RSD Puzzle #100

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

BOARD CERTIFIED IN ELECTROMYOGRAPHY

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

RSD and Diabetic Neuropathy have a few things in common and are different in other aspects.

1. The pain of RSD and the pain of Diabetic Neuropathy are both "neuropathic pain". This means vascular involvement and small C fiber thermal receptor sensory nerve fibers dysfunction in both diseases.

2. Both Diabetic Neuropathy and RSD are aggravated by stress. The reason being that the neuropathic pain sensory nerve fibers do not terminate in the neural cortex parietal lobe, but they terminate in the limbic system (temporal frontal lobe). The limbic system modulates stress and gets some of its signals related to stress from sympathetic nerve stimulation.

3. RSD aggravates Diabetic Neuropathy, and Diabetic Neuropathy aggravates RSD.

The following are the major differences between the two diseases:

1. The neuropathic pain of Diabetic Neuropathy is the sole manifestation of this painful Neuropathy. The painful Neuropathy is accompanied by not only burning pain, but also stabbing and electric shock type of pain because in both diseases (Diabetic Neuropathy and RSD) neuropathic pain causes damage and electric short in the nerve fibers. This is the reason anticonvulsants (especially Tegretol) are so effective in both diseases. Obviously, Tegretol has to be non-generic. Carbamazepine, which is the generic name of Tegretol, does not do any good for either condition. Neurontin is also not as effective as the true, brand-name Tegretol. The neuropathic pain also causes temperature changes in the extremities in both diseases.

2. However, the RSD requires three other conditions to meet the minimum requirement of diagnosis of RSD. In other words, simple neuropathic pain is not enough for the diagnosis of RSD.

3. The other three conditions, other than the neuropathic pain, are:

A. Reflex constriction of the muscles in the extremities in the form of flexor spasm, dystonia, tremor, or weakness of the extremities due to muscle spasm (Orbeli phenomenon).

B. Inflammation in the form of edema, swelling of the extremities, skin rash in the referred pain area away from the nerve damage, and neurodermatitis in the referred pain areas away from the nerve damage.

In addition, in RSD the inflammation can cause trophic changes of the skin and hair, as well as inflammation of pain in the synovia and bursa of the joints. Such changes are usually not seen in simple Diabetic Neuropathy. So, if there are the above mentioned manifestations of inflammation, then were are not dealing with simple Diabetic Neuropathy, but the complication of RSD.

C. The disturbance of the limbic system in RSD is more persistent and more resistant to treatment with anti-depressants.

The above three criteria (A,B, and C), added to the neuropathic pain, form the four minimal principles of the diagnosis of RSD. Bone scan cannot be used as a diagnostic tool for either of the two diseases, because in RSD bone scan is abnormal in only half of the cases and bone scan is usually normal in Diabetic Neuropathy. Thermography cannot be used to differentiate between the two conditions because Thermography is abnormal in any type of neuropathic pain be it RSD, Diabetic Neuropathy, Shingles, or traumatic vascular injury without RSD.

In regard to treatment, the treatment is the same in both conditions. The best, most effective treatment, consists of the anticonvulsants mentioned above, along with proper anti-depressants such as Desipramine and Trazodone, but not Elavil. Elavil causes fatigue and weight gain, which is not good for either of the conditions.

Finally, if you suffer from both Diabetic Neuropathy and RSD, or if you suffer only from Diabetic Neuropathy, it is imperative that you do not take heavy doses of insulin because hypoglycemia due to large doses of insulin damages the nerves in the brain and in the extremities. It is best to be conservative in regard to the doses of insulin.

More important that insulin is the "Four F" diet, which is very beneficial for both diseases. This consists of fresh fruit, fresh vegetables, fresh fish, and fresh fowl; a minimum of four meals day and a snack at bedtime consisting of a low fat dairy product combined with a small amount of bread and a fruit, avoidance of the "Five C's": candy, cookies, cake, chocolate, and cocktails. The "Five C's", especially chocolate, aggravate both conditions. Avoidance of processed visceral type of meat such as liver, kielbasa, sausage, and hot dogs.

H. Hooshmand, M.D.

The material on the Neurological Associates Pain Management Center Homepage and all it's associated, linked or reference pages is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician. H. Hooshmand, M.D., Neurological Associates Pain Management Center and Associates will not be held liable for any damage or loss as a result of information provided on this page or associated documentation. Again, this WEB SITE is simply published as an information source and should not be used to treat or make judgments on RSD/CRPS. All associated material on this web site may not be copied, reproduced or quoted without expressed written permission from the owner; Copyright © 1999-2008 H. Hooshmand, M.D.