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PubMed2000

Glenohumeral joint subluxation and reflex sympathetic dystrophy in hemiplegic patients.

OBJECTIVE: To examine the relation between glenohumeral joint subluxation and reflex sympathetic dystrophy (RSD) in hemiplegic patients. DESIGN: Case-control study. SETTING: Inpatient rehabilitation hospital. PATIENTS: Thirty-five hemiplegic patients with RSD (RSD group) and 35 hemiplegic patients without RSD (non-RSD group) were included in the study. Patients with rotator cuff rupture, brachial plexus injury, or spasticity greater than stage 2 on the Ashworth scale were excluded. MAIN OUTCOME MEASURES: Both the RSD and non-RSD groups were assessed for presence and grade of subluxation from radiographs using a 5-point categorization. The degree of shoulder pain of the non-RSD group was assessed by a visual analogue scale of 10 points. RESULTS: Glenohumeral subluxation was found in 74.3% of the RSD and 40% of the non-RSD group (p = .004). In the non-RSD group, 78.6% of the patients with subluxation and 38.1% of the patients without subluxation reported shoulder pain (p = .019). No correlation was found between the degree of shoulder pain and grade of subluxation in the non-RSD group (p = .152). CONCLUSION: Findings from this study suggest that shoulder subluxation may be a causative factor for RSD. Therefore, prevention and appropriate treatment of glenohumeral joint subluxation should be included in rehabilitation of hemiplegic patients.

Female↗
PubMed2006

[Mechanism of post-stroke reflex sympathetic dystrophy: study with needle electromyography].

OBJECTIVE: To explore the mechanism of post-stroke reflex sympathetic dystrophy (RSD) patients electromyographic abnormality and confirm its clinical value. METHODS: Fifty patients with first-onset stroke, aged 33 - 78, including 30 with RSD and 20 without RSD, underwent needle electromyography (EMG) to test the nerve conduction velocity (NCV) and sensory nerve conduction velocity (SCV) of bilateral median nerves, and the number and position of spontaneous EMG activity of bilateral short abductor muscles of thumb and abductor muscles little finger. RESULTS: The median nerve compound muscle action potential (CMAP) amplitude of the affected upper extremities of the RSD group was 8.6 mV +/- 2.9 mV, significantly lower than that of the non-RSD group (13.2 mV +/- 4.6 mV, P < 0.01). The incidence of spontaneous electrical potential of the RSD group was 100%; significantly higher than hat of the non-RSD group (65%, P < 0.001). The quantity of spontaneous EMG activity on the short abductor muscles of thumb and abductor muscles little finger was increased in the RSD group (P < 0.01). The motor nerve conduction velocity and electrophysiological presentation of sensory nerve of these 2 groups were all normal and without significant differences between them. CONCLUSION: Partial axonal degeneration occurs on the distal motor never fibers of the affected upper extremity of the RSD patients, which may be related to subsequent peripheral nerve injury after central nerve system impairment.

Adult↗
PubMed1996

Long-term results of peripheral nerve stimulation for reflex sympathetic dystrophy.

This prospective, consecutive series describes peripheral nerve stimulation (PNS) for treatment of severe reflex sympathetic dystrophy (RSD) or complex regional pain syndrome, in patients with symptoms entirely or mainly in the distribution of one major peripheral nerve. Plate-type electrodes were placed surgically on affected nerves and tested for 2 to 4 days. Programmable generators were implanted if 50% or more pain reduction and objective improvement in physical changes were achieved. Patients were followed for 2 to 4 years and a disinterested third-party interviewer performed final patient evaluations. Of 32 patients tested, 30 (94%) underwent permanent PNS placement. Long-term good or fair relief was experienced in 19 (63%) of 30 patients. In successfully treated patients, allodynic and spontaneous pain was reduced on a scale of 10 from 8.3 +/- 0.3 preimplantation to 3.5 +/- 0.4 (mean +/- standard error of the mean) at latest follow up (p<0.001). Changes in vasomotor tone and patient activity levels were markedly improved but motor weakness and trophic changes showed less improvement. Six (20%) of the 30 patients undergoing PNS placement returned to part-time or full-time work after being unemployed prestimulator implantation. Initial involvement of more than one major peripheral nerve correlated with a poor or no relief rating (p<0.01). Operative modifications that minimize technical complications are described. This study indicates that PNS can provide good relief for RSD that is limited to the distribution of one major nerve.

