MAYO CLINIC HEALTH LETTER Tools for Healthier Lives VOLUME 29 NUMBER 1 JANUARY 2011

Inside this issue HEALTH TIPS . . . . . . . . . . . . . 3 Avoiding food and drug interactions. NEWS AND OUR VIEWS . . . . 4 Daily steps count toward health. Do calcium supplements increase the risk of heart attack? HOME DIALYSIS . . . . . . . . . . . 4 Advances in kidney care. WHOLE GRAINS . . . . . . . . . . . 6 Getting what you need. ORGAN TRANSPLANTS . . . . . 7 Need continues to grow.

Wrist arthritis Reducing pain, increasing function You’ve had a dull ache in your wrist for some time, right in the same area where you broke it years ago. Recently, though, it’s become much more painful to do certain tasks — such as turning a doorknob or carrying a grocery bag. You wonder if that broken wrist all those years ago has something to do with the wrist pain that you’re experiencing now. It just might.

A common source of wrist pain in older adults is the development of arthritis, which can take several forms. Wrist arthritis most commonly develops as a result of past trauma or fracture in the affected wrist area. For many, there are simple steps that can reduce pain and maintain as much function as possible.

Many angles

The wrist is a complicated joint made up of eight small, roundish bones with various joints. The joints of the wrist bones serve as an interface between the two long bones of the forearm and the five bones that connect to each finger. ➧

SECOND OPINION . . . . . . . . 8

Coming in February EXERCISE FOR YOUR HEART More powerful than you think. ARTHRITIS OF THE KNEE Staying fit and active. DISRUPTED BLOOD CELLS Cure is elusive for these progressive disorders. JUICING FRUITS AND VEGETABLES A better way to eat?

Rheumatoid arthritis

Arthritis due to past trauma

With rheumatoid arthritis, the joint linings (synovial membranes) are attacked by the immune system, resulting in inflammation of the joint. This can lead to destruction of cartilage and bone, which may eventually cause permanent joint damage. Symptoms of arthritis caused by past trauma usually include pain, stiffness and weakness.

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Your wrists give your hands amazing range of motion and are fairly durable. Arthritis due solely to normal wear and tear doesn’t often occur in the wrist. Rather, arthritis at the wrist usually occurs only when there has been a past trauma — such as a wrist bone fracture or ligament tear. When this traumatic arthritis occurs, symptoms usually include pain, stiffness and weakness. Rheumatoid arthritis is the second most common form of arthritis. In it, the joint linings (synovial membranes) are attacked by the immune system, resulting in inflammation of the joint. This can lead to destruction of cartilage and bone, which may eventually cause permanent joint damage. Rheumatoid arthritis affects many joints, but commonly involves both wrists. It often causes joints to feel warm, painful, swollen and stiff, particularly in the morning. Fortunately, numerous drugs are available that can be effective at suppressing the parts of your immune system that can lead to joint inflammation and damage. Wrist arthritis can also develop when the joint is affected by Lyme disease, gout, or autoimmune problems such as lupus.

Getting along

Wrist pain can have many causes, and a careful examination is required to make a diagnosis. The main difference between treatment for traumatic arthritis and rheumatoid arthritis is that rheumatoid arthritis often requires the specialized care of a rheumatologist, who can help manage the disease, primarily with careful selection of disease-modifying and immune-suppressing drugs. There are many ways you can address wrist arthritis, including: ■ Using your wrists wisely — Learn to recognize the difference between the general discomfort of arthritis and the pain that can result from putting too much strain on the joint or from overusing it.

