REFLEX SYMPATHETIC  DYSTROPHY (RSD)

Part 1 of 2

Over the past 9 years,  I received several emails from people suffering from Reflex Sympathetic Dystrophy (RSD). A recent email from a very desperate and concerned  reader looking for information about (RSD) caused me to pause and reflect.  For those unfamiliar with this disorder, it is one of the most frustrating,  frightening and misunderstood neuromuscular problems one can experience.  I have had patients develop RSD after a simple ankle sprain, major trauma  or prolonged casting. It is speculated that the body seems to overreact  to this trauma and the neuromuscular system goes haywire. The person  can experience severe pain, burning, tingling, numbness, weakness, swelling,  stiffness, warmth, excessive perspiration, excessive hair growth and  more – all from a relatively minor trauma.

The current wisdom in  pain management now classifies RSD as chronic regional pain syndrome  (CRPS). CRPS is a malfunction of the nervous and immune systems as they  respond to tissue damage from trauma or after a period of immobilization.  A number of precipitating factors have been associated with CRPS including:  sprain, contusion, fracture, heart attack, stroke, irritation or injury  to a single spinal nerve, injury to the spinal cord, diabetic neuropathy,  cancer, multiple sclerosis, poor circulation, infections, surgery, repetitive  motion disorders (carpal tunnel syndrome), and cumulative trauma.

The sympathetic nervous  system seems to assume an abnormal function after the incident. The  original injury initiates a pain impulse carried by sensory nerves to  the central nervous system. The pain impulse in turn triggers an impulse  in the sympathetic nervous system which returns to the original site  of injury. The sympathetic impulse triggers the inflammatory response  causing the blood vessels to spasm, leading to swelling and increased  pain. The pain triggers another response, establishing a cycle of pain  and swelling. Even a minor injury might trigger CRPS causing nerves  to misfire, sending constant pain signals to the brain.

CRPS is divided into two  categories: Type I (Reflex Sympathetic Dystrophy) and Type II (Causalgia).  Pathology of causalgia is damage to a major nerve trunk. In RSD, there  is usually damage to some very minor nerves. The symptoms and clinical  presentation of the conditions overlap as do the treatments. The contents  of this article will focus on RSD.

Some experts believe there are three stages associated with RSD, marked by progressive changes in the skin, muscles, joints, ligaments,  and bones of the affected area. The “staging” of RSD is a concept  that is somewhat speculative because progression has not yet been validated  by clinical research studies. Also, the course of the disease seems  to be so unpredictable between various patients that staging is not  helpful in the treatment of RSD. Not all of the clinical features listed  below for the various stages of RSD may be present and speed of progression  varies greatly in different individuals:

RSD STAGES:

• Stage One - lasts from 1 to 3 months and is characterized by severe/burning   pain, muscle spasm, joint stiffness, swelling, rapid hair growth, and   alterations in blood vessels that cause the skin to change color/temperature   (warm, red, dry, or cool and pale).
• Stage Two - lasts from 3 to 6 months and is characterized by intensifying   pain, swelling, decreased hair growth, cracked/brittle/grooved/spotty   nails, cold/pale/blue/moist skin, thinning bones, stiff joints, weak   muscle tone, and muscle wasting.
• Stage Three - the syndrome progresses to the point where changes in   the skin and bone are no longer reversible. Pain becomes unyielding   and may involve the entire limb or affected area. There may be marked   muscle loss, severely limited mobility, and involuntary contractions   of the muscles and tendons that move the joints. Limbs may become contorted.

RSD DIAGNOSIS:

RSD  is diagnosed primarily through observation of the signs and symptoms.  Since there is no specific diagnostic test for RSD, the most important  role for testing is to help rule out other conditions. However, there  are a couple of tests which can be useful in providing evidence for  RSD.

The  backbone test for this disease is a sympathetic block. In over 95% of  patients, the blockade will take away their pain. The sympathetic block  will not only provide diagnostic and prognostic information, but may  also provide a cure or partial remission of RSD.

Additional RSD tests:

1. Thermography:  A non-invasive means of measuring heat emission from the body surface using a special  infrared video camera.

2.  Quantitative sweat test

3.  Triple phase bone scan

4.  Cold and mechanical allodynia: applying a stimulus to the area to see  if it causes pain.

5.  IV phentolamine test: a pharmacologic test for changes in blood pressure.

6.  X-rays, EMG, Nerve Condition Studies, CAT scan, and MRI studies:  All of these tests may be normal in RSD/CRPS. These studies may help  to identify other possible causes of pain; for example, RSD plus a carpal  tunnel syndrome.

For More Information:

• National Institute of Health – National Institute of Neurological Disorders   and Stroke – www.nihs.nih.gov
• Reflex Sympathetic Dystrophy Syndrome Association – www.rsds.org

Contributor: Janet Caputo, PT, DPT,  OCS: Clinic Director at Mackarey & Mackarey Physical Therapy Consultants,  LLC in Scranton, PA.

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum! in the Scranton Times-Tribune. Next Week RSD- Part 2.

This article is not intended as a substitute  for medical treatment. If you have questions related to your medical  condition, please contact your family physician. For further inquires  related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in  orthopaedic and sports physical therapy. Dr. Mackarey is in private  practice and is an associate professor of clinical medicine at The Commonwealth  Medical College.