Electric Stimulation Therapy↗
PubMed1996

[Muscular spasms associated with a reflex sympathetic dystrophy].

The appearance of involuntary movements in the clinical course of reflex sympathetic dystrophy (DSR) constitutes a rare clinical entity. In this context, the most frequent changes in movements are muscle spasms and focal dystonia, although postural tremor, muscle weakness and rhythmic myoclonus have also been described. The disorder is more frequent in young women and in the lower limbs. It may have a focal, segmental, multifocal, hemicorporal or symmetrical distribution. It is almost always secondary to local trauma. The pathogenesis and most effective treatment are unknown. We present the case of a 62 year old woman with muscle spasms of both legs and feet as a complication of spontaneously appearing DSR. The electromyogram showed continuous non-rhythmic discharges with morphologically normal motor unit potentials in both anterior tibial muscles. The clinical course and symptomatic improvement following treatment with benzodiazepine seems to suggest that the disorder is of central origin.

Causalgia↗
PubMed1999

Quantitative evaluation of three-phase bone scintigraphy before and after the treatment of post-traumatic reflex sympathetic dystrophy.

Three-phase bone scans performed in 65 patients with post-traumatic reflex sympathetic dystrophy (RSD) were reviewed to evaluate which changes in uptake of the tracer appear before and after treatment, whether the form of treatment affects the intensity of uptake, and to investigate the correlation between the results of treatment and the intensity of the uptake both at initial and final scintigraphic examination. Forty-nine patients were treated using three different methods; 16 patients were observed without treatment. Bone scintigraphy was performed twice in each patient: first before treatment or observation and then at the final assessment, from 6 to 18 months after the end of treatment. Clinical results were rated as follows: good, moderate and poor. Scintigrams were evaluated quantitatively after processing the data obtained from the selected regions of interest. A significant reduction in the initially increased uptake of the tracer was noted in each phase/region of interest 6-18 months after initial imaging. At final assessment, mean uptake ratios in treated and non-treated patients were similar. This suggests that treatment does not affect the rate of reduction of uptake. In patients with good and moderate response to treatment, mean uptake ratios at initial scanning were significantly higher than in patients with poor outcome. This indicates that three-phase bone scintigraphy has prognostic value in RSD: marked hyperfixation of the tracer indicates better final outcome. At final imaging, the mean uptake ratios of patients with good, moderate and poor response to treatment did not differ significantly. This suggests that three-phase bone scintigraphy has no value in monitoring the course of treatment of RSD.

Adult↗
PubMed1997

Reflex Sympathetic Dystrophy in the Upper Extremity.

The diagnosis and treatment of pain are among the most challenging problems facing orthopaedic surgeons, and reflex sympathetic dystrophy is probably the most frustrating and difficult pain syndrome to manage. Pain, swelling, and autonomic dysfunction are cardinal signs of the condition. Although the pathogenesis is still unclear, many theories have been proposed. Because reflex sympathetic dystrophy is sympathetically mediated, diagnosis can be confirmed on the basis of response of the pain to sympathetic blockade. Treatment may include an appropriate exercise program, a-adrenergic blocking agents, mood-elevating drugs, calcium channel blockers, intravenous regional blocks, and stellate ganglion blocks. Recent additions to therapy include electroacupuncture, transcutaneous electrical nerve stimulation, and biofeedback. Prognosis is, at best, guarded with this perplexing condition, but the best response is obtained when diagnosis is made early (within the first 2 or 3 weeks after injury) and treatment is initiated during the first stage of the disease.