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When you begin to understand the actions that cause pain, you can try to avoid or modify those actions. For example, if you have arthritis in your right wrist and it hurts to turn a doorknob, you may be able to use your left hand to do the job. It also may help to grasp the doorknob while keeping your forearm and small finger side of your hand parallel with the door. Still another option might be to have lever-style door handles installed. These don’t require a turning motion to open. Many other products exist that can help you perform everyday tasks with less wrist strain. ■ Applying heat or cold — Using electric heat pads or soaking your wrists in warm water can ease pain, decrease joint stiffness and relax tense muscles. An ice pack wrapped in cloth or hand soaks in cool to cold water can help reduce pain in the event of a flare-up from too much activity. Contrast baths also may be helpful. Start by soaking your hands in water that’s between 100 and 110 F for about five to 10 minutes. Then switch to water that’s between 65 and 75 F for about one minute. Cycle back and forth for about 30 minutes and end with the warm water.

With your doctor’s help

With any form of wrist arthritis, your doctor may be able to help you with additional steps to control pain and maximize wrist function, including: ■ Topical pain-relieving drugs — The prescription gel diclofenac (Voltaren, Solaraze, others) can be rubbed directly on the skin around the affected joint. Topical anti-inflammatory drugs appear to cause fewer side effects than do oral anti-inflammatory drugs, such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve, Naprosyn). Other topical creams, gels or sprays that may help with pain include January 2011

products containing methyl salicylate (BenGay, Icy Hot, others) or capsaicin (Capzasin, Zostrix, others). ■ Pain medications — Nonprescription pain medications, such as acetaminophen (Tylenol, others), ibuprofen or naproxen, can help ease the pain of arthritis. But talk to your doctor if you feel the need to frequently take these pain relievers. Regular use of certain oral pain-relieving medications can cause serious side effects. Taking your health history into account, your doctor can help you choose an effective pain medication and drug dose that minimizes the risk of side effects. Typically, acetaminophen taken at appropriate doses is considered the pain medication with the lowest risk of side effects. ■ Splints — These limit the movement of your wrist. If you are having a flare-up of pain, a splint can supMAYO CLINIC HEALTH LETTER Managing Editor Aleta Capelle

Medical Editor Robert Sheeler, M.D.

Associate Editors Carol Gunderson Joey Keillor

Associate Medical Editor Amindra Arora, M.D.

Medical Illustration Michael King Customer Service Manager Ann Allen

Editorial Research Deirdre Herman Proofreading Miranda Attlesey Donna Hanson Julie Maas

Administrative Assistant Jane Sultze

EDITORIAL BOARD Shreyasee Amin, M.D., Rheumatology; Amindra Arora, M.D., Gastroenterology and Hepatology; Brent Bauer, M.D., Internal Medicine; Julie Bjoraker, M.D., Internal Medicine; Lisa Buss Preszler, Pharm.D., Pharmacy; Bart Clarke, M.D., Endocrinology and Metabolism; William Cliby, M.D., Gynecologic Surgery; Diane Dahm, M.D., Orthopedics; Mark Davis, M.D., Derma­tology; Timothy Hobday, M.D., Oncology; Lois Krahn, M.D., Psychiatry; Amy Krambeck, M.D., Urology; Suzanne Norby, M.D., Nephrology; Robert Sheeler, M.D., Family Medicine; Phillip Sheridan, D.D.S., Perio­don­tics; Peter Southorn, M.D., Anes­ thesiology; Ronald Swee, M.D., Radiology; Farris Timimi, M.D., Cardiology; Aleta Capelle, Health Information. Ex officio: Carol Gunderson, Joey Keillor. Mayo Clinic Health Letter (ISSN 0741-6245) is published monthly by Mayo Foundation for Medical Education and Research, a subsidiary of Mayo Foundation, 200 First St. SW, Rochester, MN 55905. Subscription price is $29.55 a year, which includes a cumulative index published in December. Periodicals postage paid at Rochester, Minn., and at additional mailing offices. POSTMASTER: Send address changes to Mayo Clinic Health Letter, Subscription Services, P.O. Box 9302, Big Sandy, TX 75755-9302.

