Reflex Sympathetic Dystrophy Overview

Overview

Reflex Sympathetic Dystrophy (RSD) or Complex Regional Pain Syndrome (CRPS) is a neurological disorder which has been recognized since the Civil War when it was called causalgia due to the associated severe burning occurring after an injury.

RSD and CRPS are both characterized by symptoms including severe burning pain, extreme sensitivity to light touch, swelling, and excessive sweating, with abnormal nail and hair growth. On examination the skin can be warm, shiny and red and later become cool and bluish and dry. With RSD and CRPS, eventually the joints become stiff following which the muscles and bones atrophy. While frequently occurring after a localized injury, CRPS and RSD can also be seen following a stroke, heart attack, spinal disorders, surgery and repetitive motion disorders such as carpal tunnel syndrome.

 

Causes 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 10% to 20% of cases, no direct cause can be found. Injury that precedes the onset of RSD / CRPS may or may not be significant.
 
Characteristic signs and symptoms of reflex sympathetic dystrophy
 
  • Burning pain
  • Extreme sensitivity to touch which is disproportionate to the stimulus
  • Skin color changes (red or bluish)
  • Skin temperature changes (hot or cold)
  • Joint pain
  • Redness in effected extremity
  • Swelling (edema)
  • Frequent infections
  • Difficulty starting movement
  • Increased muscle tone, stiffness
  • Muscle spasm
  • Tremor
  • Weakness
  • Dermatitis, eczema (inflammation of the skin)
  • Excessive sweating
  • Fatigue
  • Migraine headache
 
Physical examination of RSD / CRPS involves observing the skin color and temperature, swelling, and vascular reactivity; overgrown and grooved nails; swollen and stiff joints; muscle weakness and atrophy.

There are three stages of Reflex Sympathetic Dystrophy

Stage 1 (acute) of RSD

The first three months of this disease is associated with localized swelling, increased temperature in the injured limb with excessive sweating and abnormal nail and hair growth.


Stage 2 of RSD
The pain becomes more severe and diffuse with increased swelling, change in nail and hair growth, with initiation of muscle wasting.

Stage 3 of RSD

There is a marked muscle wasting with intractable pain that can potentially become generalized.
The pattern of spread of RSD symptoms may be contiguous (gradual enlargement of the affected area), independent spread (appearing in a distant area), or mirror-image (occurring in the opposite limb closely matching the same size and location of the original area).

The differential diagnosis includes peripheral neuropathy, entrapment neuropathies, thoracic outlet syndrome, deep vein thrombosis, cellulitis, vascular insufficiency, and lymphedema. These and other conditions associated with RSD / CRPS are ruled out with appropriate testing that may include MRI scan, a full laboratory panel, electrophysiological studies of the nerves and muscles (e.g., EMG, NCV), and a test known as a thermogram, which uses an infrared video camera to measure the emission of heat from the affected limb.


Treatment of Chronic Regional Pain Syndrome (CRPS) / RSD
 
Below is the Washington State Department criteria for treating Chronic Regional Pain Syndrome RSD
   
 
CRPS EXAMINATION FINDINGS AND
DIAGNOSTIC TEST RESULTS

CONSERVATIVE CARE
At least four of the following
must be present in order
for a diagnosis of CRPS
to be made.

CRPS EXAMINATION FINDINGS

  1. Temperature/color change
  2. Edema
  3. Trophic skin, hair,
    nail growth abnormalities
  4. Impaired motor function
  5. Hyperpathia/allodynia
  6. Sudomotor changes

    RSD / CRPS DIAGNOSTIC TEST RESULTS
  7. Three phase bone scan that is abnormal in pattern characteristics for CRPS. This test is not needed if 4 or more of the above examination findings are present.

Early aggressive care is encouraged. Emphasis should be on improved functioning of the symptomatic limb.

FIRST SIX WEEKS OF CARE:

  • Sympathetic blocks, maximum of five. Each block should be followed immediately by physical/occupational therapy.
  • Physical/occupational therapy should be focused on increasing functional level (see Table 2).
  • Other treatment (e.g., medication at MD's discretion) as long as it promotes improved function.

AFTER THE 1ST SIX WEEKS OF CARE AFTER BEING DIAGNOSED WITH RSD / CRPS:

  • Strongly consider psychiatric or psychological consultation if disability caused by RSD / CRPS symptoms has extended beyond 3 months
  • Continued physical/occupational therapy based on documented progress towards goals established during first 6 weeks (referenced above).
  • Sympathetic blocks only if RSD / CRPS patient was positively responsive response to previous blocks has been positive, maximum of 3** every six weeks for a maximum of 12 weeks.
SURGICAL INTERVENTIONS
(SYMPATHETECTOMY) FOR
TREATMENT OF RSD / CRPS THIS CONDITION IS NOT COVERED
**A maximum of 11 blocks
can be delivered over the
total 18 week period
 
 
Table 2. Protocol for Physical Therapy/Occupational Therapy for CRPS
 
  1. CRPS / RSD Evaluation should:
    1. Include a date of onset of original injury (helpful in determining if early or late stage) and a date of onset of the CRPS symptoms.
    2. Establish a baseline for strength and motion.
    3. Establish a baseline for weight bearing for lower extremity.
    4. If lower extremity, evaluate distance able to walk and need for assistive device.
    5. If upper extremity, establish a baseline for grip strength, pinch strength, and shoulder range of motion.
    6. If possible, objectify swelling (e.g., do volume displacements).
    7. Define functional limitations.
  2. Set specific functional goals for treatment related to affected extremity.
  3. All RSD / CRPS treatment programs should include a core of:
    1. A progressive active exercise program, including a monitored home exercise program
    2. Progressive weight bearing for the lower extremity (if involved)
    3. Progressive improvement of grip strength, pinch strength, and shoulder range of motion of the upper extremity (if involved)
    4. A desensitization program
  4. For specific RSD / CRPS cases, additional treatment options may be indicated to enhance effectiveness of the above core elements. Documentation should reflect reasons for these additional treatment options.
  5. Documentation of the specific RSD / CRPS case should include:
    1. At least every two weeks, assessment of progress toward goals
    2. Response to treatment used in addition to core elements (listed above in section 3)
  • Evidence of motivation and participation by the RSD / CRPS patient in home exercise program (i.e., diary or quota system)
 
The strategy of treatment includes physical therapy, pain control with narcotics, spinal stimulators, morphine pumps, stelate ganglion blocks, sympathectomy, and numerous oral and topical medications, all of which are frequently unsuccessful.
 
While being extremely effective in treating RSD/CRPS, HBOT is not readily recognized in the medical community as a treatment option.