Journal Article↗
PubMed2001

Treatment of reflex sympathetic dystrophy (CRPS type 1): a research synthesis of 21 randomized clinical trials.

A blinded meta analysis was performed on randomized clinical trials (RCT) on the medicinal treatment of reflex sympathetic dystrophy (complex regional pain syndrome type I) to assess the methodological quality and quantify the analgesic effect of treatments by calculating individual and summary effect sizes. The internal validity of 21 RCTs was investigated and the quality weighted summary effect size was calculated using a fixed effect model (Glass Delta). The methodological quality ranged from moderate to good (average 46%). Differences were found between the trials in inclusion/exclusion criteria, treatment methods, duration of treatments and trials, and measurement instruments. Statistical analysis was possible for four subgroups; one evaluating the analgesic effects of sympathetic suppressors in general (n = 12), one subgroup concerning the analgesic effects of guanethidine (n = 6), one investigating the analgesic effect of intravenous regional sympathetic blocks (n = 9), and one subgroup (n = 5) evaluating the analgesic effect of calcitonin. Except for the calcitonin subgroup (P = 0.002), the quality-weighted summary effect size of these subgroups were not significant. No significant analgesic effect by sympathetic suppressing agents could be established. Calcitonin seems to provide effective pain relief in reflex sympathetic dystrophy patients. The results of the present study show that weighting methodological quality influences the magnitude of the effect sizes of specific treatment methods. Future studies should control for methodological quality.

Analgesics↗
PubMed1999

Contralateral thalamic perfusion in patients with reflex sympathetic dystrophy syndrome.

Iodine-123-labelled iodoamphetamine single-photon emission computed tomography of patients with reflex sympathetic dystrophy syndrome showed substantial variation in thalamic perfusion of the side contralateral to the painful limb. The variations are related to time from the onset of symptoms, which suggests that the thalamus undergoes adaptive changes in the course of this neurological disorder.

Adult↗
PubMed1993

Reflex sympathetic dystrophy after modified radical mastectomy: a case report.

Despite the long history of descriptions of reflex sympathetic dystrophy (RSD), much confusion remains regarding its pathogenesis, diagnosis, and treatment. It most commonly occurs after trauma and is more frequent in women, white persons, and the elderly. The first case of RSD after mastectomy is reported and the proposed pathophysiology and management of RSD are reviewed.

Arm↗
PubMed1994

Reflex sympathetic dystrophy following total knee replacement.

Twenty-nine patients who eventually had a diagnosis of reflex sympathetic dystrophy (RSD) following total knee replacement were treated with lumbar sympathetic blocks with local anesthetic. The diagnosis was made based on the complaint of constant pain unrelated to physical activity in the absence of overt sepsis or implant loosening. In six of these cases, other factors may have clouded the diagnosis. Thirteen (44.8%) patients obtained complete relief following an average of 1.8 blocks. Three of these patients had symptoms for more than two years. Twelve patients had complete or partial relief for varying periods of time, but the relief was not sustained. Three obtained no relief at all, and in one the block could not be successfully carried out. This success rate, while shedding no light on the etiology or diagnostic accuracy, has encouraged the authors to continue with this method of treatment in such cases.

Adult↗
PubMed1998

Role of neuropeptides in pathogenesis of reflex sympathetic dystrophy.

In 1993, a study was undertaken at the Hand Clinics of Loyola University Medical Center in Chicago to investigate the role of the neuropeptides in the pathogenesis of Reflex Sympathetic Dystrophy. All of the patients had recurrent or continuous pain, swelling, and stiffness of one or both extremities following either acute trauma or surgical intervention. All of the patients showed a markedly increased level of bradykinin as well as calcitonin gene-related peptide. The levels of bradykinin were four times as high as the controls. A few showed increased levels of the other neuropeptides. With these results, we agree with Veldman, Goris and others who consider Reflex Sympathetic Dystrophy to be an exaggerated regional inflammatory disorder.

