Category: Painful Conditions

REFLEX SYMPATHETIC DYSTROPHY (RSD)
/ COMPLEX REGIONAL PAIN SYNDROME

Overview

Reflex sympathetic dystrophy is a syndrome that may develop when the body has been injured. This injury can result from a motor vehicle accident, a gunshot wound, an accident around the house or even after surgery. Any sort of wound can result in reflex sympathetic dystrophy. Normally, the nerve signals pain when the body is injured. This causes a reflex, which makes the body pull away from the painful stimulus. The blood vessels will then protect the body by constricting to reduce blood loss. In patients without reflex sympathetic dystrophy, these responses gradually disappear, blood vessels open up, the fear and suffering decreases and the body takes appropriate actions to heal the wound. In patients with reflex sympathetic dystrophy, however, the body never gets quite back to normal. The nerves stay hyperactive causing increased pain because of continual blood vessel spasms. This tightening of the blood vessels causes swelling of the limb, discoloration and increased pain.  This pain from the reduced blood flow keeps the nerves excited, which then keeps the blood vessels tight and continues in a cycle. Increased pain and reduced blood flow are the hallmark of this disorder.

Diagnosis

The patient will note hypersensitivity. Patients with reflex sympathetic dystrophy do not like the limb being touched at all and will seek to protect it from even casual encounters or the wind. The slightest touch can be interpreted as pain. The doctor will note objective changes in the limb such as discoloration and increased sweating. The limb will feel two degrees cooler, the pain will increase in cold weather, and there may be alterations in the appearance of the hair on the limb. In addition, the skin becomes shiny, the bones lose their calcium and nail growth may change in appearance. X-rays and bone scans can help demonstrate reduction in blood flow and reduction of calcium in the bones. Overall, the limb may appear to be wasting away. This wasting is called dystrophy and develops as a consequence of low blood flow. In late stages of RSD, the hand or foot becomes withered and nonfunctional, virtually a useless appendage.

Treatment

Reflex sympathetic dystrophy is divided into three stages. Stage one is the least severe and three is the most severe. Depending on the stage, the treatment will vary.

Stage One: There may be some slight swelling, hypersensitivity and occasional discoloration following an injury. The skin will appear normal and there will be a minimal loss of calcium from the bones. Patients in this stage are very treatable with a combination of medications, injections and physical therapy. Neurontin is the medication of choice given to decrease activity in the overactive nerves. Other medications may be used as well to help open the blood vessels. Physical therapy is important to keep the limb from wasting away and also to decrease the sensitivity in the limb. A skilled physical therapist can design a program to help the limb recover. It is important that the nervous system returns to normal. This can be done with a sequence of nerve blocks that can help treat the underlying condition by interrupting the reflex arc of pain in the nervous system. The nerves are temporarily put to sleep with a local anesthetic causing them to forget the memory of the injury. Usually nerve blocks are given as a sequence of 3 to 10 injections.

Two: Significant wasting of the limb occurs. Calcium is very low in the bones, the skin is shinny and the blood vessels are in significant spasm all the time. Surgery becomes an option to permanently interrupt the nerves so the blood vessels can open and nourish the limb. The nerves can also be injected with drugs to permanently disrupt their function. Another alternative is the placement of a spinal stimulating device. This can interrupt the nerves without destroying them and help reverse the changes of stage two sympathetic dystrophy. In addition, another alternative is the placement of a morphine or local anesthetic pump for temporary or permanent use in order to decrease activity in the nerves.

Three: The tendons and muscles have wasted away and the limb cannot be used at all. The bones are virtually demineralized and the skin is very shinny. Unfortunately, in stage three, there is no treatment. Cutting the nerves or treating the patient with spinal narcotic infusion or with spinal stimulation will not cause the limb to regenerate. Fortunately, in this day and age, with the development of advanced pain management centers, few patients progress to stage three.

