RSD Puzzle #035

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 #35
"MY RSD IS FOUR YEARS OLD. I HAVE RECENTLY STARTED
HAVING FREQUENT INFECTIONS AND MY DOCTOR TELLS ME
THAT MY IMMUNE SYSTEM IS NOT FUNCTIONING PROPERLY.
CAN RSD CAUSE THIS PROBLEM?"

The sympathetic and parasympathetic systems in coordination provide the following functions:

1. Control of vital signs (blood pressure, pulse, and respiration).

2. Controlling and up regulating and down regulating the immune system.

3. Control the body temperature. The over acting sympathetic system results in cold skin and hot deep structures (bone, muscle, and viscera). The parasympathetic system does the opposite.

Professor B. G. W. Arnason of University of Chicago has demonstrated the reciprocal feedback of the nervous and immune systems. As he puts it "if the nervous system talks to the immune system via the sympathetic nervous system and possibly via the parasympathetic nerves, it seems likely that the immune system talks back". He has proven that the sympathetic system increases the CD8 T-cells function and the parasympathetic system does the opposite. In acute stage, stimulation of the sympathetic system up regulates the CD8 (killer) T-cells and the parasympathetic system does the opposite.

In the first few months of abnormal sympathetic function (acute RSD during the first 6 months) the sympathetic and parasympathetic systems show a significant plasticity and can adjust their activities to preserve the immune system. However, after two to three years, (chronic RSD) this power of plasticity and ability to fluctuate the balance of the immune system disappears. As a result, the immune function is thrown off balance with resultant development of frequent infections, and in the long run, development of a tendency for cancer. Certain treatments influence the plasticity and balance of the two systems positively or negatively. The following are the treatments that deteriorate the immune function.

1. Unnecessary surgery. This is especially true in the case of RSD involving the hand or foot causing inflammation and swelling at the wrist or ankle mimicking the picture of carpal tunnel or tarsal tunnel syndrome. Surgery at the wrist or ankle in such patients aggravates the condition tremendously and weakens the immune system. Sticking needles and giving injections in the swollen areas of carpal tunnel or tarsal tunnel also accelerates the deterioration of the immune system and should be avoided.

2. Intake of drugs such as alcohol, addicting narcotics, and addicting BZs.

3. A continuous distress due to the legal entanglements related to the trauma that initially caused RSD.

4. Inactivity and lack of exercise.

5. Certain, so-called foods such as hot dogs. It has been shown that children who eat more than four hot dogs a week have five times higher incidence of suffering from cancerous brain tumor than the children who do not eat hot dogs.

6. Use of ice on the extremity accelerates the constriction of the blood vessels, and aggravates the RSD hastening the development of the disturbance of the immune system.

Obviously, any measure taken in the opposite direction will prevent deterioration of the function of the immune system.

Treatments in the form of nerve blocks, antidepressants that provide natural REM sleep (such as Trazodone), and physiotherapy along with application of moist heat prevent the disturbance of the immune system.

Once the patient develops the picture of disturbance of the immune system, treatment with medications such as I.V. Immunoglobulin or ACTH may be helpful. Even though corticosteroids such as Prednisone or Decadron slow down the abnormal function of the immune system, they have a tendency to result in atrophy of the adrenal glands. The atrophy of the adrenal glands aggravates the function of the immune system.

ACTH in judicious doses does not cause atrophy of the adrenal glands and have beneficial effects both on the immune system and on reducing the swelling of the soft tissues secondary to RSD.

One of the complications of RSD, especially after the immune system is disturbed, is development of frequent attacks of neurodermatitis, skin rash, and break down of the skin.

Medications such as Zonalon (topical Sinequan) TAC (Tetracaine-adrenaline-cocaine) are helpful in counteracting the skin break down in such patients. Another similar topical lotion called LAT (Lidocaine-adrenaline-tetracaine) is similarly effective. The use of magnesium sulfate and hot water in some cases in more acute stages, the use of Capsaicin may be helpful. Clonidine Patch at any stage of RSD is a very effective, helpful treatment, not only for the skin dysfunction, but also as a sympathetic nerve block agent.

H. Hooshmand, M.D.

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