Adult↗
PubMed1995

Reflex sympathetic dystrophy: changing concepts and taxonomy.

We present a revised taxonomic system for disorders previously called reflex sympathetic dystrophy (RSD) and causalgia. The system resulted from a special consensus conference that was convened on this topic and is based upon the patient's history, presenting symptoms, and findings at the time of diagnosis. The disorders are grouped under the umbrella term CRPS: complex regional pain syndrome. This overall term, CRPS, requires the presence of regional pain and sensory changes following a noxious event. Further, the pain is associated with findings such as abnormal skin color, temperature change, abnormal sudomotor activity, or edema. The combination of these findings exceeds their expected magnitude in response to known physical damage during and following the inciting event. Two types of CRPS have been recognized: type I, corresponds to RSD and occurs without a definable nerve lesion, and type II, formerly called causalgia refers to cases where a definable nerve lesion is present. The term sympathetically maintained pain (SMP) was also evaluated and considered to be a variable phenomenon associated with a variety of disorders, including CRPS types I and II. These revised categories have been included in the 2nd edition of the IASP Classification of Chronic Pain Syndromes.

Causalgia↗
PubMedDate not supplied

What makes treatment for reflex sympathetic dystrophy successful?

Therapists throughout the world find it challenging to treat and rehabilitate patients with reflex sympathetic dystrophy. An insufficient understanding of the disease process often hinders the diagnosis, causing the patient unnecessary pain and distress. This paper presents effective diagnostic and treatment methods that emphasize patient trust as well as relaxation and range-of-motion exercises. The paper describes the cases of 120 women, aged 35 to 75 years, and 30 men, aged 30 to 60 years. The condition was diagnosed in these patients three months after the onset of primary symptoms and was successfully treated.

Adult↗
PubMed1996

Psychological differences between reflex sympathetic dystrophy and non-RSD chronic pain patients.

This study examined possible psychological differences between Reflex Sympathetic Dystrophy (RSD) and non-RSD chronic pain patients. Unlike the few previous studies in this area, this study controlled statistically for age and pain duration differences across diagnostic groups, and included a non-RSD limb pain control group. Subjects were a consecutive series of 34 RSD, 50 non-RSD limb pain (Limb), and 165 low back pain (LBP) patients presenting for treatment at the Rush Pain Center. Analyses revealed that RSD patients reported more somatization and phobic anxiety on the Brief Symptom Inventory than LBP patients. RSD patients also reported greater coping with pain through diverting attention than LBP patients did on the Coping Strategies Questionnaire. Comparisons between the RSD and Limb groups revealed no significant differences with the exception of somatization scores. The relationship between distress and pain severity was found to be stronger in RSD and Limb patients than in LBP patients. These results provide partial support for clinical assumptions that RSD patients are more psychologically dysfunctional than other chronic pain patients. However, these conclusions do not generalize across all comparison groups. The fact that RSD and non-RSD limb pain patients were quite similar on nearly all measures suggests that sympathetic mediation of pain is not the source of these psychological differences.

Adaptation, Psychological↗
PubMed1998

Reflex sympathetic dystrophy: is the immune system involved?

OBJECTIVE: Evaluation of immune system function in patients with reflex sympathetic dystrophy (RSD). DESIGN: Survey on blood samples obtained from RSD patients and from a randomly selected control group. The lymphocyte populations (T, B, NK cells), and the activated T cells (CD25, and HLA-Dr-positive CD4 and CD8 cells) were analyzed by flow cytometry with dual-color direct immunofluorescence after whole-blood lysis. Clinical chemistry parameters were analyzed in additional serum samples. SETTING: Tertiary care center (outpatient rehabilitation clinic). SUBJECTS: Thirteen patients (nine women) with RSD and a control group of 21 healthy individuals. MAIN OUTCOME MEASURES: The results of the flow cytometry analysis of RSD patients were related to those of the control subjects. Means were analyzed, and confidence intervals for differences of the means were calculated. The means of the clinical chemical analysis were related to local reference values. RESULTS: The flow cytometry analysis did not differ between RSD patients and healthy controls. Although in some patients an individual parameter of clinical chemical analysis differed from its reference value, all of the mean values were within reference limits. Stratification on medications with immunomodulatory effects and on probability of a definite diagnosis of RSD had no influence on the results. CONCLUSION: No association between immunologic indices and RSD was found. This finding is relevant, because recent theories stress that it is not the sympathetic nervous system but a local inflammatory reaction that is fundamental in the pathogenesis of RSD. The results of this study do not support this theory.

