Double Blind Placebo Controlled Study of Outpatient Intravenous Ketamine for the Treatment of CRPS

PRE TREATMENT:

Prior to treatment, after informed consent is obtained, each subject will be randomized into
the ketamine or placebo (normal saline) infusion group. Both the patient and all other
individuals involved in the study will be blinded as to the treatment except Guillermo
Alexander PhD who will be responsible for the randomization and Margaret Rose RN who will be
responsible for preparing the infusion solution. The patient will then receive a complete
neurological examination and will be asked to complete a short form McGill and Quality of
life questionnaires (Attachment 1).

Two weeks before treatment, 2 week and 3 months post treatment the following sensory and
motor tests will be performed.

Thermal Detection Thresholds: Cool detection thresholds, which are mediated via A fibers and
warm detection thresholds, which are mediated by small unmyelinated C fibers, will be
determined using the TSA-II NeuroSensory Analyzer (Medoc Advanced Medical Systems U.S.,
Minneapolis, MN). The device consists of a computer controlled thermoelectric probe with a
surface area of 9 cm2 that is attached using a velcro strap to the area of skin to be tested
(thenar eminence and hypothenar eminence in the hands and the dorsal foot). For each trial
the thermal stimulator starts at the thermo-neutral baseline temperature of 32oC, and
increases for warming thresholds, or decreases for cooling thresholds, linearly at a rate of
1oC per second, until the subject pushes a button that stops and records the temperature and
returns the unit to baseline temperature. Three trials are averaged for cool and for warm
threshold for each site tested.

Thermal Pain: Thermal pain tolerance will be determined at the same sites and using the same
method described above for thermal detection thresholds. The only difference is that for
thermal pain trials, the subject will be instructed to push the control button (which
immediately resets the stimulator back to baseline temperature) when the thermal stimulus
(cold or hot) becomes painful. The TSA-II hardware automatically resets if the temperature
reaches -10oC (for cooling) or 50oC (for heating) and the control button has not been pushed.
This temperature range has been determined to not cause damage to skin or underlying tissue.

Dynamic Mechano-allodynia: Dynamic mechano-allodynia will be determined by stroking the skin
three times within 5 seconds at a rate of 5 cm/sec with a 2.5 cm wide standard foam
paintbrush. Allodynia severity will be measured on the subject's response using a numerical
rating scale. The subject reports both the amount of pain on a 0-10 scale (0: no pain; 10:
worst pain ever experienced) and the extent to which the sensation spread.

Static Mechano-allodynia and Temporal Summation: Static mechano-allodynia and temporal
summation will be determined by pin-prick with a standard safety pin once every three seconds
for a total of 5 times. The subject will be instructed to report the level of pain on a 0-10
scale (0: no pain; 10: worst pain ever experienced) and the extent to which the sensation
spread after each repetition. The test will stop if the subject reports unacceptable pain at
any point during the test.

Deep pressure pain thresholds: Deep pressure pain thresholds will be determined with a
pressure algometer (Wagner Instruments, Greenwich, CT) which is a hand held device with a
1cm2 rub¬ber tip capable of measuring applied pressures of 0-5 kg. The device is held at a
90o angle to the body surface being tested. The pressure is gradually increased by 1
kg/second until the subject reports that the stimulus is painful or a pressure of 4 kg/cm2
has been reached. In the upper extremity thresholds to pain will be determined at: 1)second
costosternal joint; 2) acromioclavicular joint; 3) lateral epicondyle; 4) radial styloid; 5)
ulnar styloid; 6) second metacarpal; 6) fifth metacarpal. In the lower extremity thresholds
to pain will be determined at: 1) greater trochanter; 2) lateral femoral condyle; 3) tibial
tubercle; 4) mid shin; 5) medial malleolus; 6) lateral malleolus; 7) first metatarsal; 8)
fifth metatarsal.

Quantification of Motor Function (finger tap): Finger tap rate will be determined using a
computer program developed by our group. The subject is instructed to press the spacebar of a
standard computer keyboard as fast as possible with the index finger of each hand
respectively for 30 seconds. The program determines the rate and plots the results.

Cutaneous Temperature: Skin temperature will be measured by use of an infra-red thermometer
(Dermatemp Infrared Temperature Scanner, model DT-1001, Exergen Corp., Watertown, MA)

A pregnancy test will be administered to all females of child bearing potential and blood
will also be drawn for SMA-20, CBC w/ Differential and a full thyroid panel. All subjects
will be asked to wear an activity watch until the treatment begins (two week). This watch
(Attachment 2) will evaluate the subject's level of activity and at random programmed
intervals records the subject's pain level for the two weeks prior to treatment. This is
accomplished by sounding a tone at which time the subject is instructed to presses a key pad
and enter a number from 0-10 (0 = no pain and 10 = unbearable pain). The patient will be
asked to complete the short form McGill and Quality of life questionnaires weekly until the
start of the infusions.

