IME,Inc.
211 Beaumont
Traverse City,
Michigan MI 49684
Tel: (800)
968-4637
(800) 968-4637 |
Independent Medical Evaluations, Inc.
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COMPLEX
REGIONAL PAIN SYNDROME/REFLEX SYMPATHETIC DYSTROPHY While many
health care providers still use the term RSD, now the words
"complex regional pain syndrome" (CRPS) encompass both
what used to be RSD and what was called causalgia. We now
recognize different stages in this syndrome. Type I includes no
evidence of nerve damage (RSD) and Type II has evidence of nerve
damage (causalgia). The term RSD
has lost its usefulness as a clinical designation because it has
been used so indiscriminately that it no longer is clear what it
means. We see the disorder as increasingly being diagnosed in
association with cumulative trauma disorder. There may be a
variety of reasons why the diagnosis is surging -- physicians
are becoming aware of the diagnosis, workers' compensation cost
shifting, absence of clinical practice guidelines and the growth
of the pain center industry. The theory
behind RSD holds that damage
to a peripheral nerve causes a malfunctioning of other nerve
fibers. These fibers misfire creating a burning pain, as well as
an abnormally hot or sometimes cold hand. The misfiring fibers
are part of what is called the sympathetic nervous system, which
is responsible for a host of body functions that we do not
control on a conscious level. For example, the sympathetic
system regulates the body's temperature by constricting blood
vessels. The sympathetic system has a twin system known as the
parasympathetic system. Every organ of the body is served by
both sets of nerves. Together, these twin systems regulate
things such as how fast the heart beats, how much we sweat, and
how rapidly our intestines digest our food. Together the two are
called the autonomic nervous system. Many
prescription drugs take advantage of the autonomic system. Drugs
to lower blood pressure, for example, block the messages of the
sympathetic system to reduce the rate and force of the heart
beat. But, even
though medicine understands some of what these nerves do, the
physiology of the nervous system and the biochemistry of the
tiny molecules known as neurotransmitters, turn out to be quite
complex. Some researchers report evidence that damage to
peripheral nerves can lead to permanent changes in the central
nervous system, and this may explain RSD symptoms. Doctors have
found that some patients with symptoms of RSD can get pain relief
if the sympathetic
nerves to the painful extremity are blocked by an anesthetic or
even removed in a surgery known as sympathectomy. The
characteristic symptoms of RSD are burning pain, swelling of the
extremity, hypersensitivity to touch, and eventually, a wasting of
the limb. Three stages of
RSD are recognized. In the early stage, there is swelling and
rapid nail growth. In stage 2, there is chronic edema, brittle
nails and the joints begin to atrophy. The most advanced stage
includes fibrosis, tendon contractures and muscle wasting. Unfortunately,
patients diagnosed with RSD are not a homogeneous population; a
majority of them have neither nerve injury nor other organic
dysfunction to explain their symptomatology. These patients with
RSD may have other treatable disorders, such as diabetic
neuropathy, tumors on nerves, nerve entrapment or spinal cord
disease. The specialists
who may be qualified to treat RSD are anesthesiologists and
neurologists. There
is no one test to identify RSD, although there are some tests that
are helpful in ruling it out. A thorough medical history and a
careful physical examination are essential. The presence of
objective signs and consistency of symptoms are also important.
Doctors may observe differences in skin temperature between the
affected and unaffected limbs. X-rays can be
helpful by showing bone loss in the affected limb, but sometimes
these are not useful early in the course of the disorder. A triple-phase bone scan with an injected substance to reveal
blood flow in the limb is helpful. Nerve blocks have
been used mainly to block pain in order to allow movement of the
limb and prevent atrophy. Because
the doctor has no way to measure the pain relief, except the
patients report, a successful block by itself does not confirm a
diagnosis. Some other treatments used include: a short course of
oral steroids given early in the course of the disease; injections
of anesthetic drugs to block nerves suspected of causing pain;
physical therapy to keep limbs moving and prevent atrophy;
psychological therapy; surgical cutting of the sympathetic nerves
and a multidisciplinary approach from a pain clinic. Most people who
have RSD have it in an arm or leg. Experts agree that keeping that
limb mobile is vitally important to treating this disorder. The
key is to eliminate the pain to help the patient keep moving the
limb, and often physical therapy is coordinated with the nerve
blocks. Treatment plans take into account both physical and
psychological needs to prevent disability. It is important to note
that subjective pain without the above criteria does not equal RSD. Legal Nurse
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