Get Started
Get Started

Health & Exercise Forum

Reflex Sympathetic Dystrophy - Part 2 of 2

Jun 17, 2013

Dr. Mackarey's Health & Exercise ForumREFLEX 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 –
  • Reflex Sympathetic Dystrophy Syndrome Association –

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:

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.