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Reflex Sympathetic Dystrophy Syndrome

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

Overview

Reflex sympathetic dystrophy syndrome is a condition that develops after an injury, <a href="https://merisehat.pk/disease/stroke">stroke</a>, or even a heart attack and results in chronic pain, typically in the arm or leg.

However, clinicians no longer refer to the condition as reflex sympathetic dystrophy syndrome. It&#39;s a more traditional name for Type I Complex Regional Pain Syndrome (CRPS). 
&nbsp;

Reflex sympathetic dystrophy (RSD) is a type of complex regional pain syndrome (CRPS) that occurs when the immune system and sympathetic nervous system stop working properly. It causes excruciating pain in one or more limbs that lasts for months or more. 
&nbsp;

According to an early study, 26.2 per 100,000 people were affected by CRPS on average<a href="#accordion">[1]</a>. Also, women were affected three times more than men and the upper extremity was more frequently affected compared to the lower extremity. According to the National Institute of Neurological Disorders and Stroke, even though the condition can occur at any age, it rarely affects children under 10 and the elderly, with individuals aged 40 years and above being the most frequently affected<a href="#accordion">[8]</a>. 
&nbsp;

The condition typically arises following an injury or another illness. It can cause several mental and emotional problems, which is why it&#39;s crucial to start prompt treatment and prevent symptoms from worsening. 
&nbsp;

&nbsp;There are two types of CRPS<a href="#accordion">[6]</a>: 
&nbsp;

<ol>
	<li>
	<h5>Type 1 CRPS</h5>
	</li>
</ol>

This particular CRPS, also known as RSD, typically appears after trauma or injury that does not directly harm the nerves in the affected limb. It makes up around 90% of all CRPS instances<a href="#accordion">[7]</a>. 
&nbsp;

<ol start="2">
	<li>
	<h5>Type 2 CRPS</h5>
	</li>
</ol>

Once referred to as causalgia, this typically appears after nerve damage or injury. 

Despite having different underlying causes, both Type 1 and Type 2 present with similar symptoms. 
&nbsp;

Causes

RSD happens when nerve injury causes the immune and sympathetic nervous systems to malfunction. 
&nbsp;

RSD has a wide range of potential causes, including the following:

<ul>
	<li>Amputation</li>
	<li>Burns</li>
	<li>Bruises</li>
	<li>Fractures</li>
	<li>Cuts</li>
	<li>Casts</li>
	<li>Sprains</li>
	<li>Minor surgery</li>
	<li>Radiation therapy</li>
	<li>Infection</li>
	<li>Emotional stress</li>
	<li>Rarely, stroke and heart attack 
	&nbsp;</li>
</ul>

Since the sympathetic nervous system controls the blood flow movements, which regulate the blood pressure and heart rate, any injury or trauma means the system tells the blood vessels to become narrow to avoid losing blood at the affected site. It would later signal the blood vessels to open up to speed up the recovery process. 
&nbsp;

However, with RSD, the sympathetic nervous system gets mixed signals. Yes, it will turn on post-injury, yes; but it will not back off. As a result, the individual experiences severe pain and swelling at the affected site. 
&nbsp;

Signs and Symptoms

RSD symptoms usually develop gradually, i.e., they worsen over time.

The condition typically manifests in the arm, shoulder, leg, or hip. The pain radiates from the place of the injury to other parts of the body. It&rsquo;s an intense and constant pain that&rsquo;s usually described as burning, throbbing, aching, and deep. 
&nbsp;

It can affect the immune system later, which can lead to:

<ul>
	<li>Redness</li>
	<li>Warm skin around the injury</li>
	<li>Swelling</li>
	<li>Extremely sensitive skin (e.g., showering and putting on clothes hurt) 
	&nbsp;</li>
</ul>

Other RSD Signs And Symptoms Include:

<ul>
	<li>Changes in the skin&#39;s texture or nail or hair growth</li>
	<li>Excessive sweating in specific parts of the body</li>
	<li>Muscle spasms or weakness</li>
	<li>Rigid or stiff joints</li>
	<li>Difficulty moving the injured spot</li>
	<li>Pallor, erythema, or cyanosis 
	&nbsp;</li>
</ul>

Diagnosis

Often, it takes some time for doctors to recognize RSD. Most people don&rsquo;t realize there&rsquo;s any abnormality in their pain either.