Maintaining movement Simple range-of-motion exercises that involve gently moving your wrist in different directions may help reduce joint stiffness. Wrist strengthening can help increase the support your muscles provide to your wrist joint. You don’t need to put undue strain on your wrist joint — or even move it at all — to strengthen it. You can do this by resisting movement. Hold your wrist joint straight and gently apply force to it, either with the opposite hand, by holding a small dumbbell, or by using an elastic band. Gently rotating your arm with a weighted object such as a hammer can build strength with minimal wrist movement. Do these exercises slowly and gently. If you have pain when doing an exercise, stop the exercise and relax. If the pain goes away, you may be able to repeat the exercise with reduced speed and intensity. If pain continues, talk with your doctor or a physical therapist before resuming the exercise.

port the wrist and give it the rest it needs to recover. You may have less pain when wearing a splint during a wrist-intensive activity. Generic splints can be purchased in drugstores, or they can be custom made. Styles range from the minimal support of an elastic sleeve to very rigid and movement-limiting plastic supports. ■ Corticosteroid injections — An injection of this anti-inflammatory medication in the area of the painful joint often can reduce pain and swelling for weeks to months. Up to three injections in a year are considered safe for most people. However, the injected medication can have a cumulative damaging effect on tendons and cartilage and isn’t recommended for regular use.

Many Mayo Clinic hand specialists allow no more than three injections in the same place, even if the injections are spread over several years.

Surgery as a last resort

Surgery is much less common than in the past because the drugs used to control rheumatoid arthritis are so much more effective. The main surgical procedures include: ■ Joint fusion — This may involve partial or total fusion of the joints in the wrist. ■ Joint replacement with an artificial joint — Replacing your wrist with an artificial joint allows you more movement than does total joint fusion. The success rate isn’t as high as for other, more frequently replaced joints, such as the hip and knee. ❒ January 2011

Health tips Avoiding food and drug interactions What you eat or drink may delay, accelerate, decrease or increase drug absorption. Beware of consuming large amounts of: ■ Grapefruit juice — Avoid grapefruit juice when taking certain statins to treat high cholesterol — particularly simvastatin (Zocor), lovastatin (Mevacor) and atorvastatin (Lipitor) — or certain calcium channel blockers, such as felodipine, nifedipine (Procardia XL) and nisoldipine (Sular). Grapefruit juice should be avoided when taking the organ transplant drug cyclosporine (Neoral, Sandimmune, others) and anti-anxiety drug buspirone (Buspar). Grapefruit can increase levels of these drugs in the body, which can lead to more side effects. ■ Vitamin K — If you use the blood-thinning drug warfarin (Coumadin), be consistent in how much vitamin K you eat. Avoid eating large amounts of foods rich in vitamin K, such as kale, spinach and Brussels sprouts. These can decrease the desired effect of warfarin. ■ Dairy products — Calcium-containing foods can decrease the effect of certain antibiotics, such as ciprofloxacin (Ciloxan), levofloxacin (Levaquin) and doxycycline. They also can interfere with the thyroid replacement drug levothyroxine (Synthroid, Levothroid, others). ■ Caffeine — Some drugs, particularly the antibiotic ciprofloxacin (Cipro), exaggerate the effects of caffeine. ❒

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News and our views Daily steps count toward health Increasing the number of steps taken in a day may reduce the likelihood of developing metabolic syndrome. Metabolic syndrome is a cluster of three or more conditions — increased blood pressure, elevated insulin levels, excess body fat around the waist or abnormal cholesterol levels — that occur together, increasing your risk of heart disease, stroke and diabetes. The study, published in the June 2010 issue of The American Journal of Preventive Medicine, involved 1,446 adults. For seven days, each participant wore an accelerometer to record the number of steps taken. Those who took between 5,000 and 9,999 steps a day were considered low to somewhat active, and those taking 10,000 or more steps were deemed active to highly active. About 2,000 steps is considered roughly the same as one mile. Among men, the odds of metabolic syndrome were 24 percent lower in the low to somewhat active group and 69 percent lower in the active to highly active group. Women in the low to somewhat active group had a 53 percent decreased risk of metabolic syndrome. The odds decreased by 72 percent in the most active group. For each additional 1,000 steps in a day, there was an approximate 10 percent decrease in the odds of developing metabolic syndrome. Mayo Clinic cardiologists say the study clearly demonstrates that activity amounts are related to reduced cardiovascular risk and specifically to reduced chances of developing metabolic syndrome. ❒

Do calcium supplements increase the risk of heart attack?