PRE INFUSION:

On the first day of treatment but prior to the start of the infusions, the patient will be
weighed, undergo a neurologic exam, have vital signs evaluated and have an intravenous line
inserted.

On all ten treatment days, patients on both the ketamine and placebo groups are placed on the
cardiac monitor for cardiac rhythm, blood pressure, pulse and oxygen saturation monitoring.
In addition, Clonidine (0.1 mg, po) and Versed (4 mg, iv) will be administered. Clonidine has
been shown, in animals, to potentiate the neuropathic pain-relieving action of NMDA receptor
blockers like ketamine while preventing their neurotoxic side effects. Versed at this dose,
provides mild sedation and relieves anxiety.

INFUSION PLAN:

All patients will be infused intravenously with 100 ml of normal saline with or without
ketamine for four hours (25 ml/hr) daily for 10 days. The maximum intravenous ketamine
infusion dose for this study will be 0.35 mg/kg/hr, not to exceed 25 mg/hr (100 mg of
ketamine over a 4 hour period). On the first day, the intravenous ketamine infusion will be
set to 50% of the maximum rate. On the second day, the intravenous ketamine infusion will be
increased to 75% of the maximum rate. On the third day, the intravenous ketamine infusion
will be increased to the maximum rate. The daily ketamine infusion rate is maintained at this
level for the duration of the ten day study.

CONSIDERATIONS: (Other Treatments and Meds)

Increased salivation:

Glycopyrrolate (Robinul) Initially 1mg TID then maintenance dose BID prn

Psychiatric symptoms:

Ativan 1mg - HAVE AVAILABLE prn Continued use of current medications with the exception of
NMDA receptor blockers such as amantadine, memantine, Magnesium sulfate.

Administer other adjuncts prn O2 2-3 L/min. via Nasal Cannula - HAVE AVAILABLE prn

LABS:

Ketamine Level (red top tube) on infusion days 1, 5, 6 and 10.

NURSING CARE & ORDERS:

During the IV Ketamine Infusion:

Continuous cardiac monitoring, Pulse oximetry with q 1 hr blood pressure monitoring V/S q 1
hr Versed (2 mg iv) administration may be repeated two hours into or at the completion of the
infusion.

Activity:

Patient can leave infusion chair with assistance for bathroom visit. Patient is allowed to
bring head set (music) or a book to read. No cell phones or laptop computers are allowed.

Following the last (10th) infusion, the patient will be seen at two weeks then monthly at the
Neurology Pain Clinic for the following 3 months. All subjects will be asked to wear an
activity watch from the time of the last infusion until the two week post treatment visit.
Patients will be instructed to complete the

Inclusion Criteria:

- Patients diagnosed with CRPS based on the modified IASP (International Association for
the Study of Pain) research criteria (Harden RN and Bruehl SP

- Diagnostic Criteria: The Statistical Derivation of the Four Criterion Factors.

- In CRPS: Current Diagnosis and Therapy, Progress in Pain Research and Management, Vol
32: pp 45-58, 2005), whose condition is intractable for at least six months and have
failed at least three of the following therapies:

- Nerve blocks

- Opioid analgesics

- Non-opioid analgesics

- Non-steroidal anti-inflammatory drugs

- Anti-seizure medications

- Antidepressants

- Muscle relaxants; or

- Physical therapy.

- The patients must be ketamine naïve and can be of either gender including all racial
and minority groups. The patient's age must be between 18 and 65 years, inclusive.

- The study subjects must report pain levels equal to or greater than 4 on a scale of
0-10 (0 = no pain and 10 = unbearable pain). The pain must be stable over time and not
vary more that 1 pain level.

- The patient must be on a stable dose of CRPS medications for 28 days prior to and
throughout the duration of the study.

- The patient must be accompanied by a responsible adult.

- The patient will be instructed that he/she will not be allowed to drive home following
the infusion. Therefore in order to be included in the study the subjects must arrange
for transportation for the 10 day duration of the study.

Exclusion Criteria:

- Patients less than 18 years of age will be excluded. In this initial study, patients
over 65 years of age will be excluded due to possible unforeseen concomitant medical
problem.

- Patients that have previously undergone intravenous ketamine infusions will be
excluded from the study.

- Patients who are pregnant, are lactating, have known psychotic or psychiatric illness,
are afflicted with glaucoma or have thyrotoxicosis will also be excluded.

- Any patient that is unable to provide consent due to cognitive difficulties will not
be used in this study.

- Patients that can not provide the means to be transported home following daily
infusions will be excluded from the study.

- The investigators feel that issues concerning monetary gain and or loss due to the
patient's medical condition may adversely affect the study, therefore, patients with
active litigation, compensation or disability issues related to their CRPS will be
excluded.

- Patients with a history of substance abuse will be excluded.

- Patients on certain blood pressure lowering medications such as calcium blockers, or
beta blockers will be excluded from the study.

- Patients with major medical problems including but not limited to; uncontrolled
hypertension, hypotension, cardiac failure, renal failure or liver failure will not be
used in this study.