RSD-Reflex Sympathetic Dystrophy |
NAME HAS CHANGED
Educational Objectives: Recently, the term reflex sympathetic dystrophy (RSD) has been replaced by complex
regional pain syndrome - type I (CRPS-I). The name change reflected a growing dissatisfaction with the implied
mechanisms that contribute to pain associated with CRPS-I. Although the name has changed, the pathophysiology
of CRPS-I remains contentious. The focus of this workshop is to take a fresh look at possible mechanisms that
contribute to the pain of CRPS-I. Particular attention will be paid to mechanisms that influence immune system and
vascular function in the affected tissue, and how that affects pain sensitivity in CRPS-I limbs. Participants will
receive a brief review of the clinical characteristics and long-studied theories about the mechanisms of CRPS-I.
Participants will be challenged to question old theories and entertain new ideas about the potential underlying
mechanisms of CRPS-I. Participants will learn about the contribution of the immune system and vascular
dysfunction to CRPS-I, and the parallels between recent human and animal research on nerve, immune and
endothelial cell interactions in CRPS-I.
INTRODUCTION
Reflex Sympathetic Dystrophy (RSD), or Complex Regional Pain Syndrome (CRPS-I) is a syndrome of sustained, diffuse, burning pain following an initiating, noxious event that is traumatic, medical, infectious, or vascular. The syndrome is felt to be both instigated and maintained by the sympathetic nervous system and usually affects the limb, most often the distal portion. Peculiar to sympathetically maintained pain (SMP) is the lack of correlation of SMP to severity of the initiating noxious event. Clinical signs and symptoms are pain, hyperesthesia, vasomotor and sudomotor disturbances and increased motor tone, followed by weakness, muscle atrophy, skin and hair changes, and trophic changes involving the bones and joints. Initially pain is localized to the site of injury but can spread beyond the affected area over time. Pain and physical signs do not conform to known patterns of segmental dermatomes, myotomes, or sclerotomes, or to peripheral nerve distribution. Typically the disease is progressive unless interrupted by treatment; prognosis is better with early recognition and treatment.
Traditional pain management focuses on interrupting sympathetic nervous system activity with pharmacologic agents, nerve blocks, surgical or chemical sympathectomy. Physical therapy and psychological counseling are useful adjuncts.
Acupuncture has been utilized successfully in the adult patient with RSD. 2,3 Electro-acupuncture is frequently the method employed. Acupuncture has also been used successfully in the pediatric pain patient.4,5 In my practice, I have successfully treated three pediatric patients with RSD using 7 External Dragons and Devils acupuncture. Two of the patients had complete, permanent relief of pain with this treatment and one patient had significant (80% relief) after two treatments (External then Internal Dragons and Devils).
Case Reports
Case 1 History
A 16-year-old male presented with a 5-week history of severe, burning left foot pain following avulsion fracture and dislocation of the left hip due to a 4-wheeler accident. Following the accident the left hip and leg had been immobilized and was successfully healing. Two weeks after the accident, the patient noted the onset of severe, constant, burning pain of the left foot, dorsal and plantar surfaces at the lateral border of the foot. The patient was unable to wear a sock or a shoe and slept with the foot out from under the covers. He had been diagnosed with RSD, although he had not had any diagnostic sympathetic block. An EMG had been attempted but aborted due to severe pain.
At the initial visit in May 2000, the patient was on Elavil 20 mg QHS and Lortab 7.5 mg TID prn. The patient and his father were concerned about continuing narcotics in light of a strong family history of alcoholism and addiction. The patient also expressed a fear of needles. VAS was reported 8/10 at the time of initial interview.
Treatment
After obtaining written parental consent, 3 body needles and 2 ear needles were placed after patient gave permission for each needle to be placed; this technique honored his fear of needles, introduced him to acupuncture, and empowered him to decide when the treatment should stop. Bilateral GB 34, Right LR 3, and left ear sympathetic and foot (phase 3) were placed and left for 30 minutes. The patient slept during the treatment. In follow-up 1 week later the patient reported minimal to no improvement in his pain.
During the second visit, 7 External Dragons and Devils acupuncture treatment was administered (GV 20, bilateral BL 11, BL 23, BL 61) for 30 minutes. The patient slept soundly during the treatment. In follow-up 10 days later by phone, the patient’s father reported complete pain relief by day 7 and by day 9 the patient was off Lortab. Follow-up 1 year later confirmed that the patient had remained pain-free and narcotic-free. VAS was 0/10.
Case 2 History
A 10-year-old female presented with a 5-month history of left lower extremity pain following an accident while playing soccer in her backyard (slipped and fell). Initial X rays were negative for fracture but because of continued pain the left foot and ankle were casted for 10 days. The patient experienced severe, constant pain in the left ankle and lateral foot while the cast was in place. After cast removal, the pain spread proximally and the patient was diagnosed with RSD. She was evaluated at 3 prominent pain centers across the nation and treated with a series of diagnostic and therapeutic sympathetic blocks, which provided temporary relief. She had tried medications including Ultram, Neurontin, and Elavil, and had discontinued them all due to ineffectiveness and adverse side effects. Physical therapy provided minimal relief. She was ambulating with the aid of crutches. VAS was reported 7/10 at the time of initial interview.