A recent study in the July 2010 issue of the British medical journal BMJ showed that taking calcium supplements raised the risk of heart attack by 27 percent. However, these results need to be balanced against past studies that have found calcium supplementation to have little or no effect on heart attack risk. In addition, the BMJ study had some weaknesses. For example, multivitamins or supplements containing calcium plus vitamin D — which is often how calcium is taken — were not evaluated in the review. For men ages 51 to 70, the Institute of Medicine’s latest recommendation is for 1,000 milligrams (mg) of calcium a day. The recommendation increases to 1,200 mg a day for women age 51 and older and men age 71 and older. Recommended levels may be as high as 1,500 mg daily for those with — or at risk of — osteoporosis. Mayo Clinic experts recommend keeping consumption of calcium from diet and supplements combined to no more than 1,500 mg daily. In addition, consider talking to your doctor about your optimal calcium intake, taking into account your age, risk of osteoporosis, risk of heart problems and possibly other factors. If you take a calcium supplement, take one that contains vitamin D, which may provide added benefits. ❒

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Home dialysis Advances in kidney care Hundreds of thousands of Americans rely on kidney dialysis. Dialysis does what a healthy kidney would do. It’s used to help manage end-stage kidney disease when your kidneys are unable to remove enough waste products and fluid. Hemodialysis is one type of dialysis in which blood passes directly from the body through a machine that filters the blood and then returns it to the body. You may associate kidney dialysis with center-based treatment programs. As a growing number of medical centers also offer home hemodialysis, the number of people doing so is increasing. Machines for home use are getting simpler and safer. And costs are significantly lower than for conventional center-based dialysis. It isn’t for everyone, but it may be worth considering.

Outside the box

Most people receiving kidney dialysis travel to a clinic three times a week to have their “blood cleaned.” In conventional hemodialysis, each pre-scheduled visit typically involves sitting for three to five hours while your blood is filtered and then returned to your body through a specialized dialysis machine. More time may be needed to be sure blood pressure returns to normal and any bleeding from the needle transfer site is stopped. With travel time and the common experience of feeling exhausted for several hours afterward, the better part of a day may be spent dealing with one dialysis session. For some, an alternative type of dialysis may be home hemodialysis. Although availability is limited, home hemodialysis offers those who can do it the flexibility to perform

dialysis in their own home and at times suited to their lifestyle. In addition, there’s evidence that dialyzing at home leads to better results. Significant improvements in overall well-being, heart function and sleeping patterns are evident when dialysis is done more frequently at home, either during the day or while sleeping at night. Studies have consistently shown that daily dialysis six times a week or nightly dialysis three to six times a week leads to fewer hospitalizations and a reduction in the number of medications needed. People who are the sickest generally do the best with daily home dialysis.

Home hemodialysis offers those who can do it the flexibility to perform dialysis in their own home and at times that may be better suited to their lifestyle.

Some considerations

Determining whether home hemodialysis is a good fit for you depends on various factors, including whether your dialysis center can provide it and if you have someone to help with your treatments. As with any form of hemodialysis, easy access to your bloodstream is key. Before your first dialysis, a surgeon creates a vascular access — typically in your arm just under the skin — where needles can be placed during dialysis to remove blood from and return it to your body. Home hemodialysis machines are designed to be user-friendly. Even so, training for use at home may take several weeks to a couple of months. Training often starts with learning to do treatments while at a clinic and with the help of the person who will help you at home. In addition to setting your own schedule for treatments, another advantage of home hemodialysis includes being able to consider in consultation with your nephrologist having treatments more frequently or while sleeping. Instead of three days at a treatment center plus travel time, you may plan for home treatments on five or six days a week that can finish in two to three hours.