The doctor will rule out other conditions, including <a href="https://merisehat.pk/disease/rheumatoid-arthritis">rheumatoid arthritis</a>, muscle diseases, small fiber polyneuropathies, <a href="https://merisehat.pk/disease/lyme-disease">Lyme disease</a>, Raynaud&rsquo;s disease, and blood clots in veins in the legs and feet, before diagnosing RSD<a href="#accordion">[10]</a>. 
&nbsp;

The first sign that it might be RSD is when pain doesn&#39;t go away or feels more severe than it should for the specific type of injury.

Since there&rsquo;s no single test to confirm RSD, doctors begin by taking note of the patient&rsquo;s medical history and doing a physical examination.

A few tests can also help determine whether the person has RSD, including: 
&nbsp;

<h5>Bone Scan</h5>

This test helps detect if any of the bones in the arms or legs are wearing off at the ends and/or if the normal blood flow in the patient&rsquo;s body is disrupted. 
&nbsp;

<h5>MRI</h5>

An MRI is used to examine the tissues for any noticeable changes. 
&nbsp;

<h5>Sweat Test</h5>

This gives doctors an insight into whether the patient perspires more on one side than the other. 
&nbsp;

<h5>Thermography Test</h5>

This assesses if the blood temperature at the site of injury is different than at any other part of the body. 
&nbsp;

<h5>X-Rays</h5>

If the doctor suspects that the syndrome is at a more advanced stage, they will order X-rays to check for mineral loss in the bones. 
&nbsp;

Treatment

Treatment depends on early identification. The earlier it&rsquo;s detected, the better the treatment will work. However, some cases of RSD treatments don&rsquo;t respond. 
&nbsp;

The following medicines are usually prescribed for the condition<a href="#accordion">[9]</a>:

<ul>
	<li>Anesthetic creams like lidocaine</li>
	<li>Antidepressants</li>
	<li>NSAIDs</li>
	<li>Anti-seizure drugs</li>
	<li>Nasal spray</li>
	<li>Nerve-blocking injections</li>
	<li>Over-the-counter medicines, including aspirin, ibuprofen, or naproxen</li>
</ul>

<ul>
	<li>NOTE: Corticosteroids, like methylprednisolone, and opioids, like fentanyl and oxycodone are usually avoided because of a lack of data.&nbsp; 
	&nbsp;</li>
</ul>

Other symptom management strategies include:

<ul>
	<li>Spinal cord stimulation to relieve pain</li>
	<li>Physical therapy to help with movement</li>
	<li>Psychotherapy to relax</li>
	<li>Heat therapy and topical analgesics to reduce swelling and discomfort</li>
	<li>Transcutaneous electrical nerve stimulation (TENS) to ease chronic pain</li>
	<li>Splints to help with hand pain 
	&nbsp;</li>
</ul>

Surgery called sympathectomy is kept as a last resort to treat RSD if all other methods don&#39;t work. 
&nbsp;

Reflex sympathetic dystrophy (RSD) can cause multiple issues that can lower a person&#39;s quality of life if it is not detected early. These complications include 
&nbsp;

<ol>
	<li>Atrophy Or Tissue Wasting: The bones, muscles, and skin weaken or deteriorate to the extent that the patient has trouble moving a leg or an arm due to stiffness or pain. 
	&nbsp;</li>
	<li>Contracture Or Muscle Tightening: The muscles tighten so much that the affected finger/hand and toe/foot contract into a fixed position. 
	&nbsp;</li>
</ol>

The following are some of the major risk factors for RSD development: 
&nbsp;

<ol>
	<li>
	<h5>Gender</h5>
	</li>
</ol>

RSD is more likely to affect women than men. 
&nbsp;

<ol start="2">
	<li>
	<h5>Age</h5>
	</li>
</ol>

RSD seems to strike more frequently in adults between 40 and 60 years. 
&nbsp;

<ol start="3">
	<li>
	<h5>&nbsp;Other Medical Conditions</h5>
	</li>
</ol>

RSD may be more likely to occur in people with autoimmune or inflammatory conditions. Also, psychological factors, such as anxiety, depression, and anger, can worsen the symptoms of CRPS. Besides, conditions like diabetes and peripheral neuropathy cause poor nerve health, which increases the risk of RSD. 
&nbsp;

<ol start="4">
	<li>
	<h5>Genetics</h5>
	</li>
</ol>

According to some research, there may be a hereditary propensity to developing RSD<a href="#accordion">[11]</a>. 
&nbsp;

Note: It is important to remember that not everyone who possesses one or more of these risk factors will have RSD, and not everyone who experiences RSD have these risk factors. Discuss your concerns with your healthcare professional if you are worried about your chance of developing RSD. 
&nbsp;

Since researchers don&rsquo;t know the exact cause of CRPS, there&rsquo;s no known way to prevent it. 
&nbsp;

<ol>
	<li>
	<h5>Keeping A Healthy Lifestyle</h5>
	</li>
</ol>

RSD may also be avoided by leading a healthy lifestyle that includes frequent exercise, a well-balanced diet, quitting smoking, and reducing stress. Studies suggest that consuming a high dose of vitamin C after a wrist fracture may potentially reduce the risk of developing complex regional pain syndrome (CRPS) compared to individuals who do not consume vitamin C supplementation<a href="#accordion">[7]</a>.

