Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 200

From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time.

“RSD: Reflex Sympathetic Dystrophy CRPS: Complex Regional Pain Syndrome”

Both orders are one and the same. In 30 years, I have encountered 4 verified RSD/CRPS patients. It is a horrible malady that will negatively affect the patient for a lifetime. The problem is that it is often over-diagnosed when the practitioner can’t conclude a diagnosis. Over the last few weeks, I have fielded many questions about RSD/CRPS. Therefore, here are the facts, with a qualifier at the end.
Source of this generic overview:
 Multiple Names:
·         Reflex Sympathetic Dystrophy Syndrome - RSDS
·         Complex Regional Pain Syndrome
·         Shoulder-Hand Syndrome
·         Causalgia
·         Sudeck's Atrophy

The syndrome is as complicated as its nomenclature.

What Causes RSD?

According to the National Institute of Neurological Disorders and Stroke (NINDS), RSD is "a chronic pain condition that is believed to be the result of dysfunction in the central or peripheral nervous systems."

According to MedicineNet, RSD involves "irritation and abnormal excitation of nervous tissue, leading to abnormal impulses along nerves that affect blood vessels and skin."

Animal studies indicate that norepinephrine, a catecholamine released from sympathetic nerves, acquires the capacity to activate pain pathways after tissue or nerve injury, resulting in RSD.

Another theory suggests RSD which follows an injury is caused by triggering an immune response and symptoms associated with inflammation (redness, warmth, swelling).

RSD is not thought to have a single cause, but rather multiple causes producing similar symptoms.

What Are The Symptoms Of RSD?

RSD usually affects one of the extremities (arms, legs, hands, or feet). The primary symptom of RSD is intense, continuous pain. According to NINDS, the list of symptoms includes:
·         burning pain
·         increased skin sensitivity
·         skin temperature changes (warmer or cooler than opposing extremity)
·         skin color changes (blotchy, purple, pale, red)
·         skin texture changes (shiny, thin, sweaty)
·         changes in nail and hair growth patterns
·         stiffness and swelling in affected joints
·         decreased ability to move affected extremity

Pain can spread to a wider area (i.e. from finger to entire arm) and can spread to the opposite extremity (i.e. from left arm to right arm). Emotional stress can cause symptoms to worsen.

Some experts suggest there are three stages of RSD, during which progressive changes occur in the skin, muscles, joints, ligaments, and bones of the affected area. The progression has not been confirmed by clinical studies though.

Stages Of RSD

Stage 1
·         lasts 1 to 3 months
·         severe, burning pain
·         muscle spasm
·         joint stiffness
·         rapid hair growth
·         skin color and temperature changes

Stage 2
·         lasts from 3 to 6 months
·         pain which becomes more intense
·         swelling
·         decreased hair growth
·         nails which are cracked, brittle, grooved, spotty
·         softened bones
·         stiff joints
·         weak muscle tone

Stage 3
·         irreversible changes to skin and bone
·         pain is continuous
·         muscle atrophy
·         severe limited mobility
·         contractions of muscles and tendons (limbs may be twisted)

What Triggers RSD?

There can be numerous triggers for RSD including:
·         injury or trauma
·         surgery
·         degenerative arthritis of the neck
·         shoulder problems
·         heart disease
·         stroke
·         diabetes
·         cancer
·         infection
·         brain diseases
·         thyroid disorders
·         carpal tunnel
·         shingles
·         certain medications

In an estimated one-third of patients with RSD, there is no associated trigger.

How Is RSD Diagnosed?

A patient's clinical history (signs and symptoms) are the major factor in diagnosing RSD. The diagnosis is made difficult because many of the symptoms overlap with other conditions.

There is no specific blood test or other diagnostic test for RSD. X-rays can show thinning of bones (osteoporosis). Nuclear bone scans can show characteristic uptake patterns which help diagnose RSD.

NOTE: Triple phase bone scan is currently the most accurate method of concluding an accurate diagnosis

How Is RSD Treated?

Treatment focuses on relieving painful symptoms associated with RSD. Treatment can include:
·         physical therapy and exercise
·         psychotherapy to relieve stress, anxiety, and depression
·         sympathetic nerve blocks
·         surgery including sympathectomy (considered controversial)
·         spinal cord stimulation
·         intrathecal drug pumps
·         medications including: 
·         topical analgesics
·         anti-seizure drugs
·         antidepressants
·         corticosteroids
·         opioids
I can say with a great degree of certainty that I personally would never treat an RSD/CRPS patient. According to Jean-Robert Desrouleaux MD, Board Certified Neurologist, who has treated many RSD/CRPS patients, the only hope to get ahead and mitigate long term sequellae of this malady is with aggressive corticosteroids very early in onset. In this instance, a trial of conservative care will prevent the only known treatment to help the patient as it will delay care and you may lose the window of opportunity to treat this issue. Again, it has been stressed to me that early intervention is the only hope.
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