RSD Puzzle #087

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

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RSD PUZZLE #87
RSD AND CEREBRAL PALSY

Occasionally, the patients with Cerebral Palsy (CP) are afflicted by neuropathic pain, and even by the full picture of RSD.

Cerebral Palsy is a nonspecific, generalized terminology referring to any injury before or after birth, to any child, resulting in permanent and chronic disturbance of the central nervous system (CNS) function.

The effect of pain on the CP is quite variable. Some patients show quite a high tolerance to pain, whereas others have a low threshold for pain. Usually, the mild cases of cerebral palsy are left undiagnosed. Usually such a child is categorized under a diagnoses such as hyperactivity, ADHD, Clumsiness, or "slow learner".

In rear cases of CP, the patient manifest central sympathetic nervous system dysfunction in the form of central pain and even disturbance of sympathetic dysfunction affecting the entire one side of the body.

Usually, in such cases the patients is referred for evaluation of severe headaches, or pain of an unknown cause. One of the earliest manifestations is attacks of severe pain waking the patient up during late night sleep. The patient acts very sensitive to light and noise, may show the manifestation of hypersensitivity of the skin to touch (allodynia), and tendency for flexion and withdrawal of the involved extremities.

Thermography is quite diagnostic, in that it usually shows partial virtual sympathectomy and paralysis of the sympathetic system involving one side of the body, manifested in the form of hyperthermia and heat loss due to the partial inability of the sympathetic system to preserve the body heat through vasoconstriction of the skin on the involved extremities.

Such children, or the grownups who have been left undiagnosed, have an extremely low threshold for pain, Their response to pain is quite emotional, and out of proportion to the pain stimulus.

This is not because the child is spoiled or simply exaggerates the pain. This is because of the fact that disturbance of the sympathetic system causes severe allodynia and hyperpathia resulting in sensitivity to touch, or even to breathe. The patient has a tendency to react paradoxically to muscle relaxants and tranquilizers such as Valium, Xanax, etc. Instead of a calming effect, such medications stimulate the patient, causing agitation and anxiety. This paradoxical phenomenon makes the treat treatment with sympathetic nerve blocks extremely difficult.

In addition, the sympathetic nerve blocks are not usually helpful because the patient already has
a paralyzed sympathetic system, rather than a simply hyperactive sympathetic system. If the thermography shows increased temperature in the involved area, then there is no sense in proceeding with sympathetic nerve blocks, because the sympathetic nerves are already dysfunctional. This is one of the best examples of sympathetic dysfunction leading to RSD without the accompanying sympathetic hyperactivity.

Treatment of choice for this condition is a combination of treatment with effective analgesic antidepressants such as Desipramine, Trazodone, or Doxepin. The antidepressant treatment should be combined with treatment with a specific anticonvulsant. The most effective anticonvulsant for this condition is Tegretol. Tegretol, in non-generic brand name form, is the most effective pain reliever for causalgic pain. In addition, Cai and McCaslin (in European Journal of Pharmacology, 1992)[1] have reported that the combination of Desipramine and Tegretol is quite effective in blocking NMDA receptors and relieving the pain.

Obviously, as is the case with all neuropathic pains, and especially RSD, just prescribing medication is not enough. The change of life habits is also very important. The proper diet, which would avoid any use of chocolate, hot dogs, sausage, etc., and would encourage the four F's diet (fresh fruit, fresh vegetables, fish and fowl), as well as avoidance of extensive distressful exercise or extensive bed rest are essential in the treatment of this sad condition. As mentioned above, the condition is rare, and falls into the category of "Central Pain".

H. Hooshmand, M.D.

1. Cai Z, McCaslin PP: Amitriptyline, desipramine, cyproheptadine and carbamazepine, in concentrations used therapeutically, reduce kainate- and N-methyl-D- aspartate-induced intracellular Ca2+ levels in neuronal culture. Eur J Pharmacol 219:53-57 1992.

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