More frequent dialysis at home means removing less fluid a session, allowing for improvement in how you may feel during and between treatments. Longer, nightly hemodialysis while you sleep allows for a slower blood flow rate during dialysis, which can be easier on the blood vessels used for access, and on your heart. More phosphorus and other wastes can be removed with these longer treatments. Your dialysis care team can determine how many days and hours of home hemodialysis are needed for optimal care. Some clinics monitor treat-

Peritoneal dialysis Another method of cleaning your blood when your kidneys are no longer able to do so is peritoneal dialysis. During peritoneal dialysis, blood vessels in your abdominal lining (peritoneum) fill in for your kidneys, with the help of a fluid (dialysate) washed in and out of the peritoneal space. January 2011

ment results remotely from information collected by your home dialysis machine. However, regular blood tests are needed to be sure enough wastes are being removed from your blood.

Quality time

Those who do home hemodialysis report having more energy, sleeping better and feeling less nauseous. The main limiting factors are a lack of centers, a fear of doing it at home, and not having a family member who can help with the process. Although large studies directly comparing home hemodialysis with conventional in-center treatment are lacking, many smaller studies have noted improved outcomes in people doing home hemodialysis on a daily or nightly basis. These include: ■ Improved blood pressure control with fewer medications ■ Better control of the level of phosphate in your blood ■ Reduced need for more stringent diet and fluid limitations associated with conventional dialysis ■ Improvement in a type of heart damage associated with high blood pressure ❒ www.HealthLetter.MayoClinic.com

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Whole grains Getting what you need You’ve got the goal of eating at least five servings of fruits and vegetables each day. You’re aiming for 1,200 milligrams of calcium, and you probably have other nutrition targets as well. But what about whole grains? It’s commonly recommended that you include these in your diet. How much should you be getting? It’s a good question, because specific recommendations for whole grain consumption aren’t something you often see — and when you do, the values can be hard to interpret.

What’s in a grain?

Whole grains include any type of grain that has been minimally processed so that edible components of the grain kernel — the bran, germ and endosperm — remain. Whole grains come in many forms, from the familiar — whole wheat, oats, brown rice, wild rice, barley, corn, popcorn and buckwheat — to the less familiar such as black or red rice, amaranth, millet or quinoa (KEEN-wah). In contrast, refined grains are processed so that most of the bran and some of the germ are removed. The most common refined grains include white wheat flour and white rice. White wheat flour makes an appearance in many foods such as enriched pasta, white bread, white tortillas, and many cereals and snacks. Grains are refined to give the grain a finer texture and to improve shelf life. However, this process removes the most nutrient-dense portions of the grain. Refined grains are then fortified and enriched with several vitamins and minerals. However, only a small number of vitamins and minerals are added back, and

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Whole-grain food

1-ounce equivalent

100% whole-wheat bread

1 slice

100% whole-grain crackers, such as Triscuit Thin Crisps or similar store brand Oatmeal

5 crackers

Popcorn Breakfast cereal: wholewheat flakes Brown rice, barley, wholewheat pasta Whole-wheat tortilla

1/2 cup cooked or 1 instant oatmeal packet 3 cups popped 1 cup flakes 1/2 cup cooked 1 6-inch tortilla

Source: USDA National Nutrient Database for Standard Reference, Release 22

not in the same proportion as in the whole grain. Whole grains contain other beneficial phytochemicals. Phytochemicals aren’t necessary in the diet as are vitamins, but they still offer health benefits. Whole grains also contain more soluble and insoluble fiber and protein. The added nutrition of whole grains can be important to your health. Research indicates that regular consumption of whole grains — especially when substituted for refined grain consumption — is associated with a healthy weight, improvement in cholesterol levels, lower blood pressure, reduced risk of heart disease and type 2 diabetes, and prevention of certain cancers.

