Reflex Sympathetic Dystrophy
What is Reflex Sympathetic Dystrophy?
 Reflex Sympathetic Dystrophy (RSD), also called Complex Regional Pain Syndrome (CRPS I), is a painful nervous condition of the sympathetic nervous system. It often occurs involving the hand or foot after injury. If untreated, the pain and weakness that RSD may cause can limit use of the injured region. Early treatment can help you get well.
 
While healing from a hand or foot injury, you may have unexpected pain when you should be feeling better.
What Triggers RSD?
Getting injured may trigger RSD. It may be something minor such as a sprain or a cut. The cause of RSD may be more severe such as a fracture. As you begin the healing process, you may feel new and distinctly different severe pain in the injured region. That pain may spread through the injured limb. Over time, other symptoms may appear.
Recognizing Symptoms and Signs
Symptoms and signs of RSD can begin right away or about 2 weeks after injury. If treatment is not initiated promptly, symptoms can worsen or change overtime. These symptoms and signs occur in the injured region:
Early-Stage RSD
- Severe, burning pain
- Sensitive to touch
- Swollen, reddish appearance
- Stiffening of the joint and extremity
- Warm and sweaty sensation
Late-State RSD
- Skin slowly withering (shriveling)
- Skin that becomes dry and shiny
- Loss of strength
- Strange hair growth
- Ridges in skin look flatter than normal
- Edema and osteoporosis
Making the Diagnosis of RSD/CRPS
The diagnosis of RSD/CRPS can be made in the following context. A history of trauma to the affected area associated with pain that is disproportionate to the inciting event plus one or more of the following:
- Abnormal function of the sympathetic nervous system
- Swelling
- Movement disorder
- Changes in tissue growth (dystrophy and atrophy)
Thus patients do not have to meet all of the clinical manifestations listed above to make the diagnosis of RSD/CRPS. The new CRPS classification system acknowledges this fact by stating that some patients with RSD/CRPS may have a third type of CRPS by categorizing it as "otherwise not specified". There seems to be a small group of patients whose pain following trauma resolves over time, leaving the patient with a movement disorder. The pain and symptoms of RSD/CRPS may exceed both the magnitude and duration of symptoms expected from the normal healing process expected from the inciting event. Similarly, the RSD/CRPS diagnosis is precluded by the existence of known pathology that can be explained by the observed symptoms and degree of pain. There are "grades" of this syndrome described in the literature with symptoms ranging from minor to severe.
Clinical Features of RSD/CRPS
 Pain – The hallmark of RSD/CRPS is pain and mobility problems out of proportion to those expected from the initial injury. The first and primary complaint occurring in one or more extremities is described as severe, constant, burning and/or deep aching pain. All tactile stimulation of the skin (e.g. wearing clothing, a light breeze) may be perceived as painful (allodynia). Repetitive tactile stimulation (e.g. tapping on the skin) may cause increasing pain with each tap and when the repetitive stimulation stops, there may be a prolonged after-sensation of pain (hyperpathia). There may be diffuse tenderness or point-tender spots in the muscles of the affected region due to small muscle spasms called muscle trigger points (myofascial pain syndrome). There may be spontaneous sharp jabs of pain in the affected region that seem to come from nowhere (paroxysmal dysesthesias and lancinating pains).
- Skin changes - skin may appear shiny (dystrophy-atrophy), dry or scaly. Hair may initially grow coarse and then thin. Nails in the affected extremity may be more brittle, grow faster and then slower. Faster growing nails is almost proof that the patient has RSD/CRPS. RSD/CRPS is associated with a variety of skin disorders including rashes, ulcers and pustules. 8 Although extremely rare, some patients have required amputation of an extremity due to life-threatening reoccurring infections of the skin. Abnormal sympathetic (vasomotor changes) activity may be associated with skin that is either warm or cold to touch. The patient may perceive sensations of warmth or coolness in the affected limb without even touching it (vasomotor changes). The skin may show increased sweating (sudomotor changes) or increased chilling of the skin with goose flesh (pilomotor changes). Changes in skin color can range from a white mottled appearance to a red or blue appearance. Changes in skin color (and pain) can be triggered by changes in the room temperature, especially cold environments. However, many of these changes occur without any apparent provocation. Patients describe their disease as though it had a mind of its own.
