RSD Puzzle #011

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

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BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

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RSD PUZZLE #11
RSD-Children, Treatment and Therapy

"My daughter is 13 years old. She had a fall with a mild twisting of the right knee. The x-ray, MRI, and arthroscopy have all been normal. She has had physical therapy, and ice application to her knee. Since physical therapy, she has ended up in a wheelchair. The surgeon wants to explore the knee. What should I do?"

This puzzle brings up three important points.

1. RSD in children. RSD occurs as frequently in children as in adults. The difference is that the prognosis of RSD in the children is excellent. This is due to the surge of growth hormone, endorphins, sex hormone, and other hormones during adolescence provide the body with excellent power of healing as far as the sympathetic system is concerned. In this age group it is hard to force the child into stages III and IV and make them become crippled. Even sympathectomy, which practically universally fails in RSD, helps these patients. It does not mean that they need sympathectomy, it means that any form of treatment is forgiven in this group short of amputation and unnecessary surgery. The excellent outcome of any kind of treatment for RSD among the soldiers is on the same basis and principle. This is because the soldiers are usually 18-21 years of age.

2. The second point brought up in this case, is that the patient ended up in a wheelchair after physical therapy. This is not at all unusual. Physical therapy is the treatment of choice and most imperative and critical treatment for RSD. However, application of ice to the RSD limb is unforgivable, and aggravates the condition. Fortunately, the patients become aware of this important lesson the hard way. The moment the ice is applied, the patient scream with pain and they stop the physical therapist from applying the ice. On the other hand, the children are expected to be obedient and they follow any order.

Application of alternative ice and heat which is so frequently in use in the treatment of RSD makes no logical sense and is just as harmful and useless. It is not at all uncommon for physical therapy to push the patient into a wheelchair and deteriorate the patient's condition because of the ridiculous "no pain-no gain" principle, and because of the application of ice.

3. The third point is the surgical exploration of the target organ of RSD. This desperate act is common place especially among podiatrists, orthopedists, and some hand surgeons.

Any invasive treatment be it insertion of needle for nerve blocks, surgical exploration, arthroscopy, or neurectomy if applied to the area of RSD inflammation (the target organ manifestation of the RSD) only aggravates and deteriorates he patient's condition, and changes a stage I RSD into a stage III in a matter of hours or days. This is also true regarding the cases that suffer from RSD due to lumbar spine injury, and an indwelling paravertebral catheter for sympathetic nerve block is inserted in the area of inflammation. In such cases, in a matter of less than 24 hours, the patient can become paralyzed and can develop urinary incontinence if the catheter is continuously in contact with the chain of ganglia. If such a catheter is inserted and it causes intractable pain, it should not be left inside over night and it should be removed immediately.

If the MRI of the joint (i.e., knee, wrist, ankle, hand, or foot) shows no torn ligament and mainly shows inflammation, fluid infiltration, and early stages of bone necrosis (osteoporosis and areas of decreased density of the bone), then it becomes obvious that the cause of the pain is simply RSD. In this situation, operative procedure in such an area ends up with disastrous results.

CONCLUSION: In the case of the above mentioned teenager in the wheelchair, the patient was started on Baclofen, moist heat, physical therapy, exercise. The patient quickly graduated from a wheelchair to a walker and after two weeks she did not need any assistive device. Epidural blocks and paravertebral nerve blocks at L2-L3 level on the side of the knee injury cleared the pain and after two months, the child was active and pain free. After 4 months, she returned back to normal life without any need for any treatment.

This is not an exception to the rule, but the rule of thumb. Hydrotherapy along with the use of Epsom salt accelerated the healing, mobilization, and recovery.

H. Hooshmand, MD

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 © 1999-2006 H. Hooshmand, M.D.