Other than that, manage existing health conditions, like <a href="https://merisehat.pk/disease/diabetes-type-1-and-2">diabetes</a>, to ensure better healing of the nerves. 
&nbsp;

NOTE: Do not start any supplements prior to discussing it with your healthcare provider. 
&nbsp;

<ol start="2">
	<li>
	<h5>Avoiding Prolonged Immobilization</h5>
	</li>
</ol>

RSD risk can be increased by keeping a limb immobile for an extended period, like after surgery. Moving the injured limb as soon as possible after an operation or an injury can reduce this risk<a href="#accordion">[7].</a> 
&nbsp;

<ol start="3">
	<li>
	<h5>Seeking Early Treatment</h5>
	</li>
</ol>

Seek early treatment to prevent the illness from worsening if symptoms, like persistent pain, edema, stiffness, changes in the temperature or skin color, occur. 
&nbsp;

Although the most prevalent symptoms of CRPS are allodynia (pain due to a stimulus that does not normally provoke pain) and persistent pain, skin conditions can also be distressing, and early dermatologic signs can be a major worry.

The most effective treatment for skin issues requires managing the underlying CRPS,&nbsp; as standard treatment for the prevalent dermatologic symptoms of CRPS is challenging and frequently ineffective. 
&nbsp;

Dermatologic management is targeted to treat the distinctive skin abnormalities caused by CRPS. Currently available therapies include:

<ul>
	<li>Removing any nidus of tissue trauma</li>
	<li>Sympathetic neural blockade with a local anesthetic</li>
	<li>Spinal cord stimulation to interrupt dysregulated sympathetic innervation Physiotherapy or occupational therapy to desensitize the skin 
	&nbsp;</li>
</ul>

The management of CRPS and its related dermatologic disorders frequently necessitates interdisciplinary care and coordination of several specialists<a href="#accordion">[5]</a>. 
&nbsp;

Key Points

<ul>
	<li>Reflex sympathetic dystrophy syndrome is a condition that develops after an injury, stroke, or even a heart attack and results in chronic pain, typically in the arm or leg.</li>
	<li>It is a type of complex regional pain syndrome (CRPS) that occurs when the immune system and sympathetic nervous system stop working properly</li>
	<li>RSD symptoms include persistent pain, swollen joints, stiffness, and variations in skin tone or warmth.</li>
	<li>Nerve blocks, physical therapy, pharmaceutical combinations, and other pain- symptom-management techniques may all be used to treat RSD. 
	&nbsp;</li>
</ul>

[1] de Mos M, De Bruijn AGJ, Huygen F, Dieleman JP, Stricker BHC, Sturkenboom M. The incidence of complex regional pain syndrome: a population-based study. Pain. 2007;129(1–2):12–20.

[2] Todorova J, Dantchev N, Petrova G. Complex regional pain syndrome acceptance and the alternative denominations in the medical literature. Med Princ Pract. 2013;22(3):295–300.

[3] Perez RSGM, Kwakkel G, Zuurmond WWA, De Lange JJ. Treatment of reflex sympathetic dystrophy (CRPS type 1): a research synthesis of 21 randomized clinical trials. J Pain Symptom Manage. 2001;21(6):511–26.

[4] Nierengarten MB. The Empowered Patient’s Guide to Complex Regional Pain Syndrome (CRPS). Feb 16, 2021.

[5] Montgomery SNB, Elbuluk N. Skin Manifestations of Complex Regional Pain Syndrome. 2022;

[6] Complex regional pain syndrome (reflex sympathetic dystrophy) - orthoinfo - aaos. OrthoInfo.

[7] Complex regional pain syndrome. Mayo Clinic.

[8] Goh EL, Chidambaram S, Ma D. Complex regional pain syndrome: a recent update. Burns Trauma. 2017;5:2. Published January 19, 2017 Jan. doi:10.1186/s41038-016-0066-4