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Jane
(* not real name) was a patient I got to know really well during
my residency training. For many years she would complain of intense
sharp pains that first started at her left wrist, gradually made
its way to shoulders and back. Over the counter pain pills didnt
seem to help, and despite numerous x-rays and CT scans, nothing
was found. It got so bad, it seemed even clothing would exacerbate
her pain. She ended up having to wear a tube top wherever she went,
which certainly caused a ruckus at home and at the workplace.
She
received lecherous advances from strangers who interpreted her less
than discrete apparel as an easy come-on for sex. This once vibrant
woman, once a receptionist for a telecommunications company, now
was asked to transfer to a much less public position as a telemarketer.
Only through numerous visits with her doctor, was the diagnosis
of reflex sympathetic dystrophy given. Jane is now learning to cope
with her disease, with a combination of treatments, yet every day
is a struggle.
Reflex
sympathetic dystrophy is a controversial, often misunderstood disease
among the medical establishment. Also known as Complex
Regional Pain Syndrome (CRPS), its causes are unknown.
Reflex sympathetic dystrophy affects the sympathetic nervous system,
which controls various bodily functions, among which is regulating
our bodys temperature through blood vessel constriction. Although
anyone may be affected, it is commonly seen in middle-aged women.
It often is in relation to recent trauma, although 25-30% report
never having had a previous injury. A similar percentage has also
been seen following a stroke or heart a ttack.
Symptoms
usually severe burning pain usually affecting an arm, leg, hands,
or shoulder. There is often a change in temperature and intense
sweating of the limb. The extremity may also be swollen, and there
is an intense overprotection and avoidance of the limb by the person
affected with RSD.
There
have been various therapies postulating how RSD works. Many think
RSD is a result of misfiring or overactive
sympathetic nerve fibers. An abnormal response to the
normal pain cycle ensues, resulting in intractable pain. If this
pain persists, it may result in permanent disability as different
components of the body become affected. which seemed to improve
with nerve blocks, long the mainstay of treatment.
There
are three stages of RSD that
are commonly categorized. Each stage can vary in time with different
individuals, but they are approximately six months in duration and
all involve chronic pain. The first stage, also known as the acute
stage, the affected extremity has redness or swelling. The second
stage may have a bit lessened intensity of pain, but changes in
the skin, hair, and nail are seen. Stage three is severe function
restriction, osteoporosis, and muscle atrophy. At this last stage,
it is often thought to be irreversible.
Diagnosing
treatment is often one of exclusion. History and physical is a very
important component to RSD. Other testing may involve nerve studies,
x-rays, bone and CAT scans. A trial of a sympathetic nerve block
may also aid in elucidating the diagnosis.
Treatment
has been multifocal. Although nerve blocks were commonly used, most
successful therapies employ begin with vigorous physical therapy.
To encourage more limb movement, have been found to decrease the
progression of the disease. A key component of treatment is early
recognition.
Anti-inflammatory
medications such as ibuprofen has been employed. Narcotics have
proven to be of short-term benefit and not as useful. A TENS
(Transcutaneous Electrial Nerve Stimulator) is a battery-operated
device that has been tried to help block nerve impulses. Last resort
may include surgery, involving sympathetectomy.
Living
with RSD is a constant struggle. Significant changes can affect
family and the workplace. Avoidance of stressful situations is sometimes
the most helpful course of action.
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