Spotting whole grains

You can’t necessarily identify a whole-grain product by its color. For example, refined-grain bread can be made to look brown with molasses, and you can find wholegrain white bread that’s made with an albino variety of wheat. Instead, look for the words “whole grain” on the package, and make sure a type of whole grain — such as whole wheat — appears among the first items in the ingredient list. Try to choose items with at least 3 grams of dietary fiber a serving.

January 2011

Terms such as “100 percent wheat,” “multi-grain,” “seven-grain” “stoneground,” or “bran” don’t necessarily indicate a product is made mostly of whole grains.

What you need

For adults older than 50, eating just three 1-ounce equivalents of whole grains a day by substituting whole grains for refined grains can be beneficial in terms of preventing disease and maintaining a healthy weight. Use the above chart to help you tally up the ounce equivalents you eat in a day. If you’re keeping your calorie consumption in check, you’ll likely gain greater health benefits by increasing your daily intake of wholegrain ounce equivalents. You may be able to do this by making wholegrain foods your usual choice and refined grains the occasional choice. Start with simple substitutions such as whole-grain bread instead of white bread, whole-grain pasta instead of enriched pasta or brown rice instead of white. You can get more creative by trying a whole grain that you’ve never tried before — such as quinoa — adding barley to a soup, or substituting whole-wheat flour for up to half of the flour in baked goods or pancake batter. ❒

Organ transplants Need continues to grow Every year, thousands of transplant success stories emerge from hospital operating rooms. The field of transplant medicine offers proven treatments for serious and often fatal diseases and conditions. However, organ availability falls short of meeting the needs of the growing number of people — more than 86,000 — on the national organ transplant waiting list. Efforts by doctors and scientists to develop ways to increase the supply of transplant organs — such as kidney and liver transplants from living donors — have helped. There’s ongoing biological engineering research to create tissues and possibly organs from human stem cells. However, people who elect to be organ donors when they die remain by far the most important source of organs for transplant.

A matter of survival

One-year survival rates after a transplant speak to the advances made in surgical techniques and drug regimens to prevent organ rejection. According to the most recent available data, those with the highest one-year survival rates — which ranged from 95 to 98 percent — are kidney transplant recipients and pancreas transplant recipients. One-year survival rates for those receiving a liver, intestine, lung or heart transplant are approximately 81 to 90 percent. Organ transplants aren’t just for the young. Among organ transplant recipients, about 15 percent are adults age 65 and older. Historically, living donor transplants have typically been done within families — a close relative might donate to another family member. But living donor transplants between unrelated individuals also are being done. Generally, living donors must be physically fit and in good general health, free from high blood pressure, diabetes and cancer as well as kidney, heart, liver and lung disease.

In 2009, living donor transplants accounted for 24 percent of the organ transplants done. Organs eligible for live donation include a single kidney, a segment of the liver, a lobe of the lung, a portion of the pancreas and a portion of the intestine.

Never too old

Contrary to what you may have heard, you’re never too old to be a potential organ donor. There are no strict upper or lower age limits. In the end, organ condition trumps age. Even if you have a medical condition, organ donation may still be possible. Several factors are considered, including the types of illnesses you had before your death, your physical condition prior to death, and which organs and tissues might be donated. To sign up as an organ donor, visit: http://organdonor.gov. You can also designate yourself as an organ donor when you obtain or renew your driver’s license. For more information about living donation and organ transplantation, call the United Network for Organ Sharing toll-free at 1-888-894-6361. ❒

U.S. organ transplant numbers and recipient survival rates Organ transplants 2009 Number of procedures in the U.S. Number of living donor transplants Current approximate number on waiting list Number performed on ages 50 to 64 Percent survival at 5 years (2001 to 2006)

Kidney

Liver

Heart

Lung

Pancreas

Intestine

16,829

6,320

2,211

1,660

379

180

6,387

219

1

0

2

86, 254

16,001

Not applicable 3,144

77

1,434

255

6,555

3,607

964

812

81

38

81%

72%

75%

53%

79%

41%

Number preformed on age 65 and older Percent survival at 5 years (2001 to 2006)

2,659

697

287

368

1

1

68%

64%

67%

44%

Not known

60%

Source: The Organ Procurement and Transplantation Network and Scientific Registry of Transplant Recipients.

