological
disorders. I began an intensive program
of acupuncture, herbal soaks, vigorous
massage called tuina, exercise therapy,
and herbs six hours a day six days a week.
It was slow medicine. When I spoke to
my family in the US, I joked with them
that the two words I heard most from the
Chinese doctors were “rest” and “later”. I
lived in a hospital setting with American
and international patients, all of whom
were experiencing this same challenging
program. Three weeks after I arrived I
emailed my family to tell them of the first
miracle, I had regained full mobility of my
frozen foot. I gave up my cane. Over the
next months I saw other changes: I began
to sleep through the night, I lost weight, I
had days when my pain was manageable.
I went on several outings and began to
socialize again. Soon, I was going to the
gym six days a week walking on a treadmill,
riding an exercise bike. I rediscovered
laughter. Before I left the hospital in
June I took a six hour bus trip to the Great
Wall and climbed the hundred steps with
the other stroke survivors on that trip.
“I’m grateful I took the risk to
find an answer to this cruel
and perplexing disease, RSD.”
By the time I left the hospital I was able
to sleep through the night. I’d stopped all
pain medications. I’d lost forty pounds.
My depression diminished. I began working
in the community room at the hospital,
opening and closing the room for the
American staff and providing programs for
international patients there several nights
a week. It was exhilarating to be of use to
others, to be productive again.
Today I am pain free most days, although
weather changes can cause my foot to
ache. I’m continuing to lose weight and
I’m working in the hospital where I was
a patient. I enjoy a good night’s sleep,
regular exercise, and regained my prized
independence. I’m grateful I took the risk
to find an answer to this cruel and perplexing
disease, RSD.
7

Mailbag
Dear Jim,
Thanks for the story from John. He
obviously made an impressive recovery
and this is a story of hope.
From the medical science point of view
there are many pieces of info missing so
this is at best an anecdotal case. But in
reality, the experience of one person just
confirms what we knew all along: that
the best treatment for any chronic pain
patient, including RSD sufferers, is a
multidisciplinary comprehensive approach
which is clearly outlined in John’s story.
Another fact that is apparent here is that
even though the physicians in China did
not understand RSD, they treated the
patient based on their best judgments and
upon generally accepted principles. They
key here is “intense therapy,” which is too
often the missing link here in the US.
How many times have we seen our enthusiastic
approach to treating the condition
frustrated by insurance and other third
party restrictions?
Notwithstanding the above, I think the
program at the Tianjing Regional Medical
Center deserves a second look, to see if
they have other similar cases of success.
There is definitely something we can
learn from in this case.
Best,
Jeffrey Ngeow, MD
Clinical Associate Professor of
Anesthesiology, Weill Medical College
of Cornell University
Dear Jim:
I hope this letter finds you well. Your
commitment to this organization is astounding.
There was no RSDSA when I
was first diagnosed in May 1988. There
were, but a few minuscule gripe groups.
We were a haphazard bunch back in
those days, who were just lucky to find
each other and an ear to chew. You have
diligently pulled us together, and instead
of allowing us to weep and wallow in our
despair, you have formed a loud, progressive
and reverberating organization. You
have put us on the medical and political
maps. Thank you.
A few days ago I received the latest
edition of the RSDSA Review (Volume
20, Issue 2). The Clinical Q and A with
Dr. Prager hit an emotional button, and
I felt I needed to share my own experience
with pregnancy and RSD.
In February 1992, after years of surgeries,
oral and intravenous medications,
psychologists, psychiatrists, occupational
and physical therapies, experimental treatments…
and on the advice of Dr. Robert
Schwartzman (2 years earlier) I went
ahead and had a morphine pump implanted.
Needless to say, the morphine pump
was in its infancy for RSD back then, but
I also knew that my various oral medications,
including a patch, were not allowing
me to lead a life and be a participant of
any sort in my communities. The pump,
which has not always been a smooth and
reliable partner in life, later allowed me to
marry and in 1994 become pregnant. Today
I have a beautiful, sometimes arrogant
and sassy preteen daughter, who would not
be here without my morphine pump.
I think Dr. Prager offers some terrific
advice, but did not discuss the possibility
of the morphine pump. Do not think the
pump let us imagine we were out of trouble.
We spent tremendous time discussing
our venture with Dr. Schwartzman, Dr.
Howard Rosner, and various neonatal
specialists as well as psychologists and
high-risk OB-GYNs. We knew this would
be considered a high risk pregnancy (I
was 36 at the time, you do the math now),
and had a birth plan in place as a cesarean
would be necessary if I could not deliver
naturally. I couldn’t take the chance
of an epidural with my catheter. There
was far greater concern for me than the
baby, though he/she would be medically
scrutinized. You should know, there was
no information available at the time concerning
RSD and pregnancy/delivery. I
always did like the idea of being a leader.
I have to assume that almost 13 years
later we have more knowledge and experience
to offer women and couples who
are considering pregnancy. The bigger
concern is not only the effects of opiates
on the fetus, but the effect of fertility in
general. And as Dr. Prager points out,
when deliberating parenthood, you must
take into consideration your health and
pain management support system.
No plan is perfect and life throws us sour
cherries, but ultimately only the person
can sort out the questions; the answers
are never clear.
Again, wishing you the best and hope to
see you in the near future. n
Regards,
Laurie
8 RSDSA Review: Vol. 20, Issue 3

My relationship with RSD has changed
over time. Before I was diagnosed and
was going from doctor to doctor, I was
terribly frightened. I was experiencing
intense pain and symptoms that made
no sense either to me or to the doctors I
was seeing. Finally after several years,
I was given a diagnosis. I had a disease
that some doctors knew about, that others
were suffering from, and for which there
were treatments available. Despite my
suffering, I was hopeful.
Just when I thought things couldn’t get
any worse, I developed an autoimmune
disease. The first obvious symptom was
the pain from my RSD was the worst pain
I could feel, but this was much worse. I
have had many operations to clear away
the gangrene, but unfortunately, the affected
areas covering the initial site of
RSD will not heal, and I will need skin
grafts. To my many RSD medications, I
have now added prednisone and methotrexate;
the methotrexate is an immunosuppressant
drug used for cancer. It
supresses the immune system and leaves
you open to all kinds of infections.
Armed with a diagnosis, I visited the web
and found RSDSA. I went to a symposium
in Atlantic City—it seems like eons
ago—where I met others like myself,
heard doctors speak about RSD, and connected
to some very special people. My
life was really beginning to look up, and
for the first time I felt that I would find a
doctor with a treatment plan to help me.
When I finally found a doctor knowledgeable
in RSD, I was amazed at how
many treatment options were available.
I read as much as I could. The RSDSA
newsletter and website were invaluable.
There were so many stories of others with
RSD who, while not cured, were able to
resume their former activities with much
lower pain levels. If they could beat this
thing, then so could I.
As the years went by, I tried every treatment
I could find, short of ketamine. Some
would help for a day or so, and some not
at all. Instead of getting better, things got
worse. One day I woke up and realized
that I was no longer 45, but somehow was
now in my 60s. I was battling arthritis,
severe osteoporosis and breaking bones.
