REFLEX SYPATHETIC DYSTROPHY - TREATMENT
Part 2 of 2
The focus of last week’s column on reflex sympathetic dystrophy (RSD) was cause and diagnosis. This week we will discuss treatment and prognosis. The cornerstone of RSD treatment is normal use of the affected part. Therefore, all modalities are employed to facilitate movement:
- Sympathetic Nerve Block: will give significant pain relief to 95% of patients. One technique involves intravenous administration of phentolamine, a medication used to block sympathetic receptors. Another technique involves placement of an anesthetic next to the spine to block sympathetic nerves.
- Physical Therapy: Isometric strengthening and active/active-assisted range of motion are emphasized. Gentle weight bearing exercises promote healing. Proper posture/alignment minimizes muscle guarding to facilitate function. Whirlpools/massage/moist heat may relieve muscle pain/spasm. A TENS unit (a non-invasive electrical device that stimulates the surface of the skin) may decrease pain.
- Aquatic Therapy: Improves movement and decreases muscle guarding through buoyancy while water resistance challenges muscles and balance.
- Biofeedback: teaches deep relaxation techniques to increase blood flow which will increase the temperature and decrease the pain.
- Occupational Therapy: Provides edema management (specialized garments, manual mobilization techniques, elevation). Desensitization techniques/contrast baths normalize sensation through applying an unpleasant stimulus (textures, pressure, vibration, heat, cold) to a hypersensitive area. Stress loading (gradually loading the joints) through scrubbing, carrying, and weight shifting activities, promotes active movement and compression of the affected joints.
- Psychotherapy: Those with RSD may suffer from depression, insomnia, irritability, agitation, poor judgment, anxiety, or post-traumatic stress disorder. They heighten pain perception and make rehabilitation difficult.
- Medications: No single drug or combination of drugs has produced consistent long-lasting improvement. Medications commonly used to treat RSD include:
- Nonsteroidal anti-inflammatory agents
- Analgesics
- Steroids
- Anti-depressants
- Hypnotics
- Anti-convulsants
- Adrenergic alpha blocking drugs
- Calcium channel blockers
- Muscle Relaxants
- Clonidine Patch
- Capsaicin cream
- Trigger Point Injections: Injection of a local anesthetic into the muscle trigger point for pain relief.
- Removal of Trigger Areas: Neuromas may need to be removed for successful treatment of RSD. Injection of phenol or alcohol, or application of radio frequency can be effective. Cryoneurolysis (freezing of the nerve) is felt by many to be the best treatment. Surgical excision can be complicated by failure/recurrence.
- Sympathectomy (non-surgical): Chemical, radio frequency, and cryogenic sympathectomies allow a temporary sympathectomy. Their targets will re-grow in three to four months. They give the neurons a chance to rest and thereby help the patient combat the disease or, if the neurons revert to their original functioning, will eliminate the disease.
- Epidural Injections/Infusions: Local anesthetics placed into the epidural space either with single injections or infusion via in-dwelling catheters for weeks at a time.
- Surgical Sympathectomy: a surgical procedure which destroys the nerves involved in RSD. Some feel it makes RSD worse. Others report a favorable outcome. Used only when pain is temporarily but dramatically relieved by sympathetic blocks.
- Spinal Cord Stimulation: The placement of electrodes next to the spinal cord provides a tingling sensation in the painful area. It also increases blood flow.
- Intrathecal Drug Pumps: Administer drugs (opioids and local anesthetic agents) directly to the spinal fluid at lower doses than oral administration. This decreases side effects and increases drug effectiveness. Pumps, about the size of a hockey puck, are implanted under the skin of the abdomen.
- Ziconotide: a non-narcotic pain reliever developed from marine life which prevents the release of neurotransmitters involved in the transmission of pain at the spinal cord level. Ziconotide was recently approved for the treatment of chronic severe pain in which intrathecal (IT) therapy is warranted.
- Hyperbaric Oxygenation Therapy (HBOT): is a new therapy for RSD. Peripherally, HBOT supersaturates tissues that have been deprived of oxygen because of the swelling. HBOT constricts vessels which decreases swelling. Centrally, HBOT makes the switch from the sympathetic nervous system back to the central nervous system.
The prognosis for RSD varies. For some, complete recovery occurs and symptoms are minor. However, some people experience spontaneous remission, while others can have unremitting pain and crippling, irreversible changes. The longer RSD is left without direct medical intervention, the more difficult it is to treat. More research is needed to understand the causes, progression and the role of early treatment.
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!”
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.