January 2011

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Second opinion Q: Should I get a shingles vaccine if I’ve already had shingles? A: The Centers for Disease Control and Prevention (CDC) recommends that most adults age 60 or older receive the shingles vaccine (Zostavax) — even if they’ve had an episode of shingles in the past. Shingles can recur, and the vaccine can lower the risk of recurrence. Shingles is caused by the virus that causes chickenpox. Although your body develops immunity to the virus after you have chickenpox, the virus survives and remains dormant within nerve tissue. For unknown reasons, the latent virus sometimes gets reactivated years later, causing the painful, blistering rash of shingles. Getting the shingles vaccine if you’ve had chickenpox — or shingles — helps prevent reactivation of the virus. The shingles vaccine isn’t failsafe. Some people develop shingles despite vaccination. However, even when it fails to suppress the virus completely, the shingles vaccine may reduce the severity and duration of shingles. The most common side effects of the shingles vaccine are redness, pain, tenderness and swelling at the injection site, as well as headache. In addition, the shingles vaccine is a live vaccine, so it isn’t recommended for those with a weakened immune system due to HIV/AIDS, lymphoma or leukemia — or who are receiving radiation, chemotherapy or other immune Copyright

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system-suppressing drugs for organ transplants and autoimmune conditions such as rheumatoid arthritis or lupus. ❒

Q: My sister fell and injured her shoulder a few months ago. She’s developed terrible burning pain down into her arm. Her doctor says she has complex regional pain syndrome, also known as reflex sympathetic dystrophy. What is it? How is it treated? A: Complex regional pain syndrome (CRPS) is an unpredictable disorder that occurs most typically in an arm or leg. It usually — but not always — follows an injury such as a fracture, surgery, or a vascular event, such as a heart attack or stroke. Why it develops is uncertain, but it may involve abnormal interactions between the nerves and blood vessels of the affected limb. Diagnosing CRPS is a challenge. The pain that develops is typically more severe than what might be expected for the injury it’s related to, and the pain often fluctuates. Most often it’s burning pain, but dull, throbbing and occasionally sharp pains may occur in the affected limb. Extreme sensitivity to various stimuli — such as physical activity, weather, even stress or strong emotions — can aggravate pain. Areas of swelling (edema) usually develop along with changes in skin color and temperature. Eventually, movement may be limited and

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fingers or toes on the limb may become unnaturally bent. Response to treatment varies and is difficult to predict — the pain may resolve, or it may remain stable for years. However, most people who have CRPS eventually experience improvement. Early on, physical therapy — which may include strength training and exercises to increase range of motion — is a critical part of treatment. Early use of corticosteroids and possibly nonsteroidal anti-inflammatory drugs (NSAIDs) may help reduce pain so that important physical therapy can be accomplished. Other medications, such as tricyclic antidepressants and anticonvulsants also may help reduce pain. For some, opioid pain relievers are useful. In selected cases, moreinvasive therapies — such as nerve blocks or spinal cord stimulators — may be necessary. ❒

Have a question or comment? We appreciate every letter sent to Second Opinion but cannot publish an answer to each question or respond to requests for consultation on individual medical conditions. Editorial comments can be directed to: Managing Editor, Mayo Clinic Health Letter, 200 First St. SW, Rochester, MN 55905, or send email to [email protected] For information about Mayo Clinic services, you may telephone any of our three facilities: Rochester, Minn., 507-284-2511; Jacksonville, Fla., 904-953-2000; Scottsdale, Ariz., 480-301-8000 or visit www.MayoClinic.org

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