I spent long stretches in a wheel chair,
although most of the time I used a walker.
The RSD had spread to both legs and
with the added years, having the energy to
wheel myself around was getting harder.
There were no longer new treatments to
try, so maintaining an optimistic outlook
became more and more difficult.
When RSD Hits
a New Phase
By Linda Lang
“My life was
really beginning
to look up, and
for the first time
I felt that I would
find a doctor
with a treatment
plan to help me.”
when I developed vasculitis on my legs.
My body was attacking my own skin,
becoming gangrenous and exposing the
nerves in large areas where there was no
longer skin to protect them. I had thought
I now spend a lot of time in bed because
walking is so difficult. My lungs have also
become involved and dealing with both
diseases can be overwhelming. I have only
spoken to one other person who is dealing
with the same issues I am. Not much data
has been collected about what is happening
to those who have long-standing RSD,
and who are now into our 60s or older. I’m
sure that there are others out there like me
and I would sure love to hear from you.
RSDSA has done a wonderful job supporting
those who are newly diagnosed or
have suffered for a few years. We can now
gather information from those who have
had RSD for over 10 years and have not
found relief, and are experiencing the normal
problems of aging, or developed other
serious diseases. We can begin to have the
same support for this segment of RSDer’s
as well. We can share information on how
each of us manages to cope (or not) with
this new phase of RSD, which might go
a long way to ease our suffering. It also
can give doctors new information about
the directions RSD takes to help us better.
Please help us to help you. E-mail your
stories. Remember how you felt when you
were first diagnosed and got to meet or
hear about others who were experiencing
the same things as you. I know for me it
eased the feeling of being alone in this
battle, and gave me so much comfort and
hope. With your help, we could do the
same thing again for those who are finding
it so much harder to be hopeful! n
9

Cognitive Behavioral Therapy
for CRPS
By Stephen Bruehl, PhD
Patients with CRPS often are
told by their physician that they
might benefit from seeing a pain
psychologist. Yet patients may wonder
how seeing a psychologist could help
them with their pain given that CRPS is
clearly a physical problem.
There are several targets for psychological
intervention with CRPS, the most
obvious of which is helping patients
deal more effectively with the physical
and emotional impact of CRPS in their
lives. However, another key target of
treatment is learning to control the pain
without drugs. Many patients initially
have trouble believing this is even possible;
nevertheless, research has clearly
documented that for the majority of
chronic pain patients, emotional distress
frequently intensifies the severity of
pain. This does not imply that the pain
is psychological, but rather reflects the
interconnections between the parts of
the brain that underlie emotions and
the stress response, and the parts of the
brain that regulate pain.
These pain-exacerbating effects of distress
are particularly important in CRPS,
because the physiological mechanisms
believed to contribute to the pain, color
changes, and temperature changes all
can, in theory, be directly affected by
certain hormones (adrenalin) released
during stress and emotional distress.
While patients cannot control whether
they have CRPS, they can learn techniques
to control their stress responses,
which in turn can reduce pain intensity.
The most common approach to psychological
treatment for chronic pain is
Reframing helps
patients learn
to take the
“glass half full”
attitude towards
their pain rather
than the
(more natural)
“glass half empty”
attitude..
Cognitive Behavioral Therapy (CBT).
Psychologists and other mental health
practitioners who employ CBT typically
use a variety of specific techniques. The
goal of reducing pain intensity often
can be achieved by learning relaxation
techniques that reduce emotional
distress and control the stress response.
These may include breathing relaxation
(slow patterned breathing), progressive
muscle relaxation, and imagery
(ie, creating a detailed mental image of
a relaxing place). The effectiveness of
these techniques often can be increased
by combining them with biofeedback, in
which moment-by-moment changes in
the body’s stress response (reflected in
muscle tension or finger temperature),
can be observed on a computer screen to
help “fine tune” the relaxation response.
The “cognitive” part of CBT refers to
the fact that our emotional reactions to
a given life situation are determined by
what we think (“cognitions” is another
term for thoughts). For example, consider
two individuals asked to speak in
front of a large audience. The first, with
a fear of public speaking, immediately
starts thinking, “If I mess this up, I’ll
look like a fool!” and begins feeling
very nervous. The second person is an
actress, who thinks, “Great! An opportunity
to perform” and feels excited.
While the situation is identical, they
respond with very different emotional
reactions as a result of their styles of
thinking. The essence of CBT is that
styles of thinking become habits (eg,
the eternal optimist versus the chronic
pessimist) and more importantly, these
habits can be changed. CRPS often leads
to more pessimistic thinking. Negative
thoughts may intrude repeatedly, such
as “Why can’t they cure this?;” “This
is awful;” and “My life is over.” Such
thoughts lead to chronic emotional
distress, which reduces quality of life,
can increase pain intensity, and may
contribute to the development of clinical
depression or anxiety disorders.
Changing Negative Thought Patterns
The CBT therapist helps patients learn to
identify their habitual negative thoughts
and consciously modify them in a way
that is more constructive and produces
10 RSDSA Review: Vol. 20, Issue 3

less distress. A patient may habitually
respond to increased pain by thinking,
“This pain is horrible and is never going
to end,” and consequently may feel
miserable. The CBT therapist would
help the patient learn a way to reframe
the problem of pain exacerbations. For
example, responding to increased pain
by actively saying to oneself, “This is an
opportunity to use my relaxation techniques,
I can handle this,” would lead
to less distress and may in fact result in
somewhat reduced pain.
While CBT is clearly not a cure
for CRPS, numerous research
studies in patients with a variety
of chronic pain conditions indicate
that it is effective for improving
pain, mood, and function.
Reframing helps patients learn to take
the “glass half full” attitude towards their
pain rather than the (more natural) “glass
half empty” attitude. Learning to recognize
and avoid other problematic styles
of thinking is also key, including the tendency
to dwell on and magnify negative
things, ignore good things, and generally
“catastrophize” one’s situation. Other
cognitive strategies used in CBT focus
on recognizing what parts of the pain
problem the patient can’t control (eg,
having CRPS, having certain physical
limitations, how employers respond), and
focusing attention instead on the aspects
of the pain problem that can be controlled,
such as how the patient responds
to pain and limitations. With repetition,
this active countering of habitual negative
thoughts with more constructive thoughts
can create new habits of thinking that
contribute to long-term improvements
in quality of life.
Behavioral Issues
CBT often addresses behavioral issues as
well. Due to pain and physical limitations,
patients may over time engage less
and less in their previous life activities.
While this may reduce pain short-term,
by avoiding activities that could potentially
lead to pain exacerbations, it ultimately
can lead to a situation in which
patients have nothing to focus on BUT
their pain. Finding distracting and enjoyable
activities that can be done within
the CRPS patient’s physical limitation is
crucial for maintaining some sense of a
“normal” and meaningful quality of life.
