THE USC PAIN UPDATE
from the USC Pain Center
February 2001

UNDERSTANDING RSD
(Reflex Sympathetic Dystrophy)
also known as CRPS (Complex Regional Pain Syndrome)

When I was a senior medical student (more years ago than I care to admit), I was working the emergency ward at San Francisco General Hospital. A huge man walked in wearing a leather jacket, a beard to his belt, and a motorcycle helmet, (all 6 ½ feet, 500 lbs of him - at least that's how I remember him). Anyway, all the nurses scampered out of the way to let him pass, and my heart jumped into my throat when he turned into the room I was working. Nervously, I asked him what the trouble was. He raised his hand as if he was about to strike me, and I got ready to jump out of the way. He pointed to his elbow and said gruffly, "Doc, I have an 'owee' right here."

I smiled, calmed myself, and examined his arm which had been injured mildly in a fall a month earlier. The elbow and forearm were swollen and red and he would yelp with pain even when I touched the arm lightly. The neurologic examination revealed normal motor and sensory functions of the nerves.

In those days, we were taught that pain would affect specific nerves, and that any pain beyond those specific nerves was considered psychological. We would treat what we could physically, and ship them off to counseling. I had doubts that counseling would help this patient so I gave him some pain medicine and scheduled him for evaluations in the neurology and orthopedic clinics. At that time, I, like most doctors, had never even heard of RSD. It was not taught in medical school.

Today, we know that pain can affect regions of the body beyond what is expected from a given injury. RSD is one of the classic syndromes that can produce such pain. Now, we have many tricks up our sleeves to treat this terrible syndrome. RSD is one of the most confusing diagnoses both for the patient and for the medical team. Much remains unknown about RSD, but there is a greater understanding of RSD than ever before. The problem is not nearly as rare as we initially thought, complicating as many as 5% of all injuries. We hope that the added focus on this misunderstood diagnosis will help to improve patient care.

Diagnosing RSD:
There are no tests for RSD and existing diagnostic guidelines are very broad. The key criteria are pain beyond what is expected for the injury, as well as other signs of nerve dysfunction in the affected area. RSD is a neuropathic pain condition which is not caused by ongoing damage to the body, but rather is caused by abnormal functioning of the nervous system. Neuropathic pain feels different than the aches of everyday life. Commonly the pain will have a burning, tingling, and electric feeling, constant deep aches and sudden jabs of shooting pain. Stimulation with mild cold or light touch often causes pain, (such sensitivity is called allodynia).

Other signs of RSD might include abrupt temperature and color changes of the affected area (redness, pallor, blue mottling). The patient may have swelling and sweating changes, dry, flaky or shiny skin, local growth hair loss, and brittle or slow growth nails. Muscles in the area may also become weak and stiff, and jerks and twitches may occur in the affected hand or foot. (Recognition of the difficulty in diagnosing RSD led to the official name change to Complex Regional Pain Syndrome, but it is still most commonly referred to as RSD.)

Treatment:
Unfortunately, although the treatment of RSD can lead to significant improvement, it usually does not produce a complete cure. It is not rare for the symptoms to spread beyond the initially injured limb to involve another limb. Occasionally, patients can suffer a relapse after having had years of no pain, but in my experience, these relapses are usually not as severe as the initial episode.

The most effective treatment strategy is to attack the syndrome on multiple fronts. Traditional pain medications (anti-inflammatories and opioids) may help to take off the edge off the pain. Then we use the more effective long-term medications (anti-convulsants and anti-depressants). These medications are very effective at altering nerve function and seem to calm the irritability of the affected nerves resulting in much greater pain relief. Nerve blocks can often dramatically reduce the abnormal sensitivity, breaking the cycles of pain flares, and also serving the critical function of reducing the pain enough to enable the patient to pursue physical therapy.

Physical therapy is crucially important to maintain the mobility and strength of the area, (as well as to desensitize the patient to touch, pressure, and movement). It is also important to note that stress triggers activation of the sympathetic nervous system and increases muscle tension which unfortunately increases the pain of RSD. Stress management and biofeedback techniques have been very effective at reducing these reactions and significantly decreasing pain. Occupational therapy also helps the patient to get back to a more functional life.

Advanced Therapies:
When standard treatments do not produce adequate results, then more advanced treatments should be considered. New medications, or the use of old medications in new ways, are constantly being developed. We have had some success with the use of ketamine gel, magnesium supplements, and new anti-convulsants. Nerve blocks can be delivered through implanted catheters which allow for maintenance of continuous blocks. This provides prolonged periods of pain relief and desensitization. Catheters can even be implanted into the spine and attached to subcutaneous pumps. These pumps can deliver morphine or other medications directly into the spinal fluid, thereby achieving stronger effects with minute amounts of medication and less side-effects (see: Update: Sept-Oct 2000-Spinal Pumps & Stimulators). Electrical impulses can also be used to stimulate the spinal cord via electrodes that are inserted directly into the spine. Such stimulation seems to "confuse" the nervous system and can dramatically reduce the pain in 60-70% of patients.

RSD treatment is still in its infancy, but thankfully, we can now reduce the suffering of many patients.

Until next time...Steven Richeimer, M.D.

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Steven Richeimer, MD
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