Reflex Sympathetic Dystrophy Syndrome
What Is RSDS?
Reflex sympathetic dystrophy syndrome is a multi-symptom condition usually
affecting arms, legs, or both, but may affect any area of the body. It
is a disease that is poorly understood by patients, their families, and
health care professionals. In some, the disease is mild; in some, it
is moderate; and in others, it is a severe condition. It is a disease
involving the nerves, skin, muscles, blood vessels and bone.
The only common factor(s) in all patients is either
pain or stiffness. Some of the other names given to this condition
are causalgia, Sudek's Atrophy, shoulder/hand syndrome, and sympathetically
maintained pain syndrome. More recently (1995) RSDS has been renamed
CRPS-Complex Regional Pain Syndrome
What Do We Know About RSDS?
It was described during the Civil War. It is not a rare disorder and may
affect millions of people in this country. This syndrome may follow five
percent of all injuries. The diagnosis is often not made early and some
of the very mild cases may resolve without treatment and others may progress
through the stages and become chronic and often debilitating.
A very few patients who are not treated early will
experience spread of the disease and this may become a lifelong problem.
Even with early treatment, RSDS may become a chronic condition. It
can start as young as three years of age. This is not a psychological
disease. Children may develop psychological problems when physicians,
parents, teachers and other children do not believe their suffering.
What Causes RSDS?
A number of mechanisms have been proposed to describe this condition. There
is a general consensus that a vicious cycle is initiated due to injury
to a nerve or to nerve endings. Whatever the theory, it is the basic
belief that there is hyperactivity of sympathetic nervous system resulting
in various symptoms which can be explained on a scientific basis. The
sympathetic nervous system controls blood flow, along with other functions.
RSDS may start after fractures, sprains, dislocations,
soft tissue injury, head injury, stroke, spinal cord injury or brain
tumor. Some may experience rapid onset with marked deterioration and
resistance to treatment. Some have slow onset over a period of weeks
or months and show impressive progress after therapy.
What Are The Symptoms Of RSDS?
The most common symptoms are:
- Pain - This is the primary complaint, constant pain which varies
in degree from moderate to severe and burning in character.
- Stiffness - loss of motion and loss of ability to use joints and
muscles effectively.
- Muscle changes - swelling, spasms, atrophy.
- Skin changes - dryness, changes in temperature (mostly cold),
intolerance to cold or warmth, bluish coloration, changes in nail
beds, increased sweating.
- Bony changes - softening of the bone.
Is It All In My Head?
RSDS is difficult for many physicians, patients and public alike to understand.
It is not surprising that family and friends, employees, health insurance
officials, do not understand your pain and disability. The course of
the disease can fluctuate from day to day, and if you are having a good
day when seen by a doctor, he or she may find it difficult to understand
the severity of the problem.
Persons who get RSDS are not any different from the
rest of the population psychologically. Once they get RSDS and they
are in constant pain, friends, family and employer not believing them,
they may become depressed and suffer the psychological changes.
As with any group of individuals, there is a small
percentage of RSDS patients who get satisfaction from a chronic illness.
The vast majority of RSDS patients were active, productive individuals
prior to this disease and do not enjoy the pain, the loss of independence,
the loss of job and the loss of income.
How Do You Diagnosis RSDS?
There is no single symptom, clinical sign, or laboratory test that is one
hundred percent diagnostic of RSDS. Your physician will look for symptoms
like burning pain, color changes, temperature changes, edema, hair and
nail growth changes, among various other symptoms.
To assist in the diagnosis of reflex sympathetic dystrophy,
various tests can be performed. These include three-phase bone scanning,
x-rays, phentolamine test, and diagnostic sympathetic blocks.
- Three-phase bone scanning - The three-phasebone
scan has been shown to be one of the best tests fo rthe diagnosis
of reflex sympathetic dystrophy. However,this is positive in only
sixty percent of the cases with incidence of ten percent false positives,
in essenceleading to the appropriate diagnosis in only fifty percentof
the cases.
- Phentolamine test - In this test, under appropriate monitoring,
high doses of Phentolamine are infused slowly.
- Sympathetic blocks - Blocking the sympathetic
nervous system by injecting a numbing medication
around the sympathetic ganglia has been considered as the gold standard
for diagnosis of RSDS. However,recently, it has been shown that the response
to sympathetic blockade is not one hundred percent, even in classic cases.
Various other tests described in diagnosis of sympathetic dystrophy
have been shown to be unreliable or positive only in end stages when
the patient no longer responds to treatment.
How Is It Treated?
There are many forms of treatment for RSDS. Treatment may include medication,
injection therapy, physical therapy, psychological support, etc.
A coordinated approach with a multidisciplinary team of physicians
who understand the problem, and attempts to address all pain patterns,
physical as well as psychological, will be most helpful. The benefit
of multidisciplinary Pain Management Center is that it offers necessary
diagnostic treatment, alternatives carried out by individuals well
trained in their implementation and complications.
- Sympathetic blocks - Various means include paravertebral
sympathetic blocks, epidurals, andintravenous regional sympathetic
blocks. With these techniques, pain relief will be gradually lengthened
and the problem resolved. These techniques are effective in 50 -
90% of the time. The number of the blocks needed and the degree of
pain relief achieved with each injection are unpredictable.
- Radio frequency sympathetic neurolysis - A small
controlled localized burn is produced utilizing radio frequency current,
similar to a laser which produces long-term relief in some patients.
- Physical therapy - This is the second most important
part of the therapy in reflex sympathetic dystrophy. After the intense
pain is relieved with the sympathetic blocks, you are started on
a gentle active exercise program. It should be carried out by a therapist
who is familiar and well versed with the syndrome.
- Biofeedback training - Biofeedback training and
relaxation with emotional support and other psychological strategies
involving coping skills are very helpful in managing reflex sympathetic
dystrophy.
- Other techniques:
1. Medications
2. Transcutaneous electrical nerve stimulation
3. Acupuncture
4. Chemical sympathectomy
5. Implantation of dorsal column stimulator
6. Morphine pump implantation, etc.
Goals of Treatment
The major goal of Pain Management is to put you back in charge of your
life. It is possible that you will always have to live with a certain
amount of pain, but you can learn to work and enjoy life in spite of
it.
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