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[Reflex Sympathetic Dystrophy Syndrome]
by Brittany Heinrich

Although this syndrome was clearly described but unnamed over 125 years ago by three doctors; Mitchell, Moorehouse, and Keen, it still remains poorly understood today. The term RSDS, reflex sympathetic dystrophy syndrome, comes from the description of chronic pain seen in Union soldiers after war related injuries. At that time, their was not cure  for the disease so the limbs were amputated. By 1916, a French surgeon linked the pain to the sympathetic nervous system. The function of the sympathetic nervous system, when it is working [properly], is to the blood flow to the hands and feet, control the color and temperature of of the hands and feet, regulate the function of all innervated tissues and organs in the body except skeletal muscle fibers and to prepare the body for a life threatening stimulus from the environment. When the chronic pain syndrome develops, it is the result of the sympathetic nervous system being kicked into overdrive. This condition is disabling with stimulus involvement of the nerves, skin, bones, muscles and blood vessels. This occurs following a noxious event that takes place in the upper or lower extremities or the back. It is not a rare condition. In fact, it occurs in 5-10% of all injuries and surgeries [involving] the hand/arm and leg/foot, but is most prevalent after a traumatic accidental injury such as severe sprain, amputation, crushing injury to toes or fingers or a severe dislocation. However, there has been no correlation discovered between the severity of the injury and the onset of RSDS. The RSDS symptoms usually begin three to four weeks after the initial injury, but normally plant their roots in the firs ten days after injury. Normally, the first sign is a severe pain when the blanket touches the spot in bed. Soon, a person with a foot injury is always wearing sandals with hardly anything touching the foot

Today, RSDS has been put into a subdivision of CRPS, which is chronic regional pain syndrome. There are two subdivisions [of CRPS]; type 1, which is RSDS, and type 2, known as causalgia. they are very much the same except [that] in causalgia, there is already a known nerve injury. The major components to both symptom [sets] include sympathetic dysfunction, motor dysfunction, sensory dysfunction and trophic change. Diagnosis of both is a long and frustrating process. Any type of CRPS is [the] diagnosis when there is o other possible solution. This can often lead to months, or even years of not knowing what is wrong with you. Many time doctors tell patients that the pain is in their head and there is nothing physically wrong with them. From experience, I know [that] this is very frustrating and can lead to severe depression wondering what is wrong with you. Since so little is known about the sympathetic nervous system, misdiagnosis is very common with this disease.

The is only one common denominator in all patients, severe pain. However, symptoms seen in most patients include burning, edema, skin hypersensitivity, dystrophic changes, hair and nail growth ceases, altered skin [coloration], altered blood circulation, increased reaction to hot and cold temperatures; cold being much more painful, skin scaling that does not itch, and superficial, as well as, subcutaneous, tissue changes. Light touching can result in severe burning, shooting and acute pain. Throbbing, deep aching, cramping and increased pressure are also described by the patients. Changes also occur in the person's mental state and health.

There are three stages generally present in RSDS. Stage one typically includes the onset of severe pain that is limited to the site of the injury. This stage usually last three months and, in this time, edema, stiffness, limited mobility, vasospasms, muscle spasms, and hair and nail growth increase become apparent. In stage two, which lasts from three to five months, many changes take place. The pain is not longer limited to one site, the pain is even more severe, edema spreads and changes texture, hair and nail growth cease or become brittle and fall off, muscle begin to waste away, bone demineralization begins, and the skin changes color. By the third stage, the trophic change is irreversible and this stage can go on forever. The pain has spread throughout the entire limb, and the joints and tendons become weak and have limited motion. The patient normally sees a doctor during the first stage and is misdiagnosed. It can be caught in the early pat of the second stage, but many times is caught well into the second stage or even third stage.

Once the diagnosis is made, which is usually based on visual tests, what the patient feels and the doctor's observations, tests begin to take place. In these tests, the doctors are looking to find if the pain is sympathetically maintained or sympathetically independent. The most common original diagnostic test is a local anesthetic sympathetic block. This is when local anesthetic is applied to to the back at the area the nerves that control the pain area are located. Then, with the aid of an x-ray, shots are administered into the nerves. The medicine breaks down the sympathetic chain, which is carried down to the area of pain and results in short term relief. If the block is successful, the visual sign is an increase in temperature. This also indicates that the pain is sympathetically maintained. Once this has been established, a variety of things can take place. The most common are a beer block and sympathetic lumbar treatments. For a beer block, the patient comes back every week for treatment, The doctor first wraps the extremity with a thermaband so tight the limb looks like a bone, so that the blood in the extremity is pushed up to the upper portion of the extremity. Then a tourniquet/cuff is places above the pain area to stop all blood flow to the area. Once this occurs, medicine flows into the area via an IV in the foot or hand for twenty of thirty-five minutes. The cuff is then removed and blood flow returns to the area. The extremity is then numb for a short period of time, and when the feeling comes back, there should be pain relief, if it was successful. The pain is usually gone for approximately one to two weeks depending on to person. The other common treatment is sympathetic blockades. This can take place in a number of ways. If the RSDS is in an early stage, a series of the [beer] blocks mentioned [previously] will take place. If it is more advanced then a catheter may be implanted in the back at the region where the nerve are located. Then a pump may be administered so medicine is is continually flowing into the area. Another way is the have the patient come anywhere from one two four times a week for an injection into the catheter. These injections can last anywhere from two hours to two days, depending on if it's a good or bad day, which is unpredictable with RSDS. Other treatments common in advanced stage two and stage three cases are morphine pumps or a sympathectomy, dorsal column stimulator. A newer form of treatment, used in all stages that does not involve any trauma are electric sympathetic blocks. Large electrodes are placed on the stomach and back, in line with the positive one one side and the negative on the other. Electrodes that are smaller are also arranged [at] random on the injured part like a TENS unit. Electricity is then administered to the stomach and back electrodes, gradually increasing the voltage until it has reached pharmaceutical strength. Pharmacologic agents are also administered for day- and nighttime relief. However, there is only a small percentage of patients who receive satisfactory relief from the pain. In thirty percent of all cases, the pain spread to the opposite limb. This pain can continue for two years and then burn our, or become lifelong and spread throughout the body and extremities. At that point, amputation may become necessary. But, hopefully, with these treatments, pharmalogic agents and physical therapy, the parson may become pain-free.