CBT therapists often serve as a coach to
help patients identify suitable activities
and overcome any barriers to those activities
resulting from CRPS. Often this
is done in conjunction with physicians
and physical or occupational therapists.
The CBT therapist may use cognitive
techniques like those above to address
issues such as fear of pain and fear of
movement that may interfere with one’s
ability to re-engage in life. Beyond quality-of-life
issues, it is also important to
note that leading CRPS medical experts
believe that avoiding disuse of the affected
limbs and maintaining as normal
an activity level as possible are keys to
successfully managing CRPS symptoms.
While CBT is clearly not a cure for CRPS,
numerous research studies in patients with
a variety of chronic pain conditions indicate
that it is effective for improving pain,
mood, and function. CBT is a “self-management
approach” to chronic pain; its
techniques require patient effort for them
to work and the focus is on managing,
rather than curing, the condition. Patients
focused exclusively on externally applied
“cures” (eg, sympathetic blocks) are
unlikely to benefit from CBT until they
are willing to alter this treatment focus.
Some patients may feel that CBT’s implied
focus on acceptance of their chronic
pain, and working within this, means that
they are “giving up the fight” and that
this will reduce the possibility of a cure.
However, CBT is actually emphasizing
the focus on battles that are winnable
in order to win the larger war, to have a
better quality of life. Appropriate medical
and functional therapy treatments typically
continue while patients are engaged
in CBT, with the hope that these treatments
will all work together to produce
the desired outcome.
Once CBT pain management skills are
learned, they can be applied any time and
in any situation. Thus, the patient always
has effective pain management tools. In
many people, CBT can effectively reduce
the reliance on medications and other
medical interventions and live a fulfilling
life despite CRPS. If you are interested in
pursuing CBT pain management treatment,
you should discuss this possibility
with your medical provider.
Stephen Bruehl, PhD, is an Associate
Professor of Anesthesiology at
Vanderbilt University School of
Medicine in Nashville, Tennessee.
Dr. Bruehl serves on the RSDSA
Scientific Advisory Board. n
11

As with any neuropathic pain syndrome,
the response to CRPS treatment varies
with each patient. Treatment can involve
interventional techniques (sympathetic
blocks, spinal cord stimulation, analgesics)
or medications (adjuvants antidepressants,
anticonvulsants, bisphosphonates,
muscle relaxants, Beta 2 blockers, local
anesthetics, opioids etc.) 1 . For patients
with poorly-controlled pain at the time of
evaluation, opioids should be considered
earlier in the treatment plan.
Overview
The use of opioids to treat neuropathic
pain is controversial 2,3 . Arner and Meyerson
found that infusions of morphine
long-term opioid use, as well as using both
an opioid and an adjuvant in treatment (11) .
Gilron et al’s double-blind clinical trial
showed that gabapentin and morphine
extended-release are more effective when
combined with an opioid individually, suggesting
a potential analgesic effect 12 .
Methadone
Methadone has received significant attention
lately due to its prolonged half-life,
potency, and low cost. Methadone works
well with μ and δ opioid receptors and
blocks the N-methyl-D-aspartic acid
(NMDA) receptor, suggesting that it can
help manage neuropathic pain when
hyperalgesia is present 13 . Randomized
(ECG) should be done initially and after
adding these medications.
Tramadol
Another opioid of interest is tramadol,
which produces additional analgesic
effects by blocking the reuptake of serotonin,
a neurotransmitter involved in
the control of pain perception, sleep, and
mood, and norepinephrine, a neurotransmitter
that increases the heart rate, blood
pressure, and blood sugar level 21 .
A randomized study of individuals with
painful diabetic peripheral neuropathy
showed that tramadol relieves spontaneous
pain and allodynia more effectively
than placebo 22 . Caution should be used in
The Use of Opioids in CRPS-related Pain
By Ricardo A. Cruciani, MD, PhD
were ineffective in relieving neuropathic
pain, but the study was flawed because
of selection bias, small sample size, and
lack of drug titration 4,5 . Subsequent
evidence suggests that opioids might be
effective in treating neuropathic pain.
Trials for postherpetic neuralgia demonstrate
the analgesic benefits of morphine
and oxycodone, while in studies with
patients with non-malignant neuropathic
pain, a fentanyl citrate injection can provide
better relief when compared with
diazepam 6,7,8 . An open study on the use
of fentanyl patches showed that few
patients achieve lasting pain relief 9 .
A retrospective study of individually titrated
opioid infusions in patients with neuropathic
pain indicates that pain relief can
be achieved, but the ratio of opioid dose
to patient response increases in people
with neuropathic pain 10 . Recently, however,
positive effects have been found with
studies are lacking, but many reports suggest
promising results with methadone in
neuropathic pain 14-18 . Dose titration must
be done cautiously, since large differences
in the tolerance of different patients
to methadone can cause drug toxicity 19 .
There are also concerns about methadoneinduced
cardiac toxicity and current literature
is not conclusive. Although Krantz et
al report a longer QTc interval than normal
and Torsade de Pointes—a type of abnormal
accelerated ventricular rhythm—with
high doses of methadone, others could not
confirm these findings 19 . It is also suggested
that competitors of Cytochrome P450
3A4 (CYP 3A4), an important enzymatic
pathway for the disposal of methadone in
the body and the Lkr current, a delayed
purifying potassium current that allows
the cardiac fibers to return to a normal
state, could increase methadone toxicity 20 .
In these patients, an electrocardiogram
these patients when antidepressants are
added. Selective serotonin reuptake
inhibitors (SSRIs) could increase the
risk for of a possibly fatal serotonin
syndrome if they are mixed with monoamine
oxidase inhibitors (MAOIs).
Screening Tools
The fear of drug addiction is probably
our biggest concern 23 . Several tools have
been developed to assess risk factors for
drug addiction, including the Opioid Risk
Tool (ORT), the Substance Abuse Screening
Instrument, and the Prescription Drug
Use Questionnaire (PDUQ) 23 . These tests
help physicians develop risk assessment
protocol for their practices and categorize
patients according to their risk. Before
opioids are started, a careful clinical history
should be taken with special emphasis
on drug addiction issues and a consultation
with an addiction psychiatrist should be
considered with high-risk patients 24 .
12 RSDSA Review: Vol. 20, Issue 3

Conclusions
These data suggest that although neuropathic
pain may be less opioid-responsive
than nociceptive pain, effective pain relief
can be achieved by finding a dose that
works for each patient. The potential for
opioid side effects might be higher in
patients with neuropathic pain because
of the higher opioid doses required to
relieve pain. The most common side
effects are constipation and sedation,
but urinary retention, itching, and respiratory
depression are also reported.
Drug tolerance that causes an increase in
opioid dosage without disease progression
is an argument against opioid use,
and could be encountered in patients
treated long-term with opioids as well as
with short exposure to certain opioids.
The strategy to overcoming tolerance
is to safely titrate the opioid, to achieve
an appropriate analgesic response, or to
switching to a different opioid.
The data on the analgesic efficacy of opioids
in patients with CRPS are very limited.
