Real Life Problems In The Management Of Reflex Sympathetic Dystrophy

04/17/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna M.D., J.D. // (press release)

Medical Perspective:

Reflex Sympathetic Dystrophy (RSD) is a relatively uncommon pain syndrome which occurs in patients who have suffered soft tissue injuries, peripheral nerve injuries, and other conditions such as stroke, traumatic brain injury, and it can also occur in post-surgical patients. The academicians in the field of pain in 1993 changed the name of RSD to Complex Regional Pain Syndrome (CRPS). CRPS is caused by trauma or other adverse events that lead to a horrendous pain syndrome, functional impairment, and significant psychosocial dysfunction. It requires early diagnosis, aggressive coordinated care between invasive pain management physicians and occupational or physical therapists. The pain is usually out of proportion to the pain that one would expect from the trauma or adverse event suffered by the patient. CRPS is further divided into Type I that refers to patients with CRPS without a peripheral nerve lesion and Type II, which refers to patients where there is a nerve lesion.

The origin of the development of Reflex Sympathetic Dystrophy’s process is unclear but it is believed to be caused by an abnormality of the sympathetic nervous system both in the central nervous system (brain) and peripheral nervous system (nerves), which increases the sensitivity of the peripheral nerves to epinephrine and other substances that are released by the sympathetic nervous systems. This pain syndrome can be temporarily decreased by IV drugs that work locally at the peripheral nerve to block epinephrine effect. This sympathetic over-reactivity causes the clinical findings of swelling, temperature changes, color changes of the skin, and pain with range of motion. Soft tissue injuries, strokes, traumatic brain injury, fractures, surgical intervention, and injuries to peripheral nerves can cause this condition. Ninety percent of CRPS is Type I which occurs in the absence of peripheral nerve injury.

There are three stages that occur in both Type I and Type II Reflex Sympathetic Dystrophy/CRPS with more severe pain in the earlier stages and more disability in the late stages. Stage 1 is severe pain characterized as throbbing and burning, there is pain with touch, localized edema, and there is altered color and temperature. Stage 2 is thickening of the skin, progressive edema, and some muscle wasting. Stage 3 has significant decrease in movement, stiffening of joints, further skin changes, and brittle ridged nailed.

CRPS remains a clinical diagnosis and therefore requires a careful history and physical of the patient. Other diagnostic test may be helpful depending on if the patient is in Stage 1 and 2 or Stage 3. In patients in Stage 3 an X-ray of the effected extremity will show patchy osteopenia (or decreased calcification of bone). Patients in Stage 1 and Stage 2 may have abnormalities on a bone scan. A mainstay in clinical practice for both the treatment and diagnosis of CRPS are anesthesia pain blocks to either the stellate ganglion blocks to the sympathetic nerves to the upper extremity or lumbar sympathetic blocks to the lower extremity. Pain relief to the effected extremity on a transient basis will provide evidence of CRPS.

Physical therapy and occupational therapy for this condition is not well studied but will include both active and passive range of motion to the affected joints, massage to decrease edema, and modalities that will desensitize the affected extremity. Desensitizing modalities include TENS units and contrast baths which are the placement of the affected extremity in alternating cold water then hot water. As the pain and mobility improve, the patient should be involved in progressive strengthening and progressive weight bearing. Unfortunately, patients with CRPS will often be intolerant of aggressive interventions in physical therapy because of the pain that is produces; other interventions will be required.

A patient with Reflex Sympathetic Dystrophy/CRPS who is progressing poorly in therapy should be referred three times a week for sympathetic blocks followed by immediate physical therapy to utilize the transient period of pain relief to allow for range of motion, desensitizing modalities, and edema management control. This will often get a patient who has plateaued in their attempts at recovery “over the hump” and progress to improved range of motion, improved function, and decreased pain. It is my experience that patients managed aggressively with the above intervention have an improved outcome. Many patients over time will completely recover; others will be left with lasting impairments despite aggressive interventions.

Reflex Sympathetic Dystrophy Life Care Planner Perspective:

A life care plan that is properly constructed will provide a guide to all medical, rehabilitation, and all vocational needs that a catastrophically injured patient will require into the future. A life care planner will also serve as an objective educator of the current and future needs of a patient while not being swayed by the insurance or payment issues involved in a particular patient’s circumstances. The life care planner will include all necessary and appropriate care necessary in the care and management of the patient. In the case of a patient suffering with Reflex Sympathetic Dystrophy and CRPS, a prudent life care planner should understand that the plan will need to include coordinated and intensive treatment by the interventional pain physician and a physical therapist. A life care planner will need to include all future medical costs related to and including physical therapy, medication management, psychological services, physician follow ups, and future vocational counseling. All of these interventions are required to improve the functional, medical, and psychosocial welfare of the patient, while at the same time decreasing the incidence of complications.

Attorney Perspective on Reflex Sympathetic Dystrophy:

If liability can be proven, namely, if someone suffers from CRPS because of the negligent or careless act of another, or from a defective or dangerous product, an attorney must prove all past and future medical costs that are related to the CRPS. An attorney will need to rely on a team of medical providers and the expertise of a Certified Life Care Planner to prove these costs. Future damages related to the management of chronic pain, projected over a lifetime, will likely be significant. An attorney must also prove the loss of past and future wage loss and lost earnings capacity and will need to rely on the testimony from the client’s treating physicians, vocational counselors, and therapists. Pain and suffering would also be a large component of an award and testimony from the Reflex Sympathetic Dystrophy patient’s physicians, therapist, family members, and the client will be necessary to prove these damages.

Article written by Greg Vigna M.D., J.D. and Founder of Life Care Solutions Group.

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