Neurological Associates

Pain Management Center

Vero Beach, Florida

 

 

H. Hooshmand, M.D.

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RSD TEXT BOOK

INFORMATION

 

CHRONIC PAIN

REFLEX SYMPATHETIC DYSTROPHY

PREVENTION and MANAGEMENT

H. Hooshmand, M.D.

Neurological Associates Pain Management Center

 

wpe6.jpg (15806 bytes)

 

 

 

Chronic Pain: Reflex sympathetic Dystrophy Prevention and Management is the first book devoted to the subject of Reflex Sympathetic Dystrophy (RSD). The book presents a new classification for the different stages of RSD and features the most comprehensive coverage of the literature on RSD and its related aspects. Qualitative and quantitative differences between natural endorphins and synthetic narcotics are described for the first time, as are long-term follow-ups on sympathectomy patients. Other topics considered include thermographic methods for the diagnosis of RSD, the role of ACTH in the management of chronic pain, and comparisons between the effects of ACTH and those of corticosteroids. The mechanism of development of RSD is clarified through an extensive collection of drawings and anatomical pictures. The book also explains why sympathectomy fails, but nerve block and physiotherapy is successful in the treatment of RSD.

 

Chronic Pain: Reflex Sympathetic Dystrophy Prevention and Management is an important reference for neurologists, neurosurgeons, physiatrists, thermographers, anesthesiologists, orthopedic surgeons, interns, and students interested in the topic.

 

Features

 

bullet

Presents a new classification for the different stages of RSD

 

bullet

Features the most comprehensive coverage of the literature on RSD and its related aspects

 

bullet

Describes for the first time qualitative and quantitative differences between natural endorphins and synthetic narcotics

 

bullet

Examines the role of ACTH in the management of chronic pain

 

bullet

Clarifies the mechanism of development of RSD through an extensive collection of drawings and anatomical pictures

 

bullet

Explains why sympathectomy fails, but nerve block and physiotherapy is successful in the treatment of RSD

 

Contents

 

Introduction

 

bullet

History of Reflex Sympathetic Dystrophy

 

bullet

The Role of Sympathetic Nervous System in Temperature Regulation

 

bullet

Anatomy of RSD

 

bullet

Pathophysiology of the Sympathetic System

 

bullet

Sympathetic Nervous System and Motor Function

 

bullet

Manifestations of RSD

 

bullet

Origins of RSD

 

bullet

Referred Pain and Trigger Point

 

bullet

Etiology of RSD

 

bullet

Prevention of RSD

 

bullet

Management of RSD

 

 

Excerpt From:

Chronic Pain:

Reflex Sympathetic Dystrophy Prevention and Management

 

Introduction

Chronic pain is being mismanaged universally. Impatient surgeons try unsuccessfully to excise the pain. Internists load the patient with narcotics and depressing tranquilizers. Chiropractors try to cure everything with their fingers. Acupuncturists shoot darts at the patients.

The inevitable failure in control of pain is compounded by the hostile attitude of the impatient healer. The victim suffers from magnified pain due to the side effects of "treatment". The physician considers the patient crazy and relegates the pain management to the psychiatrist who is not trained in the management of pain.

Even this late in the twentieth century, the patient has to cope with the nonsensical accusation that "it's all in your head" where every kind of pain obviously resides.

The most misunderstood and complex subject in medicine is the hyperpathic pain of sympathetic dystrophy. Understanding this self-perpetuating pain- which "never stops" - requires unbiased knowledge of physiology and pathology. Above all, it requires the open mind of a physician who can understand that there is no dicotomy between "psyche" and "soma", between "brain" and "mind", or between "true" and "imagined" pain.

In contrast to somesthetic pain, sympathetic pain terminates in the limbic system. It can be more severe than the pain of cancer. It can be fatal: heart attack or suicide is more common among there patients than the rest of the population. It causes tremor, blepharospasm, flexion deformity, vasoconstriction, and severe vascular migraine headache.

RSD is more common than previously assumed by clinicians. Trauma is not at the top of the list of its variety of etiologies. It may have its origin in the periphery: head, cervical spin, trunk, or extremities. It may just as well originate in CNS: spinal cord, brain stem, or cerebral hemispheres.

Invasive surgical treatments in the form of sympathectomy, tractotomy, arthrodesis, or stimulative procedures are apt to fail in the long run. Narcotics, alcohol, and almost all benzodiazepines only exacerbate the sympathetic pain.