Some of the underlying mechanisms of
CRPS are common to several neuropathic
pain syndromes, including postherpetic
neuralgia and painful diabetic peripheral
neuropathy, which are used most often for
studying analgesic efficacy. These similarities
justify the assumption of a similar
response in patients with CRPS, but controlled
trials are necessary to determine the
efficacy in this patient population.
Ricardo A. Cruciani, MD, PhD, is the
Vice Chair and Director for the Research
Division of the Department of Pain Medicine
and Palliative Care at Beth Israel
Medical Center in New York City and
Assistant Professor for the Departments
of Neurology and Anesthesiology at the
Albert Einstein College of Medicine of
Yeshiva University. n
Glossary
Anticonvulsants: medicines used to prevent or treat
convulsions (seizures)
Electrocardiogram: test that records the electrical
activity of the heart
Hyperalgesia: an enhanced intensity of pain
sensation
Nociceptive pain: pain caused by a painful stimulus
Opioid: one of a group of synthetic sedative
narcotics like opiates, but increasingly refers to
all opium-like narcotics
Painful Diabetic Peripheral Neuropathy: most
common complication of diabetes mellitus; a
progressive disorder that results in a gradual
decrease in peripheral sensation and eventually
complete loss of sensation
Postherpetic neuralgia: neuropathic pain condition
caused by the varicella zoster virus in a dermatomal
distribution (the area governed by a particular
sensory nerve) after an attack of herpes zoster;
commonly known as shingles
Titration: method for figuring out the concentration
of a substance by adding a measured amount of
solution, which allows the unknown concentration
to be calculated
References
1. Mackey S, Feinberg S. Pharmacologic therapies
for complex regional pain syndrome. Curr Pain
Headache Rep. 2007;11(1):38-43. Review.
2. Bruera E, Valero V, Driver L, et al. Patientcontrolled
methylphenidate for cancer fatigue: a
double-blind, randomized, placebo-controlled trial.
J Clin Oncol. 2006;24(13):2073-2078.
3. Ballantyne JC, Mao J. Opioid therapy for chronic
pain. N Engl J Med. 2003;349:1943-1953. Review.
4. Arner S, Meyerson BA. Lack of analgesic effect
of opioids on neuropathic and idiopathic forms of
pain. Pain. 1988;33:11-23.
5. Dellemijn P. Are opioids effective in relieving
neuropathic pain? Pain. 1999;80:453-62.
6. Rowbotham MC, Reisner-Keller LA, Fields
HL. Both intravenous lidocaine and morphine
reduce the pain of postherpetic neuralgia. Neurol.
1991;41:1024-8.
7. Watson CPN, Babul N. Efficacy of oxycodone in
neuropathic pain: a randomized trial in postherpetic
neuralgia. Neurol. 1998;50(6):1837-41.
8. Dellemijn PLI, Vanneste JAL. Randomised double-blind
active-placebo-controlled crossover trial
of intravenous fentanyl in neuropathic pain. Lancet.
1997;349:753-758.
9. Dellemijn PLI, van Duijn H, Vanneste JAL.
Prolonged treatment with transdermal fentanyl
in neuropathic pain. J Pain Sympt Manage.
1998;16(4):220-229.
10. Portenoy RK, Foley KM, Inturrisi CE. The
nature of opioid responsiveness and its implications
for neuropathic pain: new hypotheses derived from
studies of opioid infusions. Pain. 1990;43:273-86.
11. Gimbel JS, Richards P, Portenoy RK.
Controlled-release oxycodone for pain in diabetic
neuropathy: a randomized controlled trial.
Neurology. 2003;60:927-934.
12. Gilron I, Bailey JM, Tu D, Holden RR, Weaver
DF, Houlden RL. Morphine, gabapentin, or their
combination for neuropathic pain. N Engl J Med.
2005;352:1324-1334.
13. Bruera E, Neumann CM. Role of methadone in
the management of pain in cancer patients. Oncol.
1999;13(9):275-282.
14. Makin MK, Ellershaw JE. Methadone can be
used to manage neuropathic pain related to cancer.
BMJ. 1998;317:81.
15. Vigano A, Fan D, Bruera E. Individualized use
of methadone and opioid rotation in the comprehensive
management of cancer pain associated with
poor prognostic indicators. Pain. 1996;67:115-119.
16. Gagnon B, Bruera E. Differences in the ratios of
morphine to methadone in patients with neuropathic
pain versus non-neuropathic pain. J Pain Sympt
Manage. 1999;18(2):120–125.
17. Gagnon B, Almahrezi A, Schreier G.Methadone
in the treatment of neuropathic pain. Pain Res
Manag. 2003;8(3):149-154.
18. Morley J, Bridson J, Nash T, Miles J, White S,
Makin M. Low-dose methadone has an analgesic
effect in neuropathic pain: a double-blind randomized
controlled crossover trial. Palliat Med.
2003;17:576-587.
19. Cruciani RA, Sekine R, Homel P, et al. QTc
measurements in patients on methadone. J Pain
Sympt Manag. 2005;29(4):385-391.
20. Ehret GB, Desmeules JA, Broers B. Methadone-associated
long QT syndrome: improving
pharmacotherapy for dependence on illegal opioids
and lessons learned for pharmacology. Expert Opin
Drug Saf. 2007;6(3):289-303. Review.
21. Raffa RB, Friderichs E, Reimann W, et al.
Opioid and non-opioid components independently
contribute to the mechanism of action of tramadol,
an atypical opioid analgesic. J Pharmacol Exp Ther.
1992;260:275-285.
22. Sindrup SH, Andersen G, Madsen C, et al.
Tramadol relieves pain and allodynia in polyneuropathy:
a randomized, double-blind, controlled trial.
Pain. 1999;83:85-90.
23. Webster LR, Dove B. Avoid Opioid Abuse
While Managing Pain: A Guide for Practitioners.
North Branch, Minn: Sunrise River Press; 2007.
24. Passik SD, Kirsh KL, Donaghy KB, Portenoy
RK. Pain and aberrant drug-related behaviors in
medically ill patients with and without histories of
substance abuse. Clin J Pain. 2006;22(2):173-181.
13

evidence also suggests that neuropathic
pain does not respond as well to opioids
as nociceptive pain (pain from skin,
muscles, joints) and often requires
higher doses 15, 16 . Consequently,
neuropathic pain states (especially the
neuropathic component of CRPS) often
require much higher doses of opioids,
which in turn greatly increase the risk of
side effects and adverse events. Thus, a
very careful and thoughtful analysis of
the risk (ie, side effects, adverse events,
cost) to benefit (efficacy/effectiveness)
ratio is critical in the decision to use
opioids in CRPS.
Opioids for CRPS? Think again.
By R. Norman Harden, MD
Whether or not to prescribe opioids
for chronic and non-malignant pain
conditions, such as CRPS, remains
controversial 1-3 . After years of
thoughtless and over-aggressive use
of these compounds for pain, most
practitioners have become cautious,
primarily due to the emergence of serious
side effects and adverse events associated
with chronic opioid therapy 3-6 . Although
the quality of research addressing this
clinical controversy has improved, there
still have been no definitive studies
performed 3,7,8 . Nonetheless, this class
is sometimes used in complex regional
pain syndrome (CRPS) as a “rescue”
or an “as needed” medicine.