- Swelling - pitting or hard (brawny) edema is usually diffuse and localized to the painful and tender region. If the edema is sharply demarcated on the surface of the skin along a line, it is almost proof that the patient has RSD/CRPS. However, some patients will show a sharply demarcated edema because they tie a band around the extremity for comfort. Therefore, one has to be certain that the sharply demarcated edema is not due to a previously wrapped bandage around the extremity.
- Movement Disorder - Patients with RSD/CRPS have difficulty moving because they hurt when they move. In addition, there seems to be a direct inhibitory effect of RSD/CRPS on muscle contraction. Patients describe difficulty in initiating movement, as though they have "stiff" joints. This phenomena of stiffness is most noticeable to some patients after a sympathetic nerve block when the stiffness may disappear. Decreased mobilization of extremities can lead to wasting of muscles (disuse atrophy). Some patients have little pain due to RSD/CRPS but instead they have a great deal of stiffness and difficulty initiating movement. 6 Tremors and involuntary severe jerking of extremities may be present. Psychological stress may exacerbate these symptoms. Sudden onset of muscle cramps (spasms) can be severe and completely incapacitating. Some patients describe a slow "drawing up of muscles" in the extremity due to increased muscle tone leaving the hand-fingers or foot-toes in a fixed position (dystonia).
- Spreading Symptoms - Initially, RSD/CRPS symptoms are generally localized to the site of injury. As time progresses, the pain and symptoms tend to become more diffuse. Typically, the disorder starts in an extremity. However, the pain may occur in the trunk or side of the face. On the other hand, the disorder may start in the distal extremity and spread to the trunk and face. At this stage of the disorder, an entire quadrant of the body may be involved. Maleki et. al. recently described three patterns of spreading symptoms in RSD/CRPS: 9
- A "continuity type" of spread where the symptoms spread upward from the initial site, e.g. from the hand to the shoulder.
- A "mirror-image type" where the spread was to the opposite limb.
- An "independent type" where symptoms spread to a separate, distant region of the body. This type of spread may be related to a second trauma
- Bone changes – X-rays may show wasting of bone (patchy osteoporosis) or a bone scan may show increased or decreased uptake of a certain radioactive substance (technecium 99m) in bones after intravenous injection.
- Duration of RSD/CRPS – The duration of RSD/CRPS varies, in mild cases it may last for weeks followed by remission; in many cases the pain continues for years and in some cases, indefinitely. Some patients experience periods of remission and exacerbation. Periods of remission may last for weeks, months, or years.
Treating RSD
Treatment for RSD begins with therapy that teaches you ways to move the affected region. If your pain condition prevents therapy, it may be necessary to undergo additional treatment first. The sooner treatment is initiated, the faster healing will occur.
Physical, Occupational and Hand Therapy
Physical, occupational and hand therapy aim to improve movement, build strength and reduce pain in the affected region. The type of therapy you receive depends on the part of your body affected by RSD. In some cases, the goal of therapy is the same. You will need to relearn ways to use the affected region. For instance, if RSD affects your leg and foot, you may work with a therapist to learn new gait techniques. If you have a disability affecting the hand or arm, you may practice exercises to regain function in that extremity. Treatment also may include desensitization. This involves contact with different textures on the injured region. Heat or cold may also be used. Desensitization may help you become comfortable with items that come in contact with the affected extremity. This may help reduce pain in the long term.
Pressing down while making scrubbing motions desensitizes hand RSD.
Medical Treatment
Your doctor may suggest certain treatment for your symptoms. The goal is to reduce your pain and to get you moving again. Treatment may include:
- Oral medications to relieve pain
- Nerve blocks to stop pain signals
- Spinal cord stimulators to send electrical signals that block pain
- Sympathectomy to destroy a nerve that’s causing pai
Biofeedback can help you manage pain.
Other Treatment
Nutritional supplementation coupled with a wellness product alternative may be helpful in treating this condition. Ask your doctor for a program. RSD is complex and can be extremely painful. You may feel depressed or angry about your condition. Psychological counseling and RSD support groups can help cope with your feelings. Biofeedback will make you more aware of your body’s pain signals and teach you how to turn them off. Ultimately, this may teach you how to control your pain and the
Living with RSD
You can change how RSD affects your life. Work with your doctor to find the best way to treat RSD. Getting physical, occupational and hand therapy as needed, using the affected region effectively and trying alternative modalities may bring relief.
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