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Reflex Sympathetic Dystrophy is a chronic pain disorder
involving the sympathetic nervous system. It usually is
the result of an injury or trauma, but can also be a complication
of surgery, infection, casting or splinting and myocardial
infarction (heart attack).
The
trauma sets off the body's mechanism for pain recognition,
but then the "normal system of pain perception"
begins to misfire and an abnormal cycle of intractable
pain begins. As RSD progresses, the abnormal pain of the
sympathetic nervous system has an effect on other areas
of the body and can result in total disability as muscles,
bones, skin and the autonomic immune system become involved.
The
first indication of RSD is prolonged, intractable pain
usually more severe than the injury. The symptoms are:
- chronic
burning pain in a localized area,
-
intense sensitivity to temperature and light touch,
and
- a
color change to the skin.
Most
physicians agree that there are three stages to RSD, which
progress at a different pace in each person.
Stage
1 (Acute,
1 - 3 months): Burning pain, edema, increased
nail and hair growth, hyperthermia or hypothermia, muscle
spasm, and vasospasm.
Stage
2
(Dystrophic, 3 - 6 months): Pain
becomes more intense and proximal, sometimes crossing
the midline, cold insensitivity, brawny edema, swollen
digits, hyperhidrosis, early atrophy and loss of ROM,
mottled skin, changes in the nails, with osteopenia late.
Stage
3
(Atrophy, > 6 months): Pain involving
the entire limb becomes more diffuse and subsides to a
degree. Skin is pale and cyanotic with a smooth shiny
appearance. Further bone loss and contractures are associated
with worsening atrophy and irreversible changes. There
may be a wasting of affected muscles, contraction of tendons,
and a definite withering of the affected limb.
In
all of the stages, severe chronic pain continues to be
a major complaint. Depression can accompany the life changes
of RSD and psychological therapy may help.
Although
RSD can be a progressive disorder, it should not be assumed
that all cases will advance and present all clinical symptoms
and dysfunction. Early and effective treatment may lesson
the effect of RSD in some individuals.
RSD may result from --
- minor
trauma,
- inflammation
following surgery,
-
infection,
-
lacerations,
- degenerative
joint disease,
- burns
and
- any
compression (such as casting or swelling due to injury)
that may cause prolonged pressure on peripheral nerves.
"Peripheral
neuropathies, nerve-entrapment, neuromas, thoracic outlet
syndrome and carpal or tarsal tunnel can coexist with
RSD.
It
is hard for some physicians to accept a dual disease process
and not just focus on only one of the diseases. Many other
chronic pain disorders may be mistakenly diagnosed as
sympathetically maintained pain or RSD because of similarities
in clinical presentations.
Diagnosing
RSD is very important so proper therapy can be
applied. A wrong diagnosis is like having carburetor problems
with the engine of your car and using a tire pump to try
to fix it."
DIAGNOSIS:
It is important to make an RSD diagnosis as early as possible
!
A.Early
diagnosis includes a thorough history and examination.
1.
Look for: allodynia, burning pain, edema,
color or hair growth changes, diaphoresis,
temperature changes in the skin, muscle weakness.
2. Rule out musculoskeletal, rheumatologic,
infectious, vascular, or psychiatric disorder.
B.Diagnostic
studies:
1.
Plain film x-rays - patchy periarticular
osteoporosis (in mid to later stages)
2.
Triple-phase bone scan- high specificity
and sensitivity in early to mid stages. Static
phase is most sensitive and shows increased uptake in
periarticular bone.
3.
CT scan- swiss cheese appearance of involved
bone.
4.
Thermography/Doppler- blood flow and
temperature
5.
Sympathetic block- decreases sympathetic
effector response on cutaneous nerves
TREATMENT
Excerpt from
RSD
Puzzles List: The Necessity of Early
Diagnosis and Treatment
by H. Hooshmand, M.D., P.A.
Neurological
Associates - Pain
Mgmt Center
February
2002
"You
have no dystrophic changes and no atrophy in the extremity.
You are in stage-I of RSD. Your condition is mild, and
you have had the RSD for five years. There is nothing
that can be done for you and being in stage-I RSD you
should be able to go back to normal life."
The chronicity
of RSD is far more important than the stage the patient
is in.
The accurate
predictor in regards to the patient's treatment is not
presence or lack of atrophy in the muscles of the extremity.
What
is more important is the length of time the patient
has suffered from the illness. In the
first six months, the disease is far more amenable
to successful treatment.The success rate in the first
six months, if the RSD is treated properly, is over 80-90%.
Between six months to a year,
it drops to 60-80% and after two
years, there is a risk of over 40% failure and
with the passage of each year, the disease becomes more
established and more difficult to treat.
The
other accurate indicator is the patient's age.
Up to 22 years of age, the patient has excellent recovery
power.
All
of these indicators mean nothing if the patient undergoes
treatment with ice, addicting narcotics, unnecessary
operations such as sympathectomy, spinal stimulator,
amputation, or surgery in the form of exploration in the
area of inflammation of the RSD. Such dangerous
treatments render a far lower rate of success
in the long run independent of the stage of RSD. The above
mentioned risky and dangerous treatments would be replaced
with treatment with non-addicting
narcotic pain medications (e.g., Ultram or Stadol).
Some
examples are antidepressants that are
treatment of choice for chronic pain, such as SSRI antidepressants
that are analgesic pain medication of choice for chronic
pain; Ultram, and other non-addicting
pain medications.
The
patient also needs non-addicting
muscle relaxants. Soma is extremely addictive because
it changes to Meprobamate in the body which is an addicting
tranquilizer. Robaxin is too weak to do anything for RSD.
The ideal muscle relaxant is Baclofen which has direct
effect on the anterior lateral horn cells of the spinal
cord and relaxes the muscles as well as taking away the
flexion spasms and enables the patient to get around.
If
the patient needs to have an anticonvulsant for the sharp,
stabbing, electric short type of pain (such as causalgia),
addicting anticonvulsants such as barbiturates should
be avoided. The treatment of choice in these cases would
be Tegretol (non-generic) and/or Neurontin. The patient
with RSD should not suffer from pain.
Eventually, in late stages when everything has failed,
then the patient should be treated with an infusion pump
.
See RSD
Puzzles List for other very interesting articles related
to RSD.
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