One has to question when opioids are
used in chronic pain maintenance and
prophylaxis in CRPS (around-the-clock
therapy) 9 . The standard for scientific
evidence of any therapy in medicine
is the Randomized Controlled Trial
(RCT) and unfortunately, only one
has been conducted evaluating the use
of any opioid in CRPS. Harke et al
studied controlled-release morphine
in CRPS and reported no difference
in pain reduction when compared to
placebo. 11,12 . In other words, morphine
did not relieve CRPS pain in this trial.
More research is needed to definitively
address this question, considering that
the Harke trial was complicated and may
have been underpowered 12 .
There are a few high-quality studies
of opioids for neuropathic pain that
suggest marginal efficacy 13 . However,
Since there is no evidence supporting
the use of opioids in CRPS and the
literature is not particularly supportive
of opioids for CRPS, we must conclude
the Efficacy/Effectiveness (benefit) part
of this equation does not favor opioids
in the CRPS population 9-12 . Opioids
are clearly not a panacea, and there are
many unresolved concerns about longterm
efficacy in any chronic condition,
efficacy in neuropathy, tolerance,
cognitive impairment (especially with
“rescue dosing” or initial titration),
long-term toxicity and opioid-induced
hyperalgesia 3,9 .
Good practice and common sense
requires that we critically and
continuously assess the risks and side
effects of opioid therapy in order to
maintain that primal tenet of medicine
and our Hippocratic Oath: “first do
no harm.” Furthermore, our patients
must be fully informed of the risks
considering that there is no compelling
research supporting the use of these
compounds for CRPS.
Side Effects of Opioid Therapy
The many risks of opioid therapy are
well known, from the very common
occurrence of constipation and
itchiness to the more recently-identified
hypogonadism (shrunken testicles) 3,17 .
14 RSDSA Review: Vol. 20, Issue 3

Since
hyperalgesia
is an important
diagnostic and
clinical feature
of CRPS, it makes
little sense to use
a class of drugs
that cause this
symptom and sign
for treatment
of CPRS.
Long-term cognitive impairment,
personality changes, tolerance, and longterm
toxicity are unresolved issues at the
moment. Any general pharmacological
reference, such as a recent edition of the
Physicians’ Desk Reference, will have
a good list of the problems associated
with opioids. One particular side
effect of opioid use in CRPS is opioidinduced
hyperalgesia (increased pain
perception) 18,19 . Since hyperalgesia is an
important diagnostic and clinical feature
of CRPS, it makes little sense to use a
class of drugs that cause this symptom
for treatment of CRPS. Thus,
a CRPS patient on high-dose opioids
may have a worsening of signs and
symptoms due to opioid therapy. Simply
said, high-dose chronic opioid therapy
may make CRPS pain worse.
Optimal CRPS care preferably entails
the use of non-drug therapies, nonopioid
medications for maintenance,
and occasional opioids for crisis
management, specifically when
overwhelming pain prevents progress
in functional restoration and if injection
therapy has been considered and/or
fails 20, 21 . Opioids should never be
used in isolation, and must always
be used only with a comprehensive
functional restoration program 20, 21 .
Thus, clinicians should not become
over-enthusiastic or overzealous
about opioids and should keep them
in perspective within therapeutic
techniques. A critical assessment of the
literature and the risk to benefit ratio
suggest that opioid therapy in CRPS
is extremely questionable.
R. Norman Harden, MD, is the Director
for the Center of Pain Studies and holds
the Robert G. Addison Chair in Pain
Studies at the Rehabilitation Institute
of Chicago. Dr. Harden is currently
researching medication trials for pain,
post-amputation pain, psychological
aspects of pain, complex regional
pain syndrome (CRPS), fibromyalgia,
headache, back and neck surgery, spinal
cord injury, and Multiple Sclerosis. Dr.
Harden is also currently the Chairman
for the Clinical Affairs Committee
of the Reflex Sympathetic Dystrophy
Association. n
References
1. Butler SH. Opiates for chronic pain:
present American controversy. Regul Pept.
1994;52:S295-S296.
2. Portenoy RK. Opioid therapy for chronic
nonmalignant pain: a review of the critical issues.
J Pain Sympt Manage. 1996;11(4):203-217.
3. Harden RN. Chronic opioid therapy: another
reappraisal. Am Pain Sac Bull. 2002 Jan/Feb.
4. Turner JA, Calsyn DA, Fordyce WE, Ready LB.
Drug utilization patterns in chronic pain patients.
Pain. 1982;12:357-363.
5. Schug SA, Large RG. Opioids for chronic noncancer
pain. Pain Clin Update. 1995;111(3):104.
6. Turk DC, Brody MC. Chronic opioid therapy for
persistent non-cancer pain: Panacea or oxymoron?
APS Bull. 1991:1(1):4-7.
7. Wilson PR. Editorial. Opioids and chronic pain.
Clin J Pain. 1997;13:1-2.
8. Dubner R. A call for more science, not more
rhetoric, regarding opioids and neuropathic pain.
Pain.1991:47:1-2.
9. Harden RN. Pharmacotherapy of complex
regional pain syndrome. Am J Phys Med Rehabil.
2005;84(3 Suppl):817-828.
10. Hord ED, Oaklander AL. Complex regional
pain syndrome: a review of evidence supported
treatment options. Curr Pain Headache Rep.
2003;7(3):188-196.
11. Kingery WS. A critical review of controlled
clinical trials for peripheral neuropathic pain
and complex regional pain syndromes. Pain.
1997;73:123-139.
12. Harke H, Gretenkort P, Ladleif HU, Rahman
5, Harke O. The response of neuropathic pain
and pain in complex regional pain syndrome I to
carbamazepine and sustained-release morphine in
patients pretreated with spinal cord stimulation:
a double-blinded randomized study. Anesth Analg.
2001;92(2):488-495.
13. Watson CP, Babul N. Efficacy of oxycodone in
neuropathic pain: a randomized trial in postherpetic
neuralgia. Neurol. 1998;50(6):1837-1841.
14. Beydoun A. Neuropathic pain: from
mechanisms to treatment strategies. J Pain Sympt
Manage. 2003;25(5 Suppl):S1-S3.
15. Sindrup SH, Jensen TS. Pharmacologic
treatment of pain in polyneuropathy. Neurol.
2000;55(7):915-920.
16. Benedetti F, Vighetti S, Amanzio M, et al.
Dose-response relationship of opioids in nociceptive
and neuropathic postoperative pain. Pain.
1998;74(2-3):205-11.
17. Daniell HW. Hypogonadism in men consuming
sustained-action oral opioids. J Pain.
2002;3(5):377-384.
18. Mercadante S, Ferrera P, Villari P, Arcuri E.
Hyperalgesia: An Emerging Iatrogenic Syndrome.
