Reflex Sympathetic Dystrophy is a chronic pain disorder involving the sympathetic nervous system. It usually is the result of an injury or trauma, but can also be a complication of surgery, infection, casting or splinting and myocardial infarction (heart attack). The trauma sets off the body's mechanism for pain recognition, but then the "normal system of pain perception" begins to misfire in it neural response, and an abnormal cycle of intractable pain begins. As RSD progresses, the abnormal pain of the sympathetic nervous system has an effect on other areas of the body and can result in total disability as muscles, bones, skin and the autonomic immune system become involved.

The first indication of RSD is prolonged pain usually more severe than the injury. The symptoms are severe burning pain in a localized area, intense sensitivity to temperature and light touch, and a color change to the skin.

Most physicians agree that there are three stages to RSD, which progress at different rates in different people. Initially, there is swelling and redness in the affected area. Next, the area may become blue and cold, with increased pain and stiffness of ligaments and joints, and Osteoporosis may become evident. Finally, there may be a wasting of affected muscles, contraction of tendons, and a definite withering of the affected limb. In all of the stages, severe chronic pain continues to be a major complaint.

• Although RSD can be a progressive disorder, it should not be assumed that all cases will advance and present all clinical symptoms and dysfunction. Early and effective treatment may lesson the effect of RSD in some individuals.

"Reflex Sympathetic Dystrophy is a system complex and patients do not have all the signs and symptoms or clinical features. A physician may consider RSD as a result of minor trauma, inflammation following surgery, infection, lacerations, degenerative joint disease, burns and any compression such as casting or swelling due to injury that may cause prolonged pressure on peripheral nerves. Peripheral neuropathies, nerve-entrapment, neuromas, thoracic outlet syndrome and carpal or tarsal tunnel can coexist. Many physicians have a difficult time in going to the next step when they diagnose a disease. It is hard for some to believe that you can have a dual disease process and not just focus on only one of the diseases. Many other chronic pain disorders may be mistakenly diagnosed as sympathetically maintained pain or RSD because of similarities in clinical presentations. Diagnosing RSD is very important so proper therapy can be applied. A wrong diagnosis is like having carburetor problems with the engine of your car and using a tire pump to try to fix it."

Nelson Hendler, MD; Honorary Chairman for the RSDSA of California.
Lecture Remarks at the 1998 RSD Medical Conference, San Diego, California
Chapter 7, 1998 RSD Conference Journal, RSDSA-CA ©

CLINICAL SYMPTOMS OF RSD

• Pain is the first and primary complaint, described as extremely severe and burning & aching in nature.
• Swelling and joint tenderness
• Loss or diminished motor function
• Muscle spasms and tremors
• Increased sweating at injured area
• Changes in skin temperature and color
• Bone softening - patchy osteoporosis

"The stages of RSD are the acute stage, the dystrophic stage and the atrophic stage. These stages last around 6 months, but can vary in each individual. The acute stage has intense, burning pain, neuralgia, as is in the dystrophic stage, but when it becomes the atrophic stage it becomes a little less. Bone changes, hair and nail changes, dystrophy and changes in the skin, begin to occur by the second stage. Movement of the joints may become a problem and has minimal efferent and that is why it is real important to treat it early on. Stage 2 has restrictive movement and Stage 3 there is severe restriction of function and anatomic dysfunction. The temperature early on increases and this goes along with the increased hair and nail growth and increased blood flow. Temperature of the skin decreases at the dystrophic stage and there is a mottled skin tone, pseudomotor dysfunction, Osteoporosis is likely evident and at this Stage the RSD is most difficult to treat."

David Salinger, MD; Guest Speaker for the RSDSA of California.
Lecture Remarks at the 1998 RSD Medical Conference, San Diego, California
Chapter 1, 1998 RSD Conference Journal, RSDSA-CA ©

WHAT CAUSES RSD?

• Trauma (often minor) such as a bruise, sprain, broken bone, tight fitting cast
• Surgery
• Myocardial Infarction ( heart attack )
• Infections
• Repetitive motion disorders such as Carpal Tunnel Syndrome

"The mechanism of pain transmission in Complex Regional Pain Syndrome (RSD) has had a lot of studies. There is an injury, usually a small injury or trauma, that stimulates peripheral pain receptors. These are referred to as nociceptors. The nociceptors carry the pain syndrome to the spinal cord. The spinal cord stimulates a particular cell column that is called intermediolateral cell column. In the cell column, there are specific neurons that are stimulated, referred to as Wide Dynamic Range (WDR) neurons. Stimulation of these neurons cause increased sympathetic activity from the spinal cord to the periphery.

This causes a release of norepinephrine in the periphery and has an effect on the blood vessels causing vasoconstriction and pain. It can result in muscle spasms and an increase sensitivity in the periphery of other stimuli whether it is painful and not painful.

You actually get a recruitment of receptors in the periphery that aren't normally functional and this leads to allodynia, which is pain from light touch. The application of pain and the response to tissue damage is a reflex response involving the sympathetic nervous system.

The sympathetic nervous system stimulates and leads to vasoconstriction. This leads to more pain and more sympathetic nervous system stimulation causing Substance P and prostaglandin and increases in nociceptors. What we don't know is why this hyper dynamic sympathetic space continues even after the tissue injury that initiated this has healed. If we can answer that, we will have an answer to a lot of the problems."

HOW IS RSD TREATED?

• Drug Therapy
• Nerve Blocks
• Physical Therapy
• Transcutaneous Electrical Stimulator
• Implantable devices
• Spinal Cord Stimulator
• Drug Delivery Infusion Pump
• Sympathectomy indicated in some cases