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DEPRESSION

Overview

Depression is a common disorder, which is estimated to affect up to five percent of all Americans over the age of 18 throughout the course of a year. Depression is sometimes associated with mania, the opposite mood disorder, in which the individual may feel hyper or very excitable. Both disorders can occur together. This is referred to as Manic-Depressive Disorder. More frequently, depression is experienced by itself. Depression is more common in women than in men and usually begins after the age of 25. Most patients will suffer from multiple episodes, and some patients are even prone to a chronic depressive disorder.

Diagnosis

Patients will complain of a wide variety of symptoms, including:

• Sadness
• Anxiety
• Fatigue
• Lack energy
• Loss of interest in sex and ordinary activities
• Loss of weight Suicidal thoughts

Causes of depression may include:

• Sleep problems including early morning awakening
• Poor eating habits
• Difficulty concentrating and remembering
• Difficulty making decisions
• Irritability
• Loss of health
• Physical disorders such as Parkinson’s disease, stroke and hormonal problems
• Loss of a loved one
• Changes in brain chemistry that can affect the mood
• Side effects of drugs, such as those used to treat high blood pressure
• Genetics

Ultimately, the diagnosis of depression is a clinical one. There are no specific tests that can determine a patient’s mood. A doctor may, however, order x-rays and blood work to rule out underlying physical ailments as a precaution.

Treatment

Treatment of depression is usually very successful. Frequently, a combination of psychotherapy and medications can resolve the mood disorder. Psychotherapy may be one on one or through a support group. Support groups have the added advantage of low costs and can continue long-term. Counseling sessions can help patients recognize and change negative thinking that has led to depression.

Older patients are particularly prone to depression. The elderly life circumstances tend to complicate depression quite often (e.g. living alone, loss of loved ones, health problems, etc.). It is important to change this life style and become involved in community activity, senior centers, volunteer services and to live with other people. There are many geriatric villages throughout the country and are available in most communities. Seniors band together for mutual support and social interaction in these communities.

If you are prone to depression, take an active approach to treatment. Talk to your doctor and take the prescribed medications. Get involved with a counselor or support group and consider moving to an environment where you will have more social outlets and people to talk to.

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BURSITIS

Overview

Certain areas of the musculoskeletal system experience significant stress from everyday living. Fluid filled sacs, called bursae (bursa) cushion the bones, tendons and muscles near your joints. Unfortunately bursae can become inflamed and irritated and this is call bursitis. Bursitis often occurs near joints that perform frequent repetitive motion. The most common sites for this to occur are the hips knees, shoulders and elbows.

Diagnosis

The patient with bursitis will complain of well-localized pain in the shoulder, hips or other joints. The pain may travel from one of these areas into the arm or thigh. When the doctor examines the patient, he or she will look for swelling and tenderness over the locations of the bursa.  Doctor can often diagnose bursitis based on the medical history and physical exam. If further testing is needed, the doctor my order x-rays. X ray images can’t positively establish the diagnosis of bursitis but they can help to exclude other cause of your discomfort. The bulk of bursa inflammation occurs in the soft tissue, which cannot be seen on X-ray.

Treatment

There are many treatment for bursitis. In the early stages, an anti-inflammatory drug will frequently help the problem. Ice should can also be applied over the inflamed area several times during the day to assist with swelling.  It is important to rest the affected area. For example, avoid elbow pressure by not leaning on the elbow or if the right hip is affected, try to sleep on the left side.  If these treatment strategies fail to work, the doctor may inject an anti-inflammatory drug and /or corticosteroid directly and into the bursa. These drugs are very useful for the relief of inflammation. These drugs generally bring rapid pain relief and in many cases, one injection is all you need. Although if more than one injection is needed, these medications can only be used a few times each year. Physical therapy may be ordered to strengthen the muscles in the affected area to ease pain and prevent recurrence. The physical therapist may use ultrasound and soft tissue manipulation that can sometimes be helpful. Sometimes an inflamed bursa must be surgically drained.

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PERIPHERAL NEUROPATHY

Overview

Peripheral neuropathy is a burning or aching pain due to nerve diseases. The pain can either be constant or intermittent and most often occurs in the arms or legs; however, it has been known to occur in the trunk, abdomen, head and neck. The pain can occur from irritation of one nerve or from several nerves. Generally, peripheral neuropathies are a consequence of diabetes, alcoholism or other neurological diseases.