J Pain Sympt Manage. 2003;26(2):769-775.
19. Mao J, Price DD, Mayer DJ. Mechanisms of
hyperalgesia and morphine tolerance: a current
view of their possible interactions. Pain.
1995;62(3):259-274.
20. Stanton-Hicks M, Baron R, Boas R, et
al. Consensus report: complex regional pain
syndromes: guidelines for therapy. Clin J Pain.
1998;14(2):155-166.
21. Harden RN. Ed. Complex Regional Pain
Syndrome: Treatment Guidelines. Milford, CT:
RSDSA Press; 2006.
15

For many people, the process of hiring
a lawyer is fairly straightforward. The
client in need of legal services identifies a
selection of qualified attorneys, interviews
several of those, and selects the one who
appears best suited to undertake the case.
In a perfect world, the most qualified attorney
also possesses those essential qualities—integrity,
diligence, and skill—which
further support the client’s final selection.
The fact is that we don’t live in a perfect
world, and despite the efforts of clients
to hire the best lawyer for the job, every
attorney-client relationship is not a “love
connection.” Unfortunately, clients often
fail to appreciate what is
expected of them in the attorney-client
relationship:
choosing instead to believe
that if things did not work
out as expected, it was
entirely the lawyer’s fault.
While all such relationships
may not be salvageable, a
better understanding of what
is expected on the part of both lawyer and
client can often help enhance the professional
relationship and lead to a better
outcome. The focus of this article is not
on how to fire your lawyer–although that
topic is addressed as a last resort. Rather,
this article focuses on what is expected of
both lawyer and client in order to make the
relationship work best.
The quality of the working attorney-client
relationship is vital to the success of the
case. Clients and lawyers who work well
together dramatically increase the likelihood
of obtaining a favorable result. Conversely,
lawyers and clients who display
all the symptoms of a dysfunctional relationship
tend to take it out on the case.
Changing lawyers mid-stream—putting
aside the increased cost and stress which
often accompany such a change—tends
to transmit a clear signal to the opposing
side that “problems exist.” While these
problems may have absolutely nothing to
do with the underlying case, the opposing
side may misinterpret the cause of
the break-up and conclude that the case
is in trouble, leading to lower settlement
offers. In short, attempts to salvage the
attorney-client relationship are well
worth the effort.
Rule 1: Check your cynicism
at the door.
Lawyers are highly committed to achieving
their client’s goals. Unfortunately,
client cynicism can impair the attorney-client
relationship early on, leaving clients
questioning their lawyer’s dedication,
when mutual trust should be established
How to Avoid Firing
Your Lawyer
By Eric J. Parker
Parker Scheer LLP
instead. A lawyer I worked with for many
years had a wonderful saying: Never trust
anyone who doesn’t trust you. To be honest,
the saying made little sense to me
when I first heard it, but over time, the
wisdom became evident. Professionals
who feel distrusted by their clients tend to
withdraw from the relationship in subtle
ways. Calls from clients often go unanswered
or take longer to return; attorneys
parse their words more carefully and speak
in measured sentences. Perhaps most significantly,
candor is lost and clients receive
less accurate information from the attorney
than would otherwise be communicated.
It may require a leap of faith, but by replacing
cynicism with trust at the earliest
stages of the relationship, clients can effectively
improve the chances of developing
a stronger attorney-client relationship
and achieving the desired objectives.
Rule 2: Maintain reasonable
expectations.
There is perhaps no greater challenge for a
lawyer than the management of unreasonable
client expectations. Whether the case
involves a serious, traumatically-induced
injury such as complex regional pain
syndrome (CRPS), or the purchase of a
new home, a lawyer cannot be expected
to deliver a result that is completely unreasonable.
Clients often value their own
cases well above the range typically paid
by insurance companies or juries. The
reason for this is obvious: clients live with
the enormous pain and physical limitations
imposed by their injuries, and insurance
companies do not. It is also important to
recognize that lawyers have no reason to
under-value a case. Since
most personal injury-related
cases are handled on
a contingent fee basis (typically
one third of the gross
amount recovered plus case
expenses) plaintiff’s counsel
has every motive to obtain
the very best result possible.
Rule 3: Give it time.
Like it or not, litigation takes time—and a
lot of it! A typical personal injury case can
take from one to three years to complete,
depending upon the complexity of the case
and the extent of the damages. The best
way to devalue a case is to prematurely
push for settlement. Cases prepared for
trial usually settle, whereas cases prepared
for settlement usually go to trial. The reason
for this is clear—insurance companies
perceive aggressive efforts to settle cases
as strong indications that the plaintiff is
uncomfortable having their case tried
before a jury. If true, the insurance companies
believe they can resolve the case
for lower values than would otherwise be
acceptable if the client were committed to
trial. Therefore, allowing the case to “mature”
can greatly enhance the overall value
of the settlement.
Rule 4: Be direct.
I have a phrase I use to (affectionately)
describe a certain category of clients: I
16 RSDSA Review: Vol. 20, Issue 3

call them “after thinkers.” After thinkers
are clients who nod their heads up
and down during client conferences only
to telephone me later with a variety of
questions and concerns that could have
been addressed during the conference. I
suspect that a major cause of “after thinking”
is awkwardness. Clients often feel
uncomfortable challenging a lawyer’s
opinions in real time. Unfortunately, delaying
important questions or concerns
tends to lead attorneys to conclude that
there is consensus between
lawyer and client, when
in fact such is not the
case. If you have concerns
about any aspect of your
case–ask. If you do not understand
the case plan your
lawyer has developed, ask
for an explanation. If you
still do not understand the
case plan, ask until you do
understand it.
Rule 5: Too many
cooks spoil the soup—
and the case.
If you find yourself losing confidence in
your attorney, make an appointment to
meet in person and address your concerns
face to face. Too often, dissatisfied clients
tend to seek out the opinions of other lawyers,
who have little or no familiarity with
the particular facts and circumstances surrounding
the client’s case. This results in
greater confusion on the part of the client.
Don’t expect a lawyer who has not had the
benefit of working on your case to have
the answers. It’s unreasonable and selfdefeating.
Instead, advise your lawyer that
you have concerns and insist on answers
that help you to resolve them.
A brief word about Workers’
Compensation cases
The two most common scenarios where
people find themselves injured and subsequently
seeking compensation involve
injuries suffered at work and outside of
work. If an injury occurs during your employment,
odds are that you will be filing
a “Workers’ Compensation” (WC) claim.
You may also have a direct claim against
the responsible party, known as a “Third
Party Claim.” Clients with WC claims
often find themselves frustrated with “the
system,” due in large part to the added
level of bureaucracy inherent in the WC
System in most states. Unlike direct actions,
such as non-work-related car accidents,
persons injured at work are entitled
“Despite the efforts
of clients to hire the best
lawyer for the job, every
attorney-client relationship
is not a “love connection.”
to immediate reimbursement for medical
expenses and lost earnings. However, insurance
companies tend to question many
of the claimant’s bills and other submissions.
