RSD Puzzle #004

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 PUZZLE #4
RSD and the use of assistive devices

"If the patient is in constant, severe pain, has trouble with walking, has spasms in the muscles of the lower extremities, has flexion deformity, why not use a wheelchair?"

Unfortunately, the use of assistive devices (braces, crutches, canes, walker, or wheelchair) results in inactivity and lack of use of the extremity. This, in turn, leaves the hyperactive sympathetic system unopposed and uninhibited. Normally weight bearing, walking, and the use of hands and feet stimulate the position sense (the larger sensory nerve fibers) which in turn inhibit the antero-lateral horn cells of the spinal cord. The antero-lateral horn cells of the spinal cord are the sympathetic nerves that cause constriction of the blood vessels in the extremity, cold extremity, and poor oxygenation to the small c nerve fibers (pain). Any kind of inactivity by any assistive device leaves the sympathetic nerves at the spinal cord level uninhibited and increases the firing of the sympathetic nerves with aggravation of RSD.

After sympathetic nerve block is done, the sympathetic nerve fibers are temporarily blocked. This provides a window of opportunity of a few hours to a few days for the patient to have physical therapy and stimulation of the large sensory nerve fibers (position sense) so that the antero-lateral horn cells of the spinal cord are inhibited further and the beneficial effect of the sympathetic nerve block is prolonged and perpetuated.

If after sympathetic nerve block the patient is left resting in bed without exercise of the extremities or if ice is applied to the extremities, then the sympathetic nerve block is counteracted and the patient rapidly returns back to the pre-nerve block state.

The name of the game in the management of RSD is mobilization, exercise, heat, massage, electrical stimulation, and any other stimulation that increases the position sense (proprioception) to block and inhibit the hyperactivity of the sympathetic nerve fibers.

The cardinal sins in the management of RSD are inactivity, use of ice, use of assistive devices, and amputation.

To achieve mobilization and ability to exercise, two factors should be counteracted. One is pain and the other is tendency for spasm and tremor in the extremity involved with RSD.

The pain can be treated with non-addictive pain medications (such as Stadol and other non-addictive analgesics), and the muscle spasm and tremor are best counteracted by the use of Baclofen (Lioresol). Unfortunately, Soma transforms to Meprobamate after oral intake and has the potential of addiction. Flexeril, on the other hand, has the side effects of depression and tendency for sedation and inactivity.

With the help of physical therapy, moist heat, use of enough pain medication and muscle relaxant, the patient should get rid of the wheelchair and other assistive devices.

The wrist and hand braces, and shoulder and elbow slings, result in flexion deformity of the hand, flexion deformity of the elbow, and frozen shoulder which are going to cause serious complications in the long term care.

The use of crutches, walkers and wheelchair result in avoidance of weight bearing with the serious side effects of cold skin and hot bone with rapid turn over of blood in the bone marrow, osteoporosis, and fracture of the bones which eventually may necessitate amputation. The amputation is the beginning of the end because the stump of the amputation will have hundreds of neuromas all in RSD mode.

Even the patients who have fracture of the small bones in the foot due to lack of weight bearing can regain the function of the foot by weight bearing which will result in a spontaneous healing of the small fractures. The small bones will heal in an irregular fashion but will spare the patient from amputation.

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 © 1999-2006 H. Hooshmand, M.D.