Diagnosis

Doctors will use a physical examination to confirm the area involved. Neurological examinations can sometimes reveal loss of sensation to pinprick or to hot and cold temperatures. Weakness is sometimes noted in the affected extremity. Reflexes may be affected and there may be changes in the skin over the region. Evaluations of peripheral neuropathies usually involve tests appropriate for the primary disease, which doctors suspect is causing the problem such as diabetes. Evidence of nerve damage can sometimes be demonstrated with electrical nerve testing. Doctors who treat the pain as peripheral neuropathy will often use a nerve block procedure to help diagnose the problem.

Treatment

For some patients with peripheral neuropathy, the use of oral non-steroidal anti- inflammatory medications along with traditional pain medications can be helpful. For others, special medications help directly with nerve pain. These medications are often started at low doses and gradually increased until the desired affects are reached. Long-term relief can often be obtained with the use of therapeutic nerve blocks. These include injections of anesthetic medications along with anti-inflammatory medication around the painful nerves. The injections are usually performed in a short series over several weeks until symptoms subside or a plateau is reached in the treatment. If helpful, these injections can be repeated at appropriate intervals.

Nerve stimulation techniques can be helpful in certain types of peripheral neuropathy. Stimulation can either occur on the skin over the affected region, or in some cases, with stimulator electrodes placed surgically around the nerves or in the spine at the origin of the affected nerves. Although physical therapy is not usually helpful in relieving the pain from peripheral neuropathy, therapeutic exercises can help restore loss of function and allow patients to lead more active lives. In addition, behavioral modification techniques or biofeedback training with muscle relaxation exercises can help patients be less sensitive to the irritation from the affected nerves.

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COSTOCHONDRITIS

Overview

Costochondritis is an inflammation in the cartilage of the rib cage. It usually occurs where the ribs meet the bony plate across the front of the chest called the sternum. Between each rib and the sternum is a small segment of cartilage that forms the joints. These joints can get inflamed with arthritis, which can spread across the chest wall. Chest wall movement, including deep breathing, sneezing or coughing increases the pain. The disorder is more common in young women, especially those with young children. Young mothers frequently stress their chest wall while holding their child in their arms. In addition, women frequently have physical responsibilities in which they are not strong enough to safely carry out. Increased physical demands placed upon a relatively weak musculoskeletal system can lead to costochondritis.

Diagnosis

The patient with costochondritis will have chest pain. It can be either to the left or right of the sternum. Chest pain should not to be ignored because it may indicate a serious problem with the heart or lungs. The doctor will perform a careful history and physical exam, and possibly order X-rays or blood tests to rule out serious problems. If costochondritis is present, the doctor will discover tenderness over the joints and ribs of the chest wall. Unfortunately, costochondritis itself will not show up on any X-ray, but in extreme cases a bone scan may be positive.

Treatment

Most sudden flare-ups can be treated with an ice pack and the use of oral anti- inflammatory drugs such as aspirin or Motrin. Usually over 48 hours, the patient will improve and can become active. As long as the patient doesn’t over utilize his or her arms, the chest pain will stay at a minimal level. However, it is not always practical to limit our physical activities. Indeed, many young women have the responsibilities of a job and running a household. In this situation, if the pain fails to resolve, injections with powerful anti-inflammatory drugs are used to clear up the underlying inflammation of the joints. It may be necessary to inject multiple joints. In this situation, the injections can be given under a light intravenous sedation, with a drug like Valium. This insures the patient will be comfortable during the procedure. Costochondritis is usually a one-time event, although in some patients it can become chronic.

Prevention

If you are prone to repeat bouts of costochondritis, try to avoid physical activities that seriously overload your musculoskeletal system. Engage in proper strength training to build the muscles of the chest wall, which will stabilize the joints. If you feel a bout of costochondritis coming on, rest, apply ice and take oral anti-inflammatory agents. If inflammation can be decreased early on, the pain will be minimized.

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