These denials are a common source
of frustration for injured workers, and
often result increased frustration with the
claimant’s lawyer. Before assuming that
your lawyer is responsible for the delay
in payment for lost wages or outstanding
medical bills, ask your lawyer why things
are taking so long.
What can I do when all else fails?
Although I tend to be an optimist, believing
that most troubled attorney-client
relationships can be saved, clearly some
cannot. Lawyers who fail to return client
telephone calls promptly, or ignore
repeated requests for updates on cases, or
are generally unavailable to their clients,
must take responsibility for the failure of
the relationship, and should be discharged
before the case is jeopardized. In most
states, when a client retains a lawyer in
connection with a personal injury case, the
client signs what is known as a Contingent
Fee Agreement. According to the terms of
the agreement, the attorney’s compensation
depends on the attorney’s ability to
obtain an economic recovery on behalf of
the client. However, most contingent fee
agreements also state that the attorney has
a duty to take all reasonable and necessary
steps to obtain a recovery on behalf of the
client, and his obligation
to return calls and respond
to reasonable requests for
case updates is implicit. If
the attorney breaches the
agreement, the client may
discharge the attorney “for
cause.” The attorney may
attempt to seek compensation
from the client based on
the number of hours devoted
to the case, but these claims
are difficult for attorneys to
enforce, particularly if they
have failed to live up to their
end of the deal.
The Bottom Line
Preserving a relationship with your attorney
is generally preferable to discharging
your attorney. Clients who understand
their role in the attorney-client relationship
tend to enhance the value of their case and
reduce instances of client dissatisfaction. If
the relationship cannot be saved—do not
sit on your hands—move on.
Attorney Eric J. Parker is a top-rated
trial lawyer with more than 20 years of
active experience representing victims
of negligence, including those suffering
from trauma-induced Complex Regional
Pain Syndrome (CRPS). Parker Scheer
LLP has offices in Boston, Massachusetts,
Providence, Rhode Island, and Las Vegas,
Nevada. Contact Attorney Parker at ejp@
parkerscheer.com, or visit the firm website
at www.parkerscheer.com. n
17

D o n a t i o n s
In Honor
Mr. and Mrs. Larry Abrams –
In honor of Mark Ryan
Warren Adler – In honor of
Suzanne Laraia
Diane Bertolino – In honor
of My Doctors & Nurses
Dr. and Mrs. Sterling Delano –
In honor of Elizabeth Simes
Gerda Lannom – In honor of
Gerda Lannom
James Prendergast – In honor
of Betty Maul
Dolores Spinello – In honor of
Suzanne Laraia
Thomas Tobin – In honor of
Jeanne Tobin
Barbara Tota – In honor of
Leslee Tota
In honor of Charleen Garcia
Jack and Jill Crevier
Laurie Crevier Hughes
Lynn Hewitt
Brian and Ann Smith
Julie Smith
Mr. and Mrs. Larry Smith
In Memory
Grosse Pointe Education
Association – In memory of
Kevin Stall
Mr. and Mrs. Nathan Miller –
In memory of Jerry Rodin
Jessie Olsen – In memory of
Larry Watson
In Memory of Irene Parr
Mr. and Mrs. James Egan
Mary Furlong
Patricia M. Melvin
Mr. and Mrs. James O’Toole
Mr. and Mrs. George Pantos
William Parker
In Memory of Janet Anne Ross
Gordon and Judy Bylsma
Tammy Hadlow
Patricia Kajdasz
Judith Lagano
Mr. and Mrs. Terrence Murphy
Mr. and Mrs. George Phillips
VA Community Care Center
Staff – NY
Mr. and Mrs. Thomas Walker
In Memory of Alex Viespi
Warren Adler
Joseph Ambriano
Marie Azzaro
Deborah Caswell
William Higgins
Theow Lau
Florence Leotta
Maureen Meehan
Joan Robertson
Mr. and Mrs. Richard Scibelli
Dolores Spinello
Donations $100 and Above
Amherst Firefighters – In honor
of Irene M. Morrissey Parr
Margaret Andruczyk
Susan Blutter
Buehler & Buehler Structural Engineers – In
honor of
Kimberly Mosier-Lemon
Mr. and Mrs. Philip Castiglia –
In memory of Alex Viespi
Philip and Mary Castiglia and Family – In
memory of Alex Viespi
Coal Cracker Cruisers Car Club
– In honor of Joann Spalnick
James A. Connelly
Barbara DeMarco
James and Idamarie Duffy
Dori Eber
Patricia Etts – In memory of
Mary G. Marcinelli
Dr. and Mrs. Ira L. fox
Bruce Gillman
Dr. and Mrs. Irwin Harris –
Happy Birthday to Mark Nestler
Helene Jablway
Mary Kenagy
Becky Kosher
Mrs. R. A. Lackman, Jr. – In honor
of Anna Crawford and in
memory of Rhett
Melenie O. Magnotta – In honor
of Mary Beth Ludington
Dena, Bonnie, and Robert
Manheimer
John and Jody Maron – In honor
of Charleen Garcia
Betty and Bob Maul, and Nick
Patrissi – In memory of
Jennie Cusenza
Sandy Mazzurco
California Office of Vital Records
– In memory of Kimberly Lemon
Cynthia Palka – In memory of
Janet Anne Ross
Vera Parfylo
Ann Rectorfine-Sturm
Stanley Sanders
Maureen and Stephen Scaring –
In honor of Suzanne Laraia
Mr. and Mrs. Kenneth Schieck –
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Kristen R. Shores
Sharon A. Smith – In honor of
Cathy Hartney
Dr. and Mrs. Robert Tortorelli
Abigail Weinshank – Happy
Birthday to Mark Nestler
Christine Wu
$200 and Above
Anthony Fitzgerald – In honor
of Suzanne Laraia
Warren B. Freitag, MD
Graphic Arts Logistics, LLC –
In honor of Betty Maul
Elena Kassner
Stacy Lademar
Debbie Schwartz
Mr. and Mrs. Ronald Scott
Susan Watson – In memory of
Larry Watson
$300 and Above
Diane Keil
$500 and above
John Crawford – In honor of Anna Crawford
and in memory of Rhett
Rian Kray
$800 and above
Happy Birthday to Mark Nestler from:
The Kleinman Family
The Ackerman Family
The Prussin Family
The Rabinowitz Family
The Spitzberg Family
The Sherman Family
The Mitchel Family
The Shirvan Family
Bounty of Hope Donations
$100 and above
Robert and Deborah Broatch
Michael Brucato
Thomas Caprio
Jean Campbell
Catherine Emmanuel
Mr. and Mrs. Meyer Neville
Julie R. Evans
Filimon Benefits Group, Inc.
