RSD Puzzle #055

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

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EPILEPSY, PAIN, MS

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RSD PUZZLE #55
STROKE AND RSD

Stroke can be the cause of pain in approximately 5-7% of RSD patients. It can be self-limiting as in most cases of central pain, or it can be persistent. Stroke (similar to heart attack) can be the cause of frozen shoulder and shoulder-hand syndrome, which leads to RSD.

RSD on the other hand can cause heart attack and stroke in the late stages of the disease. This can be due to hypertension secondary to RSD, or disturbance of immune system causing bleeding, clotting, or poor circulation.

According to Lee, and van Donkelaar [1] when the brain is under attack with disturbance of the immune system (one of the three main functions of the sympathetic nervous system), it eventually becomes defective to properly protect the immune system against stroke or prolonged chronic pain. The brain undergoes anatomical and functional changes that makes it more susceptible to the above mentioned damages.

In addition to the immune system disturbance in RSD contributing to the development of stroke, the fluctuating of blood pressure in the late stage (stage IV) of RSD causes a high risk for stroke.

The sympathetic nervous system has the three major duties of control of vital signs (including pulse and blood pressure), control of immune system, and control of the body temperature. As the disease becomes uncontrollable and chronic, fluctuation of the blood pressure develops. Unfortunately, the hypertension in RSD patients is traditionally treated with medications that are used for other types of hypertension. Such medications as diuretics or newer anti-hypertension medications cannot influence the sympathetic mediated hypertension. For your type of hypertension the best medications are the alpha blockers such as Hytrin, Clonidine, or ideally Dibenzyline.

If you are not on an alpha blocker, then your should discuss it with your doctor to consider such treatment.

Thirdly, like any other complication of RSD, the disease does not improve at all until the pain is under control. The best way to control such a chronic pain is treatment with analgesic effect of a specific antidepressant such as Trazodone, and treatment with non-addicting strong pain medications which are not even classified as controlled drugs such as Stadol and Ultram.

The treatment with addicting medications such as Morphine patch or any other type of strong addicting narcotics (Vicodin, Dilaudid, etc.) is going to cause fluctuation of pain because of withdrawal effect and that can aggravate your hypertension and cause further stroke.

The fourth point to bring to your attention is the cigarette smoking. I do not force my patients to go off cigarette smoking cold turkey. That is not going to be well tolerated by RSD patients. Instead, I convince them to use nicotine patch which provides more than enough nicotine to the system but bypasses the respiratory system and does not cause a change of 30% of the blood oxygen to carbon monoxide which is more damaging than the cold extremity of RSD could be.

Obviously, other addicting drugs such as chocolate, alcohol, and hot dogs should also be completely eliminated.

With best wishes.

H. Hooshmand, MD

1. Lee RG, van Donkelaar P: Mechanisms underlying functional recovery following stroke. Can J Neurol Sci. 1995; 22:257-63.

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