Treatment
Seven External Dragons and Devils acupuncture was administered (GV 20, bilateral BL 11, BL 23, BL 62) and the needles left in place for 30 minutes. On follow-up one week later the patient and her parent reported 95% resolution of her symptoms including pain. She was ambulating without crutches. VAS was reported 1/10. Her second treatment consisted of bilateral LR 3 and LI 4 with Yin Tang for 30 minutes. Follow-up by phone one week later revealed 100% resolution of all complaints. Ten months later the patient remained pain-free (VAS 0/10).
Case 3 History
A 13 year old female presented with a 3 ½ month history of right medial foot and ankle pain following an ant bite to the foot. The pain was described as constant, severe, burning and had started to spread proximally within two weeks after the initiating event. She had been diagnosed with RSD and had received five lumbar sympathetic blocks at another pain clinic which provided temporary relief. She also received physical therapy, water therapy, neuromuscular stimulation, and was on Neurontin 800 mg TID at the time of her initial visit. Physical therapy was ongoing throughout her course of acupuncture. She had been ambulating with the use of crutches and a wheelchair before starting acupuncture, as weight-bearing and shoe-bearing was painful. VAS at the time of presentation for acupuncture was 9/10.
Treatment
Initially the patient was treated with 7 External Dragons and Devils for 30 minutes. In follow-up one week later, she reported significant pain reduction to a VAS of 5/10 and had been able to wear a shoe. Three more acupuncture treatments were administered on a weekly basis.
During visits two and three, the patient’s chief complaints were consistent with a viral URI with fever, nausea, and body aches so points were chosen to clear heat, move qi and blood, and an extraction to Tai Yang was performed. After resolution of these symptoms on week four, the right foot pain was again addressed with 7 Internal Dragons and Devils. After this second treatment to address the right foot and ankle pain, the patient reported an 80% reduction in her pain. VAS was 3/10 one week after treatment number four. She continues to receive acupuncture for her pain with consistent relief.
Discussion
Very little is translated into English about the acupuncture depossession treatments known as 7 Internal Dragons and Devils and 7 External Dragons and Devils. The treatments are useful clinically when patients have experienced life changing events, frequently traumatic in nature, followed by complaints of pain or suffering for which the patient seeks relief. 6 Either internal emotional factors resulting from the initiating event or exogenous factors have “invaded” the patient’s energetic makeup to such an extent that it exerts an overriding control on that person.7 7 Internal or External Dragons and Devils acupuncture can release the dragons, which are felt to be benign, protective forces, in order to chase away the devils that manifest as the patient’s chief complaint.
In these cases of pediatric RSD, all three patients reported severe pain following a traumatic initiating event, with minimal or temporary relief with conventional medical techniques. None of the three had internalized emotional factors related to the traumatic event, so the 7 External Dragons and Devils treatment was administered. Patient 3 also had 7 Internal Dragons and Devils Acupuncture due to incomplete relief after the External treatment and some apparent internalization of the initial traumatic event (anger and frustration when describing the event).
The 7 needle Dragons and Devils treatment promotes the reintegration of the patient’s energy into a unified, harmonious system after a life-changing inciting event. Particularly with the Internal Dragons and Devils treatment, there may be signs of upheaval as the conflict is confronted and adjustment takes place.7,8 Proof that the blockage to healing has been released will be evident in that treatments that had previously been ineffective now provide relief. In this case two patients needed no further acupuncture and one who experienced significant (80%) relief continues to undergo meridian acupuncture with good results.
REFERENCES
1. Hendler N, Raja S. Reflex Sympathetic Dystrophy and Causalgia. In: Handbook of Pain Management. Baltimore, MD: Williams & Wilkins 1994; 39:484-496.
2. Kho KH. The Impact of Acupuncture on Pain in Patients with Reflex Sympathetic Dystrophy. The Pain Clinic 1995; 8(1): 59-61.
3. Gellman H. Reflex Sympathetic Dystophy: Alternative Modalities for Pain Management. AAOS Instructional Course Lectures 2000; 49:549-557.
4. Kemper KJ, Sarah R, Silver-Highfield E, Kiarhos E, Barnes L, Berde C. On Pins and Needles? Pediatric Pain Patients’ Experience with Acupuncture. Pediatrics 2000; 105(4): 941-947.
5. Lin YC, Bioteau AB, Lee AC. Acupuncture for the Management of Pediatric Pain: A Pilot Study. Medical Acupuncture 2002; 14: 45-46.
6. Helms J. Class notes, UCLA Course Medical Acupuncture for Physicians, 1999.
7. Worsley JR. Traditional Acupuncture, Vol. II 1990; 170-174.
8. Hobbes V. Class notes, Southwest Acupuncture College, 2001.
|