Adult↗
PubMed1999

The usefulness of quantitative evaluation of three-phase scintigraphy in the diagnosis of post-traumatic reflex sympathetic dystrophy.

Quantitative analysis of three-phase bone scintigrams was done in 70 patients with reflex sympathetic dystrophy (RSD) and in 30 patients who did not have RSD after injury to the hand or wrist. Regions of interest were selected and the uptake ratios (affected/unaffected) were calculated. Significant differences between affected and unaffected patients were seen in the metacarpal area in phase 2 of the scintigrams as well as in the metacarpophalangeal joints and metacarpal bones in phase 3. Combination of these images had the greatest diagnostic value. Sensitivity and specificity of 80% were achieved in the regions of interest in phase 3. The duration of RSD and the predisposing injury significantly affected the results of bone scintigraphy. It was also noted that a fracture may cause increased fixation of the tracer in each phase of three-phase bone scintigraphy in asymptomatic patients.

Adult↗
PubMed2001

Treatment of reflex sympathetic dystrophy with pamidronate: 29 cases.

OBJECTIVE: To evaluate the efficacy of treatment with pamidronate in reflex sympathetic dystrophy (RSD) refractory to previous treatment. METHODS: We studied the response (disappearance of pain and functional improvement) to pamidronate (60 mg/day for 3 days) in 29 patients with RSD refractory to previous treatment for at least 14 days. RESULTS: On day 45, complete pain disappearance was observed in 86.2% of patients and functional improvement in 70%. The mean delay until the pain disappeared was 20+/-14 days and the delay until functional improvement was observed was 29+/-18 days. The mean delay of functional improvement was shorter in patients with post-traumatic RSD. Multivariate analysis did not reveal any factor predictive of response to treatment. Six (20.7%) patients suffered from side-effects (fever, diarrhoea). CONCLUSION: Pamidronate appeared to be effective in the treatment of refractory RSD; however, these results need to be confirmed by a controlled placebo study.

Adult↗
PubMed2005

Determination of inflammation of reflex sympathetic dystrophy at early stages with Tc-99m HIG scintigraphy: preliminary results.

The pathogenesis of reflex sympathetic dystrophy (RSD) is not completely understood. However, an excessive regional inflammation, sensitization of primary somatosensory afferents, and sensitization of spinal neurons are considered to have a role in the pathogenesis of RSD. The underlying pathophysiology relating the clinical picture may help to determine the pharmacotherapeutic approach for an individual patient. Scintigraphy using radiolabelled human polyclonal non-specific immunoglobulin (HIG) has been recognized as a useful tool for the localization of inflammatory disorders. Thirty-six consecutive RSD patients associated with hemiplegia were included in this study. All the patients in this study had three phases bone scan and Tc-99m HIG scintigraphy. On admission, of 36 patients with positive bone scan, 30 had positive Tc-99m HIG scan. All the patients were symptomatic at the time of bone scanning. On the contrary, 24 out of 36 patients subsequently became asymptomatic at an 8-month re-evaluation period. Tc-99m HIG scintigraphy is a non-invasive complementary method for the determination of ongoing inflammatory reactions which also aids the clinicians to predict the response to anti-inflammatory therapy at the very early phase of RSD associated with hemiplegia. This preliminary study may be a source of inspiration for further studies with larger series and longer follow-up .

Aged↗