The physician can substantially increase the rate of success in the control of this intractable pain by taking advantage of early diagnosis, aggressive physiotherapy, multiple sympathetic blocks, as well as epidural blocks and antidepressants.

The goal of this book is to review the present knowledge regarding the understanding, prevention, and management of the scourge of reflex sympathetic dystrophy.

 

CHAPTER 1

History of Reflex Sympathetic Dysfunction

 

History

"It would be a great thing to understand pain in all its meanings."

Peter M. Latham

Reflex sympathetic dystrophy (RSD) is the most unpleasant and uncomfortable form of chronic pain. It is the extreme prototype of disabling chronic pain.

Chronic pain is the type of pain that persists long after the original injury. Obviously, recurrent attacks of acute pain due to new and repetitive damages from cancer or recurrent heart attack cannot be considered chronic pain even though they may be of longstanding duration.

It is estimated that approximately 30% of the general population suffers from chronic pain. One third of these patients suffers from RSD.

The chronic pain of RSD is typified by a marked emotional connotation. It is invariably accompanied by anxiety, phobia, and neuropsychological disturbances in the form of irritability, agitation, and depression.

Historically, chronic pain has been the subject of clinical debate among physicians for a few centuries. Greek philosophers considered the brain as the site of pain perception. The first references to hyperpathic sympathetic type of pain appeared in the literature in the late 1700s by the famous British surgeon Potts. He first mentioned that trauma can be the source of burning pain and atrophy of the extremity.

The first report of amputation for treatment of this type of pain was by Denmark in 1813. Even though amputation seems to be a drastic and extreme form of treatment for RSD, even at the present time surgeons are performing amputation for RSD accompanied by osteoporotic fractures.

Needless to say, no RSD patient should undergo amputation. Even multiple fractures in small bones of the foot can be corrected without surgery. Proper physiotherapy, weight-bearing, sympathetic blocks, etc., will always save the extremity from being amputated. However, amputation is done because of lack of understanding regarding the nature of RSD. It is done when all other measures have failed and especially because of the fact that only a small percentage of RSD patients are diagnosed in the early stages of the disease. By the time the disease becomes advance, the pathology takes a rapidly accelerating downhill course that may culminate in the disastrous procedure of amputation. Amputation not only does not cure RSD, but it can be the cause.

In 1851 the French Father of Physiology, Claude Bernard,described the role of the sympathetic nervous system in preservation of milieu interne. He was the first to describe the sympathetic nervous system as being responsible for temperature regulation of the internal balance in the body.

The first report of clear-cut pathologic sympathetic dystrophy was made by the American neurologist, S. Weir Mitchell,who reported for the first time the victims of sympathetic dystrophy on the wounded soldiers of the Civil War. He colorfully called this condition erythromelalgia, implying reddish sick pain. In 1867 he described the condition in more detailed and called it causalgia.......

 

 

Table of Contents

                                                                                            
Table of Figures
xiv
List of Tables
xvii
Acronyms
xviii
Preface
xix
Introduction
1
CHAPTER 1:

History of Reflex Sympathetic Dysfunction

3
History 3
Truth is the Only Survivor 11
CHAPTER 2:

The Role of Sympathetic Nervous System in Temperature Regulation

13
Thermal Changes 14
Temperature Changes in RSD 14
Synaptic (Disuse) RSD 17
Ephaptic (Causalgic) RSD 24
Causes of Hot Spots 25
CHAPTER 3:

Anatomy of RSD

27
Chemical Structure of the Sympathetic System 29
Chemical Anatomy 30
Other Clinical Applications of the Chemical Anatomy of SNS 30
Three-Bucket-Immersion Test 31
CHAPTER 4:

Pathophysiology of the Sympathetic System

33
Lateral (Somesthetic) System 33
Medial (Nociceptive) System 36
Stress and RSD 39
Eustress 39
Distress 39
Pain and Stress 40
Stress-Induced Analgesia (SIA) 41
Life-Threatening Pain 41
Origins of SIA and SIP 42
Stress-Induced Pain (SIP) 42
Chemicals Influencing Stress-Induced Analgesia (SIA) 42
Sympathetic Mediated Pain (SMP) 44
Somesthetic (Somatic) Pain vs. Sympathetic Pain (SMP) 44
Manifestations of Sympathetic (Hyperpathic) Pain 44
Origins of Sympathetic Pain 45
RSD of Disuse 45
Scar (Ephatic) Pain 45
Deafferentation 45
Central Transmission of Sympathetic Pain 49
Summary 49
Clinical Examples of Paleencephalic (Sympathetic) Pain 51
Modulators of Paleospinothalamic Tract 51
CHAPTER 5:

Sympathetic Nervous System and Motor Function

57
Treatment Applications 58
CHAPTER 6:

Manifestations of RSD

59
RSD of Disuse 59
Ephaptic (Causalgic) RSD 60
Nerve Root Contusion (Ephaptic) 61
Common Areas of Ephaptic Pain 62
Common Ephaptic Watershed Zones in Medical Practice 62
Causalgia 64
Causalgic Pain 64
Major Causalgia and Motor Dysfunction 65
CHAPTER 7:

Origins of RSD

67
Peripheral vs. Central Origin 67
Mechanism of RSD 67
Peripheral Mechanism 67
Central (Spinal Cord) Mechanism 68
Vicious Circle 68
Central Biasing Mechanism 69
Turbulance Phenomenon 69
WDR 69
Central (Brain Stem) Mechanism 69
The Brain Stem as a Modulator of Pain 70
The Brain Stem as a Modulator of RSD 70
The Brain Stem as an Endocrine Center 71
Serotonin and Norepinephrine as Modulators of RSD in Brain Stem 71
Brain Stem and Trigeminal Nerve 74
RSD and Migraine 75
Brain Stem and Migraine: Trigeminovascular Reflex 75
Trigeminovascular System and Migraine 76
Migraine and Ischemia 76
Substance P 77
Substance P and Sympathetic Ganglia 78
Substance P and Headache 78
Substance P and CNS 78
Role of Frontal Lobe in RSD and Migraine 78
Limbic System, RSD, and Migraine 81
Peripheral Cervicofacial (Referred Pain) Migraine 81
CHAPTER 8:

Referred Pain and Trigger Point

83
Referred Pain 83
Trigger Point and Myofascial Pain 84
Mechanism of Formation of Trigger Point 85
Clinical Diagnosis of Trigger Point 85
Craniofascial Muscles Trigger Points 86
Cervical Spine Trigger Points 86
Shoulder Area Trigger Points 86
Upper Extremities Trigger Points 86
Lower Extremities Trigger Points 86
Clinical Significance of Trigger Point 87
Cold Spots 87
Trigger Point Injection 90
CHAPTER 9:

Etiology of RSD

91
Cervical Spine and RSD 91
Cervical Spondylosis 92
Treatment of Cervical Spondylosis 93
Chronic Cervical Spine Injury 94
Sherrington's Phenomenon 95
Cervical Spine and Chest Pain 95
Tremor and Cervical Spine Pathology 95
Other Systemic Causes of RSD 95
Idiopathic Forms of RSD 96
Alcohol Abuse and RSD 96
Intercostal RSD 98
Spinal Cord RSD 98
Electrical Injuries 100
Diagnostic Tests for Electrical Injuries 101
Differential Diagnosis of RSD 102
Diseases Mistaken for RSD 102
RSD Mistaken for Other Diseases 103
CHAPTER 10:

Diagnosis of RSD

105
Clinical Tests 105
Measurement of Pain 105
Davidoff Method 106
Bone Scan 106
QSART Sweat Response Test 107
SCR 107
CBV and LDF 107
Norepinephrine Spillover 107
Other Methods 108
Use of Thermography in RSD 109
Objective vs. Subjective Pain 111
Reliability of Thermography 111
CHAPTER 11:

Prevention of RSD

113
Outline of Prevention 113
Preventive Measures 114
Early Diagnosis of RSD 115
Reflex Sympathetic Dysfunction 115
Avoidance of Alcohol 116
Acid Rain 117
Effect of Alcohol on Limbic System 117
RSD and the Effect of Drugs on the Brain Stem 119
Avoidance of Litigation 119
CHAPTER 12:

