REFLEX SYMPATHETIC DYSTROPHY BY PRINCE O PHILIP

Reflex sympathetic dystrophy (RSD), also called complex regional pain

syndrome (CRPS), is a chronic, painful, and progressive neurological condition that affects the skin, muscles, joints, and bones. The syndrome usually develops in an injured limb, such as a broken leg, or following surgery. However, many cases of RSD involve only a minor injury, such as a sprain. And in some cases, no precipitating event can be identified. RSD/CRPS is characterized by various degrees of burning pain, excessive sweating, swelling, and sensitivity to touch. Pain may begin in one area or limb and then spread to other limbs. In some cases, symptoms of RSD/CRPS diminish for a period of time and then reappear with a new injury. Types Two types of RSD/CRPS have been defined: Type 1without nerve injury Type 2 (formerly called causalgia)with nerve injury

Both types of RSD/CRPS share the same signs and symptoms. Incidence and Prevalence Millions of people in the United States may suffer from RSD/CRPS. This chronic pain syndrome affects both men and women, and also occurs in children. It can occur at any age, but usually affects people between the ages of 40 and 60 years. The National Institute of Neurological Disorders and Strokes (NINDS) reports that 2 5% of peripheral nerve injury patients and 1221% of patients with paralysis on one side of the body (hemiplegia) develop reflex sympathetic dystrophy as a complication. RSD/CRPS Causes and Risk Factors RSD/CRPS appears to involve a complex interaction among the sensory, motor, and autonomic nervous systems, and the immune system. It is thought that brain and spinal cord (central nervous system) control over these various processes is somehow changed as a result of an injury. Causes and risk factors associated with the onset of RSD/CRPS include the following:

Cerebral lesions Heart disease, heart attack Infection Paralysis on one side of the body (hemiplegia) Radiation therapy Repetitive motion disorder (e.g., carpal tunnel syndrome) Spinal cord disorders Surgery Trauma (e.g., bone fracture, gunshot and shrapnel wounds)

In 1020% of cases, no direct cause for RSD/CRPS can be found. Injury that precedes the onset of the condition may or may not be significant

Signs and Symptoms The symptoms of RSD/CRPS often progress in three stagesacute, dystrophic, and atrophic. The acute stage occurs during the first 13 months and may include burning pain, swelling, increased sensitivity to touch, increased hair and nail growth in the affected region, joint pain, and color and temperature changes. The dystrophic stage may involve constant pain and swelling. The affected limb may feel cool to the touch and appear bluish in color. Muscle stiffness, wasting of the muscles (atrophy), and early bone loss (osteoporosis) also may occur. This stage usually develops 36 months after onset of the disorder. During the atrophic stage, the skin becomes cool and shiny, increased muscle stiffness and weakness occur, and symptoms may spread to another limb. Characteristic signs and symptoms of sympathetic nervous system involvement include the following: Burning pain Extreme sensitivity to touch Skin color changes (red or bluish) Skin temperature changes (hot or cold)

Pain caused by RSD/CRPS usually in not proportionate to the degree of injury. It can be triggered by disuse of the affected limb or by stress and can be spontaneous or constant. Symptoms associated with an immune reaction include:

Joint pain Redness Swelling (edema) Frequent infections

Signs of motor system dysfunction include the following: Difficulty starting movement Increased muscle tone, stiffness Muscle spasm Tremor Weakness

Other symptoms of RSD/CPRS include the following: Dermatitis, eczema (inflammation of the skin) Excessive sweating Fatigue Migraine headache

Complications Patients with any chronic illness, including RSD/CRPS, often suffer from depression and anxiety. Skin, muscle, and bone atrophy (wasting) are possible complications of this syndrome. Atrophy may occur because of reduced function of the affected limb Treatment The goals of RSD/CRPS treatment are to control pain and maintain as much mobilization of the affected limb as possible. Treatment involves an individualized treatment plan, which often combines medications, physical therapy, nerve blocks, and psychosocial support. Medication Treatment for RSD/CRPS involves medications to control pain. The type of medication prescribed is determined by the type of pain experienced by the patient. Constant pain caused by inflammation is treated using nonsteroidal antiinflammatory drugs (NSAIDs; e.g., aspirin, ibuprofen, naproxen, indomethacin). Due to potenially severe gastrointestinal and cardiovascular side effects, NSAIDs should only be used as instructed. Constant pain not caused by inflammation may be treated with central acting agents, such as tramadol (Ultram).

Sharp pain and pain that disrupts sleep may be treated with antidepressants (e.g., amitriptyline, doxepin, nortriptyline, trazodone) or anticonvulsants (e.g., carbamazapine, pregabalin). In some cases, generalized, severe pain that does not respond to other medications may be treated with opioids (e.g., propoxyphine, codeine, morphine). Muscle cramps (spasms and dystonia) can be treated using clonazepam and baclofen. Localized pain related to nerve injury may be treated with Capsaicin cream, but the effectiveness of this medication to treat RSD/CRPS has not been proven. Medications that affect the sympathetic nervous system such as clonidine (Catapres) also may be useful in some cases. Muscle stiffness may be treated with muscle relaxants such as Tizanidine (Zanaflex) Baclofen Clonazepam (Klonopin)

Physical Therapy
Physical therapy for RSD/CRPS involves daily range of motion exercises. Patients are advised to avoid activities that could accelerate osteoporosis or cause joint injury. Nerve Block Sympathetic nerve block interrupts the transmission of pain signals from a group of nerve cell bodies (called a ganglion). Nerve block should be performed by a physician who is familiar with the technique. This procedure involves inserting a needle into the appropriate location (e.g., alongside the windpipe [trachea], in the lower [lumbar] spine) and injecting an alpha adrenergic antagonist (type of anesthesia) into the ganglion. When treating an upper extremity, this treatment is called a stellate ganglion block. The effects of the nerve block are monitored over time.

Sympathectomy RSD/CRPS patients who have a good but temporary response to nerve block may be candidates for a surgical procedure called sympathectomy. This procedure involves cutting and sealing (cauterizing) a portion of the sympathetic nerve, which runs down the spine. The goal of treatment is to suppress sympathetic nervous system activity in the affected area. The role of sympathectomy to treat RSD/CRPS is controversial and in some cases, the procedure worsens symptoms.

TENS Unit A transcutaneous electrical nerve stimulation (TENS) unit may be used to treat the affected area in patients who have RSD/CRPS. In some cases, a spinal cord stimulator is permanently implanted. This device supplies low-intensity impulses to a location in the spinal cord to interrupt the pain signals that are being transmitted to the brain. Psychosocial Support RSD/CRPS patients often become depressed and anxious because of chronic pain and reduced physical ability. Counseling, support groups, and chronic pain center programs can help patients learn coping strategies and can provide emotional and psychological support. 88888888888888888888888888888888888888888888888888888888888888888888888888888888888888 BEST OF LUCK