RSD Puzzle #069

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 #69
MORE ON PHYSICAL THERAPY AND RSD

Depending on the specialist who is treating the patient, the treatment may be limited to only pain medications by one specialist, only antidepressant by another specialist, or only nerve blocks by a third specialist.

The treatment should be attacking the disease in a multidisciplinary fashion from all angles addressing all the four pathogenic factor resulting in RSD.

1. For the allodynic pain, the patient should receive SSRI type of antidepressants or Trazodone. The tricyclics should be avoided because they have a tendency to aggravate obesity, exacerbate fatigue, and result in a drop in the blood pressure and, in rare cases cardiac irregularities. These complications may preclude the proper use of alpha blockers.

2. FOR THE PROBLEM OF COLD EXTREMITY, VASOCONSTRICTION, AND MOVEMENT DISORDER, ICE SHOULD NEVER BE APPLIED. THE PATIENT SHOULD BE TREATED WITH HOT WATER AND EPSOM SALT BATH. THE EPSOM SALT IS A HYPEROSMOLAR SALT, AND RELIEVES THE INFLAMMATION-AS WELL AS ACTING AS A CALCIUM CHANNEL BLOCKER

ICE SHOULD NEVER BE USED ON ANY RSD PATIENT BECAUSE THE USE OF ICE AGGRAVATES VASOCONSTRICTION IN THE CHRONIC RSD. IT CAUSES FURTHER HYPOTHERMIA OF THE SKIN, AND ACCELERATE THE COURSE OF THE ILLNESS. It expands the mechanoreceptors zone of recruitment and allodynia surrounding the lesion (Torebjork Principle). The majority of patients fight and refuse the application of ice because of pain aggravation. The so-called "ice and heat challenge" with alternate application of ice and heat is of no use. Realizing that this procedure has been done on experiments and research work to study aggravation of sympathetic function, there is no therapeutic value for the alternate use of the two extremes of temperatures. The stress of the alternate treatment only aggravates the disease further.

The use of ice or Capsaicin has been shown to cause inflammation and death of the nerve fibers,
especially the larger myelinated nerve fibers. Then the un-myelinated nerve fibers are left uninhibited and unopposed with acceleration of RSD (large myelinated fibers stop conducting at 20º C, but a myelinated fibers keep conducting down to zero degrees).

3. To counteract the hypothermia in the extremity due to the abnormal function of the sympathetic system, it is essential to encourage the patient to get rid of assistive devices (wheelchair, walker, cane, and crutches). The patient should be instructed to follow the golden rule of perpetual motion. In RSD the condition gets worse with prolonged inactivity or the stress
of too much activity.

4. The patient should be instructed to learn from the human heart. The human heart beats for 90 years without one or even two minutes of resting. A heart that beats 60 per minute , and on each second the heart muscle contracts for half a second and rest for another half a second. So of the 90 years heart span the heart works 45 years and rest for 45 years.

The same principle should apply for the physical therapy. The patient should be instructed not to do any extensive exercise for a long span of time, but to constantly keep changing position and alternating exercise with rest. If sitting up causes pain, then walk. If walking causes pain, then lie down. If lying down causes pain, then go back to the other forms of exercise, etc.

Inactivity gives the signal to the sympathetic system to preserve the circulation in the inactive extremity by vasoconstriction, which aggravates the RSD. Activity does the opposite by demanding more blood circulation to the surface of skin.

PAIN AND EXERCISE

Koltzenburg (1995)[1] has shown that inactivity and immobilization of the extremity, such as the use of cast, brace, wheelchair, etc., stimulates the so-called "sleeping nociceptors." Such small c-fibers nociceptors are usually dormant but with inflammation or increased muscle and deep tissue circulation secondary to CRPS, they become activated and aggravate the pain. These "sleeping nociceptors" are mainly chemoreceptors c-fibers and consist of 25% of all the chemoreceptors c-fibers in subcutaneous and deep structures of the extremity.

H.Hooshmand, M.D.

1.Koltzenburg M: Stability and plasticity of nociceptor function, in IASP Newsletter. Jan/Feb 1995; 3-4.

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.