Management of RSD

123
Summary of Management 123
Early Diagnosis 123
Physiotherapy 125
Massage 125
Avoid Ice Pack Application 126
Traction 126
Hydrotherapy 126
Discontinuation of Assistive Devices 126
Trigger Point Injection 127
Hot Trigger Point Injection 127
Chemical Sympathetic Nerve Block 127
Presynaptic b Chemical Block 127
b Blockers 127
a2-Blocker 129
Calcium Channel Blockers 129
Central a-Receptor Chemical Blockers 129
Peripheral a1-Receptor Chemical Blockers 129
Transcutaneous Electrical Nerve Stimulator (TNS) 130
Diet 131
Food as a Stimulant 131
Diet and RSD 131
Alcohol and Smoking 135
Hormone Treatment: Adrenocorticoids (Lazaroids) 135
Narcotics and Chronic Pain of RSD 136
ACTH and Endorphins 136
Endorphins and SNS 137
ACTH in Neuropsychiatric Disorders 140
TRH and CNS Depressants 143
Hormones and Seizure Disorder 144
Clinical Uses of ACTH 145
ACTH in Treatment of Pain and RSD 145
ACTH and Seizure Disorder 145
ACTH Treatment of Depression in RSD 145
Estrogens 146
Antidepressants 146
Management of Insomnia 147
Anticonvulsants 148
Antiviral Treatment 149
Discontinuation of Narcotics and Benzodiazepines 149
Biofeedback (Operant Treatment) 150
Invasive Nerve Blocks 151
Sympathetic Ganglion Nerve Blocks 151
Sympathetic Block for Efferent Complications of RSD 151
Sympathetic Ganglion Block and Motor Dysfunction of RSD 151
Dystonia 151
Regional Block 152
Fatigue and Sympathetic Nerve Block: Orbeli Phenomenon 152
Repetitive Sympathetic Nerve Block for Manifestations of RSD 152
Regional Blocks 153
Method 153
Invasive Treatment 154
Sympathectomy 154
Technique 155
Results 155
Causes of Failure after Sympathectomy 156
Morphine Pump 160
Patient-Controlled Analgesia (PCA) 161
Conclusion 162
Recent Advances and Future Trends 164
Early Diagnosis 164
Diagnostic Methods 164
Other Advances in Diagnostic Methods 165
Bone Scan 165
MRI 165
Further Advances in Etiology of RSD 165
Cancer and RSD 166
Manifestations of Different Stages of RSD 166
Headache and RSD 166
Dermatologic Manifestations of RSD 166
Pregnancy and RSD 166
Shoulder Pain and RSD 166
Regional Sympathetic Block 167
Regitine Test 167
Other Forms of Treatment 167
Opioid Withdrawal 168
Sympathectomy 168
Future Trends 168
References
169
Index
189
Author Index 201

 

 BOOK ORDERING

INFORMATION

 

This book is available from:

CRC Press

 

 

A CRC Company

Chronic Pain: Reflex Sympathetic Dystrophy, Prevention, and Management

AUTHOR/AFFILIATION: Hooshang Hooshmand, Neurological Associates, Vero Beach, Florida, USA
 
 
 
KEY FEATURES:
bulletPresents a new classification for the different stages of RSD
bulletFeatures the most comprehensive coverage of the literature on RSD and its related aspects
bulletDescribes for the first time qualitative and quantitative differences between natural endorphins and systemic narcotics
bulletExamines the role of ACTH in the management of chronic pain
bulletClarifies the mechanism of development of RSD through an extensive collection of drawings and anatomical pictures
bulletExplains why sympathectomy fails, but nerve block and physiotherapy is successful in the treatment of RSD
 
AUDIENCE: Neurologists, Neurosurgeons, Psychiatrists, Thermographers, Anesthesiologists, Orthopedic Surgeons, Interns, Students.
 
SHELVING GUIDE: Medicine, Clinical Science, Pain Management
SHORT TOC: Chronic Pain: Reflex Sympathetic Dystrophy, Prevention, and Management is devoted to the subject of Reflex Sympathetic Dystrophy (RSD). The book classifies the different stages of RSD and describes the qualitative and quantitative differences between natural endorphins and synthetic narcotics. Included are long-term follow-ups on sympathectomy patients.
 
CATALOG NUMBER: 8667
PAGE/TRIM/BINDING: 224 7 x 10 Hard Cover
ESTIMATED ILLUSTRS.
COLOR:
B & W: 58
ISBN: 0849386675
 
PRICE: $179.95 / 120.00
 
PUB DATE: March 1993
This book is available from:

CRC Press, Inc.

200 Corporate Blvd, N. W.
Boca Raton, FL 33431
1-800-272-7737
You can order this book on-line at: http://www.crcpress.com
e-mail: orders@crcpress.com

 

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 1999-2014 H. Hooshmand, M.D.

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