Leslie Geneen
Nancy and Joseph Gherardi
Carlotta Gladding
Mr. and Mrs. Victor Henningsen
Marty Higgins
Thomas Kelly
Mr. and Mrs. John Kilmartin
Donald and Marilyn Maher
Anthony Marinelli
Mr. and Mrs. James Murphy
Sue Murphy
Marie O’Driscoll
Summit Racing Equipment
Barbara Voltz
$200 and Above
Lorraine and Kenneth Ali
Clare Bohnett
Angela Calitri
Dana Maul
Police Athletic League of
Philadelphia
Dr. William and Marilyn Bellavia
$300 and Above
Martin H. Abo, CPA
Jeanne Michelle Bingaman
Joan Blackwell
Dennis J. Delisle
Laurie Englander Dubner
Christine/Henry Di Bona/Saraceni
Richard Haunss
Bob Jennings
Mr. and Mrs. James Kenny
Mary Beth and Hank Ludington
J. M. Patton Associates, Inc.
Scott MacPherson
Joseph Marcelli
Nubar Nakashian
Dr. Richard Pearsall
Robert and Margot Rosen
Sandy Alexander Inc.
Bruce Shapiro
Dr. Carol Werle
$400 and Above
Quebecor World
$500 and Above
Joe Duncan
James Gaynor
F. H. Ludington, Jr.
David J. Steinhardt
$600 and Above
Mac Byrd
CGI North America
Dora Cardinale
Case Management Network, Inc.
EMR
Dr. and Mrs. Bradley Galer
David and Liz Lowenstein
William and Amy McLean
Peter Moskovitz, MD
$800 and Above
Fujifilm
Ogilvy HealthWorld
Quebecor World
$1,000 and Above
Alpharma Pharmaceuticals LLC
Carole and Norman Barham Family
Quad/Graphics
$1,200 and Above
Susan Tufo
18 RSDSA Review: Vol. 20, Issue 3

$1,500 and Above
Ronald P. Goldfaden
Mr. and Mrs. William Laraia
Sterling and Sterling
$2,000 and Above
Steven Hardwick
Bounty Sponsors - $3,000
Rebecca Amoroso
Brown Printing Company
Cephalon, Inc.
Deloitte Consulting
Horizon Paper Company
Kodak Polychrome Graphics
Corporate Reproduction Center
Christine LaSala
Peter McLean
Medtronic Neuromodulation
Patton Boggs LLP
Diane Romano
Seersha, Ltd.
Bounty Benefactors - $5,000
Advanced Neuromodulation Systems
American International Group, Inc.
(AIG)
Purdue Pharma, L.P.
PT/OT DVD – Donations
$100 and Above
Arndt Acupuncture
Linda R. Baker
David and Judith Barnett
Jean Brand
Ruth Caputo
Donald Christman
Edward and Anna Crawford
Rodney Derstine
James Dryden
David and Edie Faile
Steven D. Feinberg, MD
Bruce Gilman
Norma Ginsburg
Steven Goren, Attorney at Law
Stephanie Heitmeyer
Jocelyn Helm
Sandra Helm
Horizon Paper Company
Gladys Husted
Janet Johnson
Joseph E. Johnson
Linda Krononberger
Mr. and Mrs. William Laraia
James Lee
John F. Leech
Karen Marcus
Mary Carroll Miller
Elizabeth M. Nielsen
Linda Norwood
RONSCO (DEL), Inc.
Mary Ross
Audrey Russ
Elisabeth Stillitano
Gayle Tonon
James E. Tyrrell, Jr.
$200 and Above
Jean and Gary Brzezinski
Margarethe Daly
Jean M. Lindgren
Diane Ore
Kelly Stock
$300 and Above
Barry Meinerth
$500 and Above
Eric Eichler
Joav and Miriam Gersten
Glenn and Tamara Gracon
Mary Alice McLarty, P.C.
Susan Tufo
$700 and Above
Posh Properties #11
$1,000 and Above
Mr. and Mrs. James Broatch
Carol J. Batdorf
Raised over $4,000
Bernie Ackerman
$5,000 and Above
Bonaventura Devine Foundation, Inc.
Mrs. Elaine Yadwin Rieser
$10,000 and Above
Endo Pharmaceuticals, Inc.
New Jersey Fundraiser
$200 and Above
Apryl Basile
2007 Atlanta CME Conference
$2,500
Endo Pharmaceuticals, Inc.
$5,000
Elan Pharmaceuticals, Inc.
Medtronic Global Pain Management
Nippon Zoki Pharmaceuticals America
Corporate Grant
$5,000
Endo Pharmaceuticals, Inc.
Donation $10,000
Printing and Imaging Association
– In honor of Betty Maul
Research In Honor
Jean Campbell – In honor of
Jim Broatch
Jean DiRado – In honor of Charleen
Garcia
Larry and Casey Smith – In honor
of Charleen Garcia
In Memory
Nancy Jacobus – In memory
of Frank Phillips
$100 and Above
Monette Ashen
Marysusan D. Autera
Mrs. Petra Buehler – In memory
of Alex Viespi and in honor
of Suzanne Laraia
Tita Cahn – In memory of Alex Viespi
Dora Cardinale
Jeff Hamsen
Donna Kahn
Mr. and Mrs. Michael J. Materazo
– In memory of Alex Viespi
Jodi Rebholz
Bruce Shapiro
$200 and Above
Emma Dennis
North American Publishing Company
$500 and Above
Edward and Anna Crawford –
In honor of Anna Crawford
and in memory of Rhett
Christopher Kinal – Wedding
Congratulations to Marilyn Murray
$1,000 and Above
In honor of Carol McGrath –
From Her Family
Research
2007 Achilles Walk in Atlanta, GA
$100 and Above
Liza Bryan
Linda Hanley
Lauren and Micah Vance
Jennifer Lang
$300 and Above
Betty Hall
2007 Walk in Minnesota
$100 and Above
Sherri Flores
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$1,000 and Above
David Breitsprecher
2007 Achilles Walk in New York City
$100 and Above
Susan and Ted Corn
B. C. and D. E. Drake
Ethelyn Geschwind
Cheryl Wexler
Stacy Lademar
Andrea Lebbin
Marjorie Leffler
Malek Properties
Michele Mauer
I. Miller
Robin Peck
Jennifer Ross
$200 and Above
Attorney Michael Frey
Thomas Tobin
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$500 and Above
Dena, Bonnie, and Robert Manheimer
$1,000 and Above
Roger and Deborah Lebbin
$3,000 and Above
Edward Delia
$5,000 and Above
Celgene Corporation
Research $15,000
James Farnsworth – In honor of his
granddaughter Katie Berberi
Research $78,000
James and Blanche Verunac
The Rachel Tobias Young Investigator Award
Lauren Kimbar
$200 and Above
Alma Tobias
Daniel Tobias
$2,000 and Above
Cooper City High School, Florida –
Fundraiser by Nicole Biller
$100,000
Anonymous
Individuals who collected research
donations via canisters
Helga and Sal Cracolici - $80.00
Rob Dryden - $203.90
RSDSA Office - $68.00
PENPALs
Harry L. Beckett
BZ1379-1100 Pike Street
Huntingdon, PA 16654-1112
Michelle Baum
3661 Managua Dr.
Westerville, OH 43081
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