The key to ending the cycle of pain along with the medical treatment and pharmalogic agents is physical therapy. Physical therapy must be administered on a daily basis to bat down the fighting nerves, regain motions ans reverse the damage. Because once the nine month mark is past, there is not much hope if getting everything back. Many important modalities are used in physical therapy [for RSDS]. A TENS unit is a small battery-operated machine which sends electrical impulses to the area via electrodes. The impulses trick the brain, which helps reduce the pain. Biofeedback is another important device to help the patient control their own pain, blood flow and skin temperature. A biodex help build up strength in patients who have lower extremity problems. it is similar to a tilt board and the patient tries to stay balanced, weight distributed evenly to both feet. Weight bearing is necessary to maintain minerals in the bones. Fluidotherapy is necessary for desensitization and warmth. A machine in used that throws up rice hulls and heats heats up while the part is in it. It is very helpful in the desensitization process. Thermaband exercise is used to increase the range of motion so the patient can return [to] as close to normal as possible with their range. The part may also edema and the thermaband is also helpful [in] reducing edema. Other devices are used for range or motion, weight bearing, and desensitization. An ultrasound is later used to help repair  the deep tissue dystrophy. In the end, though, the kay to success is loving your limb and aggressive physical therapy, 'no pain, no gain.'

Another important factor in rehabilitation is psychological. The sympathetic nervous system is continually trying to fight the treatments and, on occasion, it wins. This often happens right after the patient is peaking and the sudden halt and return of unbearable pain can be very detrimental mentally for the patient. The patient must produce positive endorphins, especially during these plateaus. Depression, anger and stress often result from RSDS, especially in patients who have suffered fro pain for years. Many patients come to the point where they can no longer work or go to school, which can lead to a lower income. They also lose their [sense] of independence, since they have to depend on so many people for everything they do. The rapport with doctors is also important. Their actions and responses directly effect the patient. Usually, an interested physician and physical therapist, knowledgeable anesthesiologist and psychologist are involved. Their attitudes throughout the process must remain positive for the patient's mental state, a family-like setting is always very helpful.

Throughout the treatments, many complications can occur. At some point the treatment being used may no longer work, and the patient may suddenly go backwards instead of forward. In this event, other treatments are tried and extensive work is done to get the patient [back] on the right track. If the patient continues to decline, then the limb may be amputated, or the area may become completely useless. Other complications may occur from side effects of the [medications]. These effects may become hard to deal with, such as weight gain, disorientation, dizziness, or having a hard time dealing with small things. Also, infections can result from treatments, which cause the treatment to be [halted], and a new [one begun]. Oral pills are also used in many cases to reduce the severe pain if other treatments do not work. Since the sympathetic nervous system is involved, the person is vulnerable to becom[ing] very emotional. Psychological and help from the doctor can often help the patient deal with the unpleasantness in many ways.

Reflex dystrophy syndrome is one name for diseases afflicting with the sympathetic nervous system. Other names include causalgia, Sudeck's atrophy, shoulder-hand syndrome, thermalgia, neurodystrophy and sympathalgia, as well as a variety of [other] names. These diseases are all similar to RSDS, since they take place in the same nervous system, but, in some cases, there are a few changes.

RSDS is a severely painful disease that affects adult and children. until the eighties, it was believed that it could not occur in children. However, it is now known that is can be just as prevalent in children and adolescence. It is also [more common] in females versus males. This disease is no joke and must be treated so the person can return to a pain-free life. But once a person has RSDS, a simple sprain can bring it right back to life. It becomes very frustrating for the patients, since he [or] she knows just a much as the doctors. Also, the pain is so severe and incomparable to any other [that] doctors, family, and friends have a hard time relating and sympathizing. With today's doctors and scientists, the sympathetic nervous system is slowly being understood. Hopefully, someday there will be a cure for the disease and the people with it will be able to return to a normal life. However, there is not one in sight, and the people with it continue to struggle to live each day normally. Only the fortunate ones are diagnoses and put in the right direction. Someday all doctors will have the knowledge to help [their] patients and realize that] the pain is not in their head, but a real, unbearable pain [that] these people have to live with.


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